Information Collection

NHSC SP – Verification of Disadvantaged Background

IC 211160 under ICR 202305-0915-001 · OMB 0915-0146.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0146 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2B NHSC SP – Verification of Disadvantaged Background	Form and Instruction
2B Verification of Disadvantaged Background Status Verification of Disadvantaged Background Status.docx	Form and Instruction
2B Verification of Disadvantaged Background Status Verification of Disadvantaged Background Status.docx	Form and Instruction

IC Title:

NHSC SP â Verification of Disadvantaged Background

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2B	Verification of Disadvantaged Background Status	Verification of Disadvantaged Background Status.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 615

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	615	68	547
Annual IC Time Burden (Hours)	154	17	137
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.