Information Collection

Authorization to Release Information Form

IC 196033 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⚠️ Notice: This information collection may be referencing outdated material.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 1 Authorization to Release Information Form	Form and Instruction
1 NC LRP Authorization to Release Information.docx NC LRP Authorization to Release Information.docx	Form and Instruction

IC Title:

Authorization to Release Information Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Mandatory

CFR Citation: 5 CFR 1320.8(d) 31 CFR 208,210 (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	NC LRP Authorization to Release Information.docx	NC LRP Authorization to Release Information.docx		Yes	No	Printable Only

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 12868

Number of Respondents: 5,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-5,500	5,500
Annual IC Time Burden (Hours)	-550	550
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.