Form NHSC_SP_001

OMB #: 0915-0146

Expiration Date: 02/28/2011

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 0915-0146. Public reporting burden for this collection of information is estimated to average 4 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

HOW TO APPLY

APPLICATION AND PROGRAM GUIDANCE

Please read the Application and Program Guidance (Guidance) in its entirety before proceeding with an application. The Guidance explains in detail the rights and obligations of individuals selected to participate in the NHSC SP. Be sure you have a complete understanding of the obligation to serve full-time for a minimum of 2 years (maximum of 4 years) at an NHSC-approved site and the financial consequences of failing to perform that obligation.

Applicants may want to keep a copy of the application package for their records.

APPLICATION DEADLINE

The online application must be submitted by 5:00 PM ET on June 1, 2011. All Supporting Documentation must be uploaded by 5:00 pm ET on May 31, 2011 or postmarked, if mailed, by June 1, 2011.

The Associate Administrator, BCRS, or his/her designee, may authorize an extension of published deadlines when justified by circumstances such as acts of nature (e.g., floods or hurricanes), widespread disruptions of mail service, or other disruptions, such as a prolonged blackout. The authorizing official will determine the affected geographical area(s) and the length of the extension granted.

COMPLETING AN APPLICATION

The NHSC SP application consists of two parts:

1. An online application and,

2. Required supporting documentation

1. ONLINE APPLICATION

The online application contains the following sections. Applicants are required to complete each of the sections below to be able to submit an online application.

1. Eligibility Screening

If an individual does not pass the initial screening portion of the online application he/she will not be able to continue with the application.

Please refer to the Eligibility Requirements section of this Guidance for further details.

2. General Information

Answers to this section pertain to the applicant’s name, social security number, mailing and email addresses, and other contact information.

3. Degree Information

Answers to this section should pertain only to the degree or certificate program for which applicants are applying for an NHSC Scholarship.

4. Background Information

Answers to this section pertain to the educational background, individual and family background, and emergency contact information.

5. Curriculum Vitae (CV) and Essays

Please do not mail in separate documentation for the CV and Essays. This information must be incorporated in the online application.

i. Curriculum Vitae (CV): An Applicant’s CV should outline relevant work/volunteer experience and should be no more than 5 pages long. CVs must be uploaded.

ii. Essays: Applicants are required to respond to the following three essay questions. Each response should be limited to 2,500 characters or less (about a half of a page). It is suggested that applicants create essays in a Word document and cut and paste them into the box provided. Applicants may also type directly into the text box.

1. How will you contribute to the mission of the National Health Service Corps in providing care to underserved communities?

2. What experiences have you had or activities have you participated in that have prepared you to work with underserved populations?

3. Please discuss your commitment to pursue a career in primary health care.

6. Submit Application

It is required that the information in the online application match the submitted supporting documentation. Application packages will be initially reviewed to determine their completeness. Application packages deemed incomplete (e.g., missing, illegible, or incomplete application materials) deadline will not be considered for funding.

NHSC SP will not accept requests for updates to a submitted application, nor the submission/resubmission of incomplete, rejected or otherwise delayed application materials after the deadline. In addition, the NHSC SP staff will not fill in any missing information or contact applicants regarding missing information.

No changes will be accepted to applicant’s choice of school or discipline entered on the submitted application prior to award. Awardees’ who elect to enter a different school and/or program after the application deadline should contact the NHSC SP immediately. .

REQUIRED SUPPORTING DOCUMENTATION

It is the applicant’s responsibility to upload, by 5:00 pm ET, or postmark, if mailed, required supporting documents by June 1, 2011. Failure to submit a complete application package by the deadline will deem the applicant ineligible and he or she will not be considered for an NHSC SP award.

Each document must be submitted with the applicant’s First Name, Last Name, Discipline and last 4 digits of social security number. Do not upload a document online and then mail the same document. Do one or the other but not both.

Applicant can either mail or upload, by 5:00 pm ET June 1, 2011, the following documents:

i. Proof of Citizenship

ii. Signed Copy of the Submitted Application

iii. Authorization to Release Information Form

Please mail the documents to:

HRSA Call Center
C/O NHSC Scholarship Program Application
12530 Parklawn Drive, Suite 350
Rockville, MD 20852

1. Proof of Status as a U.S. Citizen or U.S. National

Proof of U.S. citizenship or U.S. national status may include a birth certificate issued by a city, county or state agency in the U.S, the ID page of a U.S. passport, or a certificate of citizenship or naturalization.

