NURSE Corps Loan Repayment Program

Forms and Documents

Document Name	Status
Form 1 NURSE Corps LRP Application Form and Instruction	Modified
Form 1 Authorization to Release Information Form Form and Instruction	Modified
Form 1 Participant Semi-Annual Employment Verification Form Form and Instruction	Modified
Form 2 Authorization for Release of Employment Information Form Form	Removed
NC LRP Supporting Statement_Final_4-7-17.doc Supporting Statement A	2017-04-12
FINALNPI2016 OMB Request for Non-Substantive Change - 09.14.16.docx Justification for No Material/Nonsubstantive Change	2016-09-28

IC Document Collections

IC ID	Document Title	Status
6368	NURSE Corps LRP Application Form and Instruction	Modified
196033	Authorization to Release Information Form Form and Instruction	Modified
182803	Participant Semi-Annual Employment Verification Form Form and Instruction	Modified
182800	Authorization for Release of Employment Information Form Form	Removed

ICR Details

OMB Control No: 0915-0140	ICR Reference No: 201704-0915-005
Status: Historical Active	Previous ICR Reference No: 201609-0915-006
Agency/Subagency: HHS/HSA	Agency Tracking No: 21547
Title: NURSE Corps Loan Repayment Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/28/2017
	Date Received in OIRA: 04/13/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2020	36 Months From Approved	06/30/2017
Responses	15,600	0	21,100
Time Burden (Hours)	13,850	0	14,400
Cost Burden (Dollars)	0	0	4,125

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Abstract: The need and purpose of this information collection is to obtain information for NURSE Corps LRP applicants and participants. The information is used to consider an applicant for a NURSE Corps LRP contract award, and to monitor a participant’s compliance with the service requirements. Individuals must submit an application in order to participate in the program. The application asks for personal, professional, educational, and financial information required to determine the applicant's eligibility to participate in the NURSE Corps LRP. The semi-annual employment verification form asks for personal and employment information to determine if a participant is in compliance with the service requirements. Respondents include professional RNs or advanced practice RNs (i.e., nurse practitioners, certified registered nurse anesthetists, certified nurse-midwives, clinical nurse specialists) who are interested in participating in the NURSE Corps LRP, and official representatives at their service sites.

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Authorizing Statute(s): US Code: 42 USC 297n Section 846(a) Name of Law: Public Health Service Act
   PL: Pub.L. 107 - 205 0 Name of Law: PHSA Nurse Recruitment
   PL: Pub.L. 111 - 148 0 Name of Law: PPACA
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 5584	01/18/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 17434	04/11/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Participant Semi-Annual Employment Verification Form	2, 1	NC LRP_Participant Semi-Annual Employ Verfic Form.docx ,   NC LRP-Authorization to Release Employment Information.docx
Authorization to Release Information Form	1	NC LRP Authorization to Release Information.docx
Authorization for Release of Employment Information Form	2	Authorization to Release Employment Information Form
NURSE Corps LRP Application	2, 1	NCLRP-online-application-user-guide.doc ,   nclrp-continuation-online-application-user-guide.doc

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	15,600	21,100	0	0	-5,500	0
Annual Time Burden (Hours)	13,850	14,400	0	0	-550	0
Annual Cost Burden (Dollars)	0	4,125	0	-4,125	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This revision decreases the overall time burden by eliminating a form and not increasing the ‘‘average’’ time required to complete the NURSE Corps LRP application. The Authorization to Release Employment Information form is available as a self-certification within the NURSE Corps LRP application process with applicants clicking a box., but may be filled out by hand. This decreases the overall time burden by eliminating a form and not increasing the average time required to complete the NURSE Corps LRP application. The online application incorporates a majority of the supporting and supplemental documents allowing applicants to complete application more quickly.

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Annual Cost to Federal Government: $1,023,088

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/13/2017

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