Faculty Loan Repayment Program Application

Faculty Loan Repayment Program

Documents and Forms

Document Name Document Type
Form 1 Faculty Loan Repayment Program Application Form and Instruction
FLRP User Guide.pdf Instruction
1 FLRP User Guide.pdf FLRP User Guide.pdf Form and Instruction
2 Institution Loan Repayment Form.docx Institution-Loan Repayment Employment Form.docx Form and Instruction
2 01292024 Institution Loan Repayment Form.docx 01292024 Institution-Loan Repayment Employment Form.docx Form and Instruction
3 Authorization to Release Information Form.docx Authorization to Release Information Form.docx Form
3 01292024 Authorization to Release Information Form.docx 01292024 Authorization to Release Information Form.docx Form
4 Disadvantaged Background Form.docx Disadvantaged Background Form.docx Form and Instruction
4 01262024 Disadvantaged Background Form.docx 01292024 Disadvantaged Background Form.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Faculty Loan Repayment Program Application	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			FLRP User Guide.pdf	Yes	No	Fillable Fileable
Form and Instruction	2	01292024 Institution Loan Repayment Form.docx	01292024 Institution-Loan Repayment Employment Form.docx	Yes	Yes	Fillable Fileable
Form	3	01292024 Authorization to Release Information Form.docx	01292024 Authorization to Release Information Form.docx	Yes	Yes	Fillable Fileable
Form and Instruction	4	01262024 Disadvantaged Background Form.docx	01292024 Disadvantaged Background Form.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: HHS/HRSA/BHW Scholarship and Loan Repayment Program Records, 09–15–0037	FR Citation: 86 FR 28362

Number of Respondents: 860	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	860	116	744
Annual IC Time Burden (Hours)	527	71	456
Annual IC Cost Burden (Dollars)	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.