4 NHHSP Verification of Good Standing

U. S. Department of Health and Human Services HEALTH RESOURCES & SERVICES ADMINISTRATION Bureau of Health Workforce PAPA OLA LOKAHI Title 42 Chapter 122 Section 11709– Native Hawaiian Health Scholarship Program
APPLICANT’S NAME	DEGREE ie. Masters Degree in Nursing
COLLEGE / UNIVERSITY	PROJECTED GRADUATION MO/YR
THIS Form E - Program Course Curriculum MUST BE COMPLETED and RETURNED to NHHSP
APPLICANT applied for Admission or is Enrolled at above-mentioned College/University since/for the Academic Year 20_ - 20 . APPLICANT will be enrolled OR is anticipated to be enrolled Full-Time in an undergraduate/graduate degree-seeking program (identified above) for the Academic Year 2017-2018. LIST Degree Program CURRICULUM from (start of) FIRST YEAR to COMPLETION e.g. FALL 2017 Months: August-December SUMMER _ (Year) Months: _ YEAR ONE COURSE NUMBER CREDIT HOURS COURSE TITLE FALL _(Year) Months: _ COURSE NUMBER CREDIT HOURS COURSE TITLE
SIGNATURE DATE

SPRING _(Year) Months: _

COURSE NUMBER CREDIT HOURS COURSE TITLE

SUMMER _ (Year) Months: _

COURSE NUMBER CREDIT HOURS COURSE TITLE

YEAR TWO

FALL _(Year) Months: _

COURSE NUMBER CREDIT HOURS COURSE TITLE

SPRING _(Year) Months: _

COURSE NUMBER CREDIT HOURS COURSE TITLE

APPLICANT: PAGE 2

SUMMER _ (Year) Months: _

COURSE NUMBER CREDIT HOURS COURSE TITLE

YEAR THREE

FALL _(Year) Months: _

COURSE NUMBER CREDIT HOURS COURSE TITLE

SPRING _(Year) Months: _

COURSE NUMBER CREDIT HOURS COURSE TITLE

SUMMER _ (Year) Months: _

COURSE NUMBER CREDIT HOURS COURSE TITLE

YEAR FOUR

APPLICANT: PAGE 3

FALL _(Year) Months: _

COURSE NUMBER CREDIT HOURS COURSE TITLE

SPRING _(Year) Months: _

COURSE NUMBER CREDIT HOURS COURSE TITLE

(Year) Months: _

COURSE NUMBER CREDIT HOURS COURSE TITLE

(Year) Months: _

COURSE NUMBER CREDIT HOURS COURSE TITLE

APPLICANT: PAGE 4