Form 1 Travel Request Worksheet

NHSC Travel Request Worksheet

NHSC Travel Form 0278 Form 11-2015

NHSC Travel Request Worksheet

OMB: 0915-0278

Document [doc]
Download: doc | pdf

Form Approved

OMB No.0915-0278

Exp. Date

National Health Service Corps

Scholar Travel Request Worksheet

Non-Federal Personnel


Traveler’s Name:

Home Phone:

Work Phone:


Mailing Address:


Fax

Number:

Cell Phone:

E-Mail

Address:

Placement Year of Scholar:


Discipline:




Specialty:


Dates of Travel:

From:

To:

From:

City/St



To:

City/St


Destination Site Name/Address:




Site ID (UDS#):


Status of Site:

HPSA Score:


Remarks:







Type of Travel
Licensure


Pre-Employment Site Visit:



MUST CHECK ONE BOX

Initial Match

Site Assignment




For relocation and transfer, does the traveler have a permanent license to practice in State of service?


Permanent Change of Station

Relocation




YES


Initial Match

Site Assignment




NO


Other (specify below)








Signature of Requesting

Official, NHSC:


Date:




PUBLIC BURDEN STATEMENT

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB control number for this project is 0915-0278. Public reporting burden for this collection of information is estimated to average 4 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.


Privacy Act Notice – The Privacy Act of 1974 (5 U.S.C. 552a) requires that an agency provide the following notice to each individual whom it asks for information. (1) The authority for collecting information requested on this form is found in Title III, Part D, Subpart II of the Public Health Service Act (42 U.S.C. 254d(c).


File Typeapplication/msword
File TitleB L Seamon & Associates, Inc
AuthorBrad Seamon
Last Modified Bykthomas
File Modified2015-11-19
File Created2015-11-19

© 2024 OMB.report | Privacy Policy