Specialty Education Loan Repayment Program (SELRP) Forms [AQ63]

Forms and Documents

Document Name	Status
Form 10-255e SELRP - Participant Agreement Form	Modified
Form 10-255d SELRP - Mobility Agreement Form and Instruction	Modified
Form 10-255c SELRP - Education Loan Verification Form and Instruction	Modified
Form 10-255b SELRP - Program Status Verification Form	Modified
Form 10-255a SELRP - Application Form and Instruction	Modified
Supp Statement A_Spec Educ Loan Repay Prog (SELRP)_AQ63_revised Feb 2021.docx Supporting Statement A	2021-02-05

IC Document Collections

IC ID	Document Title	Status
241717	SELRP - Participant Agreement Form	Modified
241716	SELRP - Mobility Agreement Form and Instruction	Modified
241715	SELRP - Education Loan Verification Form and Instruction	Modified
241714	SELRP - Program Status Verification Form	Modified
241713	SELRP - Application Form and Instruction	Modified

ICR Details

OMB Control No: 2900-0879	ICR Reference No: 202102-2900-002
Status: Received in OIRA	Previous ICR Reference No: 201912-2900-003
Agency/Subagency: VA	Agency Tracking No: 2900-NEW
Title: Specialty Education Loan Repayment Program (SELRP) Forms [AQ63]
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 02/16/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	1,000	0
Time Burden (Hours)	283	0
Cost Burden (Dollars)	0	0

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Abstract: Section 303 of Public Law 115-182, the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018, or the VA MISSION Act of 2018, amended title 38 of the United States Code (U.S.C.) by establishing new sections 7691 through 7697 and created a new student loan repayment program known as the Specialty Education Loan Repayment Program (SELRP). The SELRP will serve as an incentive for physicians starting or currently in residency programs in medical specialties for which VA has determined that recruitment and retention of qualified personnel is difficult to work for VA at VA facilities that need more physicians with that medical specialty. Section 303 of the VA MISSION Act of 2018 did not establish an application procedure for the SELRP. To maintain consistency in the application process of similar VA scholarship programs and to ease the implementation such programs by VA personnel, VA will mirror proposed § 17.528 to current § 17.643, Application for the Program for Repayment of Educational Loans for Certain VA Psychiatrists (PREL.) Consistent with § 17.643(a), proposed paragraph § 17.528(a) will state that a complete application for the SELRP consists of a completed application, letters of reference, and personal statement.

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Authorizing Statute(s): PL: Pub.L. 115 - 182 303 Name of Law: MISSION Act of 2018
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
2900-AQ63	Final or interim final rulemaking	85 FR 45532	07/29/2020

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

IC Title	Form No.	Form Name
SELRP - Application	10-255a	Specialty Education Loan Repayment Program (SELRP) - Application
SELRP - Program Status Verification	10-255b	Specialty Education Loan Repayment Program (SELRP) - Program Status Verification
SELRP - Education Loan Verification	10-255c	Specialty Education Loan Repayment Program (SELRP) - Education Loan Verification
SELRP - Mobility Agreement	10-255d	Specialty Education Loan Repayment Program (SELRP) - Mobility Agreement
SELRP - Participant Agreement	10-255e	Specialty Education Loan Repayment Program (SELRP) - Participant Agreement

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ICR Summary of Burden

	Total Request	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	1,000	0	0	1,000	0	0
Annual Time Burden (Hours)	283	0	0	283	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: There is a slight reduction in burden hours due to adjustment of anticipated time to complete one form in the collection.

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Annual Cost to Federal Government: $12,187

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

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? No

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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: 02/16/2021

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