Faculty Loan Repayment Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 4 FLRP DAB Background Form Revised Clean- 5.8.26.docx	Form and Instruction	Removed	Available
Form 3 01292024 Authorization to Release Information Form.docx	Form	Removed	Available
Form 2 01292024 Institution Loan Repayment Form.docx	Form and Instruction	Removed	Available
Form 6 Participant Semi-Annual In Service Verification Form	Form and Instruction	New	Available
Form 4 Certification of Vulnerable Background Form	Form and Instruction	New	Available
Form 3 Authorization to Release Information Form	Form	New	Available
Form 5 Employer’s Agreement to Loan Repayment Match/Request for a Waiver of the Loan Repayment Match Form	Form	New	Available
Form 2 Institution/Loan Repayment Employment Form	Form and Instruction	New	Available
Form 1 FLRP Application	Form and Instruction	New	Available
FLRP Supporting Statement - Final.docx	Supporting Statement A	Uploaded 2026-11-03	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6381	Faculty Loan Repayment Program Application	Form and Instruction	Removed	FLRP DAB Background Form Revised Clean- 5.8.26.docx
6381	Faculty Loan Repayment Program Application	Form	Removed	01292024 Authorization to Release Information Form.docx
6381	Faculty Loan Repayment Program Application	Form and Instruction	Removed	01292024 Institution Loan Repayment Form.docx
6381	Faculty Loan Repayment Program Application	Instruction	Removed
283511	Participant Semi-Annual In Service Verification Form	Form and Instruction	New	Participant Semi-Annual In Service Verification Form
283510	Certification of Vulnerable Background Form	Form and Instruction	New	Certification of Vulnerable Background Form
283509	Authorization to Release Information Form	Form	New	Authorization to Release Information Form
283507	Employer's Agreement to Loan Repayment Match/Request for a Waiver of the Loan Repayment Match Form	Form	New	Employer’s Agreement to Loan Repayment Match/Request for a Waiver of the Loan Repayment Match Form
283504	Institution/Loan Repayment Employment Form	Form and Instruction	New	Institution/Loan Repayment Employment Form
283503	Eligible Applications	Form and Instruction	New	FLRP Application

ICR Details

OMB Control No: 0906-0082	ICR Reference No: 202611-0906-001
Status: Received in OIRA	Previous ICR Reference No: 202608-0906-002
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: Faculty Loan Repayment Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 11/03/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	01/31/2027
Responses	1,425	860
Time Burden (Hours)	926	527
Cost Burden (Dollars)	0	0

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Abstract: The information collected will be used to evaluate applicants’ eligibility to participate in the Faculty Loan Repayment Program (FLRP), administered by the Bureau of Health Workforce, Department of Health and Human Services (HHS). The information collected will be used to evaluate applicants’ rank and tier in the FLRP award process and to monitor FLRP-related activities.

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Authorizing Statute(s): PL: Pub.L. 105 - 392 738(a) Name of Law: Health Professions Education Partnerships Act of 1998
   US Code: 42 USC 293b Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 54335	08/21/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 69261	11/03/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
Authorization to Release Information Form	3	Authorization to Release Information Form
Certification of Vulnerable Background Form	4	Certification of Vulnerable Background Form
Eligible Applications	1	FLRP Application
Employer's Agreement to Loan Repayment Match/Request for a Waiver of the Loan Repayment Match Form	5	Employer’s Agreement to Loan Repayment Match/Request for a Waiver of the Loan Repayment Match Form
Faculty Loan Repayment Program Application	2, 3, 4	01292024 Institution Loan Repayment Form.docx ,   01292024 Authorization to Release Information Form.docx ,   FLRP DAB Background Form Revised Clean- 5.8.26.docx
Institution/Loan Repayment Employment Form	2	Institution/Loan Repayment Employment Form
Participant Semi-Annual In Service Verification Form	6	Participant Semi-Annual In Service Verification Form

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ICR Summary of Burden

table that charts list of burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,425	860	0	-485	1,050	0
Annual Time Burden (Hours)	926	527	0	-227	626	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The estimated total burden for this activity is estimated to be 926.25 hours (rounding down to 926 hours in ROCIS). The estimated burden hours percentage change from the current Notice of Action to the revised estimated burden hours reflects an increase of about 76% which is a difference of about 395 hours. This is due to an increase in the number of respondents/applicants to the FLRP as well as the addition of two new forms. The "decline" is due to a quirk in ROCIS. The prior package had all forms in one IC, whereas in this package we are including each form as a separate IC due to differences in frequency of submission, burden hours per response, and who submits the form (participant or the institution on behalf of the participant).

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Annual Cost to Federal Government: $285,218

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/03/2026

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