Form 1 NHHSP - Acceptance/Verification of Good Standing Report

Table of Contents
1. Introduction
Native Hawaiian Health Scholarship Program (NHHSP)
2. Roles and Responsibilities
2.1 NHHSP Director
2.2 NHHSP Administrative Assistant & Scholarship Application Coordinator
2.3 NHHSP Coordinated Service Planning (CSP) Program Coordinator
2.4 NHHSP Information Technology Coordinator
2.5 NHHSP Advisory Board
2.6 Application Review Committee
3. Scholarship Application Cycle
3.1 Preparing for the Opening of the Annual Application Cycle
 Application Cycle Opening Date (December 1st)
 Application and Program Guidance
 Website (http://nhhsp.org/apply2014/)
 Online Application (Lime Survey)
 Federal Register Notice (Pending HRSA Notification)
 Staff Training
3.2 Appointing the Application Review Committee
3.3 New Scholarship Applications
Online Applications
Processing New Scholarship Applications and Awards
Application Review Packet
Award Selection
3.4 Continuation Scholarship Applications
Online Applications
Required Forms
Processing Continuation Scholarship Applications and Awards
Approved Continuation Applications
4. Appendices
NHHSP Application 2014-2015 Documents & Forms

Section: 1. Introduction
Authority: Native Hawaiian Health Care Improvement Act of 1992, Public Law 102-396
Effective Date: August 1, 2012

Revision Date:

The Native Hawaiian Health Scholarship Program (herein “NHHSP”) is authorized by
the Native Hawaiian Health Care Improvement Act of 1992, Public Law 102-396. The
program is administered by the U. S. Department of Health and Human Services (HHS),
Health Resources Services Administration (HRSA), Bureau of Clinician Recruitment and
Service (BCRS), Division of the Nurse Corps Scholarship Program (NCSP) under Award
No: 5 U1MHP00019-12-00, Project Period 3/01/2002 through 7/31/2004.
The intended long-term impact of the Native Hawaiian Health Scholarship Program
(herein “NHHSP”) under the Native Hawaiian Health Care Improvement Act of 1992
is the improved health status of Native Hawaiians. This will be achieved through
comprehensive health promotion, disease prevention and health services through
the development and expansion of Native Hawaiian health care service
infrastructures. This capacity-building effort is supported, in part, by the NHHSP by
increasing the number of Native Hawaiian health care professionals trained in those
disciplines and specialties most needed to deliver quality, culturally competent,
health care to Native Hawaiians in the State of Hawai'i. Three main components
comprise the NHHSP:
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Federal Scholarships to Native Hawaiians pursuing careers in designated
health care professions,
Placement of NHHSP scholars in priority Native Hawaiian communities
following the completion of their training, and

Training of NHHSP scholars in culturally appropriate ways to provide health
care services in Hawaiian communities.

The Federal Government is to provide financial aid covering tuition, required fees and
other educational and living expenses for qualified Native Hawaiians applying to,
accepted by or enrolled in health professions programs. Students incur service obligations
and payback requirements on acceptance of their scholarship award.
The purpose of this Standard Operating Procedures (SOP) Manual is to describe the
processes by which NHHSP is administered, managed and carried out by the identified
staff members and director. The manual describes the various tasks and action steps
performed by program staff for the receiving, reviewing, processing and award of
incoming applications for new and continuation applicants. It details the full scholarship
application cycle, procedures for updating forms and materials used to support the
program. It also describes the interaction and communication with scholarship recipients
throughout their academic year and their post-graduation performance of their service
obligation, with frequent checks of employment verification, until the completion of
service and closing out of records.

Section: 2. Roles and Responsibilities
Authority: Native Hawaiian Health Care Improvement Act of 1992, Public Law 102-396
Effective Date: August 1, 2013

Revision Date:

PURPOSE: The following is a summary of the roles and responsibilities of the director
of the NHHSP Scholarship Program and key NHHSP Scholarship Program staff working
under his/her direction to fulfill the mandates and mission of the Program.
2.1 NHHSP Director
2.2 NHHSP Administrative Assistant & Grants Scholarship Coordinator
2.3 NHHSP Coordinated Service Planning (CSP) - Program Coordinator
2.4 NHHSP Information Technology Coordinator
2.5 NHHSP Advisory Board
2.6 Application Review Committee

Procedure: 2.1 Director, NHHSP
Section: 2. Roles and Responsibilities
Authority: Native Hawaiian Health Care Improvement Act of 1992, Public Law 102-396
Effective Date: August 1, 2012

Revision Date:

The NHHSP Director is responsible for:
• Overseeing the NHHSP Scholarship Program.
• Manage grant-funded program, work with agency directors, boards and funders;
monitor and support scholarship recipients, may include counseling.
• Responsible for overall management of grant-funded program in accordance with
program goals and objectives detailed in the program proposal and with
applicable federal guidelines.
• Supervise support staff.
• Formulates and communicates to external constituencies the mission, objectives
and service priorities of the program; develops annual operation, management and
budget plans to guide and implement the program and activities.
• Prepares annual grant proposals; clarifies/negotiates contents of the proposal;
fulfills program reporting requirements; ensures compliance of program activities
with the funder and terms of proposal; evaluates program effectiveness and
service delivery; develops and adjusts projects as necessary.
• May develop and update policies and procedures in compliance with government,
funder and corporate requirements and policies.
• Follows agency policies and procedures in compliance with government, funder
and corporate requirements and policies, including the Health Insurance
Portability and Accountability Act (HIPAA) policies.
• Directs, coordinates and controls program activities, prepares annual operating
budget.
• Signs all recommendations for approval/disapproval of funding for new and
continuation scholarship recipients.
• Signs all correspondence with current/past scholarship recipients in matters of
dispute regarding terms of funding/contractual obligation/service obligation
payback.
• Assisting in the resolution of questions about eligibility under the current
governing law.
• Negotiating agreements with private-sector parties interested in pursuing
cooperative agreements with the NHHSP Scholarship Program.
• Overseeing the placement process for all graduated scholarship recipients to
ensure approved service obligation placement and service requirements meet
NHHSP Scholarship Program policies.
• Recommend to HRSA/BCRS/NCSP the approval or denial of funding for new
and continuation scholars based on the findings of the NHHSP Application
Review Committee.

Procedure: 2.2 NHHSP Administrative Assistant, Scholarship Application Coordinator
Section: 2. Roles and Responsibilities
Authority: Native Hawaiian Health Care Improvement Act of 1992, Public Law 102-396
Effective Date: August 1, 2012

Revision Date:

The NHHSP Administrative Assistant, Scholarship Application Coordinator is
responsible for:
• Assist Program Director with the operations of the Native Hawaiian Health Scholarship
Program in accordance with federal guidelines and requirements and in accordance with
program objectives.
• Provides administrative support to the Program Director to include: establishing,
maintaining, and updating recipient files and records; scheduling and confirming travel
arrangements for program staff; ordering and maintaining office supplies, publications,
subscriptions, instructional materials, equipment; maintaining inventory records;
completing and submitting required reports; and responding to all routine telephone or
email inquiries as indicated by agency procedures.
• Creates, manages and updates appropriate data systems necessary to document and
monitor program activities and expenditures. Assists the Program Director in budget
preparation, in developing budget modifications and in monitoring program expenditures.
• Assist Program Director and IT Coordinator with the program’s website, to include
maintaining and updating the site as directed.
• Follows agency policies and procedures in compliance with government, funder and
corporate requirements and policies.
• May assist the Program Director with the development of policies and procedures for
his/her respective department.
• Review and process all new and continuation scholarship applications in a timely and
accurate manner with the CSP team and director.
• Generate Incomplete and Ineligible/Low Score/Lack of Funding Denial letters during the
application cycle as well as other letters as required.
• Maintains the reference library, to include the cataloging of all reference books, journals,
post-secondary catalogs, updating materials; and managing the check-out and return of
loaned materials.
• As directed, may represent the program in the community at health fairs and other similar
activities which involve the dissemination of program information and responding to
inquires about the program. Coordinates the logistical aspects of all presentations,
program activities and field trips.
• Work is generally performed in an office environment, but may also require travel to
secondary and post-secondary educational institutions, health agencies and communitybased organizations on-island and off-island. Must have reliable transportation and the
ability to travel to off-site meetings and work-related events. Neighbor Island travel may
also be required. Approximately 10% of the average work week may be spent out of the
office.
• Work involves frequent contact with program participants, administrators and other staff
of educational institutions, staff of community-based and health organizations, and staff
of federal agencies.
• Follows agency policies and procedures in compliance with government, funder and
corporate requirements and policies, including confidentiality policies and the Health
Insurance Portability and Accountability Act (HIPAA) policies.
• Obtaining and processing all continuation applications and supporting documentation.

Procedure: 2.3 NHHSP Coordinated Service Planning (CSP) Program Coordinator
Section: 2. Roles and Responsibilities
Authority: Native Hawaiian Health Care Improvement Act of 1992, Public Law 102-396
Effective Date: August 1, 2012

Revision Date:

An NHHSP Coordinated Service Planning (CSP) Coordinator is responsible for:
I. GENERAL COORDINATION, MONITORING & COUNSELING SUPPORT
SERVICES TO NHHSP SCHOLARS:

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Provide a supportive relationship with each scholar.
Update and maintain all electronic and/or hard-copy folders of each scholar.
Proactively meet with scholars to update their program status and address
successes and barriers.
Facilitate meetings between scholar, NHHSP, and third-party representatives
(e.g., academic advisors, placement site supervisors, HRSA/BCRS/NCSP) to
assess status of scholars progress and identify, address and resolve any barriers.
Facilitate other counseling services for scholars with academic, employment
preparation, professional licensure and placement issues.
Maintain excellent documentation related to scholar contact, including ancillaries
who are identified in the scholar’s contract and CSP.
Systematically monitor and review scholar status to assure a continued supportive
relationship.
Maintain a caseload of approximately 35 to 55 “active in-education, in-transition
and in-placement” scholars, while performing minimal profile updating tasks to a
listing of approximately 35 program Alumni on an annual basis.
Maintain current addresses and contact information for all scholars and third-party
CSP representatives.
Ensure confidentiality through scholar consents to obtain and release of
information.

II. COORDINATED SERVICE PLANNING (CPS) AND SCHOLAR SUPPORT SERVICES:

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Facilitate and maintain a Coordinated Service Plan (CSP) for each scholar that
identifies their specific goals and objectives and a timeline.
Complete the comprehensive CSP to accompany the program contract and DCW
at new scholar orientation. Thereafter, update the CSP as needed with a
mandatory annual review.
Maintain a list of support services for scholars that correspond to each phase of
their CSP.
Maintain CSP along with other supporting documents and make them available
at-all-times for program audits, compliance and quality assurance reviews.
Work directly with HRSA/BCRS/NCSP, scholarship recipients and educational
institutions to coordinate appropriate and timely payment of Tuition and Fees,
Other Related Costs (ORC) and stipends.
Assess and record all issues regarding scholar’s matriculation, and review with
program director and coordination team in a timely fashion or at the monthly
scheduled team meetings for further analysis and determination of acuity level,
and formulate a Corrective Action Plan (CAP).
Facilitate communications with CSP teams and record outcomes of the CAP that
may require pre-approval and facilitative or direct monitoring support by the
program director.

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Facilitate and produce all CAP’s with specific strategies and a timeline to
ameliorate the issues. An evaluation of the plan’s progress and final outcomes
must be recorded into the scholar’s CSP.
Engage with scholars twelve months prior to placement to review potential
placement sites in order of priority; monitor completion of graduation
requirements, advance trainings, and licensure; and initiate discussion regarding
transitional issues.
Provide support services to increase employment readiness such as assistance
with developing resumes, enhancing interviewing skills, and visiting potential
employment and community sites.
Facilitate linkage of the scholar to the employment site by establishing an
interview date, and ensuring a successful interface of scholar and employment
site.
Complete the Scholar Placement Plan (SPP) with each scholar at least 3 months
prior to graduation. Indicate in the plan details concerning the coordinator’s
monitoring requirements.
Facilitate and monitor all scholar requests for deferment of service obligation with
HRSA/BCRS/NCSP in the event that placement according to the scholar’s SPP is
delayed for any reason. Include in such requests a Corrective Action Plan (CAP).
Facilitate and obtain required documentation of continued scholar service
obligation and a status report from agency.
Prepare scholar to exit program following the successful completion of the service
-- preparing final documentation from NHHSP and HRSA/BCRS/NCSP for the
program exit interview with scholar.
Conduct End of Service (EOS) interviews with scholars, complete and record
final program evaluations, close-out scholar’s CSP, and provide scholar with all
EOS documentation.
WAIVER/DEFAULT PROCESSING
All waiver/default issues and requests must be reviewed by NHHSP’s director for
plan of action.
Assist scholar in processing waiver requests to submit to HRSA and OLC.
Report to HRSA and OLC scholarship recipients who will not or cannot complete
their service obligations.
Maintain confidential records related to waivers and defaults.
Prepare recommendation of waiver/default status.
Forward scholarship recipient records to HRSA and OLC.
NHHSP SCHOLARSHIP APPLICATION PROCESS
Review and process all new and continuation scholarship applications in a timely
and accurate manner as directed by NHHSP director.
Obtain and process all continuation applications and supporting documentation.
Qualify and Coordinate the obligation of HRSA funds for selected scholars via
the Data Collection Worksheet (DCW) and its process, as well as prepare all
HRSA required documents in moving toward award notifications.

