Form 5 2016 NHSC LRP Verification of Disadvantaged Background F

Verification Regarding Disadvantage Background
LOAN REPAYMENT PROGRAM

Financial Aid Official Only: Please return to the NHSC Loan Repayment Program applicant for submission with their program application.
Applicant: This completed form must be uploaded to your application when prompted to do so for consideration as having come from a
disadvantaged background. The NHSC cannot accept faxed or emailed copies.

Student’s Name

Last 4 digits SSN

CRITERIA FOR DISADVANTAGED BACKGROUND STATUS
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.

1.

Environmentally Disadvantaged
If a student who comes from an environment that has inhibited them from obtaining the knowledge, skills, and abilities to
enroll in and/or graduate from a health professions or nursing school is considered as being Environmentally Disadvantaged.
The following is a list of common characteristics that describe students who are Environmentally Disadvantaged. The examples
are provided as guidance only, and are not intended to be all-inclusive:

•
•
•
•
•
•

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 –
2.

Economically Disadvantaged
The following are characteristics that describe students who are considered Economically Disadvantaged:


Students who 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.



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.

VERIFCATION
Place a check in the box (1) that best matches the Disadvantaged Background status for this former student, based on the Criteria for
Disadvantaged Background Status described in the previous section.
I certify that the student named above is from a disadvantaged background.
I certify that the student named above is NOT from a disadvantaged background.
FINANCIAL AID OFFICIAL:

Signature

Date

Printed Name

Phone Number

Email Address

Name of School

5600 Fishers Lane
Rockville, MD 20857

NHSC.hrsa.gov