Information Collection

Initial Application to Medical Staff with Signature Documents

IC 240117 under ICR 202307-0917-001 · OMB 0917-0009.

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
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
OMB 0917-0009 Supporting Statement 2.27.20.docx SSA	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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
	Change Due to Adjustment in Agency Estimate	Previously Approved
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.