Form 2 Loan Verification Form

The Nursing Education Loan Repayment Program

NELRP AppKit 08 web version (2) (2)

Loan Verification Form

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(DRAFT)


Nursing Education Loan Repayment Program (NELRP)


Fiscal Year 2008

APPLICATION GUIDANCE




U.S. Department of Health and Human Services

Health Resources and Services Administration

Bureau of Clinician Recruitment and Service

Division of Applications and Awards

Nursing Education Loan Repayment Branch











(Revised 11/14/2007)

*** Special Items of Importance ***



Electronic Submission of the Application


Individuals applying for this funding opportunity are required to submit the application electronically. Please note that all required supplemental forms and applicable supporting documentation described in Section M. of the Guidance must be submitted in original hard copy via postal mail to:


Division of Applications and Awards

Nursing Education Loan Repayment Branch

c/o/FocalPoint Consulting Group

1025 Vermont Avenue, NW Suite 1000

Washington, DC 20005



NELRP Awards are Only Made by the Division of Applications and Awards


Only the Division of Applications and Awards can make a NELRP contract award. A NELRP contract award cannot be guaranteed by a Critical Shortage Facility (CFS) or any entity other than the Associate Administrator for the Bureau of Clinician Recruitment and Service on behalf of the Secretary, U.S. Department of Health and Human Services (Secretary). Employment at a CSF does not guarantee a NELRP contract.



NELRP Payments are Taxable


The NELRP payments made to participants are regarded as income by the U.S. Internal Revenue Service (IRS) and are subject to Federal taxes. The NELRP will withhold Federal income tax and Federal Insurance Contributions Act (FISC) tax (Social Security and Medicare) from your NELRP award and pay those taxes directly to the IRS on your behalf. All NELRP payments made and Federal taxes withheld will be reported to you and the IRS on a Form W-2 after the end of the tax year. These loan repayments may also be subject to State and local income taxes. Participants should check with their State or local tax authority concerning their tax liability for these payments.



Use of NELRP Payments


All loan repayments paid to the participant MUST be used by the participant to repay loan balances for qualifying nursing educational. NELRP funds received by a participant may not be used to pay taxes. In order to be considered for an amendment contract, the participant will be asked to provide a payment history demonstrating that the NELRP funds were applied to the qualifying nursing loan balances.



Employment Changes During the Application Process


In fairness to all applicants, for funding preference purposes, the following policies have been established:


The applicant must contact the NELRP if there are any changes in the workplace facility, as soon as possible.


Changes in the workplace facility made before the application deadline are acceptable and will be considered provided the applicant submits an Employment Verification Form for the new facility and documentation of the facility’s status (if applicable) as set forth in Section M.3. of this Guidance before the application deadline.


Changes in the workplace facility not documented before the application deadline or made after the application deadline will not be accepted or considered. Applicants in this category will have the opportunity to withdraw their application (see below).



Withdrawal of an Application Prior to Receiving a Contract Award


The NELRP contract is effective on the day it is signed by the Secretary or his/her designee. If an applicant is selected for an award, the applicant becomes obligated to provide 2 years of full-time service beginning on the effective date of the contract at the CSF identified in the application. The NELRP projects that the Secretary or his/her designee will sign contracts during the period from July 2008 through September 2008.


If an applicant will not be able to commence full-time service at the CSF identified in the application on the effective date of the contract (which the NELRP anticipates will be between July 2008 and September 2008), the applicants must notify the NELRP in writing at callcenter@hrsa.gov or 5600 Fishers Lane, Room 9-36, Rockville, Maryland 20857 by June XX, 2008, to withdraw his/her application from consideration. If the applicant withdraws his/her application by June XX, 2008, he/she will be eligible to apply to the NELRP in the future. If the applicant’s contract is signed by the Secretary and the applicant fails to commence service at the CSF identified in the application on the effective date of the contract, he/she will be in breach of their contract and will be permanently disqualified from receiving future awards under the NELRP and some other Federal programs.



Loan Consolidation Changes During the Application Process


Loan consolidations/refinances before the application deadline are acceptable, provided that the applicant submits a Loan Information and Verification Form (Loan Form) for the consolidated/refinanced loans by the application deadline. If the Loan Form is not received by the application deadline, the consolidated/refinanced loans will not be considered for loan repayment under the NELRP.


If loans are consolidated/refinanced between the application deadline and before awards are made, those loans will not be considered for loan repayment. Therefore, applicants are encouraged to consolidate/refinance their loans either before the application deadline or after receipt of an award.


All loans submitted for payment will be verified to determine whether they are eligible for repayment under the NELRP by contacting lenders or holders and checking the applicant’s credit report to cross reference information provided by the lenders or holders.



Special Instructions for CRNAs, CNMs, and NPs Employed by a Professional Group That Practices at a Critical Shortage Facility (CSF)


The professional group should complete the Employment Verification Form. The professional group must also provide a written statement on original letterhead stating that the applicant will be working exclusively at one designated CSF for at least 32 hours per week (for a minimum of 45 weeks per service year) for the 2-year duration of the applicant’s NELRP contract, if the applicant receives an award. If applicable, documentation of the facility’s status must be submitted as set forth in Section M.3 of the Guidance.



Applicants are Responsible for Submitting a Complete Application


It is the applicant’s responsibility to submit a complete application package which includes the completed application, all required supplemental forms and applicable supporting documentation (see Section M of this Guidance). The NELRP staff will not fill in any missing information or contact applicants regarding missing information. Missing, inaccurate, illegible, or incomplete information may result in a reevaluation of the applicant’s funding preference status, or qualifying loan balance or a determination of ineligibility.

Notice


This Application Guidance describes the Nursing Education Loan Repayment Program (NELRP) for registered nurses authorized by Section 846 of the Public Health Service Act, as amended, and implemented by Federal regulations (42 CFR Part 57, Section 312). Future changes in the governing statute, the implementing regulations and the administrative guidelines may also be applicable to participants in this program. In the Catalog of Federal Domestic Assistance published by the Office of Management and Budget of the Executive Office of the President, the NELRP program number is 93.908.


Please Keep This Application Guidance for Future Reference.

Applications Are Due by 5:00 P.M. E.T. on (Date).


The Electronic Application must be submitted by 5:00 p.m. E.T. on (date) and All Required Supplemental Forms and Applicable Supporting Documentation Must be Postmarked by (Date).


It is anticipated that awards will be made between June 2008 and September 2008. Awards are based on availability of funds. Applicants who submit a complete application should receive notice of whether they received an award no later than October 31, 2008.


This Application Guidance explains in detail the contractual obligations of the Secretary and the participants in the NELRP. Before signing a NELRP contract, applicants should review the entire Guidance and the NELRP contract to ensure a complete understanding of the obligation to serve full-time for 2 years in a Critical Shortage Facility and the financial consequences of failing to perform that obligation. Before signing a NELRP contract, applicants may want to seek legal counsel to review the Guidance and the contract.


SEND YOUR APPLICATION TO:

Division of Applications and Awards

Nursing Education Loan Repayment Branch

c/o FocalPoint Consulting Group

1025 Vermont Avenue, NW Suite 1000

Washington, DC 20005

Direct Questions and Inquiries to:

callcenter@hrsa.gov or Toll Free: 1-877-464-4772


Office Hours: 9:00 A.M. to 5:30 P.M., E.T.

Monday through Friday, except Federal Holidays

FOR ADDITIONAL INFORMATION:

Web Address: http://bhpr.hrsa.gov/nursing/loanrepay.htm


All Documents Must Be Submitted on White 8 ½” x 11” Paper. Faxed or Copied Completed Forms, Site Letters, and Professional Group Letters Will Not Be Accepted. Only Original Required Forms, Site Letters, and Professional Group Letters Will Be Accepted.

TABLE OF CONTENTS



DEFINITION OF TERMS


Amendment Contract

An amendment contract is an optional 1-year extension of a 2-year NELRP contract.


Basic RN Education

Basic RN Education is nursing education that qualifies the individual to take the Registered Nurse licensing examination (NCLEX-RN).


Commercial Loans

Commercial loans are defined as loans made by banks, credit unions, savings and loan associations, insurance companies, schools and other financial or credit institutions which are subject to examination and supervision in their capacity as lenders by an agency of the United States or of the State in which the lender has its principal place of business.


Contract

A written contract pursuant to Section 846 of the Public Health Service Act, as amended, under which (1) the participant agrees to engage in a period of continuous full-time employment as a registered nurse at a Critical Shortage Facility and (2) the Secretary agrees to repay, in consideration of such service, a percentage of the amount which is outstanding on the participant's qualifying nursing educational loans on the effective date of the contract.


Critical Shortage Facility (CSF)

A CSF is a health care facility which the Secretary has determined has a critical shortage of nurses. See Section C for information on different types of CSFs.


Existing Service Obligation

An obligation to work as a Registered Nurse which is owed to and provided for under an agreement with a CSF, Federal, State, or local government or any other entity, which will not be completely satisfied by (Date) (e.g. an active duty military obligation or existing commitment to an institution for educational pay back service or a sign-on bonus). Individuals cannot incur a service obligation while participating in the NELRP.


Full-Time

Full-time is defined as the provision of nursing services for a minimum of 32 hours per week. No more than 7 weeks per service year can be spent away from the CSF for vacation, holidays, continuing education, illness, maternity/paternity, or any other reason. (Approved absences totaling greater than 7 weeks in a 52-week service year require an extension of the contract end date.)


Funding Preference

Funding preference is defined as the funding of a specific category or group of approved applicants ahead of other categories or groups of approved applicants. See Section E in this Application Guidance.


Government Loans

Government loans are loans that are made by Federal, State, county or city agencies which are authorized by law to make such loans.


Greatest Financial Need

The greatest financial need funding preference is met by applicants whose total qualifying nursing education loans are 40% or greater than their annualized salary.


Holder

The commercial or government institution that currently holds the promissory note for the qualifying nursing education loan.


Lender

The commercial or government institution that initially made the qualifying loan.




Nurse Licensure Compact

The mutual recognition model of nurse licensure that allows a nurse to have a license in one State and to practice in other States subject to each State's practice law and regulation. Under mutual recognition, a nurse may practice in several States unless otherwise restricted.


Nursing Education Loan Repayment Program (NELRP)

The NELRP is authorized by Section 846 of the Public Health Service Act, as amended. Under the NELRP, the U.S. Department of Health and Human Services provides financial assistance to qualified nursing applicants to repay their qualifying loans, in exchange for their full-time service at a CSF.


Post-Master’s Nursing Certificate Program

A formal, post-graduate program that admits RNs with master’s degrees in nursing and, at completion, awards a certificate and academic credit.


