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S2S LRP – Authorization to Release Information
The National Health Service Corps Scholarship Program, Students to Service Loan Repayment Program, and the Native Hawaiian Health Scholarship Program
OMB: 0915-0146
IC ID: 211166
OMB.report
HHS/HSA
OMB 0915-0146
ICR 202305-0915-001
IC 211166
( )
Documents and Forms
Document Name
Document Type
Form 3C
S2S LRP – Authorization to Release Information
Form and Instruction
3C NHSC S2S LRP Authorization to Release Information Form.p
NHSC S2S LRP Authorization to Release Information Form.pdf
Form and Instruction
3C NHSC S2S LRP Authorization to Release Information Form.p
NHSC S2S LRP Authorization to Release Information Form.pdf
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
S2S LRP – Authorization to Release Information
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
3C
NHSC S2S LRP Authorization to Release Information Form.pdf
NHSC S2S LRP Authorization to Release Information Form.pdf
Yes
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
284
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
284
0
84
0
0
200
Annual IC Time Burden (Hours)
28
0
8
0
0
20
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.