Information Collection

Native Hawaiian Health Scholarship Program Application

IC 211172 under ICR 202512-0915-003 · OMB 0915-0146.

Documents and Forms

Document Name Document Type
Form 4A Native Hawaiian Health Scholarship Program Application Form and Instruction
Form 4A NHHSP Program Application (User Guide) Native Hawaiian Health Scholarship Program Application Form and Instruction
4A NHHSP Program Application (User Guide) 0915 0146 - NHHSP Program Application.pdf Form and Instruction
4A NHHSP Program Application (User Guide) 0915 0146 - NHHSP Program Application.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Native Hawaiian Health Scholarship Program Application	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	4A	NHHSP Program Application (User Guide)	0915 0146 - NHHSP Program Application.pdf		Yes	Yes	Fillable Fileable

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: 200	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	200	-110	310
Annual IC Time Burden (Hours)	400	-220	620
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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