Qualified Applicant

A person who meets all of the eligibility requirements set forth in this Application Guidance.


Qualifying Loans

Qualifying loans are government and commercial loans for actual costs paid for reasonable educational and living expenses related to the completed undergraduate or graduate nursing education program. See Section H for Guidance for additional information on which loans qualify for the NELRP.


Qualifying Nursing Education

Qualifying nursing education includes completed undergraduate basic RN education and completed graduate nursing education (including post-master’s nursing certificate programs) resulting in a baccalaureate or associate degree in nursing (or an equivalent degree), a diploma in nursing or a graduate degree in nursing from an accredited school of nursing.


Reasonable Educational Expenses

Reasonable educational expenses are tuition, fees, books, supplies, laboratory expenses, educational equipment, and materials for nursing education which do not exceed the school’s estimated standard student budget for educational expenses for the participant’s degree program and for the year(s) of that participant’s enrollment.


Reasonable Living Expenses

Reasonable living expenses are the costs of room and board, transportation and commuting costs, and other costs which do not exceed the school’s estimated standard student budget for living expenses at that school for the participant’s degree program and for the year(s) of that participant’s enrollment.


School of Nursing

The term “school of nursing” means an accredited collegiate, associate degree, or diploma school of nursing in a State.


The Secretary

The Secretary of Health and Human Services and any other officer or employee of the Department of Health and Human Services to whom the authority to administer the NELRP has been delegated.


State

Includes the 50 States, the District of Columbia, Puerto Rico, the Northern Mariana Islands, the U.S. Virgin Islands, Guam, American Samoa, Palau, the Marshall Islands, and the Federated States of Micronesia.



A. INTRODUCTION


There is a serious shortage of nurses at certain health care facilities in the United States. The purpose of the NELRP is to assist in the recruitment and retention of professional Registered Nurses (RNs) dedicated to providing health care in facilities with a crucial shortage of nurses and to provide an opportunity for nurses to consider a career in such facilities. The program offers RNs substantial economic assistance to repay their qualifying nursing education loans in exchange for full-time service at a health care facility with a critical shortage of nurses. The program is administered by the Bureau of Clinician Recruitment and Service (BCRS), Health resources and Services Administration, an agency of the U.S. Department of Health and Human Services.


B. SERVICE REQUIREMENTS


1) 2-Year Service Requirement


All NELRP participants must enter into a contract agreeing to work full-time (at least 32 hours per week) in an approved Critical Shortage Facility (CSF) for 2 consecutive years. In exchange, the NELRP will pay 30 percent of the participant's total qualifying nursing education loan balance each year (total of 60 percent). All loan repayments paid to the participant must be used by the participant to repay the loans for qualifying nursing education, and the participant’s payments to his/her lenders or holders are subject to verification by the government.



2) Optional Service Obligation (1-year Contract Amendment)


A participant may be eligible to amend his/her 2-year NELRP contract to serve for a third (optional) consecutive year at a CSF. If a participant enters into an optional amendment contract and works full-time for a third year in a CSF, the NELRP will pay an additional 25 percent of the participant's original qualifying nursing education loan balance.


For more details about how to request and qualify for an amendment contract, see Section J of this Guidance. All loan repayments paid to the participant must be used by the participant to repay the loans for qualifying nursing education, and the participant’s payments to his/her lenders or holders are subject to verification by the government.


C. CRITICAL SHORTAGE FACILITIES (CSFs)


1) Types of Critical Shortage Facilities


A NELRP participant is required to serve full-time as a registered nurse at a CSF. The following types of health care facilities have been determined to have a critical shortage of nurses:


  • Disproportionate Share Hospital (DSH) - A not-for-profit hospital that: 1) has a disproportionately large share of low-income patients; and 2) receives a) an augmented payment from the States under Medicaid; or b) a payment adjustment from Medicare. Hospital-based outpatient services are included under this definition.


  • Federal Hospital - Any not-for-profit Federal institution in a State that is primarily engaged in providing, by or under the supervision of physicians, to inpatients: (a) diagnostic and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons; or (b) rehabilitation of injured, disabled, or sick persons. Hospital-based outpatient services are included under this definition.


  • Non-Federal Non-Disproportionate Share Hospital - Any public or private not-for-profit institution in a State that is primarily engaged in providing care, by or under the supervision of physicians, to inpatients for: (a) diagnostic and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (b) rehabilitation of injured, disabled, or sick persons. Hospital-based outpatient services are included under this definition.


  • Ambulatory Surgical Center – A not-for-profit entity in a State that provides surgical services to individuals on an outpatient basis and is not owned or operated by a hospital.


  • Federally Designated Community Health Center – A not-for-profit entity that is receiving a grant, or funding from a grant, under section 330(e) of the Public Health Service Act, as amended, to provide primary health services and other related services to a population that is medically underserved.


  • Federally Designated Migrant Health Center – A not-for-profit entity that is receiving a grant, or funding from a grant, under section 330(g) of the Public Health Service Act, as amended, to provide primary health services and other related services to migratory and seasonal agricultural workers.


  • Federally Designated Health Care for the Homeless Health Center – A not-for-profit entity that is receiving a grant, or funding from a grant, under section 330(h) of the Public Health Service Act, as amended, to provide primary health services and other related services to homeless individuals.


  • Federally Qualified Health Center Look-Alike – A not-for-profit entity that is certified by the Secretary as meeting the requirements for receiving a grant under section 330(e), 330(g), or 330(h) of the Public Health Service Act, but is not a grantee.


  • Home Health Agency - A public agency or private not-for-profit organization as certified under section 1861(o) of the Social Security Act that is primarily engaged in providing skilled nursing care and other therapeutic services.


  • Hospice Program - A public agency or private not-for-profit organization as certified under section 1861(dd)(2) of the Social Security Act that provides 24-hour care and treatment services (as needed) to terminally ill individuals and their families. This care is provided in individuals’ homes, on an outpatient basis, and on a short-term inpatient basis, directly or under arrangements made by the agency or organization.


  • Indian Health Service Health Center - A not-for-profit health care facility (whether operated directly by the Indian Health Service or operated by a tribe or tribal organization, contractor or grantee under the Indian Self-Determination Act, as described in 42 Code of Federal Regulations (CFR) Part 136, Subparts C and H, or by an urban Indian organization receiving funds under title V of the Indian Health Care Improvement Act) that is physically separated from a hospital, and which provides clinical treatment services on an outpatient basis to persons of Indian or Alaskan Native descent as described in 42 CFR Section 136.12.



  • Native Hawaiian Health Center – A not-for-profit entity (a) which is organized under the laws of the State of Hawaii; (b) which provides or arranges for health care services through practitioners licensed by the State of Hawaii, where licensure requirements are applicable; (c) which is a public or nonprofit private entity; and (d) in which Native Hawaiian health practitioners significantly participate in the planning, management, monitoring, and evaluation of health services. See the Native Hawaiian Health Care Act of 1988 (Public Law 100-579), as amended by Public Law 102-396.


  • Nursing Home – A public or private not-for-profit institution (or a distinct part of an institution) as certified under section 1919(a) of the Social Security Act, that is primarily engaged in providing, on a regular basis, health-related care and service to individuals who because of their mental or physical condition require care and service (above the level of room and board) that can be made available to them only through institutional facilities, and is not primarily for the care and treatment of mental diseases.


  • Rural Health Clinic – A public or private not-for-profit entity that the Centers for Medicare and Medicaid Services has certified as a rural health clinic under section 1861(aa)(2) of the Social Security Act. A rural health clinic provides outpatient services to a non-urban area with an insufficient number of health care practitioners.


  • Skilled Nursing Facility- An public or private not-for-profit institution (or a distinct part of an institution) as certified under section 1819(a) of the Social Security Act, that is primarily engaged in providing skilled nursing care and related services to residents requiring medical, rehabilitation or nursing care and is not primarily for the care and treatment of mental diseases.


  • State or Local Public Health Department including a Public Health Clinic within the Department - The State, county, parish or district entity in a State that is responsible for providing population focused health services which include health promotion, disease prevention and intervention services provided in clinics that are operated by the health department.


If applicants are not sure whether a facility fits into the categories above, please contact the NELRP at: callcenter@hrsa.gov or 1-877-464-4772.


2) Ineligible Facilities


Ineligible facilities include, but are not limited to:


  • Free Standing Clinics that do not qualify as one of the above CSFs;

  • Renal Dialysis Centers;

  • Private Practice Offices;

  • Assisted Living Facilities; and

  • Private For-Profit Facilities. (Note: After Fiscal Year 2007, the Secretary may not pursuant to any agreement, assign a nurse to any private entity unless that entity is nonprofit)


D. ELIGIBILITY REQUIREMENTS


An individual is eligible to participate if he/she:


  • Has received a baccalaureate or associate degree in nursing (or an equivalent degree), a diploma in nursing or a graduate degree in nursing from an accredited school of nursing in a State;

  • Has outstanding qualifying loans obtained for nursing education leading to a degree or diploma in nursing as specified above;

  • Has completed the nursing education program for which the loan balance applies;

  • Is a U.S. citizen, U.S. national, or a lawful permanent resident of the U.S.;

  • Is employed full-time (32 hours or more per week) at a CSF;

  • Has a current permanent unrestricted license as an RN in the State in which he/she intends to practice or is authorized to practice in that State pursuant to the Nurse Licensure Compact (Please refer to the Nurse Licensure Compact state listing at: http://www.ncsbn.org/nlc/rnlpvncompact_mutual_recognition_state.asp); and

  • Has submitted a complete application, all required supplemental forms, and all supporting documentation by the application deadline.


Individuals in the Reserve components of the Armed Forces or National Guard are eligible to participate. For additional information, please see Section I.2 of this Guidance.


An individual is NOT eligible to participate if he/she:


  • Has a judgment lien against his/her property for a debt owed to the United States Government. Such individual is precluded from receiving Federal funds (including NELRP funds) until the judgment lien has been paid in full;

  • Has an existing service obligation (see Definition of Terms) that will not be satisfied by (Date);

  • Has breached an obligation for professional service to a Federal, State, or local government entity;

  • Is currently in default of a Federal debt (e.g., student loans, delinquent taxes, etc.);

  • Works for nurse staffing agencies, travel nurse agencies;

  • Works on an "as needed" basis(this includes PRNs, Pool Nurses, or other RNs who are not scheduled in a full-time capacity by NELRP definition);

  • Has a temporary or inactive RN license;

  • Is a licensed practical/vocational nurse;

  • Is a nursing faculty member employed full-time in an educational institution; or

  • Is self-employed.


