Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal

National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners: Regulations and Forms

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0126 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal Form and Instruction
1 Correction, Revision to Action, Correction of Revision t 1.Correction,RevisiontoAction,Void,NoticeofAppeal.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal	1.Correction,RevisiontoAction,Void,NoticeofAppeal.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 38,785	Number of Respondents for Small Entity: 5,000

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	38,785	38,785
Annual IC Time Burden (Hours)	9,696	9,696
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.