The National Health Service Corps Scholarship Program, Students to Service Loan Repayment Program, and the Native Hawaiian Health Scholarship Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 FY 2017 NHSC SP Application Content.pdf	Form and Instruction	Modified	Available
Form 1 NHHSP - Acceptance/Verification of Good Standing Report	Form and Instruction	Removed	Available
Form 4 NHHSP Verification of Good Standing.docx	Form	Modified	Available
Form 3 NHHSP Authorization to Release Information.docx	Form	Modified	Available
Form 2 NHHSP Letters of Recommendation Forms.docx	Form	Modified	Available
Form 1 NHHSP 2017-2018 Online Application and Forms.docx	Form and Instruction	Modified	Available
Form 1 S2S LRP - Post Graduate Training Verification Form	Form and Instruction	Removed	Available
Form 1 FY 2017 NHSC S2S LRP Disadvantaged Background.docx	Form and Instruction	Modified	Available
Form 1 S2S LRP - Receipt of Exceptional Financial Need Scholarship	Form	Removed	Available
Form 1 FY 2017 NHSC S2S LRP Verification of Good Standing.docx	Form and Instruction	Modified	Available
Form 1 FY 2017 NHSC S2S LRP Authorization to Release.docx	Form and Instruction	Modified	Available
Form 2 FY 2017 NHSC S2S LRP Additional Letter of Recommendation Instructions.docx	Form and Instruction	Modified	Repair queued
Form 1 FY 2017 NHSC S2S LRP Preceptor Letter of Recommendation Instructions.docx	Form and Instruction	Modified	Available
Form 1 FY 2017 NHSC S2S LRP Application Content.pdf	Form and Instruction	Modified	Available
Form 1 NHSC SP Enrollment Verification Form.pdf	Form and Instruction	Modified	Available
Form 1 FY 2017 NHSC Post Graduate Training Verification.pdf	Form and Instruction	Modified	Available
Form 1 NHSC SP Data Collection Worksheet Form.pdf	Form and Instruction	Modified	Available
Form 1 FY 2017 NHSC SP Disadvantaged Background.docx	Form and Instruction	Modified	Available
Form 1 FY 2017 NHSC SP Verification of Exceptional Financial Need Scholarship.docx	Form and Instruction	Modified	Available
Form 1 FY 2017 NHSC SP Verification of Good Standing.docx	Form and Instruction	Modified	Available
Form 1 FY 2017 NHSC SP Authorization to Release.docx	Form and Instruction	Modified	Available
Form 1 FY 2017 NHSC SP Recommendation Letter Email Instructions.docx	Form and Instruction	Modified	Available
FINAL Supporting Statement_0915-0146_6-2-17.docx	Supporting Statement A	Uploaded 2017-06-06	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6375	Application for Participation in the National Health Service Corps Scholarship Program	Form and Instruction	Modified	FY 2017 NHSC SP Application Content.pdf
6375	Application for Participation in the National Health Service Corps Scholarship Program	Instruction	Modified
211173	NHHSP - Acceptance/Verification of Good Standing Report	Form and Instruction	Removed	NHHSP - Acceptance/Verification of Good Standing Report
211172	Native Hawaiian Health Scholarship Program Application	Form	Modified	NHHSP Verification of Good Standing.docx
211172	Native Hawaiian Health Scholarship Program Application	Form	Modified	NHHSP Authorization to Release Information.docx
211172	Native Hawaiian Health Scholarship Program Application	Form	Modified	NHHSP Letters of Recommendation Forms.docx
211172	Native Hawaiian Health Scholarship Program Application	Form and Instruction	Modified	NHHSP 2017-2018 Online Application and Forms.docx
211172	Native Hawaiian Health Scholarship Program Application	Instruction	Modified
211171	S2S LRP - Post Graduate Training Verification Form	Form and Instruction	Removed	S2S LRP - Post Graduate Training Verification Form
211169	S2S LRP - Verification of Disadvantaged Background	Form and Instruction	Modified	FY 2017 NHSC S2S LRP Disadvantaged Background.docx
211168	S2S LRP - Receipt of Exceptional Financial Need Scholarship	Form	Removed	S2S LRP - Receipt of Exceptional Financial Need Scholarship
211167	S2S LRP – Acceptance/Verification of Good Standing Report	Form and Instruction	Modified	FY 2017 NHSC S2S LRP Verification of Good Standing.docx
211166	S2S LRP – Authorization to Release Information	Form and Instruction	Modified	FY 2017 NHSC S2S LRP Authorization to Release.docx
211165	S2S LRP - Letters of Recommendation	Form and Instruction	Modified	FY 2017 NHSC S2S LRP Additional Letter of Recommendation Instructions.docx
211165	S2S LRP - Letters of Recommendation	Form and Instruction	Modified	FY 2017 NHSC S2S LRP Preceptor Letter of Recommendation Instructions.docx
211164	NHSC Students to Service Program Application	Form and Instruction	Modified	FY 2017 NHSC S2S LRP Application Content.pdf
211164	NHSC Students to Service Program Application	Instruction	Modified
211163	NHSC SP – Enrollment Verification Form	Form and Instruction	Modified	NHSC SP Enrollment Verification Form.pdf
211162	NHSC SP – Post Graduate Training Verification Form	Form and Instruction	Modified	FY 2017 NHSC Post Graduate Training Verification.pdf
211161	NHSC SP – Data Collection Worksheet	Form and Instruction	Modified	NHSC SP Data Collection Worksheet Form.pdf
211160	NHSC SP – Verification of Disadvantaged Background	Form and Instruction	Modified	FY 2017 NHSC SP Disadvantaged Background.docx
211159	NHSC SP – Receipt of Exceptional Financial Need Scholarship	Form and Instruction	Modified	FY 2017 NHSC SP Verification of Exceptional Financial Need Scholarship.docx
211157	NHSC SP – Acceptance/Verification of Good Standing Report	Form and Instruction	Modified	FY 2017 NHSC SP Verification of Good Standing.docx
211155	NHSC SP Authorization to Release Information	Form and Instruction	Modified	FY 2017 NHSC SP Authorization to Release.docx
211154	NHSC SP Letters of Recommendation	Form and Instruction	Modified	FY 2017 NHSC SP Recommendation Letter Email Instructions.docx

