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pdfOMB No. 1845-0012
Form Approved
Exp. Date 2/29/2012
Section A
Section A.
1.
Please answer these general questions.
Tell us why you are submitting this application. (You may check more than one box.)
Initial Certification. This is a request for initial approval to participate in federal student
financial aid programs and to be initially designated as an eligible institution for other
Higher Education Amendments (HEA) programs.
Change in institutional ownership or structure. This is a request to participate in federal
student financial aid programs and to be designated as an eligible institution for other HEA
programs following a change in institutional ownership or structure.
Check here if requesting a preacquistion review.
Recertification. This is a request to continue to participate in federal student financial aid
programs and to continue to be designated as an eligible institution for other HEA
programs either in response to a recertification notice from us or because your
institution’s Program Participation Agreement (PPA) will expire soon.
Designation as an eligible institution. This is a request to be designated as an eligible
institution so that your students may receive deferments under federal student loan programs or
so that your institution may apply to participate in federal HEA programs other than Title IV
student financial aid programs, including the Hope and Lifetime Learning Tax Credits.
Reinstatement. This is a request to be reinstated to participate in federal student financial
aid programs and/or to be redesignated as an eligible institution for other HEA programs.
Update/Other (specify)
2.
What is the name of your institution?
3a. Do you have another name such as a trade name or a d/b/a name, under which you legally do business as
a postsecondary educational institution?
Yes
If yes, what is that name?
No
Page 1
Section A
3b.
During the last 4 years, have you had another name that you have not previously reported to the
Department of Education?
Yes
If yes, what was that name?
4.
5.
No
Check here if you are an institution resulting from a merger in the past four years,
and give the names and OPEID numbers of the former (pre-merger) institutions.
What are the first 6 digits of your 8-digit OPE ID number? The final 2 digits already are entered
for you.
Check here if you are an initial applicant and do not have an OPE ID number, and go
to Question 6.
Current OPE ID (or former OPE ID if seeking reinstatement)
00
Check here if you are an institution resulting from a merger in the past four years, and
give the OPE ID numbers of the former (pre-merger) institutions.
00
6a.
00
00
What is your 9-digit Taxpayer Identification Number (TIN) assigned by the IRS?
Check here if you are an institution resulting from a merger in the past four years, and
give the TINs of the former (pre-merger) institutions.
6b.
What is your 9-digit DUNS number?
Page 2
Section A
7.
8.
9.
What was your most recently completed award year?
Beginning date:
07/01/____
Ending date:
06/30/____
What is your current award year?
Beginning date:
07/ 01/____
Ending date:
06/30/____
Does your institution have a web site (or home page) on the Internet?
Yes
No
If yes, list the electronic address (URL).
10.
Who is your chief executive officer (CEO)/president/chancellor?
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr.)
Job title
Business street address
City
State (or province) and zip+4 (and country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address (if applicable)
Page 3
Section A
11.
Who is your chief fiscal officer/financial officer?
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr.)
Job title
Business street address
City
State (or province) and zip+4 (and country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address (if applicable)
12.
Who is your chief financial aid director?
This must be a capable individual designated to be responsible for administering all the Title IV, HEA programs and
coordinating those programs with the institution's other Federal and non-Federal programs of student financial assistance.
(See 34 CFR 668.16)
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr)
Job title
Business street address
City
State (or province) and zip+4 (and country, if outside the U.S.)
Page 4
Section A
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address (if applicable)
13. To whom do you wish us to send publications (such as the FSA Handbook) and printed communications
concerning federal student financial aid?
Same person as in Question 10.
Same person as in Question 12.
If neither of these people, complete the information below.
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr.)
Job title
Business street address
City
State (or province) and zip+4 (and country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address (if applicable)
Page 5
Section A
14.
Whom should we contact at your institution if we have questions about information in this form.(Note:
If there is someone you wish us to contact outside of your institution, you may enter them in question 70.)
Same person as in Question 10.
Same person as in Question 12.
Same person as in Question 13.
If none of these people, complete the information below.
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr.)
Job title
Business street address
City
State (or province) and zip+4 (and country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address (if applicable)
Page 6
Section B
Section B. Please tell us about your accreditation and
state authorization to provide
postsecondary education.
Check here if you are a foreign institution, and go to Section C.
15.
What is your accrediting agency? (Complete a. if you have institution-wide accreditation; complete
b. if you do not have institution-wide accreditation.)
a. If you have institution-wide accreditation, provide the following information for each agency.
If more than one accrediting agency provides accreditation, designate the one you wish us
to use in determining your eligibility and continued eligibility.
Abbreviation of accrediting agency(A list of abbreviations accompanies this application.)
You must include a copy of your current letter of accreditation.
c.
•
What year did your accrediting agency last accredit you?
•
For how many years is this accreditation granted?
If you do not have institution-wide accreditation, provide the following information for
each accrediting agency that either accredits a program that is currently eligible or for
which you are seeking eligibility. (This includes programs such as a hospital-based
nursing program or radiologic technology program.)
Abbreviation of accrediting agency (A list of abbreviations accompanies this application.)
You must include a copy of your current letter of accreditation.
•
What year did your accrediting agency last accredit you?
•
For how many years is this accreditation granted?
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet,
repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for each
question. Insert continuation sheets following the page where the question is asked.
Page 7
Section B
16.
Check here if you do not offer a flight program, and go to Question 17.
If you offer a flight program, provide your certification number from the U.S.
Federal Aviation Administration (FAA).
Number
Date FAA certification expires
17.
What state agencies authorize or license you to provide postsecondary educational programs?
(For this question, do not include educational programs that are provided at “distance learning” sites.)
a.
Check here if you are a public institution and do not provide at least 50% of
an educational program outside your state, and go to Section C.
b.
Check here if you are a public institution and you do provide at least 50% of an
educational program outside your state, and list (for each state other than your
“home” state) each state agency that licenses you, or otherwise provides you with
legal authority, to provide postsecondary educational programs.
c.
Check here if you are a private institution, and list each state agency that licenses
you, or otherwise provides you with legal authority, to provide postsecondary
educational programs.
d.
Check here if you or your programs are not required to be authorized or licensed by
a state agency, and include a copy of the basis for that determination.
Name of agency
Business street address
City
State (or province) and zip+4 (and country, if outside the U.S.)
Page 8
Section C
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address (if applicable)
You must include a copy of your current state license(s) or other state
authorization(s) and/or exemption(s).
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet,
repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for
each question. Insert continuation sheets following the page where the question is asked.
Section C. Please describe your institutional control
and structure.
18.
Check your type of institutional structure (check one).
Public institution
Private nonprofit 501(c)(3) institution
You must include a copy of your 501(c)(3) designation from the IRS.
For-profit institution
Foreign institution (check one)
Foreign Public institution
Foreign Private nonprofit institution (Note: a foreign private nonprofit institution is one that is owned
and operated only by one or more nonprofit corporations or associations, and either its home country tax
authority recognized by the Secretary of Education has designated the institution as a nonprofit
educational institution or if no tax authority in the home country is recognized by the Secretary of
Education, the foreign institution demonstrates to the satisfaction of the Secretary that it is a nonprofit
educational instiution)
You must include a copy of your nonprofit designation status and a certified
English translation of your nonprofit designation status.
Foreign For-profit institution (Note: Foreign graduate medical schools, foreign veterinary schools
whose students complete their clinical training at an approved veterinary school in the U.S., and
foreign nursing schools whose students complete clinical training at an approved U.S. hospital or
accredited school of nursing in the U.S., and whose students also receive a degree in nursing from an
accredited school of nursing in the U.S. are the only foreign for-profit institution eligible to apply to
participate in federal student financial aid programs.)
Page 9
Section C
19.
Check here if this is a request for initial certification, and go to Question 20.
For all other institutions, since you were last certified to participate in federal
student financial aid programs, has your institutional structure checked in Question
18 changed?
No
Yes
If yes, give the date of the change.
20.
Check here if you are a public institution, and go to Section D.
Check here if you are not a public institution, and list the names of your board of trustees
or your board of directors.
Check here if you have a board of trustees.
