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Bureau of Health Workforce Nurse Corps Supplemental Funding Evaluation

OMB: 0915-0393

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Supporting Statement A


Bureau of Health Workforce Nurse Corps

Supplemental Funding Evaluation


OMB Control No. 0915-XXXX-New


Terms of Clearance: None


A. Justification


1. Circumstances Making the Collection of Information Necessary


The Health Resources and Services Administration (HRSA) is requesting OMB approval for a new information collection request to evaluate HRSA’s Nurse Corps Loan Repayment and Scholarship Programs. HRSA is obligated to collect performance information on its grants and cooperative agreements as mandated in the Government Performance and Results Act of 1993 (GPRA)1 and the GPRA Modernization Act of 2010 (GPRAMA)2. The Nurse Corps Programs are governed by Section 846 of the Public Health Service Act as amended (42 U.S.C. 297n) and Section 846(d)-(i) of the Public Health Service Act, as amended (42 U.S C. 297n(d)-(i)), which define specific reporting requirements.


HRSA’s Bureau of Health Workforce seeks to improve the health of underserved and vulnerable populations by strengthening the nation’s health workforce and connecting skilled professionals to communities in need. The Bureau administers the Nurse Corps Loan Repayment Programs and Scholarship Program to improve the distribution of nursing graduates and professionals. The Nurse Corps Programs support nursing education and training by providing recruitment and retention incentives to nurses committed to a career in medically underserved communities. These incentives include either a loan repayment or a scholarship award in exchange for service in a health care facility with a critical shortage of nurses that is located in a Health Professional Shortage Area. The Nurse Corps Loan Repayment Program also extends loan repayments to nurse faculty serving in accredited schools of nursing. In Fiscal Year 2023, the Nurse Corps Programs had an annual budget of $92.6 million. Through the American Rescue Plan Act of 2021, the Nurse Corps Programs received supplemental funding to carry out section 846 of the Public Health Service Act. The supplemental funding was intended to increase the number of clinicians supported across all Nurse Corps Programs with a special focus on specialty areas including psychiatric nurse practitioners and women’s health.


HRSA last conducted a comprehensive evaluation of the Nurse Corps Programs in 2006. This information collection request describes plans for conducting an updated program evaluation to understand more recent program successes and challenges, including how COVID-19 affected the programs. Additionally, HRSA seeks to understand the impact of additional funding for the Nurse Corps Programs from the American Rescue Plan Act of 2021. The evaluation will seek information from participants and alumni of the Nurse Corps Programs from 2017-2023 and will assess program outcomes from before, during, and after the COVID-19 pandemic, as well as the impact of the American Rescue Plan funds. This mixed-methods evaluation will have three major components: analysis of existing information, a national survey of Nurse Corps participants and alumni, and in-depth interviews with participants and alumni.





2. Purpose and Use of the Information Collection


The purpose of the planned primary data collection activities is to capture key program process and outcome measures that are not available from administrative sources. The information collected will enable BHW to address key evaluation questions including, but not limited to:


  1. Impact of the programs on longer-term decisions to remain in the nursing workforce and at the Nurse Corps site or in another underserved area. Understanding the long-range decisions of participants is critical to understanding the success of the Nurse Corps program, as its ultimate goal is to affect longer-term change in the nursing workforce distribution. Administrative data sources do not capture intentions or longer-term employment outcomes of participants and alumni.


  1. Experience and satisfaction with program participation, from the application phase through the service obligation phase. Participants and alumni are the only source of information about their experience and satisfaction with the program, which are important evaluation outcomes that will be used to inform future programming efforts.


  1. Details of service provision and experience with COVID-19. The COVID-19 pandemic delivered dual shocks to the Nurse Corps program and the nursing workforce. On the one hand, enhanced funding for the program resulting from the American Rescue Plan led to large increases in the annual number of participants. On the other, the pandemic fundamentally reshaped the work environment of nurses, leading to increased stress, risk of illness, and changes in how work is performed. The survey will focus on the experiences of those serving before and during/after the pandemic in order to better understand how the pandemic shaped participants’ decisions to remain in the nursing workforce and in critical shortage facilities.


