3 Participant Semi-Annual In Service Verification Form

Bureau of Health Workforce
U.S. Department of Health and Human Services
Health Resources and Services Administration

Six-Month Verification Form
This document is to verify that you worked at the site(s) listed below during the period / / through / / . To ensure that
you receive service credit, please return this form no later than / / by uploading it as a customer service inquiry through
the Customer Service Portal, https://programportal.hrsa.gov. If you cannot access the Portal, you can also fax it to (301) 4515384. If any of the information on this form is incorrect, please contact the Division of Program Operations or submit an
inquiry through the Portal.
Name:

Current Phone:

Current Address:

SSN:

Program:

Years Obligated:

Discipline/Specialty:

Service Status:

Projected Obligation End Date:

TO BE COMPLETED BY THE SITE REPRESENTATIVE:
Service Site:

Service Site Address:

Work Phone:

During the period specified above, due to holidays, vacation, CPE/CME, site/school closures, illness, or other reasons, the
participant was absent from the approved service site for

days. I certify that the information submitted in this

document is true, accurate and complete to the best of my knowledge and belief and does not omit any material facts. I
understand that the information given may be investigated and that any knowing and willful false representation, or
concealment, of a material fact may be punished as a felony under U.S. Code, Title 18, Section 1001, and subject me to civil
penalties under the Program Fraud Civil Remedies Act of 1986.

Signature

Printed Name/Title

Date

TO BE COMPLETED BY THE PARTICIPANT:
I certify that I have read and complied with the service requirements for the BHW program under which I am contracted
(see also “service requirements” on next page). Further, I certify that the information submitted in this document is true,
accurate and complete to the best of my knowledge and belief and does not omit any material facts. I understand that the
information given may be investigated and that any knowing and willful false representation, or concealment, of a material
fact may be punished as a felony under U.S. Code, Title 18, Section 1001, and subject me to civil penalties under the
Program Fraud Civil Remedies Act of 1986.
Signature

Printed Name/Title

Date

Service Requirements
Below are the general service requirements for programs sponsored by the Bureau of Health Workforce. Participants are
responsible for ensuring compliance with the service requirements, as defined in their service contract or through
subsequent program modifications. For the most current service requirements, refer to the Program Guidance for the
program under which you are contracted to provide services, which is available on the program’s web site.

National Health Service Corps Loan Repayment and Scholarship Programs (NHSC LRP & SP) (www.nhsc.hrsa.gov)
Full-Time Clinical Practice. Clinician works a minimum of 40 hours/week, for a minimum of 45 weeks/service year.
•All Health Professionals, except as noted below:
At least 32 hours/week are spent providing direct patient care or teaching at the approved service site(s). The remaining 8
hours/week are spent providing clinical services for patients or teaching at the approved site(s), providing clinical services in
alternative settings (e.g., hospitals, nursing homes, shelters) as directed by the approved site(s), or performing practice-related
administrative activities. Practice-related administrative activities shall not exceed a total of 8 hours/week. Teaching activities at the
approved site(s) shall not exceed 8 hours/week, unless the teaching takes place in a Teaching Health Center. Teaching activities in a
Teaching Health Center shall not exceed 20 hours/week.

•Behavioral and Mental Health providers, OB/GYNs, Certified Nurse Midwives, Family Medicine Physicians who practice
obstetrics on a regular basis, providers of geriatric services, and pediatric dentists:
At least 21 hours/week are spent providing direct patient care or teaching at the approved service site(s). The remaining 19
hours/week are spent providing clinical services for patients or teaching at the approved site(s), providing clinical services in
alternative settings (e.g., hospitals, nursing homes, shelters) as directed by the approved site(s), or performing practice-related
administrative activities. Practice-related administrative activities shall not exceed a total of 8 hours/week. Teaching activities at the
approved site(s) shall not exceed 8 hours/week, unless the teaching takes place in a Teaching Health Center. Teaching activities in a
Teaching Health Center shall not exceed 20 hours/week.

