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Authorization to Release Information Form
The Nursing Education Loan Repayment Program
OMB: 0915-0140
IC ID: 196033
OMB.report
HHS/HSA
OMB 0915-0140
ICR 201101-0915-001
IC 196033
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0140 can be found here:
2023-01-05 - Extension without change of a currently approved collection
2022-12-27 - Extension without change of a currently approved collection
Documents and Forms
Document Name
Document Type
Form NELRP_008
Authorization to Release Information Form
Form
NELRP_008 Authorization to Release Information Form
FY 11 Forms Package.docx
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Authorization to Release Information 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:
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_008
Authorization to Release Information Form
FY 11 Forms Package.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
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 12868
Number of Respondents:
8,000
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
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
8,000
0
0
8,000
0
0
Annual IC Time Burden (Hours)
800
0
0
800
0
0
Annual IC Cost Burden (Dollars)
0
0
0
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.