FORM APPROVED OMB
NO. 0920-0576 EXP
DATE xx/xx/xxxx
Administrative Review
An entity or an individual may request administrative review of a decision denying or revoking certification of registration (42 CFR 73.20). This request must be made in writing and within 30 calendar days after the adverse decision. This request should include a statement of the factual basis for the review.
Public Reporting Burden
Public reporting
burden of providing this information is estimated to average 4 hours
per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information.
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. Send documents regarding this
burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to
CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74,
Atlanta, Georgia 30333; ATTN: PRM (0920-0576).
| File Type | application/msword |
| Author | shari steinberg |
| Last Modified By | CDC User |
| File Modified | 2012-06-15 |
| File Created | 2012-06-15 |