2 NC LRP-Authorization to Release Employment Information.d

OMB No. 0915‐0140

Expiration 04/30/2017

NURSE CORPS LOAN REPAYMENT PROGRAM (NURSE Corps LRP)

AUTHORIZATION for RELEASE of EMPLOYMENT INFORMATION

1. 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 participant 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.

2. 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, 2016.

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.

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0140. Public reporting burden for this collection of information is estimated to average 6 minutes per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, MD 20857.