Form 5 Close Out Graduation Form

DEPARTMENT OF HEALTH & HUMAN SERVICES

Health Resources and Services Administration

Bureau of Health Workforce (BHW)

Rockville, Maryland 20857

Nurse Corps Scholarship Program
Graduation/Close out Documentation
*TO BE COMPLETED BY THIRD PARTY BILLING REPRESENTATIVE*

1. Date____________________________________________________________________
2. Name of Participant_______________________________________________________
3. Institution_______________________________________________________________
4. Last Four SSN ___________________________________________________________
5. Graduation Date __________________________________________________________
6. NCSP Balance Owed? Yes______

No______

o If Yes, what is the Balance? __________________________________________


I have attached copy of invoice. Yes______

School Representative Signature
________________________________

Date
________

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].

No______

School Stamp/Seal

Form Approved
OMB No. 0915-0301
Expires 05/31/2021