Form TRW

Form Approved

OMB No.0915-0278

Exp. Date 10/31/06

National Health Service Corps

Region: ________________

Travel Request Worksheet

Non-Federal Personnel

Traveler’s Name:

Home Phone:

Work Phone:

Mailing Address:

Fax Number:

Cell Phone:

E-Mail Address:

SSN:

Placement Year of Scholar:

Discipline:

Specialty:

Dates of Travel:

From:

To:

From: City/St

To: City/St

Destination Site Name:

HPOL Year:

Site ID (BCRR) #:

HPSA #:

Sequence #:

Status of Site:

Remarks:

	Type of Travel							Category of Traveler
	Pre-Employment Site Visit:							MUST CHECK ONE BOX
	 Initial Match	 Site Assignment		 Transfer				Scholarship Recipient
	Permanent Change of Station Relocation							Loan Repayment Participant
	 Initial Match		 Site Assignment		 Transfer			Other (Specify)
	NHSC Fellowships
	Advance Storage Option
	Other (specify)

	Licensure
	For PCS and transfer, does the traveler have a temporary or permanent license to practice in State of service?
	Yes
	No

Signature of Requesting Official, NHSC:		Date:
Signature of NHSC Contract Project Officer:		Date:

PUBLIC BURDEN STATEMENT

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB control number for this project is 0915-0278. Public reporting burden for this collection of information is estimated to average 4 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

Privacy Act Notice – The Privacy Act of 1974 (5 U.S.C. 522A) requires that an agency provide the following notice to each individual whom it asks for information. (1) The authority for collecting information requested on this form is found in Title III, Part D, Subpart II of the Public Health Service Act (42 U.S.C. 2540); (2) The routine use of this information includes its disclosure to Federal, State or local agencies to assist in locating viable placement opportunities for NHSC obligated health care providers. While providing this information is voluntary, failure to provide the requested information will result in the non-consideration of a provider’s assignment.

Privacy Act Notice – The Privacy Act of 1974 (5 U.S.C. 522A) requires that an agency provide the following notice to each individual whom it asks for information.

(1) The authority for collecting information requested on this form is found in Title III, Part D, Subpart II of the Public Health Service Act (42 U.S.C. 2540; (2) The routine use of this information includes its disclosure to Federal, State or local agencies to assist in locating viable placement opportunities for NHSC obligated health care providers. While providing this information is voluntary, failure to provide the requested information will result in the non-consideration of a provider’s assignment.