INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with a covered Federal action. Use the SF-LLL-A Continuation Sheet for additional information if the space on the form is inadequate. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information. 1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. 2. Identify the status of the covered Federal action. 3. Identify the appropriate classification of this report. If this is a followup report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action. 4. Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants. 5. If the organization filing the report in item 4 checks "Subawardee", then enter the full name, address, city, state and zip code of the prime Federal recipient. Include Congressional District, if known. 6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard. 7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments. 8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1. (e.g., Request for Proposal (RFP) number; Invitation for Bid (IFB) number, grant announcement number, the contract, grant, or loan award number, the application/proposal control number assigned by the Federal agency). Include prefixes, e.g., "RFP-DE-90-001." 9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5. 10. (a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting entity identified in item 4 to influence the covered Federal action. (b)Enter the full names of the individual(s) performing services, and include full address if different from 10 (a). Enter Last Name, First Name, and Middle Initial (MI). 11. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (item 4) to the lobbying entity (item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check all boxes that apply. If this is a material change report, enter the cumulative amount of payment made or planned to be made. 12. Check the appropriate box(es). Check all boxes that apply. If payment is made through an in-kind contribution, specify the nature and value of the in-kind payment. 13. Check the appropriate box(es). Check all boxes that apply. If other, specify nature. 14. Provide a specific and detailed description of the services that the lobbyist has performed, or will be expected to perform, and the date(s) of any services rendered. Include all preparatory and related activity, not just time spent in actual contact with Federal officials. Identify the Federal official(s) or employee(s) contacted or the officer(s), employee(s), or Member(s) of Congress that were contacted. 15. Check whether or not a SF-LLL-A Continuation Sheet(s) is attached. 16. The certifying official shall sign and date the form, print his/her name, title, and telephone number. Public reporting burden for this collection of information is estimated to average 30 mintues per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, D.C. 20503. DISCLOSURE OF LOPBYING ACTIVITIES CONTINUATION SHEET Approved by OMB 0348-0046 Reporting Entity. Page Authorized for Local Reproduction (a) Act means The Health Care Quality Improvement Act of 1986, as amended (42 U.S.C. 11101-11152). (b) Claim of medical malpractice means a written claim or demand for payment based on a physician's, dentist's or other health care practitioner's furnishing (or failure to furnish) health care services and includes the filing of a complaint or administrative tort claim under the Federal Tort Claims Act, 28 USC 1346(b), 2671-2680. (c) Clinical privileges means privileges granted by a health care entity to individuals to furnish health care. (d) Dentist means a doctor of dental surgery or dental medicine legally authorized to practice dental surgery or dentistry by a State (or any individual who, without authority, holds himself or herself out to be so authorized). (e) Director means the duly appointed director of a Department of Veterans Affairs facility or any individual with authorization to act for that person in the director's absence. (f) Health care entity means a hospital, domiciliary, outpatient clinic or any other entity that provides health care services. (g) Other health care practitioner means an individual other than a physician or dentist who is licensed or otherwise authorized by a State to provide health care services. (h) Physician means a doctor of medicine or osteopathy legally authorized to practice medicine or surgery by a State (or any individual who, without authority, holds himself or herself out to be so authorized). (1) Professional review action means a recommendation by a professional review body (with at least a majority vote) to affect adversely the clinical privileges of a physician or dentist and which is taken as a result of a professional review activity based on the competence or professional conduct of an individual physician or dentist in cases in which such conduct affects or could affect adversely the health or welfare of a patient or patients. An action is not considered to be based on the competence or professional conduct of a physician or dentist if the action is primarily based on: (1) A physician's or dentist's association with, administrative supervision of, delegation of authority to, support for, or training of, a member or members of a particular class of health care practitioner or professional, or (2) Any other matter that does not relate to the competence or professional conduct of a physician or dentist in his/her practice at a Department of Veterans Affairs health care facility. (j) Professional review activity means an activity with respect to an individual physician or dentist to establish a recommendation regarding: (1) Whether the physician or dentist may have clinical privileges with respect to the medical staff of the facility; (2) The scope or conditions of such privileges or appointment; or (3) Change or modification of such privileges. (k) State means the fifty States, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, the Northern Mariana Islands, and any other territories or possessions of the United States. (1) State Licensing Board means, with respect to a physician, dentist or other health care practitioner in a State, the agency of the State which is primarily responsible for the licensing of the physician, dentist or practitioner to furnish health care services. $46.2 Purpose. The National Practitioner Data Bank, authorized by the Act and administered by the Department of Health and Human Services, was established for the purpose of collecting and releasing certain information concerning physicians, dentists and other health care practitioners. The Act mandates that the Department of Health and Human Services seek to enter into a Memorandum of Understanding with the Department of Veterans Affairs (VA) for the purpose of having VA participate in the National Practitioner Data Bank. Such a Memorandum of Understanding has been