Information Collection

0127 NHSC Loan Information and Verification Form

IC 181467 under ICR 201011-0915-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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 0127-3 0127 NHSC Loan Information and Verification Form Form
0127-3 Loan Information and Verification Form Loan Info and Verification Form.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	0127 NHSC Loan Information and Verification 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	0127-3	Loan Information and Verification Form	Loan Info and Verification Form.pdf		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: 5,175	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	15,525	2,226	13,299
Annual IC Time Burden (Hours)	4,658	1,333	3,325
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.