OMB Public Burden Statement
The purpose of this information collection is to obtain information through the Substance Use Disorder Treatment and Recovery (STAR) Loan Repayment Program (LRP), which used to assess a LRP applicant’s eligibility and qualifications for the LRP and to obtain information for STAR site applicants. Clinicians interested in participating in the STAR LRP must submit an application to the STAR to participate in the STAR program, and health care facilities must submit an STAR Site Application to determine the eligibility of sites to participate in the STAR as an approved service site. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current OMB control number. The current OMB control number for information collected through this application process is xxxx-xxxx and the expiration date is mm/dd/yyyy. This information collection is required to obtain or retain a benefit (Section 333 [254f] (a)(1) of the Public Health Service Act). Public reporting burden for this collection is estimated to xx hour(s) per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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].
00 Login and Create Account Page DRAFT docx
LOAN REPAYMENT PROGRAM APPLICATION
Login
Please log in using the fields below:
Your Email *
Your Password *
Forgot your password?
Create an Account
Want to apply for the NHSC Loan Repayment Program, NHSC SUDWORKFORCE LRP or the NHSC Rural Community Loan Repayment Program?
Create an NHSC LRP Application Account
Note: If you have previously registered to apply to the NHSC LRP or any other BHW program in the current or past application cycles, or are a current NHSC Scholar, please use your existing account information to log in.
Questions?
For more information or questions please:
Refer to the Portal FAQ
Contact the BHW Customer Care Center at 1-800-221-9393
Use TTY for hearing impaired: 1-877-897-9910
Monday-Friday (except Federal holidays), 8:00 am to 8:00 pm ET or Contact Us.
Create My Account
* required field
This application serves three separate National Health Service Corps (NHSC) loan repayment programs; NHSC Loan Repayment (LRP) 2-year, NHSC Substance Use Disorder (SUD) Workforce LRP and the NHSC Rural Community LRP . Prior to creating an account, read the 2019 National Health Service Corps (NHSC) Application and Program Guidance (APG) for the NHSC Loan Repayment Program (LRP), NHSC Rural Community LRP and the NHSC Substance Use Disorder (SUD) Workforce LRP to determine your eligibility and to ensure you are applying to the appropriate program.
To be eligible to participate in the NHSC Programs you must be able to verify that you are:
A U.S. Citizen or U.S. National
Trained, certified, registered or licensed in an eligible primary care or mental health discipline
Providing clinical services at an NHSC-approved service site
Without outstanding service obligation(s)
A current, full, permanent, unencumbered, unrestricted health professional with a license, certificate or registration in the discipline in which he/she is applying to serve
Complete the information below to register to apply. The NHSC will use the email address you provide and verify to communicate vital time-sensitive information regarding your application. Provide an email address that you can access from most anywhere. In many cases the communications include requests to take an action with a rigid deadline that cannot be extended. Missing a deadline may result in not being selected for an award.
First Name *
Last Name *
Middle Initial
Title
Suffix
Email *
Confirm Email *
Create Password * Tooltip
Confirm Password *
Security Question *
Security Answer *
Loan Repayment Program Application
2020 NATIONAL HEALTH SERVICE CORP (NHSC) LOAN REPAYMENT PROGRAM (LRP) APPLICATION
Hello Test,
Thank you for registering to apply to National Health Service Corps (NHSC). The NHSC is seeking applicants who are committed to providing primary care services to the nation's most vulnerable populations. To qualify, for a NHSC loan repayment program award, you must meet all NHSC program and practice requirements at the time you submit your application and before an award can be approved. The NHSC is currently accepting applications for the following programs through April 20, 2020, 7:30 pm ET.
NHSC Programs |
Years of Service |
Full-time Award Amount |
Half-time Award Amount |
NHSC LRP (Traditional) |
2-Years |
$50,000.00 |
$25,000.00* |
NHSC Substance Use Disorder workforce LRP |
3- Years |
$75,000.00 |
$37,500.00 |
NHSC Rural Community LRP |
3- Years |
$100,000.00 |
$50,000.00 |
*NOTE: The 2-year half-time maximum NHSC Loan Repayment Program award for any fraction of service at HPSA scores 13 and lower, is $30,000.00.