Procedure: 2.4 Information Technology Coordinator
Section: 2. Roles and Responsibilities
Authority: Native Hawaiian Health Care Improvement Act of 1992, Public Law 102-396
Effective Date: August 1, 2012

Revision Date:

Information Technology Coordinator is responsible for:
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Implementation and maintenance of office technology to ensure compliance with
NHHSP needs.
Create and maintain databases that address Applications and CSP programmatic
needs consistent with that of NHHSP’s Cooperative Agreement with HRSA.
Record and update database user guidelines as well as policies and procedures in
compliance with POL, NHHSP and Federal OMB requirements as stipulated by
HRSA.
Maintain the technical aspects of the NHHSP website, as well as maintain website
content (i.e., posting of the on-line Application survey, public announcements,
notices to scholars and other program affiliated organizations (i.e., HRSA, POL,
NHHCS, participating scholar institutions).
Develop and generate timely reports from the database as driven by NHHSP
Administration and CSP program requirements.
Provide IT related training and support to NHHSP staff.
Create database to streamline the ranking process to culminate in recommended
Short List to the HRSA/BCRS/NCSP of applicants to be awarded.
Collaborate with the Administrative Assistant in facilitating the NHHSP
Application Process.
Assist in the monitoring, light maintenance, purchasing and ordering supplies with
regards to the program’s copier.
Assist all NHHSP staff with the technical aspects of the program’s telephone
system and other technical systems (i.e., computer, email, back-up, network
connectivity, network support infrastructure).
Generate reports as directed by the Program Director.
Follow agency policies and procedures in compliance with government, funder and
corporate requirements and policies, including the Health Insurance Portability and
Accountability Act (HIPAA) policies.
Performs other related duties and responsibilities as assigned.

Procedure: 2.5 NHHSP Advisory Board
Section: 2. Roles and Responsibilities
Authority: Native Hawaiian Health Care Improvement Act of 1992, Public Law 102-396
Effective Date:

Revision Date:

NHHSP Advisory Board is responsible for:
The NHHSP Advisory Board members are selected by the Director and are made up of
former NHHSP scholars, community representatives and Papa Ola Lokahi (POL) staff
members. The primary role of the Advisory Board is to assist and help provide guidance
to the program’s Director on all matters concerning NHHSP. NHHSP Advisory Board
members may also service as members of the NHHSP Application Review Committee.

Procedure: 2.6 NHHSP Application Review Committee
Section: 2. Roles and Responsibilities
Authority: Native Hawaiian Health Care Improvement Act of 1992, Public Law 102-396
Effective Date: September 2011

Revision Date:

The Application Review Committee is responsible for:
The NHHSP Application Review Committee is selected by the Director and includes the
NHHSP staff, POL staff, members of the Advisory Board and former NHHSP scholars.
The committee assesses past performance of new and continuation applicants to ensure
the recipient’s success in a health professions education program. Members of this
committee are facilitated by the program’s Scholarship Application Coordinator who
provides all pertinent Application information and documentation on each applicant to
committee members for review. The committee members review and score new
applications, according to the policies established by NHHSP. This review is conducted
during the annual review period, scheduled during January 15th through March 31st of
each year.

Section: 3. NHHSP Scholarship Application Cycle
Authority: N/A
Effective Date: August 1, 2012

Revision Date: December 1, 2013

The NHHSP application and interview cycle opens December 1st and closes on March
31st for continuation applicants and new applicants. Applicants must apply online and
submit their applications and required documentation within 30 days upon completing the
NHHSP online session #1, which must be completed by March 1st. Online Session #2
must be completed before the applicant is scheduled for an interview, and completed no
later than March 21st and prior to the overall deadline of March 31st.
The following procedures outline the tasks required of NHHSP staff in preparation for,
during and after the application cycle has closed in order to identify the applicants who
will receive funding from NHHSP.
These procedures are written to outline the responsibilities of NHHSP staff to complete
each task. The procedures that you will find include:
3.1
3.2
3.3
3.4
3.5
3.6

Preparing for the Opening of the Annual Application Cycle
Appointing the Application Review Committee
New Scholarship Applications
Continuation Scholarship Applications
Unlocking Online Applications
Resolving Online Application Errors

Procedure: 3.1 Preparing for the Opening of the Annual Application Cycle
Section: 3. NHHSP Scholarship Application Cycle
Authority: N/A
Effective Date: August 1, 2012

Revision Date:

PURPOSE: These procedures outline the tasks required in preparation for the opening of
the annual NHHSP application cycle.
PROCEDURE:
Application and APG
1. The Director, Scholarship Application Coordinator, IT Coordinator and CSP
Program Coordinator reviews the APG to determine if the content or forms need
to be corrected or updated.
2. Once the APG has been reviewed, the APG is sent to HRSA and OLC by June 1st for
final approval. The APG is anticipated to be approved no later that December 1st.
Website
1. Upon approval of changes to the APG, the Director will work with NHHSP IT
Coordinator to update all website content to ensure consistency with updates in
the APG.
2. In addition, the Director will ensure that all contact information contained on the
website pages will be updated as needed prior to the opening of the Application
Cycle. Note: Changing information on the NHHSP website is a continuous
process, and the Director will ensure that the IT Coordinator responsible for
website updates are kept informed of all necessary changes.
Online Application
1. The Director will initiate a focus group, no later than August 1st in preparation for
updating the Online Application portals (new application, continuation
application and application review). It will be a collaborative effort in identifying
the successes and areas needing improvement for the online application.
2. The identified areas of improvement will be forwarded by the Director to the IT
Coordinator for programming and testing in preparation for the opening of the
application cycle on December 1st.
Federal Register Notice
1. HRSA will notify NHHSP as to the preparation and timeline concerning the
announcement for the Federal Register Notice.

Staff Training
1. The Director will plan and schedule staff training related to the NHHSP
application cycle, to be conducted starting no later than October 14th. Training
will focus on changes to the online application based on feedback from the annual
focus group initiated by the Director and will be reviewed by Program
Coordinators, IT Coordinator and the Scholarship Application Coordinator.

Procedure: 3.2 Appointing the Application Review Committee
Section: 3. NHHSP Scholarship Application Cycle
Authority:N/A
Effective Date: August 1, 2012

Revision Date: August 1, 2014

The NHHSP Application Review Committee is selected by the Director and includes the
NHHSP staff, POL staff, members of the Advisory Board and former NHHSP scholars.
The committee assesses past performance of new and continuation applicants to ensure
the recipient’s success in a health professions education program. Members of this
committee are facilitated by the program’s Scholarship Application Coordinator who
provides all pertinent Application information and documentation on each applicant to
committee members for review. The committee members review and score new
applications, according to the policies established by NHHSP. This review is conducted
during the annual review period, scheduled during January 15th through March 31st of
each year
PROCEDURE:
The Director will select and contact each reviewer to confirm their participation in the
Application review and interview process. From January 1st through January 14th, training
of the reviewers by the Director and Scholarship Application Coordinator will cover all
aspects of the required documents contained in the NHHSP Reviewer (Facilitator/
Evaluator) handbook.

Procedure: 3.3 New Scholarship Applications
Section: 3. NHHSP Scholarship Application Cycle
Authority:
Effective Date: August 1, 2012

Revision Date: August 1, 2013

PURPOSE: The opening of the new application cycle begins in December and continues
until March 31. During this time, all qualified Native Hawaiian students interested in
applying for NHHSP funding can submit their applications and supporting documentation
for review by the NHHSP administration. The following procedures outline the tasks
required by the Scholarship Application Coordinator and IT Coordinator, when
receiving, reviewing and processing new applications for NHHSP funding.
PROCEDURE:
Online Application
Applicants must submit their application via the online portal accessible via the online
application at www.NHHSP.org.
The NHHSP online application incorporates the Application Process and Instructions,
Application Checklist and Advisory, APG, Native Hawaiian Ancestry Advisory,
Disadvantaged Background Advisory, Official College Transcript Advisory, as well as
NHHSP forms A through I as indicated below:
Form A: Applicant Resume Instructions & Guideline
Form B: NHHSP Questionnaire & Applicant Narrative Statement
Form C: Memorandum Regarding Conflicting Federal Service Obligations
Form D: Certification Regarding Debarment, Suspension, Disqualification, and
Related Matters
Form E: Delinquent Federal Debt
Form F: Authorization to Release Information
Form G: Course Curriculum Worksheet
Form H: Academic Faculty/Advisor Evaluation of Applicant
Form I: Employer Evaluation of Applicant
In addition to submitting the online application, applicants must also submit all required
supporting documentation as outlined in the Application Process and Instructions within
30 days of their online session #1, but no later than the March 31 deadline. Submission of
this information will begin the review process by the Scholarship Application
Coordinator and Reviewers in preparation for the required interviews scheduled to take
place between January 15 and March 31st. Interviews are conducted with the applicant
either appearing in person or via skype as may be required.

Processing New and Continuation Funding Scholarship Applications and Awards
The NHHSP IT Coordinator will:
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The IT Coordinator, according to Online Application protocol as determined by
the Director and focus group will set up Application Online Session #1 and
Online Session #2 for new applicants, and provide an automated system that
indicates a seamless transition between both sessions. Upon an applicant’s
completion of Online Session #1, the database is programmed to prepare required
User ID, Passwords and notification that will alert the applicant that they are
ready to complete Online Session #2. The Online Session #2 notification is sent
by the Scholarship Application Coordinator once the applicant’s required
documentation is in receipt and noted in the database.
Per continuation funding online application protocol as determined by the
Director and focus group, the IT Coordinator will set up the Continuation Funding
Application under a separate survey on the NHHSP website. Also, a separate
FileMaker Pro database will be created to capture these specific scholars applying
for Continuation Funding Scholars (CFS). The CFS applications will have the
same deadlines as for new applicants.
Receive and date all application data via the online Lime Survey at
application.nhhsp.org and transfer such data to the NHHSP FileMaker Pro
“Application Database” on a daily workweek schedule.
The data becomes available to the Scholarship Application Coordinator for further
processing.
Supports the Scholarship Application Coordinator by producing various reports
required for the review and interview process.
Provides technical assistance to Applicants regarding the online application
process.
Provides technical assistance to the Applicants in preparation for their live Skype
interviews.
Prepares a weekly report on the status of applicants as well as any status updates
regarding the overall IT effort (i.e., website/portal systems, application data
transfers and website & data security).
Backs up the online application process and makes required changes or alterations
as directed by the Director.
Responsible for starting and closing the online website application as directed by
the Director.
May also serve as a facilitator and reviewer of applications and interviews as
indicated by the Scholarship Application Coordinator and Director.
Supports the Director, SAC, and ARC with technical assistance required for the
Application Selection Analysis.
Supports SAC with technical assistance required for notification of award status.
Provide and present IT performance analysis and recommendations for NHHSP
debriefing and evaluations of the NHHSP Application Process concerning the
website, Limesurvey, and FileMaker Pro databases by May 28th.
Support SAC and CSP/Facilitator in preparing the required selected scholar
documents and HRSA contracts to be submitted to HRSA by May 23rd.
Support the Director and SAC with the Scholar Orientation on May 21st.
Prepare selected scholar application data for transfer to the main NHHSP Scholar
Database once scholar selection is approved by HRSA per HRSA’s acknowledged
return receipt of scholar HRSA contracts and DCWs, anticipated no later than
September 30th.

