Information Collection

Title IV Clinical Privileges Actions

IC 206486 under ICR 202101-0915-002 · OMB 0915-0126.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0126 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 7 Title IV Clinical Privileges Actions	Form and Instruction
7 Title IV Clinical Privileges Actions_0915-0126.pdf Title IV Clinical Privileges Actions_0915-0126.pdf	Form and Instruction
7 Title IV Clinical Privileges Actions_0915-0126.pdf Title IV Clinical Privileges Actions_0915-0126.pdf	Form and Instruction

IC Title:

Title IV Clinical Privileges Actions

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	7	Title IV Clinical Privileges Actions_0915-0126.pdf	Title IV Clinical Privileges Actions_0915-0126.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 978

Number of Respondents for Small Entity: 100

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	978	280	698
Annual IC Time Burden (Hours)	734	210	524
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.