NFLP Program Specific Data Forms
OMB Number: 0915-0314
Expiration Date: xx/xx/xxxx
2023
Applicant and Program Information
Current Fiscal Year:
(Select the fiscal year date that is provided in the current NFLP Funding Opportunity Announcement cover page)
Previous
NFLP Recipient?
(Select 'YES' if your school has ever received past NFLP funding. Select 'NO' if your school has never received NFLP funding.)
Select
Type of
Institution:
Select
Type of
Entity:
Provide
Educator Components/Courses Offered:
Select the applicable accreditation for the graduate nursing program(s) offered and provide the required documentation:
Selection |
Accrediting Agency |
Expiration Date |
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CCNE |
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ACEN |
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ACME |
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COA |
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OTHER |
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(Applicants should determine the Federal amount requested by calculating the tuition and other educational fees for the academic year multiplied by the number of continuing NFLP students and projected new NFLP students expected to receive NFLP loan support. Applicants must consider the required 1/9 institutional contribution in case the full Federal amount requested is awarded. Enter numbers only. Special characters not allowed (i.e., commas, symbols, decimals))
Indicate
the total Federal Capital Contribution (FCC) Amount Requested $ .00
(If your institution received NFLP funding in the past, provide the actual or projected NFLP loan fund balance through June 30, 2023. NOTE: New applicants are not required to enter this data. Enter numbers only. Special characters not allowed (i.e., commas, symbols, decimals))
Indicate the institution’s NFLP loan fund balance as of the reporting
period end date of 6/30/2023 $
.00
0
NFLP Loan Fund Default Rate
a. Does the institution's NFLP default rate exceed the threshold (>5%)?
b. If yes, has a corrective action plan been included as a part of your application?
Yes No
a. Has an NFLP loan been disbursed from the institution's NFLP loan fund in the last two academic years?
NFLP Enrollees Information by Degree - Continuing Students Expected to Request NFLP Support (07/01/2023 - 06/30/2024)
Type of Institution |
* Master’s |
* Doctoral |
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FT |
PT |
FT |
PT |
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Public - Instate |
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Public - Outstate |
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Private |
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TOTALS: |
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NFLP Enrollees Information by Degree - New Students Expected to Request NFLP Support (07/01/2023 - 06/30/2024)
Type of Institution |
* Master’s |
* Doctoral |
||
FT |
PT |
FT |
PT |
|
Public - Instate |
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Public - Outstate |
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Private |
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TOTALS: |
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NFLP Graduates Information (07/01/2022 - 06/30/2023)
(Enter the number of NFLP graduates and the graduates employed as nurse faculty from the previous academic year)
Graduate Data |
Total Number of NFLP Graduates |
Total Number of NFLP Graduates Employed as Nurse Faculty |
||
* Master’s |
* Doctoral |
* Master’s |
* Doctoral |
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TOTALS: |
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NFLP Enrollees by Nurse Practice Role (07/01/2023 - 06/30/2024)
(Enter the total number of continuing and projected new NFLP students by degree program and specialty being pursued. The totals should reconcile with the totals under E.1 - Continuing enrollees and E.2 - Projected new enrollees.)
Nurse Practice Specialty |
NFLP Enrollees by Degree & Specialty (07/01/2023 - 06/30/2024) |
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* Master’s |
* Doctoral |
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Primary Care Nurse Practitioner |
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Acute Care Nurse Practitioner |
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Nurse - Midwife |
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Nurse - Anesthetist |
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Clinical Nurse Specialist |
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Public Health Nurse |
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Nurse Administrator |
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Nurse Educator |
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Other: |
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TOTALS: |
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Sum of Master's and Doctoral: |
0 |
F. Tuition, Terms and Credit Hours
(Provide
the
required
tuition
information
in
this
section
for
each
distinct
graduate
nursing
degree
program
that
will
support
NFLP
enrollees
to
prepare
as
nurse
faculty.
NOTE:
If you are a
PRIVATE institution, enter tuition data under In-State only.)
Degree Information 1:
* Tuition (Enter numbers only. Special characters not allowed i.e., commas, symbols, decimals) |
|||||
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Tuition |
In-State |
Out-of-State (Not applicable for private institution) |
||
FT (Enter total amount for one term with fees and expenses.) |
PT (Enter total amount for one term with fees and expenses.) |
FT (Enter total amount for one term with fees and expenses.) |
PT (Enter total amount for one term with fees and expenses.) |
||
Tuition Costs |
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Public Burden Statement: The Nurse Faculty Loan Program — Program Specific Data Form, Annual Performance Report Financial Data
Form and Due Diligence Form will collect outcome and financial data to capture the NFLP loan fund account activity related to financial
receivables, disbursements, and borrower account data related to employment status, loan cancellation, loan repayment and collections.
Tracking of borrowers should cease when borrower accounts are closed due to full repayment/cancellation/collection. 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 0915-0314 and it is valid until xx/xx/xxxx. This information collection is
required to obtain or retain a benefit (42 U.S.C. 297n-1). 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
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | NFLP Program Specific Data Forms |
Author | Smith, Lakisha (HRSA) |
File Modified | 0000-00-00 |
File Created | 2023-08-31 |