Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Account Discrepancy New 20 5 0 Form and Instruction 30 Account Discrepancy
Accreditation New 10 8 0 Form and Instruction 6 Accreditation
Agent Registration (Initial) New 100 25 0 Form and Instruction 26 Agent Registration (Initial)
Agent Registration (Renewal & Update) New 100 25 0 Form and Instruction 27 Agent Registration (Renewal & Update)
Authorized Agent Designation New 1290 323 0 Form and Instruction 29 Authorized Agent Designation
Civil Judgment New 10 8 0 Form and Instruction 13 Civil Judgement
Continuous Query New 387767 31021 0 Form and Instruction 21 Continuous Query
Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal New 38785 9696 0 Form and Instruction 1 Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal
Criminal Conviction (Guilty Plea or Trial) New 1023 767 0 Form and Instruction 9 Criminal Conviction (Guilty Plea or Trial)
DEA/Federal Licensure New 499 374 0 Form and Instruction 4 DEA/Federal Licensure
Deferred Conviction or Pre-Trial Diversion New 126 95 0 Form and Instruction 10 Deferred Conviction or Pre-Trial Diversion
Electronic Transfer of Funds (ETF) Authorization New 562 141 0 Form and Instruction 28 Electronic Transfer of Funds (ETF) Authorization
Entity Registration (Initial) New 35915 35915 0 Form and Instruction 24 Entity Registration (Initial)
Entity Registration (Renewal & Update) New 15461 1237 0 Form and Instruction 25 Entity Registration (Renewal & Update)
Exclusion/Debarment New 2402 1802 0 Form and Instruction 14 Exclusion/Debarment
Government Administrative New 2682 2012 0 Form and Instruction 15 Government Administrative
Health Plan Action New 561 421 0 Form and Instruction 16 Health Plan Action
Injunction New 10 8 0 Form and Instruction 12 Injunction
Medical Malpractice Payment New 14193 10645 0 Form and Instruction 2 Medical Malpractice Payment
National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Pract Removed 0 0 0 Form and Instruction NPDB Identity Proofing Forms NPDB Identity Proofing Forms
Form 0915-0126 NPDB Forms NPDB Forms
Nolo Contendere (no contest) plea New 63 47 0 Form and Instruction 11 Nolo Contendere (no contest) plea
One Time Query for an Individual New 986552 78924 0 Form and Instruction 17 One Time Query for an Individual
One Time Query for an Organization New 18892 1511 0 Form and Instruction 18 One Time Query for an Organization
Peer Review Organization New 10 8 0 Form and Instruction 5 Peer Review Organization
Professional Society New 71 53 0 Form and Instruction 8 Professional Society
Request for Secretarial Review New 83 664 0 Form and Instruction 23 Request for Secretarial Review
Section 1921 forms Removed 0 0 0 Form and Instruction 2 60.10: Adverse Actions - Private Accreditation
Form and Instruction 1 60.9: Licensure Actions
Form and Instruction 3 60.10: Adverse Actions - Peer Review Organizations
Self-Query on an Individual New 154824 65026 0 Form and Instruction 19 Self-Query on an Individual
Self-Query on an Organization New 1095 460 0 Form and Instruction 20 Self-Query on an Organization
State Licensure New 28700 21525 0 Form and Instruction 3 State Licensure
Subject Statement and Dispute New 3347 2510 0 Form and Instruction 22 Subject Statement and Dispute
Title IV Clinical Privileges Actions New 962 722 0 Form and Instruction 7 Title IV Clinical Privileges Actions
Total burden requested under this ICR: 1696115 265978 0  
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