1 NHSC Travel Request Worksheet Form

OMB No. 0906-xxxx

Expiration Date: xx/xx/xxxx

National Health Service Corps

Scholar Travel and Relocation Request Worksheet

Non-Federal Personnel

Create Interview Request
Select site(s) where you will be interviewing: State:			City:			Choose NHSC Site(s)
Interview Type: Virtual/Phone:		In-Person Travel: (Less or more than 50 miles)
Interview Date:	Travel Departure Date:				Travel Return Date:
Originating Address (Street/City/State/Zip Code):				Are you receiving funds from the NHSC site? Yes/No
If traveling with a family member, would you like to use your one-time family member option on this visit? Yes/No
Are you requesting a rental car for this visit? Yes/No
Participant’s Comment:

Create Relocation Request
Select site(s) where you will be working: State:		City:		Choose NHSC Site(s)
Address of your current residence (Street/City/State/Zip Code):		Address of your new residence (Street/City/State/Zip Code): (If unknown, select “I do not know yet”)
Relocation Date:	Relocation Type: Federal Funded:		Self-Move:
Would you like to use advance storage for this move? Yes/No
Is the NHSC site providing funding for this move? Yes/No
Participant’s Comment:

Signature of Requesting Official, NHSC:

Date:

PUBLIC BURDEN STATEMENT

The purpose of this information collection is to obtain information through the National Health Service Corps (NHSC) Scholarship Program (SP) and the Students to Service (S2S) Loan Repayment Program (LRP), which is used to review online Travel Request Worksheets to request and receive travel funds from the federal government to visit eligible NHSC sites. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB control number for this project is 0906-xxxx and is valid until xx/xx/20xx. This information collection is required to obtain or retain a benefit (Public Health Service Act, section 331(c)(1). The information is protected by the Privacy Act, but it may be disclosed outside the U.S. Department of Health and Human Services, as permitted by the Privacy Act and Freedom of Information Act, to Congress, the National Archives, and the Government Accountability Office, and pursuant to court order and various routine uses as described in the System of Record Notice 09-15-0037. Public reporting burden or this collection of information is estimated to average 4 minutes 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857.