NHSC Self-Certification Form

The National Health Service Corps (NHSC) Loan Repayment Program

⚠️ Notice: This information collection may be referencing outdated material.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 0127-6 NHSC Self-Certification Form Form
0127-6 NHSC Self-Certification Self-Certification Form.pdf Form

Information Collection (IC) Details

IC Title:	NHSC Self-Certification Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0127-6	NHSC Self-Certification	Self-Certification Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: he 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: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	5,175	5,175
Annual IC Time Burden (Hours)	518	518
Annual IC Cost Burden (Dollars)	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.