0127 NHSC Community Site Information Form

The National Health Service Corps (NHSC) Loan Repayment Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0127 can be found here:

Documents and Forms

Document Name Document Type
Form lrp community site 0127 NHSC Community Site Information Form Form
lrp community site lrp community site form 0127 site info form.doc Form

Information Collection (IC) Details

IC Title:	0127 NHSC Community Site Information Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 621

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	lrp community site form	lrp community site form	0127 site info form.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: The Public Health Service and National Health Service Corps Health Care Provider Records System	FR Citation: 58 FR 12968

Number of Respondents: 4,433	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Previously Approved
Annual Number of Responses for this IC	4,433	2,513	1,920
Annual IC Time Burden (Hours)	1,108	628	480
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.