Microsoft Word - NHSC S2S LRP Verification of Vulnerable Background Status Form (Redline)

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OMB No. 0915‐0146
Expiration Date: 3/31/2029
Bureau of Health Workforce
U.S. Department of Health and Human Services
Health Resources and Services Administration

National Health Service Corps Students to Service Loan Repayment Program
VERIFICATION OF DISADVANTAGED VUNERABLE BACKGROUND STATUS FORM
(For School Use Only ‐ Must be Completed by a Financial Aid Official)
Name of Students

Last 4 digits of SSN: XXX‐XX‐

The Financial Aid Official identified below certifies that the above‐named student:
Is

Is NOT

from a vulnerabledisadvantaged background (criteria described below). Students from a
vulnerabledisadvantaged background have either participated in or would have been eligible to
participate in Federal Programs such as the “Scholarships for Disadvantaged Students”. As defined by the
Scholarship for Disadvantaged Students Program (Sec. 737 of the Public Health Service Act, 42 U.S.C. §
293(a)), this term refers to individuals who have been identified by their schools or can document having
come from a “vulnerabledisadvantaged background” based on educational,
geographicenvironmental, and/or economic factors.)
CRITERIA FOR VULNERABLEDISADVANTAGED BACKGROUND STATUS
1. An individual comes from an environment that has inhibited the individual from obtaining the knowledge,
skills, and abilities required to enroll in and graduate from a health professions or nursing school
(GeographicallyGeogrEnvironmentally VulnerableDisadvantaged). The following are provided as
examples for guidance only and are not intended to be all‐inclusive.
The individual graduated from (or last attended) a high school with low SAT score based on most recent data available.
The individual graduated from (or last attended) a high school from which, based on most recent data
available, low percentage of seniors receive a high school diploma; or low percentage of graduates go to
college during the first year after graduation.
• The individual graduated from (or last attended) a high school with low per capita funding.
• The individual graduated from (or last attended) a high school at which, based on most recent data
available, many of the enrolled students are eligible for free or reduced price lunches.
• The individual comes from a family that receives public assistance (e.g., Aid to Families with Dependent
Children, food stamps, Medicaid, public housing).
• First generation in family to attend college.
OR
2. An individual comes from a family with an annual income below a level based on low‐income thresholds according to
family size established by the U.S. Census Bureau, adjusted annually for changes in the Consumer Price Index,
and adjusted by the Secretary of Health and Human Services (HHS) for adaptation to this program (Economically
VulnerableDisadvantaged). The Secretary defines a ‘‘low income family/household’’ for various health
professions 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. A household may be only one
person.
•
•

SUBMITTED BY:
Signature

Name & Title

Email:

Phone:

Name of School:

OMB No. 0915‐0146
Expiration Date: 3/31/2029
Bureau of Health Workforce
U.S. Department of Health and Human Services
Health Resources and Services Administration

Student may upload signed form to the NHSC S2S LRP Online Application: My BHW Account
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 scholarship applicant’s eligibility and qualifications. Clinicians interested in participating in the NHSC S2S LRP must submit an
application to the NHSC S2S LRP. 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 3/32/2029. 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 .67 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 13N82,
Rockville, Maryland, 20857.