Indian Health Service Medical Staff Credentials and Privileges Files

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0917-0009-1 Application for Medical Staff Appointment and/or Privileges	Form and Instruction	Modified	Available
Form 0917-009-15 OMB No. 0917-0009-15, Pathology Privileges Request Form	Form and Instruction	Modified	Available
Form 0917-0009-14 OMB No. 0917-0009-14, Radiolgy Privileges Request Form	Form and Instruction	Modified	Available
Form 0917-0009-13 OMB Form No. 0917-0009-14, Podiatric Privileges Request Form	Form and Instruction	Modified	Available
Form 0917-0009-12 OMB No. 0917-0009-12, Audiology Privileges Request Form	Form and Instruction	Modified	Available
Form 0917-0009-11 OMB 0917-0009-11, Psychology Privileges Request Form	Form and Instruction	Modified	Available
Optometric Privileges Request Form	Form	Removed	Available
Form 0917-0009-9 0917-0009-9, Dental Privleges Request Form	Form and Instruction	Modified	Available
Form 0917-0009-8 0917-0009-8, Anesthesia Privileges Request Form	Form and Instruction	Modified	Available
Form 0917-0009-7 0917-0009-7, Psychiatric Privileges Request Form	Form and Instruction	Modified	Available
Form 0917-0009-6 0917-0009-6, Surgical Privileges Request Form	Form and Instruction	Modified	Available
Form 0917-0009-5 0917-0009-5, OB-GYN Privileges Form	Form and Instruction	Modified	Available
Form 0917-0009-4 0917-0009-4, Medical Privileges Request Form	Form and Instruction	Modified	Available
Form 0917-0009-3 0917-0009-3, Reappointment Request Form	Form and Instruction	Modified	Available
Form 0917-0009-2 0917-0009-2, References Form	Form and Instruction	Modified	Available
60 Day FR Publication 04-02-13.pdf	Supplementary Document	Uploaded 2013-05-14	Available
OMB 0917-0009 Supporting Statement 5-23-2013.docm	Supporting Statement A	Uploaded 2013-06-05	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 and Instruction	Modified	OMB No. 0917-0009-15, Pathology Privileges Request Form
46255	Radiology	Form and Instruction	Modified	OMB No. 0917-0009-14, Radiolgy Privileges Request Form
46254	Podiatry	Form and Instruction	Modified	OMB Form No. 0917-0009-14, Podiatric Privileges Request Form
46253	Audiology	Form and Instruction	Modified	OMB No. 0917-0009-12, Audiology Privileges Request Form
46252	Psychology	Form and Instruction	Modified	OMB 0917-0009-11, Psychology Privileges Request Form
46251	Optometry	Form	Removed	Optometric Privileges Request Form
46250	Dental Privileges	Form and Instruction	Modified	0917-0009-9, Dental Privleges Request Form
46249	Anesthesis	Form and Instruction	Modified	0917-0009-8, Anesthesia Privileges Request Form
46248	Psychiatry	Form and Instruction	Modified	0917-0009-7, Psychiatric Privileges Request Form
46247	Surgery	Form and Instruction	Modified	0917-0009-6, Surgical Privileges Request Form
46246	OB-GYN	Form and Instruction	Modified	0917-0009-5, OB-GYN Privileges Form
46245	Medical Privileges Request Form	Form and Instruction	Modified	0917-0009-4, Medical Privileges Request Form
46244	Reaapointment Request	Form and Instruction	Modified	0917-0009-3, Reappointment Request Form
46243	Reference Letter	Form and Instruction	Modified	0917-0009-2, References Form

ICR Details

OMB Control No: 0917-0009	ICR Reference No: 201306-0917-001
Status: Historical Active	Previous ICR Reference No: 201004-0917-003
Agency/Subagency: HHS/IHS	Agency Tracking No: 18529
Title: Indian Health Service Medical Staff Credentials and Privileges Files
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/16/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/18/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2016	36 Months From Approved	08/31/2013
Responses	3,068	0	3,089
Time Burden (Hours)	1,784	0	1,791
Cost Burden (Dollars)	0	0	0

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Abstract: National health care standards developed by the Center for Medicare and Medicaid Services (CMS), the Joint Commission and other accrediting organizations require health care facilities to review, evaluate and verify the credentials, training and experience of medical staff applicants prior to granting medical staff privileges. To meet these standards, IHS health care facilities require all medical staff applicants to provide information concerning their education, training, licensure, and work experience and any adverse disciplinary actions taken against them. This information is then verified with references supplied by the applicant and may include: former employers, educational institutions, licensure and certification boards, the American Medical Association, the Federation of State Medical Boards, the National Practitioner Data Bank, and the applicants themselves.

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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:
	78 FR 19721	04/02/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 36198	06/17/2013
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 14

table that charts list of burden

IC Title	Form No.	Form Name
Anesthesis	0917-0009-8	0917-0009-8, Anesthesia Privileges Request Form
Audiology	0917-0009-12	OMB No. 0917-0009-12, Audiology Privileges Request Form
Dental Privileges	0917-0009-9	0917-0009-9, Dental Privleges Request Form
Indian Health Service Medical Staff Credentials and Privileges Files	0917-0009-1	Application for Medical Staff Appointment and/or Privileges
Medical Privileges Request Form	0917-0009-4	0917-0009-4, Medical Privileges Request Form
OB-GYN	0917-0009-5	0917-0009-5, OB-GYN Privileges Form
Optometry	NA	Optometric Privileges Request Form
Pathology	0917-009-15	OMB No. 0917-0009-15, Pathology Privileges Request Form
Podiatry	0917-0009-13	OMB Form No. 0917-0009-14, Podiatric Privileges Request Form
Psychiatry	0917-0009-7	0917-0009-7, Psychiatric Privileges Request Form
Psychology	0917-0009-11	OMB 0917-0009-11, Psychology Privileges Request Form
Radiology	0917-0009-14	OMB No. 0917-0009-14, Radiolgy Privileges Request Form
Reaapointment Request	0917-0009-3	0917-0009-3, Reappointment Request Form
Reference Letter	0917-0009-2	0917-0009-2, References Form
Surgery	0917-0009-6	0917-0009-6, 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	3,068	3,089	0	0	-21	0
Annual Time Burden (Hours)	1,784	1,791	0	0	-7	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $202,500

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]? No

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: 06/18/2013

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