Form 0917-0009-12 OMB No. 0917-0009-12, Audiology Privileges Request Form

Circular Appendix 95–16–C.9 (04/10)
Page 2 of 2

Audiologic PRIVILEGES REQUEST FORM

INTRODUCTION

This Audiologic Privileges Request Form must be accompanied or preceded by a completed application for medical staff appointment, including the necessary supporting documents. The request for privileges must reflect both the applicant’s and the facility’s/staff’s ability to carry out or support the various functions.

INSTRUCTIONS FOR COMPLETING THE FORM

Applicant: With a check mark in the appropriate location, indicate for each item, if you are requesting privileges. Be sure to sign the request as indicated on page 2.

Discipline-specific supervisor or consultant: Indicate your recommendation for each requested clinical privilege by placing a check mark in the appropriate location. Please explain any recommended limitations or denial of privileges on an attached sheet. Your recommendations are considered by the governing body when granting or not granting privileges.

I. Diagnostic	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
Pure-tone audiometry
Speech audiometry
Site of lesions tests (auditory)
Acoustic impedance measurements
Electronystagmography
Pediatric audiometry
Evoked potential (auditory)

II. Amplification	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
Assessment of potential success of amplification
Hearing aid evaluation
Issuing hearing aids

III. Rehabilitation	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
Auditory training
Manual communication
Speech reading
Nonverbal communication

AUDIOLOGIC PRIVILEGES REQUEST FORM

1. I hereby request the clinical privileges as indicated on the forms attached.

Applicant Date

2. I hereby recommend the clinical privileges as indicated.

Supervisor/Consultant Date

3. As Chairperson of the Medical Staff Executive Committee, I hereby recommend the clinical privileges: (check one)

As noted.

With the following exceptions, deletions, additions, or conditions:

Clinical Director Date

4. I hereby recommend the applicant for clinical privileges.

Service Unit Director Date

5. Privileges are hereby granted: (check one)

As noted.

With the following exceptions, deletions, additions, or conditions:

Chairperson of the Date

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Estimated Average Burden Time per Response

Public reporting burden for this collection of information is estimated to average 5 minutes per response including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Reports Clearance Officer, Indian Health Service, 801 Thompson Avenue, TMP Suite 450, Rockville, MD 20852, ATTN: PRA (0917–0009). Please do not send this form to this address.

overning Body