Information Collection

Application Checklist and Self-Certification Form

IC 182801 under ICR 201403-0915-003 · OMB 0915-0140.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0140 can be found here:

Documents and Forms

Document Name Document Type
Form NELRP_006 Application Checklist and Self-Certification Form Form
NELRP_006 Application Checklist and Self-Verification Form FY 11 Forms Package.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application Checklist and Self-Certification 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 Part 57 Section 312 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	NELRP_006	Application Checklist and Self-Verification Form	FY 11 Forms Package.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

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

Number of Respondents: 8,000	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	-8,000	8,000
Annual IC Time Burden (Hours)	-4,000	4,000
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.