Form NHSC_SP_004 Six-Month Service Obligation Verification Form

O.M.B.: 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 .50 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.

National Health Service Corps

Six-Month Verification Form

This document is to verify that you worked at the site(s) listed below during the period ________ through ________. To ensure that you receive service credit, please return this form no later than ________ by faxing it to: RTSC/NHSC at 1-800-718-2539.

Name:

SSN: XXX-XX-

Current Phone:

Current Address:

Service Status:

Years Obligated:

Projected Obligation End Date:

Discipline/Specialty:

Assignment:

Current Service Site:

Current Service Site Address:

Current Work Phone:

Service Site UDS Number:

Additional Service Site(s) & Addresses (if any):

Corrections to Service Site Information (if any):

If the site(s) named above is (are) not the practice site listed on your Employment Verification Form, please provide the name, address, and telephone of your current practice site(s):

Please check/complete the certifications that apply below:

• I certify that I engaged in full-time clinical practice, as defined in “Clinical Practice Definitions.”

• I certify that I engaged in half-time clinical practice, as defined in “Clinical Practice Definitions.”

• I certify that during the period specified above, due to holidays, vacation, CPE/CME, site closures, illness, or other reasons, I was absent from the approved service site(s) for _____ days

  • For purposes of reporting days on this form, full-time participants should report 1 day for every 8 hours of absence; half-time participants should report 1 day for every 4 hours of absence.

  • Participants must only report absences that cause a participant’s work hours to fall below the required minimum number of hours per week (40 hours for full-time; 20 hours for half-time); (see Clinical Practice Definitions).

Signature (I certify that all the information above is correct.) Date

NOTE: Do not leave your site until you have called the DPO at 1-800-221-9393 to verify you have completed your service obligation.

TO BE COMPLETED BY SITE EXECUTIVE DIRECTOR OR DESIGNEE

I have reviewed this form. To the best of my knowledge this information is correct.

Signature Date

Printed Name Title

If any information on this form is incorrect, please correct it and provide comments below:

CLINICAL PRACTICE DEFINITIONS

Full-Time Clinical Practice. Clinician works a minimum of 40 hours per week, for a minimum of 45 weeks per service year.

• All Health Professionals, except as noted below:

At least 32 hours/week are spent providing direct patient care or teaching in the outpatient ambulatory care setting(s) at the approved service site(s) during normally scheduled office hours. The remaining 8 hours/week are spent providing clinical services for patients or teaching at the approved site(s), providing clinical services in alternative settings (e.g., hospitals, nursing homes, shelters) as directed by the approved site(s), or performing practice-related administrative activities. Practice-related administrative activities shall not exceed a total of 8 hours/week.

Teaching activities at the approved site(s) shall not exceed 8 hours/week, unless the teaching takes place in a Teaching Health Center. Teaching activities in a Teaching Health Center shall not exceed 20 hours/week.

• OB/GYNs, Certified Nurse Midwives, Family Medicine Physicians who practice obstetrics on a regular basis, providers of geriatric services, and pediatric dentists:

At least 21 hours/week are spent providing direct patient care or teaching in the outpatient ambulatory care setting(s) at the approved service site(s) during normally scheduled office hours. The remaining 19 hours/week are spent providing clinical services for patients or teaching at the approved site(s), providing clinical services in alternative settings (e.g., hospitals, nursing homes, shelters) as directed by the approved site(s), or performing practice-related administrative activities. Practice-related administrative activities shall not exceed a total of 8 hours/week.

Teaching activities at the approved site(s) shall not exceed 8 hours/week, unless the teaching takes place in a Teaching Health Center. Teaching activities in a Teaching Health Center shall not exceed 20 hours/week.

• Behavioral and mental health providers:

At least 21 hours/week are spent providing direct patient care (direct patient counseling) in the outpatient ambulatory care setting(s) at the approved service site(s) during normally scheduled office hours. The remaining 19 hours/week are spent providing clinical services for patients or teaching at the approved site(s), providing clinical services in alternative settings as directed by the approved site(s), or performing practice-related administrative activities. Practice-related administrative activities shall not exceed a total of 8 hours/week.

Teaching activities at the approved site(s) shall not exceed 8 hours/week, unless the teaching takes place in a Teaching Health Center. Teaching activities in a Teaching Health Center shall not exceed 20 hours/week.

Half-Time Clinical Practice. Clinician works a minimum of 20 hours per week, but not exceeding 39 hours per week, for a minimum of 45 weeks per service year.

• All Health Professionals, except as noted below:

At least 16 hours/week are spent providing direct patient care in the outpatient ambulatory care setting(s) at the approved service site(s) during normally scheduled office hours. The remaining 4 hours/week are spent providing clinical services for patients or teaching at the approved site(s), providing clinical services in alternative settings (e.g., hospitals, nursing homes, shelters) as directed by the approved site(s), or performing practice-related administrative activities. Teaching and practice-related administrative activities shall not exceed a total of 4 hours/week.

• OB/GYNs, Certified Nurse Midwives, Family Medicine Physicians who practice obstetrics on a regular basis, providers of geriatric services, pediatric dentists, and behavioral and mental health providers:

At least 11 hours/week are spent providing direct patient care in the outpatient ambulatory care setting(s) at the approved service site(s) during normally scheduled office hours. The remaining 9 hours/week are spent providing clinical services for patients or teaching at the approved site(s), providing clinical services in alternative settings (e.g., hospitals, nursing homes, shelters) as directed by the approved site(s), or performing practice-related administrative activities. Teaching and practice-related administrative activities shall not exceed a total of 4 hours/week.

• Behavioral and mental health providers:

At least 11 hours/week are spent providing direct patient care (direct patient counseling) in the outpatient ambulatory care setting(s) at the approved service site(s) during normally scheduled office hours. The remaining 9 hours/week are spent providing clinical services for patients or teaching at the approved site(s), providing clinical services in alternative settings as directed by the approved site(s), or performing practice-related administrative activities. Teaching and practice-related administrative activities shall not exceed a total of 4 hours/per week.