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pdfSTATE LICENSURE: Report Correction
To submit a correction to previously submitted report DCN 7930000076906084, complete all
necessary modifications in the form below, and press Submit to Data Bank. The report
entered here will replace the original report, so please ensure that all known data is entered in
its entirety. Failure to provide sufficient information to permit identification of a single subject
may result in the report being rejected, necessitating resubmission.
Do not print this page. A printable copy of your report submission will be provided after
submission.
OMB # 0915-0126 expiration date 05/31/16
Public Burden Statement: An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB
control number. The OMB control number for this project is 0915-0126. Public reporting
burden for this collection of information is estimated to average 15 minutes to complete
the forms, including the time for reviewing instructions, searching existing data sources,
and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers
Lane, Room 10-29, Rockville, Maryland, 20857.
STATE LICENSURE: Correction of Revision to Action
To submit a correction to previously submitted report DCN 7930000076906086, complete
all necessary modifications in the form below, and press Submit to Data Bank. The report
entered here will replace the original report, so please ensure that all known data is
entered in its entirety. Failure to provide sufficient information to permit identification of a
single subject may result in the report being rejected, necessitating resubmission.
Do not print this page. A printable copy of your report submission will be provided after
submission.
OMB # 0915-0126 expiration date 05/31/16
Public Burden Statement: An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB
control number. The OMB control number for this project is 0915-0126. Public reporting
burden for this collection of information is estimated to average 15 minutes to complete
the forms, including the time for reviewing instructions, searching existing data sources,
and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers
Lane, Room 10-29, Rockville, Maryland, 20857.
STATE LICENSURE: Revision to Action
To submit a revision to action on previously submitted report DCN 7930000076906084, enter
all report data for the action, and press Submit to Data Bank. Enter all known data in its
entirety. Failure to provide sufficient information to permit identification of a single subject may
result in the report being rejected, necessitating resubmission.
Do not print this page. A printable copy of your report submission will be provided after
submission.
OMB # 0915-0126 expiration date 05/31/16
Public Burden Statement: An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB
control number. The OMB control number for this project is 0915-0126. Public reporting
burden for this collection of information is estimated to average 15 minutes to complete
the forms, including the time for reviewing instructions, searching existing data sources,
and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers
Lane, Room 10-29, Rockville, Maryland, 20857.
Entity: ENTITY 1 (FAIRFAX, VA) | User: user
Sign Out
REPORT CERTIFICATION
Please provide the following information to void the action reported in DCN 7930000076907009 about subject DOE,
JOHN. A printable copy of your report submission will be provided after submission.
Notice: The unauthorized or unjustified removal of a report from the Data Bank is punishable under Federal Statute.
Void Reason
The report was erroneously submitted (e.g., wrong practitioner named; duplicate report, payment not
delivered; action never finalized).
The report was not required to be filed; the action does not meet the legal reporting criteria.
The action was reversed because the original action should never have been taken (e.g., overturned on
appeal).
Customer Use
This optional field may be used by the submitter to identify this transaction. This information is returned without
modification and only appears on the response returned to your organization.
Customer Use:
Certification
I certify that I am authorized to submit this transaction and that all information is true and correct to the best of my
knowledge.
Authorized Submitter's Name:
Authorized Submitter's Title:
Authorized Submitter's Phone:
Date:
Ext.
12/11/2014
This form will be submitted to the appropriate Data Bank. Note: You have not met your obligation under the law until the
submitted report is accepted by the Data Bank and a Report Verification is returned.
Submit to Data Bank
Return to Options
Entity: ENTITY 1 (FAIRFAX, VA) | User: user
Sign Out
REPORT CERTIFICATION
Please provide the following information to submit a notice that the action reported in DCN 7930000076907009 about
subject DOE, JOHN has been appealed. A printable copy of your report submission will be provided after submission.
Appeal Date
Date of Appeal:
(MM/DD/YYYY)
Customer Use
This optional field may be used by the submitter to identify this transaction. This information is returned without
modification and only appears on the response returned to your organization.
Customer Use:
Certification
I certify that I am authorized to submit this transaction and that all information is true and correct to the best of my
knowledge.
Authorized Submitter's Name:
Authorized Submitter's Title:
Authorized Submitter's Phone:
Date:
Ext.
12/11/2014
This form will be submitted to the appropriate Data Bank. Note: You have not met your obligation under the law until the
submitted report is accepted by the Data Bank and a Report Verification is returned.
Submit to Data Bank
Return to Options
| File Type | application/pdf |
| Author | Denise Nguyen |
| File Modified | 2014-12-11 |
| File Created | 2014-12-11 |