The national survey of Nurse Corps participants will target the following groups of respondents: Loan Repayment Program clinical nurse participants and alumni, Loan Repayment Program nurse faculty participants and alumni, and Scholarship Program participants (both in school and completing service obligation) and alumni. The survey will be designed and delivered via web and telephone, with reminders and a URL and a PIN number for the web survey sent by both mail and email. The survey will be conducted on a census of participants from 2017-2023, an estimated 7,302 participants. The questions will cover satisfaction with the program and service obligation site, intention to remain at the site, actual location of current practice (for alumni), training on preparedness for disasters and disease outbreaks in schools of nursing and on site, types of services provided on site, panel size and visit load, and the impact of COVID-19 on service delivery. The survey will display only questions relevant to participants’ specific programs and their service obligation timeframes. Participation in the survey is voluntary, and participants will complete the survey one time.


The in-depth interviews will enable a richer understanding of program experience than is possible to achieve with survey data. In-depth interviews will be conducted with 57 participants and alumni representing the range of respondent groups: 18 interviews will be conducted with Loan Repayment Program participants and alumni; 18 interviews will be conducted with Loan Repayment Program nurse faculty participants and alumni; and 21 interviews will be conducted with Scholarship Program participants (both in school and completing their service obligation) and alumni. One-on-one in-depth interviews with Nurse Corps participants and alumni will enrich the evaluation by eliciting data on the Nurse Corps experience that are more nuanced than what is feasible to collect through a standardized survey. The 45-minute virtual interviews will be conducted after the survey with a sample of current program participants and alumni. Recruitment approaches for the in-depth interviews will include a survey question asking respondents if they would be willing to participate in an interview as well as direct recruiting from the census of program participants and alumni via email (if needed). The interviews will ask specifically about the process of and motivation for applying to the program, details about the Nurse Corps site experience, site-level resiliency strategies and whether they were successful, and experiences working through COVID-19 at Nurse Corps sites.


The information collected through the survey and in-depth interviews will enable HRSA to assess program progress and inform leaders regarding the status of the Nurse Corps investment. In addition, the data will provide actionable information for future HRSA investment strategies.


3. Use of Improved Information Technology & Burden Reduction


The data collection plan for this project has been designed to minimize respondent burden by utilizing web-based technology. The web survey will use a platform developed at Westat and currently in use for other projects at HRSA. The web-based survey platform will minimize the length of the survey using skip patterns and customized content for respondents in different programs across different years of service. We will also conduct extensive quality control testing to ensure the skip patterns and logic allow for maximum efficiency. Survey respondents may stop the survey if necessary and return to it, rather than start over, allowing them to divide the time needed to complete the survey into increments of their choosing. Telephone follow up (Computer Assisted Telephone Interviewing) will also make use of the web survey interface. Interviewers will enter data they receive over the phone into the same web survey system and resulting database. The web survey display for telephone interviewing will contain slight variations in wording to make it more conversational for interviewers and respondents. All respondents (100%) will be reporting using this technology.


To further minimize respondent burden, we will ensure that the survey takes respondents no more than 30 minutes to complete (estimating between 20 and 30 minutes). Use of a single survey instrument for a diverse set of respondents, while customizing the survey for respondents based on their program type and dates of participation, is efficient and helps to standardize the resulting data across a variety of respondent groups. The survey will consist of 75 primarily closed-ended questions, of which the average participant will receive less than 50 questions.


The web and telephone survey outreach and data collection will be harmonized by Westat’s multimode survey management system, known as M3. M3 meets the highest standards of security in order to ensure that the personally identifiable information available in contact information, as well as survey responses, are accessible only to authorized users and protected from data breaches. M3 enables efficient and effective organization and consolidation of all aspects of the data collection process across both web and telephone survey modes, including sample management activities such as respondent outreach across multiple modes of survey administration. M3 will generate outreach emails according to a specified schedule, will automatically adjust to contact only non-finalized cases at each stage, and will queue the nonresponse cases for telephone follow-up.


Zoom for Government will be used to host the in-depth interviews, which has enhanced security features compared with other types of videoconferencing software.


4. Efforts to Identify Duplication and Use of Similar Information


In order to minimize respondent burden while ensuring evaluation goals are met, we will use Nurse Corps administrative data and other existing data sources wherever possible. Administrative data on the size of the participant workforce and the scholar pipeline provide a window into the growth of the program over time, changes in distribution across geographic areas and site types, and program attrition or retention. Application data will be used to understand the reach of the programs into different regions and facility types, as well as identify drivers of application success that may be related to personal, organizational, or regional characteristics and policies. In addition, the team will use HRSA data on Federally Qualified Health Centers and American Hospital Association data on hospitals to better understand the characteristics of Nurse Corps sites. Together, hospitals and health centers comprise a majority of the Nurse Corps sites.


