Information Collection

Indian Health Service Medical Staff Credentials and Privileges Files

IC 6568 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⚠️ Notice: This information collection may be referencing outdated material.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 0917-0009-1 Indian Health Service Medical Staff Credentials and Privileges Files Form and Instruction
0917-0009-1 Application for Medical Staff Appointment and/or Privile IHS_Medi1 PDF.pdf www.ihs.gov/RiskManagement/index.cfm?module=dsp_rm_resources Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0917-0009-1	Application for Medical Staff Appointment and/or Privileges	IHS_Medi1 PDF.pdf	http://www.ihs.gov/RiskManagement/index.cfm?module=dsp_rm_resources	Yes	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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	570	570
Annual IC Time Burden (Hours)	570	570
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.