The National Health Service Corps (NHSC) Loan Repayment Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0127-1 The National Health Service Corps (NHSC) Loan Repayment Program	Form	Modified	Available
Form 0127-6 NHSC Self-Certification Form	Form	New	Available
Form 0127-5 NHSC Alumni Database	Form	New	Available
Form lrp loan form 0127 NHSC Lender	Form	Removed	Available
Form lrp checklist 0127 NHSC Checklist	Form	Removed	Available
Form 0127-4 0127 NHSC Authorization to Release Information Form	Form	Modified	Available
Form 0127-3 0127 NHSC Loan Information and Verification Form	Form	Modified	Available
Form 0127-2 0127 NHSC Community Site Information Form	Form	Modified	Available
Cover Memo for 0915-0127.doc	Supplementary Document	Uploaded 2010-11-01	Available
ss_NHSC_LRP_final-10.docx	Supporting Statement A	Uploaded 2010-11-01	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6365	The National Health Service Corps (NHSC) Loan Repayment Program	Form	Modified
195406	NHSC Self-Certification Form	Form	New
195405	NHSC Alumni Database	Form	New
181470	0127 NHSC Lender	Form	Removed
181469	0127 NHSC Checklist	Form	Removed
181468	0127 NHSC Authorization to Release Information Form	Form	Modified
181467	0127 NHSC Loan Information and Verification Form	Form	Modified
181466	0127 NHSC Community Site Information Form	Form	Modified

ICR Details

OMB Control No: 0915-0127	ICR Reference No: 201011-0915-003
Status: Historical Active	Previous ICR Reference No: 200906-0915-001
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: The National Health Service Corps (NHSC) Loan Repayment Program
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/10/2011
	Date Received in OIRA: 11/23/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2014	36 Months From Approved	01/31/2011
Responses	41,225	0	31,111
Time Burden (Hours)	12,128	0	8,030
Cost Burden (Dollars)	0	0	0

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Abstract: The National Health Service Corps (NHSC) Loan Repayment Program (LRP) was established to assure an adequate supply of trained primary care health professionals to provide services in the neediest Health Professional Shortage Areas. Under this program, HHS agrees to repay the educational loans of the primary health care professionals. In return, the health professionals agree to service for a specified period of time in a federally designated HPSA approved by the Secretary for LRP participants.

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Authorizing Statute(s): PL: Pub.L. 107 - 205 846 Name of Law: Nurse Reinvestment Act
   PL: Pub.L. 107 - 205 836h Name of Law: National Education Loan Repayment Program
   PL: Pub.L. 111 - 5 VIII Name of Law: American Recovery and Reinvestment Act
   PL: Pub.L. 111 - 148 5207 Name of Law: Patient Protection and Affordable Care Act of 2010
   US Code: 42 USC 2541 Name of Law: NHSC Scholarship Program and Loan Repayment Program
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 5 VIII Name of Law: American Recovery and Reinvestment Act
PL: Pub.L. 111 - 148 5207 Name of Law: Patient Protection and Affordable Care Act of 2010

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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:
	75 FR 17923	04/08/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 51821	08/23/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
0127 NHSC Authorization to Release Information Form	0127-4	Authorization to Release Info
NHSC Alumni Database	0127-5	Alumni contact info
NHSC Self-Certification Form	0127-6	NHSC Self-Certification
0127 NHSC Checklist	lrp checklist	lrp checklist
0127 NHSC Loan Information and Verification Form	0127-3	Loan Information and Verification Form
The National Health Service Corps (NHSC) Loan Repayment Program	0127-1	NHSC LRP
0127 NHSC Lender	lrp loan form	lrp loan form
0127 NHSC Community Site Information Form	0127-2	Employment Verification and Community Site Info For

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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	41,225	31,111	9,627	487	0	0
Annual Time Burden (Hours)	12,128	8,030	4,035	63	0	0
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: Changing Regulations

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

Burden Reduction Due to: Cutting Redundancy

Short Statement: An increase in total burden hours due to program change is being submitted. The program change is due to an additional increase in funding from the Affordable Care Act of 2010, to include approximately 5,175 annual respondents. A non-substantive change to collect and maintain basic contact information from applicants who complete their NHSC service is reflected with an additional 1,000 hours of annual burden. Two forms have been deleted due to redundancy. The net program change increase in total annual burden hours is 12,128, 11,128 of which is due to new statute and 1,000 of which is due to agency discretion.

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Annual Cost to Federal Government: $2,109,509

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? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Yes

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 11/22/2010

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