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NC SP Employment Verification Form
The Nursing Scholarship Program
OMB: 0915-0301
IC ID: 240478
OMB.report
HHS/HSA
OMB 0915-0301
ICR 202303-0915-003
IC 240478
( )
Documents and Forms
Document Name
Document Type
Form 6
NC SP Employment Verification Form
Form
6 NC SP Employment Verification Form
Employment Verification Screenshot.docx
Form
6 NC SP Employment Verification Form
Employment Verification Screenshot.docx
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
NC SP Employment Verification Form
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
6
NC SP Employment Verification Form
Employment Verification Screenshot.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
500
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
500
0
0
0
0
500
Annual IC Time Burden (Hours)
210
0
0
0
0
210
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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.
