View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0915-0146
ICR Reference No:
201404-0915-001
Status:
Historical Active
Previous ICR Reference No:
201101-0915-003
Agency/Subagency:
HHS/HSA
Agency Tracking No:
Title:
Application for Participation in the National Health Service Corps Scholarship Program
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
06/03/2014
Retrieve Notice of Action (NOA)
Date Received in OIRA:
04/23/2014
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
06/30/2017
36 Months From Approved
06/30/2014
Responses
13,339
0
3,660
Time Burden (Hours)
8,200
0
7,270
Cost Burden (Dollars)
0
0
0
Abstract:
Administered by HRSA's Bureau of Clinician Recruitment and Service (BCRS), the National Health Service Corps (NHSC) Scholarship Program (SP), NHSC Students to Service Loan Repayment Program (S2S LRP), and the Native Hawaiian Health Scholarship Program (NHHSP), provide scholarships or loan repayment to qualified students who are pursuing primary care health professions education and training. In return, students agree to provide primary health care services in medically underserved communities located in federally designated Health Professional Shortage Areas (HPSAs) once they are fully trained and licensed health professionals. Awards are made to applicants who demonstrate the greatest potential for successful completion of their education and training as well as commitment to provide primary health care services to communities of greatest need. The program applications, forms, and supporting documentation are used to collect necessary information from applicants and participants that will facilitate in the selection of the best qualified candidates for these competitive awards, and to monitor participants' enrollment in school or in postgraduate training.
Authorizing Statute(s):
PL:
Pub.L. 107 - 251 1533
Name of Law: Health Care Safety Net Amendments of 2002
US Code:
42 USC 254d(i), l, m-q
Name of Law: National Health Service Corps
US Code:
42 USC 11709
Name of Law: The Native Hawaiian Health Care Improvement Act
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
79 FR 832
01/17/2014
30-day Notice:
Federal Register Citation:
Citation Date:
79 FR 16013
03/24/2014
Did the Agency receive public comments on this ICR?
Yes
Number of Information Collection (IC) in this ICR:
18
IC Title
Form No.
Form Name
Application for Participation in the National Health Service Corps Scholarship Program
1
NHSC Scholarship Program Application
Data Collection Worksheet - School/Site Form
NHSC_SP_003
Data Collection Worksheet
Deferment Request Form - Participant Form
NHSC_SP_005
Deferment Request Form
NHHSP - Acceptance/Verification of Good Standing Report
1
NHHSP - Acceptance/Verification of Good Standing Report
NHSC SP Authorization to Release Information
1
NHSC SP Authorization to Release Information
NHSC SP Letters of Recommendation
NHSC SP – Acceptance/Verification of Good Standing Report
1
NHSC SP – Acceptance/Verification of Good Standing Report
NHSC SP – Data Collection Worksheet
1
NHSC SP – Data Collection Worksheet
NHSC SP – Enrollment Verification Form
1
NHSC SP – Enrollment Verification Form
NHSC SP – Post Graduate Training Verification Form
1
NHSC SP – Post Graduate Training Verification Form
NHSC SP – Receipt of Exceptional Financial Need Scholarship
1
NHSC SP – Receipt of Exceptional Financial Need Scholarship
NHSC SP – Verification of Disadvantaged Background
1
NHSC SP – Verification of Disadvantaged Background
NHSC Students to Service Program Application
1
NHSC Students to Service Program Application
Native Hawaiian Health Scholarship Program Application
1
Native Hawaiian Health Scholarship Program Application
S2S LRP – Authorization to Release Information
1
S2S LRP – Authorization to Release Information
S2S LRP - Letters of Recommendation
S2S LRP - Post Graduate Training Verification Form
1
S2S LRP - Post Graduate Training Verification Form
S2S LRP - Receipt of Exceptional Financial Need Scholarship
1
S2S LRP - Receipt of Exceptional Financial Need Scholarship
S2S LRP - Verification of Disadvantaged Background
1
S2S LRP - Verification of Disadvantaged Background
S2S LRP – Acceptance/Verification of Good Standing Report
1
S2S LRP – Acceptance/Verification of Good Standing Report
Six-Month Service Obligation Verification Form - School/Sites Forms
NHSC_SP_004
Six-Month Service Obligation Verification Form
ICR Summary of Burden
Total Approved
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
13,339
3,660
0
9,679
0
0
Annual Time Burden (Hours)
8,200
7,270
0
930
0
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:
Changing Forms
Short Statement:
The OMB inventory of approved total burden previously contained 7,270 hours for the NHSC SP application and forms. Given the inclusion of the burden hours and information collection for the S2S LRP and NHHSP, there will be an increase in the request for total burden hours. The current request for the NHSC SP, S2S LRP, and NHHSP applications and forms is 8,200 burden hours (a difference of 930 hours).
Annual Cost to Federal Government:
$465,604
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
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?
Uncollected
Agency Contact:
Jodi Duckhorn 301 443-1984
Common Form ICR:
No
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:
04/23/2014
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