Supporting Statement - NHSC Travel Request Worksheet - Final Draft v.2

SUPPORTING STATEMENT A

National Health Service Corps Scholar Travel Request Worksheet

OMB Control No. 0915-0278 – Revision

Note: OMB control number prefix should change to 0906-, it was previously 0915.

Terms of Clearance: None

A. Justification

1. Circumstances Making the Collection of Information Necessary

This is a request for Office of Management and Budget (OMB) approval of a revision for the Health Resources and Services Administration (HRSA), National Health Service Corps (NHSC), Travel Request Worksheet (TRW). The OMB control number for the TRW is 0915-0278 and has a current expiration date of December 31, 2024. This form is used for requests for pre-employment site visit(s) and relocation to an NHSC-approved site(s) for the purpose of securing employment in a clinical practice to fulfill the NHSC service commitment. The Public Health Service Act, Section 331(c)(1) provides that the Secretary may reimburse applicants for positions in the Corps including individuals considering entering into a written agreement pursuant to section 338D for actual and reasonable expenses incurred in traveling to and from their place of residence to an eligible site to which they may be assigned under section 333. The Secretary shall not reimburse an applicant for more than one such trip to the same approved site. The Secretary shall only reimburse an applicant for relocating to their initial employment site and not for site transfers.

The NHSC was established by Congress for the purpose of eliminating health professional shortages in Health Professional Shortage Areas (HPSAs). HPSAs are geographic areas, facilities, or population groups determined by the Secretary of Health and Human Services to have a shortage of health professionals. The NHSC provides funding support to encourage selected health care professionals to practice in HPSAs. This program is located in HRSA’s Bureau of Health Workforce (BHW).

2. Purpose and Use of Information Collection

The purpose of this form is to ensure that the program can effectively and efficiently monitor authorized travel and relocation for NHSC clinicians. The TRW form is utilized to expedite the travel and relocation approval process for physicians, dentists, nurse practitioners, certified nurse midwives, and physician assistants when the NHSC Scholarship Program (SP) or Students to Service (S2S) Loan Repayment Program participant has secured an interview or employment at an NHSC approved site(s) and has notified their respective NHSC contact. Such advance notice ensures that the NHSC clinician is fully prepared for the site visit or relocation and maximizes the available NHSC travel and relocation funding. Utilization of this form avoids unauthorized travel or relocation to unapproved NHSC sites and provides more efficient monitoring of travel and relocation allotments for each clinician.

3. Use of Improved Information Technology and Burden Reduction

This form is fully electronic. The automated form assists clinicians in requesting approval for travel for site visits before executing an employment agreement and for requesting relocation assistance in a timely manner.

4. Efforts to Identify Duplication and Use of Similar Information

There are no other sources of this information. The information requested only pertains to scholar or S2S participant placement and practice considerations and is available only from the scholar or S2S participant and the NHSC.

5. Impact on Small Businesses or Other Small Entities

This information collection does not involve small businesses or other small entities.

6. Consequences of Collecting the Information Less Frequently

Without this form, the Program cannot effectively monitor clinician travel and relocation and avoid unauthorized travel and relocation. The TRW is used each time a clinician submits a request for travel for site visits or requests relocation assistance. This form is needed to efficiently monitor travel and relocation for clinicians.

7. Special Circumstances Relating to the Guidelines in 5 CFR 1320.5

The request fully complies with the regulation.

8. Comments in Response to the Federal Register Notice/ Outside Consultation

1. A 60-day Federal Register Notice was published in the Federal Register, on December 29, 2023; vol. 88, No. 249, pp. 90190-90191. There were no public comments. A 30-day Federal Register Notice was published in the Federal Register, on March 7, 2024; vol. 89, No. 46, pp. 16585-16586. There were no public comments.

2. Seven (7) individuals were contacted for consultation regarding the clarity and format of the data collection instrument and the frequency of collection. The individuals found the data collection instrument to be clear and straightforward. There were no suggestions for improvement.

