S2S LRP – Authorization to Release Information

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

Documents and Forms

Document Name Document Type
Form 3C S2S LRP – Authorization to Release Information Form and Instruction
3C NHSC S2S LRP Authorization to Release Information Form.p NHSC S2S LRP Authorization to Release Information Form.pdf Form and Instruction
3C NHSC S2S LRP Authorization to Release Information Form.p NHSC S2S LRP Authorization to Release Information Form.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	S2S LRP – Authorization to Release Information	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3C	NHSC S2S LRP Authorization to Release Information Form.pdf	NHSC S2S LRP Authorization to Release Information Form.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 284	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	284	84	200
Annual IC Time Burden (Hours)	28	8	20
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.