Another key source of publicly available information for the evaluation will be analyses already conducted and reported in the biennial Report to Congress on the nursing workforce. The Westat team will work with the Bureau of Health Workforce to identify the ways in which we can add value to, but not duplicate, the effort that is already being expended to analyze program data on a regular basis. The Westat team will review existing analyses of the data to identify specific additions that will benefit the evaluation. This may include updating existing analyses to present data points over time, stratifying analyses, and looking at relationships among data points. This exercise will help to harmonize the analyses that Westat conducts with work that is already done for program monitoring.


As part of a comprehensive questionnaire design process, questions will be limited and refined to collect information not available through secondary sources. Any data collected will not be duplicative of that collected by BHW for program monitoring, unless necessary to determine eligibility for the survey. Survey questions will be adapted from a range of prior surveys of the health workforce, including the Bureau of Health Workforce Substance Use Disorder evaluation survey, the National Sample Survey of Registered Nurses, and relevant peer-reviewed literature. This ensures that the questionnaire makes use of established, validated measures wherever possible.


5. Impact on Small Businesses or Other Small Entities


No small businesses will be involved in this study.


6. Consequences of Collecting the Information Less Frequently

The two proposed data collections will each be conducted one time only, in late 2023 and early 2024.


Given the importance of the Nurse Corps Programs in addressing the shortage of nursing professionals in underserved areas, it is critical to evaluate program effectiveness to determine what works well, and what programmatic changes may be needed. All information collected will be used to understand the impacts of changing funding levels over time, provide feedback on implementation challenges and achievements, and inform the strategic direction of the programs. If HRSA collects less information, the BHW will be unable to fully evaluate the impact of the Nurse Corps Programs on nurse workforce supply and retention in medically underserved areas.


7. Special Circumstances Relating to the Guidelines of CFR 1320-5


The request fully complies with the regulation.


8. Comments in Response to the Federal Register Notice/Outside Consultation


8.a. Comments in Response to the Federal Register Notice


A 60-day Federal Register Notice was published in the Federal Register on April 14, 2023, vol. 88, No. 72, pp 23901-92, https://www.govinfo.gov/content/pkg/FR-2023-04-14/pdf/2023-07889.pdf. HRSA received no public comments.


A 30-day Federal Register Notice was published in the Federal Register on July 7, 2023, vol. 88, No. 129, pp 43361-62, https://www.govinfo.gov/content/pkg/FR-2023-07-07/pdf/2023-14320.pdf. HRSA received no public comments.


8.b. Outside Consultation


During evaluation design and questionnaire development, input on item content and wording was sought from subject matter experts. We also consulted on the availability of data, frequency of collection, the clarity of instructions and record keeping, disclosure, reporting format, and on the data elements to be recorded, disclosed, or reported. The survey was also pilot tested with representatives of the groups from whom information will be collected, and no problems were identified with the level of burden posed by the information collection.



9. Explanation of Any Payment/Gift to Respondents


Incentives are proposed for both the survey and in-depth interviews. Recent research on the nursing workforce has seen declining response rates due to nurses’ busy schedules, which were stretched even further, due to nursing shortages caused by the COVID-19 pandemic.


In our experience, in order to achieve a representative sample of required participants in a timely and cost-effective manner, projects must provide incentives at levels that attract, retain, and adequately compensate respondents for their time and effort. This is important for the in-depth interviews that require 45 minutes of the respondents’ precious time. A recent meta-analysis concluded that incentives with small monetary value still significantly increase response rates (Abdelazeem et al., 2022)3. Incentives are viewed as an important tool in the successful completion of research studies, especially among audiences who are harder to reach and engage in research (Abdelazeem et al., 2022; Yancey et al., 2006)4. We believe that the nursing workforce meets this criteria.


Abdelazeem et al. also note that economic and time restraints are significant barriers to focus group participation among minority groups, and monetary incentives can reduce the impact of these barriers. This is relevant because focus groups require similar time commitments as in-depth interviews. HRSA seeks to obtain feedback from minority groups to help ensure that the evaluation is representative of different segments of the population. We believe that the incentives stated below will enhance the quality and efficiency of research, including reducing non-response bias, improving participation by those in hard-to-reach groups, and increasing the efficiency and cost-effectiveness of the research (e.g., Singer & Ye, 20135; Stewart & Shamdasani, 2015)6.


We believe our compensation rates are reasonable and at the lower end of incentive rates suggested in recent academic guidance for qualitative consumer research (Stewart & Shamdasani, 2015). We also considered the use of non-monetary incentives, however, the participants necessary for this study are less likely to engage without a substantial monetary incentive (Abdelazeem et al., 2022; Yancey et al., 2006). Our recruiting partners provide compensation to respondents in multiple ways, but in this study we will offer gift cards for survey respondents and checks for in-depth interviewees in the stated amount for their participation. Use of incentives will assist in achieving recruitment goals.


Survey respondents: A $5 electronic credit redeemable at Amazon.com will be offered to web respondents to drive completion of the survey on the web. An incentive will not be offered to those completing the survey via telephone.


In-depth interviews: A $75 check will be offered to all in-depth interview participants.


10. Assurance of Confidentiality Provided to Respondents


Data will be kept private to the extent allowed by law. Respondents will be informed about this when responding to the information collections. Respondents will be told the purposes for which the information is collected and that any identifiable information about them will not be used or disclosed for any other purpose. All data will be aggregated for reporting purposes.


All respondents in this data collection effort are assured of the privacy of their answers. Respondent data will be aggregated and estimates will be produced and published at both the national level and geographic regional or demographic sub-group level. No individual-level data will be published, nor will they be accessible or provided to anyone outside HRSA and the Westat staff working on this project.


The Westat Institutional Review Board (IRB) will review and approve all final data collection protocols prior to the commencement of data collection. They reviewed an early draft of the survey instrument used for pilot testing and raised no concerns.


11. Justification for Sensitive Questions


There are no questions of a sensitive nature included in this information collection.


12. Estimates of Annualized Hour and Cost Burden


Estimates of annualized hour burden and annualized cost to respondents are shown in Tables A-1 and A-2, respectively. The surveys and interviews require one response (i.e., one single questionnaire) per respondent. We estimate that the respondent burden for completing the web or phone survey instruments is 25 minutes (.42 hour). We estimate that the respondent burden for completing an in-depth interview is 45 minutes (.75 hour). The cost to respondents who participate in the survey or interviews will be in terms of their time only.


We used Bureau of Labor Statistics wage estimates for Registered Nurses7 and nurse faculty8 to estimate the cost of this time. We estimated the hourly wage of nurse faculty based on the average annual salary divided by the standard hours in a work year, 2080. We multiplied Bureau of Labor Statistics wage rates by a factor of two to account for fringe benefits and overhead, per guidance issued by the Assistant Secretary of Planning and Evaluation.9


The total number of estimated respondents is 7,359. The total number of burden hours is 3,109.59. The estimated total respondent cost is $247,160.18.


Table A-1. Estimated Annualized Burden Hours

Type of Respondent/Form Name

No. of Respondents

No. of Responses per Respondent

Total Responses


Average Burden per Response (in hours)




Total Burden Hours

In-depth Interviews

Nurse Corps Loan Repayment Program – Clinician (Participants and Alumni)

18

1

18

.75

13.5

Nurse Corps Loan Repayment Program – Faculty (Participants and Alumni)

18

1

18

.75

13.5

Nurse Corps Scholarship Program (Participants and Alumni)

21

1

21

.75

15.75

Total

57

.........

57

.........

42.75

Web-based Surveys with Telephone Nonresponse Follow-up

Nurse Corps Loan Repayment Program – Clinician (Participants and Alumni)

5,082


1

5,082


0.42


2,134.44

Nurse Corps Loan Repayment Program – Faculty (Participants and Alumni)

804

1

804

0.42

337.68

Nurse Corps Scholarship Program (Participants and Alumni)

1,416

1

1,416

0.42

594.72

Total

7,302

.........

7,302

.........

3,066.84



Table A-2. Estimated Annualized Burden Costs

Type of Respondent/Form Name



Total

Burden Hours

Hourly

Wage Rate


Total Respondent Costs

In-depth Interviews

Nurse Corps Loan Repayment Program – Clinician (Participants and Alumni)

13.5

$79.56

$1,074.06

Nurse Corps Loan Repayment Program – Faculty (Participants and Alumni)

13.5

$78.88

$1,064.88

Nurse Corps Scholarship Program (Participants and Alumni)

15.75

$79.56

$1,253.07

Total


42.75


.........

