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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.