Verification of Disadvantaged Background Form

The National Health Service Corps (NHSC) Loan Repayment Programs

OMB: 0915-0127

IC ID: 209462

Information Collection (IC) Details

View Information Collection (IC)

Verification of Disadvantaged Background Form
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 5 Verification of Disadvantaged Background Verification of Disadvantaged Background.pdf Yes Yes Fillable Fileable

Health Health Care Services

The Public Health Service and National Health Service Corps Health Care Provider Records System  86 FR 28362

660 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 660 0 0 0 0 660
Annual IC Time Burden (Hours) 330 0 0 0 0 330
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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