Nursing Scholarship Program Supporting Statement

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Supporting Statement A

Nurse Corps Scholarship Program

OMB Control No. 0915-0301

A. JUSTIFICATION

1. CIRCUMSTANCES OF INFORMATION COLLECTION

This is a request for Office of Management and Budget (OMB) approval of a renewal of the Health Resources and Services Administration’s (HRSA) Nurse Corps Scholarship Program (NCSP) application forms. This project is OMB Approval Number 0915-0301, and expires on August 31, 2015. The legislative authority for the Nurse Corps SP is the Public Health Service Act (Attachment A), Title VIII, amended by Public Law 101-205 on August 1, 2002. The purpose of the NCSP is to provide scholarships to nursing students in exchange for a service commitment at an eligible healthcare facility with a critical shortage of nurses.

An applicant must be enrolled or accepted for enrollment at an accredited school of nursing in a graduate, baccalaureate, associate degree or diploma program. A student can apply for full-time or part-time enrollment. A student must be a U.S. citizen or national, free of any federal judgment liens, free from existing service commitments, and not in default of any federal debt. Scholarship applicants currently are screened in a two-stage process. First an application is submitted. Based on the review of the application, students are then identified by funding preference.

In FY 2014, the NCSP awarded 242 new scholarships and 13continuations totaling $22.4 million. Funding for this program is expected to continue under future appropriations.

Under the NCSP, students seeking to become registered nurses are offered the opportunity to enter into a contractual agreement with the Secretary under which the Department of Health and Human Services agrees to pay the total school tuition, required fees, other reasonable costs, and a stipend for living expenses. In exchange, the scholarship recipient agrees to provide full-time or part-time if approved by the Secretary, clinical services at a health facility designated by the NCSP as having a critical nursing shortage. The minimum service commitment is 2 years; the maximum is 4 years. Information regarding absences and type of health care facility at which NCSP scholars are serving are necessary to ensure that NCSP scholars are fulfilling their service requirements.

This is a revision with a change upgrading the vehicle used to collect the information. The Nurse Corps Scholarship Program utilizes the BHW Management Information System Solution (BMISS), an IT system used to process and manage all BHW programs.

Two forms have been added to this collection:

Graduation Closeout Form. This form is needed to verify whether or not the Nurse Corps Scholarship Program owes any outstanding balance to an educational institution attended by the scholarship participant upon graduation.

Confirmation of Interest of Award. This electronic form is needed for the applicant to accept the scholarship award, provide banking information for the stipend payment, request the number of funding years, submit the W-4, submit the enrollment verification form, and to sign the award contract electronically.

2. PURPOSE AND USE OF INFORMATION

The application is needed to determine which applicants are qualified to receive scholarship awards. Applicants are selected for awards according to the criteria required by Federal statute and the funding preference of NCSP. In providing contracts under the NCSP, the Secretary shall give priorities to qualified applicants who demonstrate the greatest financial need. The information collected will be used by the NCSP to select applicants for scholarship awards. All information is used to determine which individual applicants have a sincere desire to practice in a health care facility with a critical shortage of nurses and have a desire to remain and continue to practice after the period of service commitment. Information collected is also used to monitor NCSP scholars’ progress in school and in service to ensure compliance with program policies.

ONLINE APPLICATION FORM

The NCSP application (Attachment B) has five sections.

Sections 1 & 2. Assurances and Eligibility: This section requires the applicant to assure that if awarded a scholarship the applicant will comply with the service requirements of the NCSP. This section also collects information to ensure that the applicant is eligible to participate in the program.

Section 3. General Information: This section collects general information needed for administrative purposes (e.g., name, address, phone number, e-mail address).

Section 4. Background Information: This section collects gender, ethnicity and race information based on OMB requirements, as well as information about an alternate person to contact in case the applicant can’t be contacted using information in the application.

Section 5. Degree Information: This section collects information about the degree or diploma program for which the applicant is requesting a scholarship, the current status in the program, and the number of school years of funding requested. This section also collects information on the expected family contributions as indicated on the Student Aid Report submitted by the applicant.

Section 6. Letters of Recommendation: This section allows recommenders identified by the applicant to submit letters of recommendation on behalf of the applicant online.

Section 7. Supporting Documents: This section allows the applicant to upload all necessary supporting documents, such as essays, authorization to release information, and verification of acceptance/good standing report.

