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U.S. Department of Health and Human Services

Radiation-Emitting Products

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Attestation Form: Attestation Regarding Requirements of the Mammography Quality Standards Act

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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

 

_____________________

Date signed

 

Facility Name:  _____________________________________

Facility Address: _____________________________________

(including zip code) _____________________________________ 

   _____________________________________

 

 

Facility ID Number (from the facility’s MQSA certificate: _____________