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2023-2024 School Data Collection Worksheet
Program
School
Discipline
Degree
Nurse Corps Scholarship
Program
Capella University
Registered Nurse
Bachelor's
Data Collection Worksheets
Thank you for creating a DCW! The form can be completed in 3 easy steps. Please note that all information must be filled in
properly to avoid any processing errors, which could result in delayed and/or incorrect payments, which may adversely affect the
student.
1. Tuition
Enter the Resident (In-State) and Non-resident (Out-of-State) tuition for the entire ACADEMIC year for 1st, 2nd, 3rd, and 4th Year
Students. If your school's degree program is less than 4 years, only enter amounts for each year of your program. For example,
two year programs would only enter values in the first two columns for 1st and 2nd Year Students. You MUST enter values for
every year of your program, even if your costs are estimated to be the same for students regardless of which year they are in the
program. If your institution uses a semester system; please include the tuition amount to be enrolled in as a full-time student for
each semester (summer, fall, and spring semesters (3 semesters)). If your institution uses a quarter system; please include the
tuition amount to be enrolled in as a full time student for a fall, winter, spring, and summer quarter (4 quarters).
All fields are required unless noted as optional.
Resident
Non-Resident
1ST YEAR STUDENT
2ND YEAR STUDENT (Optional)
3RD YEAR STUDENT (Optional)
4TH YEAR STUDENT (Optional)
$0
$0
$0
$0
$0
$0
$0
$0
2. Fees (Optional)
Please enter in the fee amount for an entire ACADEMIC year for each fee type. The fee types listed are the only eligible fees for
the Nurse Corps Scholarship Program. As institutions may have varying names for the types of fees on the form, if a required fee
at your institution does not fit into any of the fee categories noted, please list that fee in the "Other" heading. You will only be
allowed to add 1 other fee. Please note that "Other" fees may not be eligible for reimbursement due to Nurse Corps Scholarship
Program fee restrictions.
The following fields are optional.
Academic Support
Services Fee
Administrative Fee
Background Check
Fee
Campus Facility Fee
Capstone Course (if
1ST YEAR STUDENT
2ND YEAR STUDENT (Optional)
3RD YEAR STUDENT (Optional)
4TH YEAR STUDENT (Optional)
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
required)
Career Resource Fee
Computer Use Fee
Counseling Fees
Curriculum Fee
Disability Insurance (if
required of all
students)
Drug Screening
Education Fee
Graduation Fee - for
students in last year of
program
Health Insurance - for
students only (if
required)
Health Services Fee
and Immunizations
1ST YEAR STUDENT
2ND YEAR STUDENT (Optional)
3RD YEAR STUDENT (Optional)
4TH YEAR STUDENT (Optional)
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Laboratory Fee
Library Fee
Malpractice Insurance
(if required)
Materials Fee
Matriculation Fee
NCLEX Review
Online Tuition Course
Processing Fee
Recreation Fee
Registration Fee
Student Activities Fee
1ST YEAR STUDENT
2ND YEAR STUDENT (Optional)
3RD YEAR STUDENT (Optional)
4TH YEAR STUDENT (Optional)
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1ST YEAR STUDENT
2ND YEAR STUDENT (Optional)
3RD YEAR STUDENT (Optional)
4TH YEAR STUDENT (Optional)
Student Association &
Union Campus
Services
$0
$0
$0
$0
Student Government
Fee
$0
$0
$0
$0
Student Initiatited
Fee
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Student Services Fee
Technology Fee
Testing for Course
Advancement
Transcript/Letter Fee
Transportation Fee
University Fee
Other Fees
3. Other Reasonable Costs (ORCS) (Optional)
Please enter the ORC amount for an entire ACADEMIC year for each ORC type. The Nurse Corps Scholarship Program only offers
ORC amounts for the following three three categories: Books, Clinical Supplies/instruments, and Uniforms.
The following fields are optional.
Books
Clinical Supplies
Uniforms
1ST YEAR STUDENT
2ND YEAR STUDENT (Optional)
3RD YEAR STUDENT (Optional)
4TH YEAR STUDENT (Optional)
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Comments (Optional)
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2023_02.0.0-SNAPSHOT
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Form Approved| OMB No. 0915-0301| Expires xx/xx/xxxx
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/xx. 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.
| File Type | application/pdf |
| File Modified | 2023-01-26 |
| File Created | 2023-01-04 |