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O.M.B.: 0915-0146 Expiration February 28, 2014 |
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| BUREAU of CLINICIAN RECRUITMENT AND SERVICE |
| College Cost of Attendance |
| DATA COLLECTION WORKSHEET (DCW) |
| 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 1 hour 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. |
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| School Name |
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| Address |
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| City / State / Zip |
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| Discipline / Degree |
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| Applicant Name |
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Year 1 |
Year 2 |
Year 3 |
Year 4 |
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2011 - 2012 |
2011 - 2012 |
2011 - 2012 |
2011 - 2012 |
Total |
| Annual Tuition |
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| Resident |
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| Non-resident |
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$- |
$- |
$- |
$- |
| Required Fees (charges directly billed by the school) |
| Technology Fee |
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$- |
$- |
| Student Activities Fee |
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$- |
| Other (specify below) |
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| Health Insurance |
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| Life/Disability |
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$- |
| Performance Assessment |
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$- |
| Examination Fee |
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$- |
| Other |
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| Total Tuition / Fees: |
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$- |
| Other Related Costs (ORC - not billed by the school) |
| Books and Supplies |
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| Uniforms |
$- |
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$- |
$- |
$- |
| Lab Costs |
$- |
$- |
$- |
$- |
$- |
| Clinical Supplies |
$- |
$- |
$- |
$- |
$- |
| Health Insurance (if not billed by the school) |
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$- |
$- |
| Malpractice Liability Insurance |
$- |
$- |
$- |
$- |
$- |
| National Boards |
$- |
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$- |
$- |
| Microscopes |
$- |
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$- |
$- |
$- |
| Instruments |
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$- |
$- |
$- |
| Other (specify below) |
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| Computer |
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$- |
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$- |
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| Background Check |
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| Transportation |
$- |
$- |
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$- |
$- |
| (specify) |
$- |
$- |
$- |
$- |
$- |
| Total ORC: |
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| ANNUAL TOTAL |
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____________________________________________________ |
| Name |
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Department / Administrative Unit |
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_______________________________________________________ |
| Title |
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Dept. Mailing Address |
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_______________________________________________________ |
| Email |
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City / State/Zip |
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_______________________________________________________ |
| (Area code) Phone Number |
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(Area code) Fax Number |
| _______________________________________________________ |
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_______________________________________________________ |
| (School Completion/Submittal) Date |
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Fed Reviewer / Date |