Information Collection

NHSC Travel Request Worksheet

IC 6531 under ICR 202110-0915-002 · OMB 0915-0278.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0278 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 NHSC Travel Request Worksheet	Form
1 NHSC Travel Request Worksheet Form_Final.docx NHSC Travel Request Worksheet Form_Final.docx	Form
1 NHSC Travel Request Worksheet Form_Final.docx NHSC Travel Request Worksheet Form_Final.docx	Form

IC Title:

NHSC Travel Request Worksheet

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	1	NHSC Travel Request Worksheet Form_Final.docx	NHSC Travel Request Worksheet Form_Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: PHS and NHSC Scholarship and Loan Repayment Records System

FR Citation: 58 FR 12968

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	Previously Approved
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	40	40
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.