Information Collection

Audiology

IC 46253 under ICR 201306-0917-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 0917-0009-12 Audiology Form and Instruction
0917-0009-12 OMB No. 0917-0009-12, Audiology Privileges Request Form Audiologic_privileges_request_form[1].doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0917-0009-12	OMB No. 0917-0009-12, Audiology Privileges Request Form	Audiologic_privileges_request_form[1].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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	7	7
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.