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	Modified	Available
Form 8 Nurse Corps Nurse Faculty Employment Verification Form	Form and Instruction	New	Available
Form 7 Nurse Corps Crtiical Shortage Facility (CSF) Verification Form	Form and Instruction	New	Available
Form 6 Participant Semi-Annual in Service Verification Form	Form and Instruction	New	Available
Form 5-1 Confirmation of Interest Form	Form and Instruction	New	Available
Form 4 Disadvantaged Background Form	Form and Instruction	New	Available
Form 2 Authorization to Release Information Form	Form and Instruction	New	Repair queued
Form 3 Employment Verification Form	Form and Instruction	Modified	Available
Nurse Corps LRP 60-day FRN.pdf	Supplementary Document	Uploaded 2020-02-04	Available
NC LRP - Supporting Statement A.docx	Supporting Statement A	Uploaded 2020-02-04	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6368	NURSE Corps LRP Application	Form and Instruction	Modified
239781	Nurse Corps Nurse Faculty Employment Verification Form	Form and Instruction	New
239779	Nurse Corps Crtiical Shortage Facility (CSF) Verification Form	Form and Instruction	New
239777	Participant Semi-Annual in Service Verification Form	Form and Instruction	New
239776	Confirmation of Interest Form	Form and Instruction	New
239775	Disadvantaged Background Form	Form and Instruction	New
239774	Authorization to Release Information Form	Form and Instruction	New
182803	Employment Verification Form	Form and Instruction	Modified

ICR Details

OMB Control No: 0915-0140	ICR Reference No: 202002-0915-001
Status: Active	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: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/27/2020
	Date Received in OIRA: 02/05/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2023	36 Months From Approved	05/31/2021
Responses	24,200	0	21,900
Time Burden (Hours)	16,450	0	25,505
Cost Burden (Dollars)	0	0	0

---

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 -0ecialists) who are interested in participating in the Nurse Corps LRP, and official representatives at their service sites.

---

Authorizing Statute(s): US Code: 42 USC 297n Section 846(a) Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 54617	10/10/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 5455	01/30/2020
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
NURSE Corps LRP Application	1	NC LRP - Application Form - Revised.docx
Employment Verification Form	3	NC LRP - EVF Form - Revised 3.pdf
Authorization to Release Information Form	2	NC LRP Authorization to Release Information - Revised.docx
Disadvantaged Background Form	4	NC LRP - DAB Form - Revised.docx
Confirmation of Interest Form	5-1, 5-2, 5-3, 5-4	NC LRP COI 1-Accept or Decline Award Page - Revised.docx ,   NC LRP COI 2-Electronic Withholding Allowance Certificate Page - Revised.docx ,   NC LRP COI 3-Sign your Electronic Contract Page - Revised.docx ,   NC LRP COI 4-Submitted Landing Page - Revised.docx
Participant Semi-Annual in Service Verification Form	6	NCLRP & NF ISV & EV Screenshots - Revised.pptx
Nurse Corps Crtiical Shortage Facility (CSF) Verification Form	7	NC LRP CSF Employment Verification Form - Revised.docx
Nurse Corps Nurse Faculty Employment Verification Form	8	NC LRP Nurse Faculty Employment Verification Form - Revised.docx

---

ICR Summary of Burden

table that charts list 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	24,200	21,900	0	2,300	0	0
Annual Time Burden (Hours)	16,450	25,505	0	-9,055	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: Yes

Burden Reduction Due to: Using Information Technology

Short Statement: The increase in burden is due to an increase in respondents. This information collection activity is web-based (with exception of some forms as previously mentioned); the application, application instructions and forms are available at http://www.hrsa.gov/loanscholarships/repayment/nursing/index.html. This allows HRSA to minimize the burden on applicants only see questions that are relevant to the program they are applying to, import loan data from the Department of Education, and save their application progress so that they can complete it on their own schedule.

---

Annual Cost to Federal Government: $973,000

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

---

Common Form ICR:  No

---

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: 02/05/2020

---