OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

The National Health Service Corps (NHSC) Loan Repayment Program Application

IC 6365 under ICR 201809-0915-001 · OMB 0915-0127.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form
Form
Form
IC Document
Information Collection (IC) Details

View Information Collection (IC)

The National Health Service Corps (NHSC) Loan Repayment Program Application
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 621

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 1 2016 NHSC LRP Online Application User Guide 2016 NHSC LRP Online Application User Guide.pdf Yes Yes Fillable Fileable
Form and Instruction 2 2017 NHSC Site-application-user-guide.pdf REVISED 2017 NHSC Site-application-user-guide.pdf Yes Yes Fillable Fileable
Form and Instruction 3 2017 NHSC-LRP-online-application-user-guide.pdf REVISED 2017 NHSC-LRP-online-application-user-guide.pdf Yes Yes Fillable Fileable
Form 2A In-Service Verification Screenshot.jpg In-Service Verification Screenshot.jpg Yes Yes Fillable Fileable
Form 3A MAT FY18 Questions Screenshot.png MAT FY18 Questions Screenshot.png Yes Yes Fillable Fileable
Form 3B Telehealth FY18 Questions Screenshot.docx Telehealth FY18 Questions Screenshot.docx Yes Yes Fillable Fileable

Health Health Care Services

The Public Health Service and National Health Service Corps Health Care Provider Records System  58 FR 12968

8,200 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 8,200 0 0 0 0 8,200
Annual IC Time Burden (Hours) 8,200 0 0 0 0 8,200
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
FINAL 0127 NON-SUBSTANTIVE CHANGE MEMO FINAL0127Non-Substantive Change Memo.docx 09/05/2018
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.