2b In-School Monitoring - School Verification form

Print Form
Nursing Scholarship Program
U.S. Department of Health and Human Services
Health Resources and Services Administration

School Enrollment Verification Form Spring 2012
FORM APPROVED
OMB No. 0915-0301
Expires 09/30/2012

*THIS FORM IS TO BE COMPLETED BY A SCHOOL OFFICIAL
School Name:
SSN (Last 4 digits)

State:
Name

Date of Graduation

Current Student Status

1

2

3

4

Year in Program

5

6

1

2

3

4

Last day of Coursework
for the Nursing Program

See Categories Below

Please indicate in the current student status column, which of the following categories apply. If applicable, list a new graduation date in the comments column.
CATEGORIES: (if applicable list more than 1 number)
1 = Full-Time Enrollment in Nursing Program
2 = Part-Time Enrollment in Nursing Program
3 = Repeating Course Work

4= Leave of Absence
5= Withdrawn/ Dropped out of School
6= Other Status (please explain)

School Seal/Stamp
*raised seal - shade with
pencil or crayon

Explain/Comments:

By signing my name below, I certify that the current status of the student listed above has been correctly identified from the categories provided above.
School Representative
SIGNATURE:

DATE:

PRINT NAME:

TITLE:

PHONE NUMBER:

E-MAIL ADDRESS:

ADDRESS:

FAX NUMBER:

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 0915-0301. Public reporting burden for the applicant for this collection of information is
estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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 14-33, Rockville, Maryland, 20857.