The NHSC and NURSE Corps Interest Capture Form

Forms and Documents

Document	Type	Status	Availability
Form 1 NHSC and NURSE Corps Interest Capture Form	Form	Modified	Available
Section 846 of the PHS Act - Attachment C.pdf	Supplementary Document	Uploaded 2020-04-22	Available
Section 338A-H of the PHS Act - Attachment B.pdf	Supplementary Document	Uploaded 2020-04-22	Repair queued
Section 331 of the PHS Act - Attachment A.pdf	Supplementary Document	Uploaded 2020-04-22	Available
Supporting Statement - NHSC-NC Int Capt Form_Final.docx	Supporting Statement A	Uploaded 2020-04-22	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
195587	NHSC and NURSE Corps Interest Capture Form	Form	Modified

ICR Details

OMB Control No: 0915-0337	ICR Reference No: 202004-0915-006
Status: Active	Previous ICR Reference No: 201704-0915-002
Agency/Subagency: HHS/HSA	Agency Tracking No: 21466
Title: The NHSC and NURSE Corps Interest Capture Form
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: 06/02/2020
	Date Received in OIRA: 04/28/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2023	36 Months From Approved	06/30/2020
Responses	2,400	0	2,400
Time Burden (Hours)	60	0	60
Cost Burden (Dollars)	0	0	0

---

Abstract: The need and proposed use of this information collection is to share resources and information regarding the NHSC and Nurse Corps programs with interested conference/event participants. The respondents will be conference/event participants interested in the NHSC or Nurse Corps programs.

---

Authorizing Statute(s): US Code: 42 USC 254l-1, Section 338B Name of Law: PHSA
   US Code: 42 USC 254d(i)), Section 331(i) Name of Law: PHSA, as amended
   US Code: 42 USC 254m-q, Sections 338C-H Name of Law: PHSA
   US Code: 42 USC 297(n)(d), Section 846(d) Name of Law: PHSA, as amended
   US Code: 42 USC 254l Section 338A Name of Law: PHSA
  

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:
	85 FR 325	01/03/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 23523	04/28/2020
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
NHSC and NURSE Corps Interest Capture Form	1	NHSC-NC Interest Capture Form.docx

---

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	2,400	2,400	0	0	0	0
Annual Time Burden (Hours)	60	60	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $5,893

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.     No

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.     No

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? No

---

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: 04/28/2020

---