The NHHSP Scholarship Application Coordinator (SAC) will:
1. Receive, date and review all applications via the NHHSP Application Database to
include new applicants as well as Continuation Funding Scholars (CFS).
2. Receive, date, inventory and file all required applicant hardcopy documents
submitted via mail, fax, e-mail and hand-deliveries.
3. When applicable and as driven by the new applicant Application Database,
notification is sent via email to advise applicants of their eligibility to access the
NHHSP Online Session #2, where applicants respond to additional secondary
profile information. Online Session #2 must be completed before the applicant is
scheduled for an interview. Online Session #2 must be completed no later than
March 21st and prior to the overall deadline of March 31st.
4. The CFS applications and required documentation are to be received, dated, and
prepared to be transferred to the existing scholars’ CSP Program Coordinator for
all processing.
5. Schedules and notifies applicants via phone of their Interviews and records such
in the database and on the NHHSP Program Calendar. Applicants are also
notified via e-mail confirming their interview date and time.
6. Schedules and notifies Interview Facilitators (CSP Coordinators) and Interview
Evaluators (members of the ARC) via Microsoft Outlook scheduler of interview
dates and times.
7. Prepares and disseminates pertinent information and documents of applicants to
be reviewed by Interview Facilitators and Evaluators (members of the ARC).
• Application Review instructions.
• Application Interview Evaluation Form with the applicant’s identifying
information.
• Conflict of Interest/Confidentiality/Request for Information form.
• Applicant Resume (Form A).
• Applicant Narrative Statement (Form B).
• Applicant Verified GPA worksheet.
• Interview questionnaire.
• Facilitator note sheets.
• Evaluator note sheets.
• Facilitator’s Summary Evaluation Form (Score Sheet Summary).
8. Collects, reviews, and stores all interview documents upon completion of the
Applicant interview. Verifies interview scores are mathematically correct and
enters such in the Application Database Applicant Selection Analysis. Makes
required notations and any follow-up with Applicant in the Application Database
“Notes” field.
9. Interface with Director and Application Review Committee on the Application
Selection Analysis stored in the Database.
10. Responds to all applicant updates and inquiries with the support of other NHHSP
staff. Makes required notations of such contacts in the Application Database
“Notes” field.
11. Maintains and secures the hardcopy applicant files and documents.
12. Assists Director and Application Review Committee in notifying selected
applicants of their potential award, as well as those applicants selected as
“Alternates” by May 9th.
13. Assists Director and Application Review Committee in immediately notifying
those applicants who are ineligible.
14. Assist Director and ARC in notifying by May 9th those applicants who were not
selected for an award.

15. Scans and secures both original and copy of each applicant’s proof of Native
Hawaiian Ancestry. The scanned copy is archived in the Application Database.
16. All original birth certificates and documents that show proof of Native Hawaiian
Ancestry for those applicants selected will be retained by NHHSP. Such original
documents for those applicants not selected will be mailed back to the applicant.
17. Assist the Director and other NHHSP staff in preparing the newly-selected
scholars’ cohort contracts and required documents to be sent to HRSA by May
22nd.
18. Assist the Director in preparing and scheduling the NHHSP application process
debriefing and evaluations to take place no later than May 28th.

The CSP Coordinator/Interview Facilitator will:
1. Obtain Applicant documents from the SAC and access (new and CFS) applicants
online application via the Application Database for a complete review.
2. Confirm -- a second time -- that the applicant submitted required original
supporting documents.
3. Verify that all required signatures are present.
4. Thoroughly review the supporting documentation for new applicants as follows
and determine if the applicant is eligibile, ineligible or incomplete. The CSP
Facilitator will also identify the applicant’s assets and deficits and will notate such
in the Facilitator’s notes in preparation for required follow up and the applicant’s
interview. The CSP/Facilitator will review the following items:
 Proof of Hawaiian Ancestry
 Applicants Official College Transcripts (Verify Post-Secondary Grade Point Average)
 Applicant’s Letter of Acceptance from College Institution
 Form A: Applicant Resume
 Form B: NHHSP Questionnaire & Applicant Narrative Statement
 Form C: Memorandum Regarding Conflicting Federal Service Obligations
 Form D: Certification Regarding Debarment, Suspension, Disqualification, and Related
Matters
 Form E: Delinquent Federal Debt
 Form F: Authorization to Release Information
 Form G: Course Curriculum Worksheet
 Form H: Academic Faculty/Advisor Evaluation of Applicant
 Form I: Employer Evaluation of Applicant
5. Send an email or contact the applicant by phone and explain what documentation
requires attention, if necessary.
6. Based on the review of the applicant and their supporting documents,
CSP/Facilitator will prepare and conduct a briefing for Evaluators 15 minutes
prior to the applicants 45 minute interview. The Facilitator will reiterate scoring
instructions with Evaluators and summarize the outcomes of the evaluation in a
15 minute wrap up session following the applicant’s interview. The pre-interview
briefing serves to fortify the applicant’s information already provided to
Evaluators in their evaluation packets.
7. If necessary, the CSP/Facilitator updates the Applicant Database with “Verified”
profile information, GPA, education program start date, projected graduation date,
and the number of months applicant is requesting scholarship funding.
8. The CSP/Facilitator collects all evaluator packets for each interview including all
notes and returns them to the SAC for further processing and filing. Also,
included are further instructions to the SAC on any necessary follow-up.

9. Per Director, identify and prepare Data Collection Worksheet (DCW) requests to
colleges and institutions for verification of Tuition and Fees and Other Related
Costs for new applicants and CFS scholars. The CSP/Facilitator will also
calculate the scholar stipend to be entered into the DCW as well as the Database.
10. Upon receipt of institutions final DCW, CSP/Facilitator will enter DCW figures
into the Application Database, and prepare final DCW for submittal to HRSA by
May 23rd.
11. CSP/Facilitator will participate with ARC and the Director in the final analysis
and selection of the new scholar cohort and verify the list of CFS scholars.
12. CSP/Facililtator will participate with the Director and SAC in the Scholar
Orientation planned for May 21st.
13. CSP/Facilitator will assist SAC with final preparation of all required selected
scholars’ documents and HRSA contracts for submittal to HRSA by May 23rd.
14. CSP/Facililtator will participate in the debriefing and evaluation session planned
for May 27th – May 28th.
15. Once scholar HRSA contracts and DCWs are approved by HRSA, the Director
will assign the new cohort to a specific CSP Coordinator. The approved CFS
scholars will remain with their current CSP Program Coordinator for processing.
The CSP Coordinators are to verify the existence of the new and CFS cohort in
the NHHSP Scholar Database, obtain scholar hardcopy files from SAC, then
notify the scholar of their appointment as the CSP Program Coordinator of record.
Award Selection
1. By the end of the first week of May:
•

A review of the selection analysis will be reviewed by NHHSP Staff and the
ARC as facilitated by the Director. The general selection criteria is referenced
in the APG. The specific criteria used in the analysis reflect the scores for the
following items:
- Interview Score
- Scores from Academic and Work Related References.
- Verified Cumulative Post-Secondary Education Grade Point Average.
- Priority Points for Continuation Funding Scholars.
- Priority Points for NHHSP Alumni Scholars.
- Priority Points for Institution Certified Disadvantaged Background Applicants.
- Priority Profession Points
- Concession Points for Master Practitioner(s)/Advocate(s) Recognized by the Native
Hawaiian Health Community.
- Concession Points for Neighbor Island Applicants Disadvantaged by the
Requirement to Re-locate and be Domiciled on another Hawaiian Island to Attend
College in the State of Hawai`i.
- Merit Points for Academic Advance Standing Status which Considerably Reduces
the Normal Length of Time a Scholar must spend in their College Program.

•

The Director, with the support of the SAC, will prepare the short list of new
selected applicants and continuation funding scholars to be reviewed by
NHHSP Staff and the ARC for approval before sending a preliminary list of
NHHSP selections to HRSA by May 7th.
The SAC with the support of the IT Coordinator will send out notification by
May 9th to selected scholars via EchoSign to ascertain whether they intend to
accept or decline an offer of an award. Selected scholars will have 5 working
days to respond or notify NHHSP no later than May 14th.

•

•

•

The SAC with the support of the IT Coordinator will send out notification to
those applicants selected as alternates in the application process by May 9th.
Notification will be made by EchoSign with the request for the applicant to
indicate whether or not they intend to accept the status as an Alternate.
NHHSP will ask for a response within 5 working days or no later than May
14th. Notification to applicants selected as Alternates cannot be done until
HRSA completes their review of the NHHSP recommended selected cohort
which may not be completed until September 30th.
Once NHHSP is in receipt of HRSA’s acknowledgement of selected scholars,
their budgets, and DCWs, NHHSP will:
-

-

Generate Award Letters for scholarship recipients and request that
scholar complete Direct Deposit Sign-Up document and W-4
declaration, and return to NHHSP that will be sent on to HRSA to
establish scholar BMISS account.
Generate Third-Party billing request to the recipient’s
college/university bursar’s office on behalf of NHHSP/HRSA.
Review HRSA approved DCW scholar funding and enter final budget
figures into NHHSP Scholar Database.

Procedure: 3.4 Continuation Scholarship Applications
Section: 3. NHHSP Scholarship Application Cycle
Authority:
Effective Date:

Revision Date:

PURPOSE: The online continuation application cycle opens December 1st and continues
through March 31st. The online instructions details the required continuation application
documents as referenced below. All current scholarship recipients who are remaining in
their respective college programs identified in their Education Profile may apply for
continued scholarship funding via the nhhsp.org as instructed by your CSP Program
Coordinator.
PROCEDURE:
Online Applications
1. The online application for continuation applicants incorporates the Continuation
Application that requests supporting documentation, including most recent
transcript, updated curriculum, resume, Academic and Employer Evaluations,
graduation date, and any changes to the scholar’s identifying information.
2. In addition to submitting their online application, continuation students must
submit all required supporting documentation no later than March 31st.
Submission of this information will begin the review process.
Required Forms










Form A: Applicant Resume
Form B: NHHSP Questionnaire & Applicant Narrative Statement (not required).
Form C: Memorandum Regarding Conflicting Federal Service Obligations
Form D: Certification Regarding Debarment, Suspension, Disqualification, and Related
Matters
Form E: Delinquent Federal Debt
Form F: Authorization to Release Information
Form G: Course Curriculum Worksheet
Form H: Academic Faculty/Advisor Evaluation of Applicant
Form I: Employer Evaluation of Applicant

Processing Continuation Funding Scholar (CFS) Applications and Awards
The SAC will receive all application documents from the CFS scholar and review the
scholars’ online application data. All documentation received by the SAC will be
submitted to the CFS scholar’s current Program Coordinator for a full review and
processing. The Program Coordinator will have access to the online application in the
CFS application database.

1. The complete continuation application packets must contain:
•
•
•

The Forms that are referenced above.
Letter of Acceptance/Proof of Application or Letter of Good Academic
Standing.
Most recent official Transcripts.

2. The CSP Program Coordinator will send a reminder to continuation applicants of
any outstanding documentation required to complete the application by March
21st. This notification will provide the applicant the opportunity to complete his or
her application by the March 31st deadline in order to be eligible to receive
continued scholarship support.
3. The CSP Program Coordinator will schedule an interview with the CFS scholar to
review all application documents and verify all required information to make a
recommendation for funding to the Director and the ARC. This interview will be
conducted either in person or via Skype and will take approximately 45 minutes.
The interview will be facilitated by the CSP Program Coordinator with members
of the ARC in attendance along with the Director. The interview must be
completed no later than March 14th.

Approved Continuation Applications
The following steps must be completed no later than the first week of May:
•

The CSP Program Coordinator(s) will prepare the CFS scholar applicants’
application packet and make recommendation to the ARC and Director for
consideration in the current cohort funding year.

•

The Director and the ARC will make the final recommendations to include CFS
scholars in the short list submitted to HRSA on May 7th. Should a CFS scholar
not be recommended, the scholar will be notified within 1 week of the final
decision.
The CSP Program Coordinator(s) will make certain that the awards made to
approved CFS scholars in the current cohort funding year is indicated in the
Scholar Database accordingly (i.e., 2013-2014 scholar receiving 2014-2015 CFS
cohort funding award).

•

Once NHHSP is in receipt of HRSA’s acknowledgement of selected scholars,
their budgets, and DCWs, NHHSP will:
-

-

Generate Award Letters for scholarship recipients and request that
scholar complete once again the Direct Deposit Sign-Up document and
W-4 declaration, and return to NHHSP that will be sent on to HRSA to
update or re-establish scholar BMISS account.
Generate Third-Party billing request to the recipient’s
college/university bursar’s office on behalf of NHHSP/HRSA.
Review HRSA approved DCW scholar funding and enter final budget
figures into NHHSP Scholar Database.