E. FUNDING PREFERENCES


The NELRP does not have sufficient funds to make an award to all qualified applicants, and uses funding preferences to determine the sequential order in which eligible applicants are considered for an award. As provided in section 846(e) of the Public Health Service Act, as amended, a funding preference will be given to eligible applicants with greatest financial need, which the NELRP defines as those applicants whose total qualifying nursing education loans are 40% or greater than their annualized salary. In addition, a funding preference is given to nurses providing service in the types of heath care facilities that have the most severe nursing shortage. Applicants are grouped into one of the preference levels described below based on their debt to salary ratio and place of employment. Awards are then made to applicants starting with the first preference category described below by decreasing debt to salary ratio until funds are expended.


DEBT/SALARY 40% OR GREATER


  • First Preference for Funding will be given to applicants with greatest financial need working in the following types of Critical Shortage Facilities: Disproportionate Share Hospital (DSH); Nursing Home; State or Local Public Health Department including a Public Health Clinic within these Departments; Federally Designated Community Health Center; Federally Designated Migrant Health Center; Indian Health Service Health Center or Rural Health Clinic.


  • Second Preference for Funding will be given to applicants with greatest financial need working in the following types of Critical Shortage Facilities: Federally Designated Health Care for the Homeless Health Center; Native Hawaiian Health Center or Non-Federal non-DSH.


  • Third Preference for Funding will be given to applicants with the greatest financial need working in the following types of Critical Shortage Facilities: Federally Qualified Health Center Look-Alike; Ambulatory Surgical Center; Home Health Agency; Hospice; Skilled Nursing Facility or Federal Hospital.


DEBT/SALARY 40% AND BELOW


  • Fourth Preference for Funding will be given to applicants regardless of financial need working in the following types of Critical Shortage Facilities: Disproportionate Share Hospital (DSH); Nursing Home; State or Local Public Health Department including a Public Health Clinic within these Departments; Federally Designated Community Health Center; Federally Designated Migrant Health Center; Indian Health Service Health Center or Rural Health Clinic.


  • Fifth Preference for Funding will be given to applicants regardless of financial need working in the following types of Critical Shortage Facilities: Federally Designated Health Care for the Homeless Health Center; Native Hawaiian Health Center or Non-Federal non-DSH.


  • Sixth Preference for Funding will be given to applicants regardless of financial need working in the following types of Critical Shortage Facilities: Federally Qualified Health Center Look-Alike; Ambulatory Surgical Center; Home Health Agency; Hospice; Skilled Nursing Facility or Federal Hospital.

F. AVAILABLE BENEFITS


The NELRP will provide funds to the program participants to repay their outstanding qualifying nursing educational loans. Recipients of NELRP contracts receive the following benefits:


  • For the first year of service, the NELRP will pay 30 percent of the total loan balance(s) for qualifying nursing education, as of the effective date of the contract.


  • For a second year of service, the NELRP will pay 30 percent of the total loan balance(s) for qualifying nursing education, as of the effective date of the contract.


  • For a third year of service, the NELRP will pay 25 percent of the original loan balance(s) for qualifying nursing education, as of the effective date of the contract. See Section J.2. of this Guidance.


The NELRP participant will receive salary and benefits from the employing CSF.  Employment compensation packages are negotiated between the nurse and the facility.  The CSF cannot guarantee a NELRP contract award. Therefore, the NELRP loan repayments must not be part of the salary negotiations between nurses and the CSF.


G. METHOD OF PAYMENT


The agency disburses each monthly payment through an electronic funds transfer to the participant's checking or savings account identified on the Payment Information Form submitted by the applicant. The first direct deposit is made approximately 30 days after the effective date of the contract. It is the participant's responsibility to use the NELRP payments (the amounts received by the participant after tax withholding) to pay the lenders or holders of qualified nursing loans. Periodically, the NELRP may contact a participant’s lenders or holders to verify that payments have been made. Please note that, unlike some other Federal programs, the NELRP does not provide any tax assistance payments.


Participants must immediately notify the NELRP in writing of any changes of mailing address, email address, name, or financial institution (bank) information to ensure an uninterrupted flow of loan repayment funds. In the case of a name change, please provide legal documentation, such as a copy of a marriage certificate. For a change of address, please contact the NELRP at callcenter@hrsa.gov or 1-877-464-4772 (toll free).


If for any reason a participant does not receive a scheduled payment, the participant should call the NELRP as soon as possible at 1-877-464-4772 or email callcenter@hrsa.gov. Please be advised that if the NELRP has any questions concerning a participant’s eligibility for continuing payments, the NELRP will delay payments pending clarification of the participant’s eligibility status.


NOTE: Under the Treasury Offset Program, the Department of the Treasury is authorized to offset NELRP payments for delinquent Federal and State debts, including child support payments. In keeping with the President’s Executive Orders concerning compliance with child support orders, the NELRP stresses the importance of honoring any child support obligations the participant may have.


H. QUALIFYING EDUCATIONAL LOANS


1) Loans Eligible for Repayment


A NELRP participant will receive funds to repay a portion of the principal and interest of qualifying loans (see Definition of Terms) obtained by the participant, at the time of the participant's undergraduate and/or graduate nursing education, to pay for:


  • Tuition, fees, and other reasonable educational expenses (see Definition of Terms) for qualifying nursing education; and


  • Reasonable living expenses (see Definition of Terms) incurred for qualifying nursing education.



2) Examples of Eligible Loans


  • Nursing Student Loans;


  • Stafford Loans; and


  • Supplemental Loans for Students.


3) Examples of Loans Not Eligible


  • Loans for which the applicant incurred an obligation to serve as a nurse;


  • Loans obtained for training in vocational or practical nursing (LPN);


  • Loans obtained from family members or private institutions not subject to Federal or State examination and supervision as lenders;


  • Loans made prior to or after the applicant's nursing education;


  • Loans that have been paid in full;


  • Any portion of a consolidated/refinanced educational loan that is not clearly identified as being for reasonable educational expenses and reasonable living expenses incurred for qualifying nursing education by the applicant (See Definition of Terms).


  • Consolidated/refinanced educational loans that include another person’s loans;


  • Credit card payments for nursing education expenses are not qualifying loans;


  • Parent Plus Loans;


  • Federal Perkins Loans (unless the applicant can provide documentation as indicated in Section M.2. (Instructions for Completing Required Supplemental Forms) that such loans are not subject to cancellation); and


  • Loans obtained for non-nursing education or for courses taken toward a non-nursing degree that may later qualify as a prerequisite for a nursing program.


I. LEAVING THE CSF (CHANGING JOBS)


Participants are expected to complete their full service obligation at their initial service site. Should participants become unable to complete their obligation at their initial NELRP service site, they must continue their service at another NELRP-approved CSF. When a participant desires a transfer, a written request must be submitted to the NELRP for approval before the participant leaves his or her current service site. The participant must also obtain and submit a letter/certificate from the desired transfer site as set forth in Section M.3. of this Guidance (if applicable), which documents the CSF’s status as a first funding preference facility at the time the transfer request is made. If a participant transfers to a new location, moving expenses will not be paid.


1) Transfers


ALL TRANSFER SITES MUST BE APPROVED BY THE DIVISION OF SCHOLAR AND CLINICAN SUPPORT (DSCS). FAILURE TO RECEIVE PRIOR APPROVAL WILL RESULT IN IMMEDIATE SUSPENSION OF PAYMENTS UNTIL THE DSCS STAFF RECEIVES VERIFICATION EMPLOYMMENT AT AN ELIGIBLE TRANSFER FACILITY. CONTINUED FAILURE TO DOCUMENT FULL-TIME EMPLOYMENT AT AN APPROVED CSF MAY RESULT IN THE PARTICIPANT BEING RECOMMENDED TO THE LEGAL AND COMPLIANCE BRANCH (LCB) FOR DEFAULT OF HIS/HER CONTRACT.


The following requirements apply to participants who request a transfer:


  • In order for the BCRS to approve the participant’s transfer; the participant must transfer to one of CSFs that is included in the funding preference at the time the participant makes the transfer request.


  • Participants who transfer from one CSF to another may not incur a service obligation to the new facility or employer while participating in the NELRP.


  • If there is no break in service between the initial site and the transfer site, the NELRP will continue to make loan repayments to the participant. However, if such participant fails to resume service within 30 days of the stop-work date at the initial CSF, the NELRP will stop all loan repayments. Once the participant has commenced full-time service at another approved CSF, loan repayments will be resumed and the service end date will be extended to account for the entire service obligation period.


  • If a NELRP participant ceases full-time employment at the initial site and does not resume service at a NELRP-approved CSF within 60 days, the participant will be recommended for default of his/her NELRP obligation.


Requests for transfer approvals must be submitted to the NELRP staff in writing the request would include the reason for the transfer, along with a letter/certification regarding the CSF’s status as a first preference facility and indicate if the facility is a private nonprofit, private for profit, or public/government owned at the following address:


U. S. Department of Health and Human Services

Health Resources and Services Administration

Bureau of Clinician Recruitment and Service

Division of Scholar and Clinical Support

Clinician Service Support Branch

5600 Fishers Lane; Room 8A-55

Rockville, MD 20857


Participants with questions may call 1-800-221-9393 or email: callcenter@hrsa.gov.


2) Members of a Reserve Component of the Armed Forces


Individuals in the Reserve component of the Armed Forces or National Guard are eligible to participant in the NELRP. However, reservists should understand the following:


  • If a reservist is away from the NELRP service site due to military training and/or service, the time away will be combined with the participant’s other absences from the service site during that service year. If the reservist’s military training and/or service, in combination with all other absences from the service site does not exceed 7 weeks per service year, no further action is necessary.


  • If a reservist’s military training and/or service (including a call to active duty), in combination with all other absences from the NELRP service site, will exceed 7 weeks per service year, the reservist must notify the DSCS immediately and submit a written request for a suspension of the NELRP service obligation (see Section L of this Guidance). The suspension request should include documentation of the reservist’s training or call to active duty orders. The NELRP payments will be stopped while the reservist is on an approved suspension and will resume when the reservist returns to full-time service. The NELRP service obligation will be extended to account for the break in service due to the reserve or active duty obligation.


  • If the CSF where the reservist was serving at the time of deployment is unable to reemploy that reservist, the reservist will be expected to complete his/her NELRP service obligation at another NELRP-approved CSF. The reservist must contact the DSCS and request a transfer, and receive approval, in accordance with the transfer policy (see Section I.1. of this Guidance) prior to commencing employment at the facility. If the reservist fails to resume service at a NELRP-approved CSF within 60 days of the end of the deployment, the reservist will be recommended for default of his/her NELRP obligation.


J. FEDERAL CONTRACTING PROCESS


1) Initial Contract


A 2-year contract must be signed and returned to the NELRP along with the application, all required supplemental forms, and all applicable supplemental documentation (see Section M of this Guidance).


