NHSC Travel Request Worksheet

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0278 can be found here:

Documents and Forms

Document Name Document Type
Form 1 NHSC Travel Request Worksheet Form
1 NHSC Travel Form NHSC Travel Form 0278 Form 11-2015_Clean.doc Form

Information Collection (IC) Details

IC Title:	NHSC Travel Request Worksheet	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	NHSC Travel Form	NHSC Travel Form 0278 Form 11-2015_Clean.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: PHS and NHSC Scholarship and Loan Repayment Records System	FR Citation: 58 FR 12968

Number of Respondents: 300	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	600	100	500
Annual IC Time Burden (Hours)	40	7	33
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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