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

Documents and Forms

Document Name Document Type
Form 3E S2S LRP – Authorization to Release Information Form and Instruction
3E NHSC S2S LRP Authorization to Release Information Form.p 0915 0146 - NHSC S2S Authorization to Release Form.pdf Form and Instruction

Information Collection (IC) Details

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: 42 CFR 62.6

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3E	NHSC S2S LRP Authorization to Release Information Form.pdf	0915 0146 - NHSC S2S Authorization to Release Form.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Public Health Service National Health Service Corps Scholarship/Loan Repayment Participants Records System	FR Citation: 58 FR 12968

Number of Respondents: 348	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	348	64	284
Annual IC Time Burden (Hours)	35	7	28
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.