2. A Signed Copy of the Submitted Application

Upon submission of the online application, a PDF copy of the application will be made available on the Supporting Documentation page. Applicants can view this document by clicking on the Signed Copy of Submitted Application. Applicants must submit a signed copy. This is a required document for all applicants

3. Authorization to Release Information Form

Authorizes entities identified in the form to disclose information regarding applicants and participants.

The following documents must be mailed:

1. Verification of Acceptance/Good Standing

2. Academic Letter or Recommendation

3. Non-Academic Letter of Recommendation

4. Transcript

5. Tuition and Fee Schedule

4. Verification of Acceptance/Good Standing Report

No applicant will receive an award until he or she is enrolled or accepted for full-time enrollment in a fully accredited program during the 2011-2012 school year (applicant must begin classes by September 30, 2011). Each applicant is required to submit a report from the school verifying his or her acceptance or enrollment in good standing. The verification report must bear the training institution’s raised seal or stamp. Faxes or photocopies are not acceptable. The school identified in the Verification of Acceptance/Good Standing Report will be the applicant’s “initial school of record.”

If this document states that there are conditions (not yet fulfilled) for acceptance into the school and/or program, other than standard contingencies that apply to all admitted applicants, applicants will not be eligible for consideration for an award for the 2011-2012 school year, unless all contingencies or conditions for acceptance are removed and documented in writing by the start of the school year.

5. Academic Letter of Recommendation

If the applicant is currently enrolled in the health professions training program, the letter should be from the Department Chair, faculty advisor or a faculty member of that academic program who is familiar with the student. If the applicant has not begun the training associated with the scholarship, the letter should be from the Department Chair, faculty advisor, or a faculty member of the applicant’s most recent academic program who is familiar with the applicant. The letter should include the information described in the “Academic Official’s Evaluation Letter – Instructions.” (link)

6. Non-Academic Letter of Recommendation

The letter should be from an individual who is familiar with the applicant’s professional, community, and/or civic activities, especially those related to underserved communities. The evaluator can be an employer or previous employer, community leader, colleague, or anyone who has knowledge of the applicant’s interest and motivation to provide care to underserved communities. The letter should include the information described in the “Non-Academic Evaluation Letter – Instructions.” (link)

7. Transcript

Each applicant must include a transcript from his/her current educational institution or, if not currently attending an educational institution, a transcript from the last educational institution he/she attended. An unofficial transcript is acceptable.

8. Tuition and Fees Schedule

A tuition and fees schedule for the 2011 - 2012 school year or, if not yet available, the most recent tuition and fees schedule published by the school in the school catalog or on its website.

ADDITIONAL SUPPORTING DOCUMENTATION

Based on applicant’s responses to the online application, the following documents will be required to be submitted. Only applicants who have these documents listed on their Supporting Documents page of the online application should submit them. These documents will be added to their Supporting Documents list once the online application has been submitted.

Each document must include the applicant’s First Name, Last Name, Discipline and last 4 digits of social security number and be postmarked by June 1, 2011.

These documents cannot be uploaded. Please mail the documents to:

HRSA Call Center
C/O NHSC Scholarship Program Application
12530 Parklawn Drive, Suite 350
Rockville, MD 20852

1. Verification of Exceptional Financial Need (EFN) Status

This document certifies that the applicant has participated in the EFN Program. This applies only to medical and dental students.

2. Verification of Disadvantaged Background

This document certifies that the applicant comes from a disadvantaged background and either participated in or would have been eligible to participate in Federal programs such as “Scholarships for Disadvantaged Students,” “Loans to Disadvantaged Students,” or the “Nursing Workforce Diversity Grant Program.”

3. Power of Attorney

This document is required if the application is completed on behalf of the applicant by someone else.

APPLICANTS ARE RESPONSIBLE FOR SUBMITTING A COMPLETE APPLICATION

It is required that the information in the online application match the submitted supporting documentation. Application packages will be initially reviewed to determine their completeness. Application packages deemed incomplete (e.g., missing, illegible, or incomplete application materials) as of the application deadline will not be considered for funding.

The NHSC SP will not accept requests for updates to a submitted online application (other than name, phone number, home and email address updates), or accept the submission/resubmission of incomplete, rejected or otherwise delayed application materials after the application deadline. In addition, the NHSC SP staff will not fill in any missing information or contact applicants regarding missing information.

No changes will be accepted to an applicant’s choice of school or discipline entered on the submitted application prior to award. Applicants who elect to enter a different school and/or program after the application deadline should contact the NHSC SP immediately.

APPLICATION STATUS

2. Online Application

Applicants will receive a receipt of submission once the application has been successfully submitted online. Applicants can verify that sections of the application are complete when there is a checkmark by each on the status page.