If the applicant is selected for participation into the NELRP, the contract is signed by the Secretary or the Secretary’s designee. A copy of the signed participant’s contract, a payment schedule, and letter of acceptance will be sent to the participant no later than October 31, 2008.


The applicant’s contract cannot be signed by the Secretary or the Secretary’s designee unless all REQUIRED information on the application, required supplemental forms, and supporting documentation has been provided, and a complete application package has been received and approved by the Division of Applications and Awards, Nursing Education Loan Repayment Branch. A Checklist describing the application materials is included in this Guidance for your convenience.


PLEASE NOTE: A signed NELRP contract that does not contain the 11 terms and conditions on one sheet of white paper (8 ½ inch x 11 inch) will not be accepted.


NOTE: The participant's service obligation to the NELRP officially begins on the date the contract is signed by the Secretary or the Secretary’s designee. If the participant fails to commence service on the effective date of the contract, he/she will be placed in default of their contract.


2) Amendment Contract


Participants who receive a 2-year contract may be eligible to amend their NELRP contract to serve for a third consecutive year under the following conditions:


  • The participant must notify the staff in the Nursing Education Loan Repayment Program in writing, at least 6 months prior to the end of the second service year, that the participant wishes to amend the NELRP contract for a third year.


  • The participant must continue to serve at a NELRP-approved CSF. If the participant's current site is no longer a CSF, an amendment contract will not be awarded. If such a participant wishes to continue in the NELRP, he/she must contact the DSCS to request approval for a transfer (see Section I of this Guidance). If a participant transfers to a new location, moving expenses will not be paid.


  • The NELRP payments must have been applied to reduce the original qualifying nursing education loan balances. A participant's loan balances will be verified and a payment history from their lender will be required to show that all NELRP funds received previously were applied toward the approved qualifying loans during the contract period. Failure to apply the loan payments to reduce the original qualifying nursing education loans will result in the denial of a request for an amendment contract.


  • The participant must not have an existing service obligation to the CSF or another entity.


Participants who meet the above requirements and are approved to receive an amendment contract will receive payments equal to an additional 25 percent of their original qualifying nursing education loan balance. The amendment contract will not be effective until the participant has completed his/her 2-year service period under the initial contract. The amendment service period must begin immediately following the completion of the initial service commitment (i.e. no breaks in service between the contracts are allowed). The contract amendment will not become effective until the participant has fully completed their initial NELRP service commitment.


There is no guarantee that a 2 year service commitment contract will be amended beyond the initial 2 years. Applicants for contract amendments must continue to meet the eligibility criteria, must be in full compliance with their existing NELRP service obligation, and must be planning to work for the duration of the contract amendment at an eligible CSF. Award of amendment contracts is subject to the availability of funds.


K. BREACHING THE NELRP CONTRACT


The following applies to applicants who breach their NELRP contract:


  • Effect of Not Completing 2 Years of Service - A participant who fails to complete 2 years of full-time service at an approved CSF is liable to repay all the NELRP payments he or she received, plus interest at the maximum legal prevailing rate. Breach of the contract will permanently disqualify the individual from receiving future awards under the NELRP and some other Federal programs.


  • Effect of Not Completing Third Year of Service - A participant who enters into an amendment contract agreeing to provide a third year of full-time service at an approved CSF, but fails to do so, is liable to repay all payments received for the third year of service, plus interest at the maximum legal prevailing rate. Breach of the contract will permanently disqualify the individual from receiving future awards under the NELRP and some other Federal programs.


  • Payment of Debt Due Within 3 Years - Any payments due to the Federal government, under the paragraphs above, is due within 3 years of the participant's service breach date. The debt amount will be subject to interest at the maximum legal prevailing rate from the date of the breach until paid in full. Other charges and penalties for delinquent or past due payments may be assessed.


L. WAIVER, SUSPENSION, CANCELLATION


A participant may seek a waiver or suspension of the service or payment obligation incurred under this contract by submitting a written request to the Secretary setting forth the basis, circumstances, and causes which support the requested action. The Secretary may waive (where the basis is permanent) or suspend (where the basis is temporary) any service or payment obligation incurred by a participant whenever compliance by the participant: 1) is impossible, or 2) would involve an extreme hardship such that enforcement of the obligation would be unconscionable.


  • Compliance by a participant with a service or payment obligation will be considered impossible if the Secretary determines, on the basis of information and documentation as may be required, that the participant suffers from a physical or mental disability resulting in the permanent inability of the participant to perform the service or other activities which would be necessary to comply with the obligation.


  • In determining whether compliance with the service or payment obligation would impose an extreme hardship, the Secretary, on the basis of information and documentation as may be required, will consider:

  • The participant's present financial resources and obligations;

  • The participant's estimated future financial resources and obligations; and

  • The extent to which the participant has problems of a personal nature, such as physical or mental disability, or a terminal illness in the immediate family, which so intrude on the participant's present and future ability to perform as to raise a presumption that the individual will be unable to perform the required service or payment obligation.




Suspensions for Personal Medical Reasons, Family Medical Leave, Reservist Deployments, or Maternity/Paternity


If a participant has problems of a personal nature (such as a physical or mental disability or terminal illness in the immediate family) or goes on maternity/paternity leave and such situations will cause the participant to be away from the NELRP service site for more than 7 weeks per service year in conjunction with all his/her other absences from the site for any other reason (e.g., vacation, holidays, continuing education, temporary illness), the participant must immediately notify the DSCS at 1-800-221-9393 (toll free) or email callcenter@hrsa.gov and submit a written request for a suspension to the DSCS at the address below.


If the participant’s request for a suspension is approved, his/her NELRP payments will resume when he/she returns to full-time service, and the service end date will be extended to account for the break in full-time service. If the participant does not qualify for a suspension, he/she may be recommended for default.


Cancellation


Upon receipt by DSCS of a death certificate for a participant, the NELRP service or payment obligation will be cancelled.


Requests for suspensions and waivers should be submitted to:


Division of Scholar Clinician Support

Clinician Service Support Branch

5600 Fishers Lane; Room 8A-55

Rockville, MD 20857

M. HOW TO APPLY


To apply for a NELRP contract, you must submit a complete application package consisting of: 1) a NELRP Application; 2) all Required Supplemental Forms; and 3) all applicable Supporting Documentation:


1) Online NELRP Application


2) Supplemental Forms


  • Completed Loan Information and Verification Form(s)

  • Completed Employment Verification Form

  • Completed Authorization for Release of Employment Information Form

  • Completed Payment Information Form

  • Completed NELRP Contract

  • Completed and signed Checklist


3) Supporting Documentation


  • Documentation of your status as a U.S. citizen, U.S. National, or Lawful Permanent Resident (if you were born outside of the U.S.)

  • Letter/Certification from CSF

  • Statement from Professional Group (if applicable)


Instructions for completing these three components are provided in the following three sections. If any of the materials/documents described below are not included with the application, if required documents are not signed or are otherwise incomplete, or if the contract, forms and documents are not clearly printed on separate sheets of white 8 ½ inch x 11 inch paper, the application will be deemed incomplete and will not be processed further for receipt of the NELRP award.


DO NOT SEND ORIGINAL PROMISSORY NOTES, LOAN CONSOLIDATION FORMS, OR PROOF OR CITIZENSHIP DOCUMENTS THAT CANNOT BE REPLACED. DOCUMENTS MUST BE RETAINED IN AN OFFICIAL FILE AND WILL NOT BE RETURNED. All mailed required supplemental forms and supporting documentation MUST be postmarked by (DATE).


1) Instructions for Completing the NELRP Application Form


Please read this entire Application Guidance to determine your eligibility for participation.


Instructions for completing the web-based application are provided as necessary, when you are entering your application information electronically.


All Required Supplemental Forms and applicable Supporting Documentation must be submitted in hard copy and mailed to the NELRP whether the application is submitted electronically or in paper to:


Division of Applications and Awards

Nursing Education Loan Repayment Branch

c/o/ Focal Point Consulting Group

1025 Vermont Avenue, NW Suite 1000

Washington, DC 20005


2) Instructions for Completing Required Supplemental Forms


Loan Information and Verification Form(s)


Applicants must complete a Loan Information and Verification Form (Loan Form) for each lender (or holder) for their qualifying nursing education loan (s) to be considered for repayment. This form authorizes your lender to release information about your loan to the NELRP. (If you need additional forms, you may photocopy the form).


Applicants are required to send in documents verifying their loans. This includes a copy of the original loan applications, a copy of the promissory notes, disclosure statements, and statements from the current holder, indication the borrower’s name, original amount borrowed, date of original disbursements, and the type of loan.


Be sure to include the most current lender (or holder) of the loan and the lender's (or holder's) complete address and telephone number. Provide the lender’s (or holder’s) automated access telephone number that will permit the NELRP to obtain loan information for verification purposes. The most current balance of each loan -- principal and interest -- must be determined as accurately as possible and reported on the Loan Form.


Please include ALL loan balances for undergraduate and/or graduate nursing education with the initial application. Only those loan balances submitted with the initial application will be considered for an award.


Applicants who have consolidated/refinanced their loans must provide either (1) a copy of their promissory note(s) for the original loan(s) or (2) a copy of the consolidated promissory note from the current lender(s) that shows, for each loan being consolidated, the amount, date of original disbursement, and type of loan. NOTE: Master Promissory Notes are not acceptable because they do not provide the required information (i.e., original loan dates and amounts). Examples of qualifying loans are provided in Section H of this Guidance. Please note that for consolidated/refinanced loans, copies of promissory notes submitted must clearly identify the original loans that were for eligible costs of nursing education. If an eligible educational loan is consolidated/refinanced with any debt of a person other than the applicant, no portion of the consolidated/refinanced loan will be eligible for loan repayment.


If undergraduate or graduate nursing educational loans have been consolidated or refinanced, the documentation noted above is required to establish that the loans coincide with the nursing education periods stated on the Application.


Applicants who have Perkins loans that are not eligible for cancellation must provide documentation (a) from the school that the loans are not subject to cancellation under

34 C.F.R. Part 674, or (b) from the current lender indicating that the Perkins loans were consolidated and paid off.


Employment Verification Form


The applicant’s employer must fill out this form completely and return it to the applicant for submission with the other application materials. Please note that while the employer is responsible for completing the form, the applicant is responsible for assuring that all information is entered accurately, and the applicant is responsible for the timely submission of the completed form.


Authorization for Release of Employment Information Form


This form must be completed by the applicant to authorize the release of information regarding the applicant’s employment status to the NELRP. If the applicant is awarded a NELRP contract, his/her employment status will be verified semiannually.


