Information Collection

Health Education Assistant Loan (HEAL) Program: Physicians's Certification of Borrower's Total and Permanent Disability Form

IC 6426 under ICR 200102-0915-002 · OMB 0915-0204.

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Information Collection (IC) Details

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IC Title:	Health Education Assistant Loan (HEAL) Program: Physicians's Certification of Borrower's Total and Permanent Disability Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HRSA-539				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 254	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	351	51	300
Annual IC Time Burden (Hours)	88	-87	175
Annual IC Cost Burden (Dollars)	2,000	1,000	1,000

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.