Information Collection

0127 NHSC Checklist

IC 181469 under ICR 200906-0915-001 · OMB 0915-0127.

⚠️ Notice: This information collection may be referencing outdated material.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 checklist 0127 NHSC Checklist Form
lrp checklist lrp checklist 0127 checklist.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	0127 NHSC Checklist	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 checklist	lrp checklist	0127 checklist.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)	887	503	384
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.