Payment Information Form


This form must be completed as part of the application packet to transmit the NELRP disbursement via electronic funds transfer (direct deposit) to the participant’s bank account to ensure the uninterrupted flow of loan repayment funds.


NELRP Contract


Before signing the NELRP contract, an applicant should carefully review all 11 terms and conditions to be certain that he/she fully understands the obligations of a NELRP participant and the Secretary as described in the contract. In particular, an applicant should carefully review paragraph 7 relating to breaching the contract and paragraph 9 relating to a waiver or suspension of the obligation. The applicant’s signature alone on this contract does not constitute a contractual agreement. This contract becomes legally binding only when signed by the Secretary or the Secretary’s designee, which will occur between July 2008 and September 2008, if the applicant receives a NELRP award.


No service credit will be given for employment at a CSF before the effective date of a NELRP contract award. The effective date of a contract award is the date the contract is countersigned by the Secretary.


The signature block and all 11 terms and conditions must be included on the same page of the contract. A signed, printed NELRP contract that does not contain the 11 terms and conditions will not be accepted.


Completed Checklist


The Checklist assists applicants and the NELRP staff in verifying the completeness of the application. Return the checklist along with all of the other required application materials. Carefully read the statement at the bottom of the checklist. The statement must be signed for the application to be considered complete.


3) Instructions for Providing Required Supporting Documentation


Documentation of Status as a U.S. Citizen, U.S. National, or Lawful Permanent Resident


Applicants born outside of the United States must provide proof of U.S. citizenship or status as a U.S. National or Lawful Permanent Resident (e.g., a copy of a U.S. Passport ID page or Green Card).


Letter/Certification from Site (Original Only)


NOTE: Letters from sites must be dated after (Date) when the application cycle begins. Letters that are not dated or dated before the application cycle begins will not be accepted. Letter must indicate if the facility is private nonprofit, private for profit, or public/government owed.


  • An applicant who is employed at a Disproportionate Share Hospital (DSH) (see Types of Critical Shortage Facilities) must obtain a letter on original letterhead, signed by an appropriate hospital official verifying the hospital’s current status as a DSH. A report listing of DSH facilities is not acceptable.


  • An applicant who is employed at a Federally Designated Community Health Center, Federally Designated Migrant Health Center, Federally Designated Health Care for the Homeless Health Center, Federally Qualified Health Center Look-Alike, Indian Health Service Health Center, or Rural Health Clinic, must obtain a letter (on original letterhead, signed by an appropriate facility official) or a copy of an official certificate from the facility verifying, as applicable, that it is (a) the recipient of a Federal grant as described in Section C of this Guidance, or (b) receives funds from another organization under a grant as described in Section C of this Guidance, or (c) is certified as specified in Section C of this Guidance.


  • An applicant who is employed at a Nursing Home must obtain a letter (on original letterhead, signed by an appropriate facility official) verifying that the facility is certified as an institution (or a distinct part of an institution) engaged in providing, on a regular basis, health-related care and services as specified in Section C of this Guidance.


  • An applicant who is employed at a State or Local Public Health Department, including a Public Health Clinic within the Department, must obtain a letter (on original letterhead, signed by an appropriate facility official) verifying that the facility is a State, county, parish, or district entity responsible for providing population focused heath services as specified in Section C of this Guidance.


  • An applicant who is employed at a Federal Hospital must obtain a letter (on original letterhead, signed by an appropriate facility official) verifying that the facility is in a State that is primarily engaged in providing, by or under the supervision of physicians, to inpatients: (a) diagnostic and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (b) rehabilitation of injured, disabled, or sick persons. Hospital-based outpatient services are included under this definition as specified in Section C of this Guidance.


  • An applicant who is employed at a Non-Federal Non-Disproportionate Share Hospital must obtain a letter (on original letterhead, signed by an appropriate facility official) verifying that the facility is a public or private institution in a State that is primarily engaged in providing care, by or under the supervision of physicians, to inpatients for: (a) diagnostic and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (b) rehabilitation of injured, disabled, or sick persons. Hospital-based outpatient services are included under this definition as specified in Section C of this Guidance.


  • An applicant who is employed at a Ambulatory Surgical Center must obtain a letter (on original letterhead, signed by an appropriate facility official) verifying that the facility is in a State that provides surgical services to individuals on an outpatient basis and is not owned or operated by a hospital as specified in Section C of this Guidance.


  • An applicant who is employed at a Home Health Agency must obtain a letter (on original letterhead, signed by an appropriate facility official) verifying that the facility is a public agency or private organization as certified under section 1861(o) of the Social Security Act that is primarily engaged in providing skilled nursing care and other therapeutic services as specified in Section C of this Guidance.


  • An applicant who is employed at a Hospice Program must obtain a letter (on original letterhead, signed by an appropriate facility official) verifying that the facility is a public agency or private organization as certified under section 1861(dd)(2) of the Social Security Act that provides 24-hour care and treatment services (as needed) to terminally ill individuals and their families. This care is provided in individuals’ homes, on an outpatient basis, and on a short-term inpatient basis, directly or under arrangements made by the agency or organization as specified in Section C of this Guidance.


  • An applicant who is employed at a Native Hawaiian Health Center must obtain a letter (on original letterhead, signed by an appropriate facility official) verifying that the facility is an entity (a) which is organized under the laws of the State of Hawaii; (b) which provides or arranges for health care services through practitioners licensed by the State of Hawaii, where licensure requirements are applicable; (c) which is a public or nonprofit private entity; and (d) in which Native Hawaiian health practitioners significantly participate in the planning, management, monitoring, and evaluation of health services as specified in Section C of this Guidance.


  • An applicant who is employed at a Skilled Nursing Facility must obtain a letter (on original letterhead, signed by an appropriate facility official) verifying that the facility is an institution (or a distinct part of an institution) as certified under section 1819(a) of the Social Security Act, that is primarily engaged in providing skilled nursing care and related services to residents requiring medical, rehabilitation or nursing care and is not primarily for the care and treatment of mental diseases as specified in Section C of this Guidance.


Statement from Professional Group (if applicable)


Advanced nurse practitioners (CRNAs, CNMs, NPs) employed by a professional group that practices at a CSF must provide a written statement on original letterhead from the professional group stating that the applicant will be working exclusively at one designated CSF for at least 32 hours per week (for a minimum of 45 weeks per service year) for the 2-year duration of the applicant’s NELRP contract, if the applicant receives an award. Letters from professional groups must be dated after (DATE) when the application cycle begins. Letters that are not dated before the application cycle will not be accepted.


Loan Disclosure Statement and Documentation


Applicants must submit written documentation of each nursing education loan(s) to be considered for NELRP loan repayment. Written documentation includes either (1) a copy of the promissory note(s) for each loan(s) or (2) a copy of the loan disclosure statement(s) or (3) an original letter (on official letterhead) from the school, lender or holder indicating the date of the loan, the amount of the loan and the type of loan disbursed.


Nursing degree(s), diploma, post-master certification and current nursing license


Applicants must provide documentation of current, unrestricted nursing license for the State in which they plan to practice under NELRP. Applicants must also, submit a copy of the nursing degree(s), diploma or post-master certificate for which they would like NELRP loan repayment consideration.


School Transcripts


Applicants must provide a school transcript for all nursing education they would like consideration under the NELRP loan Repayment.




IMPORTANT REMINDERS



Please notice the "WARNING" and “CERTIFICATION” at the beginning and at the end of the Application, respectively, concerning the provisions of Federal law (the United States Code) for knowingly making false statements or misrepresentations.


The electronic application must be submitted by 5:00 P.M. E.T. on (Date). All required supplemental forms and all applicable supporting documentation must be postmarked by (Date).


The application form and all other documentation will NOT be returned.


Failure to provide ALL information on ALL required forms and applicable supporting documentation described in Section M of this Guidance by the above deadlines will result in disqualification for an award. The NELRP staff will perform no further review of incomplete applications.

DISCRIMINATION PROHIBITED


Title VI of the Civil Rights Act of 1964 states: "No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance."


Section 504 of the Rehabilitation Act of 1973, as amended, provides that no otherwise qualified individual with a disability in the United States shall, solely by reason of his/her disability, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.


Title IX of the Education Amendments of 1972, as amended provides that no person in the United States shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any education program or activity receiving Federal financial assistance.


Title III of the Age Discrimination Act of 1975, as amended provides that no person in the United States shall, on the basis of age, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.


PRIVACY ACT NOTIFICATION STATEMENT


General

This information is provided pursuant to the Privacy Act of 1974 (Public Law 94-579), as amended, to individuals supplying information for inclusion in a system of records.


Authority

Section 846 of the Public Health Service Act, as amended.


Purpose and Uses

The purpose of the NELRP is to assist in the recruitment and retention of professional Registered Nurses (RNs) dedicated to providing health care in facilities with a critical shortage of nurses and to provide an opportunity for nurses to consider a career in such facilities. The information you provide will be used to evaluate your eligibility for participating in the NELRP. In addition, the NELRP will obtain a credit bureau report for purposes of determining your eligibility.


A participant’s contract, application, required supplemental forms, supporting documentation, correspondences, and related data are maintained in a system of records to be used within the Department of Health and Human Services to monitor NELRP-related activities. The information may also be disclosed outside the Department, as permitted by the Privacy Act and Freedom of Information Act, to the Congress, the National Archives, the General Accounting Office, pursuant to court order and various routine uses.


Effects of Nondisclosure

Disclosure of the information sought is voluntary; however, if not submitted, except for the reply to Part II, Item 10. (Race/Ethnicity) of the Application for the NELRP, OMB control number 0915-0140, an application will be considered incomplete.

















FREQUENTLY ASKED QUESTIONS





General Questions

What is the Nursing Education Loan Repayment Program (NELRP)?
The goals of the NELRP are to assist in the recruitment and retention of professional registered nurses dedicated to providing health care in facilities with a critical shortage of nurses and to provide an opportunity for nurses to pursue a career in such facilities. The program offers Registered Nurses (RN) substantial economic assistance to repay their qualifying educational loans in exchange for full-time service at a health care facility with a critical shortage of nurses.

In return, the NELRP will pay 30 percent of the participant’s total qualifying loan balance each year for the fist 2 years (total of 60 percent). A participant may be eligible to amend his/her two-year NELRP Contract to serve for a third (optional) consecutive year at a CSF. If a participant works full-time for a third year in a CSF, the NELRP will pay an additional 25 percent of the participant’s original qualifying loan balance. By statute NELRP payments cannot exceed 85% of participant’s original qualifying loan balance.


Should I read and retain the entire application kit and frequently asked questions (FAQ’s)?