3. Supporting Documents

Please allow at least 30 business days for the NHSC SP to review your documentation and update the status of documents that are mailed. Once supporting documents have been processed the status of that document will be labeled "Received."

4. Application Review

Application packages are ready for review when the online application has been submitted and each supporting document has a status of “Received”. The application review process occurs over several months. We will be providing email updates, as applicable, as well as updates on the Status page of the online application. It is the responsibility of the applicants to ensure their contact information is correct and current.

AWARD RECIPIENTS

NOTIFICATION

5. Selection for an NHSC SP Award

1. Individuals selected for awards will be notified by email/letter, no later than September 30, 2011.

2. To accept the award, applicants must respond by the deadline in the notice of award email/letter. If the applicant does not respond to the NHSC SP by that deadline, the offer of award expires and the award will be offered to an alternate.

3. Individuals selected for an award must be enrolled as a full-time student during the 2011-2012 school year and full-time class attendance must begin on or before September 30, 2011.

d Eligible individuals who do not receive a scholarship award will be notified no later than October 31, 2011.

6. Declining Scholarship Support

Applicants who will not begin classes on or before September 30, 2011, including applicants who will be on a leave of absence from school through September 30, 2011, must decline the award. All other applicants may decline awards. The declination of an award is without penalty, and permits the promotion of alternates to selectee status.

Once an applicant declines the offer of award, the award will be offered to an alternate. There will be no opportunity to reclaim the award. A decision to decline the scholarship award is final and cannot be changed under any circumstances.

NATIONAL HEALTH SERVICE CORPS SCHOLARSHIP PROGRAM

School Year 2011-2012 Application Supporting Documents

To apply to the National Health Service Corps Scholarship Program, you need to submit the online application at https://healthcareheroes.hrsa.gov/nhscsp/ AND either mail or upload by 5pm ET June 1, 2011 the forms and documents as directed in the “How to Apply” section of the Application and Program Guidance.

DO NOT upload AND mail a copy of your application and required documents. Duplicate documents may result in a delay in processing your application and possible non-award due to insufficient funds.

Documents that must be mailed should be sent to:

HRSA Call Center
C/O NHSC Scholarship Program Application
12530 Parklawn Drive, Suite 350
Rockville, MD 20852

Have Questions? Call 1-800-221-9393 (TTY: 1-877-897-9910)

Monday through Friday (except Federal Holidays) 9:00 am to 5:00 pm ET

Email Address: [email protected]

NATIONAL HEALTH SERVICE CORPS SCHOLARSHIP PROGRAM

AUTHORIZATION TO RELEASE INFORMATION

If I become a participant in the National Health Service Corps (NHSC) Scholarship Program, I,

__________________________________________________________, hereby authorize:

(Print Name - First, Middle Initial, Last)

1. The school where I am/was enrolled while participating in the NHSC Scholarship Program to disclose information pertaining to my school enrollment to the Department of Health and Human Services (DHHS), and/or its contractors. Information pertaining to my school enrollment includes, but is not limited to, my transcripts and grades, academic standing, enrollment and degree status, curriculum and examination requirements for graduation, tuition and fees, leave-of-absence, withdrawal, or dismissal from school. This information will be used by DHHS to determine my eligibility to continue to receive scholarship benefits and the amount of those benefits.

2. If applicable, I hereby authorize any post-degree advanced training program(s), for which I receive a deferment (i.e., approval) from DHHS to complete, to disclose to DHHS, and/or its contractors, information pertaining to my participation in the post-degree advanced training program(s) including, but not limited to, my curriculum and examination requirements, status in the program, completion date, leave-of-absence, withdrawal or dismissal from the program.

3. The entity/entities where I am/was approved to provide service in satisfaction of my NHSC Scholarship Program obligation to disclose to DHHS, and/or its contractors, information pertaining to my compliance with the NHSC scholarship service requirements. Such information includes, but is not limited to, my practice location(s), practice responsibilities, work schedule or other documentation indicating the hours that I worked and the hours I was away from the site, records relating to my work performance and (if applicable) the circumstances relating to the termination of my employment at the service location.

The above authorizations take effect on the date that I become a participant in the NHSC Scholarship Program and shall remain in effect until the date my NHSC scholarship commitment has been fulfilled.

In addition, I hereby authorize the DHHS, and/or its contractors, to release my name, address(es) and social security number to see if I appear on the Excluded Parties List System. This authorization takes effect on the date I sign this release form. If I do not become a participant, this authorization shall remain in effect until September 30, 2011.

These authorizations may be revoked by me in writing at any time.

