The National Health Service Corps Scholarship Program, Students to Service Loan Repayment Program, and the Native Hawaiian Health Scholarship Program

Forms and Documents

Document Name	Status
Form 1-1 NHSC Scholarship Program Application Form and Instruction	Modified
Form 4-7 NHHSP Graduation Documentation Form Form and Instruction	New
Form 4-6 NHHSP Change in Program Curriculum Form Form and Instruction	New
Form 4-5 NHHSP Scholar Enrollment Verification Form Form and Instruction	New
Form 4-4 NHHSP Acceptance/Verification of Good Standing Report Form and Instruction	New
Form 4-3 NHHSP Authorization to Release Information Form and Instruction	New
Form 3-5 S2S LRP - Verification of Disadvantaged Background Form and Instruction	Modified
Form 3-4 S2S LRP – Acceptance/Verification of Good Standing Report Form and Instruction	Modified
Form 3-3 S2S LRP – Authorization to Release Information Form and Instruction	Modified
Form 3-1 NHSC Students to Service Repayment Program Application Form and Instruction	Modified
Form 2-3 NHSC SP Awardees Schools – Enrollment Verification Form Form and Instruction	Modified
Form 2-2 NHSC SP Awardees Schools – Post Graduate Training Verification Form Form and Instruction	Modified
Form 2-1 NHSC SP Awardees Schools – Data Collection Worksheet Form and Instruction	Modified
Form 4-2 NHHSP Letters of Recommendation Form and Instruction	Modified
Form 1-4 NHSC SP – Acceptance/Verification of Good Standing Report Form and Instruction	Modified
Form 1-3 NHSC SP Authorization to Release Information Form and Instruction	Modified
FINAL Supporting Statement - NHSC SP, S2S, NHHSP.docx Supporting Statement A	2020-06-17
NHSC Site COVID-19 Questions.docx Supplementary Document	2020-04-20
NHSC Participant COVID-19 Questions.docx Supplementary Document	2020-04-20
Final Change Memo - OMB 0915-0127 and 0146 COVID-19.docx Justification for No Material/Nonsubstantive Change	2020-04-20

IC Document Collections

IC ID	Document Title	Status
6375	NHSC Scholarship Program Application Form and Instruction	Modified
242296	NHHSP Graduation Documentation Form Form and Instruction	New
242295	NHHSP Change in Program Curriculum Form Form and Instruction	New
242294	NHHSP Scholar Enrollment Verification Form Form and Instruction	New
242293	NHHSP Acceptance/Verification of Good Standing Report Form and Instruction	New
242292	NHHSP Authorization to Release Information Form and Instruction	New
211172	Native Hawaiian Health Scholarship Program Application Instruction	Modified
211169	S2S LRP - Verification of Disadvantaged Background Form and Instruction	Modified
211167	S2S LRP – Acceptance/Verification of Good Standing Report Form and Instruction	Modified
211166	S2S LRP – Authorization to Release Information Form and Instruction	Modified
211165	S2S LRP - Letters of Recommendation Other-Preceptor L or R	Modified
211164	NHSC Students to Service Repayment Program Application Form and Instruction	Modified
211163	NHSC SP Awardees Schools – Enrollment Verification Form Form and Instruction	Modified
211162	NHSC SP Awardees Schools – Post Graduate Training Verification Form Form and Instruction	Modified
211161	NHSC SP Awardees Schools – Data Collection Worksheet Form and Instruction	Modified
211160	NHSC SP – Verification of Disadvantaged Background Other-Verification of Dis Background	Modified
211159	NHHSP Letters of Recommendation Form and Instruction	Modified
211157	NHSC SP – Acceptance/Verification of Good Standing Report Form and Instruction	Modified
211155	NHSC SP Authorization to Release Information Form and Instruction	Modified
211154	NHSC SP Letters of Recommendation Other-Letters of Recommendation	Modified

