Information Collection

S2S LRP – Authorization to Release Information

IC 211166 under ICR 202512-0915-003 · OMB 0915-0146.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0146 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3E S2S LRP – Authorization to Release Information	Form and Instruction
Form 3E NHSC S2S LRP Authorization to Release Information Form.pdf S2S LRP – Authorization to Release Information	Form and Instruction
3E NHSC S2S LRP Authorization to Release Information Form.p 0915 0146 - NHSC S2S Authorization to Release Form.pdf	Form and Instruction
3E NHSC S2S LRP Authorization to Release Information Form.p 0915 0146 - NHSC S2S Authorization to Release Form.pdf	Form and Instruction

IC Title:

S2S LRP â Authorization to Release Information

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 62.6

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 and Instruction	3E				Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Public Health Service National Health Service Corps Scholarship/Loan Repayment Participants Records System

FR Citation: 58 FR 12968

Number of Respondents: 348

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	348	64	284
Annual IC Time Burden (Hours)	35	7	28
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].