NHSC Waiver Request Worksheets

ICR 200208-0915-001

OMB: 0915-0234

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
6479 Migrated
ICR Details
0915-0234 200208-0915-001
Historical Active 199903-0915-001
HHS/HSA
NHSC Waiver Request Worksheets
Revision of a currently approved collection   No
Regular
Approved without change 09/26/2002
Retrieve Notice of Action (NOA) 08/02/2002
  Inventory as of this Action Requested Previously Approved
09/30/2005 09/30/2005 09/30/2002
2,400 0 1,200
1,200 0 638
0 0 0

The Worksheets provide information used to determine approved/ disapproval of requests to waive reimbursement requirements for the costs associated with the placement of NHSC members.

None
None


No

1
IC Title Form No. Form Name
NHSC Waiver Request Worksheets HRSA-553, HRSA-554

  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 2,400 1,200 0 961 239 0
Annual Time Burden (Hours) 1,200 638 0 450 112 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
08/02/2002


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