Check here if you have a board of directors.
Check here if you have more than 10 on your board, and list only the board’s
executive committee and provide the name of a contact person in Question 21.
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr.)
Page 10
Section C
21.
If you provide only the board’s executive committee in Question 20, tell us who is the
appropriate person to contact for further information about your board (for example, the board’s
recording secretary)?
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr.)
Job title
Business street address
City
State (or province) and zip+4 (and country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address (if applicable)
Page 11
Section D
Section D. If you are a for-profit institution, or are a
not-for-profit institution with a change in
control, please answer these questions. (This
includes for-profit foreign graduate
medical, veterinary, and nursing schools
and foreign not-for-profit institutions with a
change in control.)
Check here if you are not a for-profit institution, or are a not-for-profit institution that
has not undergone a change in control and go to Section E.
22.
Check the type of ownership you have (check one).
Corporation - publicly traded
Corporation - not publicly traded
Partnership
Proprietorship
23.
If you are a corporation, give the name and address of the contact person (sometimes known as
the “registered agent”) within the state or foreign country where you are incorporated.
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr.)
Job title
Company name, if applicable
Business street address
City
State (or province) and zip+4 (and country, if outside the U.S.)
Page 12
ext:
Fax number (including area code)
ext:
E-mail address (if applicable)
24.
Provide the following information for each person or entity that directly or indirectly owns a 25%
or greater interest in your institution.
a. The owner or person is (check one):
a corporation (complete b. and c.)
Publicly traded - Provide the stock exchange trading symbol ___________
Closely held corporation
Subchapter S Corporation
Limited Liability Company
Other, identify _________________________
b.
an unincorporated business entity (such as a partnership or trust) (complete b. and c.)
General partner/partnership
Limited liability
partnership Proprietorship
Voting trust
Other, identify _________________________
an individual (complete d.)
Name of corporation or other entity
Business street address
City
State (or province) and zip+4 (and country, if outside the U.S.)
Page 13
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address (if applicable)
Percentage of ownership
Date ownership began
Identify the state or country in which you are incorporated.
Page 14
TIN
Section D
c.
List the following information for each person or entity that directly or indirectly owns a
25% or greater interest in this corporate owner or entity:
Name of owner
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr.)
Business street address
City
State (or province) and zip+4 (and country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address (if applicable)
Home address
City
State (or
province) and zip (and country, if outside the U.S.)
Percentage of ownership
Date ownership began
SSN of owner (required)
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet,
repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as
appropriate for each question. Insert continuation sheets following the page where the question is asked.
Page 15
Section D
d.
If the owner is an individual (who holds ownership individually, or together with one or
more members of his or her family, or in combination with others, such as a voting trust)
provide the following information.
Name of owner
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr.)
Business street address and home address
City
State (or province) and zip+4 (and country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address (if applicable)
Percentage of ownership
Date ownership began
SSN of owner (required)
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet,
repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for
each question. Insert continuation sheets following the page where the question is asked.
Page 16
Section D
25.
Has a person or entity listed in Question 24 or a member of that person's family or a director of your
institution owned 25% or more or held a position listed below of another institution that is now
participating in or ever participated in federal student financial aid programs or of a third-party
servicer listed in Question 58?
The ownership could be:
• individual, or
• held by one or more family members, or
• in combination with others, such as a voting trust.
The position held at another institution could be any of the following:
• member of the board of directors, or
• chief executive officer, or
• other executive officer, general partner or director of the institution or servicer.
No
Yes
If yes, what is the name of the owner (either the name of a person or an entity) or the director?
(If a person, include prefix, such as Mr., Ms., Dr.)
If applicable, what is the name of the third-party servicer that is or was owned?
If applicable, what is the name of the institution that is or was owned?
If applicable, what is the current or former OPE ID of this institution?
Is there any liability currently owed to the Department that was established during the
period of ownership or position held? (If yes, please explain in Section K, Question 69)
Yes
No
Check here if you need space to give more than one answer and continue on a separate sheet. On the
separate sheet, repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so
on as appropriate for each question. Insert continuation sheets following the page where the question is asked.
Page 17
Section E
Section E. Please provide the following information for
each educational program that you are
requesting be eligible to participate in
federal student financial aid programs.
26.
Please check each box that describes the educational programs that you provide as of the date you
submit this application or that you will provide during the current award year. Provide
information only on programs that you wish to be eligible for federal student financial aid.
(You may check more than one box.)
Note: The institution must be able to demonstrate a reasonable relationship between the length of the program and the
entry-level requirement for the recognized occupation for which the program prepares the student. The
Secretary considers the relationship to be reasonable if the number of clock hours provided in the program
does not exceed by more than 50 percent the minimum number of clock hours required for training in the
recognized occupation for which the program prepares the student, as established by the State in which the
program is offered, if the State has established such a requirement, or as established by any Federal agency. If
the program exceeds by more than 50 percent of the State or Federal minimum number of clock hours, please
explain in Section K, Question 69.
Note: Post-baccalaureate students pursuing prerequisite coursework (such as prerequisite courses for
medical school) have their eligibility determined on the basis of student eligibility for federal
student financial aid criteria rather than program eligibility criteria. Therefore, these types of
programs are not included here.
a.
associate degree programs
b.
bachelor’s degree programs
c.
master’s degree programs or doctoral degree programs
d.
first professional degree programs
Do you measure student's progress in any of these degree programs by direct
assessment instead of credit or clock hours?
No
Yes
e.
graduate or professional programs that
•
do not lead to a post-baccalaureate degree,
•
are at least 10 weeks, and
•
provide at least 8 semester or trimester credit hours, 12 quarter
credit hours, or 300 clock hours of instruction.
•
prepare students for gainful employment in a recognized occupation
f.
g.
two-academic-year transfer programs (see glossary)
undergraduate programs that
•
lead to a certificate or other recognized educational credential,
•
prepare students for gainful employment in a recognized occupation,
•
are at least 15 weeks, and
•
provide at least 16 semester or trimester credit hours, 24 quarter
credit hours, or 600 clock hours of instruction.
Page 18
Section E
h.
undergraduate programs that
•
lead to a certificate or other recognized educational credential,
•
prepare students for gainful employment in a recognized occupation,
•
are at least 10 weeks,
•
provide at least 8 semester or trimester credit hours, 12 quarter credit hours,
or 300 clock hours of instruction,
AND
•
require an enrolling regular student to have an associate degree or higher degree.
i.
undergraduate programs that
•
lead to a certificate or other recognized educational credential,
•
prepare students for gainful employment in a recognized occupation,
•
are at least 10 weeks,
•
provide at least 300 but not more than 599 clock hours of instruction,
•
do not exceed by more than 50% the minimum number of clock hours
established by the state for such training programs, and
have been provided for at least one year.
•
j.
Post-baccalaureate teacher certification program necessary to become a teacher in an
elementary of secondary school in that state. Please refer to the glossary for more
information about this program type.
k.
Comprehensive Transition and Postsecondary Program (for students with intellectual
disabilities - please refer to 34 C.F.R. 668.231 for information about the requirements of
this program)
Check here if you award an associate degree, bachelor’s degree, or higher degree to all
your students who successfully complete any of your programs, and go to Question 28.
If you checked boxes e., g., h., or i. in Question 26, provide the following information.
a.
If you checked box e. in Question 26, list the following information for each program.
Name of program
CIP code (A list of CIP codes accompanies this application.)
Page 19
Section E
Number of weeks
Clock hours (number of hours) of instruction
Number of credit hours
Type (check one)
semester credit hours
trimester credit hours
quarter credit hours
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet,
repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for
each question. Insert continuation sheets following the page where the question is asked.
b. If you checked boxes g. or h. in Question 26, list the following information for each program.
Name of program
CIP code (A list of CIP codes accompanies this application.)
Date first provided
Number of weeks
Clock hours (number of hours) of instruction (This is required information.)
If you offer the program in credit hours,
Number of credit hours
Type (check one)
semester credit hours
trimester credit hours
Page 20
quarter credit hours
Section E
Is each course within the program acceptable for full credit toward your associate degree
or higher degree.
