Verification of Disadvantaged Background Form

The National Health Service Corps (NHSC) Loan Repayment Programs

Documents and Forms

Document Name Document Type
Form 5 Verification of Disadvantaged Background Form Form and Instruction
5 Verification of Disadvantaged Background Verification of Disadvantaged Background.pdf Form and Instruction
5 Verification of Disadvantaged Background Verification of Disadvantaged Background.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Verification of Disadvantaged Background 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 and Instruction	5	Verification of Disadvantaged Background	Verification of Disadvantaged Background.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: The Public Health Service and National Health Service Corps Health Care Provider Records System	FR Citation: 86 FR 28362

Number of Respondents: 660	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	660	660
Annual IC Time Burden (Hours)	330	330
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.