2014-06337. Agency Information Collection Activities: Submission to OMB for Review and Approval; Public Comment Request

AGENCY:

Health Resources and Services Administration, HHS.

ACTION:

Notice.

SUMMARY:

In compliance with Section 3507(a)(1)(D) of the Paperwork Reduction Act of 1995, the Health Resources and Services Administration (HRSA) has submitted an Information Collection Request (ICR) to the Office of Management and Budget (OMB) for review and approval. Comments submitted during the first public review of this ICR will be provided to OMB. OMB will accept further comments from the public during the review and approval period.

DATES:

Comments on this ICR should be received within 30 days of this notice.

ADDRESSES:

Submit your comments, including the Information Collection Request Title, to the desk officer for HRSA, either by email to [e-mail] or by fax to 202-395-5806.

FOR FURTHER INFORMATION CONTACT:

To request a copy of the clearance requests submitted to OMB for review, email the HRSA Information Collection Clearance Officer at [e-mail] or call [phone].

SUPPLEMENTARY INFORMATION:

Information Collection Request Title: Application and Other Forms utilized by the National Health Service Corps Scholarship Program, the NHSC Students to Service Loan Repayment Program, and the Native Hawaiian Health Scholarship Program.

OMB No. 0915-0146—Revision

Abstract: Administered by HRSA's Bureau of Clinician Recruitment and Service (BCRS), the National Health Service Corps (NHSC) Scholarship Program (SP), NHSC Students to Service Loan Repayment Program (S2S LRP), and the Native Hawaiian Health Scholarship Program (NHHSP), provide scholarships or loan repayment to qualified students who are pursuing primary care health professions education and training. In return, students agree to provide primary health care services in medically underserved communities located in federally designated Health Professional Shortage Areas (HPSAs) once they are fully trained and licensed health professionals. Awards are made to applicants who demonstrate the greatest potential for successful completion of their education and training as well as commitment to provide primary health care services to communities of greatest need. The program applications, forms, and supporting documentation are used to collect necessary information from applicants and participants that will facilitate in the selection of the best qualified candidates for these competitive awards, and to monitor participants' enrollment in school or in postgraduate training.

Although some program forms vary (see program-specific burden charts below), general forms include: The Program Application, Academic and Non-Academic Letters of Recommendation, the Authorization to Release Information, and the Acceptance/Verification of Good Standing Report. Additional forms for the NHSC SP, include the Data Collection Worksheet, which is completed by the educational institutions of program participants, the Post Graduate Training Verification Form (formerly the Deferment Request Form and applicable for S2S participants), which is completed by program participants and their residency director, and the Enrollment Verification Form, which is completed by program participants and the educational institution for each academic term of the program.

Need and Proposed Use of the Information: The NHSC SP, S2S LRP, and NHHSP applications, forms, and supporting documentation are used to collect necessary information from applicants that will enable BCRS to make determinations about the competitive awards.

Likely Respondents: Qualified students who are pursuing primary care health professions education and training, and are interested in working with underserved populations.

Burden Statement: Burden in this context means the time expended by persons to generate, maintain, retain, disclose or provide the information requested. This includes the time needed to review instructions; to develop, acquire, install and utilize technology and systems for the purpose of collecting, validating and verifying information, processing and maintaining information, and disclosing and providing information; to train personnel and to be able to respond to a collection of information; to search data sources; to complete and review the collection of information; and to transmit or otherwise disclose the information. The total annual burden hours estimated for this ICR are summarized in the table below.

Total Estimated Annualized Burden—Hours

NHSC Scholarship Program

Form name	Number of respondents	Number of responses per respondent	Total responses	Average burden per response (in hours)	Total burden hours
NHSC Scholarship Program Application	1800	1	1800	2.00	3600
Letters of Recommendation	1800	2	3600	.50	1800
Authorization to Release Information	1800	1	1800	.10	180
Acceptance/Verification of Good Standing Report	1800	1	1800	.25	450
Receipt of Exceptional Financial Need Scholarship	200	1	200	.25	50
Verification of Disadvantaged Background Status	300	1	300	.25	75
Total			9500		6155

The annual estimate of burden for participants/schools/residency programs is as follows:

Form name	Number of respondents	Number of responses per respondent	Total responses	Average burden per response (in hours)	Total burden hours
Data Collection Worksheet	400	1	400	1.00	400
Post Graduate Training Verification Form	200	1	200	.50	100
Enrollment Verification Form	600	2	1200	.50	600
Total			1800		1100

NHSC Students to Service Loan Repayment Program

Form name	Number of respondents	Number of responses per respondent	Total responses	Average burden per response (in hours)	Total burden hours
NHSC Students to Service Program Application	100	1	100	2.00	200
Letters of Recommendation	100	2	200	.50	100
Authorization to Release Information	100	1	100	.10	10
Acceptance/Verification of Good Standing Report	100	1	100	.25	25
Receipt of Exceptional Financial Need Scholarship	4	1	4	.25	1
Verification of Disadvantaged Background Status	25	1	25	.25	6.25
Post Graduate Training Verification Form	150	1	150	.50	75
Total			679		417.25

Native Hawaiian Health Scholarship Program

Form name*	Number of respondents	Number of responses per respondent	Total responses	Average burden per response (in hours)	Total burden hours
Native Hawaiian Health Scholarship Program Application (includes Forms A-E: Applicant Resume Instructions and Guidelines; NHHSP Questionnaire and Narrative Statement; Conflicting Federal Service Memo; Debarment, Suspension, Disqualification and Related Matters Certification; and Delinquent Federal Debt)	250	1	250	1.00	250
Letters of Recommendation (includes Forms H and I: Academic Faculty/Advisor Evaluation of Applicant and Employer Evaluation of Applicant)	250	2	500	.25	125
Authorization to Release Information (Form F)	250	1	250	.25	62.50
Acceptance/Verification of Good Standing Report (includes Form G: Course Curriculum Worksheet)	30	12	360	.25	90
Total			1360		527.50
* Please note that the forms listed above account for supporting documentation which may be uploaded as part of the application or associated with the supplemental forms.

Dated: March 18, 2014.

Jackie Painter,

Deputy Director, Division of Policy and Information Coordination.