S2S LRP - Verification of Disadvantaged Background

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0146 can be found here:

Documents and Forms

Document Name Document Type
Form 3-5 S2S LRP - Verification of Disadvantaged Background Form and Instruction
3-5 NHSC S2S LRP Disadvantaged Background Form.pdf NHSC S2S LRP Disadvantaged Background Form.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	S2S LRP - Verification of Disadvantaged Background	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	3-5	NHSC S2S LRP Disadvantaged Background Form.pdf	NHSC S2S LRP Disadvantaged Background Form.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 70	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	70	45	25
Annual IC Time Burden (Hours)	18	12	6
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.