NCSP Employment Verification Form

BUREAU OF Health Workforce

NURSE Corps SCHOLARSHIP PROGRAM: INITIAL VERIFICATION OF EMPLOYMENT

TO BE COMPLETED BY THE AUTHORIZED PERSONNEL OFFICIAL OF THE FACILITY

NSP PARTICIPANT

Name: Social Security Number: XXX-XX-

Address: Phone Number:

City: State: Zip Code: E-mail Address:

PLACE OF EMPLOYMENT

Name of Facility: Phone Number:

Address: E-mail Address:

City: State: Zip Code: Fax Number:

Please note: Under the NSP, participants must be working as registered nurses (RNs) providing nursing services at a critical shortage facility. RNs working PRN,

or as Pool Nurses, or for Travel or Nurse Staffing Agencies are not in compliance with their NSP contract. ALL sections MUST be complete for form to be valid.

Please check and complete the certifications below that apply to the NSP participant identified above:

1. I certify that the NSP participant is licensed to practice as a registered nurse without any restrictions.

Please provide the following: License Number: State: Expiration Date: (MM/DD/YYYY)

2. I certify that the NSP participant will begin employment as an RN in this job on: (MM/DD/YYYY)

3. I certify that the NSP participant is required to work _ hours per week of clinical practice in this job.

4. Do you currently work at multiple sites?

   • Yes

   • No

5. If yes, are you working at the same employer at all CSF types?

   • Yes

   • No

6. I certify that the NSP participant will begin employment as an RN in this job at the following type of health care facility (check one):

Please select facility type from table below:

Ambulatory Surgical Center – An entity in a State that provides surgical services to individuals on an outpatient basis and is not owned or operated by a hospital.	Critical Access Hospital (CAH) – A facility that is (a) located in a State that has established with the Centers for Medicare and Medicaid Services (CMS) a Medicare rural hospital flexibility program, (b) designated by the State as a CAH, (c) certified by the CMS as a CAH, and (d) in compliance with all applicable CAH conditions of participation.
Certified Community Behavioral Health Clinic (CCBHC) - A clinic that is certified as a CCBHC by a State in accordance with criteria published by the HHS Secretary and with the requirements of the Protecting Access to Medicare Act of 2014. The criteria include requirements for staffing, availability and accessibility of services, care coordination, scope of services, quality and other reporting, and organizational authority. Certified Community Mental Health Centers (CMHCs) would also fall under this category. A CMHC is an entity that meets applicable licensing or certification requirements for CMHCs in the State in which it is located and provides (1)outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically mentally ill, and residents of its mental health service area who have been discharged from inpatient treatment at a mental health facility; (2) 24- hour-a-day emergency care services; (3) day treatment, or other partial hospitalization services, or psychosocial rehabilitation services; and (4) screening for patients being considered for admission to State mental health facilities to determine the appropriateness of such admission.	Disproportionate Share Hospital (DSH) – A hospital that: 1) has a disproportionately large share of low-income patients; and 2) receives (a) an augmented payment from the State under Medicaid; or (b) a payment adjustment from Medicare. Hospital-based outpatient services are included under this definition.
End Stage Renal Disease (ESRD) Dialysis Centers - An ESRD facility is an entity that provides outpatient maintenance dialysis services, or home dialysis training and support services, or both. ESRD facilities are classified in Section 1881 of the Social Security Act and codified in 42 CFR 413.174 as being either hospital-based or independent facilities.	Federally Qualified Health Center (FQHC) – FQHCs include (1) nonprofit entities that receive a grant, or funding from a grant, under section 330 of the Public Health Service Act to provide primary health services and other related services to a population that is medically underserved; (2) FQHC “Look-Alikes” which are nonprofit entities that are certified by the Secretary as meeting the requirements for receiving a grant under section 330 of the Public Health Service Act but are not grantees; and (3) outpatient health programs or facilities

