National Health Service Corps Scholar/Students to Service Travel Request Worksheet

Forms and Documents

Document Name	Status
Form 1 NHSC Travel Request Worksheet Form	Modified
Supporting Statement Travel Request Worksheet 11.14.2018_Clean.doc Supporting Statement A	2018-12-20

IC Document Collections

IC ID	Document Title	Status
6531	NHSC Travel Request Worksheet Form	Modified

ICR Details

OMB Control No: 0915-0278	ICR Reference No: 201812-0915-003
Status: Active	Previous ICR Reference No: 201512-0915-001
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: National Health Service Corps Scholar/Students to Service Travel Request Worksheet
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/08/2019
	Date Received in OIRA: 01/31/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2022	36 Months From Approved	02/28/2019
Responses	600	0	500
Time Burden (Hours)	40	0	33
Cost Burden (Dollars)	0	0	0

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Abstract: Clinicians participating in the HRSA National Health Service Corps (NHSC) Scholarship Program (SP) and the Students to Service (S2S) Loan Repayment Program (LRP) use the online Travel Request Worksheet to receive travel funds from the Federal Government to perform pre-employment interviews at sites on the Health Workforce Connector. The Travel Request Worksheet is also used to initiate the relocation process after a NHSC scholar or S2S participant has successfully been matched to an approved practice site.

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Authorizing Statute(s): US Code: 42 USC 331(c)(1) 333, 338D 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:
	83 FR 48317	09/24/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 755	01/31/2019
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
NHSC Travel Request Worksheet	1	NHSC Travel Form

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	600	500	0	100	0	0
Annual Time Burden (Hours)	40	33	0	7	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: Increase in burden is due to an increase in the anticipated number of respondents.

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Annual Cost to Federal Government: $1,172

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]? No

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: 01/31/2019

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