The Nursing Scholarship Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Eligible Applications/Application Program Guidance	Form	Modified	Available
Form 1 Eligible Applications/Application Program Guidance	Form	Modified	Repair queued
Form 10 Authorization To Release Information	Form	Modified	Available
Form 10 Authorization to Release Information Form	Form	Modified	Repair queued
Form 9 CSF Verification Form.pdf	Form	Removed	Available
Form 9 CSF Verification Form	Form	Removed	Repair queued
Form 8 Verification of Acceptance Form	Form	Modified	Available
Form 8 Verification of Acceptance Form	Form	Modified	Repair queued
Form 7 In Service Verification Form	Form	Modified	Available
Form 7 In Service Verification Form	Form	Modified	Repair queued
Form 6 NC SP Employment Verification Form	Form	Modified	Available
Form 6 NC SP Employment Verification Form	Form	Modified	Repair queued
Form 5 Graduation Close Out Form	Form	Modified	Available
Form 5 Graduation Close Out Form	Form	Modified	Repair queued
Form 4 Data Collection Worksheet Form	Form	Modified	Available
Form 4 Data Collection Worksheet Form	Form	Modified	Repair queued
Form 3 Confirmation of Interest Form	Form and Instruction	Modified	Available
Form 3 Confirmation of Interest Form	Form and Instruction	Modified	Repair queued
Form 2 School Enrollment Verification Form	Form	Modified	Available
Form 2 School Enrollment Verification Form	Form	Modified	Repair queued
NC SP - Supporting Statement .docx	Supporting Statement A	Uploaded 2023-03-17	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43610	Eligible Applications/Application Program Guidance	Form	Modified	Eligible Applications/Application Program Guidance
43610	Eligible Applications/Application Program Guidance	Form	Modified
240484	Authorization to Release Information Form	Form	Modified	Authorization To Release Information
240484	Authorization to Release Information Form	Form	Modified
240483	CSF Verification Form	Form	Removed	CSF Verification Form.pdf
240483	CSF Verification Form	Form	Removed
240481	Verification of Acceptance Form	Form	Modified	Verification of Acceptance Form
240481	Verification of Acceptance Form	Form	Modified
240480	In Service Verification Form	Form	Modified	In Service Verification Form
240480	In Service Verification Form	Form	Modified
240478	NC SP Employment Verification Form	Form	Modified	NC SP Employment Verification Form
240478	NC SP Employment Verification Form	Form	Modified
240475	Graduation Close Out Form	Form	Modified	Graduation Close Out Form
240475	Graduation Close Out Form	Form	Modified
240473	Data Collection Worksheet Form	Form	Modified	Data Collection Worksheet Form
240473	Data Collection Worksheet Form	Form	Modified
240471	Confirmation of Interest Form	Form and Instruction	Modified	Confirmation of Interest Form
240471	Confirmation of Interest Form	Form and Instruction	Modified
240469	School Enrollment Verification Form	Form	Modified	School Enrollment Verification Form
240469	School Enrollment Verification Form	Form	Modified

ICR Details

OMB Control No: 0915-0301	ICR Reference No: 202303-0915-003
Status: Historical Active	Previous ICR Reference No: 202003-0915-001
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: The Nursing Scholarship Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/16/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/11/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2026	36 Months From Approved	05/31/2023
Responses	8,750	0	8,950
Time Burden (Hours)	7,099	0	7,139
Cost Burden (Dollars)	0	0	0

---

Abstract: The NCSP collects information to determine an applicant’s eligibility for the program, monitor a participant’s continued enrollment in a school of nursing, monitor the participant’s compliance with the NCSP service obligation, and prepare annual reports to Congress.

---

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

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 74428	12/05/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 16454	03/17/2023
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 9

table that charts list of burden

IC Title	Form No.	Form Name
Authorization to Release Information Form	10	Authorization To Release Information
CSF Verification Form	9	CSF Verification Form.pdf
Confirmation of Interest Form	3	Confirmation of Interest Form
Data Collection Worksheet Form	4	Data Collection Worksheet Form
Eligible Applications/Application Program Guidance	1	Eligible Applications/Application Program Guidance
Graduation Close Out Form	5	Graduation Close Out Form
In Service Verification Form	7	In Service Verification Form
NC SP Employment Verification Form	6	NC SP Employment Verification Form
School Enrollment Verification Form	2	School Enrollment Verification Form
Verification of Acceptance Form	8	Verification of Acceptance Form

---

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	8,750	8,950	0	0	-200	0
Annual Time Burden (Hours)	7,099	7,139	0	0	-40	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: The total burden hour request has been changed from 6934 to 7099 hours as a result of the inclusion of two new forms that were not previously included in the 60 day FRN, which are needed to effectively monitor participant service and to determine eligibility of participants to continue to receive scholarship benefits and the amount of those benefits.

---

Annual Cost to Federal Government: $2,799,704

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.     No

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.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

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

---

Common Form ICR:  No

---

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: 04/11/2023

---