Information Collection

Participant Semi-Annual In Service Verification Form

IC 283511 under ICR 202611-0906-001 · OMB 0906-0082.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 6 Participant Semi-Annual In Service Verification Form Participant Semi-Annual In Service Verification Form	Form and Instruction
6 Participant Semi-Annual In Service Verification Form FLRP ISV Screenshots.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	6				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: HHS/HRSA/BHW Scholarship and Loan Repayment Program Records

FR Citation: 86 FR 28362

Number of Respondents: 150

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	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	300	150	150
Annual IC Time Burden (Hours)	150	75	75
Annual IC Cost Burden (Dollars)	0	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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