Yes
No
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate
sheet, repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as
appropriate for each question. Insert continuation sheets following the page where the question is asked.
c.
If you checked box i. in Question 26, list the following information for each program.
Name of program
CIP code (A list of CIP codes accompanies this application.)
Date first provided
Number of weeks
Clock hours (number of hours) of instruction.
Maximum number of clock hours authorized by the state licensing agency
Completion rate*
Placement rate*
*Provide the completion rate and the placement rate for your most recently completed award
year. (Instructions on how to calculate the completion rate are found in 34 CFR 668.8(f).
Instructions on how to calculate the placement rate are found in 34 CFR 668.8(g).)
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet,
repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for
each question. Insert continuation sheets following the page where the question is asked.
Page 21
Section E
d. If you checked box k. in Question 26, list the following information for each program.
Name of program
CIP code (A list of CIP codes accompanies this application.)
Date first provided
Number of weeks
Clock hours (number of hours) of instruction (This is required information.)
If you offer the program in credit hours,
Number of credit hours
Type (check one)
semester credit hours
trimester credit hours
quarter credit hours
Is each course within the program acceptable for full credit toward your associate degree
or higher degree.
Yes
No
*If not previously provided, the institution must provide a detailed description of this
Comprehensive Transition and Postsecondary Program addressing all of the components of
the program as defined in 34 C.F.R. 668.231. The institution must send this information as a
pdf attachment to [email protected].
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate
sheet, repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as
appropriate for each question. Insert continuation sheets following the page where the question is asked.
28.
Do you contract with an organization or ineligible institution (such as internship, externships, practicum in
nursing, midwifery, medical technician, etc.) to provide more than 25% of any educational program?
Note: If you contract more than 50% of the program to an organization or ineligible
institution, the program is not eligible for Title IV.
Yes
No
If yes, provide the following information.
a.
Name of program
Page 22
Section E
Name of organization or ineligible institution
Corporation name, if applicable
Business street address
City
State (or province) and zip+4 (and country, if outside the U.S.)
Former OPE ID number of the other institution, if applicable
What percent of the program is contracted out?
You must include a copy of the approval from your accrediting agency for contracting
this program.
b.
Check here if any owner or person listed in Question 24 or Question 25
directly or indirectly
• owns or controls 25% or more of the ineligible institution
or
• serves as a director or as an executive officer of the ineligible institution.
What is the name of this owner or person?
c.
Did the ineligible institution withdraw from participating in federal student financial aid
programs under a termination, show cause, suspension, or similar type of proceeding
initiated by its state licensing agency, accrediting agency, guarantor, or the U.S.
Secretary of Education?
Yes
No
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet,
repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for
each question. Insert continuation sheets following the page where the question is asked.
New substitute Question 28 for foreign institutions only:
Report all educational programs offered by your institution that are:
•
for purposes of students who receive Title IV, HEA programs funds
through your institution, offered through an arrangement (including, but
not limited, study-abroad agreements, contractual agreements, consortium
agreements, twinning programs, dual-degree programs, joint-degree
program, dual-enrollment programs) with another organization or
institution that is not eligible to participate in the U.S. Federal Student Aid
Programs
or
•
for purposes of students who receive Title IV, HEA programs funds
through your institution, offered at a location in the United States (except
for medical, veterinary or nursing clinical training) through an arrangement
(including, but not limited, study-abroad agreements, contractual
agreements, consortium agreements, twinning programs, dual-degree
programs, joint-degree program, dual-enrollment programs) with another
institution or organization to provide any portion of your educational
program(s) at a location in the United States.
or
•
provided to students who receive Title IV, HEA program funds through
your institution at a location in the United States under your institution’s
ownership or administrative control (except for state approved clinical
training for medicine, veterinary medicine, or nursing programs).
Name of Educational Program: [
]
This educational program is (check all that apply):
[ ] check here if the program is offered through an arrangement
(including, but not limited, study-abroad agreements, contractual
agreements, consortium agreements, twinning programs, dualdegree programs, joint-degree program, dual-enrollment
programs) with another organization or institution that is not
eligible to participate in the U.S. Federal Student Aid Programs
[ ] check here if the program is offered at a location in the United
States (except for medical, veterinary or nursing clinical training)
through an arrangement (including, but not limited, study-abroad
agreements, contractual agreements, consortium agreements,
twinning programs, dual-degree programs, joint-degree program,
dual-enrollment programs) with another institution or organization
to provide any portion of your educational program(s) at a location
in the United States.
[ ] check here if the program is provided to students who receive Title
IV, HEA program funds through your institution at a location in
the United States under your institution’s ownership or
administrative control (except for state approved clinical training
for medicine, veterinary medicine, or nursing programs).
Location(s) where students receive instruction for this educational program
Business Street Address 1
Business Street Address 2
City
State/Territory/ Foreign Province
Zip Code + / Postal Code
Country
Contact person name, phone number and email address at this location
[ ]
Check here if you need space to identify more than one location for this educational program
and continue on a separate sheet. On the separate sheet, identify the name of the educational
program repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3,
and so on as appropriate for each question. Insert continuation sheets following the page
where the question is asked.
Name of Institution or Organization
that provides the program
[
OPEID of the institution (if applicable) [
]
]
Address of the partner institution
Business Street Address 1
Business Street Address 2
City
State/Territory/ Foreign Province
Zip Code + / Postal Code
Country
Contact person name, phone number and email for the educational partner
[ ]
[ ]
Check here if you need space to identify more than one institution or organization for this
educational program and continue on a separate sheet. On the separate sheet, identify the name
of the educational program, repeat the question being answered, numbering each sheet as page
1 of 3, page 2 of 3, and so on as appropriate for each question. Insert continuation sheets
following the page where the question is asked.
Check here if you need space to identify more than one educational program and continue on a separate sheet. On
the separate sheet, repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on
as appropriate for each question. Insert continuation sheets following the page where the question is asked.
Page 23
Section F
Section F.
29.
Please tell us about your locations.
What is your principal location?
Name of location
Business street address
City
County
State (or province) and zip+4 (and country, if outside the U.S.)
30.
Provide the following information for any of your locations (other than your principal location) that
meet any one of these three criteria and at which you provide educational programs to students
whom you wish to participate in federal student financial aid programs:
•
It is a location where students could complete 50% or more of an educational
program that you offer during the current award year.
or
•
or
•
It is a location where students could complete at least 50% of an educational program over
a two-year period (consisting of the current award year and the most recently completed
award year).
It is a location where you provide any educational programs if, during the past two-year
period (consisting of the current award year and the most recently completed award year),
you told students that they could complete at least 50% of any educational programs there.
Name of location
Business street address
City
County
State (or province) and zip+4 (and country, if outside the U.S.)
Page 24
Section G
OPE ID number of location or if no OPE ID number, check here
DUNS number
Would you like to receive mailings from the Department at this location?
No
Yes
Check here if the mailing address is different from the address above, and provide
the mailing address below.
Mailing address
City
State (or province) and zip+4 (and country, if outside the U.S.)
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet,
repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for
each question. Insert continuation sheets following the page where the question is asked.
New Question for Domestic School
[ ]
Check here if your educational enterprise enrolls students who are eligible to receive
Title IV, HEA program funds to attend a location outside of a State AND report the
following information for your entire educational enterprise:
(Note: for the purpose of this question, an “educational enterprise” consists of two or
more locations offering all or part of an educational program that are directly or
indirectly under common ownership.)
Number of students who currently attend the U.S. location(s) of your educational
enterprise and who are currently eligible to receive Title IV, HEA program funds
Number of students who currently attend the foreign location(s) of your
educational enterprise and who are currently eligible to receive title IV, HEA
program funds
If you are not reporting your foreign location(s) as an additional location in Question 30, report
your educational enterprise’s foreign location(s) below.
Name of foreign location
Business street address
City
Province/Territory
Country and Postal Code
OPE ID number of foreign location or if no OPE ID number, check here
[ ]
Check here if you need space to give more than one answer and continue on a separate sheet. On the
separate sheet, repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3,
and so on as appropriate for each question. Insert continuation sheets following the page where the
question is asked.
