DEA/Federal Licensure

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 4 DEA/Federal Licensure Form and Instruction
4 DEA_Federal Licensure.pdf DEA_Federal Licensure.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	DEA/Federal Licensure	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	4	DEA_Federal Licensure.pdf	DEA_Federal Licensure.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: 555	Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	555	-45	600
Annual IC Time Burden (Hours)	416	-34	450
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.