3E Verification of Disadvantaged Background Status

OMB No.: 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 DISADVANTAGED BACKGROUND STATUS

Name of Student: _Last 4 digits SSN: XXX-XX-

The Individual identified below certifies that the above-named student:

☐ is ☐ is NOT

from a disadvantaged background (criteria described below). Students from a disadvantaged background have either participated in or would have been eligible to participate in Federal Programs such as the “Scholarships for Disadvantaged Students,” “Loans to Disadvantaged Students” or the “Nursing Workforce Diversity Grant Program.”

CRITERIA FOR DISADVANTAGED BACKGROUND STATUS

1. An individual comes from an environment that has inhibited the individual from obtaining the knowledge, skills, and abilities required to enroll in and graduate from a health professions or nursing school (Environmentally Disadvantaged). The following are provided as examples for guidance only and are not intended to be all-inclusive.

• The individual graduated from (or last attended) a high school with low SAT score based on most recent data available.

• The individual graduated from (or last attended) a high school from which, based on most recent data available, low percentage of seniors receive a high school diploma; or low percentage of graduates go to college during the first year after graduation.

• The individual graduated from (or last attended) a high school with low per capita funding.

• The individual graduated from (or last attended) a high school at which, based on most recent data available, many of the enrolled students are eligible for free or reduced price lunches.

• The individual comes from a family that receives public assistance (e.g., Aid to Families with Dependent Children, food stamps, Medicaid, public housing).

• First generation in family to attend college

OR

2. An individual comes from a family with an annual income below a level based on low-income thresholds according to family size established by the U.S. Census Bureau, adjusted annually for changes in the Consumer Price Index, and adjusted by the Secretary of Health and Human Services (HHS) for adaptation to this program (Economically Disadvantaged). The Secretary defines a ‘‘low income family/household’’ for various health professions and nursing programs included in Titles III, VII and VIII of the Public Health Service Act as having an annual income that does not exceed 200 percent of the Department’s poverty guidelines. A family is a group of two or more individuals related by birth, marriage, or adoption who live together. A household may be only one person.

SUBMITTED BY:

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

Student may upload signed form to the NHSC S2S LRP 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, Section 338C-H of PHS Act; NHSC S2S: Section 338B and Section 331(i) of the PHS Act; NHHSP: 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].