Information Collection Request

NURSE Corps Loan Repayment Program

ICR 202212-0915-001 · OMB 0915-0140 · Historical Inactive

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0915-0140 can be found here:

Forms and Documents

Forms and supporting documents for this ICR
Document	Type	Status	Availability
Form 1 NURSE Corps LRP Application	Form and Instruction	Unchanged	Available
Form 1 NURSE Corps LRP Application	Form and Instruction	Unchanged	Repair queued
Form 8 Nurse Corps Nurse Faculty Employment Verification Form	Form and Instruction	Unchanged	Available
Form 8 Nurse Corps Nurse Faculty Employment Verification Form	Form and Instruction	Unchanged	Repair queued
Form 7 Nurse Corps Crtiical Shortage Facility (CSF) Verification Form	Form and Instruction	Unchanged	Available
Form 7 Nurse Corps Crtiical Shortage Facility (CSF) Verification Form	Form and Instruction	Unchanged	Repair queued
Form 6 Participant Semi-Annual in Service Verification Form	Form and Instruction	Unchanged	Available
Form 6 Participant Semi-Annual in Service Verification Form	Form and Instruction	Unchanged	Repair queued
Form 5-1 Confirmation of Interest Form	Form and Instruction	Unchanged	Available
Form 5-1 Confirmation of Interest Form	Form and Instruction	Unchanged	Repair queued
Form 4 Disadvantaged Background Form	Form and Instruction	Unchanged	Available
Form 4 Disadvantaged Background Form	Form and Instruction	Unchanged	Repair queued
Form 2 Authorization to Release Information Form	Form and Instruction	Unchanged	Available
Form 2 Authorization to Release Information Form	Form and Instruction	Unchanged	Missing upstream
Form 3 Employment Verification Form	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
6368	NURSE Corps LRP Application	Form and Instruction	Unchanged
6368	NURSE Corps LRP Application	Form and Instruction	Unchanged
239781	Nurse Corps Nurse Faculty Employment Verification Form	Form and Instruction	Unchanged
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
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
239777	Participant Semi-Annual in Service Verification Form	Form and Instruction	Unchanged
239776	Confirmation of Interest Form	Form and Instruction	Unchanged
239776	Confirmation of Interest Form	Form and Instruction	Unchanged
239775	Disadvantaged Background Form	Form and Instruction	Unchanged
239775	Disadvantaged Background Form	Form and Instruction	Unchanged
239774	Authorization to Release Information Form	Form and Instruction	Unchanged
239774	Authorization to Release Information Form	Form and Instruction	Unchanged
182803	Employment Verification Form	Form and Instruction	Unchanged
182803	Employment Verification Form	Form and Instruction	Unchanged

ICR Details

Record metadata
Status	Historical Inactive
Agency/Subagency	HHS/HSA
OMB Control No	0915-0140
Type of Information Collection	Extension without change of a currently approved collection
Previous ICR Reference No	202002-0915-001
Agency Tracking No	21547
Date Submitted to OIRA	2022-12-27
Requested Expiration Date	1969-12-31