For foreign schools only: Identify below any educational sites not listed elsewhere in this application
where students may receive training or instruction through an educational program offered by your
institution (report locations where students receive classroom instruction, lecture, internships, clinical
training, externship, research, special studies, or practicum instruction, including instruction provided
through current study abroad agreements, dual degree or joint degree program agreements, or other
exchange agreements.)
Note: If you are applying for approval of your foreign medical school, foreign veterinary school, or
foreign nursing school, do not report your medical, veterinary, or nursing instructional sites in
this section. You will report medical, veterinary, and nursing instructional sites elsewhere in
this application.
Educational Site Name: [
]
Is 50% or more of any of your educational program(s) offered at this educational site?
[ ] Yes or
[ ] No
Provide the address for this Educational Location
Business Street Address 1: [
]
Business Street Address 2: [
]
Business Street Address 3: [
]
City: [
]
State/Territory: [
]
Foreign Province: [
]
County: [
]
Zip Code + 4: [
]
Postal Code: [
]
Country: [
]
Would you like to receive mailings from the Department at this site?
[ ] Yes or
[ ] No
[ ] Check here if your mailing address is the same as the address you entered above.
If this location’s Mailing Address is different from the address you entered above, provide the Mailing
Address for this site below.
Business Street Address 1: [
]
Business Street Address 2: [
]
Business Street Address 3: [
]
City: [
]
State/Territory: [
]
Foreign Province: [
]
Zip Code + 4: [
]
Postal Code: [
]
Country: [
]
Section G. Please tell us about your correspondence
courses, your students enrolled under abilityto-benefit provisions, and your incarcerated
students.
31.
Are any of your programs offered in whole or part by correspondence or telecommunication?
Yes
No
For the most recently completed award year, were more than 50% of your courses taught by means of
correspondence? (See CFR 600.7, and 668.38)
Note: If a course is offered through traditional methods and through correspondence, then that course should be
counted under both traditional methods and correspondence. Therefore, the same course might be
counted more than once.
32a.
Yes
No
Page 25
Section H
32b. For the most recently completed award year, were 50% or more of your regular students enrolled in
correspondence courses? (See 34 CFR 600.7, and 668.38)
Yes
33.
No
For the most recently completed award year, were more than 50% of your regular students abilityto-benefit students? (See 34 CFR 600.7 and 668.32)
Note: Do not include students who are being educated at your institution under a specific contract
with federal, state, or local governments for training purposes (such as most contracts under the
Job Training Partnership Act)
Yes
34.
No
During the most recently completed award year, were more than 25% of your regular
students incarcerated? (See 34 CFR 600.2, 600.7, and 668.32)
Yes
No
Section H. Please complete this section if this is an
initial application or you were certified but
you have a change in your ownership or
structure or you are seeking reinstatement.
Check here if this is not an initial application or a change in ownership or structure or
for reinstatement, and go to Section I.
Note: Here “change in ownership or structure” refers to a change in ownership, conversion to or
from a non-profit institution, or a merger of two or more institutions.
If you acquired the institution or if the institution is the result of a merger of two or more
former institutions, you will be liable for any debts incurred by your predecessors under
federal student financial aid programs.
35.
Tell us why you are completing this section.
This is an initial application and you are a new institution without a prior history.
Enter your start date and answer Questions 36, 37, and 38, then go to Section I.
Page 26
Section H
This is an initial application and you are a new institution with a prior history (for example, you
have been in operation for one or two years). Answer all the questions in this section.
Tell us on what date you were both legally authorized to provide and began continuously
providing the education or training program(s) for which you are seeking eligibility.
Start Date
Note: If you are a for-profit institution or if you offer only
a progam(s) of less than one academic year, you
must have been in existence for at least two years
to be eligible to participate in federal student financial
aid programs. (See 34 CFR 600.5 and 600.6)
You are an institution with a change in your ownership. Answer Questions 36, 37, and 38,
then go to Section I.
You are an institution that converted to a not-for-profit institution. Answer Questions 36,
37, and 38, then go to Section I.
You are an institution that converted to a for-profit institution. Answer Questions 36, 37,
and 38 then go to Section I.
You are an institution resulting from a merger in the past four years. Answer Questions 36,
37, and 38 about the newly formed institution, then go to Section I.
You are an institution seeking reinstatement. Answer all the questions in this section.
36.
How many full-time equivalent (FTE) financial aid staff members do you
have? Administrative, counselors, or other professionals
Clerical
FTE
FTE
Page 27
Section H
37.
Indicate all of the federal student financial aid programs in which you are seeking approval to
participate. (Note: Foreign institutions, including foreign graduate medical schools, may apply
only for the William D. Ford Federal Direct Loan Program (Direct Loan Program))
Federal Pell Grant Program
Federal Perkins Loan Program
Federal Supplemental Educational Opportunity Grant (FSEOG) Program
Federal Work-Study (FWS) Program
Indicate specific programs within FWS for which you are seeking approval
to participate. Federal Work-Study-regular or general
Job Location and Development (JLD)
Program Private-Sector Employment
Federal Family Education Loan (FFEL) Program- No Longer Available
(formerly called the Guaranteed Student Loan Program)
Indicate specific programs within FFEL for which you are seeking approval to
participate. Federal Stafford Loan Program (subsidized)
Federal Stafford Loan Program
(unsubsidized) Federal PLUS Loan Program
William D. Ford Federal Direct Loan Program (Direct Loan Program)
Indicate specific programs within the Direct Loan Program for which you are
seeking approval to participate.
Federal Direct Loan Program (subsidized)
Federal Direct Loan Program (unsubsidized)
Federal Direct PLUS Loan Program
38. Do you anticipate an increase of 10% or more in your student body in the next award year?
Yes No
If yes, how many regular students do you estimate would be eligible to receive federal student
financial aid for the remainder of the current award year and each of the next two award years if you
become eligible to participate in federal student financial aid programs?
Estimated number for the remainder of the current award year
Estimated number for the next award year
Estimated number for the award year following the next award year
Page 28
Section I
39.
Provide the following information about your regular students. (If a student drops out and
then reenrolls, count the student each time.)
a.
How many regular students were enrolled at your institution during your most
recently completed award year?
b.
How many regular students in a. dropped out during the 100% refund period during your
most recently completed award year?
c.
How many regular students in a. dropped out after the 100% refund period during your
most recently completed award year?
40.
If you provide vocational programs, list all such educational
programs (not classes):
• that you have provided continuously for at least 24 months
and
• for which you would like regular students to be eligible for federal student financial
aid.
Name of program
Check here if you need space to give more answers and continue on a separate sheet. On the separate sheet,
repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as
appropriate for each question. Insert continuation sheets following the page where the question is asked.
Section I. If you are a foreign institution, please complete this
section. (This includes foreign graduate medical
schools, foreign veterinary schools, and foreign
nursing schools.)
Check here if you are not a foreign institution, and go to Section J.
Note:
If you are a foreign institution, you must include a copy of your most recent catalog and a certified
English translation (see glossary) of all sections dealing with degrees and programs
provided at your institution.
41. Do you admit as regular students only people who have a credential of secondary school completion or its
recognized equivalent?
Yes
No
Page 29
Section I
42. In the country where you are located, are you legally authorized to provide an educational program
beyond the secondary school level?
Yes
No
You must include a copy of your legal authorization and its certified English translation.
If yes, what is the name and address of the agency or ministry within the country that
enforces this authority?
Name of agency
Business street address
City
Country
Telephone number (Complete international telephone number)
ext:
Fax number (including area code)
ext:
E-mail address (if applicable)
43. Are you legally authorized to award a degree that is equivalent to an associate, baccalaureate,
graduate, or professional degree awarded in the United States?
Yes
No
You must include a copy of your legal authorization and its certified English translation.
44. Do you provide an educational program that is at least a two-academic-year program acceptable for
full credit toward the equivalent of a baccalaureate degree awarded in the United States?
Yes
No
Page 30
Section I
45.
Do you provide any educational programs that meet all three of these criteria?