Section 8. Self Certification: This section requires the applicant to certify that the applicant is not presently debarred, suspended, excluded, or disqualified from participation in covered transactions by any Federal agency or department. This section also requires the applicant to certify that the applicant has read and understands the terms of the NSP program guidance.

Section 9. Review and Submit: This section allows the applicant to review each section and submit the application.

APPLICATION PROGRAM GUIDANCE

The Application Program Guidance (Attachment C) describes the NCSP program for students in training to become registered nurses. It covers applicant eligibility requirements, funding preferences for awards, scholarship benefits, and service requirements. The guidance has five sections.

Section I. Program Overview: This covers eligibility requirements, funding preferences, scholarship benefits, program and service requirements, and program compliance.

Section II. Instructions for Completing the Application: This covers general instructions for completing the online application, supporting documents, and deadline dates.

Section III. Definitions: This provides an alphabetical list of terms and their definitions that are contained in the application program guidance.

Section IV. Frequently Asked Questions: This provides answers to questions frequently asked in the past.

Section V. Supporting Documents: This provides the supporting documents necessary for an application to be considered complete.

Graduation Close Out Form

The School Verification Form (Attachment D) is completed by the scholar’s academic institution. The form requests information pertaining to whether or not any outstanding balance is due the educational institution from the NCSP on behalf of the scholar. The information is collected once a year upon graduation.

Confirmation of Interest of Award

The Confirmation of Interest Form (Attachment E) is needed for the applicant to accept the scholarship award, provide banking information for stipend payment, confirm the number of years of funding requested, submit the W-4, submit the enrollment verification form, and to sign the award contract electronically. This information is collected once for new awardees through BMISS.

Contract

The contract (Attachment F) authorizes the Secretary of Health and Human Services to provide applicants selected to be participants in the Nursing Scholarship Program with scholarship awards. In return for the awards, applicants must agree to serve for a period of not less than 2 year as nurses in a health care facility with a critical shortage of nurses. The contract has six sections.

Section A. Obligations of the Secretary: This covers what the Secretary of the Department of Health and Human Services agrees to provide the selected applicant.

Section B. Obligations of the Applicant: This covers what the selected applicant agrees to provide the NSP while in training and during obligated service periods.

Section C. Breach of Scholarship Contract: This covers the liability of the applicant when there is a breach of contract.

Section D. Cancellation, Suspension, and Waiver of Obligation: This covers what happens upon the applicant’s death or the conditions when the Secretary can waive or suspend an applicant’s service or payment obligation,

Section E. Contract Extension: This covers the procedures to request annual extensions of contracts.

Section F. Contract Termination: This covers the procedures to terminate a contract.

Data Collection Worksheet

The Data Collection Worksheet (Attachment G) is completed by the scholar’s academic institution through the BHW Management Information System Solution (BMISS). The Worksheet requests the cost of tuition, required fees, and other reasonable costs for each academic year. This information is necessary to determine the amount of the scholarship award for the payment of NCSP scholar’s tuition, fees, and other reasonable educational costs. The information is collected once a year for new awardees.

School Enrollment Verification Form

The School Verification Form (Attachment H) is completed by the scholar’s academic institution. The form requests information pertaining to the scholar’s student status, such as full-time, part-time, repeating course work, or on leave of absence. This information is utilized to determine if the scholar is eligible for continued NCSP financial support. The information is collected four times a year.

Initial Employment Verification Form

The Initial Employment Verification Form (Attachment I) is needed to identify and approve the health care facilities at which new NCSP scholar graduates find employment as well as when scholars transfer to a different site. This is to ensure that scholars will be serving at a health care facility with a critical shortage of nurses. This information is collected once, upon graduation of the nursing school, and each time a scholar requests to transfer to a different site.

Employer/Participant Service Verification Form

The Service Verification Form (Attachment J) is completed by both the scholar and the scholar’s employer. The form is necessary to monitor the successful completion of scholars’ service obligations. Information on the number of days of absences is collected to see if an extension of the service obligation is needed. This is completed every six months and is completed online through the BMISS.

3. Use of Improved Information Technology and Burden Reduction

The Nursing Scholarship Program utilizes the BHW Management Information System Solution (BMISS), an IT system used to process and monitor all BHW programs. The link to the online NCSP application is available here: https://programportal.hrsa.gov/

Banking information which was previously uploaded is now electronically completed through BMISS. Individuals are able to log-in to BMISS to fill out the necessary information online.

