Supporting Statement Travel Request Worksheet 11.14.2018_Clean

National Health Service Corps Scholar Travel Request Worksheet

SUPPORTING STATEMENT

0915-0278

Terms of Clearance: None

A. Justification

1. Circumstances Making the Collection of Information Necessary

This is a request for Office of Management and Budget (OMB) approval of an extension for the Health Resources and Services Administration (HRSA), National Health Service Corps (NHSC), Travel Request Worksheet (TRW). The OMB control number for the TRW is 0915-0278 with a current expiration date of January 31, 2019. This form is used for requests for pre-employment site visit(s) and relocation to an NHSC authorized site(s) for the purpose of securing employment in a clinical practice to fulfill the NHSC service commitment. The Public Health Service Act, Section 331(c)(1) provides that the Secretary may reimburse applicants for positions in the Corps including individuals considering entering into a written agreement pursuant to section 338D for actual and reasonable expenses incurred in traveling to and from their place of residence to an eligible site to which they may be assigned under section 333. The Secretary shall not reimburse an applicant for more than one such trip to the same approved site.

The NHSC was established by Congress for the purpose of eliminating health professional shortages in Health Professional Shortage Areas (HPSAs). HPSAs are geographic areas, facilities or population groups determined by the Secretary of Health and Human Service to have a shortage of health professionals. The NHSC provides funding support to encourage selected primary health care professionals to practice in HPSAs. This program is located in HRSA’s Bureau of Health Workforce (BHW).

2. Purpose and Use of Information Collection

The purpose of this form is to ensure that the program can effectively and efficiently monitor authorized travel for NHSC clinicians. The TRW form is utilized to expedite the travel approval process for physicians, dentists, nurse practitioners, certified nurse midwives, and physician assistants to site visit(s) and relocation requests when the scholarship recipient or Students to Service Program participant has secured an interview at an NHSC approved site(s) and has notified their respective NHSC contact. Such advance notice ensures that the scholarship recipient is fully prepared for the site visit and maximizes the available NHSC travel funding. Utilization of this form avoids unauthorized travel to unapproved NHSC sites and provides more efficient monitoring of travel allotments for each clinician.

3. Use of Improved Information Technology and Burden Reduction

This form is fully electronic. The automated form assists clinicians in requesting approval for travel for site visits before executing an employment agreement and for requesting relocation assistance in a timely manner.

4. Efforts to Identify Duplication and Use of Similar Information

There are no other sources of this information. The information requested only pertains to scholar placement and practice considerations and is available only from the scholar and the NHSC.

5. Impact on Small Businesses or Other Small Entities

This information collection does not involve small businesses or other small entities.

6. Consequences of Collecting the Information Less Frequently

Without this form the Program cannot effectively monitor clinician travel and avoid unauthorized travel. The TRW is used each time a clinician submits a request for travel for site visits or requests relocation assistance. This form is needed to efficiently monitor travel and relocation for clinicians.

7. Special Circumstances Relating to the Guidelines in 5 CFR 1320.5

The information will be collected in a manner consistent with guidelines contained in 5CFR 1320.5.

8. Comments in Response to the Federal Register Notice/ Outside Consultation

1. A 60-day Federal Register Notice was published in the Federal Register on September 24, 2018, vol.83, No. 185; pp. 48317. There were no public comments.

2. The following individuals were contacted for consultation regarding the clarity and format of the data collection instrument and the frequency of collection:

Castelaz McCallister

2165431287

780 Chickahonimy Lane #308
Carrollton, VA 23314

Kimberly Franks

9185104713

9 Mattson Ave

Worcester, MA 01606

Jonathan Foster

2183415548

75 Station Landing #522

Medford, MA 02155

9. Explanation of any Payment/Gift to Respondents

Respondents will not be remunerated.

10. Assurance of Confidentiality Provided to Respondents

The Privacy Act of 1974 (5 U.S.C. 522a) requires an agency to provide notification to individuals who supply information. The required Privacy Act notification is included on the proposed form. Access to these records is strictly limited to all authorized NHSC principal staff that are aware of their responsibilities under the Privacy Act.

Disclosure of the applicant’s Social Security Number (SSN) is required for reimbursement of NHSC applicants. The records associated with the information collection are protected by the Privacy Act. In accordance with the requirements of the Privacy Act, HRSA has established the system of records entitled, “Public Health and National Health Service Corps (PH/NHSC) Scholarship Training Program, Physician Shortage Area Scholarship Program (PSASP), National Health Service Corps Scholarship Program (NHSC SP), National Health Service Corps Loan Repayment Program (NHSC LRP), NHSC Student/Resident Experiences and Rotations in Community Health (SEARCH), Nursing Education Loan Repayment Program (NELRP), Nursing Scholarship Program (NSP), Native Hawaiian Health Scholarship Program (NHHSP), and Faculty Loan Repayment Program (FLRP), Applicants and/or Participants Records System, HHS/HRSA/BCRS,” No. 09-15-0037, which contains information on NHSC scholarship recipients. 

11. Justification for Sensitive Questions

There are no questions of a sensitive nature.

12. Estimates of Annualized Hour and Cost Burden

The burden estimate is as follows:

Form	Number of Respondents	Responses per Respondent	Total Responses	Hours per Response	Total Hour Burden	Wage Rate	Total Hour Cost
Travel Request Worksheet	300	2	600	.0667	40	$33.491 times 2 (accounting for fringe benefits and overhead)	$2,679.2

The burden is based upon discussions with respondents who have completed the form and have reported that the form takes approximately 4 minutes to complete.

13. Estimates of Other Total Annual Cost Burden to Respondents or

Record-keepers/Capital Costs

There is no capital or start up costs, nor is there any operation or maintenance costs to the respondents.

14. Annualized Cost to the Federal Government

The estimated annualized cost to the Government is approximately $1172.10. This cost is calculated as follows:

Reviewing and researching the travel request received for a determination of approval or denial of such request- GS-12 Federal employee at $39.07 per hour for 30 hours = $1172.10.

15. Explanation for Program Changes or Adjustments

This current burden for this project is 33 hours. This request is for a total of 40 hours, an increase of 7 hours. This is due to an increase in the anticipated number of respondents.
16. Plans for Tabulation, Publication, and Project Time Schedule

There are no plans for tabulation, analysis or publications from this activity.

17. Reason(s) Display of OMB Expiration Date is Inappropriate

The expiration date will be displayed.

18. Exceptions to Certification for Paperwork Reduction Act Submissions

There are no exceptions to the certification.

1 The wage rate is based upon Bureau of Labor Statistics data for the mean hourly wage of a Registered Nurse; http://www.bls.gov/oes/current/999301.htm#31-0000

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