Form 1 FY 2017 NHSC S2S LRP 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 Students to Service Loan Repayment Program

Verification of Good Standing

(To be completed by a school official only)

The Verification of Good Standing report certifies that the student identified below is enrolled and in good standing for the 2016-17 academic year as indicated. Please note that all information will be verified for accuracy.

1. Student’s Name (First, Middle Initial, Last):

2. Student’s SSN (Last 4 digits):

3. What program is the student currently enrolled in:

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

5. Degree the student will receive upon completion of the program: _

6. Is the student in their final year of the program: Yes No

7. When will the all course work and rotations be completed?

8. Anticipated date of graduation (mm/dd/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.

School Official’s Signature Printed Name Date

Title Phone Email

Name of School

Student may upload signed form to the NHSC S2S LRP 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.