Form 4 Survey of NHSC Alumni (LRP)

2011 Survey of NHSC Alumni from the Late 1990s
This questionnaire is intended for you as a clinician of any discipline if you served in the National Health Service Corps in
the late 1990s. We want to hear from you whether or not you completed your NHSC service and regardless of where you
have worked since. We seek to learn where people’s careers have taken them over the past ten years.
If you were not in the NHSC in the late 1990s, either in the Scholarship or Loan Repayment Program, please check the box
below and you do not need to complete the rest of the questionnaire but please mail it back to us in the enclosed envelope.
□ I was not serving in the NHSC in the late 1990’s
Any explanation/elaboration? __________________________________________________________________
__________________________________________________________________

All others please complete the questionnaire. Thank You!
Use of identifiers and Reporting Burden
The information you provide will not be revealed to the NHSC or to others in any way that can be linked to you, your community or
practice. All information provided will be handled anonymously and reported in aggregate. The identification number shown on this page
only allows us to keep track of the questionnaires as they are returned.
Public reporting burden for this collection of information is estimated to average 9 minutes. The OMB control number for this project is
XXX, expiration XX.

1. Did you complete your NHSC contract (service obligation) by providing clinical service in a NHSC site?
1. Yes  If “yes”, when did you complete your contract/service (including after any new or
“amendment” contracts with the NHSC Loan Repayment Program)?
Month: _________ Year: _________
0. No  If no, did you . . .
a.
b.
c.
d.

(check one box)

buy out of all or part of your contract?
default on all or part of your contract?
receive a waiver from the NHSC for all or part of your contract?
other? Please explain: ______________________________

2. After completing your original NHSC contract, did you sign a new or “amendment” contract with the
NHSC Loan Repayment Program?
1. Yes

0. No

3. According to the NHSC’s records, you were serving at the following location in December 1997.
Practice name: _________________________
a.

City: _______________ State: _______________

Was this indeed your principal NHSC work address in December 1997?
2. Yes
1. No, I was serving in the NHSC then but at a different location: (please identify)
Practice name:

____________________ City: ___________________ State: __________

0. No, I was not serving in the NHSC in December 1997.

1

b. Was the practice we or you identified in 3a. your last NHSC practice, i.e., you didn’t change sites even if you
served a new or “amendment” NHSC Loan Repayment Program contract?
1. Yes, this was my last NHSC practice site
0. No, I finished my NHSC service at a different site.  Please identify:
Practice name:

____________________ City: ___________________ State __________

4. Is the practice we or you identified in 3a. still the principal practice where you work?
1. Yes  If yes, please skip to question 6 below.
0. No  If no, when did you leave this last NHSC site?

Month: _________ Year: _________

5. Please list all positions you have worked for six months or longer since leaving your last NHSC practice site. Include
periods of other clinical and non-clinical work, as well as periods of training and when you did not work.
List current position first, then others going backward in time.

a.
b.
c.
d.
e.
f.
g.

Start Date
Year
Month

End Date
Month
Year

___
___
___
___
___
___
___

___
___
___
___
___
___
___

___
___
___
___
___
___
___

___
___
___
___
___
___
___

Position
Clinical Other Specify*

□
□
□
□
□
□
□

□
□
□
□
□
□
□









_
_
_
_
_
_
_

City/Town

State

Zip
(if known)

_______
_______
_______
_______
_______
_______
_______

_______
_______
_______
_______
_______
_______
_______

______
______
______
______
______
______
______

This organization
focuses on care for
underserved?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

*If responded Other, please note appropriate number above:

1.
2.
3.
4.
5.

non-clinical work
in training
teaching
other work
not working

6. If you are now in clinical practice, what proportion of the patients in your current practice are covered under:
(Numbers may not total to 100%)
1. Medicaid ____% 2. Medicare ____% 3. IHS or tribal coverage ____% 4. uninsured _____%
0.

□ check if you are not now in clinical practice

YOUR RECOMMENDATIONS
7. What can the NHSC leadership and staff do to make the NHSC a better program for its clinicians?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
8. What can the NHSC do to make it more likely that its alumni would continue to serve needy populations?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

2