NHHSP Authorization to Release Information

The National Health Service Corps Scholarship Program, Students to Service Loan Repayment Program, and the Native Hawaiian Health Scholarship Program

Documents and Forms

Document Name Document Type
Form 4B NHHSP Authorization to Release Information Form and Instruction
4B NHHSP Authorization to Release Information NHHSP Authorization to Release Information.docx Form and Instruction
4B NHHSP Authorization to Release Information NHHSP Authorization to Release Information.docx Form and Instruction

Information Collection (IC) Details

IC Title:	NHHSP Authorization to Release Information	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 and Instruction	4B	NHHSP Authorization to Release Information	NHHSP Authorization to Release Information.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 310	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	310	310
Annual IC Time Burden (Hours)	78	78
Annual IC Cost Burden (Dollars)	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.