The National Health Service Corps Scholarship Program, Students to Service Loan Repayment Program, and the Native Hawaiian Health Scholarship Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1A NHSC Scholarship Program Application	Form and Instruction	Modified	Available
Form 1A NHSC Scholarship Program Application	Form and Instruction	Modified	Repair queued
Form 4H NHHSP Letters of Reccomendation	Form and Instruction	New	Available
Form 4H NHHSP Letters of Reccomendation	Form and Instruction	New	Repair queued
Form 4G NHHSP Graduation Documentation Form	Form and Instruction	Modified	Available
Form 4G NHHSP Graduation Documentation Form	Form and Instruction	Modified	Repair queued
Form 4F NHHSP Change in Program Curriculum Form	Form and Instruction	Modified	Available
Form 4F NHHSP Change in Program Curriculum Form	Form and Instruction	Modified	Repair queued
Form 4E NHHSP Scholar Enroll Verification Form	Form and Instruction	Modified	Available
Form 4E NHHSP Scholar Enrollment Verification Form	Form and Instruction	Modified	Available
Form 4C NHHSP Acceptance Verification of Good Standing Form	Form and Instruction	Modified	Available
Form 4C NHHSP Acceptance/Verification of Good Standing Report	Form and Instruction	Modified	Repair queued
Form 4B NHHSP Authorization to Release Information	Form and Instruction	Modified	Available
Form 4B NHHSP Authorization to Release Information	Form and Instruction	Modified	Repair queued
Form 4A NHHSP Program Application (User Guide)	Form and Instruction	Modified	Available
Form 4A Native Hawaiian Health Scholarship Program Application	Form and Instruction	Modified	Repair queued
Form 3E Verification of Disadvantaged Background Status	Form and Instruction	Modified	Available
Form 3E S2S LRP - Verification of Disadvantaged Background	Form and Instruction	Modified	Repair queued
Form 3D Acceptance Verification of Good Standing Form	Form and Instruction	Modified	Available
Form 3D S2S LRP – Acceptance/Verification of Good Standing Report	Form and Instruction	Modified	Repair queued
Form 3C NHSC S2S LRP Authorization to Release Information Form.pdf	Form and Instruction	Modified	Available
Form 3C S2S LRP – Authorization to Release Information	Form and Instruction	Modified	Repair queued
Form 3B-Preceptor 3B	Form and Instruction	Modified	Available
Form 3B-Instructions Letters of Recommendations-Instructions	Form and Instruction	Modified	Available
Form 3B-Instructions S2S LRP - Letters of Recommendation	Form and Instruction	Modified	Repair queued
Form 3-1 NHSC S2S LRP Application Screenshots.docx	Form and Instruction	Modified	Available
Form 3-1 NHSC Students to Service Repayment Program Application	Form and Instruction	Modified	Repair queued
Form 2E Enrollment Verification Form	Form and Instruction	Modified	Available
Form 2E NHSC SP Awardees Schools – Enrollment Verification Form	Form and Instruction	Modified	Repair queued
Form 2D Post Graduate Training Verification	Form and Instruction	Modified	Available
Form 2D NHSC SP Awardees Schools – Post Graduate Training Verification Form	Form and Instruction	Modified	Repair queued
Form 2C Data Collection Worksheet Form	Form and Instruction	Modified	Available
Form 2C NHSC SP Awardees Schools – Data Collection Worksheet	Form and Instruction	Modified	Repair queued
Form 2B Verification of Disadvantaged Background Status	Form and Instruction	Modified	Available
Form 2B NHSC SP – Verification of Disadvantaged Background	Form and Instruction	Modified	Repair queued
Form 4-2 NHHSP Instructions - Letters of Recommendation.pdf	Form and Instruction	Removed	Available
Form 4-2 NHHSP Letters of Recommendation	Form and Instruction	Removed	Repair queued
Form 1D NHSC SP-Acceptance Verification of Good Standing Report	Form and Instruction	Modified	Available
Form 1D NHSC SP – Acceptance/Verification of Good Standing Report	Form and Instruction	Modified	Repair queued
Form 1C Authorization to Release Information	Form and Instruction	Modified	Available
Form 1C NHSC SP Authorization to Release Information	Form and Instruction	Modified	Repair queued
Form 1B Letters of Recommendation	Form and Instruction	Modified	Available
Form 1B NHSC SP Letters of Recommendation	Form and Instruction	Modified	Repair queued
Revised BHW Scholarship Programs Supporting Statement.docx	Supporting Statement A	Uploaded 2023-05-08	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6375	NHSC Scholarship Program Application	Form and Instruction	Modified	NHSC Scholarship Program Application