____________________________________ ____________

(Signature of Individual) (Date) (Last 4 Digits of

Social Security Number)

Return to:

NHSC Scholarship Program

c/o HRSA Call Center

12530 Parklawn Drive, Suite 350

Rockville, Maryland 20852

Must be received or postmarked by June 1, 2011

National Health Service Corps

Scholarship Program

U.S. Department of Health and Human Services

Health Resources and Services Administration

VERIFICATION OF ACCEPTANCE/GOOD STANDING REPORT

(For School Use Only)

This Verification of Acceptance/Good Standing Report certifies that the student identified below has been accepted for admission or is enrolled in good standing for the 2011-2012 academic year as indicated.

1. Student’s Name (Last, First, Middle) 2. Student’s Social Security Number (Last 4 digits)
   
   

3. Program the student is admitted to/enrolled in good standing

4. Degree/certificate student will receive upon completion of the program

5. Student classification as of the 2011-2012 school year

1^st 2^nd  3^rd 4^th 5^th 6^th

6. If the student is newly enrolled, is there a contingency to the student’s acceptance to the program other than standard contingencies that apply to all admitted applicants? Examples include the student needing to repeat a course or the student receiving an “Incomplete” status for a course. Yes No

If YES, please explain:
(All contingencies must be met by June 30, 2011)

7. Student Status (check all that is applicable):

Full-Time Enrollment Part-Time Enrollment  Repeating Course Work

Leave of Absence Withdrawn  Other (Please explain): ­

8. What schedule does the academic year operate on?

Semester system Quarter system  Trimester system  Other (Please explain):

9. Length of the full-time program (months or years):

10. Date student began the program (mm/yyyy):

11. Date class begins for the academic year 2011-2012 (mm/yyyy):

12. Anticipated date of graduation (mm/yyyy):

me

By signing my name below, I certify that the current status of the student listed above has been correctly identified. I further certify that, where necessary, I have corrected the “Year in Program” and “Date of Graduation” for the student to accurately reflect the anticipated graduation date given the current enrollment. I understand that false information may be punishable as a felony under U.S. Code, Title 18, Section 1001.

SUBMITTED BY:

Signature & Date:

Name & Title:

Phone Number:

E-Mail Address:

Name of School:

THIS REPORT MUST HAVE THE SCHOOL’S RAISED SEAL OR STAMP ON IT TO BE ACCEPTED. Must be received or postmarked by June 30, 2011

Mail to: NHSC Scholarship Program

c/o HRSA Call Center, 12350 Parklawn Drive, Suite 350, Rockville, Maryland 20852

NATIONAL HEALTH SERVICE CORPS SCHOLARSHIP PROGRAM

ACADEMIC OFFICIAL’S EVALUATION LETTER - INSTRUCTIONS

If the applicant is currently enrolled in the health professions training program, the letter should be from the applicant’s Department Chair, Faculty advisor or a faculty member of that academic program who is familiar with the student. If the applicant has not begun the training associated with the scholarship, the letter should be from the Department Chair, Faculty advisor, or a faculty member of the applicant’s most recent academic program who is familiar with the applicant.

The letter should include the following:

Student’s name;

Last 4 Digits of Social Security Number;

Student’s discipline;

A description of the Academic official’s relationship to the applicant and the length of time the official has known the applicant;

A discussion of the following points:

1. The applicant’s education/work achievements,

2. The applicant’s ability to work and communicate constructively with other people, and

3. The official’s assessment of the applicant’s particular characteristics, interest and motivation to serve populations in areas of greatest need in health professional shortage areas. This assessment should include the evaluator’s knowledge of the applicant’s work experiences, pertinent course work, special projects, research, or other activities that demonstrate an interest in and commitment to serving underserved populations.

Evaluator’s Name (Printed)

Title

Address (unless already on letterhead)

Signature

This letter should be on the institution’s letterhead and must be submitted in a sealed envelope with the evaluator’s signature across the seal.

This letter must be received or postmarked by June 1, 2011. It should be mailed to the following address:

NHSC Scholarship Program

c/o HRSA Call Center

12530 Parklawn Drive, Suite 350

Rockville, Maryland 20852

NATIONAL HEALTH SERVICE CORPS SCHOLARSHIP PROGRAM

NON-ACADEMIC EVALUATION LETTER - INSTRUCTIONS

The Non-Academic Evaluation Letter should be from an individual who is familiar with the applicant’s professional, community, and/or civic activities, especially those related to underserved communities. The evaluator can be an employer or previous employer, community leader, colleague, or anyone who has knowledge of the applicant’s interest and motivation to provide care to underserved communities.