Appendices

2/28/2014

2014-2015 NHHSP Application Online Session #1

2014-2015 NHHSP Application Online Session #1
Progre ss:

Aloha Applicant,
You are about to begin Session 1 of the 20142015 NHHSP Online Application. Be sure that
you have read the NHHSP Application Process
& Instructions thoroughly and are prepared to
complete this application.
REMINDER: Have you completed NHHSP
recommendations in Step 1 to gather the
required information for Online Session #1 Applicant Profile?
If you are ready to apply, click "Next" below.
- The NHHSP Staff
The re are 54 que stions in this surve y.

Next

http://application.nhhsp.org/index.php/survey/index/sid/712995/newtest/Y/lang/en

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2014-2015 NHHSP Application Online Session #1
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Online Session #1—PART (I): Eligibility Screening:
* Are you of Native Hawaiian Ancestry and able to provide proof and documentation
of such (i.e., Birth Certificate)?
Yes

No

According to 42 U.S.C . 11711(3), “the te rm ‘Native Hawaiian’ m e ans any individual who is—
(A) a citize n of the Unite d State s, and
(B) a de sce ndant of the aboriginal pe ople , who prior to 1778, occupie d and e x e rcise d
sove re ignty in the are a that now constitute s the State of Hawai`i, as e vide nce d by—
(i)
Ge ne alogical re cords,
(ii)
Kūpuna (e lde rs) or Kam a‘aina (long-te rm com m unity re side nts) ve rification, or
(iii) Birth re cords of the State of Hawai`i.”

* Are you willing to relocate to any island after your education and required
licensure to complete the mandatory service obligation component of the NHHSP?
Yes

No

* Are you currently under a federally-funded scholarship that has a service
obligation component to be completed in the future?
Yes

No

*
Do any of the following situations apply to you?
Pursuant to 2 CFR 180.335 (2006) as implemented by 2 CFR 376.10 (2007), an applicant
applying to enter into an application to participate in this program is required to notify
the Federal agency office if the applicant knows that he or she:
A. Is presently debarred, suspended, excluded, or disqualified from participation in
covered transactions by any Federal agency or department;
B. Within the 3-year period preceding the application, has been convicted of, or
had a civil judgment rendered against him or her for any of the following offenses:
* commission of fraud or a criminal offense in connection with obtaining,
attempting to obtain, or performing a public (Federal, State, or local)
transaction or a contract under a public transaction;
* violation of Federal or State antitrust statutes; or
* commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, tax evasion, receiving
stolen property, making false claims, or obstruction of justice;
C. Is presently indicted or otherwise criminally or civilly charged by a governmental
entity (Federal, State, or local) with the commission of any of the offenses set forth
above; or
- Within a 3-year period preceding the application, has had any public

transaction (Federal, State, or local) terminated for cause or default.
Yes

*

No

Are you delinquent on the repayment of any Federal Debt(s)?
Yes

No

Examples of Federal Debt include delinquent taxes, audit disallowances, guaranteed or direct student
loans, FHA loans, and other miscellaneous administrative debts. The definition of delinquency for the
purposes of direct and guaranteed loans are any loan(s) more than 31 days past due on a scheduled
payment. Deferred loans are not considered delinquent by the Native Hawaiian Health Scholarship Program.

* Please Select the Specific Professional Degree you are seeking from the NHHSP
list of eligible programs/degrees for School Year 2014-2015 (If your particular
program/degree is not listed here, you are ineligible for the NHHSP Program, and
can exit the Pre-Qualifying process now):
Choose one of the following answers

Clinical Psychology; Doctoral Degree - PsyD or PhD
Dentistry; Doctoral Degree - DDS or DMD
Dental Hygiene; Bachelor’s of Science Dental Hygiene
Dietetics; Master’s of Science Dietetics
Marriage Family Therapy; Master’s Degree - MFT
Associates Degree in Nursing - ADN
Bachelor’s of Science Degree in Nursing - BSN
Master’s of Science Degree in Nursing; Public Health - MSNMPH
Master’s of Science Degree in Nursing; Nurse Practitioner MSN-NP
Master’s of Science Degree in Nursing; Midwifery - MSN-NM
Medicine; Doctoral Degree in Medicine - MD or DO
Optometry; Doctoral Degree - MD or OD
Pharmacy; Doctoral Degree - PharmD
Physician's Assistant; Master’s Degree - PA
Public Health; Master’s Degree in Public Health - MPH
Social Work; Master’s in Social Work - MSW

*
Are you:
A.) Already enrolled or accepted as a full-time student in a fully accredited health
professions program located in a State, the District of Columbia, the Commonwealth of
Puerto Rico, the Commonwealth of the Northern Marianas, the U.S. Virgin Islands, the
Territory of Guam, the Territory of American Samoa, the Republic of Palau, the Republic of
the Marshall Islands, and the Federated States of Micronesia, and registered or
registering for classes beginning no sooner than July 1, 2014, but no later than
September 30, 2014. Applicants attending unaccredited schools, on a part time basis,
and outside of these geographic areas are not eligible for the Program, although they

may be citizens of the United States and of Native Hawaiian ancestry.
OR
B.) A new student applying in a fully accredited health professions program located in
a State, the District of Columbia, the Commonwealth of Puerto Rico, the Commonwealth
of the Northern Marianas, the U.S. Virgin Islands, the Territory of Guam, the Territory of
American Samoa, the Republic of Palau, the Republic of the Marshall Islands, and the
Federated States of Micronesia, and registering for classes beginning no sooner than
July 1, 2014, but no later than September 30, 2014. Applicants attending
unaccredited schools, on a part time basis, and outside of these geographic areas are
not eligible for the Program, although they may be citizens of the United States and of
Native Hawaiian ancestry.
OR
C.) Neither of the above (If selecting “C”, you are not eligible for a scholarship with
NHHSP, and can exit the Pre-Qualifying process now).
Choose one of the following answers

Please choose...

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2014-2015 NHHSP Application Online Session #1
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Online Session #1—PART (II): Applicant Profile
* Do you authorize your educational institution, university or college, to disclose
and release information to NHHSP, Papa Ola Lokahi, Inc. (POL), and the federal
Department of Health and Human Services (DHHS) about your enrollment? A form
will be provided for your written consent.
Yes

*

First Name:

*

Middle Name:

*

Last Name:

No

Maiden Name (if applicable, as indicated on applicant's birth certificate):

*

Indicate your gender:

Choose one of the following answers

Female
Male

*

Last four digits of your Social Security Number:

*

Date of Birth (MM-DD-YYYY):

...
Hint: Select Month first, then Year, then Day when choosing a date.

*

Home island:

Choose one of the following answers

Please choose...

*

Street Address:

Students in transition: You must provide an address that is not subject to change in the next 12
months.

*

City:

Students in transition: You must provide an address that is not subject to change in the next 12
months. You must type out the full name of your City (no abbreviations).

*

State:

Students in transition: You must provide an address that is not subject to change in the next 12
months. You must type out the full name of your State (no abbreviations).

*

ZIP:

Students in transition: You must provide an address that is not subject to change in the next 12
months.

*

Phone No (ex: 808-123-1234):

Students in transition: You must provide a phone number that is not subject to change in the next 12
months.

*

E-Mail Address:

Students in transition: You must provide an e-mail address that is not subject to change in the next 12
months.

*

Name of Institution, University or College Applied or Applying to:

Choose one of the following answers

Please choose...
If your College or University is not on this list, choose "Other" and type the name of the College for
which you are seeking an NHHSP scholarship.

*

Is your School/College and Program primarily online?
Yes

No

* What is the 6-digit Federal School Code for the institution you are seeking NHHSP
funding for?

Click here to visit FAFSA.gov's School Code Search Tool.

*

Name of specific School/College and Program applied or applying to:

e.g. The John A. Burns School of Medicine, or the Daniel K. Inouye College of Pharmacy.

*

Program Street Address:

*

Program City:

You must type out the full name of your City (no abbreviations).

*

Program State:

You must type out the full name of your State (no abbreviations).

*

Program ZIP:

*

College/University and Program Advisor - Contact Person (name):

Indicate the person's name and title. If uncertain at this time, please indicate "Uncertain."

College/University and Program Advisor - Contact Person Phone No (ex: 808-1231234):

*

Is the School/College and Program you've selected ACCREDITED?

Choose one of the following answers

Yes
No
Not Sure
It is mandatory that NHHSP scholars attend ACCREDITED Schools/Colleges and Programs that are
congruent with national healthcare professional standards and ethics established by such organizations
as the American Medical Association (AMA), the National Association of Social Workers (NASW), American
Dental Association (ADA), etc.

* Are you eligible for In-State tuition at the college/university that you anticipate to
attend in 2014-2015?
Choose one of the following answers

Yes
No

*
Have you received a "Verification of Disadvantaged Background Status" from your
School/College's financial aid office?
If "Yes," prepare to submit the documents to NHHSP.
Choose one of the following answers

Yes
No
Not Applicable
CRITERIA FOR DISADVANTAGED BACKGROUND STATUS:
- Come from an environment that has inhibited them 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 of “Environmentally Disadvantages” for guidance
only and are not intended to be all-inclusive.

Examples:
- Person from high school with low average SAT/ACT scores or below the average State test results.
- Person from a school district where 50 percent or less of graduates go to college.
- Person who has a diagnosed physical or mental impairment that substantially limits participation in
educational experiences.
- Person for who English is not his or her primary language and for whom language is still a barrier to
academic performance.
- Person who is first generation to attend college.
- Person from a high school where at least 30 percent of enrolled students are eligible for free or reduced
price lunches.
– OR –
- Come from a family with an annual income below a level based on low-income thresholds established by
the U.S. Census Bureau, adjusted annually for changes in the Consumer Price Index (Economically
Disadvantaged).
- The Secretary defines a ‘‘low income family’’ 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 or an individual who is not living with any relatives.

*

Have you received an NHHSP scholarship award in the past?
Yes

*

No

Do you have a high school diploma or GED?

Choose one of the following answers

High School
Diploma
GED

*

Please indicate your current Education level:

Choose one of the following answers

Please choose...

*

What was your degree in?

e.g. Medicine, Social Work, Nursing, Public Health, etc.

*

Indicate your cumulative GPA based on your most recent college transcript.

Provide your GPA as indicated on your transcript.

*
Based on your current or proposed college/program curriculum (for which you are
seeking an NHHSP award), how many months of schooling will be required to obtain
your desired degree beginning July 1, 2014?
Choose one of the following answers

Please choose...
e.g. Four year Medical Student: Enrolled at JABSOM beginnning January 1, 2014, is applying to NHHSP
for funding now. This student is not eligible to receive funds from NHHSP to reimburse the tuition and
expenses for the Spring 2014 semester because the NHHSP award for this funding cycle begins July 1, 2014.
4 Years = 48 Months = Total Program months minus 6 months (Spring Jan-June 2014) = 42 months.

*
Based on your desired degree and course curriculum, indicate the approximate date
you started or will start your program:
NOTE: The Letter of Acceptance from your college is required by NHHSP. This letter
will verify your start date.

...
Hint: Select Month first, then Year, then Day when choosing a date. If you do not know the exact day
your program will start, choose the expected month and year, and choose the 1st, as the day of the
month.

*
When is your projected graduation date?

...
Hint: Select Month first, then Year, then Day when choosing a date. If you do not know the exact day
you will graduate, choose the expected month and year, and choose the 1st, as the day of the month.

*
What is your program's published and estimated annual cost for your Tuition, Taxes,
and Fees (TTF)?

*
What is your program's published and estimated annual cost for your Other Related [
Educational ] Costs (ORC)?

e.g. Books, supplies, lab costs, clinical supplies, health insurance, etc.

