National Health Service Corps Ambassador Portal

Forms and Documents

Document	Type	Status	Availability
Form 1 NHSC Ambassador Portal	Form and Instruction	New	Available
Supporting Statement.docx	Supporting Statement A	Uploaded 2014-05-29	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
211727	NHSC Ambassador Portal	Form and Instruction	New

ICR Details

OMB Control No: 0915-0388	ICR Reference No: 201405-0915-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: National Health Service Corps Ambassador Portal
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/14/2014
	Date Received in OIRA: 06/03/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2017	36 Months From Approved
Responses	700	0	0
Time Burden (Hours)	70	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The need and purpose of this information collection is to create a database where interested parties can search for NHSC Ambassadors (that meet specific search criteria) to serve as local resources on the NHSC programs. The other purpose is that NHSC can have access to volunteers who are available to spread important programmatic information on behalf of the NHSC.

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Authorizing Statute(s): US Code: 42 USC 254I Name of Law: Public Health Service Act Section 338A
   US Code: 42 USC 254m-q Name of Law: Public Health Service Act Section 338C-H
   US Code: 42 USC 254I-1 Name of Law: Public Health Service Act Section 338B
   US Code: 42 USC 254d(i) Name of Law: Public Health Service Act Section 331 (i)
  

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 14056	03/12/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 30626	05/28/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
NHSC Ambassador Portal	1	NHSC Ambassador Portal

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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	700	0	0	700	0	0
Annual Time Burden (Hours)	70	0	0	70	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: No

Burden Reduction Due to:

Short Statement: This is a new information collection.

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Annual Cost to Federal Government: $13,459

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: 06/03/2014

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