Six-Month Service Obligation Verification Form - School/Sites Forms

Application for Participation in the National Health Service Corps Scholarship Program

OMB: 0915-0146

IC ID: 196054

Information Collection (IC) Details

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Six-Month Service Obligation Verification Form - School/Sites Forms
 
No New
 
Required to Obtain or Retain Benefits
 
42 CFR 62.6

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form NHSC_SP_004 Six-Month Service Obligation Verification Form 6-Month Verification Form_revised_12012010.docx Yes Yes Fillable Fileable

Health Health Care Services

Public Health Service National Health Service Corps Scholarship/Loan Repayment Participants Records System  58 FR 12968

700 0
   
Individuals or Households
 
   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 1,400 0 1,400 0 0 0
Annual IC Time Burden (Hours) 700 0 700 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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