Information Collection

HRSA HHS NHSC Participant Stakeholder

IC 233381 under ICR 201805-1090-002 · OMB 1090-0007.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1090-0007 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 023-20317 A1 HRSA HHS NHSC Participant Stakeholder	Form and Instruction
023-20317 A1 NHSC HRSA Participant Survey-023-20317 A1 NHSC 2018 Participant Survey_IA 20317.xlsx	Form and Instruction
1090-0007 Generic Clearance Request Form HRSA Participants_IA 20317 A1-.pdf 20317 A1	IC Document
OMB Mapping HRSA NHSC Participant Survey 20317 A1.xlsx 20317 A1	IC Document

IC Title:

HRSA HHS NHSC Participant Stakeholder

Agency IC Tracking Number:

023-20317 A1

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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	023-20317 A1	NHSC HRSA Participant Survey-023-20317 A1	NHSC 2018 Participant Survey_IA 20317.xlsx		Yes	Yes	Fillable Printable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

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
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
20317 A1	1090-0007 Generic Clearance Request Form HRSA Participants_IA 20317 A1-.pdf	10/03/2018
20317 A1	OMB Mapping HRSA NHSC Participant Survey 20317 A1.xlsx	10/03/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.