Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Affiliation Verification New 4225 1056 0 Form and Instruction 0917-0009 Affiliation Verification
Credentialing by Proxy Intake Form New 250 63 0 Form and Instruction 0917-0009 Cred by Proxy
Education Verification New 3289 822 0 Form and Instruction 0917-0009 Education Verification
Indian Health Service (IHS) Conditions of Application and Release New 3840 320 0 Form and Instruction 0917-0009 Conditions of Application and Release
Indian Health Service Statement of Health New 878 73 0 Form and Instruction 0917-0009 Statement of Health
Initial Application New 878 878 0 Form and Instruction 0917-0009 Initial App
Initial Application to Medical Staff with Signature Documents Removed 0 0 0 Form and Instruction 0917-0009 IHS Medical Staff - Initial Application
Malpractice Verification New 2535 634 0 Form and Instruction 0917-0009 Malpractice Verification
Peer Reference Verification New 6180 1545 0 Form and Instruction 0917-0009 Peer Reference Form
Pre-Application MD APP New 500 250 0 Form and Instruction 0917-0009 Pre-Application MD App
Reappointment Application New 2212 1106 0 Form and Instruction 0917-0009 Reappointment App
Reappointment Application Removed 0 0 0 Form and Instruction 0917-0009 IHS MEDICAL STAFF - REAPPOINTMENT APPLICATION
Total burden requested under this ICR: 24787 6747 0  
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