Form NFLP Nurse Faculty Loan Program - Data Form

OMB No. 0915-xxxx
Expiration 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-xxxx. Public reporting burden for this
collection of information is estimated to average 8 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: HRSA Reports Clearance Officer, 5600 Fishers Lane,
Room 10-33, Rockville, Maryland, 20857.

Nurse Faculty Loan Program (NFLP) - Program Specific Data Form
Fiscal Year: (Leave Blank)

Application Tracking Number: (Leave Blank)

OPSID Number (if applicable):

Applicant Organization:

A. FEDERAL FUNDS REQUESTED
Indicate the total Federal Capital Contribution (FCC) Amount Requested:

$

Indicate the total Institutional Capital Contribution Amount (1/9 of FCC) Expected:

$

B. NFLP ENROLLEE AND GRADUATE INFORMATION

Type of Institution

Total
Continuing
Master’s
NFLP
Enrollees

Total
Continuing
Doctoral
NFLP
Enrollees

Total New
Master’s
Students
Requesting
NFLP
Support

Total New
Doctoral
Students
Requesting
NFLP
Support

FT

FT

FT

FT

PT

PT

PT

Total
Number of NFLP
GRADUATES
(7/01/xxxx –
6/30/xxxx)

PT

MASTER’S

DOCTORAL

Total
Number of NFLP
Students DROPPED
(7/01/xxxx –
6/30/xxxx)
MASTER’S

DOCTORAL

Public (In-State)
Public (Out-of-State)
Private

TOTALS:

C. PROGRAM INFORMATION (Provide information for each degree level program that prepares nurse faculty.)
Program Level
(Master’s and/or
Doctoral)

Length of Program
in Months

Number of Credit Hours to
Complete the Program

Distance Learning Offered? (Yes/No)

D. ACCREDITATION
Expiration Date(s):

Name of Accrediting Body (ACNM, CCNE, COA, and/or NLNAC):

Date of Next Site Visit:

(Month/Year)

(Month/Year)

E. TUITION & FEES (Provide tuition/fees for the current Academic Year)
MASTER’S PROGRAM

DOCTORAL PROGRAM

DATA ELEMENT
In-State

(If tuition, fees, or credit hours vary, specify range)
FT

Out-of-State
PT

FT

PT

In-State
FT

PT

Out-of-State
FT

PT

Tuition Per Term: PUBLIC Institution
Tuition Per Term: PRIVATE Institution
1
Fees Per Term/Semester
2
# of Terms/Semesters Required per Academic Year
# of Credit Hours Required for Full-time and Part-time Status

1

Include annual and one-time fees (i.e., registration, technology, insurance, and lab).
Applicants should specify if the summer session is required for the academic program. If applicable, specify the number of quarters or
trimesters for the academic program
2

F. NFLP LOAN FUND BALANCE/UNUSED ACCUMULATION -IMPORTANT NOTE: The loan fund balance reported is very important. Schools should confer with the appropriate
officials at your institution. Please provide the following:
Provide the projected NFLP loan fund balance from July 1, xxxx
through June 30, xxxx.
$___________________
If applicable, schools are strongly encouraged to include any projected
loan obligations for NFLP students who plan to enroll during the
summer session – June, xxxx through August, xxxx.

$___________________