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Online Session #1—PART (III): Applicant Documents and Forms
*
Online Session #1—PART (III):
Application Documents and Forms
This step identifies specific documents to be read and acknowledged by the Applicant,
as well as forms that must be completed and submitted to NHHSP within 30 days
from the date of the Applicant’s Online Session #1. The applicant must download
these documents and forms to their computer. Important Note: While you are online
in our website, click on the bolded headlines below to download:
□ Download Application Checklist: This form is for the applicant to keep track of task
completion and submittal dates of required program documents.
□ Download a copy of the NHHSP—School Year 2014-2015 Application & Program
Guidance, and known as the APG. Applicants should read and retain this document
contain-ing the authorities, purpose, and guidelines regarding the program.
□ Download Instructions: Proof and Documentation by Applicant of Native Hawaiian
Ancestry: This document is for the applicant’s review and action. Applicants must submit
- by the deadline indicated above - an original copy of their birth certificate and/or other
documentation to show proof of their Hawaiian Ancestry. These documents will be
returned to the applicant by NHHSP after scholarship awards are made. NOTE: Those
applicants who are reapplying to NHHSP, and have already submitted their birth
certificate or proof to NHHSP in the previous 2011 and 2012 application years, please
indi-cate so in a brief statement (noting the application year) and submit to NHHSP by
the deadline.
□ Official College Transcripts: Applicants must request their official College Transcripts
from ALL of their previous and current College institutions, and have the College send
them directly to the Native Hawaiian Health Scholarship Program at 894 Queens Street,
Honolulu, Ha-wai`i, 96813. NOTE: Applicants who are reapplying and have already
submitted their transcripts in the previous 2011 and 2012 application years, must have
their College send only updated transcripts. NOTE: Applicants applying specifically for an
Associate’s Degree in Nursing, must have their High School transcripts sent directly from
the School to NHHSP, as well as verification (college transcripts/current enrollment)
indicating the completion or progress of all A.D.N. program prerequisite courses.
Also, download, complete, and submit the following forms within 30 days from the date of
the Applicant’s Online Session #1. The applicant must download these forms and their
instructions to their computer. Click on the bolded and underlined headings to download:
Form A: Applicant Resume Instructions & Guideline
Form B: NHHSP Questionnaire & Applicant Narrative Statement
Form C: Memorandum Regarding Conflicting Federal Service Obligations
Form D: Certification Regarding Debarment, Suspension, Disqualification, and Related
Matters

Form E: Delinquent Federal Debt
Form F: Authorization to Release Information
Form G: Course Curriculum Worksheet
Form H: Academic Faculty/Advisor Evaluation of Applicant
Form I: Employer Evaluation of Applicant
Original Birth Certificate and/or Proof of Ancestry, along with completed and signed
hardcopies of Forms A through G must be mailed to:
The Native Hawaiian Health Scholarship Program
894 Queen St., Honolulu, HI 96813
Forms H & I that require Faculty/Advisors and Employers Evaluations, as well as all
Official Transcripts from Colleges and other educational institutions must be mailed
specifically by those Evaluators and institutions, directly to NHHSP at the above
address.

DEADLINE: SUBMIT WITHIN 30 DAYS AFTER COMPLETING
NHHSP ONLINE SESSION #1
Failure to submit the above documents & forms within the 30 days, will result in your
online application data being removed from our system. If an applicant requires an
extension to this deadline, they must indicate so in writing, with specifics, to the
above address, ATTN: NHHSP Administrative Assistant.

IN ADDITION TO ALL OF THE ABOVE, AN OFFICIAL LETTER OF
PROGRAM/COLLEGE ACCEPTANCE AND, IF APPLICABLE,
“VERIFICATION OF DISADVANTAGED BACKGROUND STATUS”,
IS DUE AS SOON AS POSSIBLE, BUT NO LATER THAN MARCH 1,
2014
Click here for information on Verification of Disadvantaged Background Status which
will require documentation from your Program/College financial aid office.

Have you downloaded all required Native Hawaiian Health
Scholarship Program Application documentation, and are you
prepared to submit all documents identified in Step 4 to the
NHHSP no later than 30 days from the time you click the
"Submit" button below (if so, choose "Yes" below)?
STOP... CAUTION...
IF YOU SELECT "NO," REGARDLESS OF YOUR REASON, ALL OF
THE INFORMATION YOU PROVIDED IN THIS ONLINE SESSION

#1 WILL BE LOST AND UNRECOVERABLE.
YOU MUST CLICK THE SUBMIT BUTTON BELOW TO COMPLETE
ONLINE SESSION #1.
Yes

Previous

No

Submit

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2014-2015 NHHSP Application Online Session #2
Aloha, Applicant.
W e lcom e to Ste p 5, the Native Hawaiian He alth Scholarship Program 's online application O nline Se ssion
#2.
- The NHHSP Staff

0%

100%

2014-2015 NHHSP Application Online Session #2 - Applicant Identification
*

Enter the password provided in your instructional e-mail.

studytheapg2014
NOTE: NOT your Applicant ID.

* Enter the Applicant ID provided to you in the Online Session #2 Instructional Email:

XXXXXXXXX

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2014-2015 NHHSP Application Online Session #2
Aloha, Applicant.
W e lcom e to Ste p 5, the Native Hawaiian He alth Scholarship Program 's online application O nline Se ssion
#2.
- The NHHSP Staff

0%

100%

Student and Household Income and Expense Information
NHHSP collects other identifying data to assist us in better understanding our scholars and
issues that affect them. This helps us better prepare for our Coordinated Service Planning
effort and staff training.
*

What is your Marital Status?

Choose one of the following answers

Single, Divorced, or Widowed
Married/Remarried
Separated
Other:

*

Do you have any children? If so, indicate the number of children below:

Choose one of the following answers

None
1
2
3
4
Other:

*

How many of your children are 17 and under?

Choose one of the following answers

None
1
2
3
4
Other:

*

STUDENT HOUSEHOLD INCOME INFORMATION:
Did you file a 2012 Income Tax Return?
Yes

*

Did you file a 2013-2014 FAFSA?
Yes

*

No

No

Exemptions Claimed on your filed 2012 Taxes:

Choose one of the following answers

Please choose...

*

What is your adjusted Gross Income from IRS Form filed for 2012?

Please round to the nearest dollar. If there is no income, indicate "0."

*

Students Estimated Income Earned from Work in 2013 (Jan. - Dec. 2013):

Please round to the nearest dollar. If there is no income, indicate "0."

*

Spouse's Estimated Income Earned from Work in 2013 (Jan. - Dec. 2013):

Please round to the nearest dollar. If there is no income, indicate "0."

*

Will you (Student) continue to work in 2014?

Choose one of the following answers

Please choose...

*

Will your Spouse continue to work in 2014?

Choose one of the following answers

Please choose...

*

Indicate Household information, income and estimate your
Current Household Monthly Expenses: Note that your household

includes you and those members of your family that you are
responsible for.
Indicate your current housing situation:
Choose one of the following answers

Please choose...
If "Other," please explain.

*

Total Number of people in your household that you are personally responsible for:

* Total monthly income from you, spouse, & any other member of your household
that you are responsible for:

Please round to the nearest dollar.

*

Monthly Rent or Mortgage (include property taxes, association dues, etc...):

Please round to the nearest dollar. If you do not incur expenses in this category, indicate "0" in your
answer.

* Monthly Household Maintenance Cost - Cleaning products, pest control, security,
yard maintenance, etc...:

Please round to the nearest dollar. If you do not incur expenses in this category, indicate "0" in your
answer.

* Monthly household Utilities - phone, cable, water, electricity, gas, sewer, and
garbage:

Please round to the nearest dollar. If you do not incur expenses in this category, indicate "0" in your
answer.

*

Monthly Public Transportation Cost - Bus pass, cab rides, metro, etc..:

Please round to the nearest dollar. If you do not incur expenses in this category, indicate "0" in your
answer.

*

Monthly Auto Payments, Gas, Maintenance, Parking & Insurance:

Please round to the nearest dollar. If you do not incur expenses in this category, indicate "0" in your
answer.

* Monthly Health Care Insurance, Office visit deductibles, Dental, Drug, and
Medication costs:

Please round to the nearest dollar. If you do not incur expenses in this category, indicate "0" in your
answer.

* Monthly Child Care Cost - Daycare, babysitter, diapers, formula, baby supplies,
and child support:

Please round to the nearest dollar. If you do not incur expenses in this category, indicate "0" in your
answer.

* Monthly Kupuna Care Cost - Daycare, respite care, hygiene needs, handicapaccessible modifications and equipment, etc...:

Please round to the nearest dollar. If you do not incur expenses in this category, indicate "0" in your
answer.

*

Monthly Education Cost:

Please round to the nearest dollar. If you do not incur expenses in this category, indicate "0" in your
answer.

*

Monthly Student Loans:

Please round to the nearest dollar. If you do not incur expenses in this category, indicate "0" in your
answer.

*

Monthly Savings:

Please round to the nearest dollar. If you do not incur expenses in this category, indicate "0" in your
answer.

*

Monthly Clothing Cost:

Please round to the nearest dollar. If you do not incur expenses in this category, indicate "0" in your
answer.

*

Monthly Personal Care Cost - Toiletries, Haircuts, and other items:

Please round to the nearest dollar. If you do not incur expenses in this category, indicate "0" in your
answer.

*

Monthly Pet Care:

Please round to the nearest dollar. If you do not incur expenses in this category, indicate "0" in your
answer.

* Monthly Leisure Cost - Entertainment, Movies, Gifts, Vacations, Hobbies, Parties,
etc...:

Please round to the nearest dollar. If you do not incur expenses in this category, indicate "0" in your
answer.

*

Monthly Charitable Donations:

Please round to the nearest dollar. If you do not incur expenses in this category, indicate "0" in your
answer.

*

Will your housing situation remain the same in 2014-2015?

Choose one of the following answers

Yes

Please enter your comment here:

No

If "No," please explain in the "Comments" section.

*

Will your household income and expenses change in 2014-2015?

Choose one of the following answers

Yes
No

Please enter your comment here:

If "No," please explain in the "Comments" section.

*

What is your mother's Educational Level?

Choose one of the following answers

Middle School/Jr. High
High School/GED
College or beyond
Other:

*

What is your father's Educational Level?

Choose one of the following answers

Middle School/Jr. High
High School/GED
College or beyond
Other:

Previous

Next

Ex it and cle ar surve y

2014-2015 NHHSP Application Online Session #2
Aloha, Applicant.
W e lcom e to Ste p 5, the Native Hawaiian He alth Scholarship Program 's online application O nline Se ssion
#2.
- The NHHSP Staff

0%

100%

2014-2015 NHHSP Application Online Session #2 is Pau!

You have completed the 2014-2015 NHHSP Online Application.
The NHHSP will be contacting you to schedule an interview.

Previous

Submit

Ex it and cle ar surve y

NHHSP Application Process & Instructions
Step 1. Ho`omakaukau (Make ready):
Before beginning the online application, read the instructions and gather the required information indicated below. Once the information is obtained, return to www.nhhsp.org to begin the Application process
that will be done in four Parts. The Parts include: (I) Online Eligibility Screening, (II) Online Application—
Session #1– Applicant Profile, (III) Downloading and Mailing of Application Documents and Forms, and
(IV) Online Application—Session #2. Please note that Parts (I) through (III) of the process must be completed online in one session. The applicant will receive notification from NHHSP to return online to complete Part (IV), Online Application—Session #2.
Besides basic identifying information about the applicant, applicants will need to gather the following
information to study ahead of time and have available while online to complete Step 3, Online Application Session #1– Applicant Profile:
 The name of the PROGRAM you are attending or applying to, and the specific name of the UNIVERSITY and CAMPUS if applicable (e.g. the John A. Burns School of Medicine at the University
of Hawai`i at Manoa).
 The address and 6-digit FAFSA School Code for the Program/University.
 The name and phone number of a Contact Person/Advisor at the Program/University.
 The cumulative GPA on the most recent college transcripts. (Do not include high school GPA)
 The high school GPA if you are applying for the only Associates Degree offered by NHHSP =
Associates Degree in Nursing.
 The timeline associated with the curriculum of the proposed Program (i.e. Program start and
graduation date.)
 The college’s published annual cost of: (1) Tuition, Fees, and Taxes (TTF), and (2) Other Related
[ Educational ] Costs (ORC) as indicated by the Program/University.

APPLICANTS WHO HAVE COMPLETED STEP 1 ARE READY TO MOVE ON TO THE ONLINE
SESSION #1, GO TO http://nhhsp.org/app2014session1 TO BEGIN STEP 2.
THIS SHOULD TAKE APPROXIMATELY 30 MINUTES TO COMPLETE.

Step 2. Online Session #1—PART (I): Eligibility Screening:
Preparing the above information is critical in this process. The applicant must complete Steps 2 and 3 in a
single online session. An applicant’s inability to complete the steps in a single online session will require
the applicant to exit the system and repeat Steps 1 through 3. Answer all questions to the best of your
ability. The determination of your eligibility will be made while online. If you are not eligible, a message
will appear to indicate why. If the applicant does not change his/her “ineligible” answer(s), the session
will end. If you are eligible, you will be prompted to proceed to Step 3, and complete the “Applicant Profile” using the information referenced above.

