Form 1 Form - Agent Attestation

OMB # 0906-0028 Expiration Date XX/XX/202X
Public Burden Statement: The NPDB engages in compliance activities to ensure the
accuracy and completeness of the information in the NPDB. Through the Attestation
process, the NPDB can better determine which, hospitals, medical malpractice payers,
health plans, health centers and other eligible entities, are meeting the reporting,
querying, and confidentiality requirements, and which of these entities may require
additional outreach and assistance. The biennial Attestation process strengthens the
robustness of the data in the NPDB, improving the accuracy of the query responses for
entities with access to NPDB reports. 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 information
collection is 0906-0028 and it is valid until XX/XX/202X. This information collection is
voluntary. Public reporting burden for this collection of information is estimated to
average 1 hour per response, 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 14N136B, Rockville, Maryland, 20857 or
paperwork@hrsa.gov.

OMB # 0906-0028 Expiration Date XX/XX/202X

OMB # 0906-0028 Expiration Date XX/XX/202X

OMB # 0906-0028 Expiration Date XX/XX/202X