Health Education Assistance Loan (HEAL) Program Physician's Certification of Borrower's Total and Permanent Disability Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6424	Health Education Assistance Loan (HEAL) Program Physician's Certification of Borrower's Total and Permanent Disability Form	Form	Migrated

ICR Details

OMB Control No: 0915-0204	ICR Reference No: 199512-0915-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Health Education Assistance Loan (HEAL) Program Physician's Certification of Borrower's Total and Permanent Disability Form
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/06/1996
	Date Received in OIRA: 12/01/1995
Terms of Clearance: This information collection, as amended by memoranda dated January 23 and February 2, 1996, is approved through February 1998, subject to the following terms of clearance: 1. Upon resubmission, HHS shall coordinate with the Department of Education to develop consistent forms for their related direct loan programs, including the possibility of use of a common form. 2. Questions 4, 5, and 6 in section II shall be optional. The form, however, may state that if the certification lacks suffi- cient information to demonstrate full and permanent disability on behalf of the borrower, HHS may require that additional infor- mation be submitted. 3. Upon resubmission, HHS shall report on the change in burden as a result of the change in information collection. HHS shall also report on any changes in the levels of total claims and of denied claims, and the real or perceived extent of waste, fraud, and abuse in this program.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/1999	02/28/1999
Responses	126	0	0
Time Burden (Hours)	126	0	0
Cost Burden (Dollars)	588,000	0	0

---

Abstract: This form certifies that the HEAL borrower meets the total and permanent disability requirements for cancellation of the obligation to repay HEAL student loans through 1) borrower's consent to release medical records to the Department and the lender; 2) physician's certification of inability to earn income; and 3) lender's report of unpaid balance of the loan.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Health Education Assistance Loan (HEAL) Program Physician's Certification of Borrower's Total and Permanent Disability Form	HRSA-539

---

ICR Summary of Burden

table that charts list 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	126	0	0	126	0	0
Annual Time Burden (Hours)	126	0	0	126	0	0
Annual Cost Burden (Dollars)	588,000	0	0	588,000	0	0

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

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: $0

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? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

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)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

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: 12/01/1995

---