Participant Semi-Annual Employment Verification Form

The Nursing Education Loan Repayment Program

⚠️ Notice: This information collection may be referencing outdated material.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 4 Participant Semi-Annual Employment Verification Form Form and Instruction
4 ISV SAMPLE ISV_BMISS.pdf 2012.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Participant Semi-Annual Employment Verification Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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 and Instruction	4	ISV	SAMPLE ISV_BMISS.pdf 2012.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

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: 2,300	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	4,600	4,600
Annual IC Time Burden (Hours)	2,300	2,300
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.