Authorization to Release Information Form

The Nursing Scholarship Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0301 can be found here:

Documents and Forms

Document Name Document Type
Form 10 Authorization to Release Information Form Form
10 Authorization To Release Information Form Authorization To Release Information FINAL.pdf Form

Information Collection (IC) Details

IC Title:	Authorization to Release Information Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	10	Authorization To Release Information Form	Authorization To Release Information FINAL.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	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
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	40	40
Annual IC Cost Burden (Dollars)	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.