ss 0278 2006

National Health Service Corps Travel Request Worksheet

SUPPORTING STATEMENT

A. Justification

1. Circumstances of Information Collection

This is a request for an extension of approval from the Office of Management and Budget (OMB) for the Health Resources and Services Administration (HRSA), National Health Service Corps (NHSC), Travel Request Worksheet (TRW). The OMB number for the TRW is 0915-0278, and the current expiration date is 10/31/2006. The TRW is used for requests for pre-employment site visit(s) and relocation to an NHSC authorized site(s) for the purpose of securing employment in a clinical practice in which to fulfill the NHSC service commitment. The Public Health Service Act, Section 331(c) states that the Secretary may reimburse applicants for positions in the Corps (including individuals considering entering into a written agreement pursuant to section 338D) for actual and reasonable expenses incurred in traveling to and from their place of residence to a health professional shortage area (designated under section 332) to which they may be assigned. The Secretary shall not reimburse an applicant for more than one such trip to the same approved site.

The NHSC was established by Congress for the purpose of eliminating health manpower shortages in Health Professional Shortage Areas (HPSAs). HPSAs are geographic areas, facilities or population groups determined by the Secretary of Health and Human Service to have a shortage of health professionals. The NHSC provides funding support to encourage selected primary health care professionals to practice in HPSAs. This program is located in HRSA’s, Bureau of Health Professions (BHPr).

2. Purpose and Use of Information

The purpose of this form is to ensure that the program can effectively and efficiently monitor authorized travel for NHSC clinicians. The TRW form is utilized to expedite the travel approval process for physicians, dentists, nurse practitioners, certified nurse midwives, and physician assistants to site visit(s) and relocation requests when the scholarship recipient has secured an interview at an NHSC approved site(s) and has notified their respective NHSC contact. Such advance notice ensures that the scholarship recipient is fully prepared for the site visit and maximizes the available NHSC travel funding. Utilization of this form avoids unauthorized travel to unapproved NHSC sites and provides more efficient monitoring of travel allotments for each clinician. A copy of the form is provided in Tab A.

3. Use of Improved Information Technology

This form is fully electronic. The automated form assists clinicians in requesting approval for travel for site visits before executing an employment agreement and for requests for relocation assistance in a timely manner.

4. Efforts to Identify Duplication

The information requested only pertains to scholar placement and practice considerations and is available only from the scholar and the NHSC.

5. Involvement of Small Entities

This information collection does not involve small businesses or other small entities.

6. Consequences If Information Collected Less Frequently

Without this form the Program can not effectively monitor clinician travel and avoid unauthorized travel. Each clinician has a maximum travel allotment of $1,500 available from which authorized expenses will be deducted. The TRW is used each time a clinician submits a request for travel for site visits or requests relocation assistance. This form is needed to efficiently monitor travel for clinicians.

7. Consistency with the Guidelines in 5CFR 1320.5(d)(2)

The information will be collected in a manner consistent with guidelines contained in 5CFR 1320.5(d)(2).

8. Consultation Outside the Agency

The notice required in 5 CFR 1320.8(d) was published in the Federal Register on August 16, 2006 (71 FR 47233-47234). No comments were received.

The following individuals were contacted for consultation regarding the clarity and format of the data collection instrument and the frequency of collection:

Justin Henry Sacripante, PA

11 Main Street, Suite 7

PMB 193

Westbrook, ME 04092

207-807-5217

Jill Harrison, MD

P.O. Box 6083

Aurora, IL

312-996-4685

Steve Hegedus, MD

1694 Quarry Trace

Columbus, OH 43203

614-595-6983

9. Remuneration of Respondents

Respondents will not be remunerated.

10. Assurance of Confidentiality

The Privacy Act of 1974 (5 U.S.C. 522a) requires an agency to provide notification to individuals who supply information. The required Privacy Act notification is included on the proposed form. Access to these records is strictly limited to authorized NHSC principal staff who are aware of their responsibilities under the Privacy Act.

Disclosure of the applicant’s Social Security Number (SSN) is required for reimbursement of NHSC applicants. The records associated with the information collection are protected by the Privacy Act. In accordance with the requirements of the Privacy Act, the PHS has established the system of records entitled, APHS and NHSC Scholarship and Loan Repayments Records System, HHS/HRSA/BPHC, 09-15-0037.@ This system contains information on NHSC scholarship recipients (established March 8, 1993, 58 FR 12968).

11. Questions of a Sensitive Nature

There is one question of a sensitive nature. The social security number required for scholarship recipients and/or loan repayment participants for purposes of reimbursement. The authority for collecting this information is found in Title III, Part D, Subpart II of the Public Health Service Act (42 U.S.C. 2340).

12. Estimates of Annualized Hour Burden

The burden estimate is as follows:

Form	Number of Respondents	Responses per Respondent	Hours per Response	Total Hour Burden	Wage Rate	Total Hour Cost
TRW	250	2	.06	30	$30	$1,230

The burden is based upon discussions with respondents who have completed the form, and who reported that the form takes approximately 4 minutes to complete. Based on the advice of the respondents the estimate for 4 minutes to complete the application is (250 respondents x 2 annual application x 4 minutes = 30 hours)

13. Estimates of Annualized Cost Burden to Respondents

There are no capital or start up costs, nor are there any operation or maintenance costs to the respondents.

14. Estimates of Annualized Cost to the Government

The estimated annualized cost to the Government is approximately $630. This cost is calculated as follows:

Reviewing and researching the travel request received for a determination of approval or denial of such request. GS-12 Federal employee at $30 per hour for 21 hours = $630.

15. Changes in Burden

This current burden for this project is 41 hours. This request is for a total of 30 hours, a decrease of 11 hours. This is a program adjustment, as the decrease is due to an estimate of slightly fewer respondents.

16. Time Schedule, Publication and Analysis Plans

There are no plans for tabulation, analysis or publications from this activity.

17. Exemption for Display of Expiration Date

The expiration date will be displayed.

18. Certifications

The data collection fully complies with guidelines set forth in 5 CFR 1320.9. The required certifications are included in the package.

List of Attachments

Tab A: Travel Request Worksheet

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