The NELRP recommends that you read the entire application kit and FAQ’s before you submit an application and that you retain these materials for future reference. (If you are applying via the Web, you should print these materials in their entirety prior to completing the electronic application.) These documents will assist you with applying to the NELRP and provide information that is useful during your participation in the program should you receive an award. For example, they provide instructions on what to do when you need to transfer to another job site, and contain information regarding how to request a suspension of your obligation if you have problems of a personal nature that require you to be away from your service site for more than 7 weeks per service year. They also contain instructions on what to do if you have a change of banking information. Following proper procedures in dealing with a given situation during participation in the program may help prevent a delay or temporary stop in payments, or a default action being taken.


Should I review the supplemental forms before I mail them to the NELRP?

Yes. It is important to review supplemental forms for completeness and accuracy before you submit them to the NELRP. Forms must be clearly printed in their entirety on separate sheets of white 8 ½” x 11” paper. Incomplete forms and inaccurate information on forms will result in the applicant being deemed ineligible to participate in the NELRP.


Should I make a copy of supplemental materials before I mail them to the NELRP?

Yes. A copy of the application documents that you mail to the NELRP should be maintained for your records and for future reference if needed.

Will application materials submitted after the deadline be considered?
No. All required and supplemental materials must be postmarked by 5:00 pm ET on (Date). Electronically submitted applications must be transmitted by 5:00 pm ET on (Date).

Can I apply to this program more than once?
Yes. If you applied in a previous year and were declared ineligible or approved but unfunded and you meet the current eligibility requirements, you may apply again. Or, if you received a nursing education loan repayment award in the past, but have received an additional and/or higher level nursing degree and have qualifying nursing student loans incurred for obtaining that degree, you may apply again. Each year an applicant wishes to apply to the NELRP, he/she must submit a new application, supplemental forms, and supporting documentation, if applicable.

I applied, (submitted an application and forms) to the NELRP in FY 2007, but did not receive funding, must I complete an application and resubmit all the required supplemental forms and supporting documentation again for FY 2008?
Yes.

Will the NELRP conduct a credit check?
As part of the loan verification process, we obtain a credit report on the applicant to verify the existence of judgment liens against the applicant’s property for a debt owed to the United States and to verify the existence of the loan amounts claimed by the applicant in his/her NELRP application.

How can I obtain additional information about the NELRP and other nursing scholarship and loan repayment programs?
For help with your NELRP application, e-mail CallCenter@hrsa.gov or phone toll-free 1-877-464-4772, Monday through Friday (except Federal holidays), 9 am to 5:30 pm ET. For information on other programs, see HRSA financial aid programs for nurses and nursing students at http://www.hrsa.gov/help/healthprofessions.htm.

Eligibility: Degrees & Licensure

What type of nursing degree must I have to be eligible?
A person who has received a baccalaureate or associate degree in nursing (or an equivalent degree), a diploma in nursing, or a graduate degree in nursing, from an accredited school of nursing in a State is eligible.

Does this program apply to non-nursing but nursing-related degrees such as Masters of Public Health (MPH) or Masters of Health Administration (MHA)?
No. This program applies only to an individual who has received a qualifying degree in nursing as indicated above.

Are Licensed Practical Nurses (LPN) eligible for this program?
No. The NELRP is limited to Registered Nurses.

Are nurse educators eligible for this program?
Yes, if the nurse educator is working full-time as a registered nurse in a critical shortage facility. Educational institutions are not critical shortage facilities.

Is there a date by which I must graduate and pass my NCLEX?
Your license information must be included on the NELRP application and employment verification form. So, you must have received your nursing degree and have a permanent unrestricted RN license in the State in which you intend to serve, or in a State that participates in a Nurse Licensure Compact with the State in which you intend to serve, by the application deadline date of (Date).

What do I need to do to prepare for applying to this program?
To be considered for the FY 2007 NELRP application cycle you must meet the following eligibility requirements by the application deadline date of (Date):


1) have a current permanent unrestricted license as an RN in the State in which you intend to practice or in a State participating in the mutual recognition compact. For more information, see the Nurse Licensure Compact state listing at http://www.ncsbn.org/nlc/rnlpvncompact_mutual_recognition_state.asp
2) have received a baccalaureate or associate degree in nursing (or an equivalent degree), a diploma in nursing, or a graduate degree in nursing from an accredited school of nursing in a State;
3) have outstanding qualifying loans obtained for nursing education leading to a degree or diploma in nursing as specified above;
4) must have completed the nursing education program(s) for which the loan balance applies;
5) be a U. S. citizen, U. S. national, or a lawful permanent resident of the United States;
6) be employed full-time (32 hours or more per week) at a CSF;
7) meet all additional requirements described in Section D of the Application Guidance; and

8) submit a complete application, a signed Contract, and all required supplemental forms and supporting documentation (postmarked no later than 5:00 pm ET (Date).


Eligibility: Educational Loans


What types of loans are considered to be eligible?
Government and commercial loans obtained by the participant, contemporaneous with participant’s undergraduate and graduate nursing education, to pay for:
1) school tuition and required fees for undergraduate and graduate nursing education;
2) other reasonable educational expenses (see definition of terms in Application Guidance) for undergraduate and graduate nursing education; and
3) reasonable living expenses (see definition of terms in Application Guidance during undergraduate and graduate nursing education.


What are some examples of eligible loans?

1) Nursing Student Loans
2) Stafford Loans
3) Supplemental Loans for Students (SLS)


What are some examples of loans that are not eligible for repayment?
Examples include:


1) loans for which the applicant incurred a service obligation to serve as a nurse, which will not be fulfilled by the application date;

2) loans obtained for training in vocational or practical nursing (LPN);
3) loans obtained from family members, or private institutions not subject to Federal or State examination and supervision as lenders;
4) loans made prior to or after the applicant’s nursing education;
5) loans that have been paid in full;

6) Any portion of a consolidated/refinanced educational loan that is not clearly identified as being for reasonable educational expenses and reasonable living expenses incurred for qualifying nursing education by the applicant, or any consolidated/refinanced loan that includes another person’s loans;
7) credit card payments for nursing education expenses;
8) Parent Plus Loans;
9) Federal Perkins Loans (unless the applicant can provide documentation from the school or lender that the loan is not subject to cancellation);
10) Loans not obtained from a government loan program, academic institution, or a commercially chartered lending institution, as well as commercial loans obtained from entities that are not subject to Federal or State examination and supervision as lenders; or
11) Loans obtained for non-nursing education or a non-nursing degree that may later qualify as a prerequisite for a nursing program.

Why is a Parent Plus Loan ineligible for repayment under NELRP?
Parent Plus Loans are ineligible because the parent is liable for repayment of the loan.

I consolidated my nursing loans. Are they still eligible for repayment?
Yes, under certain circumstances. See Section H.3. and Section M.2, of the Application Guidance.

What is a promissory note?
A promissory note is a legally binding contract between a lender and a borrower. The promissory note contains the loan amount, type, terms, and conditions of the loan, including repayment and default provisions. Copies of this document can be obtained from your lending institution or loan servicing agent. (Master Promissory Notes are not considered to be sufficient documentation).

Eligibility: Employment

Can you provide a list of CSFs where I could fulfill the service obligation? Any health care facility (regardless of location) meeting the definition of a CSF as described in Section C of the Application Kit is eligible under the NELRP.

I work as an RN for a private for-profit facility, is my facility eligible?

No, effective October 1, 2007 only non-profit CSF’s are statutorily eligible for the NELRP.

Will I be paid for my work in addition to the loan repayment?

Yes. The Contract for loan repayment is between the applicant and the NELRP. An employer will know that the nurse is participating in the NELRP; however, the employer will not be informed of the specific payments the NELRP is making to the participant. Therefore, when compensation packages are negotiated between the nurse and the facility, loan repayments should not be part of the salary negotiations.

How many hours must I work at the CSF to be considered full-time?
Full-time service requires no less than 32 hours of nursing service per week (for a minimum of 45 weeks per service year) at a single CSF.

If I receive a NELRP award, how do I deal with extended time away from my service site during my service period for medical or other personal reasons?


Notify the DSCS in advance of your expected departure from work date and return to work date. The time away from your service site will be combined with your other absences during the service year. If your cumulative time away from your service site will exceed 7 weeks per service year, your NELRP payments will be stopped, and you must submit a written request for a suspension of your service obligation. See Section L of the Application Guidance. Upon receipt of documentation or return to full-time service, your NELRP payments will be resumed and your service end date will be extended to compensate for the break in “full-time” service.

If I am working part-time, am I eligible for the program?
No. All applicants must work a minimum of 32 hours per week at a single CSF to be eligible for the NELRP.

Does my employer have any role in my applying for this program?
Yes. Only to the extent of completing an employment verification form, and if applicable, providing documentation as to the facility’s status as a Disproportionate Share Hospital, Federally Designated Community, Migrant or Homeless Health Center, Rural Health Clinic, Federally Qualified Health Center Look-Alike, Indian Health Service Health Center, or State or Local Public Health Department, as indicated in Section M.3. of the Application Guidance.

Do the years that I have already worked at my facility count toward my service requirement?
No, the NELRP service obligation begins on the effective date of the Contract.

If I decide to work at a CSF several years after graduation, am I eligible to apply?
Yes. If you are willing to agree to a 2-year service obligation at a CSF and still have outstanding, qualifying student loans from your nursing education, you may apply as long as you meet the NELRP eligibility criteria.

I am a nurse (Certified Registered Nurse Anesthetist (CRNA), Certified Nurse Midwife (CNM) or Nurse Practitioner (NP)) employed by a professional group that practices exclusively at a CSF (I am not directly employed by the CSF, but by the professional group), am I eligible for the NELRP?
Yes. Nurses employed by a professional group are eligible for the NELRP provided that they meet all other eligibility requirements as set forth in Section D of the Application Guidance.

I am employed by a professional group. Who should complete the Employment Verification Form and do I need to provide additional employment documentation?
The professional group should complete the Employment Verification Form. The professional group also must provide a written statement on company letterhead stating that the applicant will be working at the designated CSF for at least 32 hours per week (for a minimum of 45 weeks per service year) for the 2-year duration of the applicant’s NELRP Contract if the applicant receives an award. If applicable, documentation of the facility’s status as set forth in Section M.3 of the Application Guidance must be submitted.

After Submitting Your Application


How is it determined who will receive an award?
Determination of which eligible applicants will receive an award is based on the financial need of the applicant and the type of CSF where the applicant would be serving. See the Funding Preferences in Section E of the Application Guidance.


Will the NELRP keep me apprised of my application status as it is processed?
All applicants who have completed an on-line application will be advised in writing of our decision at the conclusion of the evaluation and award process by October 31, 2008.


Can I make changes to my web application after it is submitted?

