Indian Health Service Medical Staff Credentials and Privileges Files

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Application for Medical Staff Appointment and/or Privileges	Form and Instruction	Modified	Available
Pathology Privileges Request Form	Form	Modified	Available
Radiology Privileges Request Form	Form	Modified	Available
podiatric Privileges Request Form	Form	Modified	Available
Audiologic Privileges Request Form	Form	Modified	Available
Psychology Privileges Request Form	Form	Modified	Available
Optometric Privileges Request Form	Form	Modified	Available
Dental Privileges Request Form	Form	Modified	Available
Anesthesia Privileges Request Form	Form	Modified	Available
Psychiatric Privileges Request Form	Form	Modified	Available
Surgical Privileges Request Form	Form	Modified	Available
OB-GYN Privileges Request Form	Form	Modified	Available
Medical Privileges Request Form	Form	Modified	Available
Request for Reappointment To The Medical Staff	Form	Modified	Repair queued
Suggested Format for Letter to Be Sent to References of Applicants or For Telephone Solicitation of References	Form	Modified	Available
30 day IHS MSCPF 3-31-10.pdf	Supplementary Document	Uploaded 2010-04-23	Available
60 day 12-4-09.pdf	Supplementary Document	Uploaded 2010-03-23	Available
OMB Credentials Supporting Statement.docm	Supporting Statement A	Uploaded 2010-04-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6568	Indian Health Service Medical Staff Credentials and Privileges Files	Form and Instruction	Modified	Application for Medical Staff Appointment and/or Privileges
46256	Pathology	Form	Modified	Pathology Privileges Request Form
46255	Radiology	Form	Modified	Radiology Privileges Request Form
46254	Podiatry	Form	Modified	podiatric Privileges Request Form
46253	Audiology	Form	Modified	Audiologic Privileges Request Form
46252	Psychology	Form	Modified	Psychology Privileges Request Form
46251	Optometry	Form	Modified	Optometric Privileges Request Form
46250	Dental Privileges	Form	Modified	Dental Privileges Request Form
46249	Anesthesis	Form	Modified	Anesthesia Privileges Request Form
46248	Psychiatry	Form	Modified	Psychiatric Privileges Request Form
46247	Surgery	Form	Modified	Surgical Privileges Request Form
46246	OB-GYN	Form	Modified	OB-GYN Privileges Request Form
46245	Internal Medicine/Family Practice Privilege	Form	Modified	Medical Privileges Request Form
46244	Reaapointment Request	Form	Modified	Request for Reappointment To The Medical Staff
46243	Reference Letter	Form	Modified	Suggested Format for Letter to Be Sent to References of Applicants or For Telephone Solicitation of References

ICR Details

OMB Control No: 0917-0009	ICR Reference No: 201004-0917-003
Status: Historical Active	Previous ICR Reference No: 200611-0917-002
Agency/Subagency: HHS/IHS	Agency Tracking No:
Title: Indian Health Service Medical Staff Credentials and Privileges Files
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/03/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/30/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2013	36 Months From Approved	06/30/2010
Responses	3,089	0	3,265
Time Burden (Hours)	1,791	0	1,929
Cost Burden (Dollars)	0	0	0

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Abstract: Information is needed and used by the Indian Health Service Medical Staff to meet JCAHO accreditation requirements and to review, evaluate and verify the credentials, training, and experience of applicants applying for medical staff privileges at IHS health care facilities.

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Authorizing Statute(s): US Code: 25 USC 13 Name of Law: Synder Act
   US Code: 42 USC 2001-2004 Name of Law: IHS Transfer Act
   US Code: 25 USC 450 Name of Law: Indian Self-Determination and Education Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 63754	12/04/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 16139	03/31/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 15

table that charts list of burden

IC Title	Form No.	Form Name
Anesthesis	NA	Anesthesia Privileges Request Form
Audiology	NA	Audiologic Privileges Request Form
Dental Privileges	NA	Dental Privileges Request Form
Indian Health Service Medical Staff Credentials and Privileges Files	NA	Application for Medical Staff Appointment and/or Privileges
Internal Medicine/Family Practice Privilege	NA	Medical Privileges Request Form
OB-GYN	NA	OB-GYN Privileges Request Form
Optometry	NA	Optometric Privileges Request Form
Pathology	NA	Pathology Privileges Request Form
Podiatry	NA	podiatric Privileges Request Form
Psychiatry	NA	Psychiatric Privileges Request Form
Psychology	NA	Psychology Privileges Request Form
Radiology	NA	Radiology Privileges Request Form
Reaapointment Request	NA	Request for Reappointment To The Medical Staff
Reference Letter	NA	Suggested Format for Letter to Be Sent to References of Applicants or For Telephone Solicitation of References
Surgery	NA	Surgical Privileges Request Form

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,089	3,265	0	-176	0	0
Annual Time Burden (Hours)	1,791	1,929	0	-138	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Cutting Redundancy

Short Statement: The forms were made more streamline.

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Annual Cost to Federal Government: $182,500

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/30/2010

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