3 Non-PCL AOR revised

Health Professions Student Loan and Nursing Student Loan Programs - Forms

Non-PCL AOR

Health Professions Student Loan and Nursing Student Loan Programs - Forms

OMB: 0915-0044

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FINANCIAL DATA

1. Federal Agency and Organization Element to

Which Report is Submitted

2. Federal Grant or Other Identifying Number

Assigned by Federal Agency


3a. DUNS #



4. Reporting Period

End Date


Health Resources and Services Administration

(HRSA)

Grant #:

Submission Tracking #:

OPSID:


3b. EIN




06/30/2013

PAGE 1A - STUDENT BORROWER DATA SECTION

Student/Graduate Data Cumulative Current Year

(Includes current year) (7/1/2012-6/30/2013)


1A-1. Number of Loans for the Dentistry discipline




(New Only)

1A-2. Total Dollar Amount of Loans Awarded for the Dentistry discipline



1A-3. Total Full-time Enrollment for the Dentistry discipline for the academic year (both non-LDS recipients and LDS recipients)



1A-4. Total number of Defaulted Loans for the Dentistry discipline



1A-5. Total Original Defaulted Principal Loaned for the Dentistry discipline



1A-6a. Total Number of Students who dropped out of the Dentistry discipline



1A-6b. Of the number above, how many of them were LDS student borrowers




1A-7a. Total Number of LDS Borrowers for the Dentistry discipline



1A-7b. Of the number of LDS borrowers for the Dentistry discipline above, number of Active and Non Retired/Defaulted Borrowers



1A-8. Total Number of LDS Students including those who graduated during the reporting period for the Dentistry discipline



(Age and Gender details)

1A-9. Total Graduates (LDS-Dentistry only)


1A-10. Number of LDS students including those who graduated during this reporting period that indicate an intention to serve in a medic ally underserved community



1A-11. Number of LDS students including those that graduated during this reporting period that indicate an intention to practice in primary c are


1A-12. Number of LDS students including those who graduated during this reporting period that are from rural backgrounds



Current Years Graduate Special Data Number of Graduates

1A-13. Total number of full time graduates (LDS loan recipients and Non-LDS) at your school during the current reporting period


1A-13a. Of the total number in question 1A-13, how many are URM graduates



1A-13b. Of the total number in question 1A-13, how many are non- URM graduates



1A-14. Total number of full time LDS graduates during the current reporting period who indicate intent to serve in a rural area



Prior Years Graduate Special Data Number of Graduates

1A-15a. Total Number of LDS - Dentistry Loan Recipients who graduated in academic year 2011-2012


1A-15b. Of the Total Graduates reported in question 1A-15a, the Number of Full-Time LDS - Dentistry Graduates in academic year 2011-2012 serving in Medic ally Underserved Communities


1A-15c . Of the Total Graduates reported in question 1A-15a, the Number of Full-Time LDS - Dentistry Graduates in academic year 2011-2012 serving in Primary Care


1A-15d. Of the Total Graduates reported in question 1A-15a, the Number of Full-Time LDS - Dentistry Graduates in academic year 2011-2012 who entered the field for which they received the degree


1A-15e. Of the Total Graduates in question 1A-15a, the Number of Full-Time LDS - Dentistry Graduates in academic year

2011-2012 who entered service in a rural area?



















Student Special Data (For LDS programs Only)

*1A-16. Please indicate the recruitment activities for disadvantaged students your school uses for the LDS program by checking all box(s) that apply.


(Recruitme nt de tails )

*1A-17a. Please indicate the retention and/or mentoring activities for disadvantaged students that your school uses for the LDS program by checking all boxes that apply.


(Retention details)


*1A-17b. Please indicate the type of retention and/or mentoring activities for disadvantaged students your school uses for the LDS program by checking all boxes that apply.





(Type of Re tention Activitie s de tails)


*1A-18. Please share in the box below any success stories about LDS recipients. (Maximum 250 characters)



*1A-19. How many LDS students received pipeline training from other HRSA programs (i.e., Health Careers Opportunity Program (HCOP) Centers of Excellence (COE) at any period of time? (Data collection period starts July 1, 2012).