•For clinicians working in an approved inpatient Critical Access Hospital:
At least 16 hours/week must be spent providing direct patient care or teaching in the CAH-affiliated outpatient setting. The
remaining 24 hours/week are spent providing clinical services for patients or teaching at the CAH or the CAH-affiliated outpatient
setting, providing direct patient care at the CAH-affiliated skilled nursing facility or swing bed unit, or performing practice-related
administrative activities. Practice-related administrative activities shall not exceed a total of 8 hours/week. Teaching activities at the
approved site(s) shall not exceed 8 hours/week, unless the teaching takes place in a Teaching Health Center. Teaching activities in a
Teaching Health Center shall not exceed 20 hours/week.
Half-Time Clinical Practice. Clinician works between 20 and 39 hours/week, for a minimum of 45 weeks/service year.
•All Health Professionals, except as noted below:
At least 16 hours/week are spent providing direct patient care at the approved service site(s). The remaining 4 hours/week are spent
providing care to patients or teaching at the approved site(s), providing patient care in alternative settings (e.g., hospitals, nursing
homes, shelters) as directed by the approved site(s), or performing practice-related administrative activities. Teaching and practicerelated administrative activities shall not exceed a total of 4 hours/week.

•Behavioral and Mental Health providers, OB/GYNs, Certified Nurse Midwives, Family Medicine Physicians who practice
obstetrics on a regular basis, providers of geriatric services, and pediatric dentists:
At least 11 hours/week are spent providing direct patient care at the approved service site(s). The remaining 9 hours/week are spent
providing care to patients or teaching at the approved site(s), providing patient care in alternative settings (e.g., hospitals, nursing
homes, shelters) as directed by the approved site(s), or performing practice-related administrative activities. Teaching and practicerelated administrative activities shall not exceed a total of 4 hours/week.

•For clinicians working in an approved inpatient Critical Access Hospital:
At least 8 hours/week must be spent providing direct patient care or teaching in the CAH-affiliated outpatient setting. The remaining
12 hours/week are spent providing care to patients or teaching at the CAH or the CAH-affiliated outpatient setting, providing patient
care at the CAH-affiliated skilled nursing facility or swing bed unit, or performing practice-related administrative activities.
Teaching and practice-related administrative activities shall not exceed a total of 4 hours/week.
Nurse Corps Loan Repayment Program (NCLRP) (www.hrsa.gov/loanscholarships/repayment/nursing/index.html)
•Registered Nurse at a Critical Shortage Facility: must be employed full-time as a registered nurse for a minimum of 32 hours per
week for a minimum of 45 weeks per service year.
•Registered Nurse Serving as Nurse Faculty: must be considered full-time faculty (as defined by the employer) for a minimum of 9
months per service year at a for profit or non-profit public or private school of nursing.
Nurse Corps Scholarship Program (www.hrsa.gov/loanscholarships/scholarships/Nursing/index.html)
•Full-Time Clinical Practice: defined as a minimum of 32 hours per week for a minimum of 45 weeks per year. At least 26 hours
per week must be spent providing clinical services to patients. The remaining 6 hours may be spent on administrative or other nonclinical activities.
•Part-Time Clinical Practice: defined as a minimum of 16 hours per week, up to a maximum of 31 hours per week, for a minimum of
45 weeks per year. Prior approval from the Secretary of Health and Human Services or his/her designee is required. At least 80
percent of the participant’s weekly schedule must be spent providing clinical services to patients. For example, a nurse scheduled to
work 20 hours per week must spend at least 16 hours per week providing clinical services.
Faculty Loan Repayment Program (FLRP) (www.hrsa.gov/loanscholarships/repayment/Faculty/index.html)
• Must be employed either full- or part-time (as defined by the employing institution) as a faculty member for a minimum of 9
months per service year.

OMB No. 0915‐0140 Expiration xx/xx/xxxx
Public Burden Statement:
The purpose of the Nurse Corps Loan Repayment Program (NURSE CORPS LRP) is to assist in the recruitment and retention of
professional Registered Nurses (RNs) dedicated to working in health care facilities with a critical shortage of nurses or working as
nurse faculty in eligible schools of nursing, by decreasing the economic barriers associated with pursuing careers at such critical
shortage facilities or in academic nursing. 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 0915-0140 and it is valid until xx/xx/xxxx. This information collection is required to obtain or retain a benefit (Section
846 of the Public Health Service Act, as amended (42 U.S.C. 297n). Public reporting burden for this collection of information is
estimated to average 0.7 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].