4-1 NHHSP Application

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

NHHSP Application

Native Hawaiian Health Scholarship Program Application

OMB: 0915-0146

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0915-0146 can be found here:

2023-05-09 - Revision of a currently approved collection

Document [pdf]

Download: pdf | pdf

OMB Number: 0915-0146
Expiration Date: XX/XX/20XX

NHHSP 2020-2021 Scholarship
Instruction Letter and
Application Process &
Instructions

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 338CH 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].

January 28, 2020
RE: Instruction Letter for the Application Year 2020‐2021
Dear Applicant,
Thank you for your interest in applying to the Native Hawaiian Health Scholarship/Papa Ola Lōkahi Program for the academic
year 2020‐2021.
Please review the 2020‐2021 Application Program Guidance (APG) and 2020‐2021 Application and Process Instructions
carefully before you submit your application. All completed applications are to be submitted via the online google forms and
supporting documents via e‐mail to [email protected]; no paper applications will be available or accepted. Please note
that the deadline is March 15, 2020.
In order to apply for a Native Hawaiian Health Scholarship (NHHSP) award, you MUST meet the following to be eligible:
(1) Provide the Native Hawaiian Scholarship Program with documents as evidence of your Native Hawaiian ancestry, in
accordance with the Native Hawaiian Care Improvement Act, 42 U.S.C. 11709 and 11711 (3), applicants to the Native
Hawaiian Health Scholarship Program (NHHSP) are to “Be of Native Hawaiian ancestry” and are required to provide
NHHSP “… with evidence of genealogical records, Kupuna and Kama`aina verification or birth records of the State of
Hawai`i.”
(2) Relocate to any island after your education and required licensure, to complete the mandatory service obligation
component of the award
(3) Free of other federal service obligation(s) to be completed in the future.
Applicants, except military reservists, who are already obligated to a Federal, State or other entity for professional
practice or service after academic training are not eligible for Scholarship Program awards. An exception may be made if
the obligating entity provides documentation that there is no potential conflict in fulfilling the service commitment to the
Scholarship Program and that the Scholarship Program service commitment will be performed first.
(4) Accepted or currently enrolled as a full‐time student in a fully accredited health professions program beginning no later
than September 30, 2020.
Should you meet the above eligibility, please complete the application packet and return as indicated in the instructions.
Upon receipt and review of application materials, eligible applicants will be contacted by email or telephone for a scholarship
interview.
Should you have any questions and/comments please feel free to email us at [email protected] or call the office at the
phone number listed below.
Our office hours are from 8:00 a.m. to 4:30 p.m. Monday to Friday. We are closed on State and Federal holidays. You may
leave a voice mail if you find it necessary to call after hours. Your voice mail will be answered on the next business day.
Mahalo,
Native Hawaiian Health Scholarship Program at Papa Ola Lōkahi
894 Queen Street
Honolulu, HI 96813
(808) 597‐6550 (office) ext. 203

NHHSP 2020‐2021 Application Process & Instructions
Online Application Opens: February 1, 2020
www.nhhsp.org
Closes: March 15, 2020 11:59pm HST

The NHHSP Application Process includes the following Steps:
(I)

(II)

Read the following from www.nhhsp.org/resources
1. NHHSP 2020-2021 Application & Program Guidance (APG)
2. NHHSP Letter and Application Process and Instructions
3. NHHSP Applicant Forms
Prepare Information for the Application:

Gather all the required information you will need to submit your NHHSP Application as indicated below:
1. A mailing address, last 4 digits of the applicant’s Social Security Number, the applicant’s home
island, phone number, email address, and other contact information (all information requested
here must be valid through September 30, 2020).
2. The name of the PROGRAM*** you are attending or applying to, and the specific name of the
UNIVERSITY and CAMPUS, if applicable (e.g. University of Hawai`i School of Nursing and Dental
Hygiene at Manoa). Applicants who are applying to multiple Universities will list their top 3
choices.
3. The mailing address for the Program/University(s).
4. The name and phone number of a Contact Person/Advisor at the Program/ University(s).
5. If you are applying for an NHHSP award while also applying for your program of study, you must
submit proof of your college/program acceptance and begin instruction/ classes/ coursework no
later than September 30, 2020. YOU ARE NOT ELIGIBLE FOR AN AWARD if you are scheduled to
begin your program of study any time after September 30, 2020.
6. Transcripts from all colleges/university attended.
7. The timeline associated with the curriculum of the proposed Program (i.e. Program start, and
graduation dates based on an official course curriculum and schedule).
***list of eligible programs as stated in the Annual Program Guidance and as the end of this document

(III)

NHHSP Applicant Forms
Complete NHHSP Application. Follow the instructions and complete the following:
1. Google Form – Complete the applicant profile in Google Forms (note that a Google email
address account ([email protected]) account is needed to access Google Forms)
FORMS COMPLETION ‐ Complete the application forms and upload to the respective areas in
the google form – read through each document and follow the instructions carefully:
•

Provide a headshot

•

Form A: Authorization to Release Information

•

Form B: Program Course Curriculum

•

Form C: Applicant Resume/CV (no more than 2 pages)

•

Form D: NHHSP Applicant Personal Statement (no longer than 2000 words)

•

Form E: College Letter of Acceptance/Proof of Application: If you plan to begin your
program in the Fall of 2020 (but no later than September 30, 2020) and are awaiting your
acceptance letter, then you must submit any and all correspondence from your college
regarding your application (e.g. letters of conditional acceptance pending the completion of
a prerequisite course, etc.). The deadline to submit your College Letter of Acceptance to
NHHSP is May 1, 2020 at 11:59pm HST.

