Information Collection Request

Indian Health Service Medical Staff Credentials and Privileges Files

ICR 201004-0917-003 · OMB 0917-0009 · Historical Active

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0917-0009 can be found here:

Forms and Documents

Document	Type	Status	Availability
Indian Health Service Medical Staff Credentials and Privileges Files	Form and Instruction	Modified	Available
Pathology	Form	Modified	Available
Radiology	Form	Modified	Available
Podiatry	Form	Modified	Available
Audiology	Form	Modified	Available
Psychology	Form	Modified	Repair queued
Optometry	Form	Modified	Repair queued
Dental Privileges	Form	Modified	Repair queued
Anesthesis	Form	Modified	Available
Psychiatry	Form	Modified	Repair queued
Surgery	Form	Modified	Available
OB-GYN	Form	Modified	Repair queued
Internal Medicine/Family Practice Privilege	Form	Modified	Available
Reaapointment Request	Form	Modified	Repair queued
Reference Letter	Form	Modified	Available
30 day IHS MSCPF 3-31-10.pdf	Supplementary Document	Uploaded 2010-04-23	Available
60 day 12-4-09.pdf	Supplementary Document	Uploaded 2010-03-23	Available
OMB Credentials Supporting Statement.docm	Supporting Statement A	Uploaded 2010-04-27	Available

IC Document Collections

IC ID	Collection	Type	Status
6568	Indian Health Service Medical Staff Credentials and Privileges Files	Form and Instruction	Modified
46256	Pathology	Form	Modified
46255	Radiology	Form	Modified
46254	Podiatry	Form	Modified
46253	Audiology	Form	Modified
46252	Psychology	Form	Modified
46251	Optometry	Form	Modified
46250	Dental Privileges	Form	Modified
46249	Anesthesis	Form	Modified
46248	Psychiatry	Form	Modified
46247	Surgery	Form	Modified
46246	OB-GYN	Form	Modified
46245	Internal Medicine/Family Practice Privilege	Form	Modified
46244	Reaapointment Request	Form	Modified
46243	Reference Letter	Form	Modified

ICR Details

OMB Control No: 0917-0009	ICR Reference No: 201004-0917-003
Status: Historical Active	Previous ICR Reference No: 200611-0917-002
Agency/Subagency: HHS/IHS	Agency Tracking No:
Title: Indian Health Service Medical Staff Credentials and Privileges Files
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/03/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/30/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2013	36 Months From Approved	06/30/2010
Responses	3,089	0	3,265
Time Burden (Hours)	1,791	0	1,929
Cost Burden (Dollars)	0	0	0

Abstract: Information is needed and used by the Indian Health Service Medical Staff to meet JCAHO accreditation requirements and to review, evaluate and verify the credentials, training, and experience of applicants applying for medical staff privileges at IHS health care facilities.

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:
	74 FR 63754	12/04/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 16139	03/31/2010
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 15

IC Title	Form No.	Form Name
Indian Health Service Medical Staff Credentials and Privileges Files	NA	Application for Medical Staff Appointment and/or Privileges
Reference Letter	NA	Suggested Format for Letter to Be Sent to References of Applicants or For Telephone Solicitation of References
Internal Medicine/Family Practice Privilege	NA	Medical Privileges Request Form
Reaapointment Request	NA	Request for Reappointment To The Medical Staff
OB-GYN	NA	OB-GYN Privileges Request Form
Surgery	NA	Surgical Privileges Request Form
Psychiatry	NA	Psychiatric Privileges Request Form
Anesthesis	NA	Anesthesia Privileges Request Form
Dental Privileges	NA	Dental Privileges Request Form
Optometry	NA	Optometric Privileges Request Form
Psychology	NA	Psychology Privileges Request Form
Audiology	NA	Audiologic Privileges Request Form
Podiatry	NA	podiatric Privileges Request Form
Radiology	NA	Radiology Privileges Request Form
Pathology	NA	Pathology Privileges Request Form

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	3,089	3,265	-176
Annual Time Burden (Hours)	1,791	1,929	-138
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Cutting Redundancy

Short Statement: The forms were made more streamline.

Annual Cost to Federal Government: $182,500

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]? Uncollected

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: Saleda Perryman

Common Form ICR: No