•
The program is equivalent to at least a one-academic-year training program in
the United States.
and
•
The program leads to a certificate, degree, or other educational credential that
is equivalent to one offered in the United States.
•
The program prepares students for gainful employment in an occupation that
is equivalent to one in the United States.
and
Yes
46.
No
Do you have administrative offices and/or recruiting offices in the United States that represent you?
Yes
No
If yes, provide the following information.
Name of office
Business street address
City
State and zip+4
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address (if applicable)
Page 31
Section I
Name of contact person at the office:
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr.)
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet,
repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for
each question. Insert continuation sheets following the page where the question is asked.
[ ]
Check here if you are a foreign institution that offers any educational program that
prepares students to practice osteopathic or allopathic medicine, veterinary medicine,
or nursing, and identify each type of program that your institution offers:
[ ] Osteopathic or Allopathic Medicine
[ ] Veterinary Medicine
[ ] Nursing
[ ]
Check here if you are a foreign institution does not wish to apply for approval for
your foreign graduate medical school, foreign veterinary school, or foreign nursing
school, or you are a foreign institution that is not a foreign graduate medical school,
foreign veterinary school, or foreign nursing school and go to Section J.
[ ]
Check here if you are a foreign graduate medical school, foreign veterinary school or
foreign nursing school that is seeking to apply for Title IV, HEA program eligibility
for an educational program that prepares students to practice osteopathic or
allopathic medicine, veterinary medicine, or nursing, and check each program that
you wish to be considered for Title IV, HEA program eligibility:
[ ] Osteopathic or Allopathic Medicine
[ ] Veterinary Medicine
[ ] Nursing
Section I. - Subsection for Foreign Graduate Medical Schools
47.
Identify all locations where your medical students receive basic science or clinical instruction
(Note: you are not required to report clinical locations that meet each of the following
criteria: they are not used to provide a core or required clinical training rotation, they
are not used regularly, but instead are chosen by individual students who take no more
than two electives at the clinical training location for no more than a total of eight
weeks)
Name of Location/Facility
Address
City, State/Province
Country, Zip Code/Postal Code
Telephone number (Complete international telephone number)
ext:
Fax number (including area code)
ext:
E-mail address (if applicable)
Name of contact person at the facility:
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr.)
Identify each type of medical instruction offered at this location.
[ ] Basic Science
[ ] Clinical Instruction
[ ] Core Clinical
[ ] Required Clinical
[ ] Not Required Clinical
Identify the date that instruction was first offered to your medical students at this
location
[
]
[ ]
Check here if you have an affiliation agreement or other written
arrangement to provide instruction to your students at this location.
Submit a copy of this agreement as a supporting document for this
application.
[ ]
Check here if this location been approved by the agency authorized to
evaluate medical schools in your country. Submit a copy of the site visit
report prepared by the medical evaluating agency in your country with
the supporting documents for this application.
[ ]
Check here if this facility is located within the United States and your
institution was approved to offer a clinical training program at this
location by the State where it is located on or before January 1, 1992.
Report the name and date that the State agency first provided its approval
of the clinical training program below. Provide documentation from the
State agency that approved your institution to offer a clinical training
program at this location on or before January 1, 1992 with the supporting
documents for this application.
State Agency Name [
State Approval Start Date [
[ ]
Check here if your institution ceased to offer a clinical training
program at this location or it is no longer approved to offer the
clinical training program at this location by the State where it is
located on or before January 1, 1992. Report the date that your
institution ceased to provide instruction or the State approval
ended below.
Last Date of Instruction [
State Approval End Date [
[ ]
]
]
]
]
Check here if this facility is located within the United States and your
institution received approved to offer a clinical training program at this
location by the State where it is located on or before January 1, 2008.
Provide documentation from the State agency that approved your
institution to offer a clinical training program at this location on or before
January 1, 2008 with the supporting documents for this application.
[ ]
Check here if your institution ceased to offer a clinical training
program at this location or it is no longer approved to offer the
clinical training program at this location by the State where it is
located on or before January 1, 2008. Report the date that your
institution ceased to provide instruction or the State approval
ended below.
Last Date of Instruction or State Approval End Date [
]
[ ]
Check here if this location is in a country other than the United States that
the NCFMEA has determined uses comparable medical accrediting
agency approval standards.
[ ]
Check here if the medical accrediting agency in your home country has
conducted an on-site evaluation and specifically approved this clinical
training site. Provide a copy of the most recent evaluation report as a
supporting document to this application
[ ]
Check here if clinical instruction is offered at this site is also offered in
conjunction with a medical educational program that is offered to
students enrolled in an accredited medical school located in the country
and list the names of those accredited medical schools below.
Name(s) of accredited medical school(s) offering clinical instruction at
this training site
[ ]
Check here if this location is included in the accreditation of a medical
program accredited by the Liaison Committee on Medical Education
(LCME) or the American Osteopathic Association (AOA). Submit a
copy of the accreditation document as a supporting document for this
application.
[ ]
Check here if this location is approved by any other medical licensing
board or evaluating body not already identified in this application, and
identify the name of that board/evaluating body below. Provide a copy of
this approval document as a supporting document for this application.
Name of evaluating body/medical licensing board
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate
sheet, repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as
appropriate for each question. Insert continuation sheets following the page where the question is asked.
Page 32
Section I
48.
What entity in your country is legally authorized to evaluate the quality of your graduate
medical educational program?
Name of entity
Address
City
Country
Telephone number (Complete international telephone number)
ext:
Fax number (including area code)
ext:
E-mail address (if applicable)
Name of contact person at the entity:
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr.)
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet,
repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for
each question. Insert continuation sheets following the page where the question is asked.
Page 33
Section I
49.
Are you approved by the entity (or entities) listed in Question 48 to provide a graduate
medical educational program in your country?
Yes
No
You must include a copy of each approval and its certified English translation.
50.
What is the length of the program of graduate clinical and medical instruction?
Months of Instruction
Page 34
Section I
c. What medical licensing boards and evaluating bodies in the United States currently
approve the clinical training in the United States?
[ ]
Check here if your institution has continuously, since January 1, 1992, offered
a clinical training program in the U.S. with approval from at least one U.S.
State. Provide documentation from the State agency or agencies that
demonstrate continuous State approval for one or more of your clinical training
programs for this timeframe with the supporting documents for this
application. List in question XX the U.S. clinical training program facility (or
the combination of U.S. clinical training program facilities) that demonstrates
your institution has maintained continuous approval to offer a clinical training
program by at least one U.S. State since January 1, 1992.
[ ]
Check here if your institution has continuously, since January 1, 2008, offered
a clinical training program in the U.S. with approval from at least one U.S.
State. Provide documentation from the State agency or agencies that
demonstrates continuous State approval for one or more of your clinical
training programs for this timeframe with the supporting documents for this
application. List in question XX the U.S. clinical training program facility (or
the combination of U.S. clinical training program facilities) that demonstrates
that your institution has maintained continuous approval to offer a clinical
training program by at least one U.S. State since January 1, 2008.
Does your foreign graduate medical school provide any of the following types of
medical educational programs (check each type of program that is offered):
[ ]
[ ]
Post baccalaureate/equivalent medical programs
Other types of programs that lead to employment as a doctor of
osteopathic medicine, or doctor of medicine
If your institution offers a post-baccalaurate/equivalent medical program, read and
answer each of the applicable statements below:
[
]
check here if you require U.S. citizens, U.S. nationals and U.S. lawful
permanent residents accepted for admission post-baccalaurate/
equivalent medical program to take the Medical College Admission
Test (MCAT)
[
]
check here if you require U.S. citizens, U.S. nationals and U.S. lawful
permanent residents to report their MCAT scores to you.
[
]
check here if you can report the MCAT scores achieved by U.S.
citizens, U.S. nationals and U.S. lawful permanent residents and a
statement of the number of times each U.S. citizen, U.S. national or
U.S. lawful permanent resident took the MCAT examination.
