NHSC LRP FY 2017 Supporting Statement Final

Health Resources and Services Administration

National Health Service Corps Loan Repayment Program

SUPPORTING STATEMENT- 0915-0127 Revision

A. JUSTIFICATION

1. Circumstances of Information Collection

This is a request for Office of Management and Budget (OMB) approval for a revision of the National Health Service Corps (NHSC) Loan Repayment Program (LRP) Application. An NHSC LRP application is required by 42 U.S.C. 2541-1(c). The current NHSC LRP regulations are found at 42 CFR Part 62. The current OMB approval number for the application (including the Authorization for Disclosure of Loan Information form, the Privacy Act Release Authorization form, the Verification of Disadvantaged Background form, and the Private Practice Option form) is 0915-0127, expiring on 01/31/2017. The legislative authority stating the need for the information collected in this application is found in Section 333 [254f] (a)(1) of the Public Health Service Act.

This request for a revision of approval streamlines the NHSC Site Application and Site Recertification Application (OMB Control Number 0915-0230) creating one condensed OMB clearance package under OMB number 0915-0127, thereby discontinuing 0915-0230. This condensed package also includes the addition of a new instrument (NHSC Comprehensive Behavioral Health Services Checklist) for information collection from NHSC-approved sites employing NHSC participants.

The NHSC LRP is administered by the Bureau of Health Workforce (BHW) in the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS). Under the NHSC LRP, HHS enters into contracts with selected primary care health professionals including behavioral and oral health providers who agree to provide culturally competent, interdisciplinary primary health care services to underserved populations located in Health Professional Shortage Areas (HPSAs) identified by the Secretary of HHS. In return, the NHSC LRP assists clinicians in their repayment of outstanding qualifying educational loans. Under current policy, the NHSC agrees to provide $60,000 in loan repayment in exchange for 2 years of full-time clinical service or 4 years of half-time clinical service.

2. Purpose and Use of Information

The purpose of this information collection is to obtain information through the NHSC LRP Application that is used to assess an LRP applicant’s eligibility and qualifications for the LRP, and to obtain information for NHSC site applicants. Clinicians interested in participating in the NHSC LRP must submit an application to the NHSC to participate in the program, and health care facilities must submit an NHSC Site Application and Site Recertification Application to determine the eligibility of sites to participate in the NHSC as an approved service site. The NHSC LRP participant application asks for personal, professional and financial information needed to determine the applicant's eligibility to participate in the NHSC LRP. In addition, applicants must provide information regarding the loans for which repayment is being requested. NHSC policy requires behavioral health providers to practice in a community-based setting that provides access to comprehensive behavioral health services. Accordingly, for those sites seeking to be assigned behavioral health NHSC participants, additional site information collected from an NHSC Comprehensive Behavioral Health Services Checklist will be used. NHSC sites that do not directly offer all required behavioral health services must demonstrate a formal affiliation with a comprehensive, community-based primary behavioral health setting or facility to provide these services.

3. Use of Improved Information Technology

This information collection activity is fully web-based. The NHSC LRP Application, application instructions and program information are available on the NHSC web site at http://nhsc.hrsa.gov/loanrepayment/index.html. The NHSC Site Application and Recertification Application is an interactive, online-based application which is fully accessible through the NHSC web site at http://nhsc.hrsa.gov/sites/. The NHSC Comprehensive Behavioral Health Services Checklist is downloadable from the NHSC web site at http://nhsc.hrsa.gov/downloads/bh-program-notification-checklist.pdf.

4. Efforts to Identify Duplication and Use of Similar Information

The information requested in the NHSC LRP Application, the NHSC Site Application and Recertification Application, and the NHSC Comprehensive Behavioral Health Services Checklists are specific to the applicant and unique to this program. The NHSC Site Application and Recertification Application is the only known mechanism for collecting site specific information that can be used for determining site eligibility, with the exception of data collected through site visits conducted by the NHSC Division of Regional Operations (DRO).

5. Involvement of Small Businesses or Other Small Entities

The information collection will not have a significant impact on small entities.

6. Consequences of Collecting the Information Less Frequently

The selection process for the NHSC LRP applicants necessitates the collection of required data prior to the NHSC entering into a contract for repayment of a clinician’s qualifying education loans. In the absence of collecting these data, review, selection, and approval of qualified applicants cannot be carried out. The NHSC LRP requests the information once each fiscal year until an applicant is awarded an NHSC LRP contract.

The selection process for NHSC sites necessitates the collection of required data prior to NHSC participants being allowed to serve at facilities providing behavioral health, oral health and primary health care services to ensure the sites are eligible entities in which NHSC can provide medical care to underserved populations. Once approved, these sites are required to submit a recertification application every 3 years to ensure adherence to program policy and guidelines.

