Application for Participation in the National Health Service Corps Scholarship Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 NHSC Scholarship Program Application	Form and Instruction	Modified	Available
Form 1 NHHSP - Acceptance/Verification of Good Standing Report	Form and Instruction	New	Available
Form 1 Native Hawaiian Health Scholarship Program Application	Form and Instruction	New	Available
Form 1 S2S LRP - Post Graduate Training Verification Form	Form and Instruction	New	Available
Form 1 S2S LRP - Verification of Disadvantaged Background	Form	New	Available
Form 1 S2S LRP - Receipt of Exceptional Financial Need Scholarship	Form	New	Repair queued
Form 1 S2S LRP – Acceptance/Verification of Good Standing Report	Form and Instruction	New	Available
Form 1 S2S LRP – Authorization to Release Information	Form and Instruction	New	Available
Form 1 NHSC Students to Service Program Application	Form and Instruction	New	Repair queued
Form 1 NHSC SP – Enrollment Verification Form	Form and Instruction	New	Available
Form 1 NHSC SP – Post Graduate Training Verification Form	Form and Instruction	New	Available
Form 1 NHSC SP – Data Collection Worksheet	Form and Instruction	New	Repair queued
Form 1 NHSC SP – Verification of Disadvantaged Background	Form	New	Available
Form 1 NHSC SP – Receipt of Exceptional Financial Need Scholarship	Form	New	Available
Form 1 NHSC SP – Acceptance/Verification of Good Standing Report	Form and Instruction	New	Available
Form 1 NHSC SP Authorization to Release Information	Form and Instruction	New	Available
Form NHSC_SP_005 Deferment Request Form	Form	Removed	Repair queued
Form NHSC_SP_004 Six-Month Service Obligation Verification Form	Form	Removed	Available
Form NHSC_SP_003 Data Collection Worksheet	Form	Removed	Available
Supporting Statement.docx	Supporting Statement A	Uploaded 2014-05-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6375	Application for Participation in the National Health Service Corps Scholarship Program	Form and Instruction	Modified	NHSC Scholarship Program Application
211173	NHHSP - Acceptance/Verification of Good Standing Report	Form and Instruction	New	NHHSP - Acceptance/Verification of Good Standing Report
211172	Native Hawaiian Health Scholarship Program Application	Form and Instruction	New	Native Hawaiian Health Scholarship Program Application
211171	S2S LRP - Post Graduate Training Verification Form	Form and Instruction	New	S2S LRP - Post Graduate Training Verification Form
211169	S2S LRP - Verification of Disadvantaged Background	Form	New	S2S LRP - Verification of Disadvantaged Background
211168	S2S LRP - Receipt of Exceptional Financial Need Scholarship	Form	New	S2S LRP - Receipt of Exceptional Financial Need Scholarship
211167	S2S LRP – Acceptance/Verification of Good Standing Report	Form and Instruction	New	S2S LRP – Acceptance/Verification of Good Standing Report
211166	S2S LRP – Authorization to Release Information	Form and Instruction	New	S2S LRP – Authorization to Release Information
211165	S2S LRP - Letters of Recommendation	Instruction	New
211164	NHSC Students to Service Program Application	Form and Instruction	New	NHSC Students to Service Program Application
211163	NHSC SP – Enrollment Verification Form	Form and Instruction	New	NHSC SP – Enrollment Verification Form
211162	NHSC SP – Post Graduate Training Verification Form	Form and Instruction	New	NHSC SP – Post Graduate Training Verification Form
211161	NHSC SP – Data Collection Worksheet	Form and Instruction	New	NHSC SP – Data Collection Worksheet
211160	NHSC SP – Verification of Disadvantaged Background	Form	New	NHSC SP – Verification of Disadvantaged Background
211159	NHSC SP – Receipt of Exceptional Financial Need Scholarship	Form	New	NHSC SP – Receipt of Exceptional Financial Need Scholarship
211157	NHSC SP – Acceptance/Verification of Good Standing Report	Form and Instruction	New	NHSC SP – Acceptance/Verification of Good Standing Report
211155	NHSC SP Authorization to Release Information	Form and Instruction	New	NHSC SP Authorization to Release Information
211154	NHSC SP Letters of Recommendation	Instruction	New
196055	Deferment Request Form - Participant Form	Form	Removed	Deferment Request Form
196054	Six-Month Service Obligation Verification Form - School/Sites Forms	Form	Removed	Six-Month Service Obligation Verification Form
196053	Data Collection Worksheet - School/Site Form	Form	Removed	Data Collection Worksheet

