View Information Collection (IC)

View Information Collection (IC)

IC Title:	Initial Application to Medical Staff with Signature Documents	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	IHS Medical Staff - Initial Application	Final - Initial Application OMB No 0917-0009 - 2020 - JW.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

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 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	1,200	0	1,200	0	0	0
Annual IC Time Burden (Hours)	900	0	900	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

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.