FINAL NC LRP 2019 Nonsubstantive Change Memo OMB 12-12-18

DATE: December 13, 2018

TO: Quinn Hirsch, OMB Desk Officer

FROM: Lisa Wright-Solomon, HRSA Information Collection Clearance Officer

_____________________________________________________________________________

Request: The Health Resources and Services Administration’s (HRSA) Bureau of Health Workforce (BHW) requests approval for non-substantive changes to the NURSE Corps (NC) Loan Repayment Program (LRP) Application and Program Guidance (APG) documents (OMB #, 0915-0140 expires 05/31/2021). The APG package includes the NC LRP Online Application User Guide, which asks for personal, professional, and financial information needed to determine the applicant's eligibility to participate in the NC LRP as a new recipient or through a continuation award. Also included is the In-Service Verification (ISV) forms which are used to determine if a participant is in compliance with their NC contract.

Purpose: The purpose of these proposed changes is to align the APG, Online Application User Guide, and the ISVs with the current Administration’s priority of combating the opioid epidemic via medication-assisted treatment, substance use disorder services, telehealth, as well as a tax change.

Time Sensitivity: Updates by January 17, 2019 to the BHW Management Information Systems Solution (BMISS) are essential prior to the beginning of the application period (for both the new and continuation NC LRP application cycles) so that these changes can be made to BMISS in time for the application cycle.

Applicants submit their NC LRP applications within the Customer Service Portal that houses the application during critical periods of the year for both continuations and new applicants. Designed to be compatible with the narrative and data requirements that are outlined in the APG, the inclusion of these additional questions are contingent upon the approval of the non-substantive changes outlined in this memo. Given the projected upcoming release date of January 24, 2019, delayed updates related to the Customer Service Portal will inhibit the collection of pertinent data that will help HRSA to measure key indicators associated with both substance abuse disorder service and telehealth activities.

HRSA uses the In-Service Verification form to monitor participants’ number of absences from their service site to determine if participants are in compliance with program rules. Additionally, HRSA verifies employment with employer through the Employment Verification Form, where we will add multiple site questions.

Burden: It is anticipated that the proposed changes included herein will have minimal impact on the burden of the NC LRP application process or the ISVs. No new HRSA forms will be required and the proposed additional questions will be inserted into the larger, already-approved NC LRP application and ISV forms.

PROPOSED CHANGES FOR THE NC LRP NEW AND CONTINUATION APG AND APPLICATION USER GUIDE DOCUMENTS:

Adding a total of 9 new questions each for both the New and the Continuation NC LRP APGs to be more in line with Administration priorities as well as the evolving health care landscape. (See questions below.)

Questions for FY19 NC LRP New Award Application

Mental Health Questions:

1. Are you a licensed Psychiatric Nurse Practitioner?

   1. If yes, please upload your credentials in the Supporting Documents section

   2. no

2. Do have another Behavioral Health training or certification?

   1. If yes, please upload your credentials in the Supporting Documents section

   2. No

3. Will you have substance use disorder training or certification by September 30, 2019?

   1. Yes

   2. No

Telehealth Questions:

1. Do you or will you personally provide some form of telehealth in your clinical practice? (With “Tool Tip” which is currently on new award for FY 2018.)

1. Yes

2. No

3. I don’t know

2. When providing telehealth:

1. I am the clinician at the originating site whose patient is receiving the consult/care

2. I am the clinician at the distant site providing the consult/care

3. I don’t know

4. Other

3. What percentage of your clinical practice is/will be spent providing telehealth services?

1. <10%

2. 10-24%

3. 25-49%

4. 50%>

5. I don’t know

Multiple Site Questions:

1. Do you currently work at multiple sites?

   1. Yes

   2. No

2. If yes, are you working at the same employer at all Critical Shortage Facility types?

   1. Yes

   2. No

Tax Questions:

1. Applicants selected for a Nurse Corps Loan Repayment award will know be required to fill out a W4 form for IRS tax purposes

   1. Filing status (Box 3 on Form W-4)*

   2. Last name differs from that shown on your social security card (Box 4 on Form W-4)

   3. Total number of Allowances (Box 5 on Form W-4)*

   4. Additional withholding amount (if any) (Box 6 on Form W-4)

   5. Claim exemption (Box 7 on Form W-4)

Questions for FY19 NC LRP Continuation Application:

Mental Questions:

1. Are you a licensed Psychiatric Nurse Practitioner?

   1. If yes, please upload your credentials in the Supporting Documents section

   2. no

2. Do you have another Behavioral Health training or certification?

   1. If yes, please upload your credentials in the Supporting Documents section

   2. No

3. Will you have substance use disorder training or certification by September 30, 2019?

   1. Yes

   2. No

Telehealth Questions:

1. Do you or will you personally provide some form of telehealth in your clinical practice? (With “Tool Tip” which is currently on new award for FY 2018.)

1. Yes

2. No

3. I don’t know

2. When providing telehealth:

1. I am the clinician at the originating site whose patient is receiving the consult/care

2. I am the clinician at the distant site providing the consult/care

3. I don’t know

4. Other

3. What percentage of your clinical practice is/will be spent providing telehealth services?

1. <10%

2. 10-24%

3. 25-49%

4. 50%>

5. I don’t know

Multiple Site Questions:

1. Do you currently work at multiple sites?

   1. Yes

   2. No

2. If yes, are you working at the same employer at all CSF types?

   1. Yes

   2. No

Tax Questions:

1. Applicants selected for a NCLRP award will know be required to fill out a W4 form for IRS tax purposes

   1. Filing status (Box 3 on Form W-4)*

   2. Last name differs from that shown on social security card (Box 4 on Form W-4)

   3. Total number of Allowances (Box 5 on Form W-4)*

   4. Additional withholding amount (if any) (Box 6 on Form W-4)

   5. Claim exemption (Box 7 on Form W-4)

PROPOSED CHANGES FOR THE NC IN-SERVICE VERIFICATION DOCUMENTS:

Adding a total of 6 new questions to be more in line with Administration priorities as well as the evolving health care landscape. (See questions below)

Questions include:

1. Do you or will you personally provide some form of telehealth in your clinical practice?

1. Yes

2. No

3. I don’t know

2. When providing telehealth:

1. I am the clinician at the originating site whose patient is receiving the consult/care

2. I am the clinician at the distant site providing the consult/care

3. I don’t know

4. Other

3. What telehealth technologies did you use? (Select all that apply)

1. Real-time telehealth (e.g., video conference)

2. Store-and-forward telehealth (e.g., secure email with photos or videos of patient examinations)

3. Remote patient monitoring

4. Mobile Health (mHealth)

4. What percentage of your clinical practice is/will be spent providing telehealth services?

1. <10%

2. 10-24%

3. 25-49%

4. 50%>

5. I don’t know

5. Does the clinician currently work at multiple sites?

   1. Yes

   2. No

6. If yes, are they working at the same employer at all Critical Shortage Facility types?

   1. Yes

   2. No

Attachments:

1. NC LRP Online Application User Guide

   1. Mental Health Questions Screenshot

   2. Telehealth Questions Screenshot

   3. Multiple Site Question Screenshot

   4. W-4 Tax Screenshot

2. NC LRP In-Service Verification Documents

   1. In-Service Verification Screenshot

   2. Employment Verification Form

Requested Changes to NCLRP LRP Application and Online Application User Guide (OMB #0915-0140, expires 05/31/2021), Page 8