6375	NHSC Scholarship Program Application	Form and Instruction	Modified
260078	NHHSP Letters of Reccomendation	Form and Instruction	New	NHHSP Letters of Reccomendation
260078	NHHSP Letters of Reccomendation	Form and Instruction	New
242296	NHHSP Graduation Documentation Form	Form and Instruction	Modified	NHHSP Graduation Documentation Form
242296	NHHSP Graduation Documentation Form	Form and Instruction	Modified
242295	NHHSP Change in Program Curriculum Form	Form and Instruction	Modified	NHHSP Change in Program Curriculum Form
242295	NHHSP Change in Program Curriculum Form	Form and Instruction	Modified
242294	NHHSP Scholar Enrollment Verification Form	Form and Instruction	Modified	NHHSP Scholar Enroll Verification Form
242294	NHHSP Scholar Enrollment Verification Form	Form and Instruction	Modified
242293	NHHSP Acceptance/Verification of Good Standing Report	Form and Instruction	Modified	NHHSP Acceptance Verification of Good Standing Form
242293	NHHSP Acceptance/Verification of Good Standing Report	Form and Instruction	Modified
242292	NHHSP Authorization to Release Information	Form and Instruction	Modified	NHHSP Authorization to Release Information
242292	NHHSP Authorization to Release Information	Form and Instruction	Modified
211172	Native Hawaiian Health Scholarship Program Application	Form and Instruction	Modified	NHHSP Program Application (User Guide)
211172	Native Hawaiian Health Scholarship Program Application	Form and Instruction	Modified
211169	S2S LRP - Verification of Disadvantaged Background	Form and Instruction	Modified	Verification of Disadvantaged Background Status
211169	S2S LRP - Verification of Disadvantaged Background	Form and Instruction	Modified
211167	S2S LRP – Acceptance/Verification of Good Standing Report	Form and Instruction	Modified	Acceptance Verification of Good Standing Form
211167	S2S LRP – Acceptance/Verification of Good Standing Report	Form and Instruction	Modified
211166	S2S LRP – Authorization to Release Information	Form and Instruction	Modified	NHSC S2S LRP Authorization to Release Information Form.pdf
211166	S2S LRP – Authorization to Release Information	Form and Instruction	Modified
211165	S2S LRP - Letters of Recommendation	Form and Instruction	Modified	3B
211165	S2S LRP - Letters of Recommendation	Form and Instruction	Modified	Letters of Recommendations-Instructions
211165	S2S LRP - Letters of Recommendation	Form and Instruction	Modified
211164	NHSC Students to Service Repayment Program Application	Form and Instruction	Modified	NHSC S2S LRP Application Screenshots.docx
211164	NHSC Students to Service Repayment Program Application	Form and Instruction	Modified
211163	NHSC SP Awardees Schools – Enrollment Verification Form	Form and Instruction	Modified	Enrollment Verification Form
211163	NHSC SP Awardees Schools – Enrollment Verification Form	Form and Instruction	Modified
211162	NHSC SP Awardees Schools – Post Graduate Training Verification Form	Form and Instruction	Modified	Post Graduate Training Verification
211162	NHSC SP Awardees Schools – Post Graduate Training Verification Form	Form and Instruction	Modified
211161	NHSC SP Awardees Schools – Data Collection Worksheet	Form and Instruction	Modified	Data Collection Worksheet Form
211161	NHSC SP Awardees Schools – Data Collection Worksheet	Form and Instruction	Modified
211160	NHSC SP – Verification of Disadvantaged Background	Form and Instruction	Modified	Verification of Disadvantaged Background Status
211160	NHSC SP – Verification of Disadvantaged Background	Form and Instruction	Modified
211159	NHHSP Letters of Recommendation	Form and Instruction	Removed	NHHSP Instructions - Letters of Recommendation.pdf
211159	NHHSP Letters of Recommendation	Form and Instruction	Removed
211157	NHSC SP – Acceptance/Verification of Good Standing Report	Form and Instruction	Modified	NHSC SP-Acceptance Verification of Good Standing Report
211157	NHSC SP – Acceptance/Verification of Good Standing Report	Form and Instruction	Modified
211155	NHSC SP Authorization to Release Information	Form and Instruction	Modified	Authorization to Release Information
211155	NHSC SP Authorization to Release Information	Form and Instruction	Modified
211154	NHSC SP Letters of Recommendation	Form and Instruction	Modified	Letters of Recommendation
211154	NHSC SP Letters of Recommendation	Form and Instruction	Modified

