Information Collection

Participant Semi-Annual Employment Verification Form

IC 182803 under ICR 201704-0915-005 · OMB 0915-0140.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0140 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 NC LRP_Participant Semi-Annual Employ Verfic Form.docx Participant Semi-Annual Employment Verification Form	Form and Instruction
Form 2 NC LRP-Authorization to Release Employment Information.docx Participant Semi-Annual Employment Verification Form	Form and Instruction
1 NC LRP_Participant Semi-Annual Employ Verfic Form.docx NC LRP_Participant Semi-Annual Employ Verfic Form.docx	Form and Instruction
2 NC LRP-Authorization to Release Employment Information.d NC LRP-Authorization to Release Employment Information.docx	Form and Instruction

IC Title:

Participant Semi-Annual Employment Verification Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 31 CFR 208, 210 5 CFR 1320.8(d) 42 CFR Part 57 Section 312 (To search for a specific CFR, visit the Code of Federal Regulations.)

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 and Instruction	1				Yes	Yes	Fillable Fileable
Form and Instruction	2				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

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 %

table that charts list of burden
	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

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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