Form 8 Verification of Academic Standing

BUREAU OF HEALTH WORKFORCE

VERIFICATION OF ACCEPTANCE/GOOD STANDING REPORT
This Verification of Acceptance/Good Standing Report certifies that the student identified below has been accepted for admission or is enrolled in good
standing in the nursing degree program in which student is applying for the 2020-2021 academic year as indicated. (To be completed by a school official only.)

2. Student’s Social Security Number (Last 4 digits ONLY)

1. Student’s Name (Last, First, Middle)

3. Nursing program the student is enrolled in for the academic term 2020-2021:
Diploma

Associate (ADN)

Baccalaureate (BSN)

Accelerated BSN (ABSN)

Masters (MSN-NP): Specialty _________________________________________
Direct Masters Entry NP: Specialty ____________________________________________
Masters (MS-Other): Please Explain ______________________________________________
Doctoral (DNP)

MSN RN Generalist

4. When will/did the student enter the nursing program for which funding is being requested: (mm/yy):
5. Is the student in good academic standing? Yes
No
6. Is the student considered Full-Time or Part Time in the nursing program? Full-Time

Part-Time

7. Length of the full-time nursing program (years and/or months):
8. Date professional nursing classes begin for the 2020-2021 academic year (mm/yy):
9. Nursing program end date (Completion of required classes for graduation) (mm/yy):
10.

Anticipated date of graduation (mm/yy):

11.

Students total cumulative Grade Point Average (GPA):

12. Is there a contingency to the students acceptance to the program? Examples include the student needing to
repeat a course or having received and "Incomplete" status for a course
No
Yes
If yes, please explain:
(All contingencies must be met by the start of the Fall 2020-2021 term.)
13. Nursing Program Accreditation (The NCSP will only fund students attending fully accredited institutions)
Name of National or Regional Accreditation Organization:
Accreditation Expiration / Renewal Date: (mm/yy):
Is accreditation provisional? Yes

No

School Information

Nursing School Official Contact Information

Name of School:

Name & Title:

Address:

Phone Number:

Fax:

E-mail Address:
City:

State:

Zip Code:

By signing my name below, I certify that the information provided on this Verification of Acceptance/Good Standing Report is accurate and complete to the
best of my knowledge and belief. I understand that any willfully false information may be punishable as a felony under U.S. Code, Title 18, Section 1001.

Signature of Nursing School Official:

Date

Must be received by April 30, 2020 at 7:30 pm ET.

Please upload to the Nurse Corps SP Portal: https://programportal.hrsa.gov/