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Affiliation Verification
Indian Health Service Medical Staff Credentials Application
OMB: 0917-0009
IC ID: 261339
OMB.report
HHS/IHS
OMB 0917-0009
ICR 202307-0917-001
IC 261339
( )
Documents and Forms
Document Name
Document Type
Form 0917-0009
Affiliation Verification
Form and Instruction
0917-0009 Affiliation Verification
Ltr_Affiliation Verification 41323.docx
Form and Instruction
0917-0009 Affiliation Verification
Ltr_Affiliation Verification FINAL 07 11 2024.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Affiliation Verification
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Mandatory
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
0917-0009
Affiliation Verification
Ltr_Affiliation Verification FINAL 07 11 2024.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
4,225
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
4,225
0
4,225
0
0
0
Annual IC Time Burden (Hours)
1,056
0
1,056
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.