To learn more about the 2020 National Health Service Corps (NHSC) Loan Repayment Programs, refer to the Application and Program Guidance (APG) for the NHSC Loan Repayment Program (LRP), NHSC Rural Community LRP and the NHSC Substance Use Disorder (SUD) Workforce LRP.
Certain applicants may be eligible for multiple National Health Service Corps Loan Repayment programs. The NHSC will review the information you submitted to determine your eligibility for multiple NHSC Loan Repayment Programs. If the NHSC determines that you are eligible for an award in more than one of the NHSC LRP programs, the NHSC will contact you to determine your preferred program. However, the NHSC cannot guarantee that you will be offered an award under the preferred NHSC program.
Before you get started
For your reference, review and print the Application Checklist before beginning your application. The application checklist details the application section and supporting documents. Gather the materials in advance to decrease your application time. Application Checklist.
If you have technical, difficulties while completing the application please contact the Customer Care Center from 8:00 AM to 8:00 PM ET, at 1-800-221-9393.
OMB No. xxxx-xxxx Expiration Date: xx/xx/xxxx
National Health Service Corps Eligibility
Answers to the questions below will determine your basic eligibility for a National Health Service Corps Loan Repayment award.
* required field
1. Do you or will you have a current, full, permanent, unencumbered, and unrestricted health professional license, certificate or registration in the discipline/specialty in the State in which you intend to practice under the NHSC Loan Repayment Program (LRP), the NHSC Substance Use Disorder Workforce LRP or the NHSC Rural Community LRP on or before July 18, 2019? *
Yes No
2. Are you a citizen or national of the United States?
You will be asked to provide a verifying document later in the application. Valid birth certificates, current passports or naturalization papers are accepted. *
Yes No
3. Do you have another existing/remaining service obligation as a health professional, or any other service obligation, to the Federal government (e.g., an active duty military obligation, an NHSC Scholarship Program obligation or a NURSE Corps Loan Repayment Program obligation), to a State (e.g., a State Loan Repayment Program obligation), or to any other entity (e.g., any signed obligation that obligates you to remain employed at a certain geographical location)? * Tooltip
Yes No
4. Have you ever had a judgment lien against your property arising from a Federal debt? *
Yes No
5. Have you defaulted on any Federal payment obligations, such as Health Education Assistance Loans, Nursing Student Loans, FHA or other Federal Mortgage Loans, Federal income tax liabilities, Federal student loans; OR, non-Federal payment obligations, such as court-ordered child support payments? *
Yes No
6. Are you currently in breach of a health professional service obligation to the Federal, State, or Local government? *
Yes No
7. Have you defaulted on a prior service obligation to a Federal, State, Local government, or other entity? *
Yes No
OMB No. xxxx-xxxx Expiration Date: xx/xx/xxxx
2-Program Eligibility_Page NHSC LRP and SUD DRAFT
Program Eligibility
The answers
you provide to the questions below will determine the National Health
Service Corps (NHSC) Loan Repayment Program (LRP) you are eligible to
apply for in the Application Information Section. Prior to responding
to the questions below, read the NHSC LRP Application and Program
Guidance(s) to determine the eligibility for the NHSC LRP, NHSC
Substance Use Workforce (SUD) LRP and the NHSC Rural Community LRP.
*Required fields
*1. Are you a Dental Provider?
Yes
No
*2. Are you
practicing as a Certified Nurse Anesthetist, Registered Nurse,
Pharmacist or SUD Counselor?
Certified Registered Nurse Anesthetist
Registered Nurse
Pharmacist
SUD Counselor
None of the
above
*3. Are you a SUD Counselor with masters level health profession degree?
Yes
No
*4. If no, do you have a masters level SUD Certification? *
Yes
No
3-Application Information Page. DRAFT
Application Information
You are eligible to submit an application for a loan repayment award under the program (s) displayed below.
Each Loan Repayment Program has a different eligibility criteria and service requirements based on your discipline and specialty. Review the Application and Program Guidance for each program before selecting your application type.
You will not be able to change your application type after May 28, 2019, the application deadline.
Certain applicants may be eligible for multiple Loan Repayment programs. The NHSC will review the information you submitted to determine your eligibility for multiple Loan Repayment Programs and will contact you if you are eligible for an award in more than one program. If the NHSC determines that an applicant is eligible for multiple awards, the applicant will have an opportunity to accept an award in only one program. However, the NHSC cannot guarantee that you will be offered an award under the preferred NHSC program.
