NURSE Corps Loan Repayment Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 NURSE Corps LRP Application	Form and Instruction	Unchanged	Available
Form 3 Participant Semi-Annual Employment Verification Form	Form and Instruction	Unchanged	Available
W-4 Screenshots.docx	Supplementary Document	Uploaded 2018-12-13	Available
NCLRP-Online-Application-User-Guide.pdf	Supplementary Document	Uploaded 2018-12-13	Available
NCLRP Employment Verification Form.docx	Supplementary Document	Uploaded 2018-12-13	Available
NCLRP Application Multiple Site Screenshots.pdf	Supplementary Document	Uploaded 2018-12-13	Available
NCLRP Application Mental Behavioral Health FY19 Questions Screenshot.docx	Supplementary Document	Uploaded 2018-12-13	Available
In Service Verification Telehealth question Screenshots.jpg	Supplementary Document	Uploaded 2018-12-13	Available
Application User Guide Telehealth Questions Screenshots.docx	Supplementary Document	Uploaded 2018-12-13	Available
FINAL NC LRP 2019 Nonsubstantive Change Memo OMB 12-12-18.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2018-12-13	Available
NC LRP Supporting Statement_Final_Revised.doc	Supporting Statement A	Uploaded 2018-04-23	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6368	NURSE Corps LRP Application	Form and Instruction	Unchanged
182803	Participant Semi-Annual Employment Verification Form	Form and Instruction	Unchanged

ICR Details

OMB Control No: 0915-0140	ICR Reference No: 201812-0915-001
Status: Historical Inactive	Previous ICR Reference No: 201804-0915-004
Agency/Subagency: HHS/HSA	Agency Tracking No: 21547
Title: NURSE Corps Loan Repayment Program
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Improperly submitted and continue	Conclusion Date: 12/21/2018
	Date Received in OIRA: 12/18/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2021	05/31/2021	05/31/2021
Responses	21,900	0	21,900
Time Burden (Hours)	25,505	0	25,505
Cost Burden (Dollars)	0	0	0

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Abstract: The need and purpose of this information collection is to obtain information for NURSE Corps LRP applicants and participants. The information is used to consider an applicant for a NURSE Corps LRP contract award, and to monitor a participant’s compliance with the service requirements. Individuals must submit an application in order to participate in the program. The application asks for personal, professional, educational, and financial information required to determine the applicant's eligibility to participate in the NURSE Corps LRP. The semi-annual employment verification form asks for personal and employment information to determine if a participant is in compliance with the service requirements. Respondents include professional RNs or advanced practice RNs (i.e., nurse practitioners, certified registered nurse anesthetists, certified nurse-midwives, clinical nurse specialists) who are interested in participating in the NURSE Corps LRP, and official representatives at their service sites.

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Authorizing Statute(s): PL: Pub.L. 107 - 205 0 Name of Law: PHSA Nurse Recruitment
   PL: Pub.L. 111 - 148 0 Name of Law: PPACA
   US Code: 42 USC 297n Section 846(a) Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 56040	11/27/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 15162	04/09/2018
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
NURSE Corps LRP Application	1, 2	NCLRP-Online-Application-User-Guide.doc ,   NCLRP-Authorization to Release Employment Information-Revised.docx
Participant Semi-Annual Employment Verification Form	3, 4, 5	NCLRP CSF Verification ,   NCLRP NURSE Faculty Verification ,   Participant Semi-Annual Employment Verification Form

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Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: An increase in forms added burden while a changing of forms also reduced burden. Data collected on the individual NURSE Corps LRP application and monitoring forms constitutes a system of records under the Privacy Act of 1974. The applicable Privacy Act system is the “Public Health Service and National Health Service Corps Health Care Provider Records System” (09-15-0037).

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Annual Cost to Federal Government: $1,046,529

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/18/2018

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