Information Collection

Audiology

IC 46253 under ICR 201004-0917-003 · OMB 0917-0009.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0009 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Audiology	Form
Audiologic Privileges Request Form Audiologic privileges request form.doc	Form

IC Title:

Audiology

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	NA	Audiologic Privileges Request Form	Audiologic privileges request form.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Report of Modified or Altered Systems Medical Staff Credentials and Privileges Record

FR Citation: 71 FR 16320

Number of Respondents: 7

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	7	1	6
Annual IC Time Burden (Hours)	1	0	1
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.