* required field
APPLYING FOR
Application Type * 2 Year Full Time
2 Year Half Time
3 Year Full-Time (Rural Community)
3 Year Half-Time (Rural Community)
3 Year Full-Time (Substance Use Disorder Workforce)
3 Year Half-Time (Substance Use Disorder Workforce)
Have you completed a Primary Care Training Enhancement (PCTE): Training Primary Care Champions Fellowship? (for physicians and physician assistant only)
Yes No
2. Will you complete a Primary Care Training Enhancement (PCTE): Training Primary Care Champions Fellowship by July 18, 2020? (For physicians and physician assistant only)
Yes No
3. Do you provide substance use disorder services (e.g. Buprenorphine treatment or substance use disorder counseling) at your site? *
4. Are you licensed or certified in your state to provide substance use disorder services? If yes, please upload your credentials in the Supporting Documents section. *
Yes No
5. Do you possess a DATA 2000 waiver? If yes, please upload your waiver in the Supporting Documents section. *
6. Will you have substance use disorder training or certification completed by July 18, 2020? *
Yes No
7. I am applying to work at a NHSC-approved site because of the: (Check all that apply) *
Loan repayment incentive
Substance Use Disorder treatment incentive
Opportunity to work with an underserved population
Interest in working in an underserved area
Opportunity to serve in a rural area
Location relative to my home community
None of the above
OMB No. 0915-0127 Expiration Date: 02/29/2020
4-General Information Page.docx DRAFT
General Information
* required field
Note: If you have started a fiscal year 2019 application to other NHSC or NURSE Corps programs, the personal information you enter in this section, such as your name, address, date of birth, birth location, and Social Security number will overwrite the personal information you provided with the other applications when you select "Continue" at the end of this section.
FULL NAME
First Name *
Last Name *
thayer
Middle Initial
Title
Suffix
Former First Name
Former Last Name
PREFERRED MAILING ADDRESS
Address Line 1 *
Address Line 2
Country *
State/Province/Region/Territory *
City *
Zip/Postal Code *
PHONE
My preferred phone is an international number
Preferred Phone *
My alternate phone is an international number
Alternate Phone
SOCIAL SECURITY NUMBER
SSN Tooltip
PLACE OF BIRTH
Country *
State/Province/Region/Territory *
City *
Date of Birth *
DEMOGRAPHICS
Award selection will not be determined by this section
Gender Male
Female
Ethnicity Hispanic or Latino
Not Hispanic or Latino
Race American Indian or Alaskan Native
You may multi-select Asian
different race values. Black or African-American
Native Hawaiian or Other Pacific Islander
White
Other
DISADVANTAGED BACKGROUND TOOLTIP
Have you ever been certified as having come from a disadvantaged background making you eligible to participate in federal programs such as the Scholarships for Disadvantaged Students, Loans to Disadvantaged Students, or the Nursing Workforce Diversity Grant Program; or have you ever been the recipient of a scholarship for students of Exceptional Financial Need? *
Yes No
U.S. PUBLIC HEALTH SERVICE
Are you a commissioned officer in the U.S. Public Health Service? *
Yes No
NATIONAL PROVIDER IDENTIFIER
Do you have an individual NPI Number? * * Tooltip
Yes No
NPI Number:
Forgot Your NPI Number?
Find your NPI Number by visiting the NPI Registry
Enable pop-ups to open the link or access the NPI Registry online: https://npiregistry.cms.hhs.gov/
HOW DID YOU HEAR ABOUT NHSC LOAN REPAYMENT PROGRAM
How did you hear about the NHSC LRP? *
SERVICE BEYOND YOUR NHSC OBLIGATION
Do you (and if applicable, your family) plan to remain in the community in which you will fulfill your NHSC service obligation, if you receive an award, beyond your service obligation? *
Yes No
OMB No. xxxx-xxxx Expiration Date: xx/xx/xxxx
5-Discipline and Training Page.docx DRAFT
Discipline, Training, and Certification
* required field
In this section you will identify the discipline/specialty for which you are licensed to provide clinical services and your degree information. The options provided are specific to the current list of NHSC Loan Repayment Program approved disciplines and specialties. Please review the education, training and certifications requirements for your discipline/specialty as defined in the 2019 NHSC Loan Repayment Program (LRP) Application and Program Guidance, the 2020 NHSC Substance Use Disorder (SUD) Workforce LRP Application and Program Guidance or the 2020 NHSC Rural Community LRP Application and Program Guidance. You will certify the accuracy and truthfulness of your selections before you submit your complete application. If the NHSC cannot verify the information, you entered or If you have not obtained the appropriate training, certification and license for your discipline and specialty or will not begin meeting the NHSC Clinical Practice Requirements for the service type you selected prior to July 18, 2019, you do not qualify for an NHSC Loan Repayment Program contract.
