Information Collection

Initial Application to Medical Staff with Signature Documents

IC 240117 under ICR 202002-0917-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Initial Application to Medical Staff with Signature Documents Form and Instruction
0917-0009 IHS Medical Staff - Initial Application Final - Initial Application OMB No 0917-0009 - 2020 - JW.pdf Form and Instruction
OMB 0917-0009 Supporting Statement 2.27.20.docx SSA IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Initial Application to Medical Staff with Signature Documents	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

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	IHS Medical Staff - Initial Application	Final - Initial Application OMB No 0917-0009 - 2020 - JW.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	900	900
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA	OMB 0917-0009 Supporting Statement 2.27.20.docx	02/27/2020

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