Form 9 CSF 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

NCSP PARTICIPANT
Name:

Social Security Number: XXX-XX-

Address:

PhoneNumber:

City:

State:

Zip Code:

E-mailAddress:

PLACE OF EMPLOYMENT
Name of Facility:

PhoneNumber:

Address:

E-mailAddress:

City:

State:

Zip Code:

FaxNumber:

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:
2. I certify that the NSP participant will begin employment as an RN in this job on:
3. I certify that the NSP participant is required to work

(MM/DD/YYYY)

(MM/DD/YYYY)

_ hours per week of clinical practice in this job.

4. I certify that the NSP participant will begin employment as an RN in this job at the following type of health care facility
(check): Facility Type and Profit Status
__Non Profit
__For Profit
Profit Status:
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.

OMB No. 0915-0301 Expiration Date: 05/31/2021

BUREAU OF Health Workforce
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.

Free and Charitable Clinics - Free and Charitable Clinics are safety-net
health care organizations that utilize a volunteer/staff model to provide a
range of medical, dental, pharmacy, vision and/or behavioral health services
to economically disadvantaged individuals. These clinics are 501(c)(3) taxexempt organizations, or operate as a program component or affiliate of a
501(c)(3) organization.

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 SelfDetermination 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 SelfDetermination 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 nonurban 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.

OMB No. 0915-0301 Expiration Date: 05/31/2021

BUREAU OF Health Workforce
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 FaxNumber

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/DPSC
(301) 451-5384

Public Burden Statement: The purpose of the Nurse Corps Scholarship Program (Nurse Corps SP) is to provide scholarships to nursing students in exchange for a
minimum two-year full-time service commitment (or part-time equivalent), at an eligible health care facility with a critical shortage of nurses. The information that
applicants supply is used to evaluate their eligibility, qualifications and to assess their continued compliance with the applicable standards for participation in the
Nurse Corps SP. The OMB control number for this information collection is 0915-0301 and it is valid until 05/31/2021. This information collection is voluntary. Public
reporting burden for this collection of information is estimated to average .8 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].

OMB No. 0915-0301 Expiration Date: 05/31/2021