established. Pursuant to the Memorandum of Understanding, VA will obtain information from the Data Bank concerning physicians, dentists and other health care practitioners who provide or seek to provide health care services at VA facilities and will also report information regarding malpractice payments and adverse clinical privileges actions to the Data Bank. This part essentially restates or interprets provisions of that Memorandum of Understanding and constitutes the policy of VA for participation in the National Practitioner Data Bank. Subpart B-National Practitioner Data Bank Reporting $46.3 Malpractice payment reporting. (a) VA will file a report with the National Practitioner Data Bank, in accordance with regulations at 45 CFR part 60, subpart B, as applicable, regarding any payment for the benefit of a physician, dentist, or other licensed health care practitioner which was made as the result of a settlement or judgment of a claim of medical malpractice. The report will identify the physician, dentist, or other licensed health care practitioner for whose ben efit the payment is made. It is intended that the report be filed within 30 days of the date payment is made. (This may not be possible in all cases since the Department of Veterans Affairs is not always notified of such payments within sufficient time to provide the report within 30 days of payment.) The report will provide the following information: (1) With respect to the physician, dentist or other licensed health care practitioner for whose benefit the payment is made (i) Name, (ii) Work address, (iii) Home address, if known, (iv) Social Security number, if known, and if obtained in accordance with section 7 of the Privacy Act of 1974, (v) Date of birth, (vi) Name of each professional school attended and year of graduation, (vii) For each professional license: the license number, the field of licensure, and the State in which the license is held, (viii) Drug Enforcement Administration registration number, if applicable and known, (ix) Name of each health care entity with which affiliated, if known; (2) With respect to the reporting VA facility (i) Name and address of the reporting facility, (ii) Name, title and telephone number of the responsible official submitting the report on behalf of the Federal government, (iii) Relationship of facility to the physician, dentist or other health care practitioner being reported; (3) With respect to the judgment or settlement resulting in the payment (i) Where an action or claim has been filed with an adjudicative body, identification of the adjudicative body and the case number, (ii) Date or dates on which the act(s) or omission(s) which gave rise to the action or claim occurred, (iii) Date of judgment or settlement, (iv) Amount paid, date of payment, and whether payment is for a judgment or a settlement, (v) Description and amount of judgment or settlement and any conditions attached thereto, including terms of payment, (vi) A description of the acts or omissions and injuries or illnesses upon which the action or claim was based, and or (vii) Classification of the acts omissions in accordance with a reporting code adopted by the Secretary of Health and Human Services. (b) A copy of the report referred to in paragraph (a) of this section will also be filed with the State Licensing Board in the State(s) in which the practitioner is licensed and with the State Licensing Board in the State in which the act or omission occurred upon which the medical malpractice claim was based. (c) Payment will be considered to have been made for the benefit of a physician, dentist or other licensed health care practitioner only if the Director of the facility at which the act or omission occurred upon which the malpractice claim was based, affirms a conclusion (of at least a majority) of a peer review body that payment was related to substandard care, professional incompetence or professional misconduct on the part of the physician, dentist or other licensed health care practitioner. For purposes of this part, a peer review body shall have a minimum of three individuals appointed by the facility Director (including at least one member of the profession/occupation of the practitioner(s) whose actions are under review). The conclusions of the peer review body shall, at a minimum, be based on review of documents pertinent to the claim and, to the extent practicable, shall include information collected directly from the individual for whose benefit payment was made. Prior to a determination by the Director, the individual under consideration for reporting shall be afforded the opportunity for discussion with the facility Director and any other individuals designated by the facility Director. § 46.4 Clinical privileges actions reporting. (a) VA will file an original and one copy of an adverse action report with the State Licensing Board in the State in which the facility is located in ac cordance with regulations at 45 CFR part 60, subpart B, as applicable, regarding any of the following actions: (1) An action of a Director after consideration of a professional review action that, for a period longer than 30 days, adversely affects (by reducing, restricting, suspending, revoking, or failing to renew) the clinical privileges of a physician or dentist relating to possible incompetence or improper professional conduct. (2) Acceptance of the surrender of clinical privileges or any restriction of such privileges by a physician or dentist either while under investigation by the health care entity relating to possible incompetence or improper professional conduct, or in return for not conducting such an investigation or proceeding. (b) The report specified in paragraph (a) of this section will provide the following information (1) With respect to the physician or dentist: (i) Name, (ii) Work address, (iii) Home address, if known, (iv) Social Security number, if known (and if obtained in accordance with section 7 of the Privacy Act of 1974), (v) Date of birth, (vi) Name of each professional school attended and year of graduation, (vii) For each professional license: The license number, the field of licensure, and the name of the State in which the license is held, (viii) Drug Enforcement Administration registration number, if applicable and known, (ix) A description of the acts or omissions or other reasons for privilege loss, or, if known, for surrender, (x) Action taken, date action was made final, length of action, and effective date of the action; (2) With respect to the VA facility(i) Name and address of the reporting facility, (ii) Name, title, and telephone number of the responsible official submitting the report. (c) A copy of the report referred to in paragraph (a) of this section will also be filed with the State Licensing Board in the State(s) in which the practi |