5 Verification of Disadvantaged Background

OMB No. 0915-0127
Form Approved
Exp. Date xx/xx/xxxx

NATIONAL HEALTH SERVICE CORPS
Verification Regarding Disadvantaged Background
This completed form must be uploaded to your application when prompted to do so for
consideration as having come from a disadvantaged background. The NHSC cannot
accept faxed or emailed copies.
Student’s Name:

Last 4 SSN:

CRITERIA FOR DISADVANTAGED BACKGROUND STATUS

Students from a disadvantaged background have either participated in or would have
been eligible to participate in Federal Programs such as the Scholarships for
Disadvantaged Students, Loans to Disadvantaged Students, or the Nursing Workforce
Diversity Grant Program.
1. Environmentally Disadvantaged
If a student who comes from an environment that has inhibited them from
obtaining the knowledge, skills, and abilities to enroll in and/or graduate from a
health professions or nursing school is considered as being Environmentally
Disadvantaged.
The following is a list of common characteristics that describe students who are
Environmentally Disadvantaged. The examples are provided as guidance
only, and are not intended to be all-inclusive:
•
•
•
•
•
•

Person from high school with low average SAT/ACT scores or below the
average State test results.
Person from a school district where 50 percent or less of graduates go to
college.
Person who has a diagnosed physical or mental impairment that
substantially limits participation in educational experiences.
Person for who English is not his or her primary language and for whom
language is still a barrier to academic performance.
Person who is first generation to attend college.
Person from a high school where at least 30 percent of enrolled students
are eligible for free or reduced price lunches.
– OR –

2. Economically Disadvantaged
The following are characteristics that describe students who are considered
Economically Disadvantaged:
•
•

Students who come from a family with an annual income below a level
based on low-income thresholds established by the U.S. Census Bureau,
adjusted annually for changes in the Consumer Price Index.
The Secretary defines a ‘‘low income family’’ for various health professions

1

Verification Regarding Disadvantaged Background

•

and nursing programs included in Titles III, VII and VIII of the Public
Health Service Act as having an annual income that does not exceed 200
percent of the Department’s poverty guidelines.
A family is a group of two or more individuals related by birth, marriage,
or adoption who live together or an individual who is not living with any
relatives.

VERIFICATION

Place a check in the box (1) that best matches the Disadvantaged Background status
for this former student, based on the Criteria for Disadvantaged Background
Status described in the previous section.
I certify that the student named above is from a disadvantaged background.
I certify that the student named above is NOT from a disadvantaged
background.

Submitted by:
Signature:
Printed Name:

Date:
Phone Number:

Public Burden Statement:
The purpose of this information collection is to obtain information through the National Health Service Corps (NHSC) Loan Repayment Program
(LRP), NHSC Substance Use Disorder (SUD) Workforce LRP, and the NHSC Rural Community LRP applications, which are used to assess an LRP
applicant’s eligibility and qualifications for the LRP and to obtain information for NHSC site applicants. Clinicians interested in participating in a
NHSC LRP must submit an application to the NHSC to participate in one of the NHSC programs, and health care facilities must submit an NHSC Site Application
and Site Recertification Application to determine the eligibility of sites to participate in the NHSC as an approved service site. 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 0915-0127 and it is valid until xx/xx/xxxx. This information collection is required to obtain or retain a benefit (Section
333 [254f] (a)(1) of the Public Health Service Act). Public reporting burden for this collection of information is estimated to average 0.5 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].

2