Cumulative

(Includes current year)

Current

(New LDS Recipients)

HCOP:

COE:

Other:

Other Program Titles:

HCOP:

COE:

Other:

Other Program Titles:

* Please provide the name of at least one health clinic that provides services to a significant number of individuals who are from disadvantaged backgrounds including members of minority groups, that your school uses to provide students with experience in providing clinical services to such individuals.(Maximum 100 characters)

Clinic 1:

Clinic 2:

Clinic 3:



















































FINANCIAL DATA


DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration


BUREAU OF HEALTH PROFESSIONS Annual Operating Report

Page 1b - Student Race/Ethnicity Data Section

FOR HRSA USE ONLY

Institution

Program

MIDWESTERN UNIVERSITY DOWNERS GROVE - CHICAGO COLLEGE OF OSTEOPATHIC

LDS - Osteopathic

Medicine

Submission Tracking Number

OPSID

Grant Number

Reporting Period


AORE3600012785/1


68822012(Active)


E36HP21719

07/01/2012 -

06/30/2013

1. Hispanic or Latino Students

Did your BHPr funded program have students of "Hispanic or Latino ethnicity" betw een 7/1/2012 and 6/30/2013? Y es, I can provide some of the counts by race but not all.



Hispanic or Latino Students by Race


Enrollment of Discipline (A)


New Student Recipients (B)

Recipients Other Than New W ho Did Not Graduate (C)

Recipients Other Than New W ho Graduated (D)


Total Recipients (B+C+D)

A. American Indian or Alaska Native






B. Asian - All (including underrepresented)






B1. Asian - underrepresented, if Know n





C. Black or African American






D. Native Haw aiian or Other Pacific Islander






E. W hite






F. More than one race

(Race co mbinatio ns)






TOTAL (A + B + C + D + E + F)








Hispanic or Latino Students All Races


Enrollment of Discipline (A)


New Student Recipients (B)

Recipients Other Than New W ho Did Not Graduate (C)

Recipients Other Than New W ho Graduated (D)


Total Recipients (B+C+D)

G. All races







2. Non-Hispanic or Non-Latino Students

Did your BHPr funded program have students of "Non-Hispanic or Non-Latino ethnicity" betw een 7/1/2012 and 6/30/2013? Y es, I can provide some of the counts by race but not all.



Non-Hispanic or Non-Latino Students by Race


Enrollment of Discipline (A)


New Student Recipients (B)

Recipients Other Than New W ho Did Not Graduate (C)

Recipients Other Than New W ho Graduated (D)


Total Recipients (B+C+D)

A. American Indian or Alaska Native






B. Asian - All (including underrepresented)






B1. Asian - underrepresented, if know n





C. Black or African American






D. Native Haw aiian or Other Pacific Islander






E. W hite






F. More than one race

(Race co mbinatio ns)






TOTAL (A + B + C + D + E + F)








Non-Hispanic or Non-Latino Students All Races


Enrollment of Discipline (A)


New Student Recipients (B)

Recipients Other Than New W ho Did Not Graduate (C)

Recipients Other Than New W ho Graduated (D)


Total Recipients (B+C+D)

G. All races






OMB No.: 0915-0044

Expiration Date: 07/31/2015

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FINANCIAL DATA


DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration


BUREAU OF HEALTH PROFESSIONS Annual Operating Report

Page 2 - PROGRAMS ACCOUNT SECTION

FOR HRSA USE ONLY

Institution

Program

MIDWESTERN UNIVERSITY DOWNERS GROVE - CHICAGO COLLEGE OF OSTEOPATHIC

LDS - Osteopathic

Medicine

Submission Tracking Number

OPSID

Grant Number

Reporting Period


AORE3600012785/1


68822012(Active)


E36HP21719

07/01/2012 -

06/30/2013


Program Accounts

Cumulative (includes current year)


Current Y ear

A.