***ALL Uploaded documents must be labeled as follows LAST NAME_FIRST INITIAL_FORM (A‐E)
(ex. "SMITH_J_FORM_A") ***
2. OTHER REQUIRED DOCUMENTS: There are additional instructions on specific documents that
require the applicant to SUBMIT EITHER by MAIL OR EMAIL:
•

Proof of Hawaiian Ancestry (i.e., applicant’s embossed seal birth certificate) must be
MAILED and received by NHHSP by the deadline of March 15, 2020:
Mail Proof of Hawaiian Ancestry to:
NHHSP – Attn: Admin. Assistant
894 Queen Street
Honolulu, Hawai`i 96813

•

All Past and Current College Transcripts of the applicant must be submitted by the
applicant and MAILED or EMAILED to NHHSP by March 15, 2020.
Applicants Mail or Email college transcripts to:
NHHSP – Attn: Admin. Assistant,
894 Queen Street
Honolulu, Hawai`i 96813
EMAIL: NHHSP – Attn: Admin. Assistant ‐ [email protected]

NHHSP Applicant Letters of Recommendation Instruction
1. Letters of Recommendation ‐ Two letters of recommendation are required for your application.
Please notify the recommender before providing their contact information below.
a. Letter from an Academic Faculty or Advisor is mandatory. This letter should speak to your
academic progress and commitment to your chosen profession.
b. If you are employed, the second letter of recommendation must come from your employer.
A second letter of recommendation addressing your work ethics and behavior is required
from your employer. If you are not employed, then the letter of recommendation may come
from a community organization which you volunteered for.
Letters of Recommendation are due no later than March 15, 2020 @ 11:59pm. Letters
of Recommendation can be sent via email to [email protected] or via mail to:
NHHSP – Attn: Admin. Assistant,
894 Queen Street
Honolulu, Hawai`i 96813
(IV)
(V)

Submit application
Schedule Interview
1. Upon receipt of all application materials, an interview will be scheduled with eligible applicants.
2. Interviews are mandatory and are conducted via zoom for all applicants.
3. All interviews must be completed by May 1, 2020.

IMPORTANT NOTE: Attached you will find a CHECKLIST of the required documents to assist you with
your submissions to NHHSP.
***List of Eligible Programs:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Allopathic Medicine (M.D.)
Clinical Psychology (Ph.D. or Psy.D.)
Dental Hygiene (B.S.D.H. or A.S.D.H.)
Dentistry (D.D.S or D.M.D.)
Dietetics/Nutrition (M.S.D.D.)
Nurse Practitioners (D.N.P., M.S.N., C.N.M. or N.P.)
Nurse‐Midwifery (N.M. or M.S.N.)
Nursing (A.D.N., B.S.N.)
Osteopathic Medicine (D.O.)
Physician Assistant (M.S.P.A.)
Social Work (M.S.W.)

APPLICATION PROCESS, CHECKLIST, DOCUMENTS & FORMS:
Part I: Download the 2020-2021 APG, application instructions, and applicant forms

Part II: Prepare Information for the Application
Part III: Complete Application packet
Part IV: Submit application via google forms
Part V: Schedule interview
Prepare and submit the following applicant forms via google forms:
Headshot
Form A: Authorization to Release Information
Form B: Program Course Curriculum
Form C: Applicant Resume / CV (no more than 2 pages)
Form D: Personal Statement (no more than 1-page)
Form E: College Letter of Acceptance
Complete and submit the following application documents per instructions:
Proof & Documentation by Applicant of Native Hawaiian Ancestry
Unofficial College Transcripts
Request Letters of Recommendations with direct submission to NHHSP:
Academic Faculty/Advisor Evaluation (mandatory)
Employer Letter of Recommendation (preferred)
Community Organization Letter of Recommendation

All required original hardcopy documents must be postmarked and no later than
March 15, 2020.
NHHSP – Attn: Admin. Assistant,
894 Queen Street
Honolulu, Hawai`i 96813

Date
Completed:

NHHSP 2020-2021 Scholarship
Pre-Qualification and Applicant
Profile – Google Form

4/30/2020

2020-2021 NHHSP Scholarship Application Pre-Qualification Questions

2020-2021 NHHSP Scholarship Application
Pre-Quali cation Questions
Ho`omakaukau: Before you begin your 2020-2021 NHHSP Application, you need to determine
whether or not you are eligible for an Award.
* Required

Please select your specific degree from the drop-down list of 17 eligible degrees to
apply. *
In order to apply for an NHHSP award, you MUST be accepted and enrolled Full-Time in one of the fullyaccredited program below no later than September 30, 2020. If you will not be enrolled in one of the degree
programs below by Sept 30, 2020, you are not eligible to apply.

