Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Account Discrepancy Unchanged 20 5 0 Form and Instruction 30 Account Discrepancy
Accreditation Unchanged 10 8 0 Form and Instruction 6 Accreditation
Agent Registration (Initial) Unchanged 100 25 0 Form and Instruction 26 Agent Registration (Initial)
Agent Registration (Renewal & Update) Unchanged 100 25 0 Form and Instruction 27 Agent Registration (Renewal & Update)
Authorized Agent Designation Unchanged 1290 323 0 Form and Instruction 29 Authorized Agent Designation
Civil Judgment Unchanged 10 8 0 Form and Instruction 13 Civil Judgement
Continuous Query Unchanged 387767 31021 0 Form and Instruction 21 Continuous Query
Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal Unchanged 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) Unchanged 1023 767 0 Form and Instruction 9 Criminal Conviction (Guilty Plea or Trial)
DEA/Federal Licensure Unchanged 499 374 0 Form and Instruction 4 DEA/Federal Licensure
Deferred Conviction or Pre-Trial Diversion Unchanged 126 95 0 Form and Instruction 10 Deferred Conviction or Pre-Trial Diversion
Electronic Transfer of Funds (ETF) Authorization Unchanged 562 141 0 Form and Instruction 28 Electronic Transfer of Funds (ETF) Authorization
Entity Registration (Initial) Unchanged 35915 35915 0 Form and Instruction 24 Entity Registration (Initial)
Entity Registration (Renewal & Update) Unchanged 15461 1237 0 Form and Instruction 25 Entity Registration (Renewal & Update)
Exclusion/Debarment Unchanged 2402 1802 0 Form and Instruction 14 Exclusion/Debarment
Government Administrative Unchanged 2682 2012 0 Form and Instruction 15 Government Administrative
Health Plan Action Unchanged 561 421 0 Form and Instruction 16 Health Plan Action
Injunction Unchanged 10 8 0 Form and Instruction 12 Injunction
Medical Malpractice Payment Unchanged 14193 10645 0 Form and Instruction 2 Medical Malpractice Payment
Nolo Contendere (no contest) plea Unchanged 63 47 0 Form and Instruction 11 Nolo Contendere (no contest) plea
One Time Query for an Individual Unchanged 986552 78924 0 Form and Instruction 17 One Time Query for an Individual
One Time Query for an Organization Unchanged 18892 1511 0 Form and Instruction 18 One Time Query for an Organization
Peer Review Organization Unchanged 10 8 0 Form and Instruction 5 Peer Review Organization
Professional Society Unchanged 71 53 0 Form and Instruction 8 Professional Society
Request for Secretarial Review Modified 83 664 0 Form and Instruction 23 Dispute Resolution
Self-Query on an Individual Unchanged 154824 65026 0 Form and Instruction 19 Self-Query on an Individual
Self-Query on an Organization Unchanged 1095 460 0 Form and Instruction 20 Self-Query on an Organization
State Licensure Unchanged 28700 21525 0 Form and Instruction 3 State Licensure
Subject Statement and Dispute Unchanged 3347 2510 0 Form and Instruction 22 Subject Statement and Dispute
Title IV Clinical Privileges Actions Unchanged 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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