2 NHHSP Letters of Recommendation Forms

The National Health Service Corps Scholarship Program, Students to Service Loan Repayment Program, and the Native Hawaiian Health Scholarship Program

NHHSP Letters of Recommendation Forms

Native Hawaiian Health Scholarship Program Application

OMB: 0915-0146

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ACADEMIC FACULTY/ADVISOR EVALUATION FORM

Instructions

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Applicant:

Mail or e-Mail the attached evaluation form, along with this instruction page to your evaluator.


Ensure that your designated ACADEMIC evaluator has received, completed, signed and mailed their evaluation directly to NHHSP.



NOTE: The Academic Faculty/Advisor Evaluation form is MANDATORY.




Evaluator:

Complete and mail the attached form directly to:


Native Hawaiian Health Scholarship Program ATTN: NHHSP Operations Coordinator

894 Queen Street

Honolulu, HI 96813



REMINDER: THE ATTACHED FORM MUST BE MAILED TO NHHSP NO LATER THAN MARCH 1, 2017.



If you have any questions, contact the NHHSP Operations Coordinator at (808) 597-6550 ext. 203 or [email protected]


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U. S. Department of Health and Human Services HEALTH RESOURCES & SERVICES ADMINISTRATION

Bureau of Health Workforce PAPA OLA LOKAHI






Title 42 Chapter 122 Section 11709– Native Hawaiian Health Scholarship Program

APPLICANT’S NAME

eMAIL ADDRESS

PHONE: CELL HOME

COLLEGE / UNIVERSITY

PROJECTED Graduation MO/YR

The student/NHHSP Applicant, identified above, is applying for a Scholarship with the Native Hawaiian Health Scholarship Program (NHHSP). The requested information is pursuant to Section 751-756 of the Public Health Service Act, and the applicable program regulations which provide for consideration be given, based on academic faculty/advisor recommendation when evaluating and selecting individuals for scholarships.


The information provided on this form is treated as confidential and may only be disclosed outside the U. S. Department of Health and Human Services in accordance with provisions of the Privacy Act of 1974 (P.L. 93-579) and the terms and conditions of the applicable Privacy Act Notice published by the Department in the Federal Register.


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Return this completed & signed ACADEMIC EVALUATION’ Form #1 to NHHSP


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  1. How do you rate the educational and/or work achievement of this Applicant?

5 - OUTSTANDING 4 - ABOVE AVERAGE 3 - AVERAGE 2 - BELOW AVERAGE 1 - POOR

Comments:




  1. How do you rate the Applicant’s relationships with other people? Consider such things as ability to work and get along with others. 5 - OUTSTANDING 4 - ABOVE AVERAGE 3 - AVERAGE 2 - BELOW AVERAGE 1 - POOR

Comments:




  1. Based on this Applicant’s personal, emotional, and ethical attributes, how do you rate his/her overall potential for the practice of primary health care, especially in a Health Provider Shortage Area (HPSA)?

5 - OUTSTANDING 4 - ABOVE AVERAGE 3 - AVERAGE 2 - BELOW AVERAGE 1 - POOR

Comments:



  1. Relationship to NHHSP Applicant:

  2. How long have you known the Applicant?

Statement of Conflict of Interest: I certify I am not related to NHHSP Applicant by blood or marriage.

I certify that the information provided in this evaluation is accurate. I understand that it may be investigated and that any willfully false representation is sufficient for rejection of this application.

NAME (Print or type)

POSITION TITLE (Required)

PLACE OF EMPLOYMENT (Required)

SIGNATURE

DATE




EMPLOYER EVALUATION FORM

Instructions

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Applicant:

Mail or eMail the attached evaluation form, along with this instruction page to your evaluator.


Ensure that your designated EMPLOYER evaluator has received, completed, signed and mailed the evaluation form directly to NHHSP.


NOTE:

If you are currently unemployed, a Community Resource/Personal Reference Evaluation form may be completed and submitted in lieu of an Employer Evaluation form.




Evaluator:

Complete and mail the attached form directly to:


Native Hawaiian Health Scholarship Program ATTN: NHHSP Operations Coordinator

894 Queen Street

Honolulu, HI 96813



REMINDER: THIS FORM MUST BE SUBMITTED TO NHHSP NO LATER THAN MARCH 1, 2017.



If you have any questions, contact the NHHSP Operations Coordinator at (808) 597-6550 ext. 203 or [email protected]


Shape14



U. S. Department of Health and Human Services HEALTH RESOURCES & SERVICES ADMINISTRATION

Bureau of Health Workforce PAPA OLA LOKAHI






Title 42 Chapter 122 Section 11709– Native Hawaiian Health Scholarship Program

NHHSP APPLICANT’S NAME

eMAIL ADDRESS


APPLICANT’S place of Employment

PHONE: CELL HOME

The NHHSP Applicant, identified above, is applying to receive a Native Hawaiian Health Scholarship Program (NHHSP) scholarship. The information on this form is requested pursuant to Section 751-756 of the Public Health Service Act, and the applicable program regulations which provide for consideration be given, based on employer recommendation, when evaluating and selecting individuals for scholarships.

