1 NFLP Program Specific Data Form

Fields marked with an asterisk (*) are required

NFLP Program Specific Data Forms

OMB Number: 0915-0314

Expiration Date: xx/xx/xxxx

1. 

   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:

2. Accreditation

• Select the applicable accreditation for the graduate nursing program(s) offered and provide the required documentation:

Selection	Accrediting Agency	Expiration Date
	CCNE
	ACEN
	ACME
	COA
	OTHER

3. Federal Funds Requested

(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

1. NFLP Loan Fund Balance/Unused Accumulation

(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

2. 

   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

3. Last NFLP Student Loan Award

• a. Has an NFLP loan been disbursed from the institution's NFLP loan fund in the last two academic years?

1. NFLP Enrollees Information by Degree - Continuing Students Expected to Request NFLP Support (07/01/2023 - 06/30/2024)

Type of Institution	* Master’s		* Doctoral
	FT	PT	FT	PT
Public - Instate
Public - Outstate
Private
TOTALS:

3. 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
Public - Outstate
Private
TOTALS:

5. 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
TOTALS:

6. 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)
		* Master’s	* Doctoral
Primary Care Nurse Practitioner
Acute Care Nurse Practitioner
Nurse - Midwife
Nurse - Anesthetist
Clinical Nurse Specialist
Public Health Nurse
Nurse Administrator
Nurse Educator
Other:
TOTALS:
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: Program Degree Level Type of Term # of Terms/Quarters Per Year Minimum Credit Hours Required for Full-time Status * Tuition (Enter numbers only. Special characters not allowed i.e., commas, symbols, decimals)
	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

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

[email protected].