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OMB Control No: 0915-0127	ICR Reference No: 201701-0915-003
Status: Historical Active	Previous ICR Reference No: 201609-0915-004
Agency/Subagency: HHS/HSA	Agency Tracking No: 20941
Title: The National Health Service Corps (NHSC) Loan Repayment Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/28/2017
	Date Received in OIRA: 01/09/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2020	36 Months From Approved	02/28/2017
Responses	23,575	0	9,350
Time Burden (Hours)	11,578	0	8,555
Cost Burden (Dollars)	0	0	0

Abstract: The National Health Service Corps (NHSC) Loan Repayment Program (LRP) was established to assure an adequate supply of trained primary care health professionals to provide services in the neediest Health Professional Shortage Areas (HPSAs) of the United States. Under this program, the Department of Health and Human Services agrees to repay the qualifying educational loans of selected primary care health professionals. In return, the health professionals agree to serve for a specified period of time in a NHSC-approved site located in a federally-designated HPSA approved by the Secretary for LRP participants. The forms utilized by the LRP include the following: the NHSC LRP Application, the Authorization for Disclosure of Loan Information form, the Privacy Act Release Authorization form, and if applicable, the Verification of Disadvantaged Background form and the Private Practice Option form. The first four of the aforementioned NHSC LRP forms collect information that is needed for selecting participants and repaying qualifying educational loans. The last referenced form, the Private Practice Option Form, is needed to collect information for all participants who have applied for that service option. NHSC-approved sites are health care facilities that provide comprehensive outpatient, ambulatory, primary health care services to populations residing in HPSAs. Related in-patient services may be provided by NHSC-approved Critical Access Hospitals (CAHs). In order to become an NHSC-approved site, new sites must submit a Site Application for review and approval. Existing NHSC-approved sites are required to complete a Site Recertification Application in order to maintain their NHSC-approved status. Both the NHSC Site Application and Site Recertification Application request information on the clinical service site, sponsoring agency, recruitment contact, staffing levels, service users, charges for services, employment policies, and fiscal management capabilities. Assistance in completing these applications may be obtained through the appropriate State Primary Care Offices and the NHSC. The information collected on the applications is used for determining the eligibility of sites for the assignment of NHSC health professionals and to verify the need for NHSC clinicians. NHSC service site approval is valid for 3 years. Sites wishing to remain eligible for the assignment of NHSC providers, must submit a Site Recertification Application every 3 years.

Authorizing Statute(s): US Code: 42 USC 2541 - 1(c), 333 [254f] (a)(1) Name of Law: Public Health Service 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:
	81 FR 59229	08/29/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 1352	01/05/2017
Did the Agency receive public comments on this ICR? No

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	23,575	9,350	14,225
Annual Time Burden (Hours)	11,578	8,555	3,023
Annual Cost Burden (Dollars)	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: No

Burden Reduction Due to:

Short Statement: Program has added two forms to this ICR, thus increasing the burden. New forms are the Behavioral Health Services Checklist and the NHSC Site Application.

Annual Cost to Federal Government: $540,881

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]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Yes

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: Elyana Bowman 301 443-3983 enadjem@hrsa.gov

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