Mark only one oval.
Clinical Psychology; Doctoral Degree - PsyD or PhD Clinical Psychology; Doctoral
Degree - PsyD or PhD
Dentistry; Doctoral Degree - DDS or DMD Dentistry; Doctoral Degree - DDS or DMD
Dental Hygiene; Bachelor’s of Science Dental Hygiene Dental Hygiene; Bachelor’s of
Science Dental Hygiene
Dietetics; Master’s of Science Dietetics Dietetics; Master’s of Science Dietetics
Associates Degree in Nursing - ADN Associates Degree in Nursing - ADN
Bachelor’s of Science Degree in Nursing - BSN Bachelor’s of Science Degree in Nursing BSN
Master’s of Science Degree in Nursing
Master’s of Science Degree in Nursing; Nurse Practitioner - MSN-NP Master’s of
Science Degree in Nursing; Nurse Practitioner - MSN-NP
Master’s of Science Degree in Nursing; Midwifery - MSN-NM Master’s of Science Degree
in Nursing; Midwifery - MSN-NM
Doctorate in Nursing Practice - DNP
Medicine; Doctoral Degree in Medicine - MD or DO Medicine; Doctoral Degree in
Medicine - MD or DO
Physician's Assistant; Master’s Degree - PA Physician's Assistant; Master’s Degree - PA
Social Work; Master’s in Social Work - MSW

https://docs.google.com/forms/d/1nGMvNfL6w1TNk8Z76tU2UJ_-G2AYSmVuyhemwsGSXiw/edit

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2020-2021 NHHSP Scholarship Application Pre-Qualification Questions

Are you of Native Hawaiian Ancestry and able to provide proof and documentation
of such (i.e. Original Seal-Embossed Certificate of Birth)? *
In accordance with 42 U.S.C. 11711(3), “the term ‘Native Hawaiian’ means any individual who is—(A) a citizen
of the United States, and (B) a descendant of the aboriginal people, who prior to 1778, occupied and
exercised sovereignty in the area that now constitutes the State of Hawai`i, as evidenced by — (i)
Genealogical records, (ii) Kūpuna (elders) or Kama‘aina (long term community residents) verification, or (iii)
Birth records of the State of Hawai`i.”

Mark only one oval.
Yes

Skip to question 3

No
Skip to section 3 (We are sorry, but based on your answer you are not currently eligible for
the Native Hawaiian Health Scholarship Program.)

Skip to question 3

We are sorry, but based on your answer you are not currently eligible for the Native
Hawaiian Health Scholarship Program.

Are you willing to relocate to any island after your education and required licensure
to complete the mandatory service obligation component of the NHHSP? *
Mark only one oval.
Yes

Skip to question 4

No
Skip to section 5 (We are sorry, but based on your answer you are not currently eligible for
the Native Hawaiian Health Scholarship Program.)

Skip to question 4

We are sorry, but based on your
answer you are not currently eligible
for the Native Hawaiian Health
Scholarship Program.

You must be willing and able to relocate to anywhere
in the stat of Hawai`i after graduation and licensure to
complete the service component of your scholarship.

https://docs.google.com/forms/d/1nGMvNfL6w1TNk8Z76tU2UJ_-G2AYSmVuyhemwsGSXiw/edit

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2020-2021 NHHSP Scholarship Application Pre-Qualification Questions

Are you currently under a federally funded scholarship that has a service obligation
component to be completed in the future? *
Applicants, except military reservists, who are already obligated to a Federal, State or other entity for
professional practice or service after academic training are not eligible for Scholarship Program awards. An
exception may be made if the obligating entity provides documentation that there is no potential conflict in
fulfilling the service commitment to the Scholarship Program and that the Scholarship Program service
commitment will be performed first.

Mark only one oval.
Yes
Skip to section 7 (We are sorry, but based on your answer you are not currently eligible for
the Native Hawaiian Health Scholarship Program.)
No

Skip to question 5

We are sorry,
but based on
your answer
you are not
currently
eligible for the
Native Hawaiian
Health
Scholarship
Program.

Applicants, except military reservists, who are already obligated to a Federal,
State or other entity for professional practice or service after academic training
are not eligible for Scholarship Program awards. An exception may be made if
the obligating entity provides documentation that there is no potential conflict in
fulfilling the service commitment to the Scholarship Program and that the
Scholarship Program service commitment will be performed first.

Are you delinquent on the repayment of any Federal Debt(s)? *
Examples of Federal Debt include delinquent taxes, audit disallowances, guaranteed or direct student loans,
FHA loans, and other miscellaneous administrative debts. The definition of delinquency for the purposes of
direct and guaranteed loans are any loan(s) more than 31 days past due on a scheduled payment. Deferred
loans are not considered delinquent by the Native Hawaiian Health Scholarship Program.

Mark only one oval.
Yes
Skip to section 9 (We are sorry, but based on your answer you are not currently eligible for
the Native Hawaiian Health Scholarship Program.)
No

Skip to question 6

Skip to question 6
https://docs.google.com/forms/d/1nGMvNfL6w1TNk8Z76tU2UJ_-G2AYSmVuyhemwsGSXiw/edit

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We are sorry, but based on your answer you are not
currently eligible for the Native Hawaiian Health Scholarship
Program.

