Form 001_BCRS Travek Re 001_BCRS Travek Re 001_BCRS Travek Request

Form Approved
OMB No.0915-0278
Exp. Date 12/31/2009

NATIONAL HEALTH SERVICE CORPS
Region: ________________
Travel Request Worksheet
Non-Federal Personnel

Traveler’s Name:

Home Phone:

Mailing Address:
Cell Phone:

Dates of Travel:

Fax
Number:
SSN:
xxx-xx-________
Specialty:

E-Mail
Address:
Discipline:

Placement Year of
Scholar:
From:

To:

Destination Site
Name/Address:
HPSA #:

Work Phone:

From:
City/St

To:
City/St

HPOL
Year:
Sequence #:

Site ID (BCRR) #:
Status of
Site:

Remarks:



Type of Travel
Pre-Employment Site Visit:
Initial
Match

Site
Assignment



Transfer

Loan Repayment Participant

Permanent Change of Station
Relocation
Initial
Match

Site
Assignment

Category of Traveler
MUST CHECK ONE BOX
Scholarship Recipient

Other (Specify in box below)

Transfer

Other (specify in box below)



Licensure
For relocation and transfer, does the traveler
have a permanent license to practice in State of
service?

Yes
No

Signature of Requesting
Official, NHSC:
Signature of NHSC
Contract Project Officer:

Date:
Date:

PUBLIC BURDEN STATEMENT
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control
number. The OMB control number for this project is 0915-0278. Public reporting burden for this collection of information is estimated to average 4
minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and
completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland,
20857.
Privacy Act Notice – The Privacy Act of 1974 (5 U.S.C. 522A) requires that an agency provide the following notice to each individual whom it asks for
information. (1) The authority for collecting information requested on this form is found in Title III, Part D, Subpart II of the Public Health Service Act (42
U.S.C. 2540); (2) The routine use of this information includes its disclosure to Federal, State or local agencies to assist in locating viable placement
opportunities for NHSC obligated health care providers. While providing this information is voluntary, failure to provide the requested information will
result in the non-consideration of a provider’s assignment.