The National Health Service Corps (NHSC) Loan Repayment Programs

ICR 202404-0915-002

OMB: 0915-0127

Federal Form Document

Forms and Documents

Document Name	Status
Form 1 NHSC LRP Application Form and Instruction	Modified
Form 8 NHSC Spanish Language Assessment Proficiency Test Form Form and Instruction	New
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 LRP Supporting Statement A.docx Supporting Statement A	2024-04-10

IC Document Collections

IC ID	Document Title	Status
6365	NHSC LRP Application Form and Instruction	Modified
266757	NHSC Spanish Language Assessment Proficiency Test Form Form and Instruction	New
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