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Supporting Statement for the Application and Forms for Participation in the Nursing
Scholarship Program at the Health Resources and Services Administration

A.
1.

JUSTIFICATION
CIRCUMSTANCES OF INFORMATION COLLECTION

This is a request for Office of Management and Budget (OMB) approval of an extension of the
Health Resources and Services Administration’s (HRSA) Nursing Scholarship Program (NSP)
application forms. This project is OMB Approval Number 0915-0301, and expires on July 31,
2009. The legislative authority for the NSP is the Public Health Service Act (Attachment A), Title
VIII, amended by Public Law 101-205 on August 1, 2002. The purpose of the NSP is to provide
scholarships to nursing students in exchange for a service commitment at an eligible healthcare
facility with a critical shortage of nurses. This is an extension without change to the existing
information collection request.
An applicant must be enrolled or accepted for enrollment at an accrediting school of nursing in a
graduate, baccalaureate, associate degree or diploma program. A student can apply for full-time
or part-time enrollment. However, NSP currently gives preference to full-time students. A
student must be a U.S. citizen or national, free of any federal judgment liens, free from existing
service commitments and not in default of any federal debt.
In FY 2008, the NSP awarded 169 scholarships totaling $8.7 million. Funding for this program is
expected to continue under future appropriations.
Under the NSP, students seeking to become registered nurses are offered the opportunity to enter
into a contractual agreement with the Secretary under which the Department of Health and
Human Services agrees to pay the total school tuition, required fees, and a stipend for living
expenses. In exchange, the scholarship recipient agrees to provide full-time clinical services at a
health facility designated by the NSP as having a critical nursing shortage. The minimum service
commitment is 2 years; the maximum is 4 years.
Scholarship applicants currently are screened in a two-stage process. First an application is
submitted. Based on the review of the application, students are identified as to a category for
funding preference.
2.

PURPOSE AND USE OF INFORMATION

The application is needed to determine which applicants are qualified to receive scholarship
awards. Applicants are selected for awards according to the criteria required by Federal statute
and the funding preference of NSP. In providing contracts under the NSP, the Secretary shall
give priorities to qualified applicant who:
1.
2.

Demonstrate the greatest financial need;
Are full-time students; and

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3.

Are enrolled in an undergraduate program.

The information collected will be used by staff of the NSP to select applicants for scholarship
awards. All information is used to determine that individual applicants have a sincere desire to
practice in a critical shortage facility and have a desire to remain and continue to practice after the
period of service commitment.
APPLICATION FORM
The application (Attachment B) is based upon the version utilized by the National Health Service
Corps Scholarship Program. The NSP application form has five sections.
Section A. General Information: This section collects general information needed for
administrative purposes (e.g., name, address, gender, e-mail address).
Section B. Professional Degree Program: This section collects information about the
degree or diploma program for which the applicant is requesting a scholarship and
the current status in the program.
Section C. Expected Family Contribution: This section collects information on the
expected family contributions as indicated on the Student Aid Report submitted by
the applicant.
Section D. Alternate Contact: This section collects information about an alternate person
to contact in case the applicant can’t be contacted using information in the
application.
Section E. Background: This section collects gender, ethnicity and race information based
on OMB requirements.

Section E. Certification: This section requires the applicant to certify that the information
given is accurate and complete to the best of their knowledge and belief.

APPLICANT INFORMATION BULLETIN
The Applicant Information Bulletin (Attachment C) describes the NSP program for students in
training to become registered nurses. It covers applicant eligibility requirements, funding
preferences for awards, scholarship benefits, and fulfilling the service commitment. It also
includes the administrative guidelines in effect as of May 14, 2009. The bulletin has four
sections.
Section I. Program Requirements and Policies : This covers eligibility requirements,
funding preferences, scholarship benefits, fulfilling the service commitments and
cancellation of the commitment.

