Application for Participation in the IHS Scholarship Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form multiple forms Scholarship Application	Form and Instruction	Modified	Available
856-20.pdf	Supplementary Document	Uploaded 2007-12-04	Available
856-19.pdf	Supplementary Document	Uploaded 2007-12-04	Available
856-18.pdf	Supplementary Document	Uploaded 2007-12-04	Available
856-17.pdf	Supplementary Document	Uploaded 2007-12-04	Available
856-16.pdf	Supplementary Document	Uploaded 2007-12-04	Available
856-15.pdf	Supplementary Document	Uploaded 2007-12-04	Available
856-14.pdf	Supplementary Document	Uploaded 2007-12-04	Available
856-13.pdf	Supplementary Document	Uploaded 2007-12-04	Available
856-12.pdf	Supplementary Document	Uploaded 2007-12-04	Available
856-11.pdf	Supplementary Document	Uploaded 2007-12-04	Available
856-10.pdf	Supplementary Document	Uploaded 2007-12-04	Available
856-9.pdf	Supplementary Document	Uploaded 2007-12-04	Available
IHS-818.pdf	Supplementary Document	Uploaded 2007-12-04	Available
IHS-817.pdf	Supplementary Document	Uploaded 2007-12-04	Available
816.pdf	Supplementary Document	Uploaded 2007-12-04	Available
815.pdf	Supplementary Document	Uploaded 2007-12-04	Available
856-8.pdf	Supplementary Document	Uploaded 2007-12-04	Available
856-7.pdf	Supplementary Document	Uploaded 2007-12-04	Available
856-6.pdf	Supplementary Document	Uploaded 2007-12-04	Available
856-5.pdf	Supplementary Document	Uploaded 2007-12-04	Available
856-4.pdf	Supplementary Document	Uploaded 2007-12-04	Available
856-2.pdf	Supplementary Document	Uploaded 2007-12-04	Available
856-3.pdf	Supplementary Document	Uploaded 2007-12-04	Available
856.pdf	Supplementary Document	Uploaded 2007-12-04	Available
IHSfinal SS 12-3-07[2).wpd	Supporting Statement A	Uploaded 2007-12-05	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6562	Scholarship Application	Form and Instruction	Modified
183630	Request for Deferment		New
183629	Preferred Assignment		New
183628	Status Report		New
183627	Request Travel Reimbursement		New
183626	Site Preference		New
183625	Notice of Graduation		New
183624	Placement		New
183623	Request Summer School		New
183622	Request Assistance		New
183621	Academic Problem/Change		New
183620	Enrollment		New
183619	Stipend Check		New
183618	Health Professions Contract		New
183617	Scholoarship Program Agreement		New
183616	Address Change Notice		New
183615	Receipt of Application		New
183614	Accept/Decline		New
183613	MPH		New
183612	Federal Debt		New
183611	Justification		New
183610	Faculty/Employer Evaluation		New
183609	Checklist		New
183608	Course Verification		New

ICR Details

OMB Control No: 0917-0006	ICR Reference No: 200801-0917-002
Status: Historical Active	Previous ICR Reference No: 200405-0917-001
Agency/Subagency: HHS/IHS	Agency Tracking No:
Title: Application for Participation in the IHS Scholarship Program
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/04/2008
	Date Received in OIRA: 01/31/2008
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2011	36 Months From Approved
Responses	17,330	0	0
Time Burden (Hours)	6,539	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Program forms collect information used to solicit, process and award scholarships, monitor academic performance and place awardees in payback sites. The data is needed to plan, manage, direct, operate and evaluate the IHSA Scholarship program.

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Authorizing Statute(s): PL: Pub.L. 94 - 437 522 Name of Law: Indian Health Care Improvement
  

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 45054	08/10/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 62658	11/06/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 24

table that charts list of burden

IC Title	Form No.	Form Name
Scholarship Application	multiple forms, multiple forms	Student Handbook ,   Application Handbook
Course Verification
Checklist
Faculty/Employer Evaluation
Justification
Federal Debt
Request Assistance
Request Summer School
MPH
Accept/Decline
Academic Problem/Change
Receipt of Application
Address Change Notice
Scholoarship Program Agreement
Health Professions Contract
Stipend Check
Enrollment
Site Preference
Request Travel Reimbursement
Status Report
Preferred Assignment
Request for Deferment
Placement
Notice of Graduation

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ICR Summary of Burden

table that charts list 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	17,330	0	0	0	0	17,330
Annual Time Burden (Hours)	6,539	0	0	1,003	0	5,536
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This a reinstatement of a previously approved submission. Although the forms have not changed the public will have increased elctronic access to them.

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Annual Cost to Federal Government: $90,000

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? Yes

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: 01/31/2008

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