NHSC S2S LRP - Acceptance Verification of Good Standing Form

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OMB No: 0915-0146
Expiration Date: xx/xx/xxxx
Bureau of Health Workforce
U.S. Department of Health and Human Services
Health Resources and Services Administration

National Health Service Service Corps Students to Service Loan Repayment Program
VERIFICATION OF GOOD STANDING FORM
(To Be Completed by a School Official Only)
The Verification of Good Standing report certifies that the student identified below is enrolled and in good standing for the
202x-202x academic year as indicated. Please note that all information will be verified for accuracy.

1. Student's Name (Last, First, Middle):
2. What program is the student currently enrolled in?
3. Degree/certificate the student will receive upon completion of the program:

4. Is the student in good standing?

No

Yes

(If No, please explain.)
5. Is the student in the final year of school?

Yes

No

6. Did the student take and pass step/level 1 of the USMLE/COMPLEX or NBDE?
Yes

No

N/A

(If No, when will the student take the exam?) (select a date)
7. When will all of the course work and rotations be completed? (select a date)
8. Anticipated date of graduation (select a date):
By signing my name below, I certify that the current status of the student listed above has been correctly identified. I
further certify that, where necessary, I have corrected the "Year in Program" and "Date of Graduation" for the student
to accurately reflect the anticipated graduation date given the current enrollment. I understand that any willfully
false information may be punishable as felony under U.S. Code, Title 18m Section 1001.
SUBMITTED BY:
Signature:

Date:

Name:

Title:

Phone Number:

Email Address:

Name of School:
Student may upload signed form to the NHSC S2S LRP Online Application: My BHW Account
For questions on how/where to submit this form, please contact the Customer Care Center at: 1-800-221-9393.
Public Burden Statement: The purpose of this information collection is to obtain information through the National Health Service Corps Students to Service Loan
Repayment Program (NHSC S2S LRP) that is used to assess a loan repayment applicant’s eligibility and qualifications. Clinicians interested in participating in the
NHSC S2S LRP must submit an application to the NHSC S2S LRP through the My BHW online portal. 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
0915-0146 and it is valid until xx/xx/xxxx. This information collection is required to obtain or retain a benefit [Section 338B of the Public Health Service Act (42 USC
254l-1), as amended; Section 331(i) of the Public Health Service Act (42 USC 254d(i)), as amended)]. The information is protected by the Privacy Act, but it may be
disclosed outside the U.S. Department of Health and Human Services, as permitted by the Privacy Act and Freedom of Information Act, to Congress, the National
Archives, and the Government Accountability Office, and pursuant to court order and various routine uses as described in the System of Record Notice 09-15-0037.
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 14NWH04, Rockville, Maryland, 20857.