4. Efforts to Identify Duplication and Use of Similar Information

The information requested in the application and forms is specific to the applicant and unique to this program. No similar information is collected from this group of individuals.

5. Impact of Small Businesses or Other Small Entities

No small businesses will be involved in this study.

6. Consequences of Collecting the Information Less Frequently

The online application and data collection worksheet are necessary for the selection process for making NCSP awards, which must be completed annually prior to the beginning of the academic school year. In the absence of collecting this data, review, selection, and approval of qualified applicants cannot be carried out. Moreover, the Confirmation of Interest Form is completed once to allow the applicants to accept the award, indicate the number of funding years requested, and provide banking information for stipend payments. The School Verification Form is required four times a year to ensure the NCSP participant is maintaining good standing in the academic nursing program and is eligible to continue receiving benefits. The Graduation Close Out Form is required once to ensure the Nurse Corps Scholarship Program does not have an outstanding balance due to academic institutions. Initial Employment Verification Form is required only once, unless the scholar requests to transfer to another site, to ensure the scholar will be serving at an eligible facility. The Service Verification Form is required twice a year to ensure participants are meeting their service requirements and to monitor the completion of the participants’ service obligations.

7. Special Circumstances Relating to the Guidelines 5 CFR 1320.5(d)(2)

The request fully complies with the regulation.

8. Comments in Response to the Federal Register Notice/Outside Consultation:

Section 8A:

A 60 day notice was published in the Federal Register on February 6, 2015, vol. 80, No.25; pp 6732. . There were no public comments.

Section 8B:

Recipients were consulted in FY 2015 for the following forms: Application, Data Collection Worksheet, Confirmation of Interest, Enrollment Verification, Graduation Close Out and Service Verification.

Renee Creel Larina Branch

555 North Indian Creek Dr. 2237 175^th St Apt 2D

Clarkston, GA 20021 Lansing, IL 60438

678-891-3863 703-323-5149

Jane Kress Freddie Chew

University of Indianapolis Linfield College

1400 E. Hanna Ave 2255 NW Northrup St.

Indianapolis, IN 46227 Portland, OR 97210

317-788-2128 503-413-8102

Nathania Del Valle

Hartford Hospital

80 Seymour St,

Hartford, CT 06102

860-972-7126

9. Explanation of any Payment/Gift to Respondents

Respondents will not receive any remuneration.

10. Assurance of Confidentiality Provided to Respondents

Data collected on the individual NCSP application form constitutes a system of records as defined under the Privacy Act of 1974. The program is covered by an existing System of Records, Public Health and National Health Service Corps (PH/NHSC) Scholarship Training Program, the Physician Shortage Area Scholarship Program (PSASP), National Health Service Corps Scholarship Program (NHSC SP), National Health Service Corps Loan Repayment Program  (NHSC LRP), NHSC Student/Resident Experiences and Rotations in Community Health (SEARCH), Nurse Corps Loan Repayment Program (NCLRP), Nurse Corps Scholarship Program (NCSP), Native Hawaiian Health Scholarship Program (NHHSP), and Faculty Loan Repayment Program (FLRP), Applicants and/or Participants Records System, HHS/HRSA/BHW (0915-0037).

All information collected through use of the NCSP application process, as well as storage of this information, will be in compliance with the Privacy Act. A Privacy Act Notice, describing the authority for collecting the information, several routine uses which may be made of the information collected and the necessity of reporting to receive scholarship award consideration, is contained in the NCSP Application Program Guidance.

11. Justification for Sensitive Questions

HHS requires that race and ethnicity be collected on all HHS data collection instruments. Questions regarding race and ethnicity are asked in the online application; however, responses to these questions are optional. The Social Security number is required because the amount received for the stipend and tuition payments must be reported to the Internal Revenue Service as income to the scholarship recipient. All NCSP payments made to scholars, or on their behalf to nursing schools, are taxable pursuant to the legislative citation (26 USC 117(c)).

