Microsoft Word - NHSC SP 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 Scholarship Program
VERIFICATION OF VULNERABLEDISADVANTAGED BACKGROUND STATUS FORM
(For School Use Only ‐ Must be Completed by a Financial Aid Official)

Last 4 digits of SSN: XXX‐XX‐

Name of Student:

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

Is NOT

from a geographically or economically 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 (GeographicallyEnvironmentally
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:

Phone Number:

Email:

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 SP Online Application: My BHW Account

Public Burden Statement: The purpose of this information collection is to obtain information through the National Health Service Corps
Scholarship Program (NHSC SP), which is used to assess an applicant’s eligibility and qualifications for the NHSC SP. Clinicians interested in
participating in the NHSC SP must submit an application to the NHSC SP 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 Office of Management
and Budget control number. The Office of Management and Budget control number for this information collection is 0915-0146 and it is
valid until 3/31/2029. This information collection is required to obtain or retain a benefit (National Health Service Corps Scholarship Program:
Section 338A of the Public Health Service Act and Section 338C-H of Public Health Service Act.). The information is protected by the Privacy Act,
but it may be disclosed outside theU.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 Health Resources and Services Administration Reports Clearance
Officer, 5600 Fishers Lane, Room 13N82, Rockville, Maryland 20857.