ICR Details

OMB Control No: 0915-0146	ICR Reference No: 201706-0915-003
Status: Historical Active	Previous ICR Reference No: 201609-0915-005
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: The National Health Service Corps Scholarship Program, Students to Service Loan Repayment Program, and the Native Hawaiian Health Scholarship 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: 07/25/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/15/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2020	36 Months From Approved	07/31/2017
Responses	13,085	0	13,339
Time Burden (Hours)	8,074	0	8,200
Cost Burden (Dollars)	0	0	0

---

Abstract: Administered by HRSA’s Bureau of Health Workforce (BHW), the National Health Service Corps (NHSC) Scholarship Program (SP), NHSC Students to Service Loan Repayment Program (S2S LRP), and the Native Hawaiian Health Scholarship Program (NHHSP), provide scholarships or loan repayment to qualified students who are pursuing primary care health professions education and training. In return, students agree to provide primary health care services in medically underserved communities located in federally designated Health Professional Shortage Areas (HPSAs) once they are fully trained and licensed health professionals. Awards are made to applicants who demonstrate the greatest potential for successful completion of their education and training as well as commitment to provide primary health care services to communities of greatest need. The program applications, forms, and supporting documentation are used to collect necessary information from applicants and participants that will facilitate in the selection of the best qualified candidates for these competitive awards, and to monitor participants’ enrollment in school or in postgraduate training.

---

Authorizing Statute(s): US Code: 42 USC Sect. 338A 254d(i), l, m-q Name of Law: National Health Service Corps
   US Code: 42 USC Sect. 338B 254d(i), l, 3331(i) Name of Law: National Health Service Corps
   US Code: 42 USC 11709 Name of Law: The Native Hawaiian Health Care Improvement Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 15225	03/27/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 27513	06/15/2017
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 15

table that charts list of burden

IC Title	Form No.	Form Name
Application for Participation in the National Health Service Corps Scholarship Program	1	FY 2017 NHSC SP Application Content.pdf
NHHSP - Acceptance/Verification of Good Standing Report	1	NHHSP - Acceptance/Verification of Good Standing Report
NHSC SP Authorization to Release Information	1	FY 2017 NHSC SP Authorization to Release.docx
NHSC SP Letters of Recommendation	1	FY 2017 NHSC SP Recommendation Letter Email Instructions.docx
NHSC SP – Acceptance/Verification of Good Standing Report	1	FY 2017 NHSC SP Verification of Good Standing.docx
NHSC SP – Data Collection Worksheet	1	NHSC SP Data Collection Worksheet Form.pdf
NHSC SP – Enrollment Verification Form	1	NHSC SP Enrollment Verification Form.pdf
NHSC SP – Post Graduate Training Verification Form	1	FY 2017 NHSC Post Graduate Training Verification.pdf
NHSC SP – Receipt of Exceptional Financial Need Scholarship	1	FY 2017 NHSC SP Verification of Exceptional Financial Need Scholarship.docx
NHSC SP – Verification of Disadvantaged Background	1	FY 2017 NHSC SP Disadvantaged Background.docx
NHSC Students to Service Program Application	1	FY 2017 NHSC S2S LRP Application Content.pdf
Native Hawaiian Health Scholarship Program Application	3, 2, 4, 1	NHHSP 2017-2018 Online Application and Forms.docx ,   NHHSP Letters of Recommendation Forms.docx ,   NHHSP Authorization to Release Information.docx ,   NHHSP Verification of Good Standing.docx
S2S LRP – Authorization to Release Information	1	FY 2017 NHSC S2S LRP Authorization to Release.docx
S2S LRP - Letters of Recommendation	1, 2	FY 2017 NHSC S2S LRP Preceptor Letter of Recommendation Instructions.docx ,   FY 2017 NHSC S2S LRP Additional Letter of Recommendation Instructions.docx
S2S LRP - Post Graduate Training Verification Form	1	S2S LRP - Post Graduate Training Verification Form
S2S LRP - Receipt of Exceptional Financial Need Scholarship	1	S2S LRP - Receipt of Exceptional Financial Need Scholarship
S2S LRP - Verification of Disadvantaged Background	1	FY 2017 NHSC S2S LRP Disadvantaged Background.docx
S2S LRP – Acceptance/Verification of Good Standing Report	1	FY 2017 NHSC S2S LRP Verification of Good Standing.docx

---

ICR Summary of Burden

table that charts list 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	13,085	13,339	0	-254	0	0
Annual Time Burden (Hours)	8,074	8,200	0	-126	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: Yes

Burden Reduction Due to: Cutting Redundancy

Short Statement: The revisions to this information collection request include the removal of two forms for the NHSC S2S LRP application section and the decrease of the burden estimate for the NHSC S2S LRP application. There was also an addition of forms for NHSC SP and NHSC S2S LRP, thus increasing the burden in some ICRs.

---

Annual Cost to Federal Government: $513,854

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 06/15/2017

---