Form lrp checklist lrp checklist lrp checklist

OMB No. 0915-0127

Expiration Date:

THE NATIONAL HEALTH SERVICE CORPS

LOAN REPAYMENT PROGRAM APPLICATION

CHECKLIST

You must initial each item on this Checklist, and sign and date the Checklist below. Your signature indicates that you have read this Bulletin and that you understand all items required by the application. Return the Checklist with your application. Keep a copy of the application package for your records, and submit the original. No application materials will be returned to applicants.

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0127. Public reporting burden for this collection of information is estimated to average 12 minutes per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33 Rockville, Maryland, 20857.

* Indicates item must postdate October 1, 2006

1. *Completed Application (bubble form) for National Health Service Corps (NHSC) Loan Repayment Program (LRP), (due by March 30, 2007 postmark date).

2. *Completed Loan Information and Verification Forms for each loan for which you are seeking repayment assistance from the NHSC LRP (submitted with application by March 30, 2007 postmark date).

3. *Completed Payment Information Form (submitted with application by March 30, 2007 postmark date).

4. *Completed NHSC LRP Community Site Information Form (submitted with application by March 30, 2007 postmark date).

5. *Completed Authorization to Release Information Form (submitted with application by March 30, 2007 postmark date).

6. *Signed and dated NHSC Loan Repayment Program Contract (submitted with application by March 30, 2007 postmark date).

7. Copy of your health professional degree or certificate. If a copy of your degree or certificate cannot be supplied when the application is submitted, you must submit a copy of this document by no later than July 2, 2007 (postmark date).

8. Copy of your permanent license in the State in which you intend to practice. If you have not received your license by the time you submit your application, you must submit a copy of your permanent license, postmarked by no later than July 2, 2007. If your license has restrictions, you must also submit a statement explaining the restrictions on your license. (Marriage and Family Therapists and Licensed Professional Counselors who are not required to have a license in the State in which they intend to practice must also submit a copy of their license to practice independently and unsupervised from another State. If such license has not been received by the time the application is submitted, a copy of the license must be submitted by no later than July 2, 2007 (postmark date).)

9. *Copies of the FINAL "Response to Information Disclosure Request" you obtain from the National Practitioner Data Bank (NPDB) and the Healthcare Integrity and Protection Data Bank (HIPDB). To obtain these reports, see http://www.npdb-hipdb or call 1-800-767-6732. If the "Response to Information Disclosure Request" cannot be supplied when the application is submitted, the applicant must submit copies of the FINAL NPDB and HIPDB reports to the NHSC LRP by no later than July 2, 2007 (postmark date). These documents cannot be dated prior to

October 1, 2006.

10. *Letters of reference from at least two individuals (including your current employer unless you are self-employed) who are in a position to evaluate your current clinical skills. If you are self-employed, one of the reference letters must be from the chief of the medical staff or the credentials committee at the hospital where you have admitting privileges (if you are a physician), or from an objective source such as a hospital or clinic credentials committee, a physician with whom you have a collaborative practice agreement, or the director of your training program (if you are not a physician). If you are a student or in a residency program, one reference letter can be from the director of your training program. These documents must be submitted no later than March 30, 2007 postmark date.

Reference letters must be written on letterhead and include the following: a statement of the writer's relationship to you; an evaluation of your current clinical skills; the length of time the writer has known you in a professional capacity; and the writer's typed or printed name and telephone number. These documents cannot be dated prior to

October 1, 2006.

11. Poof of U.S. citizenship or status as a U.S National. All applicants must be citizens or nationals of the United States, Commonwealth of Puerto Rico, U.S. Virgin Islands, Territory of Guam, Territory of American Samoa or Swain’s Island. Acceptable documents for proof of citizenship/national are a copy of birth certificate, a certificate of citizenship, passport or naturalization certificate (submitted with application by March 30, 2007 postmark date).

12. Power-of-Attorney (applicable if you are completing the application on behalf of another person) (submitted with application by March 30, 2007 postmark date).

13. Signed and dated Biographical Statement (submitted with application by March 30, 2007 postmark date)

14. Copy of your specialty board certification or residency completion certificate (applicable to physicians). If a copy of your specialty board certification or residence completion certificate cannot be supplied when the application is submitted, you must submit copies of the board certification or completion certificate by no later than July 2, 2007 (postmark date).

15. Copy of your national certification (applicable to PAs, NPs, NMs, LPCs and some PNSs), or professional association membership (applicable to some MFTs). If copies of these documents cannot be supplied when the application is submitted, you must submit copies of these documents by no later than July 2, 2007 (postmark date).

16. Copy of your national board/licensing examination results (applicable to SWs, CPs, and DHs). If copies of these documents cannot be supplied when the application is submitted, you must submit copies of these documents by no later than July 2, 2007 (postmark date).

17. Copy of your current curriculum vitae/resume (submitted with application by March 30, 2007 postmark date).

18. Letter from entity to which existing service obligation is owed indicating that the obligation will end on or before September 29, 2007 (applicable to applicants with existing service obligations) submitted with application by March 30, 2007. You must subsequently submit a letter from the entity verifying that your service obligation has been completed (except if your existing service obligation is under the NHSC Scholarship Program).

19. Documentation of status as a member of a Reserve Component of the Armed Forces (applicable to applicants who are reservists) (submitted with application by March 30, 2007 postmark date).

20. Proof of disadvantaged background from school official (where applicable – submitted with application by March 30, 2007 postmark date).

21. Proof of exceptional financial need (EFN) scholarship (MDs, Dos, and dentists, where applicable) (submitted with application by March 30, 2007 postmark date).

22. Copies of the original loan applications, promissory notes, agreements or statements from the current lender indicating the amount, date of original disbursement, and type of loan (submitted with application by March 30, 2007 postmark date).

23. I know the current health professional shortage area (HPSA) score for the community site in which I am interested. I understand a funding preference will be given to applicants serving in HPSAs of greatest need (based on the HPSA scores). I understand the HPSA score on the date my application is submitted (i.e., date received by the NHSC LRP) will be used for the FY 2007 award process. I understand awards will be made on an ongoing basis to eligible applicants with complete applications who propose to serve an NHSC community with a HPSA score of 17 or above. I understand eligible applicants with complete applications who propose to serve an NHSC community with a HPSA score of less than 17 will not be funded until after March 30, 2007, and will be funded after that date, by decreasing HPSA score, only to the extent funding remains available.

24. I understand that it is my responsibility to submit a complete application. I understand that my complete application must be submitted by no later than March 30, 2007 (postmark date), except that certain items (described above) which will not be available by March 30, 2007, must be submitted by no later than July 2, 2007 (postmark date). If my application is incomplete when initially submitted (except as noted above), I will not be considered for an FY 2007 NHSC LRP contract award. Incomplete applications will not be reconsidered.

25. I understand that an NHSC LRP contract award cannot be part of my employment contract. Community sites do not have any authority to guarantee an NHSC LRP contract award.

26. I understand that the NHSC LRP contract is not in effect until it is countersigned by the Director of Division of National Health Service Corps. I also understand that any practice at the NHSC community site before the contract takes effect is not eligible for NHSC loan repayments and will not count as NHSC service.

27. *Initialed, signed, and dated Checklist.

I have read and understand the items on this Checklist

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Name (Please Print) Date Signature