Information Collection

Data Collection Worksheet Form

IC 240473 under ICR 202508-0915-002 · OMB 0915-0301.

Documents and Forms

Document Name Document Type
Form 4 Data Collection Worksheet Form Form
Form 4 Data Collection Worksheet Form Data Collection Worksheet Form Form
4 Data Collection Worksheet Form 4_Data Collection Worksheet Form.pdf Form
4 Data Collection Worksheet Form 4_Data Collection Worksheet Form.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Data Collection Worksheet Form	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	4	Data Collection Worksheet Form	4_Data Collection Worksheet Form.pdf		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	FR Citation: 86 FR 28362

Number of Respondents: 600	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	600	100	500
Annual IC Time Burden (Hours)	600	100	500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.

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