4 NHHSP Verification of Good Standing

The National Health Service Corps Scholarship Program, Students to Service Loan Repayment Program, and the Native Hawaiian Health Scholarship Program

NHHSP Verification of Good Standing

Native Hawaiian Health Scholarship Program Application

OMB: 0915-0146

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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

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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

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APPLICANT: PAGE 3

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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

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorForde, Kent (HRSA)
File Modified0000-00-00
File Created2021-01-22

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