Information Collection

Application for Participation in the National Health Service Corps Scholarship Program

IC 6375 under ICR 201101-0915-003 · OMB 0915-0146.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form NHSC_SP_001 NHSC_SP_001 Application for Participation in the National Health Service Corps Scholarship Program	Form
Form NHSC_SP_002 Acceptance & Declination Form Application for Participation in the National Health Service Corps Scholarship Program	Form
FY2011 NHSC SP Guidance 10.25.10.docx	Instruction
NHSC_SP_001 NHSC_SP_001 Instructions and Forms 2011.docx	Form
NHSC_SP_002 Acceptance & Declination Form NHSC Applicant acceptance or denial letter-revised.doc	Form

IC Title:

Application for Participation in the National Health Service Corps Scholarship Program

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 62.6

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	NHSC_SP_001	Yes	Yes	Fillable Fileable
Instruction		Yes	Yes	Fillable Fileable
Form	NHSC_SP_002	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: 1,800

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,800	0	1,800
Annual IC Time Burden (Hours)	6,155	755	5,400
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.

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