Information Collection

Substance Use Disorder Treatment and Recovery (STAR) Loan Repayment Program (LRP) Privacy Act Release Authorization Form

IC 243486 under ICR 202009-0906-001 · OMB 0906-0058.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0058 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 STAR LRP Program - Privacy Act Release Authorization Form.docx Substance Use Disorder Treatment and Recovery (STAR) Loan Repayment Program (LRP) Privacy Act Release Authorization Form	Form and Instruction
3 STAR LRP Program - Privacy Act Release Authorization For STAR LRP Program - Privacy Act Release Authorization Form.docx	Form and Instruction

IC Title:

Substance Use Disorder Treatment and Recovery (STAR) Loan Repayment Program (LRP) Privacy Act Release Authorization 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:

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				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

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
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	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.

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