You cannot be a
delinquent on any federal
debts.

Are you: *
Mark only one oval.
Already enrolled or accepted as a full-time student in a fully accredited health
professions program located in a State, the District of Columbia, the Commonwealth of
Puerto Rico, the Commonwealth of the Northern Marianas, the U.S. Virgin Islands, the
Territory of Guam, the Territory of American Samoa, the Republic of Palau, the Republic of
the Marshall Islands, and the Federated States of Micronesia, and registered or registering
for classes beginning no sooner than July 1, 2020, but no later than September 30, 2020.
Applicants attending unaccredited schools, on a part time basis, and outside of these
geographic areas are not eligible for the Program, although they may be citizens of the
United States and of Native Hawaiian ancestry.
Skip to question 7
A new student applying in a fully accredited health professions program located in a
State, the District of Columbia, the Commonwealth of Puerto Rico, the Commonwealth of the
Northern Marianas, the U.S. Virgin Islands, the Territory of Guam, the Territory of American
Samoa, the Republic of Palau, the Republic of the Marshall Islands, and the Federated States
of Micronesia, and registering for classes beginning no sooner than July 1, 2020, but no later
than September 30, 2020. Applicants attending unaccredited schools, on a part time basis,
and outside of these geographic areas are not eligible for the Program, although they may be
citizens of the United States and of Native Hawaiian ancestry.
Skip to question 7
Neither of the above (If selected, you are not eligible for a scholarship with NHHSP, and
can exit the Pre-Qualifying process now).
Skip to section 11 (We are sorry, but based on your answer you are not currently eligible
for the Native Hawaiian Health Scholarship Program.)

Skip to question 7

We are sorry, but based on your answer you are not currently eligible for the Native
Hawaiian Health Scholarship Program.

Name of most recent High School or College/University attended: *

https://docs.google.com/forms/d/1nGMvNfL6w1TNk8Z76tU2UJ_-G2AYSmVuyhemwsGSXiw/edit

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2020-2021 NHHSP Scholarship Application Pre-Qualification Questions

Graduated? *
Mark only one oval.
Yes
No

Cumulative GPA (Must be 3.0 in order to qualify based on merit.): *

Skip to section 13 (Based on your answers from the pre-qualification questions, you are eligible for the
Native Hawaiian Health Scholarship. Thank you for your interest in applying to the Native Hawaiian
Health Scholarship/Papa Ola Lōkahi Program for the academic year 2020-2021.)
Please review the 2020-2021 Application
Program Guidance (APG) and 2020-2021
Application and Process Instructions
carefully before you begin your application;
these documents can be found on the
www.NHHSP.org website under Resources.

Based on your answers from the prequalification questions, you are eligible for
the Native Hawaiian Health Scholarship.
Thank you for your interest in applying to
the Native Hawaiian Health
Scholarship/Papa Ola Lōkahi Program for
the academic year 2020-2021.

Should you have any questions
and/comments please feel free to email us at
[email protected] or call the office at
the phone number listed below.
Our office hours are from 8:00 a.m. to 4:30
p.m. Monday to Friday. We are closed on
State and Federal holidays. You may leave a
voice mail if you find it necessary to call after
hours. Your voice mail will be answered on
the next business day.
Native Hawaiian Health Scholarship Program
at Papa Ola Lōkahi
894 Queen Street
Honolulu, HI 96813
(808) 597-6550 (office) ext. 203

This content is neither created nor endorsed by Google.

Forms
https://docs.google.com/forms/d/1nGMvNfL6w1TNk8Z76tU2UJ_-G2AYSmVuyhemwsGSXiw/edit

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NHHSP 2020-2021 Scholarship Applicant Profile

NHHSP 2020-2021 Scholarship Applicant
Pro le
Please use a Google Email address to complete a Scholarship Applicant Profile. You will receive
a copy of your response, and a link to edit your response will be available on this Google Account
once you click on SUBMIT. The link will also be a way to come back to your application and
upload needed forms and other documents.
* Required

Email address *

Applicant General Information

First Name *

Middle Name

Last Name *

Maiden Name

https://docs.google.com/forms/d/1Selj0ISo1btsgLP5B1f4ISyE-yGouN2qtgAdtJbDD8w/edit

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NHHSP 2020-2021 Scholarship Applicant Profile

Gender *
Mark only one oval.
Male
Female

Date of Birth *

Example: January 7, 2019

Secondary Email Address *

Current Home Address

Home Address 1 *

10.

Home Address 2

11.

Home City *

12.

Home State *

https://docs.google.com/forms/d/1Selj0ISo1btsgLP5B1f4ISyE-yGouN2qtgAdtJbDD8w/edit

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13.

NHHSP 2020-2021 Scholarship Applicant Profile

Home ZIP Code *

Contact Information

14.

Mobile Number *

15.

Home Phone Number

16.

Work Phone Number

17.

Work Phone Ext. (If Applicable)

18.