ICR Details

OMB Control No: 0915-0146	ICR Reference No: 201404-0915-001
Status: Historical Active	Previous ICR Reference No: 201101-0915-003
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Application for Participation in the National Health Service Corps Scholarship Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/03/2014
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/23/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2017	36 Months From Approved	06/30/2014
Responses	13,339	0	3,660
Time Burden (Hours)	8,200	0	7,270
Cost Burden (Dollars)	0	0	0

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Abstract: Administered by HRSA's Bureau of Clinician Recruitment and Service (BCRS), the National Health Service Corps (NHSC) Scholarship Program (SP), NHSC Students to Service Loan Repayment Program (S2S LRP), and the Native Hawaiian Health Scholarship Program (NHHSP), provide scholarships or loan repayment to qualified students who are pursuing primary care health professions education and training. In return, students agree to provide primary health care services in medically underserved communities located in federally designated Health Professional Shortage Areas (HPSAs) once they are fully trained and licensed health professionals. Awards are made to applicants who demonstrate the greatest potential for successful completion of their education and training as well as commitment to provide primary health care services to communities of greatest need. The program applications, forms, and supporting documentation are used to collect necessary information from applicants and participants that will facilitate in the selection of the best qualified candidates for these competitive awards, and to monitor participants' enrollment in school or in postgraduate training.

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Authorizing Statute(s): PL: Pub.L. 107 - 251 1533 Name of Law: Health Care Safety Net Amendments of 2002
   US Code: 42 USC 254d(i), l, m-q Name of Law: National Health Service Corps
   US Code: 42 USC 11709 Name of Law: The Native Hawaiian Health Care Improvement Act
  

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:
	79 FR 832	01/17/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 16013	03/24/2014
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 18

table that charts list of burden

IC Title	Form No.	Form Name
Application for Participation in the National Health Service Corps Scholarship Program	1	NHSC Scholarship Program Application
Data Collection Worksheet - School/Site Form	NHSC_SP_003	Data Collection Worksheet
Deferment Request Form - Participant Form	NHSC_SP_005	Deferment Request Form
NHHSP - Acceptance/Verification of Good Standing Report	1	NHHSP - Acceptance/Verification of Good Standing Report
NHSC SP Authorization to Release Information	1	NHSC SP Authorization to Release Information
NHSC SP Letters of Recommendation
NHSC SP – Acceptance/Verification of Good Standing Report	1	NHSC SP – Acceptance/Verification of Good Standing Report
NHSC SP – Data Collection Worksheet	1	NHSC SP – Data Collection Worksheet
NHSC SP – Enrollment Verification Form	1	NHSC SP – Enrollment Verification Form
NHSC SP – Post Graduate Training Verification Form	1	NHSC SP – Post Graduate Training Verification Form
NHSC SP – Receipt of Exceptional Financial Need Scholarship	1	NHSC SP – Receipt of Exceptional Financial Need Scholarship
NHSC SP – Verification of Disadvantaged Background	1	NHSC SP – Verification of Disadvantaged Background
NHSC Students to Service Program Application	1	NHSC Students to Service Program Application
Native Hawaiian Health Scholarship Program Application	1	Native Hawaiian Health Scholarship Program Application
S2S LRP – Authorization to Release Information	1	S2S LRP – Authorization to Release Information
S2S LRP - Letters of Recommendation
S2S LRP - Post Graduate Training Verification Form	1	S2S LRP - Post Graduate Training Verification Form
S2S LRP - Receipt of Exceptional Financial Need Scholarship	1	S2S LRP - Receipt of Exceptional Financial Need Scholarship
S2S LRP - Verification of Disadvantaged Background	1	S2S LRP - Verification of Disadvantaged Background
S2S LRP – Acceptance/Verification of Good Standing Report	1	S2S LRP – Acceptance/Verification of Good Standing Report
Six-Month Service Obligation Verification Form - School/Sites Forms	NHSC_SP_004	Six-Month Service Obligation Verification Form

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ICR Summary of Burden

table that charts list 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	13,339	3,660	0	9,679	0	0
Annual Time Burden (Hours)	8,200	7,270	0	930	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: Changing Forms

Short Statement: The OMB inventory of approved total burden previously contained 7,270 hours for the NHSC SP application and forms. Given the inclusion of the burden hours and information collection for the S2S LRP and NHHSP, there will be an increase in the request for total burden hours. The current request for the NHSC SP, S2S LRP, and NHHSP applications and forms is 8,200 burden hours (a difference of 930 hours).

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Annual Cost to Federal Government: $465,604

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

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: 04/23/2014

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