Information Collection

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

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0127 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 2016 NHSC LRP Online Application User Guide The National Health Service Corps (NHSC) Loan Repayment Program Application	Form and Instruction
Form 2 2017 NHSC Site-application-user-guide.pdf REVISED The National Health Service Corps (NHSC) Loan Repayment Program Application	Form and Instruction
Form 3 2017 NHSC-LRP-online-application-user-guide.pdf REVISED The National Health Service Corps (NHSC) Loan Repayment Program Application	Form and Instruction
Form 2A In-Service Verification Screenshot.jpg The National Health Service Corps (NHSC) Loan Repayment Program Application	Form
Form 3A MAT FY18 Questions Screenshot.png The National Health Service Corps (NHSC) Loan Repayment Program Application	Form
Form 3B Telehealth FY18 Questions Screenshot.docx The National Health Service Corps (NHSC) Loan Repayment Program Application	Form
1 2016 NHSC LRP Online Application User Guide 2016 NHSC LRP Online Application User Guide.pdf	Form and Instruction
2 2017 NHSC Site-application-user-guide.pdf REVISED 2017 NHSC Site-application-user-guide.pdf	Form and Instruction
3 2017 NHSC-LRP-online-application-user-guide.pdf REVISED 2017 NHSC-LRP-online-application-user-guide.pdf	Form and Instruction
2A In-Service Verification Screenshot.jpg In-Service Verification Screenshot.jpg	Form
3A MAT FY18 Questions Screenshot.png MAT FY18 Questions Screenshot.png	Form
3B Telehealth FY18 Questions Screenshot.docx Telehealth FY18 Questions Screenshot.docx	Form
FINAL0127Non-Substantive Change Memo.docx FINAL 0127 NON-SUBSTANTIVE CHANGE MEMO	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

The National Health Service Corps (NHSC) Loan Repayment 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: 42 CFR 621

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	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

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: The Public Health Service and National Health Service Corps Health Care Provider Records System

FR Citation: 58 FR 12968

Number of Respondents: 8,200

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	Previously Approved
Annual Number of Responses for this IC	8,200	8,200
Annual IC Time Burden (Hours)	8,200	8,200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.