2 School Enrollment Verification Form

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Nurse Corps Scholarship Program

Student Enrollment Verification Form

THIS FORM IS TO BE COMPLETED BY A SCHOOL OFFICIAL

School Name

State

Program Year 1 2 3 4

Term Summer

Year 2022

Name (Last, First, MI)

Nursing Program Completion Date

Term/Semester Start Date

Term/Semester End Date

Graduation Date

Enrolled Degree Program

Enrolled Degree Program. Please indicate the student’s current enrollment status by selecting which of the following categories apply. Check more than one category if necessary. Also, if applicable, list a new graduation date in the comment’s column.

School Seal/Stamp *raised seal - shade with pencil or crayon

Diploma

ADN

BSN

Full-Time Enrollment in Nursing Program

ABSN

Part-Time Enrollment in Nursing Program

MN

Repeating Course Work

Direct Entry Masters-NP

Leave of Absence

MSN-NP

Withdrawn/ Dropped out of School

DNP

Specialty for NPs and Direct Entry Masters NPs Specify:

Not Enrolled (Summer Only)

Other (Explain)

Other Status (please explain)

Explain:

Explain/Comments:

By signing my name below, I certify that the current status of the student listed above has been correctly identified from the categories provided above.

School Representative Signature

Date

Print Name

Title

Phone Number

Email Address

Address

Fax Number

Public Burden Statement: The purpose of the Nurse Corps Scholarship Program (Nurse Corps SP) is to provide scholarships to nursing students in exchange for a minimum two-year full-time service commitment (or part-time equivalent), at an eligible health care facility with a critical shortage of nurses. The information that applicants supply is used to evaluate their eligibility, qualifications and to assess their continued compliance with the applicable standards for participation in the Nurse Corps SP. The OMB control number for this information collection is 0915-0301 and it is valid until xx/xx/xxxx. This information collection is required to obtain a benefit (Section 846(d) of the Public Health Service Act (42 United States Code 297n (d)), as amended). 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.

Form Approved| OMB No. 0915-0301 |Expires xx/xx/xxxx