Form 1 NHSC SP – Verification of Disadvantaged Background

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

VERIFICATION OF DISADVANTAGED BACKGROUND STATUS
(For School Use Only – Must be Completed by Financial Aid Official)

Name of Student: __________________________________Last 4 digits SSN:XXX-XX-_______________
The Financial Aid Official identified below certifies that the above-named student:
 is

 is NOT

from a disadvantaged background (criteria described below). Students from a disadvantaged background have
either participated in or would have been eligible to participate in Federal Programs such as the “Scholarships for
Disadvantaged Students,” “Loans to Disadvantaged Students” or the “Nursing Workforce Diversity Grant Program.”
CRITERIA FOR DISADVANTAGED BACKGROUND STATUS
1.

An individual comes from an environment that has inhibited the individual from obtaining the knowledge, skills, and
abilities required to enroll in and graduate from a health professions or nursing school (Environmentally
Disadvantaged). The following are provided as examples for guidance only and are not intended to be all-inclusive.











The individual graduated from (or last attended) a high school with low SAT score based on most recent data
available.
The individual graduated from (or last attended) a high school from which, based on most recent data available,
low percentage of seniors receive a high school diploma; or low percentage of graduates go to college during the
first year after graduation.
The individual graduated from (or last attended) a high school with low per capita funding.
The individual graduated from (or last attended) a high school at which, based on most recent data available,
many of the enrolled students are eligible for free or reduced price lunches.
The individual comes from a family that receives public assistance (e.g., Aid to Families with Dependent Children,
food stamps, Medicaid, public housing).
First generation in family to attend college
OR

2.

An individual comes from a family with an annual income below a level based on low-income thresholds according to
family size established by the U.S. Census Bureau, adjusted annually for changes in the Consumer Price Index, and adjusted
by the Secretary of Health and Human Services (HHS) for adaptation to this program (Economically Disadvantaged). The
Secretary defines a ‘‘low income family/household’’ for various health professions and nursing programs included in Titles
III, VII and VIII of the Public Health Service Act as having an annual income that does not exceed 200 percent of the
Department’s poverty guidelines. A family is a group of two or more individuals related by birth, marriage, or adoption
who live together. A household may be only one person.

SUBMITTED BY:
Signature & Date: _____________________
______________________________ ______
Name & Title:
________________________________ Phone Number: ___________________
E-Mail Address: __________________________
Name of School: _________________________
Student may upload signed form to the NHSC SP Online Application: https://programportal.hrsa.gov/