Review the following statements concerning data collection and reporting, and check
each that apply to your institution:
[ ]
Check here if your institution has determined the consent requirements
for and requires the necessary consents of ALL students accepted for
admission for whom the institution must report to comply with data
collection and submission requirements, including, but not limited to:
(Check each that applies)
[ ]
MCAT scores
[ ]
USMLE scores
[ ]
U.S. medical residency programs placement rate data
[ ]
U.S. citizenship/residency rate data
[ ]
Check here if your institution has a data collection and reporting
system that allows you to report all required information to the
Department of Education and your medical school accrediting agency.
[ ]
Check here if a privacy law or a data protection law in your country
prevents you from providing MCAT scores, USMLE scores, placement
rates in U.S. medical residency programs, or citizenship/residency data
for your medical students or graduates to the U.S. Department of
Education or to your medical school’s accrediting agency.
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet,
repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for
each question. Insert continuation sheets following the page where the question is asked.
52.
List the dates of graduation and the number of regular students who graduated within the past three
12-month periods.
Dates
Dates
Dates
Graduates
Graduates
Graduates
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate
sheet, repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as
appropriate for each question. Insert continuation sheets following the page where the question is asked.
Identify the number of medical school graduates in your most recent medical school
graduating class who were U.S. citizens, U.S. Nationals, or eligible noncitizens.
[
]
Identify the number of graduates in your most recent medical school graduating class who
were not U.S. citizens, U.S. Nationals, or eligible noncitizens.
[
53.
]
What are the beginning and ending dates of your institution’s most recently completed academic
year?
Beginning date
Ending date
Page 35
Section J
54.
How many full-time regular students were enrolled in your medical school during the most recently
completed academic year?
55.
How many of the regular students in Question 54 were not persons who met the U.S. citizenship or
residency criteria to be eligible for U.S. federal financial aid programs? (Note: To be eligible to
receive assistance through the U.S. federal financial aid programs, a student must be a U.S. Citizen,
a U.S. National, or an eligible non-citizen.
See the Glossary for a definition of “eligible non-
citizen.”)
What is the most recently completed calendar year for which USMLE performance data are
available? [ ]
Report for each USMLE step/test listed below the number of your medical students or recent
graduates who took each step/test as a first-time test-taker during the most recently completed
calendar year for which performance data are available. (Note: Recent graduates include each student
who graduated from the medical school during the three years preceding the year for which the
calculation is performed.)
Step 1
Step 2-CS
Step 2-CK
Number of First-time test-takers on this step/test [
Number of First-time test-takers on this step/test [
Number of First-time test-takers on this step/test [
]
]
]
Identify the method that your institution uses to report USMLE scores to the Department of
Education.
[ ]
Check here if your institution has a Performance Information Agreement (PIA) with
the Educational Commission for Foreign Medical Graduates (ECFMG) or other
designated third party AND you wish the Department to rely on data provided by this
entity about the performance your medical students and recent graduates as a first-time
test-takers on the following step/tests of the United States Medical Licensing
Examination (USMLE): Step 1, Step 2-Clinical Skills (Step 2-CS), and Step 2Clinical Knowledge (Step 2-CK).
(Note: You must have at least 8 first time test takers in each step/test during the
calendar year AND you must provide by April 30 written consent that verifies
that the pass rate as calculated by ECFMG or other designated third party is
reliable and conclusive for purposes of determining compliance. Recent
graduates include each student who graduated from the medical school during
the three years preceding the calendar year for which the calculation is
performed.)
[ ]
Check here if your institution does not agree to allow the ECFMG or other responsible
third party to calculate and provide your institution’s USMLE pass rate data directly to
the Secretary of Education AND report below USMLE performance data for every
student and every graduate of your medical school who took USMLE Step 1, Step 2CS, or Step 2-CK during the most recently completed calendar year.
(Note: Do not report personally identifiable information for individual test
takers. Reference individual students by a student reference number and retain
a cross-reference table in your institution’s records.)
[
]
Check here if you reported fewer than 8 first-time test-takers in all of the following
USMLE step/test categories: Step 1, Step 2-CS, Step 2-CK AND report below the
USMLE performance data for every student and every graduate of your medical
school who took USMLE Step 1, Step 2-CS, or Step 2-CK during the most recently
completed calendar year.
(Note: Do not report personally identifiable information for individual test
takers. Reference individual students by a student reference number and retain
a cross-reference table in your institution’s records.)
SAMPLE DATA Entry Table
Student
Reference
Number
Test Date
(MM/DD/
YYYY)
Step/Test
attempted
Score
Pass/Fail
indicator
Number
of
Step/Test
attempts
Student/
Graduate
indicator
Grad
Date
1 = 1sttimetaker
2009-1
2009-1
2009-1
2009-2
2009-2
2009-2
2009-2
2009-3
2009-3
1/1/2009
3/1/2009
4/15/2009
1/15/2009
3/15/2009
7/15/2009
9/15/2009
1/31/2009
3/15/2009
Step 1
Step 2-CS
Step 2-CS
Step 2-CS
Step 2-CS
Step 2-CS
Step 2-CS
Step 2-CS
Step 2-CK
{value}
{value}
{value}
{value}
{value}
{value}
{value}
{value}
{value}
Pass
Fail
Pass
Fail
Fail
Fail
Pass
Pass
Pass
2 or more
= Repeat
1
1
2
2
3
4
5
1
1
Student
Student
Student
Graduate
Graduate
Graduate
Graduate
Graduate
Graduate
6/11/2007
6/11/2007
6/11/2007
6/11/2007
6/15/2005
6/15/2005
[ ]
Check here if you need space to continue your answer on a separate sheet. On the separate sheet, repeat the question
being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for each question. Insert
continuation sheets following the page where the question is asked.
[ ]
Check here if your medical school is located in Canada and you have an agreement
National Board of Medical Examiners (NBME) or other entity to receive test
performance data for your medical students and recent graduates who were a first-time
test-takers on the following step/tests of the United States Medical Licensing
Examination (USMLE): Step 1, Step 2-Clinical Skills (Step 2-CS), and Step 2Clinical Knowledge (Step 2-CK).
[ ]
Check here if your medical school includes as a quantitative component of your
institution’s satisfactory academic progress standards a maximum timeframe in which
a student must complete his or her educational program within 150 percent of the
published length of the educational program measured in academic years, terms, credit
hours attempted, clock hours completed, etc., as appropriate.
[ ]
Check here if your medical school documents the educational remediation it provides
to assist students in making satisfactory academic progress.
[ ]
Check here if your medical school clearly publishes all of the languages in which
instruction is offered.
Section I. - Subsection for Foreign Veterinary Schools
47.
Identify all locations where your veterinary students receive basic science or clinical instruction
(Note: if you are a foreign public or foreign private non-profit institution, you are not required
to report clinical locations that are not used regularly, but instead are chosen by individual
students who take no more than two electives at the clinical training location for no more than
a total of eight weeks)
Name of Location/Facility
Address
City, State/Province
Country, Zip Code/Postal Code
Telephone number (Complete international telephone number)
ext:
Fax number (including area code)
ext:
E-mail address (if applicable)
Name of contact person at the facility:
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr.)
Identify each type of veterinary instruction offered at this location.
[ ] Basic Science
[ ] Clinical Instruction
Identify the date that instruction was first offered to your veterinary students at this
location
[
]
[ ]
Check here if you have an affiliation agreement or other written arrangement to
provide instruction to your students at this location. Submit a copy of this
agreement as a supporting document for this application.
[ ]
Check here if this location is specifically approved by the agency authorized to
evaluate veterinary schools in your country. Submit a copy of the site visit
report prepared by the medical evaluating agency in your country with the
supporting documents for this application.
[ ]
Check here if this facility is located within the United States and it is a clinical
training facility where your veterinary students complete veterinary clinical
training.
[ ]
Check here if this location is included in the accreditation of a veterinary
program accredited by the American Veterinary Medical Association (AVMA).
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet,
repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for
each question. Insert continuation sheets following the page where the question is asked.
[ ]
Check here if your veterinary school is accredited by the American Veterinary Medical
Association Council on Education.
[ ]
Check here if your veterinary school has begun a process to seek accreditation by the
American Veterinary Medical Association Council on Education.