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Section II. Instructions for Completing the Application: This covers general instructions
for completing the application, the NSP website for applying online, deadline dates
and addresses to mail supporting documentation.
Section III. Glossary of Terms: An alphabetical list of terms with their definitions that are
contained in the applicant information bulletin.
Section IV. Sample Nursing Scholarship Program Contract: The contract authorizes the
Secretary of Health and Human Services to provide applicants selected to be
participants in the Nursing Scholarship Program with scholarship awards. In return
for the awards, applicants must agree to serve for a period of not less than 2 year as
nurses in a health care facility with a critical shortage of nurses. The contract has
six sections.
Section A. Obligations of the Secretary: This covers what the Secretary of the
Department of Health and Human Services agrees to provide the selected
applicant.
Section B. Obligations of the Applicant: This covers what the selected applicant
agrees to provide the NSP while in training and during obligated service
periods.
Section C. Breach of Scholarship Contract: This covers the liability of the
applicant when there is a breach of contract.
Section D. Cancellation, Suspension, and Waiver of Obligation: This covers
what happens upon the applicant’s death or the conditions when the Secretary
can waive or suspend an applicant’s service or payment obligation,
Section E. Contract Extension: This covers the procedures to request annual
extensions of contracts.
Section F. Contract Termination: This covers the procedures to terminate a
contract.
DATA COLLECTION WORKSHEET
The Data Collection Worksheet (Page 35-36 of the Applicant Information Bulletin – Attachment
C) is completed by the scholar’s academic institution. The form requests the cost of tuition and
required fees for each academic year. This information is utilized to determine the amount of the
award for the payment of tuition and fees. The information is collected once a year.
SCHOOL VERIFICATION SHEET

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The School Verification Sheet (Attachment D) is completed by the scholar’s academic institution.
The form requests information pertaining to the scholar’s status such as full-time, part-time,
repeating course work or leave of absences. This information is utilized to determine if the
scholar is eligible for continued NSP support. The information is collected twice a year.
EMPLOYMENT CERTIFICATION FORM (Attachment E)
Part I. To be completed by the Scholarship Recipient: This covers recipient name,
address, type of health care facility and certification that employed as a registered nurse.
Part II. To be completed by the Employer: Using this form, the employer certifies that
the recipient is employed as a registered nurse at the facility. The information is collected
twice a year.
3. USE OF IMPROVED INFORMATION TECHNOLOGY
The Nursing Scholarship Program worked with the Health Resources and Services Administration
Office of Information Technology and the HRSA Call Center on the conversion from a paper
application submission to an on-line application that is accessible via the Internet. The NSP web
address is: http://bhpr.hrsa.gov/nursing/scholarship/.
The Data Collection Worksheet is completed by the school and must have the school’s seal or
stamp and the student submits the completed DCW with his/her application and other supporting
documents. If the applicant is selected for a scholarship, they will receive through the mail a
letter of offer, a contract, and School Verification Form. The Employment Certification Forms
are mailed out to the scholars once they graduate and start to fulfill the service commitment.

4. EFFORTS TO IDENTIFY DUPLICATION
The information requested in the application and forms is specific to the applicant and unique to
this program. No similar information is collected from this group of individuals.
5.

INVOLVEMENT OF SMALL ENTITIES

This data collection does not involve small businesses or other small entities.
6.

CONSEQUENCES IF INFORMATION IS COLLECTED LESS FREQUENTLY

The selection process for making NSP awards must be completed annually prior to the beginning
of the academic school year. In the absence of collecting this data, review, selection, and approval
of qualified applicants cannot be carried out.
7.

CONSISTENCY WITH THE GUIDELINES IN 5 CFR 1320.5(d)(2)

This information collection is consistent with 5 CFR 1320.5(d)(2).

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8.

CONSULTATION OUTSIDE THE AGENCY

The 60 day noticed required in 5 CFR 1320.8(d) was published in the Federal Register on
November 14, 2008 (Vol. 73, No. 221, page 67526). The 30 day noticed required in 5 CFR
1320.8(d) was published in the Federal Register on July 9, 2009 (Vol. 74, No. 130, page 32935).
No comments were received.
Recipients were consulted for the following forms: Application, Data Collection/School
Verification, and Enrollment Verification.
Valerie Kowalczyk
1615 East Van Buren Street
White Cloud, MI 49349-9618
(231) 563-3577
[email protected]

Diane M. Dobbins
3711 Baltimore Avenue # A
Kansas City, MO 64111-2637
(816) 216-7420
[email protected]

Yolanda Edwards
2175 Collins Blvd
Gulfport, MS 39507-2130
(228) 617-7444
[email protected]
9. REMUNERATION OF RESPONDENTS
Respondents will not receive any remuneration.
10. ASSURANCE OF CONFIDENTIALITY
Data collected on the individual NSP application form constitutes a system of records as defined
under the Privacy Act of 1974. The program is covered by an existing System of Records, Public
Health Service (PHS) and National Health Service Corps (NHSC) Scholarship/Loan Repayment
Participants Records System (0915-0037).
All information collected through use of the NSP application process, as well as storage of this
information, will be in compliance with the Privacy Act. A Privacy Act Notice, describing the
authority for collecting the information, several routine uses which may be made of the
information collected and the necessity of reporting to receive scholarship award consideration, is
contained in the NSP Applicant Information Bulletin.
11.

