Information Collection

Data Collection Worksheet Form

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	4				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 %

table that charts list of burden
	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

table that charts IC Documents
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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