Criminal Conviction (Guilty Plea or Trial)

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⚠️ Notice: This information collection may be referencing outdated material.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 9 Criminal Conviction (Guilty Plea or Trial) Form and Instruction
9 Criminal Conviction (Guilty Plea or Trial) 9 CriminalConvictionIndivAndOrgReport.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Criminal Conviction (Guilty Plea or Trial)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	9	Criminal Conviction (Guilty Plea or Trial)	9 CriminalConvictionIndivAndOrgReport.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,245	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,245	1,222	1,023
Annual IC Time Burden (Hours)	981	214	767
Annual IC Cost Burden (Dollars)	0	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.