$3,392.01

Web-based Surveys with Telephone Nonresponse Follow-up

Nurse Corps Loan Repayment Program – Clinician (Participants and Alumni)

2,134.44

$79.56

$169,816.05

Nurse Corps Loan Repayment Program – Faculty (Participants and Alumni)

337.68


$78.88

$26,636.20

Nurse Corps Scholarship Program (Participants and Alumni)

594.72


$79.56

$47,315.92

Total

3,066.84

.........

$243,768.17





13. Estimates of Other Total Annual Cost Burden to Respondents or Record Keepers/Capitalized Costs


Other than their time, there is no cost to respondents.


14. Annualized Cost to the Federal Government


The overall cost of this research to the Federal Government includes the cost of the contract to Westat for performing the evaluation as well as the cost of federal employees supporting the evaluation.


The Westat contract for this work is three years long, with a total cost of $1,999,564. The annualized cost is $666,521.33. Table A-3 shows the breakdown of labor hours and contract costs.


Table A-3. Contract Cost to the Federal Government

Description

Hours

Cost

Annualized Cost

Labor

14,516

$646,916

$215,638.67

Consultants

1,224

$168,390

$56,130.00

Other Direct Costs (supplies, network and server charges, printing, and postage)


$52,905

$17,635.00

Overhead


$884,486

$294,828.67

Fee


$246,867

$82,289.00

Total


$1,999,564

$666,521.33


In addition to the costs for the Westat contract above, the cost to the federal government consists of the salaries of the HRSA staff who (1) determine the content of the data collection instruments, (2) oversee the scope of work conducted under the aforementioned contract, and (3) assist in the analysis of the results and recommend changes in questionnaire wording. Thus, it is estimated that needed staff time for the contracting representative to cover the above mentioned items is .25 FTE at the GS-13 level per year for a total cost of $27,383.20. The estimated cost to the government in staff time is estimated to be $82,149.60 over the three year period.


The total cost to the federal government is $2,081,713.60 over the three year period, and $693,904.53 per year.


15. Explanation for Program Changes or Adjustments


This is a new information collection.


16. Plans for Tabulation, Publication, and Project Time Schedule


Project Timeline: The three-year contract runs from September 2022-September 2025. Survey data will be collected from program participants in late 2023, while in-depth interview data will be collected in 2024. The timeline for analysis and reporting is discussed in each section below. We are requesting a three-year clearance.


Tabulation: Analysis will be performed in the spring of each year (2023-2025) using the latest available data. To assess differences in groups of participants that are particularly relevant to the evaluation, we will stratify participants and conduct separate analyses by program and several categories: current participants vs alumni,10 participated pre-COVID-19 vs during/post-COVID-19,11 and whether the participant was funded through the American Rescue Plan.12 As shown in Table A-4, we will have a total of 15 different analysis groups, of which particular stratifications of greatest interest will be chosen for each set of analyses.


Table A-4: Stratification Groups


Loan Repayment Program– Clinical Nurses

Loan Repayment Program – Nurse Faculty

Scholarship Program

All Current Participants

X

X

X

All Alumni

X

X

X

Pre-COVID-19 Current Participants



X

During/Post-COVID-19 Current Participants



X

Pre-COVID-19 Alumni

X

X


During/Post-COVID-19 Alumni

X

X


Funded Through American Rescue Plan

X

X

X

Note: The groups we will examine are marked with an X.


We envision providing descriptive statistics within stratification groups as well as statistical comparisons using one-way Analysis of Variance and multi-way chi-squared contingency tables. These are standard and effective methods for determining whether results statistically differ across groups of participants. Some research questions, such as identifying the strongest predictors of retention, are best approached within a multivariate regression framework. Depending on the final survey questions and multicollinearity between responses, we will also consider the use of multivariate regressions to estimate the association between a response to a question and a set of responses to other questions. This will allow us to assess the association of responses to different questions while controlling for demographic characteristics.


For the in-depth interviews, transcripts from the interviews will be imported to qualitative analysis software for coding and analysis. Westat qualitative analysts will begin by conducting careful readings of the transcripts to inventory the topics in the discussions, keeping in mind the key evaluation questions. Afterwards, we will create a set of high-level codes that map to the topics in the discussion guide, which will enable our team to simultaneously review all content related to a specific topic across the interviews. After coding is complete, we will conduct a thematic analysis to identify themes and patterns within and across codes as they relate to the evaluation questions.


