3D Acceptance Verification of Good Standing Form

OMB Number: 0915-0146

Expiration Date: XX/XX/20XX

Bureau of Health Workforce

U.S. Department of Health and Human Services Health Resources and Services Administration

National Health Service Corps Students to Service Loan Repayment Program Verification of Good Standing

(To be completed by a school official only)

The Verification of Good Standing report certifies that the student identified below is enrolled and in good standing for the 202x-2x academic year as indicated. Please note that all information will be verified for accuracy.

1. Student’s Name (Last, First, Middle):

2. What program is the student currently enrolled in:

3. Degree/certificate the student will receive upon completion of the program:

4. Is the student in good standing: Yes No

(If No, please explain.)

5. Is the Student in the final year of school: Yes No

6. Did the student take and pass step/level 2 of USMLE/COMLEX or NBDE:

Yes No N/A

(If No, when will the student take the exam?)(mm/dd/yyy)

7. When will the all course work and rotations be completed (mm/dd/yyyy):

8. Anticipated date of graduation(mm/dd/yyyy):

By signing my name below, I certify that the current status of the student listed above has been correctly identified. I further certify that, where necessary, I have corrected the “Year in Program” and “Date of Graduation” for the student to accurately reflect the anticipated graduation date given the current enrollment. I understand that any willfully false information may be punishable as a felony under U.S. Code, Title 18, Section 1001.

SUBMITTED BY:

Signature: Date: _ Name: Title: Phone Number: E-Mail Address: Name of School:

Student may upload hand signed form to the NHSC SP Online Application: https:/programportal.hrsa.gov/

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].