Information Collection

Authorization to Release Information Form

IC 240484 under ICR 202508-0915-002 · OMB 0915-0301.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 9 Authorization to Release Information Form	Form
Form 9 Authorization To Release Information Authorization to Release Information Form	Form
9 Authorization To Release Information 9_Authorization To Release Information.docx	Form
9 Authorization To Release Information 9_Authorization To Release Information.docx	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	9				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: 3,300

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	3,300	3,100	200
Annual IC Time Burden (Hours)	660	620	40
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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