The National Health Service Corps (NHSC) Loan Repayment Program

Forms and Documents

Document Name	Status
Form 1 The National Health Service Corps (NHSC) Loan Repayment Program Application Form and Instruction	Modified
Form 5 Verification of Disadvantaged Background Form Form and Instruction	New
Form 4 Private Practice Option Form Form and Instruction	New
Form 3 Authorization for Disclosure of Loan Information Form Form and Instruction	New
Form 0127-6 NHSC Self-Certification Form Form	Removed
Form 0127-5 NHSC Alumni Database Form	Removed
Form 2 Privacy Act Release Authorization Form Form and Instruction	Modified
Form 0127-3 0127 NHSC Loan Information and Verification Form Form	Removed
Form 0127-2 0127 NHSC Community Site Information Form Form	Removed
Supporting Statement.docx Supporting Statement A	2013-11-19

IC Document Collections

IC ID	Document Title	Status
6365	The National Health Service Corps (NHSC) Loan Repayment Program Application Form and Instruction	Modified
209462	Verification of Disadvantaged Background Form Form and Instruction	New
209461	Private Practice Option Form Form and Instruction	New
209460	Authorization for Disclosure of Loan Information Form Form and Instruction	New
195406	NHSC Self-Certification Form Form	Removed
195405	NHSC Alumni Database Form	Removed
181468	Privacy Act Release Authorization Form Form and Instruction	Modified
181467	0127 NHSC Loan Information and Verification Form Form	Removed
181466	0127 NHSC Community Site Information Form Form	Removed

ICR Details

OMB Control No: 0915-0127	ICR Reference No: 201311-0915-003
Status: Historical Active	Previous ICR Reference No: 201011-0915-003
Agency/Subagency: HHS/HSA	Agency Tracking No: 20941
Title: The National Health Service Corps (NHSC) Loan Repayment 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: 01/27/2014
	Date Received in OIRA: 11/22/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2017	36 Months From Approved	01/31/2014
Responses	9,350	0	41,225
Time Burden (Hours)	8,555	0	12,128
Cost Burden (Dollars)	0	0	0

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Abstract: The National Health Service Corps (NHSC) Loan Repayment Program (LRP) was established to assure an adequate supply of trained primary care health professionals to provide services in the neediest Health Professional Shortage Areas. Under this program, HHS agrees to repay the educational loans of the primary health care professionals. In return, the health professionals agree to service for a specified period of time in a federally designated HPSA approved by the Secretary for LRP participants.

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Authorizing Statute(s): PL: Pub.L. 107 - 205 836h Name of Law: National Education Loan Repayment Program
   US Code: 42 USC 2541 Name of Law: NHSC Scholarship Program and Loan Repayment Program
   PL: Pub.L. 107 - 205 846 Name of Law: Nurse Reinvestment Act
   PL: Pub.L. 111 - 5 VIII Name of Law: American Recovery and Reinvestment Act
   PL: Pub.L. 111 - 148 5207 Name of Law: Patient Protection and Affordable Care Act of 2010
  

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:
	78 FR 54661	09/05/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 69696	11/20/2013
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 5

IC Title	Form No.	Form Name
The National Health Service Corps (NHSC) Loan Repayment Program Application	1	NHSC LRP Application
0127 NHSC Community Site Information Form	0127-2	Employment Verification and Community Site Info For
NHSC Self-Certification Form	0127-6	NHSC Self-Certification
Private Practice Option Form	4	Private Practice Option Form
Verification of Disadvantaged Background Form	5	Verification of Disadvantaged Background Form
Privacy Act Release Authorization Form	2	Privacy Act Release Authorization Form
Authorization for Disclosure of Loan Information Form	3	Authorization for Disclosure of Loan Information Form
0127 NHSC Loan Information and Verification Form	0127-3	Loan Information and Verification Form
NHSC Alumni Database	0127-5	Alumni contact info

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ICR Summary 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	9,350	41,225	0	-31,875	0	0
Annual Time Burden (Hours)	8,555	12,128	0	-3,573	0	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The estimated total burden hours for this activity are 8,555 hours. This substantial decrease in burden hours (a difference of 3,573 hours) accounts for the streamlined application. The current online application incorporates a majority of the supporting and supplemental documents, thereby significantly reducing the number of burden hours spent by respondents. The modified application also lowers the number of responses needed from respondents, from 41,225 to 9,350 responses. Additionally, it is important to note that some of the forms may not be applicable and/or required by all participants. For example, the Private Practice Option is one such form that is only completed by those participants interested in exercising this particular service option. As a result, these form adjustments serve as another factor impacting the number of responses and burden hours for this activity.

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Annual Cost to Federal Government: $449,232

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]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Yes

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: 11/22/2013

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