Attestation Regarding Requirements of The Mammography Quality Standards Act (MQSA)
For those personnel who qualified under the interim regulations, the following attestation may be used to document initial training and initial experience, if the training was completed prior to 10/1/1994. This attestation may not be used to document state licensure or board certification.
Use the following language to create an attestation document. Attach additional sheets if necessary.
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, [Insert Name], 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:
[Insert details of initial training and/or initial experience]
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 $11,000 fine and imprisonment of up to five years, or civil liability under the MQSA, or both.
[Insert Attester’s Signature and Title]
[Insert Date Signed]
Facility Name: [Insert Facility Name]
Facility Address: [Insert Facility address, including zip code]
Facility ID Number: [Insert Facility MQSA ID Number from the facility’s MQSA certificate]