Attestation Form: Attestation Regarding Requirements of the Mammography Quality Standards Act
ATTESTATION REGARDING REQUIREMENTS OF
THE MAMMOGRAPHY QUALITY STANDARDS ACT
Attestation must include as much of the following information as possible:
Name of the institution/facility where the applicable training or mammography reading/interpreting, or other activity, took place; name of the course(s) or training (where applicable); the attendance, reading/interpreting, or other activity dates; and the supervising/responsible person (where applicable) for the institution/facility.
Please provide these details in the space below. Attach additional sheets if necessary.
I, ________________________, attest that, to the best of my knowledge and my belief, the following information provided in this declaration is true and correct. I understand that FDA may request additional information to substantiate the statements made in this declaration: ______________________________________________________________________
I understand that knowingly providing false information in a matter within the jurisdiction of an agency of the United States could result in criminal liability, punishable by up to $10,000 fine and imprisonment of up to five years, or civil liability under the MQSA, or both.
Attester’s Signature and Title
Facility Name: _____________________________________
Facility Address: ____________________________________
(including zip code) __________________________________
Facility ID Number (from the facility’s MQSA certificate: _____________