Home Island *
Mark only one oval.
Hawaiʻi Island
Maui
Lanaʻi
Molokaʻi
Oʻahu
Kauaʻi

https://docs.google.com/forms/d/1Selj0ISo1btsgLP5B1f4ISyE-yGouN2qtgAdtJbDD8w/edit

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NHHSP 2020-2021 Scholarship Applicant Profile

Current Mailing Address

19.

Mailing Address 1 *

20.

Mailing Address 2

21.

Mailing City *

22.

Mailing State *

23.

Mailing ZIP Code *

24.

Did you apply for the NHHSP Scholarship last year? *
Mark only one oval.
Yes
No

https://docs.google.com/forms/d/1Selj0ISo1btsgLP5B1f4ISyE-yGouN2qtgAdtJbDD8w/edit

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25.

NHHSP 2020-2021 Scholarship Applicant Profile

Have you received an NHHSP Scholarship before? *
Mark only one oval.
Yes
No

26.

If "yes," what year did you receive the NHHSP Scholarship

27.

What is your cumulative GPA? *

28.

Number of years requesting? (1-4 years) *

https://docs.google.com/forms/d/1Selj0ISo1btsgLP5B1f4ISyE-yGouN2qtgAdtJbDD8w/edit

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NHHSP 2020-2021 Scholarship Applicant Profile

29.

Select the discipline you are applying to or currently enrolled in: *
Mark only one oval.
Allopathic Physician
Clinical Psychology
Dental Hygiene
Dentist
Dietetics/Nutrition
Nurse Mid-Wife
Nurse Practitioner
Osteopathic Physician
Physician Assistant
Registered Nurse
Social Work

Applicant
Photo

30.

Uploaded Photo must be labeled as follows LAST NAME_FIRST NAME_PORTRAIT. You
may click NEXT to upload at a later time; you will receive a copy of your response, and a
link to edit your response will be available once you click on SUBMIT.

Applicant Photo: Please upload a head shot or portrait photo of yourself.
Files submitted:

Form A:
Authorization to
Release
Information

31.

http://nhhsp.org/images/pdf-files/2020-2021/Form_A.pdf
You may click NEXT to upload at a later time; you will receive a copy of your
response, and a link to edit your response will be available once you click on
SUBMIT.

Please upload your Form A below and must be labeled as follows LAST
NAME_FIRST INITIAL_FORM_(A-E) (ex. "SMITH_J_FORM_A")
Files submitted:

https://docs.google.com/forms/d/1Selj0ISo1btsgLP5B1f4ISyE-yGouN2qtgAdtJbDD8w/edit

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NHHSP 2020-2021 Scholarship Applicant Profile

http://nhhsp.org/images/pdf-files/2020-2021/Form_B_SEM.pdf
http://nhhsp.org/images/pdf-files/2020-2021/Form_B_QTR.pdf

Form B:
Program
Course
Curriculum

32.

You may click NEXT to upload at a later time; you will receive a copy of your
response, and a link to edit your response will be available once you click on
SUBMIT.

Please upload your Form B below and must be labeled as follows LAST
NAME_FIRST INITIAL_FORM_(A-E) (ex. "SMITH_J_FORM_B")
Files submitted:

Form C:
Applicant
Resume

33.

Instructions and Format: Resumes are limited to 2 pages with a 12 point font or bigger
in black. Your resume MUST be readable, saved and uploaded as a PDF.
You may click NEXT to upload at a later time; you will receive a copy of your response,
and a link to edit your response will be available once you click on SUBMIT.

Please upload your Form C below and must be labeled as follows LAST
NAME_FIRST INITIAL_FORM_(A-E) (ex. "SMITH_J_FORM_C")
Files submitted:

Form D:
NHHSP
Applicant
Personal
Statement

34.

Instructions and Format: Provide a 1-page personal statement which includes your
reasons for pursuing a career in the healthcare field, your short and long‐term goals, and
how you plan to serve the Native Hawaiian community as part of your career. Please use
a 12 point font or bigger and MUST be saved and uploaded as a PDF.
You may click NEXT to upload at a later time; you will receive a copy of your response,
and a link to edit your response will be available once you click on SUBMIT.

Please upload your Form D below and must be labeled as follows LAST
NAME_FIRST INITIAL_FORM_(A-E) (ex. "SMITH_J_FORM_D")
Files submitted:

https://docs.google.com/forms/d/1Selj0ISo1btsgLP5B1f4ISyE-yGouN2qtgAdtJbDD8w/edit

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NHHSP 2020-2021 Scholarship Applicant Profile

To be eligible for a 2020-2021 NHHSP award, Applicants are required to enroll
in a fully accredited health profession degree program as a full-time student.
Applicants must begin their course work by September 30, 2020.
NOTE: Ensure that program prerequisites are completed
For NHHSP Application Year 2020-2021, submit a copy of your
College/University Acceptance Letter no later than May 1, 2020.

Form E:
College/University
Acceptance
Letter/Proof of
Application

If your program begins in the Fall of 2020 and your college/university
acceptance letter is not received by March 15, 2020, submit all
correspondence from your college/university regarding your application (e.g.
letter of conditional acceptance pending the completion of a prerequisite
course, etc.).
The deadline to submit your Official College/University Acceptance Letter is
May 1, 2020 at
4:00pm HST.
If you have any questions, contact the NHHSP Administrative Assistant at
(808) 597-6550 ext.203 or email [email protected]
Due no later than May 1, 2020 at 11:59 PM HST
Mail or email required documents to ([email protected]):
NHHSP - Attn: Admin. Assistant
894 Queen Street
Honolulu, HI 96813
You may click NEXT to upload at a later time; you will receive a copy of your
response, and a link to edit your response will be available once you click on
SUBMIT.

35.

Please upload your Form E below and must be labeled as follows LAST NAME_FIRST
INITIAL_FORM_(A-E) (ex. "SMITH_J_FORM_E")
Files submitted:

https://docs.google.com/forms/d/1Selj0ISo1btsgLP5B1f4ISyE-yGouN2qtgAdtJbDD8w/edit

8/11

4/30/2020

NHHSP 2020-2021 Scholarship Applicant Profile

Applicants are required to submit proof of Native Hawaiian Ancestry.
In accordance with 42.U.S.C.11711(3), “the term ‘Native Hawaiian ‘ means any individual
who is
(A) a citizen of the United States, and
(B) a descendant of the aboriginal people who prior to 1778, occupied and exercised
sovereignty in the area that now constitutes the State of Hawai‘i, as evidenced by –
i. Genealogical records
ii. Kūpuna (elders) or Kama‘aina (long-term community residents) verification, or
iii. Birth records of the State of Hawai‘i.”

Proof of
Native
Hawaiian
Ancestry

Applicants will submit an original (with embossed seal) certificate of birth that verifies
Native Hawaiian ancestry. If Hawaiian ancestry is not listed, the Applicant will enclose an
original (with embossed seal) certificate of birth, of the Applicant’s Native Hawaiian
parent, along with Applicant’s birth certificate. Those with names not matching the original
certificate of birth will submit copies of documents (marriage certificate / legal name
change) demonstrating such name change.
Certificates of birth will be submitted along with other pertinent documents identified in
the Application Process, Documents, and Forms Checklist.
All birth certificate mailed to NHHSP will be returned to the Applicant after the close of the
Application Period.
Mail Proof of Hawaiian Ancestry to:
NHHSP - Attn: Admin. Assistant
894 Queen Street
Honolulu, HI 96813
Due no later than March 15, 2020
You may click NEXT to upload at a later time; you will receive a copy of your response, and
a link to edit your response will be available once you click on SUBMIT.

Applicants must submit their College Transcripts from ALL previous and current
College/University institutions.
College Transcripts from all past and current College/University Institutions will be
submitted to:

College
Transcript
Instructions

NHHSP - Attn: Admin. Assistant
894 Queen Street
Honolulu, HI 96813
If your college offers digital copies of your readable college transcript, please send
them to [email protected]
Due no later than March 15, 2020 at 11:59 PM HST
Note: Official College Transcripts will be required for those pre-selected for a NHHSP
award.
You may click NEXT to upload at a later time; you will receive a copy of your
response, and a link to edit your response will be available once you click on SUBMIT.

https://docs.google.com/forms/d/1Selj0ISo1btsgLP5B1f4ISyE-yGouN2qtgAdtJbDD8w/edit

9/11

4/30/2020

NHHSP 2020-2021 Scholarship Applicant Profile

Two letters of recommendation are required for your application. Please notify
the recommender before providing their contact information below.
A. Letter from an Academic Faculty or Advisor is mandatory. This letter
should speak to your academic progress and commitment to your chosen
profession.
B. If you are employed, the second letter of recommendation must come
from your employer. A second letter of recommendation addressing your work
ethics and behavior is required from your employer. If you are not employed,
then the letter of recommendation may come from a community organization
which you volunteered for.

Letters of
Recommendation

Letters of Recommendation are due by the Recommender no later than March
15, 2020 @ 11:59pm. Letters of Recommendation can be sent via email to
[email protected] or via mail to:
NHHSP – Attn: Admin. Assistant,
894 Queen Street
Honolulu, Hawai`i 96813
You may click SUBMIT to upload at a later time; you will receive a copy of your
response, and a link to edit your response will be available once you click on
SUBMIT.

1st Letter of Recommendation

36.

A. First Name *

37.

A. Last Name *

38.

A. Title *

39.

A. Email *

https://docs.google.com/forms/d/1Selj0ISo1btsgLP5B1f4ISyE-yGouN2qtgAdtJbDD8w/edit

10/11

4/30/2020

NHHSP 2020-2021 Scholarship Applicant Profile

2nd Letter of Recommendation

40.

B. First Name *

41.

B. Last Name *

42.

B. Title *

43.

B. Email *

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Forms

https://docs.google.com/forms/d/1Selj0ISo1btsgLP5B1f4ISyE-yGouN2qtgAdtJbDD8w/edit

11/11

NHHSP 2020-2021 Scholarship
Applicant Forms and Instructions

Authorization to Release Information
As an applicant to the Native Hawaiian Health Scholarship Program (NHHSP),
I,

Print First Name

Middle Initial

Last Name

hereby authorize the College/University where I am/was enrolled, to disclose information to
NHHSP, Papa Ola Lokahi Inc. (POL) and the U.S. Department of Health and Human Services
(DHHS), pertaining to my enrollment while participating in NHHSP. “Information pertaining to
my school enrollment” includes, but not limited to, my college transcript and grades, academic
standing, enrollment and degree status, curriculum and examination requirements for
graduation, tuition and fees, and leave-of-absence, withdrawal, or dismissal from school.
If I become a participant in NHHSP, I also authorize any post-degree training program for which
I received a deferment from the NHHSP to disclose to POL and DHHS information pertaining to
my participation in the post degree program including, but not limited to, my curriculum, status
in the program, completion date, examination requirements, and my leave-of-absence,
withdrawal or dismissal from the program.
The above authorizations take effect on the date indicated below with my signature.
In addition, I hereby authorize POL and DHHS, to release my name, addresses and social
security number to see if I appear on the Excluded Parties List System. This authorization takes
effect on the date I sign this release form. If I do not become an NHHSP participant, this
authorization shall remain in effect until November 30, 2020.
If I become an NHHSP participant, all of the above authorizations shall remain in effect until the
date my NHHSP scholarship commitment has been fulfilled or these authorizations have been
revoked by me in writing.

NHHSP Applicant Signature

Date

2020-2021 Application Year
Form A: Authorization to Release Information

U.S. Department of Health and Human Services
Health Resources & Services Administration
Papa Ola Lōkahi

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

Program Course Curriculum

APPLICANTS’ NAME

COLLEGE/UNIVERSITY NAME

DEGREE(i.e., masters of science in nursing)

PROJECTED GRADUATION MO/YR

THIS Program Course Curriculum document MUST BE COMPLETED and RETURNED to NHHSP
APPLICANT applied for Admission or is Enrolled at above-mentioned College/University since/for the Academic Year 20____ 20____. APPLICANT will be enrolled OR is anticipated to be enrolled Full-Time in an undergraduate/graduate degree-seeking program
(identified above) for the Academic Year 2020-2021.
LIST Degree Program CURRICULUM from (start of) FIRST YEAR to COMPLETION
e.g. FALL 2020
Summer ________ (Year)
Course Number

Fall _________ (Year)
Course Number

NHHSP Applicant Signature

Months: August - December

Months: _______________
Credit Hours

Year One
Course Title

Months: _______________
Credit Hours

Course Title

Date

Winter _________ (Year)
Course Number

Spring _________ (Year)
Course Number

Summer _________ (Year)
Course Number

Fall _________ (Year)
Course Number

NHHSP Applicant Name

Months: _______________
Credit Hours

Year One
Course Title

Months: _______________
Credit Hours

Year Two
Course Title

Months: _______________
Credit Hours

Course Title

Months: _______________
Credit Hours

Course Title

Winter _________ (Year)
Course Number

Spring _________ (Year)
Course Number

Summer _________ (Year)
Course Number

Fall _________ (Year)
Course Number

NHHSP Applicant Name

Months: _______________
Credit Hours

Year Three
Course Title

Months: _______________
Credit Hours

Course Title

Months: _______________
Credit Hours

Course Title

Months: _______________
Credit Hours

Year Four
Course Title

Winter _________ (Year)
Course Number

Spring _________ (Year)
Course Number

_______ (Term) _________ (Year)
Course Number

NHHSP Applicant Name

Months: _______________
Credit Hours

Year Four
Course Title

Months: _______________
Credit Hours

Course Title

Months: _______________
Credit Hours

Course Title

Months: _______________
Credit Hours

Course Title

NHHSP Applicant Name

U.S. Department of Health and Human Services
Health Resources & Services Administration
Papa Ola Lōkahi

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

Program Course Curriculum

APPLICANTS’ NAME

COLLEGE/UNIVERSITY NAME

DEGREE(i.e., masters of science in nursing)

PROJECTED GRADUATION MO/YR

Fall _________ (Year)
Course Number

NHHSP Applicant Signature

Months: August - December

Months: _______________
Credit Hours

Year One
Course Title

Months: _______________
Credit Hours

Course Title

Date

Spring _________ (Year)
Course Number

Summer _________ (Year)
Course Number

Fall _________ (Year)
Course Number

Spring _________ (Year)
Course Number

NHHSP Applicant Name

Months: _______________
Credit Hours

Year One
Course Title

Months: _______________
Credit Hours

Year Two
Course Title

Months: _______________
Credit Hours

Course Title

Months: _______________
Credit Hours

Course Title

Summer _________ (Year)
Course Number

Fall _________ (Year)
Course Number

Spring _________ (Year)
Course Number

Summer _________ (Year)
Course Number

NHHSP Applicant Name

Months: _______________
Credit Hours

Year Three
Course Title

Months: _______________
Credit Hours

Course Title

Months: _______________
Credit Hours

Course Title

Months: _______________
Credit Hours

Year Four
Course Title

Fall _________ (Year)
Course Number

Spring _________ (Year)
Course Number

_______ (Term) _________ (Year)
Course Number

NHHSP Applicant Name

Months: _______________
Credit Hours

Year Four
Course Title

Months: _______________
Credit Hours

Course Title

Months: _______________
Credit Hours

Course Title

Months: _______________
Credit Hours

Course Title

NHHSP Applicant Name

The Native Hawaiian Health Scholarship Program
2020-2021 Application – Applicant Resume Form

Copy + Paste your resume below. Submitted resumes are limited to 2 pages with a 12 point or bigger font.