Yes, but only the NELRP staff can enter the changes on an electronic application after its submission and a “Confirmation of Application Receipt” is received by the applicant. Requests for changes are accepted until 5:00 pm ET on (Date). To request a change, submit an email to CallCenter@hrsa.gov; include the following: full name used on application, last four digits of Social Security Number, State of employment, how the information currently appears on the application and how it should appear when corrected. Please note that changes will be made at the close of the application cycle and will not be visible to applicants.


Can I withdraw my application? If so, what is the process?
An applicant may withdraw his/her application by (Date) and still be eligible to apply to the NELRP in the future. If the applicant’s Contract is signed by the Secretary prior to the applicant’s withdrawal and the applicant fails to commence service on the effective date of the contract, the applicant will be in breach of the Contract and will be permanently disqualified from receiving future awards under the NELRP and some other Federal Programs. Applicants who decide to withdraw from competition for an award must notify the NELRP at:

Nursing Education Loan Repayment Program
5600 Fishers Lane, Room 9-36
Rockville, MD 20857

Or by email at CallCenter@hrsa.gov or by fax at 301-443-0791


How is the first funding preference awarded?

The NELRP first funding preference is awarded to eligible applicants who meet two criteria: greatest financial need and employment at a first funding preference critical shortage facility.


The greatest financial need funding preference is awarded to individuals whose qualifying loan balance at the time the loans are verified is equal to or greater than 40 percent of the individual’s annualized salary. Divide your total qualifying loan balance by your annualized salary and if the result is .40 or greater, you meet the greatest financial need funding preference.


To receive the first funding preference, you must also be employed at one of the following types of not-for-profit critical shortage facilities:

  • Disproportionate Share Hospital

  • Nursing Home

  • Federally Designated Health Center

  • Federally Designated Migrant Health Center

  • Public Health Department

  • Rural Health Clinic

  • Indian Health Service Health Center


After Receiving an Award


When does the 2-year service obligation begin?
On the date the Secretary signs the NELRP Contract.


How do I receive my loan repayments?
Monthly payments are disbursed through an electronic funds transfer to the participant's checking or savings account as indicated on the Payment Information Form. The first direct deposit is made approximately 30 days after the effective date of the contract.


What time of the month are payments deposited?
Payments usually are deposited into bank accounts around the middle of the month. However, payments can be delayed due to holidays, network difficulties, heavy workload volume, etc.


I am planning to set up an electronic draft of NELRP payments to my lender(s). What time of the month should I do that?
Because there is no guarantee that payments will be deposited at the same time each month, it is recommended that electronic drafts be scheduled as late in the month as possible.


What should I do if I have not received my NELRP deposit by the end of the month?
Contact the Nursing Education Loan Repayment Branch (NELRPB) office as soon as possible between 9 am and 5:30 pm ET at 1-877-464-4772.

My checking and/or savings account has changed, what do I need to do?

To receive instructions for making changes and/or updates to your banking information contact the NELRP office at 1-877-464-4772, Monday through Friday (except Federal holidays), 9 am to 5:30 pm ET. It is imperative that you notify the NELRP promptly of all changes to your banking information, since all NELRP payments are credited to your account electronically. Without a correct account number we are unable to make the payment correctly.


Do I have to use these monthly payments to repay my educational loans?
Yes. The participant MUST use all loan repayments provided to repay qualifying educational loan balances. Periodically the NELRP will contact your lenders to verify that payments have been made.


In order to be considered for an amendment contract, for a third year of service, the participant will be asked to provide a payment history showing how the original funds were applied.

These funds may not be used to pay Federal, State, or local tax liabilities.


Do I have to pay taxes on the NELRP payments?
Yes. The NELRP payments made to participants are regarded as income by the U.S. Internal Revenue Service and are subject to Federal tax. The NELRP will send an annual statement of these payments (Form 1099) to all participants and to the IRS. These loan payments may also be subject to State and local income tax. Participants should check with their State or local tax authority concerning their tax liability for these payments.


What role does my employer have during my participation in the program?

The RN enters into 2 separate contracts. One contract is with the NELRP and the second is with the critical nursing shortage facility to provide service in exchange for payment of their educational debt.


To assure performance of the required service obligation under the NELRP, we require your employer to complete an employment verification form every 6 months during your participation in the program. Completing the form requires minimal effort by your employer.


If your employer does not cooperate in completing the employment verification form in its entirety as instructed, your NELRP payments will be immediately stopped. If the problem is not resolved and we cannot verify your compliance with the NELRP’s full-time service requirement, you will be placed in default of your NELRP contract and will be liable to repay all NELRP funds received plus interest.


I want to transfer to another facility, what do I need to do?

NELRP participants are expected to complete their full service obligation at their initial service site. However, if a participant is unable to complete service at the initial site, he/she may request a transfer to another CSF.


You must submit a written request to the DSCS for approval before leaving your existing service site, and transfer to one of the types of CSFs that is included in the first funding preference category at the time you make your request, or you may be recommended for default. See Section I of the Application Guidance.


Who do I contact if I want to submit a request to have my Contract waived or suspended? A request for waiver or suspension must be submitted in writing setting forth the basis, circumstances, and causes which support the requested action. See Section L of the Application Guidance. Submit your request to:


Division of Scholar and Clinical Support

Clinician Service Support Branch

5600 Fishers Lane; Room 8A-55

Rockville, MD 20857

Or by e-mail to: CallCenter@hrsa.gov or fax to 301-594-4077


I am moving to a new address, how do I update my mailing address?
Send a written request for the change to:


Division of Scholar and Clinical Support

Clinician Service Support Branch

5600 Fishers Lane; Room 8A-55

Rockville, MD 20857
Or by e-mail to: CallCenter@hrsa.gov or fax to 301-594-4077


I was recently married, how do I change my name?
Forward a written request with a copy of your marriage license to:


Division of Scholar and Clinical Support

Clinician Service Support Branch

5600 Fishers Lane; Room 8A-55

Rockville, MD 20857
Or fax to 301-594-4077






Nursing Education Loan Repayment Program

FY 2008 Forms


All required supplemental forms and applicable supporting documentation must be submitted in original hard copy, postmarked no later than (date), via postal mail to:


Division of Applications and Awards

Nursing Education Loan Repayment Branch

c/o FocalPoint Consulting Group

1025 Vermont Avenue, NW Suite 1000

Washington, DC 20005








FORMS













O.M.B.: 0915-0140

Expiration Date:

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 currently valid OMB control number. Public reporting burden for this collection is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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 Office, 5600 Fishers Lane, Room 11A-33, Rockville, Maryland 20857.


CHECKLIST


Applicants must initial each item and sign and date the Checklist. An application that is incomplete or includes a photocopy of any application materials (with the exception of the applicant’s promissory notes, loan consolidation documents, or proof of status as a U.S. citizen, U.S. National, or Lawful Permanent Resident) will not be processed. You will not be contacted for additional information if your application is incomplete. Please make sure all forms are accurate and complete with original signatures prior to submission of your application.


Return the Checklist with your required supplemental forms and supporting documentation. Keep a copy of the completed application materials for your records.



Supplemental Forms


____ Completed Loan Information and Verification Form (Loan Form): A Loan Form for each lender or holder for the nursing education loan(s), a copy of promissory note(s) for any consolidated/refinanced loans, and documentation that any Perkins Loans are not subject to cancellation is required. See Section M.2. of the Application Guidance for detailed instructions regarding the additional documentation that must be submitted for consolidated/refinanced loans and Perkins loans.


____ Completed Direct Deposit Sign-Up Form: It has been mandated that Federal payments are to be processed via electronic funds transfer/direct deposit into the designated account. Do not put the name of your lender for the name of your “(Bank) Financial Institution” on this form. Voided checks are not acceptable.


____ Signed and Dated NELRP Contract: You must return the original signed and dated contract. A signed, printed NELRP contract that does not contain the 11 terms and conditions will not be accepted. I understand that this contract does not take effect until signed by the Secretary or the Secretary’s designee.


____ Completed Employment Verification Form: Your employer must fill out this form completely and you must include this form with your application.


____ Authorization for Release of Employment Information: I understand that if I become a NELRP participant, my employment status will be verified semiannually.








Supporting Documentation


____ Documentation of your status as a U.S. Citizen, U.S. National, or Lawful Permanent Resident (if applicable): This documentation is required only if you were born outside of the U.S. Examples include a copy of a certificate of citizenship or naturalization, U.S. Passport ID page, or Green Card.


____ Letter/Certification From Site: Applicants must submit documentation of the facility’s status as set forth in Section M.3. of this Guidance. The Facility must indicate in the letter if the facility is private nonprofit, private for-profit, or public/government owed.


____ Statement From Professional Group (if applicable): Advanced practice nurses employed by a professional group that practices at a CSF must provide a written statement from the professional group indicating that the applicant will be working exclusively at one designated CSF for at least 32 hours per week (for a minimum of 45 weeks per service year) for the 2-year duration of the applicant’s NELRP contract, if the applicant receives an award.


____ Nursing Education Loan/Lender Documents: Applicants must submit written documentation of each nursing education loan(s) to be considered for NELRP loan repayment. Written documentation includes either (1) a copy of the promissory note(s) for each loan(s) or (2) a copy of the loan disclosure statement(s) or (3) an original letter (on official letterhead) from the school, lender or holder indicating the date of the loan, the amount of the loan and the type of loan disbursed.


____ Nursing degree(s), diploma, post-master certification and current nursing license: Applicants must provide documentation of current, unrestricted nursing license for the State in which they plan to practice under NELRP. Applicants must also, submit a copy of the nursing degree(s), diploma or post-master certificate for which they would like NELRP loan repayment consideration.


____ School Transcripts: Applicants must provide a school transcript for all nursing education for which they would like NELRP loan repayment consideration.


I certify that the information given in all the application documents is accurate and complete to the best of my knowledge and belief. I understand that it may be investigated and that any willfully false representation is sufficient cause for rejection of this application, or, if awarded loan repayment, that I am liable for repayment of all awarded funds and further that any false statement herein may be punished as a crime under U.S. Code, Title 18, Section 1001 and subject me to civil penalties under the Program Fraud Civil Remedies Act of 1986 (45 CFR 79).


____________________________________________________________________________

Name (Please Print) Signature Date















O.M.B.: 0915-0140

Expiration Date:


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 currently valid OMB control number. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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 Office, 5600 Fishers Lane, Room 11A-33, Rockville, Maryland 20857.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

HEALTH RESOURCES AND SERVICES ADMINISTRATION

BUREAU OF CLINICIAN RECRUITMENT AND SERVICE

NURSING EDUCATION LOAN REPAYMENT PROGRAM

LOAN INFORMATION AND VERIFICATION FORM


APPLICANT: Complete one copy of this form for each lender with loans you wish to be considered for repayment under the NELRP. Your original loan date(s) must coincide with your school attendance dates for loans to be eligible for repayment. Please print clearly and complete all items to facilitate verification. If this form is incomplete or if any information is incorrect, you will be deemed ineligible and your application will not be processed.


