NURSE Corps Loan Repayment Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 8 LRP Application User Guide	Form and Instruction	Modified	Available
Form 1 NC LRP - Application Form - Revised.docx	Form and Instruction	Modified	Available
Form 1 NURSE Corps LRP Application	Form and Instruction	Modified	Repair queued
Form 1 Employment Verification Form Mock-Up	Form and Instruction	Modified	Available
Form 1 Nurse Corps Nurse Faculty Employment Verification Form	Form and Instruction	Modified	Repair queued
Form 2 NC LRP Employment Verification Form	Form and Instruction	Modified	Available
Form 2 Nurse Corps Crtiical Shortage Facility (CSF) Verification Form	Form and Instruction	Modified	Repair queued
Form 3 Participant Semi-Annual In Service Verification Form	Form and Instruction	Modified	Available
Form 3 Participant Semi-Annual in Service Verification Form	Form and Instruction	Modified	Repair queued
Form 4 Confirmation of Interest Form	Form and Instruction	Modified	Available
Form 4 Confirmation of Interest Form	Form and Instruction	Modified	Repair queued
Form 5 Disadvantaged Background Form	Form and Instruction	Modified	Available
Form 5 Disadvantaged Background Form	Form and Instruction	Modified	Repair queued
Form 6 NC LRD Authorization to Release Information Form	Form and Instruction	Modified	Available
Form 6 Authorization to Release Information Form	Form and Instruction	Modified	Repair queued
Form 7 LRP Nurse Faculty Employment Verification Form	Form and Instruction	Modified	Available
Form 7 Employment Verification Form	Form and Instruction	Modified	Repair queued
NC LRP - Supporting Statement A.docx	Supporting Statement A	Uploaded 2023-01-05	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6368	NURSE Corps LRP Application	Form and Instruction	Modified	LRP Application User Guide
6368	NURSE Corps LRP Application	Form and Instruction	Modified	NC LRP - Application Form - Revised.docx
6368	NURSE Corps LRP Application	Form and Instruction	Modified
239781	Nurse Corps Nurse Faculty Employment Verification Form	Form and Instruction	Modified	Employment Verification Form Mock-Up
239781	Nurse Corps Nurse Faculty Employment Verification Form	Form and Instruction	Modified
239779	Nurse Corps Crtiical Shortage Facility (CSF) Verification Form	Form and Instruction	Modified	NC LRP Employment Verification Form
239779	Nurse Corps Crtiical Shortage Facility (CSF) Verification Form	Form and Instruction	Modified
239777	Participant Semi-Annual in Service Verification Form	Form and Instruction	Modified	Participant Semi-Annual In Service Verification Form
239777	Participant Semi-Annual in Service Verification Form	Form and Instruction	Modified
239776	Confirmation of Interest Form	Form and Instruction	Modified	Confirmation of Interest Form
239776	Confirmation of Interest Form	Form and Instruction	Modified
239775	Disadvantaged Background Form	Form and Instruction	Modified	Disadvantaged Background Form
239775	Disadvantaged Background Form	Form and Instruction	Modified
239774	Authorization to Release Information Form	Form and Instruction	Modified	NC LRD Authorization to Release Information Form
239774	Authorization to Release Information Form	Form and Instruction	Modified
182803	Employment Verification Form	Form and Instruction	Modified	LRP Nurse Faculty Employment Verification Form
182803	Employment Verification Form	Form and Instruction	Modified

ICR Details

OMB Control No: 0915-0140	ICR Reference No: 202301-0915-001
Status: Historical Active	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: Approved without change	Conclusion Date: 02/11/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/05/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2026	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	6	NC LRD Authorization to Release Information Form
Confirmation of Interest Form	4	Confirmation of Interest Form
Disadvantaged Background Form	5	Disadvantaged Background Form
Employment Verification Form	7	LRP Nurse Faculty Employment Verification Form
NURSE Corps LRP Application	8, 1	NC LRP - Application Form - Revised.docx ,   LRP Application User Guide
Nurse Corps Crtiical Shortage Facility (CSF) Verification Form	2	NC LRP Employment Verification Form
Nurse Corps Nurse Faculty Employment Verification Form	1	Employment Verification Form Mock-Up
Participant Semi-Annual in Service Verification Form	3	Participant Semi-Annual In Service Verification Form

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	24,200	24,200	0	0	0	0
Annual Time Burden (Hours)	16,450	16,450	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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: $1,048,080

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: 01/05/2023

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