NURSE Corps Loan Repayment Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 NC LRP - Application Form - Revised.docx	Form and Instruction	Unchanged	Available
Form 1 NURSE Corps LRP Application	Form and Instruction	Unchanged	Repair queued
Form 8 NC LRP Nurse Faculty Employment Verification Form - Revised.docx	Form and Instruction	Unchanged	Available
Form 8 Nurse Corps Nurse Faculty Employment Verification Form	Form and Instruction	Unchanged	Repair queued
Form 7 NC LRP CSF Employment Verification Form - Revised.docx	Form and Instruction	Unchanged	Available
Form 7 Nurse Corps Crtiical Shortage Facility (CSF) Verification Form	Form and Instruction	Unchanged	Repair queued
Form 6 NCLRP & NF ISV & EV Screenshots - Revised.pptx	Form and Instruction	Unchanged	Available
Form 6 Participant Semi-Annual in Service Verification Form	Form and Instruction	Unchanged	Repair queued
Form 5-4 NC LRP COI 4-Submitted Landing Page - Revised.docx	Form and Instruction	Unchanged	Available
Form 5-3 NC LRP COI 3-Sign your Electronic Contract Page - Revised.docx	Form and Instruction	Unchanged	Available
Form 5-2 NC LRP COI 2-Electronic Withholding Allowance Certificate Page - Revised.docx	Form and Instruction	Unchanged	Available
Form 5-1 NC LRP COI 1-Accept or Decline Award Page - Revised.docx	Form and Instruction	Unchanged	Available
Form 5-1 Confirmation of Interest Form	Form and Instruction	Unchanged	Repair queued
Form 4 NC LRP - DAB Form - Revised.docx	Form and Instruction	Unchanged	Available
Form 4 Disadvantaged Background Form	Form and Instruction	Unchanged	Repair queued
Form 2 NC LRP Authorization to Release Information - Revised.docx	Form and Instruction	Unchanged	Available
Form 2 Authorization to Release Information Form	Form and Instruction	Unchanged	Repair queued
Form 3 NC LRP - EVF Form - Revised 3.pdf	Form and Instruction	Unchanged	Available
Form 3 Employment Verification Form	Form and Instruction	Unchanged	Repair queued
Nurse Corps LRP 60-day FRN.pdf	Supplementary Document	Uploaded 2020-02-04	Available
Nurse Corps LRP 60-day FRN.pdf	Supplementary Document	Uploaded 2020-02-04	Repair queued
NC LRP - Supporting Statement A.docx	Supporting Statement A	Uploaded 2020-02-04	Available
NC LRP - Supporting Statement A.docx	Supporting Statement A	Uploaded 2020-02-04	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6368	NURSE Corps LRP Application	Form and Instruction	Unchanged	NC LRP - Application Form - Revised.docx
6368	NURSE Corps LRP Application	Form and Instruction	Unchanged
239781	Nurse Corps Nurse Faculty Employment Verification Form	Form and Instruction	Unchanged	NC LRP Nurse Faculty Employment Verification Form - Revised.docx
239781	Nurse Corps Nurse Faculty Employment Verification Form	Form and Instruction	Unchanged
239779	Nurse Corps Crtiical Shortage Facility (CSF) Verification Form	Form and Instruction	Unchanged	NC LRP CSF Employment Verification Form - Revised.docx
239779	Nurse Corps Crtiical Shortage Facility (CSF) Verification Form	Form and Instruction	Unchanged
239777	Participant Semi-Annual in Service Verification Form	Form and Instruction	Unchanged	NCLRP & NF ISV & EV Screenshots - Revised.pptx
239777	Participant Semi-Annual in Service Verification Form	Form and Instruction	Unchanged
239776	Confirmation of Interest Form	Form and Instruction	Unchanged	NC LRP COI 4-Submitted Landing Page - Revised.docx
239776	Confirmation of Interest Form	Form and Instruction	Unchanged	NC LRP COI 3-Sign your Electronic Contract Page - Revised.docx
239776	Confirmation of Interest Form	Form and Instruction	Unchanged	NC LRP COI 2-Electronic Withholding Allowance Certificate Page - Revised.docx
239776	Confirmation of Interest Form	Form and Instruction	Unchanged	NC LRP COI 1-Accept or Decline Award Page - Revised.docx
239776	Confirmation of Interest Form	Form and Instruction	Unchanged
239775	Disadvantaged Background Form	Form and Instruction	Unchanged	NC LRP - DAB Form - Revised.docx
239775	Disadvantaged Background Form	Form and Instruction	Unchanged
239774	Authorization to Release Information Form	Form and Instruction	Unchanged	NC LRP Authorization to Release Information - Revised.docx
239774	Authorization to Release Information Form	Form and Instruction	Unchanged
182803	Employment Verification Form	Form and Instruction	Unchanged	NC LRP - EVF Form - Revised 3.pdf
182803	Employment Verification Form	Form and Instruction	Unchanged

ICR Details

OMB Control No: 0915-0140	ICR Reference No: 202212-0915-001
Status: Historical Inactive	Previous ICR Reference No: 202002-0915-001
Agency/Subagency: HHS/HSA	Agency Tracking No: 21547
Title: NURSE Corps Loan Repayment Program
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Improperly submitted and continue	Conclusion Date: 01/03/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/27/2022
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2023	36 Months From Approved	03/31/2023
Responses	24,200	0	24,200
Time Burden (Hours)	16,450	0	16,450
Cost Burden (Dollars)	0	0	0

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Abstract: The need and purpose of this information collection is to obtain information for Nurse Corps LRP applicants and participants. The information is used to consider an applicant for a Nurse Corps LRP contract award, and to monitor a participant’s compliance with the service requirements. Individuals must submit an application in order to participate in the program. The application asks for personal, professional, educational, and financial information required to determine the applicant's eligibility to participate in the Nurse Corps LRP. The semi-annual employment verification form asks for personal and employment information to determine if a participant is in compliance with the service requirements. Respondents include professional RNs or advanced practice RNs (i.e., nurse practitioners, certified registered nurse anesthetists, certified nurse-midwives, clinical nurse -0ecialists) who are interested in participating in the Nurse Corps LRP, and official representatives at their service sites.

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Authorizing Statute(s): US Code: 42 USC 297n Section 846(a) Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 59106	09/29/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 78114	12/21/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
Authorization to Release Information Form	2	NC LRP Authorization to Release Information - Revised.docx
Confirmation of Interest Form	5-1, 5-2, 5-3, 5-4	NC LRP COI 1-Accept or Decline Award Page - Revised.docx ,   NC LRP COI 2-Electronic Withholding Allowance Certificate Page - Revised.docx ,   NC LRP COI 3-Sign your Electronic Contract Page - Revised.docx ,   NC LRP COI 4-Submitted Landing Page - Revised.docx
Disadvantaged Background Form	4	NC LRP - DAB Form - Revised.docx
Employment Verification Form	3	NC LRP - EVF Form - Revised 3.pdf
NURSE Corps LRP Application	1	NC LRP - Application Form - Revised.docx
Nurse Corps Crtiical Shortage Facility (CSF) Verification Form	7	NC LRP CSF Employment Verification Form - Revised.docx
Nurse Corps Nurse Faculty Employment Verification Form	8	NC LRP Nurse Faculty Employment Verification Form - Revised.docx
Participant Semi-Annual in Service Verification Form	6	NCLRP & NF ISV & EV Screenshots - Revised.pptx

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Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $973,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/27/2022

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