Form 4 NHSC LRP FY 2020 - Verification of Disadvantaged Backgro

Public Burden Statement: The purpose of this information collection is to obtain information
through the National Health Service Corps (NHSC) Loan Repayment Program (LRP), NHSC
Substance Use Disorder (SUD) Workforce LRP, and the NHSC Rural Community LRP applications,
which are used to assess an LRP applicant’s eligibility and qualifications for the LRP and to
obtain information for NHSC site applicants. Clinicians interested in participating in a NHSC LRP
must submit an application to the NHSC to participate in one of the NHSC programs, and health
care facilities must submit an NHSC Site Application and Site Recertification Application to
determine the eligibility of sites to participate in the NHSC as an approved service site. 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 information collection is 0915-0127 and it is valid until XX/XX/202X. This information
collection is required to obtain or retain a benefit (Section 333 [254f] (a)(1) of the Public Health
Service Act). Public reporting burden for this collection of information is estimated to average
0.5 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 14N136B, Rockville, Maryland, 20857 or [email protected].

Verification Regarding Disadvantaged
Background
Loan Repayment Program
Financial Aid Official Only: Please return to the NHSC Loan Repayment Program applicant for submission with their program application.
Applicant: Upload this completed form to your application when prompted to do so for consideration as having come from a disadvantaged
background. The NHSC cannot accept faxed or emailed copies.

Student’s Name

Last 4 digits SSN

CRITERIA FOR DISADVANTAGED BACKGROUND STATUS
Students from a disadvantaged background have either participated in, or would have been eligible to participate in, federal programs such as the
Scholarships for Disadvantaged Students, Loans to Disadvantaged Students, or the Nursing Workforce Diversity Grant Program.

1. Environmentally Disadvantaged
If a student who comes from an environment that has inhibited them from obtaining the knowledge, skills, and abilities to
enroll in and/or graduate from a health professions or nursing school is considered as being Environmentally Disadvantaged.
The following is a list of common characteristics that describe students who are Environmentally Disadvantaged. The
examples are provided as guidance only, and are not intended to be all-inclusive:

•
•
•

Person from high school with low average SAT/ACT scores or below the average state test results.
Person from a school district where 50 percent or less of graduates go to college.
Person who has a diagnosed physical or mental impairment that substantially limits participation in educational
experiences.

•

Person for whom English is not his or her primary language and for whom language is still a barrier to academic
performance.

•
•

Person who is first generation to attend college.
Person from a high school where at least 30 percent of enrolled students are eligible for free or reduced price
lunches.

– OR –
2. Economically Disadvantaged
The following characteristics describe students who are considered Economically Disadvantaged:
•

Students who come from a family with an annual income below a level based on low-income thresholds established by the
U.S. Census Bureau, adjusted annually for changes in the Consumer Price Index.

•

The Secretary defines a ‘‘low income family’’ for various health professions and nursing programs included in Titles III, VII
and VIII of the Public Health Service Act as having an annual income that does not exceed 200 percent of the Department’s
poverty guidelines.

•

A family is a group of two or more individuals related by birth, marriage, or adoption who live together or an individual who
is not living with any relatives.

VERIFICATION
Place a check in the box (1) that best matches the Disadvantaged Background status for this former student, based on the Criteria for
Disadvantaged Background Status described in the previous section.
I certify that the student named above is from a disadvantaged background.
I certify that the student named above is NOT from a disadvantaged background.

Email Address

Name of School

5600 Fishers Lane
Rockville, MD 20857

NHSC.hrsa.gov

Verification Regarding Disadvantaged
Background
Loan Repayment Program
FINANCIAL AID OFFICIAL:

Signature

Printed Name

Date

Phone Number