NHHSP Application Process & Instructions
Step 3. Online Session #1—PART (II): Applicant Profile
This step captures basic profile information about the applicant needed by NHHSP, including contact information, educational history, and information regarding the degree for which the applicant seeks NHHSP
funding. The information the applicant is instructed to gather in Step 1 is critical in completing the
“Applicant Profile”. Again, this step must be completed in the Online Session #1. When the applicant successfully completes this step, a prompt will appear to direct you to Step 4.

Step 4. Online Session #1—PART (III): Application Documents and Forms
This step identifies specific documents to be read and acknowledged by the Applicant, as well as forms
that must be completed and submitted to NHHSP within 30 days from the date of the Applicant’s Online
Session #1. The applicant must download these documents and forms to their computer. Important
Note: While you are online in our website, click on the bolded headlines below to download:
□

Download Application Checklist: This form is for the applicant to keep track of task completion and
submittal dates of required program documents.

□

Download the draft (subject to change) copy of the NHHSP—School Year 2014-2015 Application &
Program Guidance , and known as the APG. Applicants should read and retain this document containing the authorities, purpose, and guidelines regarding the program.

□

Download Instructions: Proof and Documentation by Applicant of Native Hawaiian Ancestry: This
document is for the applicant’s review and action. Applicants must submit - by the deadline indicated
above - an original copy of their birth certificate and/or other documentation to show proof of their
Hawaiian Ancestry. These documents will be returned to the applicant by NHHSP after scholarship
awards are made. NOTE: Those applicants who are reapplying to NHHSP, and have already submitted
their birth certificate or proof to NHHSP in the previous 2011 and 2012 application years, please indicate so in a brief statement (noting the application year) and submit to NHHSP by the deadline.

Download Instructions: Official College Transcripts: Applicants must request their official College
Transcripts from ALL of their previous and current College institutions, and have the College send
them directly to the Native Hawaiian Health Scholarship Program at 894 Queens Street, Honolulu, Hawai`i, 96813. NOTE: Applicants who are reapplying and have already submitted their transcripts in the
previous 2011 and 2012 application years, must have their College send only updated transcripts.
NOTE: Applicants applying specifically for an Associate’s Degree in Nursing, must have their High
School transcripts sent directly from the School to NHHSP, as well as verification (college transcripts/
current enrollment) indicating the completion or progress of all A.D.N. program prerequisite courses.
□

NHHSP Application Process & Instructions
Also, download, complete, and submit the following Forms within 30 days from the date of the Applicant’s Online Session #1. The applicant must download these forms and their instructions to their computer. Click on the bolded and underlined headings to download:
Form A: Applicant Resume Instructions & Guideline
Form B: NHHSP Questionnaire & Applicant Narrative Statement
Form C: Memorandum Regarding Conflicting Federal Service Obligations
Form D: Certification Regarding Debarment, Suspension, Disqualification, and Related Matters
Form E: Delinquent Federal Debt
Form F: Authorization to Release Information
Form G: Course Curriculum Worksheet
Form H: Academic Faculty/Advisor Evaluation of Applicant
Form I: Employer Evaluation of Applicant
Original Birth Certificate and/or Proof of Ancestry, along with completed and signed hardcopies of
Forms A through G must be mailed to:

The Native Hawaiian Health Scholarship Program
894 Queen St., Honolulu, HI 96813
Forms H & I that require Faculty/Advisors and Employers Evaluations, as well as all Official Transcripts
from Colleges and other educational institutions must be mailed specifically by those Evaluators and
institutions, directly to NHHSP at the above address.

DEADLINE: SUBMIT WITHIN 30 DAYS AFTER COMPLETING NHHSP ONLINE SESSION #1
Failure to submit the above documents & forms within the 30 days, will result in your online application
data being removed from our system. If an applicant requires an extension to this deadline, they must
indicate so in writing, with specifics, to the above address, ATTN: NHHSP Administrative Assistant.

IN ADDITION TO ALL OF THE ABOVE, AN OFFICIAL LETTER OF PROGRAM/COLLEGE
ACCEPTANCE AND, IF APPLICABLE, “VERIFICATION OF DISADVANTAGED BACKGROUND
STATUS”, IS DUE AS SOON AS POSSIBLE, BUT NO LATER THAN MARCH 1, 2014
Click here for information on Verification of Disadvantaged Background Status which will require
documentation from your Program/College financial aid office.

NHHSP Application Process & Instructions
Step 5. Online Session #2
After successfully completing Online Session #1 and the submission of required documents and forms,
applicants will be e-mailed a notification containing a link and password granting them access to Online
Session #2.
Online Session #2 will take no more than 15 minutes to complete, and must be completed no more than 5
working days after the notification e-mail is sent to the Applicant by NHHSP. Gather your latest FAFSA
application data (make sure to indicate the FAFSA submission date) to assist you in completing Online
Session #2.

Step 6. Interview
Once an applicant has successfully completed Online Session #2, they are eligible for an interview. The
NHHSP Administrative Assistant will contact eligible applicants to schedule an interview to take place between January 15, 2014 and March 14, 2014.

IF APPLICANTS HAVE ANY QUESTIONS CONCERNING THE ONLINE APPLICATION,
DOCUMENTS AND FORMS, DO NOT HESITATE TO CONTACT THE NHHSP OFFICE AT:

(808)597-6550

or

[email protected]

IF APPLICANTS HAVE QUESTIONS REGARDING THE SELECTION CRITERIA CONCERNING
THEIR APPLICATION, PLEASE REVIEW THE APG.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
HEALTH RESOURSE AND SERVICES ADMINISTRATION
PAPA OLA LOKAHI, THE NATIVE HAWAIIAN HEALTH SCHOLARSHIP PROGRAM

Title 42 Chapter 122 Section 11709– Native Hawaiian Health Scholarship Program

APPLICATION STEPS & CHECKLIST For School Year 2014 - 2015
APPLICANT’S NAME

APPLICATION PROCESS, CHECKLIST, DOCUMENTS & FORMS:
Step 1:
Step 2:
Step 3:
Step 4:

Ho`omakaukau (Make ready)
Online Session #1— PART (I) Eligibility Screening
Online Session #1 – PART (II) Applicant Profile
Online Session #1— PART (III) Documents and Forms

Downloaded draft copy 2014-2015 APG:

Date Completed:
______________
______________
______________
______________
______________

Documents/Forms to be mailed to NHHSP within 30 days of completing Online Session #1:
1. Original Birth Certificate and/or Proof of Native Hawaiian Ancestry
______________
2. Form A: Applicant Resume Instructions & Guideline
______________
3. Form B: NHHSP Questionnaire & Applicant Narrative Statement
______________

4. Form C: Memorandum Regarding Conflicting Federal
Service Obligations
5. Form D: Certification Regarding Debarment, Suspension,
Disqualification, and Related Matters
6. Form E: Delinquent Federal Debt
7. Form F: Authorization to Release Information
8. Form G: Course Curriculum Worksheet
9. Form H: Academic Faculty/Advisor Evaluation of Applicant
10. Form I: Employer Evaluation of Applicant
11. Official College Transcripts:
Date Requested: ___________

______________
______________
______________
______________
______________
______________
______________
______________

Other Documents to be mailed to NHHSP by March 1, 2014:

12. Official Letter of Acceptance from Program/College
13. Verification of Disadvantaged Background Status - (if applicable)

______________
______________

Step 5: Online Session #2
______________
Once the above documents & forms are received by NHHSP, an e-mail with username & password will
be sent to the applicant to complete Online Session #2. Upon completing this step, you will be notified
of a scheduled date and time for your Personal Interview.
Step 6: Personal Interview: Scheduled Date & Time: ______________

______________

REMINDER: Mail requested hardcopy originals to: The Native Hawaiian Health Scholarship Program
894 Queen Street, Honolulu, HI 96813
ATTN: NHHSP Administrative Assistant
If you have any questions concerning the Application process, Documents and Forms, contact NHHSP at:
(808) 597-6550.

Instruc ons ‐ Verifica on of Na ve Hawaiian Ancestry
Aloha, 
As part of applying for a Na ve Hawaiian Health Scholarship Program (NHHSP) award, applicants 
must show proof of Na ve Hawaiian ancestry.  As per the Applica on & Program Guidance (APG), those of 
Na ve Hawaiian descent are defined as: 
According to 42 U.S.C. 11711(3), “the term ‘Na ve Hawaiian’ means any individual who is
(A) a ci zen of the United States, and
(B) (B) a descendant of the aboriginal people, who prior to 1778, occupied and exercised sovereignty in the
area that now cons tutes the State of Hawai`i, as evidenced by—
(i) Genealogical records,
(ii) Kūpuna (elders) or Kama‘aina (long‐term community residents) verifica on,
or (iii) Birth records of the State of Hawai`i.”
Applicants must submit original copies of their birth cer ficate to verify their Na ve Hawaiian  ancestry.  Birth  cer ficates  must  be  submi ed  along  with  the  other  documents  iden fied  in  Step  4  of  the 
NHHSP Applica on Process & Instruc ons document. 

Mail all documents (including Birth Cer ficate) to:

The Na ve Hawaiian Health Scholarship Program 
           894 Queen St. 
           Honolulu, HI  96813 

Instruc ons ‐ Official College Transcripts
Applicants must request their official College Transcripts from ALL of their previous
and current College institutions, and have the College send them directly to:
The Native Hawaiian Health Scholarship Program
894 Queen St, Honolulu, HI 96813
NOTE: Applicants who are reapplying and have already submitted their transcripts
in the previous 2011 and 2012 application years, must have their College send only
updated transcripts.
NOTE: Applicants applying specifically for an Associate’s Degree in Nursing, must
have their High School transcripts sent directly from the School to NHHSP, as well
as verification (college transcripts/current enrollment) indicating the completion or
progress of all A.D.N. program prerequisite courses.

Verification of Disadvantaged Background Status
NATIVE HAWAIIAN HEALTH SCHOLARSHIP PROGRAM (NHHSP)
VERIFICATION REGARDING DISADVANTAGED BACKGROUND
For School Use Only – Must be completed by Financial Aid Official. Once completed, please return to the NHHSP applicant for
submission with their program application.
Student’s Name

Last 4 digits SSN

The Financial Aid Official identified below certifies that the above-named student (check one below):

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:
- Come from an environment that has inhibited them 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 of “Environmentally Disadvantages” for guidance only and are not intended to be all-inclusive.
Examples:
- Person from high school with low average SAT/ACT scores or below the average State test results.
- Person from a school district where 50 percent or less of graduates go to college.
- Person who has a diagnosed physical or mental impairment that substantially limits participation in educational experiences.
- Person for who English is not his or her primary language and for whom language is still a barrier to academic performance.
- Person who is first generation to attend college.
- Person from a high school where at least 30 percent of enrolled students are eligible for free or reduced price lunches.
– OR –
- Come from a family with an annual income below a level based on low-income thresholds established by the U.S. Census Bureau, adjusted annually for changes in the Consumer Price Index (Economically Disadvantaged).
- The Secretary defines a ‘‘low income family’’ 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 or
an individual who is not living with any relatives.
FINANCIAL AID OFFICIAL:
Signature

Date

Printed Name

Phone Number & E-Mail Address:

Last Name, First Name, Middle Initial:

The Native Hawaiian Health Scholarship Program
Form A – Applicant Resume Form
INSTRUCTIONS - Limit your resume to no longer than two pages with a 12 point font.

The Native Hawaiian Health Scholarship Program
Form A – Applicant Resume Form
INSTRUCTIONS - Limit your resume to no longer than two pages with a 12 point font.

The Native Hawaiian Health Scholarship Program
Form B - NHHSP Questionnaire & Applicant Narrative Statement (Fillable PDF). Answer the questions below. Use a 12-point
font, and limit your responses to no more than 300 words per answer, then print all responses upon completion.

Last Name, First Name, Middle Initial:

1. Explain your reasons for requesting this scholarship.

The Native Hawaiian Health Scholarship Program
Form B - NHHSP Questionnaire & Applicant Narrative Statement

Answer the questions below. Use a 12-point font, and limit your responses to no more than 300 words per answer.

2. Share your thoughts on what has motivated you to seek an education and
career in healthcare?

The Native Hawaiian Health Scholarship Program
Form B - NHHSP Questionnaire & Applicant Narrative Statement

Answer the questions below. Use a 12-point font, and limit your responses to no more than 300 words per answer.

