HEAL Program: Physician's Certification of Borrower's Total and Permanent Disability

Forms and Documents

Document Name	Status
Form HRSA- 539 HEAL Program: Physician's Certification of Borrower's Total and Permanent Disability Form and Instruction	Modified
APRIL2007_0915_0204_ss[1].doc Supporting Statement A	0000-00-00

IC Document Collections

IC ID	Document Title	Status
6427	HEAL Program: Physician's Certification of Borrower's Total and Permanent Disability Form and Instruction	Modified

ICR Details

OMB Control No: 0915-0204	ICR Reference No: 200704-0915-001
Status: Historical Active	Previous ICR Reference No: 200403-0915-002
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: HEAL Program: Physician's Certification of Borrower's Total and Permanent Disability
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/11/2007
	Date Received in OIRA: 04/19/2007
Terms of Clearance: Previous terms of clearance remain in effect.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2010	36 Months From Approved	06/30/2007
Responses	245	0	282
Time Burden (Hours)	61	0	71
Cost Burden (Dollars)	0	0	2,000

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Abstract: The forms certifies that the HEAL borrower meets the total and permanent disability requirements for cancellation of the obligation to repay HEAL student loans. The information collected on the certification and disability form is essential for proper administration of the HEAL program.

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Authorizing Statute(s): US Code: 42 USC 714 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 4270	01/30/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 18662	04/13/2007
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
HEAL Program: Physician's Certification of Borrower's Total and Permanent Disability	HRSA- 539	Physician's Cert. of Borrower's Total and Permanent Disability

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ICR Summary 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	245	282	0	-37	0	0
Annual Time Burden (Hours)	61	71	0	-10	0	0
Annual Cost Burden (Dollars)	0	2,000	0	-2,000	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

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

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The decrease in burden is due to program adjustments. Specifically a decrease in the number of disability claims has reduced the burden.

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Annual Cost to Federal Government: $42,370

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

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Common Form ICR:  No

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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: 04/19/2007

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