Scholarships for Disadvantaged Students Application Program Specific Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Scholarships for Disadvantaged Students (SDS) Program Application Form	Form and Instruction	Modified	Available
Form 2 Scholarships for Disadvantaged Students Performance Report Form	Form and Instruction	Removed	Available
SSA-SDS FINAL 3-3-17doc.doc	Supporting Statement A	Uploaded 2017-03-03	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6377	Scholarships for Disadvantaged Students (SDS) Program Application Form	Form and Instruction	Modified
209465	Scholarships for Disadvantaged Students Performance Report Form	Form and Instruction	Removed

ICR Details

OMB Control No: 0915-0149	ICR Reference No: 201612-0915-003
Status: Historical Active	Previous ICR Reference No: 201311-0915-004
Agency/Subagency: HHS/HSA	Agency Tracking No: 20517
Title: Scholarships for Disadvantaged Students Application Program Specific Form
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: 03/03/2017
	Date Received in OIRA: 12/08/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2020	36 Months From Approved	03/31/2017
Responses	400	0	598
Time Burden (Hours)	5,200	0	9,952
Cost Burden (Dollars)	0	0	0

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Abstract: Information collected for the SDS application is needed by the Department to identify interested applicants to the Program. It is used to determine whether applicant schools meet the requirements of enabling legislation, to determine eligibility for program participation, and to establish priority points for funding. Each school will determine the eligibility of students based on financial need and whether a student is from a disadvantaged background. Eligible applicants are accredited schools of medicine, osteopathic medicine, dentistry, nursing, pharmacy, podiatric medicine, optometry, veterinary medicine, public health, chiropractic, allied health, a school offering a graduate program in behavioral and mental health practice, or an entity providing programs for the training of physician assistants.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 7101 Name of Law: Affordable care Act of 2010
   PL: Pub.L. 105 - 392 737 Name of Law: Scholarships for Disadvantaged Students
   US Code: 42 USC 293a Name of Law: Public Health Service 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:
	81 FR 46941	07/19/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 86720	12/01/2016
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Scholarships for Disadvantaged Students (SDS) Program Application Form	1	SDS Program Specific Form.pdf
Scholarships for Disadvantaged Students Performance Report Form	2, 2b	SDSPR ,   SDSPR guidance

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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	400	598	0	0	-198	0
Annual Time Burden (Hours)	5,200	9,952	0	0	-4,752	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There is a decrease in burden as a form has been removed from this revision, thus reducing the burden for this ICR.

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Annual Cost to Federal Government: $26,400

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]? Yes

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: 12/08/2016

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