View Information Collection Request (ICR) Package
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View Information Collection (IC) List
View Supporting Statement and Other Documents
Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0917-0009
ICR Reference No:
201607-0917-001
Status:
Historical Active
Previous ICR Reference No:
201306-0917-001
Agency/Subagency:
HHS/IHS
Agency Tracking No:
18529
Title:
Indian Health Service Medical Staff Credentials and Privileges Files
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
02/17/2017
Retrieve Notice of Action (NOA)
Date Received in OIRA:
08/11/2016
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
02/29/2020
36 Months From Approved
02/28/2017
Responses
3,068
0
3,068
Time Burden (Hours)
1,784
0
1,784
Cost Burden (Dollars)
0
0
0
Abstract:
National health care standards developed by the Center for Medicare and Medicaid Services (CMS), the Joint Commission and other accrediting organizations require health care facilities to review, evaluate and verify the credentials, training and experience of medical staff applicants prior to granting medical staff privileges. To meet these standards, IHS health care facilities require all medical staff applicants to provide information concerning their education, training, licensure, and work experience and any adverse disciplinary actions taken against them. This information is then verified with references supplied by the applicant and may include: former employers, educational institutions, licensure and certification boards, the American Medical Association, the Federation of State Medical Boards, the National Practitioner Data Bank, and the applicants themselves.
Authorizing Statute(s):
US Code:
25 USC 13
Name of Law: Synder Act
US Code:
42 USC 2001-2004
Name of Law: IHS Transfer Act
US Code:
25 USC 450
Name of Law: Indian Self-Determination and Education Act
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
81 FR 23318
04/20/2016
30-day Notice:
Federal Register Citation:
Citation Date:
81 FR 44885
07/11/2016
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
14
IC Title
Form No.
Form Name
Anesthesis
0917-0009-8
0917-0009-8, Anesthesia Privileges Request Form
Audiology
0917-0009-12
OMB No. 0917-0009-12, Audiology Privileges Request Form
Dental Privileges
0917-0009-9
0917-0009-9, Dental Privleges Request Form
Indian Health Service Medical Staff Credentials and Privileges Files
0917-0009-1
Application for Medical Staff Appointment and/or Privileges
Medical Privileges Request Form
0917-0009-4
0917-0009-4, Medical Privileges Request Form
OB-GYN
0917-0009-5
0917-0009-5, OB-GYN Privileges Form
Pathology
0917-009-15
OMB No. 0917-0009-15, Pathology Privileges Request Form
Podiatry
0917-0009-13
OMB Form No. 0917-0009-14, Podiatric Privileges Request Form
Psychiatry
0917-0009-7
0917-0009-7, Psychiatric Privileges Request Form
Psychology
0917-0009-11
OMB 0917-0009-11, Psychology Privileges Request Form
Radiology
0917-0009-14
OMB No. 0917-0009-14, Radiolgy Privileges Request Form
Reaapointment Request
0917-0009-3
0917-0009-3, Reappointment Request Form
Reference Letter
0917-0009-2
0917-0009-2, References Form
Surgery
0917-0009-6
0917-0009-6, Surgical Privileges Request Form
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
3,068
3,068
0
0
0
0
Annual Time Burden (Hours)
1,784
1,784
0
0
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Annual Cost to Federal Government:
$202,500
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
Yes
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Evonne Bennett-Barnes 301 443-4750 evonne.bennett-barnes@ihs.gov
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
08/11/2016
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