Information Collection

Indian Health Service Medical Staff Credentials and Privileges Files

IC 6568 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⚠️ Notice: This information collection may be referencing outdated material.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
Indian Health Service Medical Staff Credentials and Privileges Files	Form and Instruction
Application for Medical Staff Appointment and/or Privile Application for Medical Staff Appointment and or Privileges.pdf	Form and Instruction

IC Title:

Indian Health Service Medical Staff Credentials and Privileges Files

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 and Instruction	NA	Application for Medical Staff Appointment and/or Privileges	Application for Medical Staff Appointment and or Privileges.pdf		No	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: The Report of an Altered System of Records Medical Staff Credentials and Privileges Records

FR Citation: 74 FR 173

Number of Respondents: 570

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	570	-30	600
Annual IC Time Burden (Hours)	570	-30	600
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.