8 Verification of Acceptance Form

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Nurse Corps Scholarship Program

Verification of Acceptance/Good Standing Report

This Verification of Acceptance/Good Standing Report certifies that the student identified below has been accepted for admission or is enrolled in good standing in the nursing degree program in which student is applying for the 202x-202x academic year as indicated. (To be completed by a school official only.)
Student’s Name (Last, First, Middle)						Student’s Social Security Number (Last 4 Digits Only)
Nursing degree/certificate the student will receive upon completion of program						Is this a Nursing degree or certificate, a Dual degree and/or Direct Masters Entry NP (Eligible: Enrolled in NP curriculum portion) If yes, please explain: Yes No
Student year in program as of			Is the student in good academic standing? Yes No			Is there a contingency to the students' acceptance to the program? Examples include the student needing to repeat a course or having received and "Incomplete" status for a course Yes No If yes, please explain:
the 202x-202x school year
1 2 3 4
(All contingencies must be met by the start of the fall 202x-202x term.)
Is the student considered Full- Time or Part Time in the nursing program?			Length of the Full-Time nursing program (years and/or months)			Date nursing classes begin for the 202x-202x academic year				Nursing program end date (Completion of required classes for graduation)
Full-time Part-time
Date of graduation						Students’ total cumulative GPA
Nursing Program Accreditation (The NCSP will only fund students attending fully accredited institutions)
Name of National or Regional Accreditation Organization						Accreditation Expiration / Renewal Date			Is accreditation provisional? Yes No
School Information						Nursing School Contact Information
Name of School						Name
Address						Title
City						Email
State				Zip		Phone			Fax
By signing my name below, I certify that the information provided on this Verification of Acceptance/Good Standing Report is accurate and complete to the best of my knowledge and belief. I understand that any willfully false information may be punishable as a felony under U.S. Code, Title 18, Section 1001.
Signature of Nursing School Official								Date

Please upload to the Nurse Corps SP Portal: https://programportal.hrsa.gov/

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.

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