The letter should include the following:

Student’s name;

Last 4 Digits of Social Security Number;

Student’s discipline;

A description of the Individual’s relationship to the applicant and the length of time he or she has known the applicant;

A discussion of the following points:

1. The applicant’s community/civic or other non-academic achievements,

2. The applicant’s ability to work and communicate constructively with other people, and

3. The official’s assessment of the applicant’s particular characteristics, interest and motivation to serve populations in areas of greatest need in health professional shortage areas. This assessment should include the evaluator’s knowledge of the applicant’s, work experiences, pertinent course work, special projects, research, or other activities that demonstrate an interest and commitment to serving underserved populations.

Evaluator’s Name (Printed)

Title or Organization

Address (unless already on letterhead)

Signature

If the letter is from an individual representing a particular organization or institution, the letter should be on official letterhead. The letter must be submitted in a sealed envelope with the evaluator’s signature across the seal.

This letter must be received or postmarked by June 1, 2011. It should be mailed to the following address:

NHSC Scholarship Program

c/o HRSA Call Center

12530 Parklawn Drive, Suite 350

Rockville, Maryland 20852

RECEIPT OF EXCEPTIONAL FINANCIAL NEED SCHOLARSHIP

(For School Use Only – Must be Completed by Financial Aid Official)

Mail to: NHSC Scholarship Program

c/o HRSA Call Center

12350 Parklawn Drive, Suite 350

Rockville, Maryland 20852

Name of Student: ______________________________________________________

Last 4 digits of the Student’s Social Security Number: ________________________________________

The below-identified Financial Aid Official certifies that the above-named student

 has received

 has not received

a Scholarship for Students of Exceptional Financial Need (EFN) under former section 758 of the Public Health Service Act (applicable to medical and dental students only).

SUBMITTED BY:

Signature & Date: ____________________________________________________

Name: _____________________________________________________________

Title & Phone Number: ________________________________________________

E-Mail Address: _____________________________________________________

Name of School: _____________________________________________________

Must be received or postmarked by June 1, 2011.

VERIFICATION REGARDING DISADVANTAGED BACKGROUND

(For School Use Only – Must be Completed by Financial Aid Official)

Mail to: NHSC Scholarship Program

c/o HRSA Call Center

12350 Parklawn Drive, Suite 350

Rockville, Maryland 20852

Name of Student: ______________________________________________________

Last 4 digits of the Student’s Social Security Number: ________________________________________

The below-identified Financial Aid Official certifies that the above-named student

 is

 is not

from a disadvantaged background (criteria described on page 2) and either participated in or would have been eligible to participate in Federal Programs such as the “Scholarships for Disadvantaged Students,” “Loans to Disadvantaged Students” or the “Nursing Workforce Diversity Grant Program.”

SUBMITTED BY:

Signature & Date: __________________________________________________________

Name: ___________­________________________________________________________

Title & Phone Number: ______________________________________________________

E-Mail Address: ___________________________________________________________

Name of School: ___________________________________________________________

Must be received or postmarked by June 1, 2011

CRITERIA FOR DISADVANTAGED BACKGROUND STATUS

Students are deemed eligible for the Scholarships for Disadvantaged Students, Loans to Disadvantaged Students, and Nursing Workforce Diversity Grant Programs if they meet the following Disadvantaged Background criteria:

1. Come from an environment that has inhibited them from obtaining the knowledge, skills, and abilities required to enroll in and graduate from a health professions or nursing school (Educationally Disadvantaged). The following are provided as examples of “Educational Disadvantages” for guidance only and are not intended to be all-inclusive. Applicants should seek guidance from their educational institution as to how “Educationally Disadvantaged” is defined by their institution.

Examples:

• Person from high school with low average SAT/ACT scores or below the average State test results.

• Person from a school district where 50 percent or less of graduates go to college.

• Person who has a diagnosed physical or mental impairment that substantially limits participation in educational experiences.

• Person for whom English is not his or her primary language and for whom language is still a barrier to academic performance.

• Person who is first generation to attend college.

• Person from a high school where at least 30 percent of enrolled students are eligible for free or reduced price lunches.

OR

2. Come from a family with an annual income below a level based on low-income thresholds established by the U.S. Census Bureau, adjusted annually for changes in the Consumer Price Index (Economically Disadvantaged).

The Secretary defines a ‘‘low income family’’ for various health professions and nursing programs included in Titles III, VII and VIII of the Public Health Service Act as having an annual income that does not exceed 200 percent of the Department’s poverty guidelines. A family is a group of two or more individuals related by birth, marriage, or adoption who live together or an individual who is not living with any relatives.