DISCIPLINE AND SPECIALTY
Discipline *
Are you currently eligible to practice your profession independently without supervision? *
Yes No
Do you meet the degree, training and certification requirements for this discipline and specialty, as defined in the fiscal year 2019 NHSC LRP, NHSC Substance Use Disorder Workforce LRP or the NHSC Rural Community LRP Application and Program Guidance (s)? *
Yes No
By selecting this discipline, you are certifying that you currently possess a master's degree or higher degree with a major study in counseling from a school accredited by a U.S. Department of Education nationally recognized regional or State institutional accrediting agency; and, successfully completed at least 2 years of post-graduate supervised clinical experience as an LPC.
DEGREE
When did you receive the health profession degree relevant to the above information selected? *
Type of Degree or Certificate *
OMB No. xxxx-xxxx Expiration Date: xx/xx/xxxx
6-Employment Page.docx Combined DRAFT
Employment
* required field
National Health Service Corps (NHSC) Employment Requirement
Applicants for a Loan Repayment Program (LRP) contract must be employed NHSC-approved service sites are located in federally designated Health Professional Shortage Area (HPSA). HPSAs are designated as having a shortage of primary medical care, mental health and dental healthcare professionals. They are provided a score of 26 to 0, with 26 representing communities with the highest health professional recruitment needs. NHSC considers HPSA scores, along with the eligibility requirements detailed in the 2019 Application and Program Guidance (APG), when determining a selection for an NHSC LRP, Substance Use Disorder Workforce LRP or Rural Community LRP contract.
Applicants for the Substance Use Disorder Workforce LRP or Rural Community LRP contract must be employed at an active NHSC-approved SUD treatment Facility.
For the most up-to-date HPSA and NHSC-approved service sites across the Nation, please go to the Health Workforce Connector.
Select your NHSC-approved service site(s).
Note: You may see multiple sites with the same name but different addresses. Select the site(s) where you actually provide direct patient care and will meet the NHSC Clinical Practice Requirements for your discipline/specialty.
For Rural Community and Substance Use Disorder applicants: If you are unable to add your preferred site(s) to your application, it may not have received the additional NHSC approval for substance use disorder treatment. If you apply to multiple sites, all of your selected sites must meet the Substance Use Disorder requirements
State or Territory
City
Check this box if your site is not listed in the search results.
If you are unable to select a site, please contact [email protected]
Have you listed each site where you work or will begin working? *
Yes, all of my sites have been added.
No, some of my sites are not yet added. I will come back to this section and add them before submitting.
Telehealth Services
Do you or will you personally provide some form of telehealth in your clinical practice? Tooltip
Yes
No
I don't know
When providing telehealth:
I am the clinician at the originating site whose patient is receiving the consult/care
I am the clinician at the distant site providing the consult/care
I don't know
Other
What percentage of your clinical practice is/will be spent providing telehealth services?
<10%
10-24%
25-49%
50%>
I don't know
OMB No. 0915-0127 Expiration Date: 02/29/2020
7-Employment Verification Page.docx DRAFT
Employment Verification
To begin the Employment Verification (EV) process, select "Initiate" next to the site(s) listed below. The NHSC POC(s) will receive an email instructing them to verify your employment by logging into the Program Portal for Site POCs. For detailed information about the site including the POC(s) on file, click on the site name below. You are responsible for ensuring that your site POC has submitted the employment verification form on your behalf by the May 28, 2019, application deadline! Once you have submitted your application you will have the ability to review the responses made by your employer. Instructions for viewing your application and the EV responses are provided once you submit your application. For additional information regarding the employment verification process see the NHSC Employment Verification FAQs.
