Form 27 State Licensing Board Data Request

NPDB Data Request

OMB Number: 0915-0126, Expiration Date: 04/30/2024, Public Burden Statement: The NPDB is a web-based repository of reports containing information on medical malpractice payments and certain adverse actions related to health care
practitioners, providers, and suppliers. Established by Congress in 1986, it is a workforce tool that prevents practitioners from moving state-to-state without disclosure or discovery of previous damaging performance. The statutes and
regulations that govern and maintain NPDB operations include: Title IV of Public Law 99-660, Health Care Quality Improvement Act (HCQIA) of 1986, Section 1921 of the Social Security Act, Section 1128E of the Social Security Act, and Section
6403 of the Patient Protection and Affordable Care Act of 2010. The NPDB regulations implementing these laws are codified at 45 CFR Part 60. 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 0915-0126 and it is valid until XX/XX/202X. This information collection is mandatory (45 CFR Part 60).
45 CFR Section 60.20 provides information on the confidentiality of the NPDB. Information reported to the NPDB is considered confidential and shall not be disclosed outside of HHS, except as specified in Sections 60.17, 60.18, and 60.21.
Public reporting burden for this collection of information is estimated to average 10.5 hours 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.

Instructions: Please complete the spreadsheet for all professions listed on the Compliance Review Summary page. Include all adverse actions taken during the compliance review period that are reportable to the National Practitioner
Data Bank (NPDB) – refer to “Reporting State Licensure and Certification Actions” (https://www.npdb.hrsa.gov/resources/aboutGuidebooks.jsp?page=EStateLicensureActions.jsp) in the NPDB Guidebook. If no reportable actions were
taken, add the Profession Name and "No Actions" under Action Type. Save the completed spreadsheet and upload it on the Compliance Review Summary page.

#

First Name

Last Name

MI

Suffix

License Number

State Issued

Profession Name

Example

John

Doe

H

Jr

HA‐123A

AK

Healthcare Assistant Revocation

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39

Type of Action

Action Date

Comments/Details

1/2/2013

License revoked for failure to comply with terms of board order AK‐XY‐
1234.