Information Collection

Faculty Loan Repayment Program Application

IC 6381 under ICR 202311-0915-001 · OMB 0915-0150.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Faculty Loan Repayment Program Application	Form and Instruction
FLRP User Guide.pdf	Instruction
1 FLRP User Guide.pdf FLRP User Guide.pdf	Form and Instruction
2 Institution Loan Repayment Form.docx Institution-Loan Repayment Employment Form.docx	Form and Instruction
2 01292024 Institution Loan Repayment Form.docx 01292024 Institution-Loan Repayment Employment Form.docx	Form and Instruction
3 Authorization to Release Information Form.docx Authorization to Release Information Form.docx	Form
3 01292024 Authorization to Release Information Form.docx 01292024 Authorization to Release Information Form.docx	Form
4 Disadvantaged Background Form.docx Disadvantaged Background Form.docx	Form and Instruction
4 01262024 Disadvantaged Background Form.docx 01292024 Disadvantaged Background Form.docx	Form and Instruction

IC Title:

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			FLRP User Guide.pdf	Yes	No	Fillable Fileable
Form and Instruction	2	01292024 Institution Loan Repayment Form.docx	01292024 Institution-Loan Repayment Employment Form.docx	Yes	Yes	Fillable Fileable
Form	3	01292024 Authorization to Release Information Form.docx	01292024 Authorization to Release Information Form.docx	Yes	Yes	Fillable Fileable
Form and Instruction	4	01262024 Disadvantaged Background Form.docx	01292024 Disadvantaged Background Form.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: HHS/HRSA/BHW Scholarship and Loan Repayment Program Records, 09â15â0037

FR Citation: 86 FR 28362

Number of Respondents: 860

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	860	116	744
Annual IC Time Burden (Hours)	527	71	456
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.