CURRENT REQUESTS
Site Name Verification Type Date Created Status Action
SouthEast Alaska Regional Health Consortium Application 12/31/2018 Complete View
Mt. Edgecumbe Hospital (CAH)
OMB No. xxxx-xxxx Expiration Date: xx/xx/xxxx
Loan Information
In this section, you will be required to add the loans that you want approved for repayment under the NHSC Loan Repayment Program.
To expedite this process, you may import your federal student loan(s) from the U.S. Department of Education's National Student Loan Data System (NSLDS) directly into the online application. For loans imported from the NSLDS, no supporting documents are required.
To Access Your Federal Student Loan(s) use the "Access your Loans" button below. You will be directed to the Department of Education's Federal Student Aid login page and required to log in using your Federal Student Aid ID (FSA ID). If you have any questions about your FSA ID, please visit: https://www.nslds.ed.gov/npas/pub/faq.htm
After successfully logging in to FSA, you will be automatically directed back to your application with your loans displayed below. Once your loans have been imported, please ensure all loans you wish to submit are listed. You may also select the 'Return to Source' button from the FSA ID Login screen at any time.
For additional loans that are not covered in the NSLDS and may be private education loans, you can still manually enter the loans along with supporting documents. Any loans that do not appear in your NSLDS account must be added to your application manually. If you attempt to add a loan that you believe is NOT a federal student loan(s), but receive an error message, please check the loan data and try again. It is possible that the loan is a duplicate to one that you have added electronically.
Important Note: If you experience any technical difficulties, please contact the Bureau of Health Workforce's Customer Care Center at 1-800-221-9393 (TTY: 1-877-897-9910) Monday through Friday (except federal holidays) from 8:00 AM to 8:00 PM ET or email us. If you are unable to resolve your technical difficulties or concerns in time to submit your complete application prior to May 28, 2019, the application deadline, please enter your loans manually. The period for submitting applications will not be extended due to difficulties with submitting your loans.
To manually add Loans click the "Need Help?" link to manually add loans you wish to submit for loan repayment.
When entering your loan information manually, you must enter loan information and supporting documentation for each servicing lender that you wish to be considered for repayment. The following documents will be required:
Account Statement (Both Private and Federal) - Most recent statement from your lender/servicer that has your name, current loan balance and interest rate. This may be the official paper version, or a printed web version, that is scanned, uploaded, and not older than 30 days from the date you will submit your application.
NSLDS Aid Summary Report (Federal Loans) - Most recent summary report taken from your National Student Loan Data Systems (NSLDS) account. This may be the official paper version, or a printed web version, that is scanned and uploaded. Note: This is the summary report only, which lists your federal student loans in one document and is available at http://www.nslds.ed.gov.
Disbursement Report or Promissory Note (Non-Federal Loans) - A copy of the document provided by your lender/servicer that outlines the details of your loan agreement, including your name, the date the loan was obtained, the purpose of the loan, account numbers, and the loans included in a consolidation (if applicable).
If you have a consolidated loan, you must enter in all of the information in the table. All of the information must coincide with the information in the loan documents. If they do not coincide, the loan will be deemed ineligible.
LOG INTO YOUR NATIONAL STUDENT LOAN DATA SYSTEM ACCOUNT
NEED HELP?
Don't have a Federal Student Aid ID or want to enter loans manually?
MANUALLY ADDED LOANS
]
Name Account # Balance Interest Rate Submitted All Required Docs ? Action
FedLoan Servicing 5012836983 $139,523.59 6.630% Yes Edit
OMB No. xxxx-xxxx Expiration Date: xx/xx/xxxx
Loan Details
* required field
Back to Loan Information
You have elected to add your qualifying education loans to your application manually. This method is required for adding ALL loans that are NOT federal student loan(s). If you have elected to add your federal student loan(s) using this method you must not attempt to add them using the electronic import method, or you will receive an error message and put you at risk of missing the application deadline. You are strongly encouraged to print and read the NHSC Loan Module Detailed Instructions before adding your loans
Include all qualifying education loans, even if they exceed the maximum award amount. Please exclude letters, special characters (i.e. $, %), and commas when entering outstanding loan balances and interest rates. If you have multiple loans with the same servicer/lender, you must enter each loan separately.
