2C Data Collection Worksheet Form

The National Health Service Corps Scholarship Program, Students to Service Loan Repayment Program, and the Native Hawaiian Health Scholarship Program

Data Collection Worksheet Form

OMB: 0915-0146

Document [pdf]

Download: pdf | pdf

Data Collection Worksheet Form

OMB Number: 0915-0146
Expiration Date: XX/XX/20XX

* required field
School

Discipline

Degree

Cornell University - Weill Cornell Medical College

Allopathic Physician

Thank you for creating a DCW! The form can be completed in 4 easy steps. For any questions on filling out this information please contact NHSC SP at
[email protected].

1. TUITION
Enter the Resident (In-State) and Non-resident (Out-of-State) tuition for the 2017-2018 (July 1 to June 30) school 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.
1st Year Student

2nd Year Student

3rd Year Student

4th Year Student

Resident *

Non-Resident *

2. SCHOOL INCURRED FEES
Review and enter amounts for the list of items grouped under School Incurred Fees. These fees are incurred by the school as part of the tuition and
required fees. The NHSC SP would expect items defined as Fees to be included in the tuition invoice submitted by the school and reimbursed by NHSC SP
directly to the school.
1st Year Student

2nd Year Student

3rd Year Student

4th Year Student

Education Fees

University Fees

Administrative Fees

Matriculation Fees

Curriculum Fees

Academic Support Services Fee

Campus Transportation Fees

Health Services Fees and
Immunizations

Student Activities Fee

Surcharge (when added by the
school to the tuition)

Student Services Fee

Laboratory Fees

Building Use or Facility Fee

Technology Fee

Computer Lab Fee

Recreation Fee

Processing Fee

Campus Life Fee

Other Fees

Immunizations

Graduation fee

Professional fee

School ID Cards / ID Fees

3. STUDENT EXPENSES
Review and enter amounts for the list of items grouped under Student Expenses. The Student Expenses or Other Reasonable Costs (ORC) amount is paid
by the NHSC SP directly to the student to cover additional reasonable expenses incurred by the student that are not covered under the tuition and fees
billed by the school. The NHSC SP will disburse a one-time Other Reasonable Cost (ORC) payment to the student when they receive their first monthly
stipend.
1st Year Student

2nd Year Student

3rd Year Student

4th Year Student

Books

Uniforms

Clinical Supply Costs

Microscope

Instruments

National Boards

Computer/Software

CPR Certification Fee

Miscellaneous Cost

Clinical Rotation/Travel Fee

4. INSURANCE
Review and enter amounts for the list of items grouped under Insurance. Insurance items may be incurred by the school as part of the tuition and required
fees or incurred as an ORC by the Student. Please complete the form based on if the cost of insurance is incurred by the school or incurred by the student.
1st Year Student

2nd Year Student

3rd Year Student

4th Year Student

Health Insurance (school incurred)

Malpractice Insurance (school

Disability Insurance (school incurred)

Health Insurance (student incurred)

Disability Insurance (student

incurred)

incurred)
Please explain any "other" fees in the comments section below.
I approve this Data Collection Worksheet

New Comments

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Public Burden Statement: The purpose of the NHSC SP, NHSC S2S LRP, and the NHHSP is to provide scholarships or loan
repayment to qualified students who are pursuing primary care health professions education and training. In return,
students agree to provide primary health care services at approved facilities located in designated Health Professional
Shortage Areas (HPSAs) once they are fully trained and licensed health professionals. 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 0915-0146 and it is valid until XX/XX/202X.
This information collection is required to obtain or retain a benefit (NHSC SP: Section 338A of the PHS Act and Section
338C-H of PHS Act; NHSC S2S LRP: Section 338B of the PHS Act and Section 331(i) of the PHS Act; NHHSP: The Native
Hawaiian Health Care Improvement Act of 1992, as amended [42 U.S.C. 11709]. 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 or [email protected].

File Type	application/pdf
File Title	Data Collection Worksheet Form- School Representative Portal
Author	Galipo, Christopher (HRSA)
File Modified	2020-05-12
File Created	2017-05-15