Information Collection

S2S LRP - Verification of Vulnerable Background

IC 211169 under ICR 202608-0915-003 · OMB 0915-0146.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3G NHSC S2S LRP Verification of Vulnerable Background Status Form S2S LRP - Verification of Vulnerable Background	Form and Instruction
3G NHSC S2S LRP Verification of Vulnerable Background Statu NHSC S2S LRP Verification of Vulnerable Background Status Form.docx	Form and Instruction
NHSC S2S LRP Verification of Vulnerable Background Status Form (Redline).pdf NHSC S2S LRP Verification of Vulnerable Background Status Form (Redline)	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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 and Instruction	3G				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: 115

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	115	115
Annual IC Time Burden (Hours)	29	29
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
NHSC S2S LRP Verification of Vulnerable Background Status Form (Redline)		06/30/2026

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].