To add your loans successfully and to ensure that your loans have the best chance to qualify for repayment when reviewed, you must retrieve, scan and upload the current account statements from your loan servicers and the Aid Summary Report from your NSLDS online account (federal student loan(s)) or a disbursement report for any private loans, for each loan.
For each field completed below, the supporting documents must verify the information you have entered.
Name of current servicing lender *
Loan account number *
Original date of the loan * Tooltip
Original amount of the loan *
Current balance (Principal & accrued Interest) *
Type of loan * Tooltip
Is this loan in default? * Is this loan in default? *
Yes No
Is this loan under federal court judgment? *
Yes No
Purpose of loan *
Is this a consolidated loan? *
Yes No
OMB No. xxxx-xxxx Expiration Date: xx/xx/xxxx
Supporting Documents
Back to Loan Information
The following loan documents are required to assess whether your loans qualify for repayment under the NHSC Loan Repayment Program. Each document should only be uploaded to the loan that it reflects. Each document should show clear verification that it is official and comes from the Servicer/Lender. In most cases, the required information can be obtained from official web-accounts or found on paper documents that you have received from the servicer or lender. They can be printed, scanned, and uploaded to your application in this section.
The account statements should only be obtained directly from the lender/servicer. Documents can be printed, scanned, and uploaded to your application in this section.
A description of the required information for each document type can be found below. If a required document does not contain the required information or is not legible enough to review the loan profile, it will be deemed "incomplete" and the loan itself will not qualify for repayment.
ACCOUNT STATEMENTS
LOAN ORIGINATION AND DISBURSEMENT REPORTS
CONSOLIDATED EDUCATIONAL LOANS
Please note: The following file types are not suitable for being uploaded: jpg, doc, xls & tif. Password protected files are not acceptable and will disqualify the loan. Loan documents must be official and obtained directly from the lender/servicer. Copies of website versions are acceptable.
UPLOADED DOCUMENTS
Document Title Document File Status Action
Account Statement Received Remove
NSLDS/Aid Summary Report Received Remove
Consolidated Loan Supporting Document Received Remove
UPLOAD DOCUMENT
Account Statement
NSLDS/Aid Summary Report
Consolidated Loan Supporting Document
OMB No. xxxx-xxxx Expiration Date: xx/xx/xxxx
8-Supporting Documents Page.docx DRAFT
Supporting Documents
* required field
You are encouraged to save your documents as .PDF files before uploading to your application. You should not attempt to upload documents larger than 5MB, or files formatted as .TIFF, .JPEG, .PNG and .TXT. In addition, the NHSC must be able to review the details of your application documents clearly. Submitting pictures, password protected, and incomplete or illegible documents will disqualify your application from consideration. All information provided in the supporting documents and online application must match exactly. Any disparities will cause your application to be deemed ineligible.
PROPER USE OF AWARD
For use by Former NHSC Loan Repayment Program Participants ONLY!
If you are a former NHSC Loan Repayment Program participant, you are required to upload official documentation that will verify your use of the entire amount award you received with your most recent contract, to pay down the education loans that were approved for repayment with your most recent award.
Example: If you were disbursed $50,000 in 2002 and completed your service in 2004, you are required to upload documentation verifying that you paid $50,000 to the loans that were approved for repayment within that contract obligation period.
If you are not able to provide documentation at the time you submit your application that clearly verifies that you paid the entire amount within that contract period to the loans that were approved, your application will be disqualified during review and you will not be eligible for participation in NHSC programs indefinitely. Please provide the following required documents:
Proof of Payment History for Prior NHSC LRP Service - Mandatory for Previous NHSC LRP Participants.
Proof of U.S. Citizenship or U.S. National - Current passport, birth certificate, or nationalized citizenship certificate.
Substance Use Disorder License or Certification (if applicable) - certificate of completion or diploma from a Substance Use Disorder or Addiction medicine training program(s).
ADDITIONAL DOCUMENTS
Proof of Payment History for Prior NHSC LRP Service
Verification of Disadvantaged Background
UPLOAD DOCUMENTS
Document Title Document File Status Delete
DATA 2000 Waiver Not Received
Proof of Payment History for Prior NHSC LRP Service Not Received
Proof of U.S. Citizenship or U.S. National Received delete
Substance Use Disorder Licensure or Certification Received delete
Additional Supporting Document Not Received
LOAN DOCUMENTS
Servicing Lender & Account # Document Title Document File Status
FedLoan Servicing 5012836983 NSLDS/Aid Summary Report Received
FedLoan Servicing 5012836983 Account Statement Received
FedLoan Servicing 5012836983 Consolidated Loan Supporting Document
OMB No. xxxx-xxxx Expiration Date: xx/xx/xxxx
10-Self Certification Page.docx DRAFT
Self-Certification
* required field
1. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, DISQUALIFICATION AND RELATED MATTERS FORM
Pursuant to 2 CFR 180.335 (2006) as implemented by 2 CFR 376.10 (2007), an applicant applying to enter into a covered transaction (which includes an application to participate in the NHSC LRP) is required to notify the Federal agency office if the applicant knows that he or she:
Is presently debarred, suspended, excluded, or disqualified from participation in covered transactions by any Federal agency or department;
Within the 3-year period preceding the application, has been convicted of, or had a civil judgment rendered against him or her for any of the following offenses:
Commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or a contract under a public transaction;
Violation of Federal or State antitrust statutes;
Commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, receiving stolen property, making false claims, or obstruction of justice; or
Commission of any other offense indicating a lack of business integrity or business honesty that seriously and directly affects his/her present responsibility
Is presently indicated or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local) with the commission of any of the offenses set forth above; or
Within a 3-year period preceding the application, has had any public transaction (Federal, State, or local) terminated for cause or default.
I certify that none of the above statements apply to me.
2. AUTHORIZATION FOR DISCLOSURE OF FINANCIAL INFORMATION
Pursuant to the Right to Financial Privacy Act of 1978 (RFPA) (12 USC 3404), having read the statement of my RFPA rights, I hereby authorize the government or financial institution named in item 1 on each Loan Details page to release financial records relating to educational loans(s) identified on the Loan Details page to the HHS for the purpose of assessing and verifying the amount and eligibility of the educational loan for payment under the HHS. This authorization is valid for 3 months from the date of my signature, and may be revoked in writing at any time before my records are disclosed. *
3. CERTIFY BY CHECKING THE BOX NEXT TO THE STATEMENTS BELOW:
I certify that I have read and understood the appropriate Application and Program Guidance (s) for the program to which I am applying for a FY 2020 contract NHSC LRP, NHSC Substance Use Disorder (SUD) Workforce LRP or NHSC Rural Community (RC) LRP.
I certify that I have a master's degree or higher degree with a major study in counseling from a school accredited by a U.S. Department of Education nationally recognized regional or State institutional accrediting agency, and have at least 2 years of post-graduate supervised counseling experience.
I certify to one of the statements below:
LPCs With a License in State of Practice: I certify that I have a current full, permanent, unencumbered, unrestricted health professional license, certificate, or registration to practice independently and unsupervised as an LPC in the State in which I intend to practice as an NHSC Loan Repayment Program participant.
LPCs Without a License in State of Practice: I certify that licensure as an LPC is not available in the State in which I intend to practice as an NHSC Loan Repayment Program participant, and that I have a current, full, permanent, unencumbered, unrestricted health professional license, certificate, or registration to practice independently and unsupervised as an LPC in a State.
I certify that all of the information that I have provided in this application and required supplemental documents is true.
OMB No. 0915-0127 Expiration Date: 02/29/2020
APPLICATION PAGES
Application Discipline Section NHSC RC LRP DRAFT
FY 20 NHSC and SUD LRP Application Checklist DRAFT
FY 20 NHSC LRP Disadvantaged Background Verification Form
FY 20 NHSC LRP Full-Time Clinical Practice Requirements DRAFT
FY 20 NHSC LRP Half-Time Clinical Practice Requirements DRAFT
FY 20 NHSC LRP Loan Module Detailed Instruction DRAFT
FY 20 NHSC LRP Participant Salary Reference Guide DRAFT
FY 20 NHSC LRP Proof of Payment DRAFT
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Lewis, Malissa (HRSA) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-13 |