5 Graduation Close Out Form

DEPARTMENT OF HEALTH & HUMAN SERVICES

Health Resources and Services Administration

Bureau of Health Workforce (BHW)

Rockville, Maryland 20857

Nurse Corps Scholarship Program
Graduation/Close out Documentation
*TO BE COMPLETED BY THIRD PARTY BILLING REPRESENTATIVE*

1. Date____________________________________________________________________
2. Name of Participant_______________________________________________________
3. Institution_______________________________________________________________
4. Last Four SSN ___________________________________________________________
5. Graduation Date __________________________________________________________
6. NCSP Balance Owed? Yes______

No______

o If Yes, what is the Balance? __________________________________________


I have attached copy of invoice. Yes______

School Representative Signature
________________________________

Date
________

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/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 .8
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.

No______

School Stamp/Seal