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

Application for Participation in the National Health Service Corps Scholarship Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0146 can be found here:

Documents and Forms

Document Name Document Type
Form NHSC_SP_004 Six-Month Service Obligation Verification Form - School/Sites Forms Form
NHSC_SP_004 Six-Month Service Obligation Verification Form 6-Month Verification Form_revised_12012010.docx Form

Information Collection (IC) Details

IC Title:	Six-Month Service Obligation Verification Form - School/Sites Forms	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 62.6

Information Collection Instruments:

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

Line of Business: Health

Subfunction: Health Care Services

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

Number of Respondents: 700	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,400	1,400
Annual IC Time Burden (Hours)	700	700
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.