12A. Estimated Annualized Burden Hours

Type of Respondent	Form Name	No. of Respondents	No. Responses per Respondent	Total number of Responses	Average Burden per Response (in hours)	Total Burden Hours
Nursing Student Applicant	NCSP Application/Application Program Guidance	2,600	1	2600	2	5,200
Academic Institution	School Enrollment Verification Form	500	4	2000	20/60 (0.33)	667
Nursing Scholar*	Confirmation of Interest Form	250	1	250	12/60 (0.2)	50
Academic Institution	DCW Form	500	1	500	1	500
Academic Institution	Graduation Close Out Form	200	1	200	10/60 (0.17)	33
Employer	Initial Employment Verification Form	500	1	500	25/60 (0.42)	208
Employer	Service Verification Form	500	2	1000	8/60 (0.13)	133
Nurse	Service Verification Form	500	2	1000	6/60 (0.1)	100
Total		5,550		8,050	4.35	6,891

Respondents are completing multiple forms.

The number of NCSP applicants is estimated to average 2,600 per year for the next 3 years. The program expects to receive 2,600 applications; this estimate is based on the average number of applications received for the cycles from Fiscal Year (FY) 2012 to FY 2014. Each applicant must complete an application only once if selected for award.

The current application requests general information, background information, and educational degree information. It is estimated that it will take an average of 2 hours to review the instructions, complete the forms, and upload the necessary documents to the NCSP online application. The Data Collection Worksheet averages 1 hour to complete and each academic institution will submit one Data Collection Worksheet, which lists the tuition and fees. The Confirmation of Interest form takes on average about .20 hours to complete and is submitted once. The graduation close out form is submitted once upon graduation and averages .16 hours to complete. The School Enrollment Verification Form takes an average of .33 hours to complete. The Initial Employment Verification takes an average of .41 hours to complete while the Service Verification Form for the Employer takes .13 hours to complete and the employee nurse take an average of .10 hours to complete.

Each academic institution will submit one Data Collection Worksheet, which lists the tuition and fees. This DCW is used to determine the amount of the scholarship award and is submitted once. The Graduation Close-Out Form is used to verify that the NCSP has paid all monies on behalf of the NCSP participant. The School Verification and the Service Verification Forms are to verify that the recipients are in compliance with NCSP program requirements (e.g., are enrolled in an approved nursing degree program, or are providing service as an RN at an approved health care facility with a critical shortage of nurses).

Scholarship applicants may be students and/or may be in the workforce and are accepted into a nursing degree program. Since applicant employment status is mixed, a value of $15 per hour was estimated.

12 B.

Estimates Annualized Burden Costs

Type of Respondent	Total Burden Hours	Hourly Wage Rate	Total Respondent Costs
Nursing Scholar Applicants	5,200	$15.00	$ 78,000
School/Academic Institutions	5,200	$20.00	$104,000
Nursing Scholars in Service	1,000	$30.00	$ 30,000
Employers	1,000	$20.00	$ 20,000
Total			$232,000

13. Estimates of other Total Annual Cost Burden to Respondents or Record keepers/Capital Costs

There are no capital or start-up costs for the respondents. There are no operation or maintenance fees.

14. ESTIMATES 0F ANNUALIZED COST TO THE GOVERNMENT

The average annual costs to the government for implementing the on-line application and processing are as follows:

Contract costs for on-line application: $83,221

Staff Review 8,500

Total annualized cost: $91,721

Contract costs for the on-line application system include upgrades, enhancements, and fixes to the online system. The initial review of the data collection worksheet, school verification and employment certification forms is estimated at 10 minutes at an hourly cost of $30 (Processing the forms: 1700 x (1/6) hour x $30/hour = 8,500).

15. Explanation for Program Changes or Adjustments

Request for revision. The total burden hours have been changed as result of a decrease in the average number of eligible applications from 2012-2014. This is a result of incomplete or ineligible applications not being processed by the online application system allowing the application process to be streamlined and more efficient than the previous paper applications which had been mailed or faxed prior to implementation of the online system. This is a request for a revision as the implementation of the BHW Management Information System Solution as the vehicle to collect online applications has been enhanced with improved IT functionality allowing more forms to be submitted electronically to verify service by the participant and employer, allow recommendation letters to be submitted online, and to allow electronic submission of participants’ banking information for stipend payments which previously had to be uploaded.

16. Plans for Tabulation, Publication, and Project Time Schedule
Approval is being requested for the maximum allowable time of three years. The information will be used solely for determining scholarship award recipients and ensure program compliance.

17. Reason(s) Display of OMB Expiration Date is Inappropriate

The OMB number and Expiration date will be displayed on every page of every form/instrument.

18. Exceptions to Certification for Paperwork Reduction Act Submissions

This project fully complies with the guidelines set forth in 5 CFR 1320.9. The required certifications are included in this package.