The information provided on this form is treated as confidential and may only be disclosed outside the U. S. Department of Health and Human Services in accordance with provisions of the Privacy Act of 1974 (P.L. 93-579) and the terms and conditions of the applicable Privacy Act Notice published by the Department in the Federal Register.


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Return this completed & signed EMPLOYER EVALUATION’ Form #2 directly to NHHSP


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1. How do you rate the educational and/or work achievement of this Applicant?

5 - OUTSTANDING 4 - ABOVE AVERAGE 3 - AVERAGE 2 - BELOW AVERAGE 1 - POOR

Comments:




  1. How do you rate the Applicant’s relationships with other people? Consider such things as ability to work and get along with others. 5 - OUTSTANDING 4 - ABOVE AVERAGE 3 - AVERAGE 2 - BELOW AVERAGE 1 - POOR

Comments:



  1. Based on this Applicant’s personal, emotional, and ethical attributes, how do you rate his/her overall potential for the practice of primary health care, especially in a Health Provider Shortage Area (HPSA)?

5 - OUTSTANDING 4 - ABOVE AVERAGE 3 - AVERAGE 2 - BELOW AVERAGE 1 - POOR

Comments:



  1. Relationship to NHHSP Applicant:

  2. Length of time known:

**If more space is required, use additional sheets of 8.5x11” paper. Write your name and social security number on each additional sheet of paper/ Securely attach additional sheets to this form


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Statement of Conflict of Interest: I certify I am not related to NHHSP Applicant by blood or marriage.

Shape23 I certify that the information provided in this evaluation is accurate. I understand that it may be investigated and that any willfully false representation is sufficient for rejection of this application.


NAME (Print or type)


POSITION TITLE (Required)

PLACE of EMPLOYMENT (Required)

SIGNATURE

DATE



COMMUNITY RESOURCE / PERSONAL REFERENCE EVALUATION FORM

Instructions

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Applicant:

Print and mail or eMail the attached evaluation form, along with this instruction page to your evaluator.


Ensure that your designated COMMUNITY RESOURCE/PERSONAL REFERENCE evaluator has received, completed, signed and mailed their evaluation directly to NHHSP.




Evaluator:

Complete and mail the attached form directly to:


Native Hawaiian Health Scholarship Program ATTN: NHHSP Operations Coordinator

894 Queen Street

Honolulu, HI 96813





REMINDER: THIS FORM MUST BE SUBMITTED TO NHHSP NO LATER THAN MARCH 1, 2017.




If you have any questions contact the NHHSP Operations Coordinator at (808) 597-6550 ext. 203

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U. S. Department of Health and Human Services HEALTH RESOURCES & SERVICES ADMINISTRATION

Bureau of Health Workforce PAPA OLA LOKAHI






Title 42 Chapter 122 Section 11709– Native Hawaiian Health Scholarship Program

NHHSP APPLICANT’S NAME


eMAIL ADDRESS


APPLICANT’S relationship to Evaluator


PHONE: CELL HOME

The NHHSP Applicant, identified above, is applying to receive a Native Hawaiian Health Scholarship Program (NHHSP) scholarship. The requested information on this form is pursuant to Section 751-756 of the Public Health Service Act, and the applicable program regulations which provide for consideration be given, based on community resource or personal reference recommendation, when evaluating and selecting individuals for scholarships.


The information provided on this form is treated as confidential and may only be disclosed outside the Department of Health and Human Services in accordance with provisions of the Privacy Act of 1974 (P.L. 93-579) and the terms and conditions of the applicable Privacy Act Notice published by the Department in the Federal Register.

Return this completed & signed COMMUNITY RESOURCE/PERSONAL REFERENCE’ Form #3 directly to NHHSP.


  1. How do you rate the educational and/or work achievement of this Applicant?

5 - OUTSTANDING 4 - ABOVE AVERAGE 3 - AVERAGE 2 - BELOW AVERAGE 1 - POOR

Comments:




  1. How do you rate the Applicant’s relationships with other people? Consider such things as ability to work and get along with others. 5 - OUTSTANDING 4 - ABOVE AVERAGE 3 - AVERAGE 2 - BELOW AVERAGE 1 - POOR

Comments:




  1. Based on this Applicant’s personal, emotional, and ethical attributes, how do you rate his/her overall potential for the practice of primary health care, especially in a Health Provider Shortage Area (HPSA)?

5 - OUTSTANDING 4 - ABOVE AVERAGE 3 - AVERAGE 2 - BELOW AVERAGE 1 - POOR

Comments:




  1. Applicant’s role/job at Community Agency:

  2. Length of time known:

**If more space is required, useadditional sheets of 8.5x11” paper. Writeyour name and social security number on each additional sheet of paper/ Securely attach additional sheets to this form


Statement of Conflict of Interest: I certify I am not related to the NHHSP Applicant by blood or marriage.

I certify that the information provided in this evaluation is accurate. I understand that it may be investigated and that any willfully false representation is sufficient for rejection of this application.

NAME (Print or type)

Position Title (at Community Agency)


ame of Community Agency

SIGNATURE


DATE






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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorForde, Kent (HRSA)
File Modified0000-00-00
File Created2021-01-14

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