Download:
pdf |
pdf6/16/25, 11:36 AM
Employment Verification
Nurse Corps Loan Repayment Program
U.S. Department of Health and Human Services
Health Resources and Services Administration
OMB No. 0915-0140 Expiration Date: xx/xx/xxxx
Participant Name
Number
https://bmiss.hrsa.gov/service-request/person/employment-verification/request/overview?serviceRequestId=c13e7768-b761-4a9a-9f92-7fe196db4f28
1/6
6/16/25, 11:36 AM
Employment Verification
https://bmiss.hrsa.gov/service-request/person/employment-verification/request/overview?serviceRequestId=c13e7768-b761-4a9a-9f92-7fe196db4f28
2/6
6/16/25, 11:36 AM
Employment Verification
Site Name
Site Address
https://bmiss.hrsa.gov/service-request/person/employment-verification/request/overview?serviceRequestId=c13e7768-b761-4a9a-9f92-7fe196db4f28
3/6
6/16/25, 11:36 AM
Employment Verification
https://bmiss.hrsa.gov/service-request/person/employment-verification/request/overview?serviceRequestId=c13e7768-b761-4a9a-9f92-7fe196db4f28
4/6
6/16/25, 11:36 AM
Employment Verification
https://bmiss.hrsa.gov/service-request/person/employment-verification/request/overview?serviceRequestId=c13e7768-b761-4a9a-9f92-7fe196db4f28
5/6
6/16/25, 11:36 AM
Employment Verification
https://bmiss.hrsa.gov/service-request/person/employment-verification/request/overview?serviceRequestId=c13e7768-b761-4a9a-9f92-7fe196db4f28
6/6
6/16/25, 11:58 AM
Employment Verification
https://bmiss.hrsa.gov/service-request/person/employment-verification/request/overview?serviceRequestId=2d96450c-4c93-46db-a1fa-b595d72b3f70
1/7
6/16/25, 11:58 AM
Employment Verification
https://bmiss.hrsa.gov/service-request/person/employment-verification/request/overview?serviceRequestId=2d96450c-4c93-46db-a1fa-b595d72b3f70
2/7
6/16/25, 11:58 AM
Employment Verification
https://bmiss.hrsa.gov/service-request/person/employment-verification/request/overview?serviceRequestId=2d96450c-4c93-46db-a1fa-b595d72b3f70
3/7
6/16/25, 11:58 AM
Employment Verification
https://bmiss.hrsa.gov/service-request/person/employment-verification/request/overview?serviceRequestId=2d96450c-4c93-46db-a1fa-b595d72b3f70
4/7
6/16/25, 11:58 AM
Employment Verification
https://bmiss.hrsa.gov/service-request/person/employment-verification/request/overview?serviceRequestId=2d96450c-4c93-46db-a1fa-b595d72b3f70
5/7
6/16/25, 11:58 AM
Employment Verification
https://bmiss.hrsa.gov/service-request/person/employment-verification/request/overview?serviceRequestId=2d96450c-4c93-46db-a1fa-b595d72b3f70
6/7
6/16/25, 11:58 AM
ë
Employment Verification
áë
á_
Public Burden Statement: The purpose of this information collection is to obtain information through the Nurse Corps Loan Repayment Program
(LRP) that is used to assess a Loan Repayment Program applicant’s eligibility and qualifications for the Loan Repayment Program and to monitor a
participant’s compliance with the program’s service requirements. Applicants interested in participating in the Nurse Corps LRP must submit an
application to the Nurse Corps through the My BHW online portal. 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
0915-0140 and it is valid until 02/28/2026. This information collection is required to obtain or retain a benefit (Section 846 of the Public Health Service
Act, as amended [42 U.S.C. 297n]). 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 for this collection of information is estimated to average 0.68 hours 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
14NWH04, Rockville, Maryland, 20857.
https://bmiss.hrsa.gov/service-request/person/employment-verification/request/overview?serviceRequestId=2d96450c-4c93-46db-a1fa-b595d72b3f70
7/7
| File Type | application/pdf |
| File Title | Employment Verification |
| Author | MWesterlind |
| File Modified | 2025-09-22 |
| File Created | 2025-06-16 |