8 Initial Employment Verification Form

BUREAU OF Health Workforce

NURSE Corps SCHOLARSHIP PROGRAM: 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 note: Under the NSP, participants must be working as registered nurses (RNs) providing nursing services at a critical shortage facility. RNs working PRN,
or as Pool Nurses, or for Travel or Nurse Staffing Agencies are not in compliance with their NSP contract. ALL sections MUST be complete for form to be valid.

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:
2. I certify that the NSP participant will begin employment as an RN in this job on:
3. I certify that the NSP participant is required to work

(MM/DD/YYYY)

(MM/DD/YYYY)

_ 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):
Please select facility type from table below:
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.

OMB No. 0915-0301 Expiration Date: 08/31/2015

BUREAU OF Health Workforce

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.

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.
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.
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.

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.
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.

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 nonurban area with an insufficient number of health care practitioners.

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:
NURSE Corps Program/DPO
(301) 451-5384

OMB No. 0915-0301 Expiration Date: 08/31/2015
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current OMB control number. Public
reporting burden for this collection of information is estimated to average 30 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 Office, 5600 Fishers Lane, Room 11A33, Rockville, Maryland 20857.