Information Collection

NHHSP Acceptance/Verification of Good Standing Report

IC 242293 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⚠️ Notice: This information collection may be referencing outdated material.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 4C NHHSP Acceptance/Verification of Good Standing Report	Form and Instruction
Form 4C NHHSP Acceptance Verification of Good Standing Form NHHSP Acceptance/Verification of Good Standing Report	Form and Instruction
4C NHHSP Acceptance Verification of Good Standing Form 0915 0146 - NHHSP Good Standing Report.docx	Form and Instruction
4C NHHSP Acceptance Verification of Good Standing Form 0915 0146 - NHHSP Good Standing Report.docx	Form and Instruction

IC Title:

NHHSP Acceptance/Verification of Good Standing Report

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	4C				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: 40

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	Previously Approved
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	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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