Appendix_C-_NHSC_Travel_Form_0915-0278.doc

Appendix C National Health Service Corps Scholar Travel Request Worksheet

Non-Federal Personnel

Mailing Address:

Fax

Number:

Address:

SSN:

xxx-xx-________

Placement Year of Scholar:

Discipline:

Specialty:

City/St

To:

City/St

Destination Site Name/Address:

Site ID (UDS#):

Remarks:

Pre-Employment Site Visit:

MUST CHECK ONE BOX

For relocation and transfer, does the traveler have a permanent license to practice in State of service?

Permanent Change of Station

Relocation

YES

NO

Other (specify below)

Signature of Requesting

Official, NHSC:

Date:

PUBLIC BURDEN STATEMENT

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB control number for this project is 0915-0278. Public reporting burden for this collection of information is estimated to average 4 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed 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 HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

Privacy Act Notice – The Privacy Act of 1974 (5 U.S.C. 552a) requires that an agency provide the following notice to each individual whom it asks for information. (1) The authority for collecting information requested on this form is found in Title III, Part D, Subpart II of the Public Health Service Act (42 U.S.C. 254d(c).

Form Approved

OMB No.0915-0278

Exp. Date 2/2013