QUESTIONS OF A SENSITIVE NATURE

There are no sensitive questions in the application. The Social Security number is required
because the amount received for the stipend and tuition payments must be reported to the Internal
Revenue Service as income to the scholarship recipient. All NSP payments made to scholars, or
on their behalf to nursing schools, are taxable pursuant to the legislative citation (26 USC 117(c)).
12.

ESTIMATES OF ANNUALIZED HOUR BURDEN

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Estimates of respondent burden are as follows:

Type of Report
Number of
Respondents
4,000
500

Responses
per
Respondent
1
1

Total
Responses

Hours per
Response

Total
Burden
Hours
8,000
1,000

Wage
Rate
$15
$15

Total
Hour
Cost
$120,000
$15,000

Application
4,000
2
In-school
500
2
monitoring*
(Includes the Data
Collection
Worksheet and
the School
Verification
Worksheet)
In-service
600
1
1,200
1
1,200
$15
$18,000
monitoring**
Total
5,100
10,200
10,200
$153,000
* Respondents for these forms are the academic institutions for the applicants.
**In-Service monitoring checks and ensures that NSP scholars who have completed their education are fulfilling their
service commitment according the program requirements and policies (Employment Certification Form)

Basis for Estimates
The number of NSP applicants is estimated to average 4,000 per year for the next 3 years. The
program expects to receive 4,000 applications; this estimate is based on the number of applications
received for the cycle ending in May of 2009. Each applicant must complete an application only
once if selected for award.
Each awardee will submit one Data Collection worksheet, which lists the tuition and fees. This is
used to determine the amount of the award and is submitted once. The School Verification and the
Employment Certifications are to verify that the recipients are in the appropriate program. These
forms are completed twice a year.
The current application requests general information;, educational background, and expected family
contribution. It is estimated that it will take an average of 2 hours to review the instructions,
complete the forms, and package the supporting documentation for mailing to the Nursing
Scholarship Program (4,000 applicants x 2 hours/response = 8,000). The Data Collection
Worksheet, School Verification and Employment Certification Forms take an average of .25 hours
to complete and mail to the Nursing Scholarship Program.
Scholarship applicants may be students and/or may be in the workforce.
employment status is mixed, a value of $15 per hour was estimated.

Since applicant

13. ESTIMATES OF ANNUALIZED COST BURDEN TO RESPONDENTS
There are no capital or start-up costs for the respondents. There are no operation or maintenance
fees.

14. ESTIMATES OF ANNUALIZED COST TO THE GOVERNMENT
The average annual costs to the government for implementing the on-line application and
processing are as follows:
Contract costs for on-line application:
$150,000
Processing application
65,625
Processing forms
22,500
Total annualized cost:
$238,125
Contract costs for the on-line application include providing technical and logistical assistance to
scholars completing the application and data analysis of the information submitted.
The initial review of the data collection worksheet, school verification and employment certification
forms is estimated at 10 minutes; a more detailed review at an additional 20 minutes for a total of
30 minutes at an hourly cost of $30 (Processing the forms: 1500 x 0.50 hour x $30/hour = 22,500).
15. CHANGES IN BURDEN
This is a request for an extension without change with a program adjustment due to an increase in
burden as a result of an increased amount of respondents in 2009 (from 4,400 to 5,100) and an
increase in the hours per response (1.25 to 2 hours).
16. TIME SCHEDULE, PUBLICATION AND ANALYSIS PLANS
Approval is being requested for the maximum allowable time of three years. The information will
be used solely for the determining scholarship award recipients.
18. CERTIFICATIONS
This project fully complies with the guidelines set forth in 5 CFR 1320.9. The required
certifications are included in this package.
LIST OF ATTACHMENTS
Attachment A: Authorizing Legislation and Regulations
Attachment B: Application Form
Attachment C: Applicant Information Bulletin
Attachment D: School Verification Sheet
Attachment E: Employment Verification Form