Form 1 NHSC Travel Request Worksheet Form_Final

OMB No. 0915-0278

Expiration Date: xx/xx/20xx

National Health Service Corps

Scholar Travel Request Worksheet

Non-Federal Personnel

Traveler’s Name:							Home Phone:			Work Phone:
Mailing Address:								Fax Number:
Cell Phone:				E-Mail Address:
Placement Year of Scholar:			Discipline:						Specialty:
Dates of Travel:	From:	To:			From: City/St				To: City/St
Destination Site Name/Address:
Site ID (UDS#):					Status of Site:				HPSA Score:
Remarks:

	Type of Travel					Licensure
	Pre-Employment Site Visit:					MUST CHECK ONE BOX
	 Initial Match	 Site Assignment				For relocation and transfer, does the traveler have a permanent license to practice in State of service?
	Permanent Change of Station Relocation					YES
	 Initial Match	 Site Assignment				NO
	Other (specify below)

Signature of Requesting Official, NHSC:

Date:

PUBLIC BURDEN STATEMENT

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB control number for this project is 0915-0278 and is valid until xx/xx/20xx. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 1 minutes per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].

Privacy Act Notice – The Privacy Act of 1974 (5 U.S.C. 552a) requires that an agency provide the following notice to each individual whom it asks for information. (1) The authority for collecting information requested on this form is found in Title III, Part D, Subpart II of the Public Health Service Act (42 U.S.C. 254d(c).