ss_0915-0278

National Health Service Corps Travel Request Worksheet
SUPPORTING STATEMENT
A. Justification
1. Circumstances of Information Collection
This is a request for an extension of approval from the Office of Management and Budget
(OMB) for the Health Resources and Services Administration (HRSA), National Health Service
Corps (NHSC), Travel Request Worksheet (TRW). The OMB number for the TRW is 09150278, and the current expiration date is 12/31/2009. The TRW is used for requests for preemployment site visit(s) and relocation to an NHSC authorized site(s) for the purpose of securing
employment in a clinical practice in which to fulfill the NHSC service commitment. The Public
Health Service Act, Section 331(c) states that the Secretary may reimburse applicants for
positions in the Corps (including individuals considering entering into a written agreement
pursuant to section 338D) for actual and reasonable expenses incurred in traveling to and from
their place of residence to a health professional shortage area (designated under section 332) to
which they may be assigned. The Secretary shall not reimburse an applicant for more than one
such trip to the same approved site.
The NHSC was established by Congress for the purpose of eliminating health professional
shortages in Health Professional Shortage Areas (HPSAs). HPSAs are geographic areas,
facilities or population groups determined by the Secretary of Health and Human Service to have
a shortage of health professionals. The NHSC provides funding support to encourage selected
primary health care professionals to practice in HPSAs. This program is located in HRSA’s,
Bureau of Clinician Recruitment and Service (BCRS).
2. Purpose and Use of Information
The purpose of this form is to ensure that the program can effectively and efficiently monitor
authorized travel for NHSC clinicians. The TRW form is utilized to expedite the travel approval
process for physicians, dentists, nurse practitioners, certified nurse midwives, and physician
assistants to site visit(s) and relocation requests when the scholarship recipient has secured an
interview at an NHSC approved site(s) and has notified their respective NHSC contact. Such
advance notice ensures that the scholarship recipient is fully prepared for the site visit and
maximizes the available NHSC travel funding. Utilization of this form avoids unauthorized
travel to unapproved NHSC sites and provides more efficient monitoring of travel allotments for
each clinician.
3. Use of Improved Information Technology
This form is fully electronic. The automated form assists clinicians in requesting approval for
travel for site visits before executing an employment agreement and for requests for relocation
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assistance in a timely manner.
4. Efforts to Identify Duplication
The information requested only pertains to scholar placement and practice considerations and is
available only from the scholar and the NHSC.
5. Involvement of Small Entities
This information collection does not involve small businesses or other small entities.
6. Consequences If Information Collected Less Frequently
Without this form the Program can not effectively monitor clinician travel and avoid
unauthorized travel. Each clinician has a maximum travel allotment of $1,500 available from
which authorized expenses will be deducted. The TRW is used each time a clinician submits a
request for travel for site visits or requests relocation assistance. This form is needed to
efficiently monitor travel for clinicians.
7. Consistency with the Guidelines in 5CFR 1320.5(d)(2)
The information will be collected in a manner consistent with guidelines contained in 5CFR
1320.5(d)(2).
8. Consultation Outside the Agency
The notice required in 5 CFR 1320.8(d) was published in the Federal Register on October 6,
2009 (Vol. 74, No. 192, Page 51279). The thirty day notice was published on December 1, 2009
(Vol. 229, No. 74, Page 62792). No comments were received.
The following individuals were contacted for consultation regarding the clarity and format of the
data collection instrument and the frequency of collection:
Catherine Harrington, M.D.
2004 Oak Ridge Drive
Portland, TX 78374
615-945-0563
Monica Williams, D.D.S.
975 Haywood Drive
Chipley, FL 32428
615-823-0161

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Jamie North, M.D.
1121 Brown Street
Alton, IL 62002
615-364-8923
9. Remuneration of Respondents
Respondents will not be remunerated.
10. Assurance of Confidentiality
The Privacy Act of 1974 (5 U.S.C. 522a) requires an agency to provide notification to
individuals who supply information. The required Privacy Act notification is included on the
proposed form. Access to these records is strictly limited to authorized NHSC principal staff
who are aware of their responsibilities under the Privacy Act.
Disclosure of the last four digits of the applicant’s Social Security Number (SSN) is required for
reimbursement of NHSC applicants. The records associated with the information collection are
protected by the Privacy Act. In accordance with the requirements of the Privacy Act, the PHS
has established the system of records entitled, APHS and NHSC Scholarship and Loan
Repayments Records System, HHS/HRSA/BPHC, 09-15-0037.@ This system contains
information on NHSC scholarship recipients (established March 8, 1993, 58 FR 12968).
11. Questions of a Sensitive Nature
There is one question of a sensitive nature. The last four digits of the social security number is
required for scholarship recipients and/or loan repayment participants for purposes of
reimbursement. The authority for collecting this information is found in Title III, Part D,
Subpart II of the Public Health Service Act (42 U.S.C. 2340).
12. Estimates of Annualized Hour Burden
The burden estimate is as follows:
Form

Number of
Respondents

Travel Request Worksheet

140

Responses
per
Respondent

2

Total
Responses

280

Hours per
Response

Total
Burden
Hours

.06

16.8

The burden is based upon discussions with respondents who have completed the form, and who
reported that the form takes approximately 4 minutes to complete. Based on the advice of the
respondents the estimate for 4 minutes to complete the application is (140 respondents x 2
annual application x 4 minutes = 16.8 hours)
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13. Estimates of Annualized Cost Burden to Respondents
There are no capital or start up costs, nor are there any operation or maintenance costs to the
respondents.
14. Estimates of Annualized Cost to the Government
The estimated annualized cost to the Government is approximately $504. This cost is calculated
as follows:
Reviewing and researching the travel request received for a determination of approval or denial
of such request. GS-12 Federal employee at $30 per hour for 16.8 hours = $504.
Form

Number of
Respondents

TRW

140

Responses
per
Respondent

Hours per
Response

2

.06

Total Hour
Burden

Wage Rate

Total
Hour Cost

16.8

$30

$504

15. Changes in Burden
This current burden for this project is 30 hours. This request is for a total of 16.8 hours, a
decrease of 14.2 hours. This is a program adjustment, as the decrease is due to an estimate of
fewer respondents due to a decrease in the amount of scholars awarded.
16. Time Schedule, Publication and Analysis Plans
There are no plans for tabulation, analysis or publications from this activity.
17. Exemption for Display of Expiration Date
The expiration date will be displayed.
18. Certifications
The data collection fully complies with guidelines set forth in 5 CFR 1320.9.

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