Verification of Disadvantaged Background Form

The National Health Service Corps (NHSC) Loan Repayment Programs

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 4 Verification of Disadvantaged Background Form Form and Instruction
4 NHSC LRP FY 2020 - Verification of Disadvantaged Backgro NHSC LRP FY 2020 - Verification of Disadvantaged Background.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Verification of Disadvantaged Background Form	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 and Instruction	4	NHSC LRP FY 2020 - Verification of Disadvantaged Background.pdf	NHSC LRP FY 2020 - Verification of Disadvantaged Background.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 660	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	660	60	600
Annual IC Time Burden (Hours)	330	30	300
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.