The National Health Service Corps (NHSC) Loan Repayment Program

Forms and Documents

Document Name	Status
Form 1 The National Health Service Corps (NHSC) Loan Repayment Program Application Form and Instruction	Modified
Form 7 NHSC Site Application (including recertification) Form and Instruction	New
Form 6 NHSC Comprehensive Behavioral Health Services Checklist Form and Instruction	New
Form 5 Verification of Disadvantaged Background Form Form and Instruction	Modified
Form 4 Private Practice Option Form Form and Instruction	Modified
Form 3 Authorization for Disclosure of Loan Information Form Form and Instruction	Modified
Form 2 Privacy Act Release Authorization Form Form and Instruction	Modified
NHSC LRP FY 2017 Supporting Statement Final.docx Supporting Statement A	2017-01-05
FINALNPI2016 OMB Request for Non-Substantive Change - 09.14.16.docx Justification for No Material/Nonsubstantive Change	2016-09-28

IC Document Collections

IC ID	Document Title	Status
6365	The National Health Service Corps (NHSC) Loan Repayment Program Application Form and Instruction	Modified
225047	NHSC Site Application (including recertification) Form and Instruction	New
225046	NHSC Comprehensive Behavioral Health Services Checklist Form and Instruction	New
209462	Verification of Disadvantaged Background Form Form and Instruction	Modified
209461	Private Practice Option Form Form and Instruction	Modified
209460	Authorization for Disclosure of Loan Information Form Form and Instruction	Modified
181468	Privacy Act Release Authorization Form Form and Instruction	Modified

ICR Details

OMB Control No: 0915-0127	ICR Reference No: 201701-0915-003
Status: Historical Active	Previous ICR Reference No: 201609-0915-004
Agency/Subagency: HHS/HSA	Agency Tracking No: 20941
Title: The National Health Service Corps (NHSC) Loan Repayment Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/28/2017
	Date Received in OIRA: 01/09/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2020	36 Months From Approved	02/28/2017
Responses	23,575	0	9,350
Time Burden (Hours)	11,578	0	8,555
Cost Burden (Dollars)	0	0	0

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Abstract: The National Health Service Corps (NHSC) Loan Repayment Program (LRP) was established to assure an adequate supply of trained primary care health professionals to provide services in the neediest Health Professional Shortage Areas (HPSAs) of the United States. Under this program, the Department of Health and Human Services agrees to repay the qualifying educational loans of selected primary care health professionals. In return, the health professionals agree to serve for a specified period of time in a NHSC-approved site located in a federally-designated HPSA approved by the Secretary for LRP participants. The forms utilized by the LRP include the following: the NHSC LRP Application, the Authorization for Disclosure of Loan Information form, the Privacy Act Release Authorization form, and if applicable, the Verification of Disadvantaged Background form and the Private Practice Option form. The first four of the aforementioned NHSC LRP forms collect information that is needed for selecting participants and repaying qualifying educational loans. The last referenced form, the Private Practice Option Form, is needed to collect information for all participants who have applied for that service option. NHSC-approved sites are health care facilities that provide comprehensive outpatient, ambulatory, primary health care services to populations residing in HPSAs. Related in-patient services may be provided by NHSC-approved Critical Access Hospitals (CAHs). In order to become an NHSC-approved site, new sites must submit a Site Application for review and approval. Existing NHSC-approved sites are required to complete a Site Recertification Application in order to maintain their NHSC-approved status. Both the NHSC Site Application and Site Recertification Application request information on the clinical service site, sponsoring agency, recruitment contact, staffing levels, service users, charges for services, employment policies, and fiscal management capabilities. Assistance in completing these applications may be obtained through the appropriate State Primary Care Offices and the NHSC. The information collected on the applications is used for determining the eligibility of sites for the assignment of NHSC health professionals and to verify the need for NHSC clinicians. NHSC service site approval is valid for 3 years. Sites wishing to remain eligible for the assignment of NHSC providers, must submit a Site Recertification Application every 3 years.

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Authorizing Statute(s): US Code: 42 USC 2541 - 1(c), 333 [254f] (a)(1) 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 59229	08/29/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 1352	01/05/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 7

IC Title	Form No.	Form Name
Privacy Act Release Authorization Form	2	FY16 NHSC LRP Privacy Act Release Authorization Form
Authorization for Disclosure of Loan Information Form	3	FY16 NHSC Authorization for Disclosure of Loan Information
Private Practice Option Form	4	Private Practice Option
Verification of Disadvantaged Background Form	5	2016 NHSC LRP Verification of Disadvantaged Background Form
NHSC Comprehensive Behavioral Health Services Checklist	6	NHSC Behavioral Health Checklist
NHSC Site Application (including recertification)	7	site-app-user-guide FY 16.pdf
The National Health Service Corps (NHSC) Loan Repayment Program Application	1	2016 NHSC LRP Online Application User Guide

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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	23,575	9,350	0	14,225	0	0
Annual Time Burden (Hours)	11,578	8,555	0	3,023	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: Program has added two forms to this ICR, thus increasing the burden. New forms are the Behavioral Health Services Checklist and the NHSC Site Application.

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Annual Cost to Federal Government: $540,881

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]? Yes

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: 01/09/2017

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