	operated by a tribe or tribal organization under the Indian Self-Determination Act or by an urban Indian organization receiving funds under Title V of the Indian Health Care Improvement Act. FQHCs include Community Health Centers, Migrant Health Centers, Health Care for the Homeless Health Centers, and Public Housing Primary Care Health Centers.
Home Health Agency – An organization certified under section 1861(o) of the Social Security Act that is primarily engaged in providing skilled nursing care and other therapeutic services.	Hospice Program – An organization certified under section 1861(dd)(2) of the Social Security Act that provides 24-hour care and treatment services (as needed) to terminally ill individuals and bereavement counseling for their immediate family members. This care is provided in individuals’ homes, on an outpatient basis, and on a short-term inpatient basis, directly or under arrangements made by the agency or organization.
Indian Health Service Health Center – A health care facility (whether operated directly by the Indian Health Service or operated by a tribe or tribal organization contractor or grantee under the Indian Self- Determination Act, as described in 42 Code of Federal Regulations (CFR) Part 136, Subparts C and H, or by an urban Indian organization receiving funds under Title V of the Indian Health Care Improvement Act) that is physically separated from a hospital, and which provides clinical treatment services on an outpatient basis to persons of Indian or Alaskan Native descent as described in 42 CFR Section 136.12.	Native Hawaiian Health Center – An entity (a) which is organized under the laws of the State of Hawaii; (b) which provides or arranges for health care services through practitioners licensed by the State of Hawaii where licensure requirements are applicable; (c) which is a public or nonprofit private entity; and (d) in which Native Hawaiian health practitioners significantly participate in the planning, management, monitoring, and evaluation of health services. See the Native Hawaiian Health Care Act of 1988 (Public Law 100-579), as amended by Public Law 102-396.
Nurse Managed Health Clinic/Center - An entity, as defined in42 U.S.C. §254c-1a(a)(2),that utilizes a nurse-practice arrangement, managed by advanced practice nurses, that provides primary care or wellness services to underserved or vulnerable populations and that is associated with a school, college, university or department of nursing, federally qualified health center, or independent nonprofit health or social services agency.	Urgent Care Center – Urgent care centers provide acute episodic care on a walk-in basis to assist patients with an illness or injury that does not appear to be limb or life–threatening and is either beyond the scope or availability of the typical primary care practice.
Public Hospital - Any hospital that is owned by a government (Federal, state, or local), receives government funding, and is primarily engaged in providing the following care, by or under the supervision of physicians, to inpatients: (a) diagnostic and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons; or (b) rehabilitation of injured, disabled, or sick persons. U.S. Department of Veterans Affairs hospitals are also included under this definition. State psychiatric hospitals must use facility HPSAs to determine site eligibility - population and geographic HPSAs cannot be used.	Private Hospital.- A hospital in a State that is a private nonprofit entity and is primarily engaged in providing the following care, by or under the supervision of physicians, to inpatients: (a) diagnostic and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (b) rehabilitation of injured, disabled, or sick persons.
Residential Nursing Home - An institution that is primarily engaged in providing, on a regular basis, health related care and service to individuals who because of their mental or physical condition require care and service (above the level of room and board) that can be made available to them only through institutional facilities. This category includes a “skilled nursing facility,” which is an institution (or distinct part of an institution), certified under section 1819(a) of the Social Security Act, that is primarily engaged in providing skill nursing care and related services to residents requiring medical, rehabilitation, or nursing care and is not primarily for the care and treatment of mental diseases; transitional facilities; assisted living; and group homes.	Rural Health Clinic – An entity that the Centers for Medicare and Medicaid Services has certified as a rural health clinic under section 1861(aa)(2) of the Social Security Act. A rural health clinic provides outpatient services to a non- urban area with an insufficient number of health care practitioners.
State or Local Public Health or Human Services Department – The State, county, parish or district entity in a State that is responsible for providing population focused health services which include health promotion, disease prevention and intervention services provided in clinics or other health care facilities that are operated by the Department.

The certifications and information provided above are true, accurate and complete to the best of my knowledge and belief.

Signature of Nursing Scholarship Participant Date

Name of Authorized Personnel Official (Please Print Clearly) Title

Signature of Personnel Official Date

Personnel Office Telephone Number Personnel Office Fax Number

Please upload the completed and signed form to the Customer Service Portal: https://programportal.hrsa.gov

OR fax the completed and signed form to:

NURSE Corps Program/DPO (301) 451-5384

OMB No. 0915-0301 Expiration Date: 08/31/2015

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current OMB control number. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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 Office, 5600 Fishers Lane, Room 11A-

33, Rockville, Maryland 20857.

OMB No. 0915-0301 Expiration Date: 08/31/2015