FEDERAL FUNDS AWARDED



B.

C ASH BALANC E - START OF REPORT PERIOD



C.

CASH RECEIPTS


1.

Federal Funds Received/Receivable




2.

Institutional C ontributions Deposited




3.

Transferred from Scholarship Fund




4.

Loan Principal C ollected




5.

Interest Income C ollected on Loans




6.

Penalty C harges C ollected on Loans




7.

Investment Income




8.

Institutional Repayments of Bad Debts, Principal




9.

Institutional Repayments of Bad Debts, Interest




10.

Institutional Repayments of Bad Debts, Penalty C harges




11.

Cash Receipts Total (sum of C.1 through C.10)



D.

C ASH DISBURSEMENTS


1.

Loaned to Students




2.

Transferred to Scholarship Fund




3.

Repayments to Federal Government, Principal




4.

Repayments to Federal Government, Interest




5.

Repayments to Federal Government, Other Income




6.

Repayments to Institution, Principal




7.

Repayments to Institution, Interest




8.

Repayments to Institution, Other Income




9.

C ollection Agent C osts, Principal




10.

C ollection Agent C osts, Interest




11.

Litigation C osts, Principal




12.

Litigation C osts, Interest




13.

C redit Bureau Fees




14.

Other C osts




15.

C ash Disbursements Total (sum of D.1 through D.14)




E.

C ASH BALANC E - END OF REPORT PERIOD

(C ASH BALANC E START OF REPORT PERIOD + C ASH REC EIPTS - C ASH DISBURSEMENTS)



OMB No.: 0915-0044

Expiration Date: 07/31/2015

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FINANCIAL DATA


DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration


BUREAU OF HEALTH PROFESSIONS Annual Operating Report

Page 3 - PROGRAMS ACCOUNT SECTION (Continued)

FOR HRSA USE ONLY

Institution

Program

MIDWESTERN UNIVERSITY DOWNERS GROVE - CHICAGO COLLEGE OF OSTEOPATHIC

LDS - Osteopathic

Medicine

Submission Tracking Number

OPSID

Grant Number

Reporting Period


AORE3600012785/1


68822012(Active)


E36HP21719

07/01/2012 -

06/30/2013


Program Accounts (Continued)

Cumulative

(includes current year)


Current Y ear


F.


LOAN CANCELLATIONS TO BORROW ERS

Number of

Borrow ers


Principal


Interest

Number of

Borrow ers


Principal


Interest



1.


Professional Practice




a. HP Practice-Shortage (10%)










b. HP Practice-Rural Shortage (15%)










c. Total (Sum of 1.a and 1.b)









2.


Nursing Employment




a. Nursing Employment (10%)










b. Nursing Employment (15%)










c. Nursing Employment (20%)










d. Nursing Employment (15%) on or after 03/23/2011










e. Nursing Employment (20%) on or after 03/23/2011










f. Nursing Employment (Other) on or after 03/23/2011










g. Total (sum of 2.a through 2.f)









3.


Death




a. On PC L Loans made on or after 10/22/85










b. On Loans except those reported in F.3.a










c. Total (Sum of 3.a and 3.b)








4.

Permanent & Total Disability Approved by HHS




a. On PC L Loans made on or after 10/22/85










b. On Loans except those reported in F.4.a










c. Total (Sum of 4.a and 4.b)








PROGRAM ACCOUNTS (Continued)

Cumulative

(includes current year)


Current Y ear


G.

BAD DEBTS APPROVED FOR W RITE-OFF BY HHS

Number of

Borrow ers


Principal


Interest

Penalty

Charges

Number of

Borrow ers


Principal


Interest

Penalty

Charges


Total Approved









OMB No.: 0915-0044

Expiration Date: 07/31/2015

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FINANCIAL DATA


DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration


BUREAU OF HEALTH PROFESSIONS Annual Operating Report

Page 4 - EXCESS CASH WORKSHEET

FOR HRSA USE ONLY

Institution

Program

MIDWESTERN UNIVERSITY DOWNERS GROVE - CHICAGO COLLEGE OF OSTEOPATHIC

LDS - Osteopathic

Medicine

Submission Tracking Number

OPSID

Grant Number

Reporting Period


AORE3600012785/1


68822012(Active)


E36HP21719

07/01/2012 -

06/30/2013


A.


