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