ICR Details

OMB Control No: 0915-0146	ICR Reference No: 202006-0915-004
Status: Active	Previous ICR Reference No: 202004-0915-005
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: The National Health Service Corps Scholarship Program, Students to Service Loan Repayment Program, and the Native Hawaiian Health Scholarship Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/21/2020
	Date Received in OIRA: 06/17/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2023	36 Months From Approved	07/31/2020
Responses	14,347	0	13,085
Time Burden (Hours)	11,289	0	8,074
Cost Burden (Dollars)	0	0	0

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Abstract: Administered by HRSA’s Bureau of Health Workforce (BHW), the National Health Service Corps (NHSC) Scholarship Program (SP), NHSC Students to Service Loan Repayment Program (S2S LRP), and the Native Hawaiian Health Scholarship Program (NHHSP), provide scholarships or loan repayment to qualified students who are pursuing primary care health professions education and training. In return, students agree to provide primary health care services in underserved communities located in federally designated Health Professional Shortage Areas (HPSAs) once they are fully trained and licensed health professionals. Awards are made to applicants who demonstrate the greatest potential for successful completion of their education and training as well as commitment to provide primary health care services to communities of greatest need. The program applications, forms, and supporting documentation are used to collect necessary information from applicants and participants that will facilitate in the selection of the best qualified candidates for these competitive awards, and to monitor participants’ enrollment in school or in postgraduate training.

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Authorizing Statute(s): US Code: 42 USC Sect. 338B 254d(i), l, 3331(i) Name of Law: National Health Service Corps
   US Code: 42 USC Sect. 338A 254d(i), l, m-q Name of Law: National Health Service Corps
   US Code: 42 USC 11709 Name of Law: The Native Hawaiian Health Care Improvement Act
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 13662	03/09/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 36220	06/15/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 20

IC Title	Form No.	Form Name
NHSC Students to Service Repayment Program Application	3-1	NHSC S2S LRP Application Screenshots.docx
S2S LRP – Authorization to Release Information	3-3	NHSC S2S LRP Authorization to Release Information Form.pdf
S2S LRP – Acceptance/Verification of Good Standing Report	3-4	NHSC S2S LRP Verification of Good Standing Form.pdf
NHSC SP Awardees Schools – Enrollment Verification Form	2-3	NHSC SP Enrollment Verification Form.pdf
NHSC SP Letters of Recommendation
S2S LRP - Verification of Disadvantaged Background	3-5	NHSC S2S LRP Disadvantaged Background Form.pdf
Native Hawaiian Health Scholarship Program Application	4-1	NHHSP Application.pdf
NHSC Scholarship Program Application	1-1	NHSC SP Application Screenshots.docx
NHSC SP – Acceptance/Verification of Good Standing Report	1-4	NHSC SP Accep Ver Good Standing Form.pdf
NHSC SP Awardees Schools – Post Graduate Training Verification Form	2-2	NHSC SP Post Graduate Training Verification Form.pdf
S2S LRP - Letters of Recommendation
NHSC SP Authorization to Release Information	1-3	NHSC SP Authorization to Release Information Form.pdf
NHHSP Letters of Recommendation	4-2	NHHSP Instructions - Letters of Recommendation.pdf
NHSC SP – Verification of Disadvantaged Background
NHSC SP Awardees Schools – Data Collection Worksheet	2-1	NHSC SP Data Collection Worksheet Form.pdf
NHHSP Authorization to Release Information	4-3	NHHSP Authorization to Release Information Form.pdf
NHHSP Acceptance/Verification of Good Standing Report	4-4	NHHSP Accept-Ver. of Good Standing Report Form.pdf
NHHSP Scholar Enrollment Verification Form	4-5	NHHSP Scholar Enrollment Verification Form.pdf
NHHSP Change in Program Curriculum Form	4-6	NHHSP Change in Curriculum Form.pdf
NHHSP Graduation Documentation Form	4-7	NHHSP Graduation Documentation Form.pdf

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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	14,347	13,085	0	1,262	0	0
Annual Time Burden (Hours)	11,289	8,074	0	3,215	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: No

Burden Reduction Due to:

Short Statement: An increase in number of respondents and the number of forms has caused an increase in burden.

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Annual Cost to Federal Government: $550,106

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]? 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

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Common Form ICR:  No

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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: 06/17/2020

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