3a In-Service Monitoring Initial Verification of Employment

Nursing Scholarship Program

U.S. Department of Health and Human Services

Health Resources and Services Administration

NURSING SCHOLARSHIP PROGRAM (NSP): INITIAL VERIFICATION OF EMPLOYMENT

TO BE COMPLETED BY THE AUTHORIZED PERSONNEL OFFICIAL OF THE FACILITY

NSP PARTICIPANT
Name: Social Security Number: XXX-XX-

Address: Phone Number:

City: State: Zip Code: E-mail Address:

PLACE OF EMPLOYMENT

Name of Facility: Phone Number:

Address: E-mail Address:

City: State: Zip Code: Fax Number:

Please check and complete the certifications below that apply to the NSP participant identified above:

• 1. I certify that the NSP participant is licensed to practice as a registered nurse without any restrictions.
  Please provide the following: License Number: State: Expiration Date: (MM/DD/YYYY)

• 2. I certify that the NSP participant will begin employment as an RN in this job on: (MM/DD/YYYY)

• 3. I certify that the NSP participant is required to work _____ hours per week of clinical practice in this job.

• 4. I certify that the NSP participant will begin employment as an RN in this job at the following type of health care facility (check one):

Ambulatory Surgical Center – An entity in a State that provides surgical services to individuals on an outpatient basis and is not owned or operated by a hospital.	Critical Access Hospital (CAH) – A facility that is (a) located in a State that has established with the Centers for Medicare and Medicaid Services (CMS) a Medicare rural hospital flexibility program, (b) designated by the State as a CAH, (c) certified by the CMS as a CAH, and (d) in compliance with all applicable CAH conditions of participation.
Disproportionate Share Hospital (DSH) – A hospital that: 1) has a disproportionately large share of low-income patients; and 2) receives (a) an augmented payment from the State under Medicaid; or (b) a payment adjustment from Medicare. Hospital-based outpatient services are included under this definition.	Federal Hospital – Any Federal institution in a State that is primarily engaged in providing, by or under the supervision of physicians, to inpatients: (a) diagnostic and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons; or (b) rehabilitation of injured, disabled, or sick persons. Hospital-based outpatient services are included under this definition.
Federally Qualified Health Center (FQHC) – FQHCs include (1) nonprofit entities that receive a grant, or funding from a grant, under section 330 of the Public Health Service Act to provide primary health services and other related services to a population that is medically underserved; (2) FQHC “Look-Alikes” which are nonprofit entities that are certified by the Secretary as meeting the requirements for receiving a grant under section 330 of the Public Health Service Act but are not grantees; and (3) outpatient health programs or facilities operated by a tribe or tribal organization under the Indian Self-Determination Act or by an urban Indian organization receiving funds under Title V of the Indian Health Care Improvement Act. FQHCs include Community Health Centers, Migrant Health Centers, Health Care for the Homeless Health Centers, and Public Housing Primary Care Health Centers.	Home Health Agency – An organization certified under section 1861(o) of the Social Security Act that is primarily engaged in providing skilled nursing care and other therapeutic services.
Hospice Program – An organization certified under section 1861(dd)(2) of the Social Security Act that provides 24-hour care and treatment services (as needed) to terminally ill individuals and bereavement counseling for their immediate family members. This care is provided in individuals’ homes, on an outpatient basis, and on a short-term inpatient basis, directly or under arrangements made by the agency or organization.	Indian Health Service Health Center – A health care facility (whether operated directly by the Indian Health Service or operated by a tribe or tribal organization contractor or grantee under the Indian Self-Determination Act, as described in 42 Code of Federal Regulations (CFR) Part 136, Subparts C and H, or by an urban Indian organization receiving funds under Title V of the Indian Health Care Improvement Act) that is physically separated from a hospital, and which provides clinical treatment services on an outpatient basis to persons of Indian or Alaskan Native descent as described in 42 CFR Section 136.12.
Native Hawaiian Health Center – An entity (a) which is organized under the laws of the State of Hawaii; (b) which provides or arranges for health care services through practitioners licensed by the State of Hawaii where licensure requirements are applicable; (c) which is a public or nonprofit private entity; and (d) in which Native Hawaiian health practitioners significantly participate in the planning, management, monitoring, and evaluation of health services. See the Native Hawaiian Health Care Act of 1988 (Public Law 100-579), as amended by Public Law 102-396.	Non-Federal Non-Disproportionate Share Hospital – Any institution in a State that is primarily engaged in providing, by or under the supervision of physicians, to inpatients: (a) diagnostic and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (b) rehabilitation of injured, disabled, or sick persons. Hospital-based outpatient services are included under this definition.
Nursing Home – An institution (or a distinct part of an institution), certified under section 1919(a) of the Social Security Act, that is primarily engaged in providing, on a regular basis, health-related care and service to individuals who because of their mental or physical condition require care and service (above the level of room and board) that can be made available to them only through institutional facilities, and is not primarily for the care and treatment of mental diseases.	Rural Health Clinic – An entity that the Centers for Medicare and Medicaid Services has certified as a rural health clinic under section 1861(aa)(2) of the Social Security Act. A rural health clinic provides outpatient services to a non-urban area with an insufficient number of health care practitioners.
Skilled Nursing Facility – An institution (or a distinct part of an institution), certified under section 1819(a) of the Social Security Act, that is primarily engaged in providing skilled nursing care and related services to residents requiring medical, rehabilitation or nursing care and is not primarily for the care and treatment of mental diseases.	State or Local Public Health or Human Services Department – The State, county, parish or district entity in a State that is responsible for providing population focused health services which include health promotion, disease prevention and intervention services provided in clinics or other health care facilities that are operated by the Department.

The certifications and information provided above are true, accurate and complete to the best of my knowledge and belief.

Signature of Nursing Scholarship Participant Date

Name of Authorized Personnel Official (Please Print Clearly) Title

Signature of Personnel Official Date

Personnel Office Telephone Number Personnel Office Fax Number

Please upload the completed and signed form to the Customer Service Portal: https://programportal.hrsa.gov

OR fax the completed and signed form to: ATTN: Nursing Scholarship Program/Arthur Williams Fax: (301) 451-5629

FOR NSP OFFICE USE ONLY:
Health Care Facility Verification:

_____ Approved

_____ Disapproved – Reason:

Name of Program Official (Print):

Signature: Date: