NHSC SP – Verification of Disadvantaged Background

OMB No: 0915-0146
Expiration Date: XX/XX/20XX
Bureau of Health Workforce
U.S. Department of Health and Human Services
Health Resources and Services Administration

National Health Service Corps Scholarship Program
VERIFICATION OF DISADVANTAGED BACKGROUND STATUS
(For School Use Only – Must be Completed by Financial Aid Official)

Name of Student:

_Last 4 digits SSN: XXX-XX-

The Financial Aid Official identified below certifies that the above-named student:
☐ is

☐is not

from a disadvantaged background (criteria described below). 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.”
CRITERIA FOR DISADVANTAGED BACKGROUND STATUS
1.

An individual comes from an environment that has inhibited the individual from obtaining the knowledge, skills, and
abilities required to enroll in and graduate from a health professions or nursing school (Environmentally
Disadvantaged). The following are provided as examples for guidance only and are not intended to be all-inclusive.
•

•

•
•

•

•

The individual graduated from (or last attended) a high school with low SAT score based on most recent data
available.
The individual graduated from (or last attended) a high school from which, based on most recent data available,
low percentage of seniors receive a high school diploma; or low percentage of graduates go to college during the
first year after graduation.
The individual graduated from (or last attended) a high school with low per capita funding.
The individual graduated from (or last attended) a high school at which, based on most recent data available,
many of the enrolled students are eligible for free or reduced price lunches.
The individual comes from a family that receives public assistance (e.g., Aid to Families with Dependent Children,
food stamps, Medicaid, public housing).
First generation in family to attend college
OR

2.

An individual comes from a family with an annual income below a level based on low-income thresholds according to family
size established by the U.S. Census Bureau, adjusted annually for changes in the Consumer Price Index, and adjusted
by the Secretary of Health and Human Services (HHS) for adaptation to this program (Economically Disadvantaged). The
Secretary defines a ‘‘low income family/household’’ 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. A household may be only one person.

Signature & Date:
Name & Title:
E-Mail Address:

SUBMITTED BY:
Phone Number:
Name of School:

Student may upload signed form to the NHSC SP Online Application: https://programportal.hrsa.gov/

Public Burden Statement: The purpose of the NHSC SP, NHSC S2S LRP, and the NHHSP is to provide scholarships or loan repayment to qualified
students who are pursuing primary care health professions education and training. In return, students agree to provide primary health care
services at approved facilities located in designated Health Professional Shortage Areas (HPSAs) once they are fully trained and licensed health
professionals. 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 0915-0146 and it is valid until XX/XX/202X.
This information collection is required to obtain or retain a benefit (NHSC SP: Section 338A, Section 338C-H of PHS Act; NHSC S2S: Section
338B and Section 331(i) of the PHS Act; NHHSP: Native Hawaiian Health Care Improvement Act of 1992, as amended [42 U.S.C. 11709]). Public
reporting burden for this collection of information is estimated to average xx 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].