Information Collection

NHSC Information Follow-up Form

IC 195587 under ICR 201704-0915-002 · OMB 0915-0337.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0337 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 NHSC-NC Int Capt Form - Attachment D.docx NHSC Information Follow-up Form	Form
1 NHSC-NC Int Capt Form - Attachment D.docx NHSC-NC Int Capt Form - Attachment D.docx	Form

IC Title:

NHSC Information Follow-up Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1				No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,400	2,400
Annual IC Time Burden (Hours)	60	60
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.

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