Form 5 Pediatric Specialty LRP Application

OMB #: 0906-0058
Expiration Date: xx/xx/xxxx

Public Burden Statement: The purpose of this information collection is to obtain performance data for the following: HRSA program participant,
program operations, and applications. In addition, these data will facilitate the ability to demonstrate alignment between BHW discretionary
programs and the Substance Use Disorder Treatment and Recovery Loan Repayment and the Pediatric Specialty Loan Repayment programs. An
agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number. The OMB control number for this information collection is 0906-0058 and it is valid until xx/xx/xxxx. This information collection is
required to obtain or retain a benefit Section 781 of the Public Health Service Act (42 U.S.C. § 295h) and Section 775 of the Public Health Service Act
(42 U.S.C. § 295f). Public reporting burden for this collection of information is estimated to average xx hour per response, including the time for
reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance
Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].