Form 1 NFLP Program Specific Data Form

Nurse Faculty Loan Program Forms

NFLP - Program Specific Data Form August

Nurse Faculty Loan Program Forms- Program Specific Data Form

OMB: 0915-0314

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Nurse Faculty Loan Program Forms

OMB Number: 0915-0314

Expiration Date: 08/31/2026

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  1. Shape3

    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)

    • Shape5 Previous NFLP Recipient?

(Select 'YES' if your school has ever received past NFLP funding. Select 'NO' if your school has never received NFLP funding.)


    • Shape6 Select Type of Institution:


    • Shape7 Select Type of Entity:




    • Shape8 Provide Educator Components/Courses Offered:

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  1. Shape11 Accreditation



    • 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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  1. 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))



    • Shape25 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


    1. Shape27 Shape28

      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


    1. Shape30 Shape31 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?

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    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:






    1. 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:






    1. 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:





    1. 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

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F. Tuition, Terms and Credit Hours

Shape38 Shape39 (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 purpose of this information collection is to obtain performance data for the following: HRSA program participants, program operations, and applications. In addition, these data will facilitate the ability to demonstrate alignment between BHW Programs and the Nurse Faculty Loan Program. 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 08/31/2026. Public reporting burden for this collection of information is estimated to average 6.25 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].



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleNFLP Program Specific Data Forms
AuthorSmith, Lakisha (HRSA)
File Modified0000-00-00
File Created2023-08-18

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