NHSC Travel Request Worksheet

National Health Service Corps Scholar/Students to Service Travel Request Worksheet

Documents and Forms

Document Name Document Type
Form 1 NHSC Travel Request Worksheet Form
1 NHSC Travel Request Worksheet Form NHSC Travel Request Worksheet Form.docx Form
1 NHSC Travel Request Worksheet Form NHSC Travel Request Worksheet Form.docx Form

Information Collection (IC) Details

IC Title:	NHSC Travel Request Worksheet	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	1	NHSC Travel Request Worksheet Form	NHSC Travel Request Worksheet Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: PHS and NHSC Scholarship and Loan Repayment Records System	FR Citation: 86 FR 28362

Number of Respondents: 800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,600	1,000	600
Annual IC Time Burden (Hours)	107	67	40
Annual IC Cost Burden (Dollars)	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.