Application for Participation in the National Health Service Corps Scholarship Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form NHSC_SP_002 Acceptance & Declination Form	Form	Modified	Available
Form NHSC_SP_001 NHSC_SP_001	Form	Modified	Available
Form NHSC_SP_005 Deferment Request Form	Form	New	Available
Form NHSC_SP_004 Six-Month Service Obligation Verification Form	Form	New	Available
Form NHSC_SP_003 Data Collection Worksheet	Form	New	Available
ss 0146 12_12-3-2010-nhsc sp.doc	Supporting Statement A	Uploaded 2011-01-24	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6375	Application for Participation in the National Health Service Corps Scholarship Program	Form	Modified	Acceptance & Declination Form
6375	Application for Participation in the National Health Service Corps Scholarship Program	Instruction	Modified
6375	Application for Participation in the National Health Service Corps Scholarship Program	Form	Modified	NHSC_SP_001
196055	Deferment Request Form - Participant Form	Form	New	Deferment Request Form
196054	Six-Month Service Obligation Verification Form - School/Sites Forms	Form	New	Six-Month Service Obligation Verification Form
196053	Data Collection Worksheet - School/Site Form	Form	New	Data Collection Worksheet

ICR Details

OMB Control No: 0915-0146	ICR Reference No: 201101-0915-003
Status: Historical Active	Previous ICR Reference No: 200801-0915-002
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Application for Participation in the National Health Service Corps Scholarship Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/25/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/29/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2014	36 Months From Approved	04/30/2011
Responses	3,660	0	1,800
Time Burden (Hours)	7,270	0	5,400
Cost Burden (Dollars)	0	0	0

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Abstract: The National Health Service Corps (NHSC) Scholarship Program offers scholarship awards to health professions students in return for the provision of full-time clinical services in a federally designated Health Professional Shortage Area. The NHSC Scholarship application collects information to select applicants for scholarship awards. The application information is necessary in order to determine those applicants that meet award criteria specified by Federal statute and regulation.

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Authorizing Statute(s): PL: Pub.L. 107 - 251 1533 Name of Law: Health Care Safety Net Amendments of 2002
   US Code: 42 USC 254 Name of Law: National Health Service Corps
  

Citations for New Statutory Requirements: None

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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 64731	10/20/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 81624	12/28/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Application for Participation in the National Health Service Corps Scholarship Program	NHSC_SP_001, NHSC_SP_002	NHSC_SP_001 ,   Acceptance & Declination Form
Data Collection Worksheet - School/Site Form	NHSC_SP_003	Data Collection Worksheet
Deferment Request Form - Participant Form	NHSC_SP_005	Deferment Request Form
Six-Month Service Obligation Verification Form - School/Sites Forms	NHSC_SP_004	Six-Month Service Obligation Verification Form

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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	3,660	1,800	0	1,860	0	0
Annual Time Burden (Hours)	7,270	5,400	0	1,115	755	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: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The OMB inventory of approved burden previously contained 5,400 hours for the NHSC application. This request is for 7,270 hours, for an increase of 1,870 hours. The increase in burden is a result of revisions in the forms and addition of forms. The previous burden estimate of 3 hour per respondent has been increased to 3.5 hours per respondent to include time for obtaining transcripts, academic and non-academic references and completing the new forms.

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Annual Cost to Federal Government: $1,508,041

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

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: 01/27/2011

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