National Health Service Corps Scholar Travel Request Worksheet
SUPPORTING STATEMENT
Terms of Clearance: None
A. Justification
1. Circumstances Making the Collection of Information Necessary
This is a request for Office of Management and Budget (OMB) approval of changes made to the Health Resources and Services Administration (HRSA), National Health Service Corps (NHSC), Travel Request Worksheet (TRW), which will now be referred to as Scholar Travel Request Worksheet (STRW). The OMB number for the STRW is 0915-0278, and the current expiration date is February 28, 2013. This form is used for requests for pre-employment site visit(s) and relocation to an NHSC authorized site(s) for the purpose of securing employment in a clinical practice in which to fulfill the NHSC service commitment. The Public Health Service Act, Section 331(c) states that the Secretary may reimburse applicants for positions in the Corps (including individuals considering entering into a written agreement pursuant to section 338(d) for actual and reasonable expenses incurred in traveling to and from their place of residence to a health professional shortage area (designated under section 332) to which they may be assigned. The Secretary shall not reimburse an applicant for more than one such trip to the same approved site.
The NHSC was established by Congress for the purpose of eliminating health professional shortages in Health Professional Shortage Areas (HPSAs). HPSAs are geographic areas, facilities or population groups determined by the Secretary of Health and Human Service to have a shortage of health professionals. The NHSC provides funding support to encourage selected primary health care professionals to practice in HPSAs. This program is located in HRSA’s, Bureau of Clinician Recruitment and Service (BCRS).
2. Purpose and Use of Information Collection
The purpose of this form is to ensure that the program can effectively and efficiently monitor authorized travel for NHSC clinicians. The STRW form is utilized to expedite the travel approval process for physicians, dentists, nurse practitioners, certified nurse midwives, and physician assistants to site visit(s) and relocation requests when the scholarship recipient has secured an interview at an NHSC approved site(s) and has notified their respective NHSC contact. Such advance notice ensures that the scholarship recipient is fully prepared for the site visit and maximizes the available NHSC travel funding. Utilization of this form avoids unauthorized travel to unapproved NHSC sites and provides more efficient monitoring of travel allotments for each clinician.
3. Use of Improved Information Technology and Burden Reduction
This form is fully electronic. The automated form assists clinicians in requesting approval for travel for site visits before executing an employment agreement and for requests for relocation assistance in a timely manner.
4. Efforts to Identify Duplication and Use of Similar Information
The information requested only pertains to scholar placement and practice considerations and is available only from the scholar and the NHSC.
5. Impact on Small Businesses or Other Small Entities
This information collection does not involve small businesses or other small entities.
6. Consequences of Collecting the Information Less Frequently
Without this form the Program can not effectively monitor clinician travel and avoid unauthorized travel. Each clinician has a maximum travel allotment of $1,200 available from which authorized expenses will be deducted. The STRW is used each time a clinician submits a request for travel for site visits or requests relocation assistance. This form is needed to efficiently monitor travel for clinicians.
7. Special Circumstances Relating to the Guidelines in 5 CFR 1320.5
The information will be collected in a manner consistent with guidelines contained in 5CFR 1320.5.
8. Comments in Response to the Federal Register Notice/ Outside Consultation
A 60-day Federal Register Notice was published in the Federal Register on October 17, 2012, vol.77, No. 201; pp. 63841. There were no public comments.
The following individuals were contacted for consultation regarding the clarity and format of the data collection instrument and the frequency of collection:
Amy K. McIntyre, M.D.
1140 West Diamond Street
Butte, MT 59701
(401) 323-0114
Laila Dantas, D.D.S.
19 Wigglesworth Dr
Roxbury Crossing, MA 02120
(508) 287-9203
Monica N. Williams, D.D.S.
333 Nelson St. SW Unit 417
Atlanta, GA 30313
(404) 971-9919
9. Explanation of any Payment/Gift to Respondents
Respondents will not be remunerated.
10. Assurance of Confidentiality Provided to Respondents
The Privacy Act of 1974 (5 U.S.C. 522a) requires an agency to provide notification to individuals who supply information. The required Privacy Act notification is included on the proposed form. Access to these records is strictly limited to all authorized NHSC principal staff that are aware of their responsibilities under the Privacy Act.
Disclosure of the applicant’s Social Security Number (SSN) is required for reimbursement of NHSC applicants. The records associated with the information collection are protected by the Privacy Act. In accordance with the requirements of the Privacy Act, HRSA has established the system of records entitled, “Public Health and National Health Service Corps (PH/NHSC) Scholarship Training Program, Physician Shortage Area Scholarship Program (PSASP), National Health Service Corps Scholarship Program (NHSC SP), National Health Service Corps Loan Repayment Program (NHSC LRP), NHSC Student/Resident Experiences and Rotations in Community Health (SEARCH), Nursing Education Loan Repayment Program (NELRP), Nursing Scholarship Program (NSP), Native Hawaiian Health Scholarship Program (NHHSP), and Faculty Loan Repayment Program (FLRP), Applicants and/or Participants Records System, HHS/HRSA/BCRS,” No. 09-15-0037, which contains information on NHSC scholarship recipients.
11. Justification for Sensitive Questions
There is one question of a sensitive nature. The social security number is required of scholarship recipients for purposes of reimbursement. The authority for collecting this information is found in Title III, Part D, Subpart II of the Public Health Service Act (42 U.S.C. 254D).
12. Estimates of Annualized Hour and Cost Burden
The burden estimate is as follows:
Form |
Number of Respondents |
Responses per Respondent |
Hours per Response |
Total Hour Burden |
Wage Rate |
Total Hour Cost |
STRW |
180 |
2 |
.0667 |
24 |
$30 |
$720.00 |
The burden is based upon discussions with respondents who have completed the form, and who reported that the form takes approximately 4 minutes to complete. Based on the advice of the respondents the estimate for 4 minutes to complete the application is (180 respondents x 2 annual applications x 4 minutes each / 60 minutes = 24 hours)
13. Estimates of Other Total Annual Cost Burden to Respondents or
Record-keepers/Capital Costs
There is no capital or start up costs, nor is there any operation or maintenance costs to the respondents.
14. Annualized Cost to the Federal Government
The estimated annualized cost to the Government is approximately $1076.40. This cost is calculated as follows:
Reviewing and researching the travel request received for a determination of approval or denial of such request. GS-12 Federal employee at $35.88 per hour for 30 hours = $1076.40.
15. Explanation for Program Changes or Adjustments
This current burden for this project is 16.8 hours. This request is for a total of 24 hours, an increase of 7.8 hours. This is a program adjustment, as the increase is due to an estimate of more respondents due to an increase in the amount of scholars awarded.
16. Plans for Tabulation, Publication, and Project Time Schedule
There are no plans for tabulation, analysis or publications from this activity.
17. Reason(s) Display of OMB Expiration Date is Inappropriate
The expiration date will be displayed.
18. Exceptions to Certification for Paperwork Reduction Act Submissions
There are no exceptions to the certification.
| File Type | application/msword |
| File Title | NHSC TRAVEL REQUEST WORKSHEET |
| Author | HRSA |
| Last Modified By | chartley |
| File Modified | 2012-11-30 |
| File Created | 2012-03-27 |