Form sds1

OMB No. 0915-0149

Expiration Date:

Scholarships for Disadvantaged Students: Application

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB control number for this project is 0915-0149. Public reporting burden for this collection of information is estimated to average 20 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 10-33, Rockville, Maryland, 20857.

PROGRAM TYPE:

Status:

ELIGIBILITY CRITERIA

A. Full-Time students in your program and their racial/ethnicity background  More Instructions

Race/Ethnicity	Full-Time Students Enrolled Hispanic/Latino Non-Hispanic/Latino
*Asian - all
*Asian Underrepresented
*Black or African American * American Indian/Alaskan Native
* Native Hawaiian or Other Pacific Islander
* White
* More than One Race
Total (Calculated Value)

B. Total full-time enrollment and full-time disadvantaged enrollment by class year for students your program  More Instructions

Class Year	Total Full-Time Class Enrollment	Total Full-Time Disadvantaged Enrollment
*First
*Second
*Third
*Fourth
*Fifth
*Sixth
Total
*Of the number of full-time disadvantaged, number who are economically disadvantaged

C. Full-Time students graduated and full-time disadvantaged students graduated from your program  More Instructions

*Total Full-Time Graduates	*Full-Time Disadvantaged Graduates
Of the number or Full-Time Disadvantaged, number who are economically disadvantaged

D. Full-Time graduates from your program serving in medically underserved communities

Medically Underserved Communities  More Instructions
*Total Full-Time Graduates
*Number of Full-Time Graduates in Medically Underserved Communities
*Of the Number of Full-Time Graduates in Medically Underserved Communities (above), number of Graduates that received SDS

ACCREDITATION  More Instructions

*Name of Accrediting Body

If "Other" specify name:

*Expiration Date (MM/DD/YYYY)

E. Cost of Tuition for Full-time Students for this Program
F. Length of Program

Point of Contact
Title
Phone Number
Email Address