3. State your overall career goals, and indicate your vision for your service
obligation placement in Hawai`i upon completing your education:

The Native Hawaiian Health Scholarship Program
Form B - NHHSP Questionnaire & Applicant Narrative Statement

Answer the question below. Use a 12-point font, and limit your responses to no more than 300 words per answer.

4. Explain how these goals will help you serve the Native Hawaiian people.

FORM C- MEMORANDUM REGARDING CONFLICTING
FEDERAL SERVICE OBLIGATIONS
To:

The Native Hawaiian Health Scholarship Program

From:

_______________________________________

Subject:

Conflicting service obligations

Print Name

I, ________________________________________, certify that I have no conflicting service obligations
that would cause a breach of contract with the Native Hawaiian Health Scholarship Program.

Signature of NHHSP 2014-2015 Applicant

Date

Form D‐ Cer fica on Regarding Debarment, Suspension,  
Disqualifica on, and Related Ma ers 
Pursuant to 2 CFR 180.335 (2006) as implemented by 2 CFR 376.10 (2007), an applicant applying to enter
into a covered transaction (which includes an application to participate in this program) is required to notify
the Federal agency office if the applicant knows that he or she:


Is presently debarred, suspended, excluded, or disqualified from participation in covered transactions by
any Federal agency or department;



Within the 3-year period preceding the application, has been convicted of, or had a civil judgment rendered against him or her for any of the following offenses:


commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or
performing a public (Federal, State, or local) transaction or a contract under a public transaction;



violation of Federal or State antitrust statutes; or



commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, receiving stolen property, making false claims, or obstruction of
justice;



Is presently indicted or otherwise criminally or civilly charged by a governmental entity (Federal, State, or
local) with the commission of any of the offenses set forth above; or



Within a 3-year period preceding the application, has had any public transaction (Federal, State, or local)
terminated for cause or default.
The 2014-15 Scholar must sign the cer fica on below which is applicable to his/her situa on. 

□

I certify that none of the above statements apply to me.

OR

□

I certify that one or more of the above statements apply to me.

PRINT name

Signature

Date

DEPARTMENT OF HEALTH AND HUMAN SERVICES
HEALTH RESOURSE AND SERVICES ADMINISTRATION
PAPA OLA LOKAHI, THE NATIVE HAWAIIAN HEALTH SCHOLARSHIP PROGRAM

Title 42 USC Chapter 122 Section 11709– Native Hawaiian Health Scholarship Program

FORM E- DELINQUENT FEDERAL DEBT

APPLICANT’S NAME

SOCIAL SECURITY NUMBER

E-MAIL ADDRESS

PHONE:

□ CELL □ HOME

INSTRUCTIONS:
The applicant must complete and forward this sheet with their application and required supporting documentation. Please check the
appropriate box below. If the “Yes” box is checked, please provide and explanation in the space provided.
Examples of Federal Debt include delinquent taxes, audit disallowances, guaranteed or direct student loans, FHA loans, and other miscellaneous administrative debts. The definition of delinquency for the purposes of direct and guaranteed loans are any loan(s) more
than 31 days past due on a scheduled payment. Deferred loans are not considered delinquent by the Native Hawaiian Health Scholarship Program.
ARE YOU DELINQUENT ON THE REPAYMENT OF ANY FEDERAL DEBT(S)?

□ Yes

□ No

If your response was “Yes,” please provide an explanation in the space provided below. Explanation must include name of Federal
Agency (to which debt is owed), type (student loan, HUD Mortgage, etc.), telephone number and name of contact person(s)
handling debt, and account number if different from your SSN. If you are selected for an award, you will be required to
provide a notarized power of attorney, at a later date, in some cases the Federal Agency may require you to use their
power of attorney document, authorizing the release of information to the NHHSP Division of Grants Operations to
inquire about your debt. If authorization is not included, your application will not be considered for an award.
Federal Agency

Type of Loan

Account #

Contact Name

Phone #

I certify that the information given in this application is accurate and complete to the best of my knowledge and belief. I understand that it may be investigated and that any willfully
false representation is sufficient cause for rejection of this application, or, if awarded a scholarship, that I am liable for repayment of all awarded funds and, further, that any false
statement herein may be subject to penalties under U.S. code, Title 18, Section 1001.
APPLICANT’S SIGNATURE
XXX-XXX-X

DATE
XX

Form F‐ Authoriza on to Release Informa on 
As an applicant in the Native Hawaiian Health Scholarship Program, (NHHSP),
I,
First Name (PRINT)

Middle Initial

Last Name

hereby authorize the school where I am/was enrolled while participating in the NHHSP to disclose information pertaining to my school enrollment to the NHHSP and Papa Ola Lokahi, Inc. (POL) and the U.S. Department of Health and Human Services (DHHS). “Information pertaining to my school enrollment” includes,
but is not limited to, my college transcripts and grades, my academic standing, my enrollment and degree
status, my curriculum and examination requirements for graduation, my tuition and fees, and my leave-ofabsence, withdrawal, or dismissal from school.
If I become a participant in the NHHSP, I also authorize any post-degree training program for which I receive
a deferment from the NHHSP to disclose to POL and DHHS information pertaining to my participation in the
post-degree program including, but not limited to, my curriculum, status in the program, completion date,
examination requirements, and my leave-of-absence, withdrawal or dismissal from the program.
The above authorizations take effect on the date indicated below with my signature.
In addition, I hereby authorize POL and DHHS, to release my name, addresses and social security number to
see if I appear on the Excluded Parties List System. This authorization takes effect on the date I sign this release form. If I do not become a participant, this authorization shall remain in effect until November 30, 2014
If I become a participant in the NHHSP, all of the above authorizations shall remain in effect until the date
my NHHSP scholarship commitment has been fulfilled or these authorizations have been revoked by me in
writing.

Signature

Date

DEPARTMENT OF HEALTH AND HUMAN SERVICES
HEALTH RESOURSE AND SERVICES ADMINISTRATION
PAPA OLA LOKAHI, THE NATIVE HAWAIIAN HEALTH SCHOLARSHIP PROGRAM

Title 42 Chapter 122 Section 11709– Native Hawaiian Health Scholarship Program

FORM G- COURSE CURRICULUM WORKSHEET
APPLICANT’S NAME

SOCIAL SECURITY NUMBER

DEGREE TRACK

EMAIL ADDRESS

THIS FORM MUST BE COMPLETED AND RETURNED TO THE NHHSP

This verifies that the applicant has applied for admission or is enrolled at (Name of College/
University) _________________________________________________ for the academic
year beginning no sooner than July 1, 2014. He/She is enrolled in a full-time undergraduate/graduate curriculum identified above. The individual will be enrolled/or is anticipated to be enrolled in the following courses commencing Summer or Fall 2014.
***INCLUDE CURRICULUM FOR MAJOR FROM FIRST YEAR TO COMPLETION***
Circle One: SEMESTER I / TRIMESTER I / QUARTER I
COURSE NUMBER
CREDIT HOURS
___________________________
______________
___________________________
______________
___________________________
______________
___________________________
______________
___________________________
______________
___________________________
______________
___________________________
______________
___________________________
______________
___________________________
______________
___________________________
______________

(E.G. Aug-Dec 2014)
Months & Year:____________
COURSE TITLE
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________

Circle One: SEMESTER II / TRIMESTER II / QUARTER II
COURSE NUMBER
CREDIT HOURS
___________________________
______________
___________________________
______________
___________________________
______________
___________________________
______________
___________________________
______________
___________________________
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Months & Year:____________
COURSE TITLE
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______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________

SIGNATURE

Circle One: SEMESTER III/TRIMESTER III/QUARTER III
COURSE NUMBER
CREDIT HOURS
___________________________
______________
___________________________
______________
___________________________
______________
___________________________
______________
___________________________
______________
___________________________
______________
___________________________
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___________________________
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___________________________
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Months & Year:____________
COURSE TITLE
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______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
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______________________________

Circle One: SEMESTER IV/TRIMESTER IV/QUARTER IV
COURSE NUMBER
CREDIT HOURS
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___________________________
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Months & Year:____________
COURSE TITLE
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Circle One: SEMESTER V/TRIMESTER V/QUARTER V
COURSE NUMBER
CREDIT HOURS
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___________________________
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Months & Year:____________
COURSE TITLE
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______________________________
______________________________
______________________________
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Circle One: SEMESTER VI/TRIMESTER VI/QUARTER VI
COURSE NUMBER
CREDIT HOURS
___________________________
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___________________________
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Months & Year:____________
COURSE TITLE
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______________________________
______________________________
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Circle One: SEMESTER VII/TRIMESTER VII/QUARTER VII
Months & Year:____________
COURSE NUMBER
CREDIT HOURS
COURSE TITLE
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Circle One: SEMESTER VIII/TRIMESTER VIII/QUARTER VIII
Months & Year:____________
COURSE NUMBER
CREDIT HOURS
COURSE TITLE
___________________________
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______________________________

Form H Instruc ons ‐ Academic Advisor Evalua on Forms
This document contains your instructions, as well as the instructions for your Evaluators and the
evaluation forms they will need to complete.
Applicants, you will need to print and mail or e-mail this PDF to your Evaluators, and it is
your responsibility to ensure that your designated Evaluators have received, completed,
and mailed their evaluations to the NHHSP on your behalf.
Evaluators, please complete the attached form and mail it directly to:
The Native Hawaiian Health Scholarship Program
ATTN: NHHSP Administrative Assistant
894 Queen St.
Honolulu, HI 96813
If you have any questions regarding these documents or the application process, contact us at:
[email protected] or at (808)597-6550.
- The Native Hawaiian Health Scholarship Program Staff

DEPARTMENT OF HEALTH AND HUMAN SERVICES
HEALTH RESOURSE AND SERVICES ADMINISTRATION
PAPA OLA LOKAHI, THE NATIVE HAWAIIAN HEALTH SCHOLARSHIP PROGRAM

Title 42 Chapter 122 Section 11709– Native Hawaiian Health Scholarship Program

FORM H- ACADEMIC FACULTY/ADVISOR EVALUATION

APPLICANT’S NAME

SOCIAL SECURITY NUMBER

EMAIL ADDRESS

PHONE:

ADDRESS

□ CELL □ HOME

The student identified above is applying to receive a Native Hawaiian Health Scholarship Program (NHHSP) scholarship. The information
on this form is requested pursuant Section 751-756 of the Public Health Service Act, as amended, and applicable program regulations
which provide that, in evaluating and selecting individuals for scholarships, consideration will be given to faculty or employer recommendations.
The information provided on this form is treated as confidential and may only be disclosed outside the Department of Health and Human
Services in accordance with provisions of the Privay Act of 1974 (P.L. 93-579) and the terms and conditions of the applicable Privacy Act
Notice published by the Department in the Federal Register.
PLEASE RETURN COMPLETED FORM TO THE NATIVE HAWAIIAN HEALTH SCHOLARSHIP PROGRAM
1. How do you rate the educational/work achievement of this applicant?
5-

□

OUTSTANDING

4-

□

ABOVE AVERAGE

3-

□

AVERAGE

2-

□

BELOW AVERAGE

0-

□

POOR

Comments:______________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
2. How do you rate the applicant’s relationships with other people? Consider such things as ability to work and get along with others.
5-

□

OUTSTANDING

4-

□

ABOVE AVERAGE

3-

□

AVERAGE

2-

□

BELOW AVERAGE

0-

□

POOR

Comments:______________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
3. Based on this applicant’s personal, emotional, and ethical attributes, how do you rate his/her overall potential for the practice of primary health care, especially in a Health Provider Shortage Area (HPSA)?
5-

□

OUTSTANDING

4-

□

ABOVE AVERAGE

3-

□

AVERAGE

2-

□

BELOW AVERAGE

0-

□

POOR

Comments:______________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
4. Type of work (applicant): ________________________________________________________________________________________
5. Length of time known: __________________________________________________________________________________________
Statement of Conflict of Interest: I certify I am not related to applicant by blood or marriage.
I certify that the information provided in this evaluation is accurate. I understand that it may be investigated and that any willfully false
representation is sufficient for rejection of this application.
NAME (Print or type)
POSITION TITLE (Required)
SIGNATURE

PLACE OF EMPLOYMENT (Required)
DATE

Form I Instruc ons ‐ Employer Evalua on Form
This document contains your instructions, as well as the instructions for your Evaluators and the
evaluation forms they will need to complete.
Applicants, you will need to print and mail or e-mail this PDF to your Evaluators, and it is
your responsibility to ensure that your designated Evaluators have received, completed,
and mailed their evaluations to the NHHSP on your behalf.
Evaluators, please complete the attached form and mail it directly to:

The Native Hawaiian Health Scholarship Program
ATTN: NHHSP Administrative Assistant
894 Queen St.
Honolulu, HI 96813

If you have any questions regarding these documents or the application process, contact us at:
[email protected] or at (808)597-6550.
- The Native Hawaiian Health Scholarship Program Staff

DEPARTMENT OF HEALTH AND HUMAN SERVICES
HEALTH RESOURSE AND SERVICES ADMINISTRATION
PAPA OLA LOKAHI, THE NATIVE HAWAIIAN HEALTH SCHOLARSHIP PROGRAM

Title 42 Chapter 122 Section 11709– Native Hawaiian Health Scholarship Program

FORM I- EMPLOYER EVALUATION

APPLICANT’S NAME

SOCIAL SECURITY NUMBER

DEGREE TRACK

EMAIL ADDRESS

The student identified above is applying to receive a Native Hawaiian Health Scholarship Program (NHHSP) scholarship. The information on this form is
requested pursuant Section 751-756 of the Public Health Service Act, as amended, and applicable program regulations which provide that, in evaluating and
selecting individuals for scholarships, consideration will be given to faculty or employer recommendations.
The information provided on this form is treated as confidential and may only be disclosed outside the Department of Health and Human Services in accordance with provisions of the Privay Act of 1974 (P.L. 93-579) and the terms and conditions of the applicable Privacy Act Notice published by the Department in
the Federal Register.