The Native Hawaiian Health Scholarship Program
2019-2020 Application – Applicant Resume Form

Copy + Paste your resume below. Submitted resumes are limited to 2 pages with a 12 point or bigger font.

Personal Statement Instructions
Applicant:
Provide a 1-page personal statement which includes your reasons for pursuing a career in the
healthcare field, your short and long‐term goals, and how you plan to serve the Native Hawaiian
community as part of your career.

2020‐2021 Application Year
Instructions: Personal Statement

College/University Acceptant Letter/Proof of Application
To be eligible for a 2020-2021 NHHSP award, Applicants are required to enroll in a fully
accredited health profession degree program as a full-time student. Applicants must begin
their course work by September 30, 2020.
NOTE: Ensure that program prerequisites are completed
For NHHSP Application Year 2020-2021, submit a copy of your College/University Acceptance
Letter no later than May 1, 2020.
If your program begins in the Fall of 2020 and your college/university acceptance letter is not
received by March 15, 2020, submit all correspondence from your college/university regarding
your application (e.g. letter of conditional acceptance pending the completion of a
prerequisite course, etc.).
The deadline to submit your Official College/University Acceptance Letter is May 1, 2020 at
4:00pm HST.
If you have any questions, contact the NHHSP Administrative Assistant at (808) 597-6550
ext.203 or email [email protected]
Mail or email required documents to:

Native Hawaiian Health Scholarship Program
ATTN: NHHSP Administrative Assistant
894 Queen Street
Honolulu HI 96813

Email: [email protected]

Due no later than May 1, 2020

2020-2021 Application Year
Instructions: College/University Acceptance Letter/Proof of Application

Proof of Native Hawaiian Ancestry
Applicants are required to submit proof of Native Hawaiian Ancestry.
In accordance with 42.U.S.C.11711(3), “the term ‘Native Hawaiian ‘ means any individual who is
(A) a citizen of the United States, and
(B) a descendant of the aboriginal people who prior to 1778, occupied and exercised
sovereignty in the area that now constitutes the State of Hawai‘i, as evidenced by –
i. Genealogical records
ii. Kūpuna (elders) or Kama‘aina (long-term community residents) verification, or
iii. Birth records of the State of Hawai‘i.”
Applicants will submit an original (with embossed seal) certificate of birth that verifies Native
Hawaiian ancestry. If Hawaiian ancestry is not listed, the Applicant will enclose an original (with
embossed seal) certificate of birth, of the Applicant’s Native Hawaiian parent, along with
Applicant’s birth certificate. Those with names not matching the original certificate of birth will
submit copies of documents (marriage certificate / legal name change) demonstrating such
name change.
Certificates of birth will be submitted along with other pertinent documents identified in the
Application Process, Documents, and Forms Checklist.
All birth certificate mailed to NHHSP will be returned to the Applicant after the close of the
Application Period.
Mail required documents to:

Native Hawaiian Health Scholarship Program
ATTN: NHHSP Administrative Assistant
894 Queen Street
Honolulu HI 96813

Due no later than March 15, 2020
2020-2021 Application Year
Instructions: Proof of Native Hawaiian Ancestry

College Transcript Instructions
Applicants must request their College Transcripts from ALL previous and current
College/University institutions
Submit Directly to:

Native Hawaiian Health Scholarship Program
ATTN: NHHSP Administrative Assistant
894 Queen Street
Honolulu, HI 96813
NHHSP will accept digital copies of college transcripts that are submitted from
the applicant themselves via Email to the following:
[email protected]

ALL previous and current College/University transcripts

Due no later than March 15, 2020

2020-2021 Application Year
Instructions: Official College/University Transcript

Letter of Recommendation Advisory
Applicant:
Two letters of recommendation are required for your application. A letter from an Academic
Faculty or Advisor is mandatory. This letter should speak to your academic progress and
commitment to your chosen profession. If you are employed, the second letter of
recommendation must come from your employer. A second letter of recommendation
addressing your work ethics and behavior is required from your employer. If you are not
employed, then the letter of recommendation may come from a community organization which
you volunteered for. It is the applicant’s responsibility to ensure that your letters of
recommendation are completed and returned by the due date.
Letters of recommendation should be returned
Via email (preferred) [email protected] or
Mailed to:

Native Hawaiian Health Scholarship Program
ATTN: NHHSP Administrative Assistant
894 Queen Street
Honolulu HI 96813

NOTE: The Academic Faculty/Advisor letter of recommendation is MANDATORY
If you have any questions, contact the NHHSP Administrative Assistant at (808) 597-6550
ext.203 or email [email protected]
Mail required documents to:

Native Hawaiian Health Scholarship Program
ATTN: NHHSP Administrative Assistant
894 Queen Street
Honolulu HI 96813

Due no later than March 15, 2020
2020-2021 Application Year
Instructions: letters of recommendation

File Type	application/pdf
File Modified	2020-05-12
File Created	2020-05-01