Information Collection

0127 NHSC Community Site Information Form

IC 181466 under ICR 201311-0915-003 · OMB 0915-0127.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0127 can be found here:

Documents and Forms

Document Name Document Type
Form 0127-2 0127 NHSC Community Site Information Form Form
0127-2 Employment Verification and Community Site Info For Employment Verification and Community Site Info Form.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	0127 NHSC Community Site Information Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 621

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0127-2	Employment Verification and Community Site Info For	Employment Verification and Community Site Info Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: The Public Health Service and National Health Service Corps Health Care Provider Records System	FR Citation: 58 FR 12968

Number of Respondents: 5,175	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-5,175	5,175
Annual IC Time Burden (Hours)	-3,881	3,881
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.