Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Anesthesis Removed 0 0 0 Form and Instruction 0917-0009-8 0917-0009-8, Anesthesia Privileges Request Form
Audiology Removed 0 0 0 Form and Instruction 0917-0009-12 OMB No. 0917-0009-12, Audiology Privileges Request Form
Dental Privileges Removed 0 0 0 Form and Instruction 0917-0009-9 0917-0009-9, Dental Privleges Request Form
Indian Health Service Medical Staff Credentials and Privileges Files Removed 0 0 0 Form and Instruction 0917-0009-1 Application for Medical Staff Appointment and/or Privileges
Initial Application to Medical Staff with Signature Documents New 1200 900 0 Form and Instruction 0917-0009 IHS Medical Staff - Initial Application
Medical Privileges Request Form Removed 0 0 0 Form and Instruction 0917-0009-4 0917-0009-4, Medical Privileges Request Form
OB-GYN Removed 0 0 0 Form and Instruction 0917-0009-5 0917-0009-5, OB-GYN Privileges Form
Pathology Removed 0 0 0 Form and Instruction 0917-009-15 OMB No. 0917-0009-15, Pathology Privileges Request Form
Podiatry Removed 0 0 0 Form and Instruction 0917-0009-13 OMB Form No. 0917-0009-14, Podiatric Privileges Request Form
Psychiatry Removed 0 0 0 Form and Instruction 0917-0009-7 0917-0009-7, Psychiatric Privileges Request Form
Psychology Removed 0 0 0 Form and Instruction 0917-0009-11 OMB 0917-0009-11, Psychology Privileges Request Form
Radiology Removed 0 0 0 Form and Instruction 0917-0009-14 OMB No. 0917-0009-14, Radiolgy Privileges Request Form
Reaapointment Request Removed 0 0 0 Form and Instruction 0917-0009-3 0917-0009-3, Reappointment Request Form
Reappointment Application New 1500 500 0 Form and Instruction 0917-0009 IHS MEDICAL STAFF - REAPPOINTMENT APPLICATION
Reference Letter Removed 0 0 0 Form and Instruction 0917-0009-2 0917-0009-2, References Form
Surgery Removed 0 0 0 Form and Instruction 0917-0009-6 0917-0009-6, Surgical Privileges Request Form
Total burden requested under this ICR: 2700 1400 0  
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