Information Collection

Native Hawaiian Health Scholarship Program Application

IC 211172 under ICR 201706-0915-003 · OMB 0915-0146.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0146 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 NHHSP 2017-2018 Online Application and Forms.docx Native Hawaiian Health Scholarship Program Application	Form and Instruction
Form 2 NHHSP Letters of Recommendation Forms.docx Native Hawaiian Health Scholarship Program Application	Form
Form 3 NHHSP Authorization to Release Information.docx Native Hawaiian Health Scholarship Program Application	Form
Form 4 NHHSP Verification of Good Standing.docx Native Hawaiian Health Scholarship Program Application	Form
NHHSP Online Application User Guide.pdf	Instruction
1 NHHSP 2017-2018 Online Application and Forms.docx NHHSP 2017-2018 Online Application and Forms.docx	Form and Instruction
2 NHHSP Letters of Recommendation Forms.docx NHHSP Letters of Recommendation Forms.docx	Form
3 NHHSP Authorization to Release Information.docx NHHSP Authorization to Release Information.docx	Form
4 NHHSP Verification of Good Standing.docx NHHSP Verification of Good Standing.docx	Form

IC Title:

Native Hawaiian Health Scholarship Program Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	NHHSP 2017-2018 Online Application and Forms.docx	NHHSP 2017-2018 Online Application and Forms.docx	Yes	Yes	Fillable Fileable
Instruction			NHHSP Online Application User Guide.pdf	Yes	Yes	Fillable Fileable
Form	2	NHHSP Letters of Recommendation Forms.docx	NHHSP Letters of Recommendation Forms.docx	Yes	Yes	Fillable Fileable
Form	3	NHHSP Authorization to Release Information.docx	NHHSP Authorization to Release Information.docx	Yes	Yes	Fillable Fileable
Form	4	NHHSP Verification of Good Standing.docx	NHHSP Verification of Good Standing.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 250

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,360	1,110	250
Annual IC Time Burden (Hours)	528	278	250
Annual IC Cost Burden (Dollars)	0	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.