__________________________________________________________________________________________________________________

1. Applicant's Name (Last, First, Middle) 2. Applicant's Social Security No. 3. Date of Birth


__________________________________________________________________________________________________________________

4. Applicant's Complete Address 5. Applicant's Telephone No.


__________________________________________________________________________________________________________________

6a. Name of Current Lending Institution 6b. Lender's Automated Access System 7. Loan Account No.

Telephone No.

__________________________________________________________________________________________________________________

8a. Full Address of Lending Institution 8b. Address Where Payments are sent (If different from Item 8a)


__________________________________________________________________________________________________________________

9a. Was the loan sold? Yes ___ No ____ (If you are not sure, check with your lender) If "yes," give the original loan holder's name and full address. __________________________________________________________________________________________________________________


9b. Was the loan consolidated? Yes ____ No ____ If “yes”, provide date(s) _________________________________________________

10. Original Date of the Loan __________________ 11. Original Amount of the Loan ___________________


12a. Current Balance (Principal & Interest) $ _______________ as of (date) _____________ 12b. Interest Rate___________


13. Purpose of the Loan as indicated on the Loan Application. ____________________________


14. Type of Loan, e.g., NSL, Stafford, etc., (Please spell out type): ____________________


15. Loan in Default? Yes ____ No ______ Date of Default: ________________


16. Federal Judgment Lien for defaulted loan(s)? Yes ______ No ______ Date of Judgment:________________


FOR CONSOLIDATED UNDERGRADUATE AND GRADUATE EDUCATION LOANS - If you have consolidated your loans for nursing education, you must attach a copy of the promissory notes for the original loan(s) or a copy of the consolidated promissory note from the current lender(s) indicating the amount, date of original disbursement and type of loan(s).


WARNING - Any person who knowingly makes a false statement or misrepresentation in this loan repayment transaction, bribes or attempts to bribe a Federal official, fraudulently obtains repayment for a loan under this statute, or commits any other illegal action in connection with this transaction is subject to a fine or imprisonment under Federal statute. I have read this statement and understand its contents.


CERTIFICATION OF APPLICANT - I hereby certify that the information I have provided is true, complete, and accurate. I am aware that any false, fictitious, or fraudulent statement may, in addition to other remedies available to the Government, subject me to civil penalties under the Program Fraud Civil Remedies Act of 1986.


AUTHORIZATION FOR DISCLOSURE OF INFORMATION - I hereby authorize the lending institution and loan holder identified above to release information regarding my educational loans to the NELRP for purposes of determining my NELRP eligibility. This authority shall remain in effect for 3 months from when the NELRP first contacts those entities, and may be revoked by me at any time before my financial records are disclosed. I understand that I have the right to obtain a copy of the entity’s record of disclosures to the NELRP.


____________________________________________________ ____________________

SIGNATURE OF APPLICANT DATE

O.M.B.: 0915-0140

Expiration Date:




AUTHORIZATION for RELEASE of EMPLOYMENT INFORMATION


for Participation in the


NURSING EDUCATION LOAN REPAYMENT PROGRAM





I authorize the release of information relative to my employment status (e.g., salary, dates of


employment, number of hours worked, position held, position description, etc.) to the Bureau of


Clinician Recruitment and Service, HRSA, DHHS, Nursing Education Loan Repayment Program


(NELRP). This information will be used by the BCRS staff to determine my eligibility to


participate in the NELRP and, if I am selected to participate in the NELRP, to determine my


compliance with the NELRP service requirements.



____________________________________________________________________

(Signature) (Date)


____________________________________________________________________

(Print Name) (Social Security No.)



O.M.B.: 0915-0140

Expiration Date:

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 currently valid OMB control number. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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 Office, 5600 Fishers Lane, Room 11A-33, Rockville, Maryland 20857.


EMPLOYMENT VERIFICATION FORM FOR APPLICANTS TO THE

NURSING EDUCATION LOAN REPAYMENT PROGRAM (NELRP)


TO BE COMPLETED BY THE AUTHORIZED PERSONNEL OFFICIAL OF THE FACILITY

IF THIS FORM IS INCOMPLETE OR IF ANY INFORMATION IS INCORRECT, THE APPLICANT WILL BE DEEMED INELIGIBLE AND THE APPLICATION WILL NOT BE PROCESSED.


Applicant's Name (your employee): ____________________________________________________


Applicant's Social Security Number: ___________________________________________________


Name of Health Care Facility: ______________________________________________


Address of Health Care Facility: _______________________________________________________


Name and Address of Group Practice (applies only to advanced practice nurses who are employed by a professional group that practices at the health care facility identified above): _______________________________________


__________________________________________________________________________________


Please note: Under the NELRP, participants must be registered nurses providing full-time nursing services at a critical shortage facility. Full-time nursing service is defined as the provision of nursing services for a minimum of 32 hours per week. No more than 7 weeks per service year can be spent away from the facility for vacation, holidays, continuing education, illness, or any other reason. Individuals who have an existing service obligation are not eligible to participate in the NELRP. RNs working PRN or as Pool Nurses, or for Travel or Nurse Staffing Agencies are not eligible for the program.

I hereby certify that the individual identified above:


1. Began employment at the facility identified above on ______________ and is currently employed in:

mm/dd/yyyy

( ) a full-time position (defined as a registered nurse providing nursing services for a minimum of 32 hours per week), or


( ) less than a full-time position (defined as a registered nurse providing nursing services for less than 32 hours per week);


2. Currently ( ) does or ( ) does not have an existing service obligation to the facility. (Defined as an obligation to provide health professional service which is owed to and provided for under an agreement with the facility and which will not be completely satisfied on or before (Date) (e.g., existing commitment to the facility for educational pay back service or a sign-on bonus).);


3. Earns an annual gross salary of $_____________ (please calculate full-time annual gross salary if employee is paid on an hourly basis);


4. Is required to work the following number of hours: Per Week ____________ or Bi-Weekly __________;


5. Is currently licensed to practice as a registered nurse without restrictions. Please provide the following information:

License Number: ___________________ State: ___________ Expiration Date:_____________; and


6. Works at the following type of facility: (a) private nonprofit ________

(b) private for profit ________

(c) public / government owned ________


_______________________________________________________________________________

Name of Authorized Personnel Official (Please Print) Title

____________________________________________________________________________________________

Signature of Personnel Official Date

________________________________________ ____________________________________

Personnel Office Telephone Number Personnel Office Fax Number


NURSING EDUCATION LOAN REPAYMENT PROGRAM

FISCAL YEAR 2008

2-YEAR CONTRACT

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

HEALTH RESOURCES AND SERVICES ADMINISTRATION

BUREAU OF CLINCIAN RECRUITMENT AND SERVICE


Under the Nursing Education Loan Repayment Program (“NELRP”), statute, section 846 of the Public Health Service Act (42 U.S.C. § 297n), as amended by Public Law 107-205 on August 1, 2002, and its implementing regulations (42 C.F.R. § 57.312), the Secretary of Health and Human Services (“Secretary”) is authorized to provide registered nurses with partial repayment of their outstanding loans for nursing education. In return for these loan repayments, the nurses agree to engage in the full-time practice of their profession for 2 years at a health care facility with a critical shortage of nurses.


The terms and conditions of participating in the NELRP are set forth below:


1. The undersigned applicant (“applicant”) agrees to serve as a registered nurse for a period of two (2) consecutive years, beginning on the effective date of this Contract at the health care facility identified in the application which the Secretary has determined has a critical shortage of nurses (i.e., a “Critical Shortage Facility” (CSF)). Full-time service is employment as a nurse at a CSF for a minimum of 32 hours per week, for a minimum of 45 weeks per service year. If the applicant is unable to complete the service obligation at the initial service site identified in the application, the applicant agrees to resume service within 60 days and complete the remaining service period at another CSF that has been approved by the Secretary as a transfer site for the applicant.


2. The applicant agrees to submit a semi-annual report, containing such information as the Secretary shall specify, regarding the applicant’s compliance with the service obligation described in paragraph 1 of this Contract.


3. The applicant agrees to inform the Secretary immediately of any change in mailing address, email address, employment location or any other change in the provision of nursing services set forth in paragraph 1 of this Contract.


4. Subject to the availability of funds:


a. For the first year of the two consecutive years of service, the Secretary agrees to pay an amount equal to 30 percent of the principal of, and interest on, the applicant’s qualifying loans for nursing education which were unpaid on the effective date of this Contract.


b. For the second year of the two consecutive years of service, the Secretary agrees to pay an amount equal to 30 percent of the principal of, and interest on, the applicant’s qualifying loans for nursing education which were unpaid on the effective date of this Contract.


  1. The applicant agrees to apply all NELRP payments received to repay the applicant’s qualifying loans for nursing education. No portion of the NELRP payments shall be used to pay taxes due to Federal, State, or local authorities.


6. The applicant and Secretary agree that this Contract may be modified by written mutual consent, prior to the expiration of this Contract, to extend the applicant’s service obligation set forth in paragraph 1 for a third consecutive year. In return for a third year of service, the Secretary would agree to pay, subject to the availability of funds, an amount equal to 25 percent of the principal of, and interest on, the applicant’s qualifying loans for nursing education which were unpaid on the effective date of this Contract.


7. If the applicant fails to provide 2 years of service as set forth in paragraph 1 of this Contract, the applicant shall repay all NELRP payments received under paragraph 4 of this Contract, plus interest at the maximum legal prevailing rate from the date of the applicant’s breach of that service obligation.


    1. The amount the Secretary is entitled to recover under paragraph 7 of this Contract must be repaid by the applicant within not more than three (3) years of applicant’s breach of the service obligation set forth in paragraph 1 of this Contract.


9. The Secretary may waive or suspend the applicant’s service or payment obligation under this Contract if compliance by the applicant (i) is impossible or (ii) would involve extreme hardship and enforcement of such obligation would be unconscionable.


  1. Any payment or service obligation incurred by the applicant under this Contract will be cancelled upon the applicant’s death.


  1. The applicant agrees to comply with the requirements of the NELRP regulations at 42 C.F.R. Section 57.312.





































The Secretary or his/her authorized representative must sign this Contract before it becomes effective.

Applicant’s Name (please print):

Applicant’s Social Security Number:

Applicant’s Signature:

Date:

FOR OFFICIAL USE ONLY

Secretary of Health and Human Services or Designee

Effective Date of Contract

HRSA-868 (Revised 01/07)


9


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File Modified2007-11-14
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