Information Collection

Applicants

IC 237381 under ICR 202602-0925-001 · OMB 0925-0361.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Application Applicants	Form
1 Application Applicant 02-25-2026.pdf	Form
Eligibilty - HD with burden statement.pdf Eligibility - Health Disparities (HD)	IC Document

IC Title:

Applicants

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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	1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: DHHS 09-25-0165 National Institutes of Health (NIH) Office of Loan Repayment and Scholarship (OLRPS) Record System, HHS/NIH/OD

FR Citation: 67 FR 60742

Number of Respondents: 2,070

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,070	770	1,300
Annual IC Time Burden (Hours)	16,560	6,160	10,400
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Eligibility - Health Disparities (HD)		08/15/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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