[ ]
Check here if your veterinary school is accredited by a veterinary accrediting agency
that is legally recognized in the country where your main campus is located, and report
that agency below. Report the name and date that the veterinary accrediting agency
first provided its approval, and provide documentation that the veterinary accrediting
agency is legally authorized to approve veterinary education in your country with the
supporting documents for this application.
Veterinary accrediting Agency Name [
Veterinary accrediting agency approval Start Date [
[ ]
]
]
Check here if your institution is no longer approved by the veterinary
accrediting agency where it is located on or before January 1, 1992.
Report the date that your institution ceased to be approved below.
Veterinary accrediting agency approval End Date [
Page 36
]
Telephone number (including area code) & ext.
Ext.
Fax Number (including area code) & ext
Ext.
E-mail address (if applicable)
Section I. - Subsection for Foreign Nursing Schools
Does your foreign nursing school meet one or more of the following definitions?
Check each that applies: (definition of a foreign nursing school 34 C.F.R. 600.57) :
[ ] Associate Degree School of Nursing
[ ] Collegiate School of Nursing
[ ] Diploma School of Nursing
Note: See definitions in the glossary
[
]
Check here if your foreign nursing school currently has an agreement with a hospital located in the
United States or an accredited school of nursing (as those terms are defined in section 801 of the
Public Health Service Act (42 United States Code 296) located in the United States where your
nursing students complete clinical training.
Identify below the method(s) by which your institution will obtain the results of the National Council
Licensure Examination for Registered Nurses (NCLEX-RN) to report to the Secretary of Education
[
]
Check here if your foreign nursing school has developed a system and entered into
agreements to obtain at its own expense all results from students and graduates who are
U.S. citizens, nationals or eligible permanent residents on the National Council Licensure
Examination for Registered Nurses (NCLEX-RN), together with the dates the students have
taken the examination, including failed examinations, in order to provide the results to the
Secretary of Education
[
]
Check here if your foreign nursing school has developed a system and entered into an
agreement to obtain a report(s) from the National Council of State Boards of Nursing
(NCSB), or an NCSB affiliate or NCSB contractor, reflecting the percentage (or data to
calculate the percentages) of the school’s students and graduates taking the NCLEX-RN in
the preceding year who passed the examination in order to provide the results to the U.S.
Department of Education.
[ ]
Check here if your institution has consent requirements and requires these consents
of ALL students accepted for admission for whom the institution must collect and
report the examination results (e.g. NCLEX-RN)
[ ]
Check here if a privacy law or a data protection law in your country prevents you
from providing NCLEX-RN results or other data to the U.S. Department of
Education or to your medical school’s accrediting agency.
What is the most recent calendar year for which NCLEX-RN performance data are available? [
]
Report the NCLEX-RN results for the most recently available year below:
(Note: Do not report personally identifiable information for individual test takers.
Reference individual students by a student reference number and retain a crossreference table in your institution’s records.)
SAMPLE DATA reporting table
Student
Reference
Number
2009-1
2009-1
2009-1
2009-2
2009-2
2009-2
2009-2
2009-3
2009-3
[ ]
[
[ ]
]
Test Date
(MM/DD/
YYYY)
1/1/2009
3/1/2009
4/15/2009
1/15/2009
3/15/2009
7/15/2009
9/15/2009
1/31/2009
3/15/2009
NCLEXRN step?
(if
appropriat
e)
Step 1
Step 2-CS
Step 2-CS
Step 2-CS
Step 2-CS
Step 2-CS
Step 2-CS
Step 2-CS
Step 2-CK
Score
Pass/Fai
l
indicato
r
Number of
Step/Test
attempts
Student/
Graduate
indicator
Grad
Date
1 = 1sttimetaker
{value}
{value}
{value}
{value}
{value}
{value}
{value}
{value}
{value}
Pass
Fail
Pass
Fail
Fail
Fail
Pass
Pass
Pass
2 or more =
Repeat
1
1
2
2
3
4
5
1
1
Student
Student
Student
Graduate
Graduate
Graduate
Graduate
Graduate
Graduate
6/11/2007
6/11/2007
6/11/2007
6/11/2007
6/15/2005
6/15/2005
Check here if you need space to continue your answer on a separate sheet. On the separate sheet, repeat the question being
answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for each question. Insert continuation
sheets following the page where the question is asked.
Check here if your foreign nursing school has graduated classes during each of the two twelve
month periods immediately preceding the date of this application and identify those graduation
dates and number of nursing school graduates in each graduating class below.
Graduation Date [
] Number of Nursing Graduates [
]
Graduation Date [
] Number of Nursing Graduates [
]
Check here if your foreign nursing school agrees to reimburse the Secretary of Education for the
costs of defaulted student loans for students attending your foreign nursing program.
47.
Identify all locations where your nursing students receive basic science or clinical instruction
Name of school/facility
Address
City, State/Province
Country, Zip Code/Postal Code
Telephone number (Complete international telephone number)
ext:
Fax number (including area code)
ext:
E-mail address (if applicable)
Name of contact person at the facility:
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr.)
Identify each type of nursing instruction offered at this location.
[ ] Basic Science
[ ] Clinical Instruction
Is this facility a U.S. hospital or an accredited school of nursing? (check all that apply)
[ ] U.S. hospital
[ ] Accredited school of nursing in the U.S.
[ ] other facility
[ ]
Check here if this is a location where your student completes nursing clinical
training
[ ]
Check here if your foreign nursing school has an agreement with this facility to ensure
proper oversight of the nursing program.
[ ]
Check here if faculty members of the foreign nursing school are based at this facility to
ensure proper educational oversight.
[ ]
[ ]
[ ]
Check here if the facility providing the clinical training program is approved by all
licensing boards and evaluating bodies in the jurisdiction where the facility is located.
Identify below the licensing boards and evaluating bodies which have approved the clinical
training program, and the dates of their approval.
Licensing Board or Evaluating Body [
Approval Start Date [ ] Approval End Date [ ]
]
Licensing Board or Evaluating Body [
Approval Start Date [ ] Approval End Date [ ]
]
Licensing Board or Evaluating Body [
Approval Start Date [ ] Approval End Date [ ]
]
Check here if students attending your nursing school are eligible to receive a degree in
nursing from the U.S. accredited school of nursing listed above
Check here if you need space to report more than foreign nursing school location and continue on a separate sheet. On the separate
sheet, repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for each
question. Insert continuation sheets following the page where the question is asked.
Section J. Please tell us about your third-party
servicers. ( This includes your Ability
to Benefit Test.)
58
.
If you contract with any third-party servicer to perform any function relating to federal
student financial aid programs, or use an ability to benefit test for students who do not have a high school
diploma or its recognized equivalent, provide the following information about each servicer/tester.
Identify which ability to benefit test you use.
Note: Do not list independent auditors. Also do not list vendors that provide books, forms, or computer programs
(in other words, do not list vendors unless they actually perform services or functions for which you are
responsible under the HEA programs).
Name of servicer’s contact person
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr.)
Job title
Page 37
Section J
Company name
Business street address
City
State (or province) and zip+4 (and country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address (if applicable)
Indicate the service provided:
Performing needs analysis
Authorizing financial aid
Disbursing financial aid
Performing loan servicing
Counseling/providing information for students
Performing loan collection
Preparing/maintaining student aid transcripts
Other (specify)
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet,
repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for
each question. Insert continuation sheets following the page where the question is asked.
Page 38
Section K
Section K. Please assure us of your administrative
capability and your financial responsibility.
Note:
To expand on any of your answers, use Question 69, or explain why the question was not answered.
59.
Do you have a system of internal checks and balances for administering federal student financial
aid that meets federal regulations? (See 34 CFR 668.16.)
Yes
60.
Do you divide the functions of determining student awards and disbursing funds that result from
those award decisions? (See 34 CFR 668.16.)
Yes
61.
Do you have procedures that ensure frequent, periodic reconciliation of fiscal office and financial
aid office award data? (See 34 CFR 668.14, 668.16, 668.24, 674.19, 675.19, 676.19, and 690.81.)
Yes
62.