The collection of data through the NHSC Comprehensive Behavioral Health Services Checklist is necessary from current NHSC-approved sites every 3 years when these sites complete the NHSC site recertification application to ensure that the sites either provide behavioral health care services or are affiliated with a facility providing behavioral health care services.

If the information were collected less frequently, the NHSC could not adequately evaluate sites and determine their eligibility to be approved NHSC sites for NHSC participant placement or transfer.

7. Special Circumstances Relating to the Guidelines in 5 CFR 1320.5 (d)(2)

This information collection is consistent with 5 CFR 1320.5 (d)(2).

8. Comments in Response to the Federal Register Notice/Outside Consultation

The notice required in 5 CFR 1320.8(d) was published in the Federal Register on August 29, 2016, Vol. 81, No. 167; pp. 59229 and 59230. There were no public comments.

The program has surveyed the following applicants and sites to obtain constructive feedback to improve the application, improve efficiency, and minimize the collection burden. There were no suggestions for changes or revisions.

The individuals contacted were former NHSC program participants and current NHSC site points of contact. Their contact information is as follows:

Kara Lampasone

13 Lakenheath Ct.

Potomac, MD 20854

(512) 921-9012

Goodland Family Health Center
106 Willow Road
Goodland, KS 67735
(785) 890-6075

Joan Susemihl

Plains Area Mental Health Center

180 10^th St. SE, Suite 201

Le Mars, IA 51031

712-546-4624

Abigail Rodriguez

Hartford Community Mental Health Center

2550 Main St #102

Hartford, CT 706094

(860) 548-0101

9. Explanation of any Payment/Gift to Respondents

Respondents will receive no remuneration.

10. Assurance of Confidentiality Provided to Respondents

Data collected on the individual NHSC LRP Application and the NHSC Site Application and Recertification Application are stored in a system of records as defined under the Privacy Act of 1974. The application is included in the System of Records Notice, "The Public Health Service and National Health Service Corps Health Care Provider Records System" (0915-0037). Information provided on each selected application will be maintained for at least 2 years and up to 10 years to permit the monitoring of NHSC LRP participants through the completion of their NHSC LRP service commitments.

The Right to Financial Privacy Act (RFPA), P.L. 95-630, regulates the Federal Government's access to the financial records of individuals maintained by a financial institution. Section 1102(a) prohibits Government access to financial records unless one of five procedures is used and the records are "reasonably described." The procedure being used by the NHSC LRP is described in Section 1104(a), which provides that an individual may authorize disclosure of his financial records if he signs a statement identifying the records and specifying the recipient and purpose of the disclosure. The relevant financial information collected through this application package complies with this requirement.

11. Justification for Sensitive Questions

Questions regarding race and ethnicity are asked in the online application; however, responses to these questions are optional. The disclosure of the applicant's Social Security Number (SSN) is required by Section 4 of the Debt Collection Act of 1982 (26 U.S.C. 6103) and the applicant provides this information on his/her lender statement(s). The disclosure of the SSN is required for participation in the program, since the amounts repaid to lenders must be reported to the Internal Revenue Service as "other income" on IRS Form 1099. Safeguards are followed concerning the use of the SSN in the Privacy Act of 1974 (5 U.S.C. 552a note).

12. Estimates of Annualized Hour and Cost Burden

12.A. Estimated Annualized Burden Hours

Type of Respondent	Form Name	Number of Respondents	Number of Responses per Respondent		Total Responses	Average Burden per Response (in hours)	Total Burden Hours
Applicant	NHSC LRP Application	8,200		1	8,200	1	8,200
Applicant	Authorization for Disclosure of Loan Information Form	6,500		1	6,500	.10	650
Applicant	Privacy Act Release Authorization Form	275		1	275	.10	27.5
Applicant	Verification of Disadvantaged Background Form	600		1	600	.50	300
Applicant	Private Practice Option Form	300		1	300	.10	30
*Health Care Facility	NHSC Comprehensive Behavioral Health Services Checklist	4,000		1	4,000	.13	520
*Health Care Facility	NHSC Site Application (including recertification)	3,700		1	3,700	.5	1,850
Total		23,575		----	23,575	----	11,577.50

*The respondent for this instrument is the health care facility where the applicant/participant fulfills his/her service obligation providing primary care health services.

