Information Collection

S2S LRP - Verification of Disadvantaged Background

IC 211169 under ICR 202006-0915-004 · OMB 0915-0146.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.