Criminal Conviction (Guilty Plea or Trial)

National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners: 45 CFR Part 60 Regulations and Forms

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).pdf Criminal Conviction (Guilty Plea or Trial).pdf Form and Instruction
9 Criminal Conviction (Guilty Plea or Trial).pdf Criminal Conviction (Guilty Plea or Trial).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).pdf	Criminal Conviction (Guilty Plea or Trial).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title: System of Record Notice 09-15-0054	FR Citation: 88 FR 17854

Number of Respondents: 1,385	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	1,385	-472	1,857
Annual IC Time Burden (Hours)	736	-146	882
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.