Form 1C NHSC SP - Proof of Citizenship

OMB Number: 0915-0146

Expiration Date: xx/xx/xxxx

NHSC SP – Proof Of Citizenship

Public Burden Statement: The purpose of this information collection is to obtain information through the National Health Service Corps Scholarship Program (NHSC SP), which is used to assess an applicant’s eligibility and qualifications for the NHSC SP. Clinicians interested in participating in the NHSC SP must submit an application to the NHSC SP through the My BHW online portal. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget control number. The Office of Management and Budget control number for this information collection is 0915-0146 and it is valid until xx/xx/xxxx. This information collection is required to obtain or retain a benefit (National Health Service Corps Scholarship Program: Section 338A of the Public Health Service Act and Section 338C-H of Public Health Service Act.). The information is protected by the Privacy Act, but it may be disclosed outside the U.S. Department of Health and Human Services, as permitted by the Privacy Act and Freedom of Information Act, to Congress, the National Archives, and the Government Accountability Office, and pursuant to court order and various routine uses as described in the System of Record Notice 09-15-0037. Public reporting burden for this collection of information is estimated to average xx hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Health Resources and Services Administration Reports Clearance Officer, 5600 Fishers Lane, Room 14NWH04, Rockville, Maryland 20857.