Information Collection

Pre-Application MD APP

IC 261326 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 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

IC Title:

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	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 %

table that charts list of burden
	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

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.