ICR Details

OMB Control No: 0915-0146	ICR Reference No: 202305-0915-001
Status: Historical Active	Previous ICR Reference No: 202006-0915-004
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: The National Health Service Corps Scholarship Program, Students to Service Loan Repayment Program, and the Native Hawaiian Health 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 with change	Conclusion Date: 07/25/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/09/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2026	36 Months From Approved	07/31/2023
Responses	18,110	0	14,347
Time Burden (Hours)	14,705	0	11,289
Cost Burden (Dollars)	0	0	0

---

Abstract: Administered by HRSA’s Bureau of Health Workforce (BHW), the National Health Service Corps (NHSC) Scholarship Program (SP), NHSC Students to Service Loan Repayment Program (S2S LRP), and the Native Hawaiian Health Scholarship Program (NHHSP), provide scholarships or loan repayment to qualified students who are pursuing primary care health professions education and training. In return, students agree to provide primary health care services in underserved communities located in federally designated Health Professional Shortage Areas (HPSAs) once they are fully trained and licensed health professionals. Awards are made to applicants who demonstrate the greatest potential for successful completion of their education and training as well as commitment to provide primary health care services to communities of greatest need. The program applications, forms, and supporting documentation are used to collect necessary information from applicants and participants that will facilitate in the selection of the best qualified candidates for these competitive awards, and to monitor participants’ enrollment in school or in postgraduate training.

---

Authorizing Statute(s): US Code: 42 USC Sect. 338B 254d(i), l, 3331(i) Name of Law: National Health Service Corps
   US Code: 42 USC Sect. 338A 254d(i), l, m-q Name of Law: National Health Service Corps
   US Code: 42 USC 11709 Name of Law: The Native Hawaiian Health Care Improvement 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:
	88 FR 9525	02/14/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 27902	05/05/2023
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 20

table that charts list of burden

IC Title	Form No.	Form Name
NHHSP Acceptance/Verification of Good Standing Report	4C	NHHSP Acceptance Verification of Good Standing Form
NHHSP Authorization to Release Information	4B	NHHSP Authorization to Release Information
NHHSP Change in Program Curriculum Form	4F	NHHSP Change in Program Curriculum Form
NHHSP Graduation Documentation Form	4G	NHHSP Graduation Documentation Form
NHHSP Letters of Reccomendation	4H	NHHSP Letters of Reccomendation
NHHSP Letters of Recommendation	4-2	NHHSP Instructions - Letters of Recommendation.pdf
NHHSP Scholar Enrollment Verification Form	4E	NHHSP Scholar Enroll Verification Form
NHSC SP Authorization to Release Information	1C	Authorization to Release Information
NHSC SP Awardees Schools – Post Graduate Training Verification Form	2D	Post Graduate Training Verification
NHSC SP Awardees Schools – Data Collection Worksheet	2C	Data Collection Worksheet Form
NHSC SP Awardees Schools – Enrollment Verification Form	2E	Enrollment Verification Form
NHSC SP Letters of Recommendation	1B	Letters of Recommendation
NHSC SP – Acceptance/Verification of Good Standing Report	1D	NHSC SP-Acceptance Verification of Good Standing Report
NHSC SP – Verification of Disadvantaged Background	2B	Verification of Disadvantaged Background Status
NHSC Scholarship Program Application	1A	NHSC Scholarship Program Application
NHSC Students to Service Repayment Program Application	3-1	NHSC S2S LRP Application Screenshots.docx
Native Hawaiian Health Scholarship Program Application	4A	NHHSP Program Application (User Guide)
S2S LRP – Authorization to Release Information	3C	NHSC S2S LRP Authorization to Release Information Form.pdf
S2S LRP - Letters of Recommendation	3B-Preceptor, 3B-Instructions	Letters of Recommendations-Instructions ,   3B
S2S LRP - Verification of Disadvantaged Background	3E	Verification of Disadvantaged Background Status
S2S LRP – Acceptance/Verification of Good Standing Report	3D	Acceptance Verification of Good Standing 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	18,110	14,347	0	4,383	-620	0
Annual Time Burden (Hours)	14,705	11,289	0	3,571	-155	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: In reviewing the application and forms for this request, the NHSC SP, NHSC S2S LRP and NHHSP programs anticipate an increase in the number of interested applicants. This resulted in an overall increase in the burden of this information collection from 11,286.40 to 14,703.90 hours.

---

Annual Cost to Federal Government: $601,288

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]? 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: 05/09/2023

---