IHS Loan Application

Indian Health Service Loan Repayment Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0014 can be found here:

Documents and Forms

Document Name Document Type
Form 0917-0014 IHS Loan Application Form and Instruction
0917-0014 Educational and Professional Background IHS Loan Repayment Application - Educational and Professional Background.pdf www.ihs.gov/loanrepayment/applynow/ Form and Instruction
0917-0014 Financial Information IHS Loan Repayment Application - Financial Information.pdf www.ihs.gov/loanrepayment/applynow/ Form and Instruction
0917-0028 General Applicant Information IHS Loan Repayment Application - General Applicant Information.pdf www.ihs.gov/loanrepayment/applynow/ Form and Instruction
60 Day FRN for OMB No. 0917-0014, 02-05-2015.docx 60 Day Federal Register Notice for 0917-0014, Loan Repayment Program IC Document
60 day FR Publication 04-28-15 (2).pdf 0917-0014, Published 60 Day Federal Register Notice, Loan Repayment Program IC Document
FINAL 30 Day FRN for OMB No 0917-0014 05-27-15- DRA Final - TCLAY.docx 0917-0014, 30 Day Federal Register Notice for Loan Repayment Program IC Document
30 Day Federal Register Notice for IHS Loan Repayment Program, June 11, 2015.pdf OMB No. 0917-0014, Published Federal Register Notice for Loan Repayment Program IC Document
FINAL_LRP_Supporting_Statement_6-22-15 DRA.docx Supporting Statement for OMB No. 0917-0014, Loan Repayment Program IC Document

Information Collection (IC) Details

IC Title:	IHS Loan Application	Agency IC Tracking Number:	0917-0014

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 5 CFR 1320

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0917-0014	Educational and Professional Background	IHS Loan Repayment Application - Educational and Professional Background.pdf	http://www.ihs.gov/loanrepayment/applynow/	Yes	Yes	Fillable Fileable Signable
Form and Instruction	0917-0014	Financial Information	IHS Loan Repayment Application - Financial Information.pdf	http://www.ihs.gov/loanrepayment/applynow/	Yes	Yes	Fillable Fileable Signable
Form and Instruction	0917-0028	General Applicant Information	IHS Loan Repayment Application - General Applicant Information.pdf	http://www.ihs.gov/loanrepayment/applynow/	Yes	Yes	Fillable Fileable Signable

Line of Business: Education

Subfunction: Higher Education

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 816	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	816	306	510
Annual IC Time Burden (Hours)	1,224	459	765
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
60 Day Federal Register Notice for 0917-0014, Loan Repayment Program	60 Day FRN for OMB No. 0917-0014, 02-05-2015.docx	06/22/2015
0917-0014, Published 60 Day Federal Register Notice, Loan Repayment Program	60 day FR Publication 04-28-15 (2).pdf	06/22/2015
0917-0014, 30 Day Federal Register Notice for Loan Repayment Program	FINAL 30 Day FRN for OMB No 0917-0014 05-27-15- DRA Final - TCLAY.docx	06/22/2015
OMB No. 0917-0014, Published Federal Register Notice for Loan Repayment Program	30 Day Federal Register Notice for IHS Loan Repayment Program, June 11, 2015.pdf	06/22/2015
Supporting Statement for OMB No. 0917-0014, Loan Repayment Program	FINAL_LRP_Supporting_Statement_6-22-15 DRA.docx	06/23/2015

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