Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Anesthesis Modified 15 15 0 Form NA Anesthesia Privileges Request Form
Audiology Modified 7 1 0 Form NA Audiologic Privileges Request Form
Dental Privileges Modified 150 50 0 Form NA Dental Privileges Request Form
Indian Health Service Medical Staff Credentials and Privileges Files Modified 570 570 0 Form and Instruction NA Application for Medical Staff Appointment and/or Privileges
Internal Medicine/Family Practice Privilege Modified 325 325 0 Form NA Medical Privileges Request Form
OB-GYN Modified 20 20 0 Form NA OB-GYN Privileges Request Form
Optometry Modified 21 7 0 Form NA Optometric Privileges Request Form
Pathology Modified 3 1 0 Form NA Pathology Privileges Request Form
Podiatry Modified 7 1 0 Form NA podiatric Privileges Request Form
Psychiatry Modified 13 13 0 Form NA Psychiatric Privileges Request Form
Psychology Modified 30 5 0 Form NA Psychology Privileges Request Form
Radiology Modified 8 3 0 Form NA Radiology Privileges Request Form
Reaapointment Request Modified 190 190 0 Form NA Request for Reappointment To The Medical Staff
Reference Letter Modified 1710 570 0 Form NA Suggested Format for Letter to Be Sent to References of Applicants or For Telephone Solicitation of References
Surgery Modified 20 20 0 Form NA Surgical Privileges Request Form
Total burden requested under this ICR: 3089 1791 0  
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