General Ledger Cash Balance as of 6/30/2012



B.

Actual Collections for 7/1/2012 - 6/30/2013



1.


Principal




2.


Interest




3.


Investment Income and Penalty Charges




4.


Institutional Repayments of Bad Debts (Principal, Interest & Penalty Charges)



C.


Federal Funds Received/Receivable 7/1/2012 - 6/30/2013



D.


Institutional Contribution for 7/1/2012 - 6/30/2013


E.

Projected Collections for 7/1/2013 - 6/30/2013



1.


Principal




2.


Interest




3.


Investment Income and Penalty Charges



F.


Projected Funds Available as of 6/30/2013 (A + B + C + D + E)


G.

Actual Expenditures for 7/1/2012 - 6/30/2013



1.


Loans to Students




2.


Costs(Collection, Litigation, Credit Bureau and Other)




3.


Repayments to Federal Government and Institution (Principal, Interest and Other Income)


H.

Projected Expenditures for 7/1/2013 - 6/30/2013



1.


Loans to Students




2.


Costs(Collection, Litigation and Credit Bureau)



I.


Projected Expenditures as of 6/30/2013 (G + H)



J.


Projected Cash Balance as of 6/30/2013 (F - I)



K.


Less Projected Expenditures for 7/1/2013 - 6/30/2015



L.


Excess Cash (J - K)



M.


General Ledger Ending Cash Balance as of 6/30/2013


OMB No.: 0915-0044

Expiration Date: 07/31/2015

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FINANCIAL DATA


DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration


BUREAU OF HEALTH PROFESSIONS Annual Operating Report

Page 5 - PROGRAMS ACCOUNT SECTION (Continued)

FOR HRSA USE ONLY

Institution

Program

MIDWESTERN UNIVERSITY DOWNERS GROVE - CHICAGO COLLEGE OF OSTEOPATHIC

LDS - Osteopathic

Medicine

Submission Tracking Number

OPSID

Grant Number

Reporting Period


AORE3600012785/1


68822012(Active)


E36HP21719

07/01/2012 -

06/30/2013

Program Accounts (Continued)

H.

FROM WORKSHEET C ALC ULATIONS


1.

Default Rate



FOR AC TIVE SC HOOLS


2.

Excess C ash from report page 4 that was or will be returned to PMS



3.

Excess C ash from report page 4 that was or will be returned to the Division of Financial Operations



FOR C LOSING SC HOOLS


4.

Amount of cash determined to be due the Federal Government and remitted separately to the Division of Financial Operations


I.

CHEC K LIST/QUESTIONS


1.

W hat is the total amount of interest that is past due?



AUDITS


2.

Does your institution provide for a biennial audit of the loan and/or scholarship funds by a qualified independent auditor?





a. Period of last audit


Fro m : / To : /




b. Date audit submitted to Regional Audit Agency


/

OMB No.: 0915-0044

Expiration Date: 07/31/2015

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FINANCIAL DATA


DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration


BUREAU OF HEALTH PROFESSIONS Annual Operating Report

Page 6a - BORROWER ACCOUNTS WORKSHEET

FOR HRSA USE ONLY

Institution

Program

MIDWESTERN UNIVERSITY DOWNERS GROVE - CHICAGO COLLEGE OF OSTEOPATHIC

LDS - Osteopathic

Medicine

Submission Tracking Number

OPSID

Grant Number

Reporting Period


AORE3600012785/1


68822012(Active)


E36HP21719

07/01/2012 -

06/30/2013


Borrower Accounts

Number of Borrowers

(1)

Principal Loaned

(2)

Principal Repaid

(3)

1.

FULLY RETIRED


A.

Repayment/Prof Pract/C ancel





B.