9. Explanation of any Payment/Gift to Respondents

Respondents will not receive any payments or gifts.

10. Assurance of Confidentiality Provided to Respondents

The Privacy Act of 1974 (5 U.S.C. 522a) requires an agency to provide notification to individuals who supply information. The required Privacy Act notification is included on the proposed form. Access to these records is strictly limited to all authorized NHSC principal staff that are aware of their responsibilities under the Privacy Act.

Disclosure of the applicant’s unique identifier is required for reimbursement of NHSC applicants. The records associated with the information collection are protected by the Privacy Act. In accordance with the requirements of the Privacy Act, HRSA has established a system of records for BHW Scholarship and Loan Repayment Programs Records, No. 09-15-0037, which contains information on NHSC scholarship recipients. Data will be kept private to the extent allowed by law.

11. Justification for Sensitive Questions

There are no questions of a sensitive nature.

12A. Estimated Annualized Burden Hours

The burden estimate is as follows:

Form Name	Number of Respondents	Number of Responses per Respondent	Total Responses	Average Burden per Response (in hours)	Total Burden Hours
Travel Request Worksheet	800	2	1600	0.0667	106.72*
Total	800		1600		106.72

* Note: 106.72 rounds up to 107 in ROCIS.

The burden is based upon historical responses from NHSC program participants collected over the past 3 years, who have completed the form. This includes the average burden per response and anticipated volume of program participants. The form takes approximately 4 minutes to complete. Burden hour estimates were derived from information provided by applicants and reflect an average of data collected over a period of 3 years.

12B. Estimated Annualized Burden Costs

The median hourly wage for healthcare practitioners has been used to account for the overall burden costs. This category was determined to be the occupational category provides the closest position for the task required.

Form	Total Burden Hours	Wage Rate	Total Hour Cost
Travel Request Worksheet	106.72	$57.841	$ 6,172.68

13. Estimates of Other Total Annual Cost Burden to Respondents or

Record-keepers/Capital Costs

Other than their time, there is no cost to respondents.

14. Annualized Cost to the Federal Government

Instrument	Base Pay Rate	Base Pay Rate (x1.5)	Project Time per FTE	Number of FTEs	Total Annual Cost
Travel Request Worksheet	$117,962/ GS-13 Step 1	$176,943/ GS-13 Step 1	.05	2	$17,694.30

Base Pay Rate based on the Office of Personnel Management Pay Scale: https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2024/DCB.pdf. Base Pay Rate multiplied by 1.5 to account for overhead costs, the total amount cost of the base rate multiplied by 1.5.

The annual cost to the government is approximately $17,694.30 for costs for the Travel and Relocation Request Worksheet for two GS-13 Step 1 employees at a 0.05 FTE rate to review and process travel and relocation requests.

15. Explanation for Program Changes or Adjustments

Due to the anticipated volume of program participants, the burden for this effort has increased from 40.02 to 106.72 hours. The request reflects an increase of 166 percent, which is a difference of 66.70 hours.

16. Plans for Tabulation, Publication, and Project Time Schedule

For the purposes of the travel/relocation assistance requests, there are no plans for tabulation, analysis, or publications from this activity.  Due to the personally identifiable information from scholars and program participants, sensitive information about plans for site visits and relocations is protected, and this information is securely stored in the BHW Management Information System Solution (BMISS).

17. Reason(s) Display of OMB Expiration Date is Inappropriate

The OMB number and expiration date will be displayed on every page of every form/instrument.

18. Exceptions to Certification for Paperwork Reduction Act Submissions

There are no exceptions to the certification.

1 The wage rate is based upon Bureau of Labor Statistics data for the median hourly wage of Healthcare Practitioners; https://www.bls.gov/oes/current/oes299099.htm. The median wage of $28.92 was multiplied by 2 to account for overhead costs.

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