Reports: We will develop two interim reports and one final report, reporting annually over the three years of the evaluation. Reports will be produced in early August of 2023, 2024, and 2025. Reports will contain an overview of the program, study design, findings, discussion of the results, recommendations, and implications of the findings. The interim and final reports will make use of all available data in each year. In 2023, the report will focus on analysis of secondary data sources, and later reports will include findings from the two data collections. The final report will comprehensively summarize all findings from the evaluation and detail overall recommendations and conclusions from the evaluation. Summary reports may be posted publicly on the web.


Publications: Three manuscripts are planned for submission to peer-reviewed journals from this work, one submitted at the end of each year of the evaluation. Potential journals under consideration for submission include Journal of Healthcare Management, Journal of Nursing Research, Nursing Management, and Nursing Outlook. Topics for the manuscripts will be selected based on consultation with HRSA staff and may include but are not limited to:

  1. an analysis focused on an emerging topic such as COVID-19 or health equity

  2. a methodological article on survey design and response rates and patterns

  3. a policy-focused paper with detailed policy/program recommendations stemming from evaluation results

  4. a qualitative paper focused on the in-depth interview results


17. Reason(s) Display of OMB Expiration Date is Inappropriate


The OMB number and Expiration date will be displayed on every page of every form/instrument.


18. Exceptions to Certification for Paperwork Reduction Act Submissions


There are no exceptions to the certification.



1 Pub. L. No. 103-62, 107 Stat. 285 (Aug. 3, 1993).

2 Pub. L. No. 111-352, 124 Stat. 3866 (Jan. 4, 2011).

3 Abdelazeem, B., Abbas, K. S., Amin, M. A., El-Shahat, N. A., Malik, B., Kalantary, A., & Eltobgy, M. (2022). The effectiveness of incentives for research participation: A systematic review and meta-analysis of randomized controlled trials. PloS one, 17(4), e0267534. https://doi.org/10.1371/journal.pone.0267534

4 Yancey AK, Ortega AN, and Kumanyika SK (2006). Effective recruitment and retention of minority research participants. Ann Rev Public Health, 27, 1-28.

5 Singer E and Ye C (2013). The use and effects of incentives in surveys. Ann Am Acad Pol Soc Sci, 645(1): 112-141.


6 Stewart DW and Shamdasani PN (2015). Focus Groups: Theory & Practice, 3rd Edition. Los Angeles: Sage.


10 A current participant is defined as a participant who has a missing completion fiscal year in the Nurse Corps Evaluation data as of the most recent data available at the time of analysis. An alumni is defined as a participant with a non-missing completion fiscal year in the Nurse Corps Evaluation data in the most recent data available at the time of analysis.

11 For this evaluation, we will examine a 3-year pre-COVID-19 period. Therefore, a pre-COVID-19 Loan Repayment Program or Loan Repayment Program for Nurse Faculty participant is defined as a participant with an obligation end date between February 3, 2017 to February 2, 2020 (the U.S. declared the COVID-19 public health emergency on February 3, 2020). A during/post-COVID-19 Loan Repayment Program or Loan Repayment Program for Nurse Faculty participant is defined as a participant with an obligation end date after February 2, 2020.

A pre-COVID-19 Scholarship Program participant is defined as a participant with an award date between February 3, 2017 to February 2, 2020. A during/post-COVID-19 Scholarship Program participant is defined as a participant with an award after February 2, 2020. Award date is used for this program’s participants because participants still in school do not yet have obligation start or end dates, but it is important to capture this population in the evaluation.

In the Nurse Corps evaluation data, only award fiscal year is included. Therefore, award date is assumed to be July 1 of the award fiscal year for scholarship participants because the scholarships apply retroactively to July 1 which is defined as the start of the school year, and September 30 of the award fiscal year for Loan Repayment Program participants because awards are mostly given in August and September, and no later than September 30.

To ensure that all analyses are consistent with these definitions and that we are examining 3-year pre-COVID-19 periods, all analyses will include only Scholarship Program participants that had an award fiscal year of 2016 or later (because February 3, 2017 is in fiscal year 2016), and only Loan Repayment Program participants that had an obligation end date after February 3, 2017.

12 A participant is defined as being funded through the American Rescue Plan based on a flag in the Nurse Corps Evaluation data.

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