Do you have a system to identify and resolve discrepancies in information you receive from
various sources about a student’s application for financial aid? (See 34 CFR 668.16.)
Yes
63.
Do you have a policy that meets federal regulations for requiring satisfactory academic progress
for recipients of federal student financial aid? (See 34 CFR 668.16 and 668.34.)
Yes
64.
Do you have procedures that ensure that your requests for federal cash do not exceed the amount
of funds you need immediately to make aid disbursements to students? (See 34 CFR 668.163.)
Yes
65.
Do you have a policy that meets federal regulations for returning Title IV funds when a student
withdraws from classes? (See 34 CFR 668.22.)
Yes
66a. Have you submitted your required annual financial statement audits to us on time? (For
initial applicants, have you established a process to ensure that you submit your required
annual financial statement audit to us on time?) (See 34 CFR 668.23.)
Yes
Page 39
Section K
66b. Have you submitted your required annual federal student financial aid compliance audits to us on
time? (For initial applicants, have you established a process to ensure that you submit your required
annual federal student financial aid compliance audit to us on time?) (See 34 CFR 668.23.)
Yes
67.
Do you use the electronic processess required by the Secretary? (See 34 CF668.16)
Yes
68.
Do you have a process to insure you obtain the necessary approvals from the Department for
expanding or re-establishing your institutional eligibility, (such as changes of ownership
resulting in a change of control, excluded changes in ownership, or adding new locations in
certain circumstances), and that you notify us within 10 days about other important changes
(such as changing your name, address or official)? (See 34 CFR 600.10, 600.20 and 600.21)
Yes
69.
(Optional) Use this area if you need extra space to tell us about any unusual circumstances or to
provide additional explanations about your application.
Check here if you need additional space and continue on a separate sheet. On the separate sheet, repeat the
question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for each
question. Insert continuation sheets following the page where the question is asked.
Page 40
Section K
70 a. (Optional) Provide the following information for any person or firm outside your institution that you
wish to designate as your agent to represent you in matters related to this application.
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr.)
Job Title
Company name
Business street address
City
State (or province) and zip+4 (and country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address (if applicable)
70 b. Who is your institution's destination point administrator (DPA)?
First name, Middle initial, Last name - No Longer Available
(include prefix, such as Mr., Ms., Dr.)
Job Title
Company Name
Business street address
Page 41
Section K
City
country, if outside the U.S.)
State (or province) and zip+4 (and
Telephone number (including area
code)
ext:
Fax number (including area code)
ext:
E-mail address (if applicable)
71. Identify gifts received from or contracts entered into with foreign sources that exceed $250,000
in the calendar year or it is owned or controlled by a foreign source. (Provide conditions or restrictions in
Question 69.
Gift Type
Date received
(mm/dd/yyyy format)
Amount
Giver Name
Country
Contract Start Date
(mm/dd/yyyy format)
Contract End Date
(mm/dd/yyyy format)
Page 42
Section L
Section L. Please have the appropriate person
in authority review, sign, and date
this document.
I hereby certify that, to the best of my knowledge and belief, all information in this document is true and
correct. I understand that if my institution provides false or misleading information, (a) the U.S. Department
of Education may deny the institution’s request for eligibility to participate in federal student financial aid
programs and/or revoke eligibility once it has been granted and (b) the institution may be liable for all
federal student financial aid funds it or its students received. I also understand that I may be subject to a fine
of not more than $25,000 or imprisonment of not more than five years, or both, for misinformation that is
material to receipt and stewardship of federal student financial aid funds.
Signature of President/CEO/Chancellor
Date
Name of institution
Name of President/CEO/Chancellor
Check here if this is the same person as in Question 10. If not, complete the information below.
Job title
Business street address
City
State (or province) and zip+4 (and country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address (if applicable)
Page 43
Section M
Section M. Please include copies of appropriate
documents as part of your application.
Indicate all copies of documents you are including with this application.
Current letter of accreditation and any attachments. (See Question 15) (Please
Note: The accreditation certificate is not sufficient documentation)
Valid state license or other state authorization (See Question 17)
For private nonprofit institutions-501(c)(3) designation from the IRS (See Question 18)
If your institution contracts with an organization or ineligible institution to provide more than 25%
of any educational program-a copy of the approval from your accrediting agency for contracting this
program (See Question 28)
For initial applicants (See Question 35)
Audited financial statements for the (two) most recently completed fiscal year(s)
Default management plan: Either
The default management plan recommended by the Secretary of
Education. (check this box, do not include the plan); or
A default management plan other than the plan recommended by the Secretary of
Education. (check this box, do not include the plan); or
The institution is exempt under 487(a)(14)(C) of the HEA from providing a
default management plan.
For institutions with a change in ownership or structure (See Question 35)
Audited financial statements of the institution's two most recently completed fiscal years that are prepared
in accordance with Generally Accepted Accounting Principles (GAAP) and audited in accordane with
Generally Accepted Government Auditing Standards (GAGAS); and
Audited financial statements of the institution's new owner's two most recently completed fiscal years
that are prepared in accordance with Generally Accepted Accounting Principles (GAAP) and audited
in accordance with Generally Accepted Government Auditing Standards (GAGAS) or equivalent
information for that owner that is acceptable to the Secretary.
Same-day balance sheet, audited in accordance with GAGAS, showing the financial condition of
the institution after the change in ownership.
Default management plan: Either
The default management plan recommended by the Secretary of
Education. (check this box, do not include the plan); or
A default management plan other than the plan recommended by the Secretary of
Education. (enclose a copy of the plan); or
The institution is exempt under 487(a)(14)(C) of the HEA from providing a default
management plan.
Page 44
Section M
For institutions seeking reinstatement (See Question 35)
Audited financial statements for the two most recently completed fiscal years that are prepared
in accordance with Generally Accepted Accounting Principles (GAAP) and audited in
accordance with Generally Accepted Government Auditing Standards (GAGAS).
Default management plan: Either
The default management plan recommended by the Secretary of
Education. (check this box, do not include the plan); or
A default management plan other than recommended by the Secretary of
Education. (enclose a copy of the plan); or
The institution is exempt under 487(a)(14)(C) of the HEA from providing a
default management plan.
For foreign institutions, including foreign graduate medical schools
For private nonprofit institutions-a certified English translation of nonprofit designation status
(See Question 18)
Most recent catalog and its certified English translation of all sections dealing with
degrees and programs provided at your institution (See Section I)
Legal authorization and its certified English translation to provide an educational program beyond
the secondary school level in the country where you are located (See Question 42)
Legal authorization and its certified English translation to award a degree that is equivalent to a
degree awarded in the United States (See Question 43)
Legal authorization and its certified English translation to provide graduate medical education
(See Question 49)
In addition, if a foreign institution is an initial applicant
Audited financial statements for the two most recent years
Default management plan: Either
The default management plan recommended by the Secretary of Education. (check this
box, do not include the plan); or
A default management plan other than the plan recommended by the Secretary of
Education. (enclose a copy of the plan); or
The institution is exempt under 487(a)(14)(C) of the HEA from providing a
default management plan.
Page 45
Section M
For institutions applying for Comprehensive Transition and Postsecondary Programs(See Question 26k)
A detailed description of your comprehensive transition and postsecondary program addressing
all of the components of the program as defined in 34 C.F.R 668.231
A copy of your institution's Satisfactory Academic Progress policy for the
comprehensive transition and postsecondary program
A copy of the notification to your primary accreditor that your institution is providing
a comprehensive transition and postsecondary program
Paperwork Reduction Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is
1845-0012. The time required to complete this information collection is estimated to average 17 hours per response,
including the time to review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have any comments concerning the accuracy of the time estimate or
suggestions for improving this form, please write to: U.S. Department of Education, 830 First Street, NE,
Washington, DC 20002-5402. If you have comments or concerns regarding the status of your individual
submission of this form, write directly to: School Participation Management Division, U.S. Department of
Education, 830 First Street, NE, Washington, DC 20002-5402.
Page 46
| File Type | application/pdf |
| Author | Authorised User |
| File Modified | 2010-10-27 |
| File Created | 2010-10-27 |