Form 2-3 NHSC SP Enrollment Verification Form

OMB Number: 0915-0146

Summer 2020

Expiration Date: XX/XX/20XX

Scholar Enrollment Verification Form (EVF)
This document is to verify that you are in good academic standing at your school of record. Please complete all
required fields and return the form with a copy of your most recent unofficial transcript with last semester grades
through the Customer Service Portal at https://programportal.hrsa.gov Failure to submit this form or accurately
complete all required information fields may delay your NHSC SP Tuition and Stipend payments.

Select all terms enrolled for entire school year: Summer___ Fall___ Winter___ Spring___ Block ___
PERSONAL INFORMATION
Name: __________________________________________

Phone (Day) : ___________________________

Mailing Address:__________________________________

Phone (Evening): ________________________

City: ____________________ State: ______Zip:_________

Email (Primary): _________________________
Email (Secondary):________________________

PROGRAM INFORMATION

School Name: ________________________________ State: _____

Did your graduation date change:

Program Length: __________ Year in Program: ________________

If yes, new graduation date:

Yes

No

____/____/______
MM

DD

YYYY

Discipline & Specialty: ___________________________________
Is this your final year:
Is your Transcript with last semester grades attached:

Yes

Yes

No

No
If yes, last day of class:

____/____/______
MM

DD

YYYY

SELECT YOUR CURRENT IN-SCHOOL STATUS BELOW (Check all that apply)
Full-Time (in good academic standing)
Part-Time*

On academic probation*

On an approved leave of absence*

_____/___/_______to____/____/_____
MM

DD

YYYY

MM

DD

YYYY

_____/___/_______to____/____/_____
MM

DD

YYYY

MM

DD

YYYY

No Term (no classes this semester)
Repeating coursework-not on academic
probation*

Declining Support from

Withdraw/Dismissed from school*
_____/___/_______

_____/___/_______to____/____/_____
Repeating coursework-on academic probation*

MM

DD

YYYY

MM

DD

MM

DD

YYYY

YYYY

Other status (explain)*
status other than full-time requires an attached confirmation letter from the school and a separate explanation from
the scholar.
*Any

_________________________________________________

______________________________________________

Scholar’s Signature

School Official’s name

Date

Phone:__________________________________________________
_____________________________________________________________
School Official’s Signature
Date

Email: __________________________________________________

I certify that the above information on this EVF is accurate and complete to the best of my knowledge and belief. I understand that any willfully
false statements made herein may be investigated and be punishable as a felony under U.S. Code, Title 18, section 1001.

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 of the PHS Act and Section 338C-H of PHS Act; NHSC S2S LRP:
Section 338B of the PHS Act and Section 331(i) of the PHS Act; NHHSP: The 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].