The National Health Service Corps (NHSC) Loan Repayment Programs

ICR 202301-0915-003

OMB: 0915-0127

Federal Form Document

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0915-0127 can be found here:

2024-04-11 - Revision of a currently approved collection

Forms and Documents

Document Name	Status
Form 1 The National Health Service Corps (NHSC) Loan Repayment Program Application Form and Instruction	Modified
Form 7 NHSC Site Application (including recertification) Form and Instruction	Modified
Form 6 NHSC Comprehensive Behavioral Health Services Checklist Form and Instruction	Modified
Form 5 Verification of Disadvantaged Background Form Form and Instruction	Modified
Form 4 Private Practice Option Form Form and Instruction	Modified
Form 3 Authorization for Disclosure of Loan Information Form Form and Instruction	Modified
Form 2 Privacy Act Release Authorization Form Form and Instruction	Modified
NHSC Participant COVID-19 Questions.docx Supplementary Document	2020-04-20
NHSC Site COVID-19 Questions.docx Supplementary Document	2020-04-20
Final Change Memo - OMB 0915-0127 and 0146 COVID-19.docx Justification for No Material/Nonsubstantive Change	2020-04-20
FINAL NHSC LRP FY 2020 Supporting Statement - 3-11-2020.docx Supporting Statement A	2020-03-25

IC Document Collections

IC ID	Document Title	Status
6365	The National Health Service Corps (NHSC) Loan Repayment Program Application Form and Instruction	Modified
225047	NHSC Site Application (including recertification) Form and Instruction	Modified
225046	NHSC Comprehensive Behavioral Health Services Checklist Form and Instruction	Modified
209462	Verification of Disadvantaged Background Form Form and Instruction	Modified
209461	Private Practice Option Form Form and Instruction	Modified
209460	Authorization for Disclosure of Loan Information Form Form and Instruction	Modified
181468	Privacy Act Release Authorization Form Form and Instruction	Modified

ICR Details

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