4G NHHSP Graduation Documentation Form

DEPARTMENT OF HEALTH & HUMAN SERVICES Health Resources and Services Administration

Bureau of Health Workforce Rockville, Maryland 20857

Native Hawaiian Health Scholarship Program

Graduation Documentation

*TO BE COMPLETED BY A SCHOOL OFFICIAL

1. Date:

2. Name of Participant:

3. Institution:

4. Last Four SSN:

5. Entrance Date into the NHHSP:

6. Graduation Date:

7. NHHSP Balance Owed? Yes _______ No _______

• If Yes, what is the Balance? ___________________________________________

• I have attached copy of invoice: Yes _______ No _______

School Stamp/Seal

School Representative Signature: Date:

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].

OMB Number: 0915-0146

Expiration Date: XX/XX/20XX