Application Checklist and Self-Certification Form

The Nursing Education Loan Repayment Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0140 can be found here:

Documents and Forms

Document Name Document Type
Form NELRP_006 Application Checklist and Self-Certification Form Form
NELRP_006 Application Checklist and Self-Verification Form FY 11 Forms Package.docx Form

Information Collection (IC) Details

IC Title:	Application Checklist and Self-Certification 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 Part 57 Section 312 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	NELRP_006	Application Checklist and Self-Verification Form	FY 11 Forms Package.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Public Health Service and National Health Service Corps Scholarship/Loan Repayment Participants Records System	FR Citation: 58 FR 12968

Number of Respondents: 8,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	8,000	1,200	6,800
Annual IC Time Burden (Hours)	4,000	600	3,400
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.