Form 2 Authorization to Release Employment Information Form

Nurse Corps Loan Repayment Program
U.S. Department of Health and Human Services
Health Resources and Services Administration

NURSE CORPS LOAN REPAYMENT PROGRAM (NURSE CORPS LRP)
AUTHORIZATION for RELEASE of EMPLOYMENT INFORMATION
i. I authorize my current, former, or future employer or the health care facility or school of nursing where I work as
an RN or nurse faculty to disclose information pertaining to my employment status to the U.S. Department of Health
and Human Services (HHS), and/or its contractors, for purposes of determining my eligibility to participate in the
NURSE CORPS LRP and, if I am selected to participate in the NURSE CORPS LRP, to determine my compliance with the
NURSE CORPS LRP service requirements. “Information pertaining to my employment status” includes, but is not
limited to, my salary, dates of employment, number of hours worked, position held, leave hours/records, nurse
licensure data, or the existence of a service obligation to my employer or the health care facility or school of nursing.
ii. To assess my eligibility to participate in the NURSE CORPS LRP and, if I am selected to participate in the NURSE
CORPS LRP, to determine my compliance with the NURSE CORPS LRP service requirements, I hereby authorize HHS,
and/or its contractors, to release the following information to my current, former, or future employer(s) or the
health care facility or school of nursing where I work as an RN or nurse faculty: my name, social security number and
other information necessary to
identify me.

This authorization will take effect on the date that I sign this release form. If I become a participant in the NURSE
CORPS LRP, this authorization shall remain in effect until the date my NURSE CORPS LRP obligation, including any
extension of the obligation pursuant to a continuation contract, has been fulfilled or this authorization is revoked by
me in writing. If I do not become a participant in the NURSE CORPS LRP, this authorization shall remain in effect until
September 30, 2013.

Signature of Applicant

Date

Name – Printed

Last 4 digits SSN

Authorization for Release of Employment Information Form
This form authorizes the applicant’s employer or the health care facility where he/she works as an RN or nurse
faculty to release information regarding the applicant’s employment status to NURSE CORPS LRP. It also authorizes
HHS, and/or its contractors, to release information to the applicant’s employer or the health care facility where
he/she works as an RN or nurse faculty for purposes of determining his/her eligibility and compliance with the
service requirements
if he/she receives a NURSE CORPS LRP award. If the applicant is awarded a NURSE CORPS LRP contract, his/her
employment status will be verified semiannually.
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OMB No. 0915-0140 Expiration 04/30/2014