The program estimates that the number of NHSC LRP applicants/respondents will average approximately 8,200 per year for the next 3 years. Each applicant must complete an online application once per fiscal year until they are awarded a NHSC LRP contract. The application consists of general information (name, address, school attended, degree obtained, employer, etc.) and information for each loan to be repaid. Information from different applicants may vary; however, it appears that the burden estimates for the forms remain reasonable based on consultation with previous respondents.

The number of NHSC Comprehensive Behavioral Health Services Checklist is an estimate of the number of existing NHSC and potential applicant sites expected to complete the instrument which is approximately 4,000. The checklist averages approximately 8 minutes to complete by a site administrator or designated site official.

Program estimates the number of NHSC Site Applications including recertification applications will average approximately 3,700 per year for the next three years (2,500 for new applications per year and 1,200 for recertification applications per year). The information requested takes approximately 30 minutes to complete by a site administrator or designated site official.

12. B. Estimated Annualized Burden Costs

Type of Respondent	Total Burden Hours	Hourly Wage Rate	Total Respondent Costs
NHSC LRP Applicant	7577.50	*$92.36	$699,857.90
Health Care Facility	4000	*$51.99	$207,960
Total	11,577.50		$907,817.90

*Based on Family and General Practitioners data at http://www.bls.gov/oes/current/oes_nat.htm#29-0000 and Medical and Health Service Manager data at http://www.bls.gov/bls/blswage.htm

There are no capital or start-up costs nor are there any operation and maintenance costs.

13. Estimates of other Total Annual Cost Burden to Respondents or Record Keepers/Capital Costs

Other than their time, there is no cost to respondents.

14. Estimates of Annualized Cost to the Government

Instrument	Base Pay Rate	Project Time per FTE	Number of FTEs	Total Annual Cost
NHSC Loan Repayment Program Online Application Contract	$77,490/(GS-12, Step 1)	.25	23	$445,569
NHSC Site Application including Recertification	$77,490/ (GS-12, Step 1)	.025	41	$79,427
NHSC Behavioral Health Services Checklist	$77,490/(GS-12, Step 1)	.005	41	$15,885
Total				$540,881

Processing of the NHSC LRP application and supporting forms (Authorization for Disclosure of Loan Information Form, Privacy Act Release Authorization Form, Verification of Disadvantaged Background Form, Private Practice Option Form) is handled internally through the BHW Business Management Information System Solution (BMISS) and by NHSC LRP staff. There are 23 FTEs involved in the processing of the applications. The cost for staff to process the applications and facilitate the loan repayment process for 23 GS-12, Step 1 employees at .25 full- time equivalent (FTE) rate is $445,569. The total estimated annual cost to the Government for the NHSC LRP application and supporting forms is $445,569.

Both the NHSC Site Application and Site Recertification Applications in addition to the Behavioral Heath Checklist are reviewed and processed internally by DRO staff with an average pay rate of $77,490 (equivalent to a GS-12, Step 1 at 2016 pay rate level). Approximately 41 DRO staff participate in reviewing the NHSC site applications including recertification applications in addition to the new Behavioral Heath Checklist at a rate of 41 GS 12, Step 1 employees at .005 FTE rate is $95,312. Project time spent on the processing activity increased and resulted in an increase of the total annual cost to the government from $79,427 to $95,312. due the time needed to process and review the new Behavioral Health Checklist. The addition of the checklist added an additional $15,885 to the overall cost burden. It is estimated that the annualized total cost to the government will be $95,312.

The grand total of costs to the government for all the instruments will be $540,881.

15. Explanation for Program Changes or Adjustments

The estimated total burden hours for this activity are 11,577.50 hours. This approximately 35% increase in burden hours from the previous burden hours (a difference of 3,022.5 hours) accounts for consolidation of the NHSC LRP OMB Clearance package with the NHSC Site Application OMB Clearance package into one package in addition to adding the new the NHSC Comprehensive Behavioral Health Services Checklist instrument to the OMB clearance package. The addition of the NHSC Site Application instrument adds 1,850 burden hours an increase of 350 over the previous number due to an increase average number of applications over the past three years and the NHSC Behavioral Health Checklist instrument adds an additional 520 burden hours to this package increasing the burden hours by 2,370. The remaining increase in burden by 652.5 is accounted for by an increase in the average number of respondents over the past three years for the Authorization for Disclosure of Loan Information Form and the Privacy Act Release Authorization Form due to updated data obtained from program.

16. Plans for Tabulation, Publication, and Project Time Schedule

There are no plans for tabulation, statistical analysis, or publication of data requested.

17. Reason(s) Display of OMB Expiration Date is Inappropriate

No exemption is requested.

18. Exceptions to Certification for Paperwork Reduction Act Submissions

There are no exceptions to the certification.