PLEASE RETURN COMPLETED FORM DIRECTLY TO THE NATIVE HAWAIIAN HEALTH SCHOLARSHIP PROGRAM
1. How do you rate the educational/work achievement of this applicant?
5-

□

OUTSTANDING

4-

□

ABOVE AVERAGE

3-

□

AVERAGE

2-

□

BELOW AVERAGE

0-

□

POOR

Comments:______________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
2. How do you rate the applicant’s relationships with other people? Consider such things as ability to work and get along with others.
5-

□

OUTSTANDING

4-

□

ABOVE AVERAGE

3-

□

AVERAGE

2-

□

BELOW AVERAGE

0-

□

POOR

Comments:______________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
3. Based on this applicant’s personal, emotional, and ethical attributes, how do you rate his/her overall potential for the practice of primary health care, especially in a Health Provider Shortage Area (HPSA)?
5-

□

OUTSTANDING

4-

□

ABOVE AVERAGE

3-

□

AVERAGE

2-

□

BELOW AVERAGE

0-

□

POOR

Comments:______________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
4. Type of work (applicant): ________________________________________________________________________________________
5. Length of time known: __________________________________________________________________________________________

**If more space is required, use additional sheets of 8.5x11” paper. Write your name and social security number on each additional sheet
of paper/ Securely attach additional sheets to this form
Statement of Conflict of Interest: I certify I am not related to applicant by blood or marriage.
I certify that the information provided in this evaluation is accurate. I understand that it may be investigated and that any willfully false
representation is sufficient for rejection of this application.
NAME (Print or type)
POSITION TITLE (Required)
SIGNATURE

XXX-XXX-X

PLACE OF EMPLOYMENT (Required)
DATE

XX

Confidentiality/Request for Information
It is the policy of the Native Hawaiian Scholarship Program to ensure
that confidential information is released to external persons
requesting such information only by designated company
representatives.

Every employee (paid and unpaid) is responsible for strictly guarding
the privacy of records and other information concerning employees,
interns/volunteers, applicants and scholars. You may not use any
information for personal reasons or reveal it to anyone outside the
program unless required by law.

I agree to adhere to this policy and I will immediately disclose any
potential breach of confidentiality to my supervisor.

___________________________

__________________

Signature

Date

___________________________
Printed Name

NHHSP Revised 2/2013

Conflict of Interest Policy
It is expected that all employees (paid and unpaid) of the Native
Hawaiian Scholarship Program will use sound judgment at all times in
avoiding actions or commitments that might create conflicts of interest
or that might do harm to the program. In particular, funds, materials,
supplies, proprietary or inside information, or other resources shall
not be used in any way to advance an employee’s personal, outside
business, financial, or other interests.
If you need advice about a potential conflict of interest, please consult
Keaulana Holt, Director, of the Native Hawaiian Health Scholarship
Program.
I agree to adhere to this policy and I will disclose immediately any
potential conflicts of interest to Keaulana Holt, Director, of the Native
Hawaiian Health Scholarship Program.

_____________________________

__________________

Signature

Date

_____________________________
Printed Name

NHHSP Revised 2/2013

INTERVIEW EVALUATION FORM
2014-2015

1. COMMITMENT TO IMPROVING ACCESS TO HEALTH CARE
(Kuleana, Ho`iho`i, Pono, A`o)

Pre-Discussion Rating:

1

2

3

4

Less interest, no experience in/or
understanding of work in Hawai`i
underserved area.

1

2

Post-Discussion Rating:

5

6

7

Interest in serving in Hawaii’s
underserved area; reasonable
conception of access to health
care issues.

3

4

5

8

9

Specific experiences and
activities show strong
commitment to career of service
in Hawai`i’s underserved area.

6

7

8

9

8

9

2. FULFILLING COMMITMENTS, BEING FAIR AND ETHICAL
(Pono, Kuleana, Ha`aha`a)

Pre-Discussion Rating:

1

2

3

4

Sometimes delays or does not
fulfill commitments; identifies
mainly external factors as causes
of problems in performance.

1

2

Post-Discussion Rating:

3

5

6

7

Fulfills basic school and work
obligations credibly; accepts
responsibility for own
performance.

4

5

Specific experiences from a
MUA and activities show
commitment to fulfillment of
obligations and great attention to
quality; takes on more than
typical share of responsibility.

6

7

8

9

3. LEADERSHIP AND TEAM ORIENTATION

(Ha`aha`a, Hana Ka Lima, Ka`i, A`o)
Pre-Discussion:

1

2

3

Displayed little humility; did not
appear comfortable when
structure is lacking; less flexible
in shifting own role to
complement the group.

1

2

Post-Discussion Rating:

3

4

5

6

Able to develop good plans,
structure situations successfully
when called upon; some
experience in supervisory or lead
position; displays cooperative
work style.

4

5

6

7

8

9

Successful in displaying a sense of
humility; successful in initiating
and structuring several types of
activities; achieves appointed or
elected leadership in several areas
and contributes productively to
cooperative efforts and where
authority is shared.

7

8

9

1
FY 2012-13

REV: 02/2013

INTERVIEW EVALUATION FORM
2014-2015

4. BEHAVIORAL FLEXIBILITY AND RESILIENCE
(`Olu`olu & Ha`aha`a)

Pre-Discussion Rating:

1

2

3

Appeared somewhat sheltered,
rigid or immature; less interest
in/or understanding of work in
Hawai`i’s underserved areas.

1

2

Post-Discussion Rating:

3

4

5

6

Some past opportunity for selftesting under stress, changing
circumstances; expected level of
poise in interview.

4

5

7

8

9

Greater success in several
situations requiring considerable
tolerance for stress, adaptation to
altered circumstances, persistence
over obstacles.

6

7

8

9

8

9

5. SUITABILITY

(`Olu`olu, Kuleana, Ho`iho`i, Pono, A`o, Ha`aha`a, Hana Ka Lima, Ka`i)
Pre-Discussion Rating:

1

2

3

Did not demonstrate alignment
with values of the NHHSP.

1

2

Post-Discussion Rating:

3

4

5

6

Interest in serving in Hawaii’s
underserved areas;
reasonable conception of
access to health care.

4

5

7

Sufficient demonstration. of
personal values align with the
values of NHHSP.

6

7

8

9

Name of Applicant: _________________________________________
Discipline: ________________________________________________
Date of Interview: ____________________
Interviewer & Interviewer Signature:
________________________
Print
__________________________
Signature

2
FY 2012-13

REV: 02/2013

SUMMARY

Evaluation Form

2014-2015

Name of Applicant: ______________________________
Discipline: ________________________________________________________________
NHHSP Facilitator: ___________________

______________________ Date: _____________
(Signature)

Post-Rating
1. COMMITMENT TO IMPROVING ACCESS TO HEALTH CARE
(Kuleana, Ho`iho`i, Pono, A`o)

2. FULFILLING COMMITMENTS, BEING FAIR AND ETHICAL
(Pono, Kuleana, Ha`aha`a)

3. LEADERSHIP AND TEAM ORIENTATION
(Ha`aha`a, Hana Ka Lima, Ka`i, A`o)

4. BEHAVIORAL FLEXIBILITY AND RESILIENCE
(`Olu`olu & Ha`aha`a)

5. SUITABILITY

(`Olu`olu, Kuleana, Ho`iho`i, Pono, A`o, Ha`aha`a, Hana Ka Lima, Ka`i)

TOTAL:
Applicant verified as EFN?

Yes

No

Applicant is Clinician / Alumni?

Yes

No

EVALUATORS
________________________________________________Date: _________________
(print name)

(signature)

______________________________________________________ Date: _________________
(print name)
(signature)
______________________________________________________ Date:__________________
(print name)
(signature)
_______________________________________________________ Date: __________________
(print name)
(signature)

Revised: 01/2014

Cumulative GPA Verification
Applicant Name:_______________________________ Reviewed By: ___________________________

INSTITUTION:

Term:

Year:

Attempted
Hours:

Completed
Hours:

Earned
Points:

Total GPA:

#001
#002
#003
#004
#005
#006
#007
#008
#009
#010
#011
#012
#013
#014
#015
#016
#017
#018
#019
#020

Date GPA Verification Completed: _______________________

Page _______ of _______

Date: _______________________________________

NHHSP
GPA Verification Worksheet

NAME OF INSTITUTION #1:
CIRCLE LEVEL OF EDUCATION:

Applicant: ___________________________________
Reviewer: ___________________________________

___________________________________________________________
High School

Undergraduate

Graduate

Post-Graduate

TRANSCRIPT COVERAGE TERMS/YEARS: ____________________________________________________
CONFERRED DEGREE:

___________________________________________________________

VERIFIED CULMULATIVE GRADE POINT AVERAGE:

__________

Notes:
NAME OF INSTITUTION #2:
CIRCLE LEVEL OF EDUCATION:

___________________________________________________________
Undergraduate

Graduate

Post-Graduate

TRANSCRIPT COVERAGE TERMS/YEARS: ____________________________________________________
CONFERRED DEGREE:

___________________________________________________________

VERIFIED CULMULATIVE GRADE POINT AVERAGE:

__________

Notes:
NAME OF INSTITUTION #3:
CIRCLE LEVEL OF EDUCATION:

___________________________________________________________
Undergraduate

Graduate

Post-Graduate

TRANSCRIPT COVERAGE TERMS/YEARS: ____________________________________________________
CONFERRED DEGREE:

___________________________________________________________

VERIFIED CULMULATIVE GRADE POINT AVERAGE:
Notes:

___________
SUB-TOTAL ACADEMIC GPA:
(From Page 1 of 2)

___________

NAME OF INSTITUTION #4:

___________________________________________________________

CIRCLE LEVEL OF EDUCATION:

Undergraduate

Graduate

Post-Graduate

TRANSCRIPT COVERAGE TERMS/YEARS: ____________________________________________________
CONFERRED DEGREE:

___________________________________________________________

VERIFIED CULMULATIVE GRADE POINT AVERAGE:

__________

Notes:
NAME OF INSTITUTION #5:

___________________________________________________________

CIRCLE LEVEL OF EDUCATION:

Undergraduate

Graduate

Post-Graduate

TRANSCRIPT COVERAGE TERMS/YEARS: ____________________________________________________
CONFERRED DEGREE:

___________________________________________________________

VERIFIED CULMULATIVE GRADE POINT AVERAGE:

__________

Notes:
SUB-TOTAL ACADEMIC GPA FROM PAGE TWO:

___________

SUB-TOTAL ACADEMIC GPA FROM PAGE ONE:

___________

_________________________________________________
GRAND TOTAL ACADEMIC GPA:

______________________________
Applicant LAST Name

___________

(From Page 2 of 2)

Date: ______________________________________

NHHSP
Interview Notes

Applicant:___________________________________
Interviewer:__________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Date: ______________________________________

NHHSP
FACILITATOR Notes

Applicant:___________________________________
Interviewer:__________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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