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Participant Semi-Annual Employment Verification Form
NURSE Corps Loan Repayment Program
OMB: 0915-0140
IC ID: 182803
OMB.report
HHS/HSA
OMB 0915-0140
ICR 201704-0915-005
IC 182803
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0140 can be found here:
2023-01-05 - Extension without change of a currently approved collection
2022-12-27 - Extension without change of a currently approved collection
Documents and Forms
Document Name
Document Type
Form 1
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
Information Collection (IC) Details
View Information Collection (IC)
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:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
1
NC LRP_Participant Semi-Annual Employ Verfic Form.docx
NC LRP_Participant Semi-Annual Employ Verfic Form.docx
Yes
Yes
Fillable Fileable
Form and Instruction
2
NC LRP-Authorization to Release Employment Information.docx
NC LRP-Authorization to Release Employment Information.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
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 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
4,600
0
0
0
0
4,600
Annual IC Time Burden (Hours)
2,300
0
0
0
0
2,300
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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.