G Attachment G - Data Collection Worksheet Screenshot

Data Collection Worksheet Form- School Representative Portal

Data Collection Worksheet Form
* required field
School

Discipline

Degree

Capella University

Registered Nurse

Graduate

Thank you for creating a DCW! The form can be completed in 3 easy steps. Please note that all information must be filled in properly to avoid any
processing errors which could result in delayed and/or incorrect payments which may adversely affect the student.
The deadline date for submission of this
information is 06/16/2017 11:59 PM EST.

1. ANNUAL TUITION (2017-2018 AMOUNT)
Please enter in the tuition amount to be enrolled for both an in-state resident as well as an out-of-state resident for an entire ACADEMIC year. Therefore, if
your institution uses a semester system; please include the tuition amount to be enrolled in as a full-time student for each semester (summer, fall, and
spring semesters (3 semesters)). If your institution uses a quarter system; please include the tuition amount to be enrolled in as a full time student for a fall,
winter, spring, and summer quarter (4 quarters).
Annual Tuition Example: if in-state tuition is $15,000 for 1 academic year (semester/quarter), please enter $15,000 for "1st Year Student" and $15,000 for
each subsequent year.
1st Year Student

2nd Year Student

3rd Year Student

4th Year Student

Resident
*

$0

$0

$0

$0

Non-Resident
*

$0

$0

$0

$0

2. FEES
Please enter in the fee amount for an entire ACADEMIC year for each fee type. The fee types listed are the only eligible fees for the NURSE Corps
Scholarship Program. As institutions may have varying names for the types of fees on the form, if a required fee at your institution does not fit into any of the
fee categories noted, please list that fee in the "Other" heading. You will only be allowed to add 1 other fee. Please note that "Other" fees may not be
eligible for reimbursement due to NURSE Corps Scholarship Program fee restrictions.
1st Year Student

2nd Year Student

3rd Year Student

4th Year Student

Academic Support Services

$0

$0

$0

$0

Administrative Fee

$0

$0

$0

$0

Background Check

$0

$0

$0

$0

Building Use / Campus Use Fee /

$0

$0

$0

$0

$0

$0

$0

$0

Career Resource Fee

$0

$0

$0

$0

Computer Use Fee

$0

$0

$0

$0

Counseling Fees

$0

$0

$0

$0

Curriculum Fee

$0

$0

$0

$0

Disability Insurance (if required of all

$0

$0

$0

$0

Drug Testing

$0

$0

$0

$0

Education Fee

$0

$0

$0

$0

Graduation Fee - for students in last

$0

$0

$0

$0

$0

$0

$0

$0

Facility Fee
Capstone Course (if required) mandatory preparatory course

students)

year of program
Health Insurance - for students only
(if required)

http://hrsabmissdev3.nih.gov:9000/extranet/school/dcw/form.seam?cid=88[9/5/2017 2:09:27 PM]

Data Collection Worksheet Form- School Representative Portal

Health Services Fee and

$0

$0

$0

$0

Laboratory Fee

$0

$0

$0

$0

Library Fee

$0

$0

$0

$0

Malpractice Insurance (if required)

$0

$0

$0

$0

Material Fees / Nursing Material Fee

$0

$0

$0

$0

Matriculation Fee

$0

$0

$0

$0

NCLEX Review (if required) -

$0

$0

$0

$0

$0

$0

$0

$0

Processing Fee

$0

$0

$0

$0

Recreation Fee

$0

$0

$0

$0

Registration Fee

$0

$0

$0

$0

Student Activities Fee

$0

$0

$0

$0

Student Association and Union - for

$0

$0

$0

$0

Student Government

$0

$0

$0

$0

Student Initiated Fees (if required) -

$0

$0

$0

$0

Student Services Fee

$0

$0

$0

$0

Technology Fee

$0

$0

$0

$0

Testing (if required) - for course

$0

$0

$0

$0

Transcript Fee

$0

$0

$0

$0

Transportation (if required) - for

$0

$0

$0

$0

University Fee

$0

$0

$0

$0

Other Fees

$0

$0

$0

$0

Immunizations

(if required and does Not include
books)

mandatory preparatory course
Online Tuition - for a course; not an
entire program

campus services; not educational
associations

to fund campus programs and
services

advancement

campus-wide system only

3. OTHER REASONABLE COSTS (ORCS)
Please enter the ORC amount for an entire ACADEMIC year for each ORC type. The NURSE Corps Scholarship Program only offers ORC amounts for the
following three three categories: Books, Clinical Supplies/instruments, and Uniforms.
1st Year Student

2nd Year Student

3rd Year Student

4th Year Student

Books

$0

$0

$0

$0

Clinical Supplies/Instruments

$0

$0

$0

$0

Uniforms

$0

$0

$0

$0

http://hrsabmissdev3.nih.gov:9000/extranet/school/dcw/form.seam?cid=88[9/5/2017 2:09:27 PM]

Data Collection Worksheet Form- School Representative Portal

Please explain any "other" fees in the comments section below.
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