Information Collection

Participant Semi-Annual Employment Verification Form

IC 182803 under ICR 201804-0915-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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 3 Participant Semi-Annual Employment Verification Form	Form and Instruction
3 NCLRP CSF Verification NURSE CORPS LOAN REPAYMENT PROGRAM (Nurse Corps LRP) EMPLOYMENT VERIFICATION AND CRITICAL SHORTAGE FACILITY FORM.docx	Form and Instruction
4 NCLRP NURSE Faculty Verification NURSE CORPS LOAN REPAYMENT PROGRAM (Nurse Corps LRP) EMPLOYMENT VERIFICATION FOR NURSE FACULTY.docx	Form and Instruction
5 Participant Semi-Annual Employment Verification Form Six Month ISV Form.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: 42 CFR Part 57 Section 312 31 CFR 208, 210 5 CFR 1320.8(d) (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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3	NCLRP CSF Verification	NURSE CORPS LOAN REPAYMENT PROGRAM (Nurse Corps LRP) EMPLOYMENT VERIFICATION AND CRITICAL SHORTAGE FACILITY FORM.docx	Yes	Yes	Fillable Fileable
Form and Instruction	4	NCLRP NURSE Faculty Verification	NURSE CORPS LOAN REPAYMENT PROGRAM (Nurse Corps LRP) EMPLOYMENT VERIFICATION FOR NURSE FACULTY.docx	Yes	Yes	Fillable Fileable
Form and Instruction	5	Participant Semi-Annual Employment Verification Form	Six Month ISV Form.docx	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: 8,600

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	16,400	11,800	4,600
Annual IC Time Burden (Hours)	13,955	11,655	2,300
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.