Form 0127-2 Employment Verification and Community Site Info For

National Health Service Corps
Loan Repayment Program
U.S. Department of Health and Human Services
Health Resources and Services Administration

EMPLOYMENT VERIFICATION AND COMMUNITY SITE INFORMATION FORM

TO BE COMPLETED BY THE AUTHORIZED PERSONNEL OFFICIAL OF THE FACILITY ONLY
Concerning Applicants for the National Health Service Corps (NHSC) Loan Repayment Program (LRP)

Name of Clinician Applicant: ____________________________________________________________________________
Last 4 Digits of the Applicant’s Social Security Number: XXX –XX -___________
Name and physical location/address of each parent and/or any satellite site(s) where the applicant is working. Do not list the site(s) where the
applicant is performing support activities for the approved NHSC site(s) (i.e., a hospital where he/she has privileges, a nursing home, a
birthing center, a school, etc.). Submit a separate form for each parent company.

Site 1 _________________________________________________

Site 2 __________________________________________________

_________________________________________________

__________________________________________________

_________________________________________________

___________________________________________________

No. of hours per week at site: ________

No. of hours per week at site: ________

Admin Use Only:
HPSA Score ________
HPSA ID _______________________ UDS # _____________________
Approved R&R □ Yes □ No

NHSC Approved Vacancy □ Yes

Admin Use Only:
HPSA Score ________
HPSA ID _______________________ UDS # _____________________
Approved R&R □ Yes □ No

Exp Date ___________

□

No

NHSC Approved Vacancy □ Yes

Discp ____________

Exp Date ___________

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No Discp ____________

Site 3 __________________________________________________

Site 4 ___________________________________________________

__________________________________________________

____________________________________________________

__________________________________________________

____________________________________________________

No. of hours per week at site: ________

No. of hours per week at site: ________

Admin Use Only:
HPSA Score ________
HPSA ID _______________________ UDS # _____________________
Approved R&R □ Yes □ No

NHSC Approved Vacancy □ Yes

Admin Use Only:
HPSA Score ________
HPSA ID _______________________ UDS # _____________________
Approved R&R □ Yes □ No

Exp Date ___________

□

No

NHSC Approved Vacancy □ Yes

Discp ____________

Exp Date ___________

□

No

Discp ____________

Please check/complete the below certifications applicable to the above site(s) and the above applicant.

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1. I certify that the applicant identified above began or will begin working at the above-named site(s) on ___________ (work start date).
2. I certify that the above applicant is engaged, or will be engaged on his/her work start date, in a full-time clinical practice, which
means a minimum of 40 hours per week, 45 weeks per year as follows:

▪

For all health professionals, except as noted below: At least 32 hours of the minimum 40 hours per week are/will be spent providing
direct outpatient care during normally scheduled clinic hours in the ambulatory care office(s) specified above. The remaining 8 hours per week
is/will be spent providing clinical services to patients in the above offices, performing clinical support activities in alternate locations as directed
by the above site(s), or performing practice-related administrative activities.

▪For OB/GYNs, FPs practicing OB on a regular basis, providers of geriatric services, certified nurse midwives, pediatric dentists

and behavioral and mental health providers: At least 21 of the minimum 40 hours per week are/will be spent providing direct outpatient
care during normally scheduled clinic hours in the ambulatory care office(s) specified above. The remaining 19 hours per week is/will be spent
providing clinical services to patients in the above offices, performing clinical support activities in alternate locations as directed by the above
site(s), or performing practice-related administrative activities (with practice-related administrative activities not to exceed 8 hours per week).

NHSC LRP Forms

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National Health Service Corps
Loan Repayment Program
U.S. Department of Health and Human Services
Health Resources and Services Administration

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3. I certify that the above applicant is engaged in less than the required full-time clinical capacity, as defined above.
4. I certify that the above applicant was working full-time (as defined above) at the above site(s), but is on extended leave from
__________________ to _____________________ due to ____________________________________ (please indicate reason for
extended leave - e.g., maternity, deployment, medical, etc.).
5. I certify that the above applicant is no longer working at the above site(s) or will be leaving the above site(s), and the last day of full-time
work was or will be ______________________________.
6.* I certify that the above applicant is/will be an employee of the above site(s) and subject to the personnel system and employment policies of the
above site(s).
7.* I certify that the above applicant will receive an income at least equal to what he or she would have received as Federal civil servant.
(See http://opm.gov/oca/09tables/indexgs.asp and http://www.opm.gov/fedclass/html/gsseries.asp for information relating to Federal civil service
salaries and job classifications for health professionals).
8.* I certify that the above site(s) provide the above applicant with malpractice insurance and tail coverage (either commercial or through the
Federal Tort Claims Act).

* If the Executive Director does not check ALL 3 of the asterisked certifications (Items 6, 7 and 8), the above applicant will need to complete the Private Practice
Option application on the NHSC website at http://nhsc.hrsa.gov/loanrepayment/ppo_app.pdf.
The certifications and information provided above are true, accurate and complete to the best of my knowledge and belief.

Executive Director Signature of Parent Company

Print Name

_______________________________________________________________________________________________
Name and Address of Parent Company
___________________________________ ___________
E-mail Address

_____________________________
Date Signed

OMB No. 0915-0127 Expires 10/31/2010

NHSC LRP Forms

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