Application Checklist and Self-Certification Form

The Nursing Education Loan Repayment Program

OMB: 0915-0140

IC ID: 182801

Information Collection (IC) Details

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Application Checklist and Self-Certification Form
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR Part 57 Section 312  (To search for a specific CFR, visit the Code of Federal Regulations.)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form NELRP_006 Application Checklist and Self-Verification Form FY 11 Forms Package.docx Yes Yes Fillable Fileable

Health Health Care Services

Public Health Service and National Health Service Corps Scholarship/Loan Repayment Participants Records System  58 FR 12968

8,000 0
   
Individuals or Households
 
   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 8,000 0 0 1,200 0 6,800
Annual IC Time Burden (Hours) 4,000 0 0 600 0 3,400
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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