C ancellation/Death





C.

C ancellation/Disability





D.

Discharged in Bankruptcy





E.

HHS Approved Write-off





F.

Uncollectible per P.L. 100-607





G.

Total (sum of 1.A through 1.F)




2.

CURRENT


A.

Student Status





B.

Grace Period





C.

Deferment Status





D.

Postponement/C ancellation





E.

Repayment - Not Past Due





F.

Past Due 1-119 Days





G.

Total (sum of 2.A through 2.F)




3.

IN BANKRUPTCY


A.

Pending Discharge/Wage Earners Agreement




4.

IN DEFAULT


A.

120 Days and Over




5.

FORBEARANCE


A.

Forbearance





TOTAL




OMB No.: 0915-0044

Expiration Date: 07/31/2015

Shape7



FINANCIAL DATA


DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration


BUREAU OF HEALTH PROFESSIONS Annual Operating Report

Page 6b - BORROWER ACCOUNTS WORKSHEET

FOR HRSA USE ONLY

Institution

Program

MIDWESTERN UNIVERSITY DOWNERS GROVE - CHICAGO COLLEGE OF OSTEOPATHIC

LDS - Osteopathic

Medicine

Submission Tracking Number

OPSID

Grant Number

Reporting Period


AORE3600012785/1


68822012(Active)


E36HP21719

07/01/2012 -

06/30/2013



Borrower Accounts

PRINCIPAL CANCELED


Employment/ Prof Pract (4)

Death/ Disability (5)


Principal Delinquent

(6)

1.

FULLY RETIRED


A.

Repayment/Prof Pract/C ancel





B.

C ancellation/Death





C.

C ancellation/Disability





D.

Discharged in Bankruptcy





E.

HHS Approved Write-off





F.

Uncollectible per P.L. 100-607





G.

Total (sum of 1.A through 1.F)




2.

CURRENT


A.

Student Status





B.

Grace Period





C.

Deferment Status





D.

Postponement/C ancellation





E.

Repayment - Not Past Due





F.

Past Due 1-119 Days





G.

Total (sum of 2.A through 2.F)




3.

IN BANKRUPTCY


A.

Pending Discharge/Wage Earners Agreement




4.

IN DEFAULT


A.

120 Days and Over




5.

FORBEARANCE


A.

Forbearance





TOTAL




OMB No.: 0915-0044

Expiration Date: 07/31/2015

Shape8



FINANCIAL DATA


DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration


BUREAU OF HEALTH PROFESSIONS Annual Operating Report

Page 6c - BORROWER ACCOUNTS WORKSHEET

FOR HRSA USE ONLY

Institution

Program

MIDWESTERN UNIVERSITY DOWNERS GROVE - CHICAGO COLLEGE OF OSTEOPATHIC

LDS - Osteopathic

Medicine

Submission Tracking Number

OPSID

Grant Number

Reporting Period


AORE3600012785/1


68822012(Active)


E36HP21719

07/01/2012 -

06/30/2013


Borrower Accounts

Principal Uncollectible

Not Past Due

(7)

Principal Outstanding but Not Due

(8)


Principal Written Off

(9)

Capitalized Interest (10)

1.

FULLY RETIRED


A.

Repayment/Prof Pract/C ancel






B.

C ancellation/Death






C.

C ancellation/Disability






D.

Discharged in Bankruptcy






E.

HHS Approved Write-off






F.

Uncollectible per P.L. 100-607






G.

Total (sum of 1.A through 1.F)





2.

CURRENT


A.

Student Status






B.

Grace Period






C.

Deferment Status






D.

Postponement/C ancellation






E.

Repayment - Not Past Due






F.

Past Due 1-119 Days






G.

Total (sum of 2.A through 2.F)





3.

IN BANKRUPTCY


A.

Pending Discharge/Wage Earners Agreement





4.

IN DEFAULT


A.

120 Days and Over





5.

Forbearance


A.

Forbearance






TOTAL





OMB No.: 0915-0044

Expiration Date: 07/31/2015

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