Indian Health Service Medical Staff Credentials and Privileges Files

Forms and Documents

Document Name	Status
Form 0917-0009-1 Indian Health Service Medical Staff Credentials and Privileges Files Form and Instruction	Modified
Form 0917-009-15 Pathology Form and Instruction	Modified
Form 0917-0009-14 Radiology Form and Instruction	Modified
Form 0917-0009-13 Podiatry Form and Instruction	Modified
Form 0917-0009-12 Audiology Form and Instruction	Modified
Form 0917-0009-11 Psychology Form and Instruction	Modified
Optometry Form	Removed
Form 0917-0009-9 Dental Privileges Form and Instruction	Modified
Form 0917-0009-8 Anesthesis Form and Instruction	Modified
Form 0917-0009-7 Psychiatry Form and Instruction	Modified
Form 0917-0009-6 Surgery Form and Instruction	Modified
Form 0917-0009-5 OB-GYN Form and Instruction	Modified
Form 0917-0009-4 Medical Privileges Request Form Form and Instruction	Modified
Form 0917-0009-3 Reaapointment Request Form and Instruction	Modified
Form 0917-0009-2 Reference Letter Form and Instruction	Modified
60 Day FR Publication 04-02-13.pdf Supplementary Document	2013-05-14
OMB 0917-0009 Supporting Statement 5-23-2013.docm Supporting Statement A	2013-06-05

IC Document Collections

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

ICR Details

OMB Control No: 0917-0009	ICR Reference No: 201306-0917-001
Status: Historical Active	Previous ICR Reference No: 201004-0917-003
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 without change	Conclusion Date: 08/16/2013
	Date Received in OIRA: 06/18/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2016	36 Months From Approved	08/31/2013
Responses	3,068	0	3,089
Time Burden (Hours)	1,784	0	1,791
Cost Burden (Dollars)	0	0	0

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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.

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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

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 19721	04/02/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 36198	06/17/2013
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 14

IC Title	Form No.	Form Name
Surgery	0917-0009-6	0917-0009-6, Surgical Privileges Request Form
Psychiatry	0917-0009-7	0917-0009-7, Psychiatric Privileges Request Form
Anesthesis	0917-0009-8	0917-0009-8, Anesthesia Privileges Request Form
Dental Privileges	0917-0009-9	0917-0009-9, Dental Privleges Request Form
Psychology	0917-0009-11	OMB 0917-0009-11, Psychology Privileges Request Form
Audiology	0917-0009-12	OMB No. 0917-0009-12, Audiology Privileges Request Form
Podiatry	0917-0009-13	OMB Form No. 0917-0009-14, Podiatric Privileges Request Form
Radiology	0917-0009-14	OMB No. 0917-0009-14, Radiolgy Privileges Request Form
Pathology	0917-009-15	OMB No. 0917-0009-15, Pathology Privileges Request Form
Optometry	NA	Optometric Privileges Request Form
Indian Health Service Medical Staff Credentials and Privileges Files	0917-0009-1	Application for Medical Staff Appointment and/or Privileges
Reference Letter	0917-0009-2	0917-0009-2, References Form
Reaapointment Request	0917-0009-3	0917-0009-3, Reappointment Request Form
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

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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	3,089	0	0	-21	0
Annual Time Burden (Hours)	1,784	1,791	0	0	-7	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:

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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

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Common Form ICR:  No

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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: 06/18/2013

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