Form 1 FY 2017 NHSC SP Verification of Good Standing

Bureau of Health Workforce

U.S. Department of Health and Human Services Health Resources and Services Administration

OMB No.: 0915-0146

Expiration Date: XX/XX/20XX

NATIONAL HEALTH SERVICE CORPS SCHOLARSHIP PROGRAM

ACCEPTANCE REPORT/VERIFICATION OF GOOD STANDING

This Acceptance Report/Verification of Good Standing certifies that the student identified below has been accepted for admission or is enrolled in good standing for the 2016-2017 school year (i.e., July 1, 2016 – June 30, 2017) as indicated. Please note all information will be verified for accuracy. (To be completed by a school official only)

1. Student’s Name (Last, First, Middle): 2. Student’s SSN (Last 4 digits):

3. What program is the student admitted to? (Please specify if the program is a dual degree or bridge program.)

3. Is the student in good standing? (If NO, please explain.)

3. Degree/certificate the student will receive upon completion of the program:

3. Student classification as of the 2016-2017 school year: 1^st 2^nd 3^rd 4^th

3. If the student is newly enrolled, is there a contingency to the student’s acceptance to the program other than standard contingencies that apply to all admitted applicants? Examples include the student needing to repeat a course or the student receiving an “Incomplete” status for a course. Yes No

If YES, please explain:

(All contingencies must be met by June 30, 2017)

3. Student Status (check all that is applicable):

Full-Time Enrollment Part-Time Enrollment Repeating Course Work On Academic Probation

Leave of Absence Withdrawn Other (Please explain):

3. What schedule does the school year operate on?

Semester system Quarter system Trimester system Other (Please explain):

3. Length of the full-time program (months or years):

3. Date student began the program (mm/yyyy):

3. Date class begins for the school year 2016-2017 (mm/yyyy):

3. Anticipated date of graduation (mm/yyyy):

By signing my name below, I certify that the current status of the student listed above has been correctly identified. I further certify that, where necessary, I have corrected the “Year in Program” and “Date of Graduation” for the student to accurately reflect the anticipated graduation date given the current enrollment. I understand that any willfully false information may be punishable as a felony under U.S. Code, Title 18, Section 1001.

SUBMITTED BY:

Signature: Date: Name: Title:

Phone Number: E-Mail:______________________________________ Address: Name of School:

Student may upload signed form to the NHSC SP Online Application: https://programportal.hrsa.gov/

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 0915–0146. Public reporting burden for this collection of information is estimated to average 0.25 hours 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.