Information Collection

Pre-Application MD APP

IC 261326 under ICR 202307-0917-001 · OMB 0917-0009.

Documents and Forms

Document Name Document Type
Form 0917-0009 Pre-Application MD APP Form and Instruction
0917-0009 Pre-Application MD App Pre-Application MD-App - FINAL 4.13.23.pdf Form and Instruction
0917-0009 Pre Application MD App Pre-Application MD-App - FINAL 07 11 24.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Pre-Application MD APP	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	Pre Application MD App	Pre-Application MD-App - FINAL 07 11 24.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Indian Health Service Medical Staff Credentials and Privileges Records	FR Citation: 88 FR 33151

Number of Respondents: 500	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	500	500
Annual IC Time Burden (Hours)	250	250
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.