Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Anesthesis Modified 15 15 0 Form and Instruction 0917-0009-8 0917-0009-8, Anesthesia Privileges Request Form
Audiology Modified 7 1 0 Form and Instruction 0917-0009-12 OMB No. 0917-0009-12, Audiology Privileges Request Form
Dental Privileges Modified 150 50 0 Form and Instruction 0917-0009-9 0917-0009-9, Dental Privleges Request Form
Indian Health Service Medical Staff Credentials and Privileges Files Modified 570 570 0 Form and Instruction 0917-0009-1 Application for Medical Staff Appointment and/or Privileges
Medical Privileges Request Form Modified 325 325 0 Form and Instruction 0917-0009-4 0917-0009-4, Medical Privileges Request Form
OB-GYN Modified 20 20 0 Form and Instruction 0917-0009-5 0917-0009-5, OB-GYN Privileges Form
Optometry Removed 0 0 0 Form NA Optometric Privileges Request Form
Pathology Modified 3 1 0 Form and Instruction 0917-009-15 OMB No. 0917-0009-15, Pathology Privileges Request Form
Podiatry Modified 7 1 0 Form and Instruction 0917-0009-13 OMB Form No. 0917-0009-14, Podiatric Privileges Request Form
Psychiatry Modified 13 13 0 Form and Instruction 0917-0009-7 0917-0009-7, Psychiatric Privileges Request Form
Psychology Modified 30 5 0 Form and Instruction 0917-0009-11 OMB 0917-0009-11, Psychology Privileges Request Form
Radiology Modified 8 3 0 Form and Instruction 0917-0009-14 OMB No. 0917-0009-14, Radiolgy Privileges Request Form
Reaapointment Request Modified 190 190 0 Form and Instruction 0917-0009-3 0917-0009-3, Reappointment Request Form
Reference Letter Modified 1710 570 0 Form and Instruction 0917-0009-2 0917-0009-2, References Form
Surgery Modified 20 20 0 Form and Instruction 0917-0009-6 0917-0009-6, Surgical Privileges Request Form
Total burden requested under this ICR: 3068 1784 0  
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