Information Collection Request
The National Health Service Corps (NHSC) Loan Repayment Programs
ICR 202301-0915-003 · OMB 0915-0127 · Received in OIRA
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0915-0127 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form 1 The National Health Service Corps (NHSC) Loan Repayment Program Application |
Form and Instruction | Modified | Repair queued |
| Form 7 NHSC Site Application (including recertification) |
Form and Instruction | Modified | Repair queued |
| Form 6 NHSC Comprehensive Behavioral Health Services Checklist |
Form and Instruction | Modified | Repair queued |
| Form 5 Verification of Disadvantaged Background Form |
Form and Instruction | Modified | Repair queued |
| Form 4 Private Practice Option Form |
Form and Instruction | Modified | Repair queued |
| Form 3 Authorization for Disclosure of Loan Information Form |
Form and Instruction | Modified | Repair queued |
| Form 2 Privacy Act Release Authorization Form |
Form and Instruction | Modified | Repair queued |
 NHSC Participant COVID-19 Questions.docx |
Supplementary Document | Uploaded 2020-04-20 | Repair queued |
| NHSC Site COVID-19 Questions.docx |
Supplementary Document | Uploaded 2020-04-20 | Repair queued |
| Final Change Memo - OMB 0915-0127 and 0146 COVID-19.docx |
Justification for No Material/Nonsubstantive Change | Uploaded 2020-04-20 | Repair queued |
| FINAL NHSC LRP FY 2020 Supporting Statement - 3-11-2020.docx |
Supporting Statement A | Uploaded 2020-03-25 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 6365 |  The National Health Service Corps (NHSC) Loan Repayment Program Application |
Form and Instruction | Modified | |
| 225047 | NHSC Site Application (including recertification) |
Form and Instruction | Modified | |
| 225046 | NHSC Comprehensive Behavioral Health Services Checklist |
Form and Instruction | Modified | |
| 209462 | Verification of Disadvantaged Background Form |
Form and Instruction | Modified | |
| 209461 | Private Practice Option Form |
Form and Instruction | Modified | |
| 209460 | Authorization for Disclosure of Loan Information Form |
Form and Instruction | Modified | |
| 181468 | Privacy Act Release Authorization Form |
Form and Instruction | Modified |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | HHS/HSA |
| OMB Control No | 0915-0127 |
| Type of Information Collection | Revision of a currently approved collection |
| Previous ICR Reference No | 202004-0915-004 |
| Agency Tracking No | 20941 |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |