Form 4 Others

Keep a copy for your records. Please sign and return the one original contract. If you receive an
award, a copy of your contract, signed by a designee of the Secretary, DHHS, will be returned to you.

OMB No. 0925-0438
Form approved for use through xx/xx/xxxx

NATIONAL INSTITUTES OF HEALTH
UNDERGRADUATE SCHOLARSHIP PROGRAM FOR
INDIVIDUALS FROM DISADVANTAGED BACKGROUNDS
SCHOOL YEAR [
]

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
NATIONAL INSTITUTES OF HEALTH
OFFICE OF LOAN REPAYMENT
AND SCHOLARSHIP

Section 487D of the Public Health Service Act (“Act”) (42 U.S.C. 2884) authorizes the Secretary of the Department of Health and Human
Services (“Secretary”), acting through the Director of the National
Institutes of Health (NIH), to provide individuals selected to be
participants in the NIH Undergraduate Scholarship Program for
Individuals from Disadvantaged Backgrounds (“UGSP”) with
scholarships. In return for these scholarships, applicants must agree to:
(a) serve full time as an NIH employee, for a period of 12 months for
each academic year of scholarship assistance, and (b) serve full time as
an NIH employee for 10 consecutive weeks of each year during which
the individual received a scholarship.

3. Submit to the Secretary, for approval, a course listing for the
academic year.

The scholarship may consist of payments, in whole or in part, for tuition,
and an amount for all other reasonable educational expenses incurred by
the student, as determined by the Secretary, and a monthly stipend for up
to a 9-month period beginning with the first month of each school year in
which the applicant is a participant in the UGSP, the total not to exceed
$20,000 per academic year.

4. Obtain approval from the Secretary before altering the approved
course listing.
5. a. Serve full time, as an NIH employee for 10 consecutive weeks
during each scholarship year.
b. Serve 1 year of service, in a manner to be determined by the
Secretary, as a full-time NIH employee for each year of scholarship
assistance;
(i) Such service will begin within 60 days of obtaining the
undergraduate educational degree involved unless deferred by
the NIH Director. If a deferral is granted, service will begin
upon expiration of the deferral period.
6. Comply with the policies of the UGSP and the provisions of Title 42,
Code of Federal Regulations, Part 62.

Section 487D of the Act requires applicants to submit with their
application such agreements as the Director of NIH determines to be
necessary. This contract is one of those agreements. The Director of NIH
shall sign only those contracts submitted by applicants who are selected
for participation (“Participant”). The terms and conditions for
participating in the UGSP for the [
] school year are set
forth below.

Section C - Breach of Scholarship Contract
1. A participant who has entered into a written contract with the Secretary
and who-

Section A - Obligations of the Secretary
Subject to the availability of funds appropriated by the U.S. Congress,
the Secretary agrees to:

c. voluntarily terminates such enrollment or is dismissed from such
educational institution before completion of such course of study;

a. fails to maintain an acceptable level of academic standing in the
approved course of study for which the scholarship is awarded; or
b. is dismissed from the educational institution for academic or
disciplinary reasons; or

1. Provide the participant with a scholarship for the school year
[
] if the participant:

in lieu of any service obligation arising under such contract shall be
liable to the United States for the amount that has been paid on behalf
of the participant under the contract.

a. Is enrolled, or is accepted for enrollment, as a full-time student in
an accredited (as determined by the Secretary) educational institution
in one of the several states of the United States, the District of
Columbia, the Commonwealth of Puerto Rico, the Commonwealth
of the Northern Mariana Islands, the U.S. Virgin Islands, Guam, or
American Samoa, and

2. After completing the undergraduate degree program for which the
scholarship was awarded, in accordance with the guidelines of the
UGSP, if the participant fails to either begin his or her service obligation
or to complete the obligation, the United States shall be entitled to
recover an amount equal to the sum of-

b. Is pursuing an approved program of study for the academic year
appropriate for a career in a profession determined to be needed by
the NIH.
2. If applicable, enter into a contract with the participant’s educational
institution under which the amounts provided in the scholarship for
tuition and other reasonable educational and living expenses are paid
directly to the educational institution.
3. Once the UGSP contract is signed by both parties, the Secretary shall
obligate such funds as will be necessary to ensure that sufficient funds
will be available to award a scholarship in an amount not to exceed
$20,000.
4. If applicable, the NIH will provide employment of at least 10
consecutive weeks during each scholarship year.
Section B - Obligations of the Participant
The participant agrees to:
1. Maintain full-time enrollment until completion of the undergraduate
course of study for which the scholarship is provided.
2. Maintain an acceptable level of academic standing, as determined by
the academic institution in accordance with regulations issued by the
Secretary, in each academic year for which a scholarship is provided.

NIH 2762-4
PAGE 1 (FRONT)
Revised 08/07

a. the total of the amounts paid by the Secretary on behalf of the
participant for any period of obligated service; and
b. an amount equal to the product of the number of months of obligated
service not completed by the applicant, multiplied by $7,500; and
c. interest on the amounts described in (a) and (b) of this paragraph at
the maximum prevailing rate, as determined by the Treasurer of
the United States, from the date of the breach; except that the
amount the United States is entitled to recover shall not be less
than $31,000.
3. The amount the United States is entitled to recover shall be paid
within 1 year (or such longer period beginning on such date as specified
by the Secretary) of the date the Secretary determines that the
applicant has failed to begin or complete the period of obligated
service.
4. If damages described in paragraph (3) above are delinquent for 3
months, the Secretary may, for the purposes of recovering such
damages:
a. utilize collection agencies contracted with by the Secretary; or
b. enter into contracts for the recovery of such damages with collection
agencies selected by the Secretary; or
c. collect said damages through deductions in Medicare payments
pursuant to section 1892 of the Social Security Act.

OMB No. 0925-0438
Form approved for use through xx/xx/xxxx

5. Any obligation of a participant for payment of damages may be
released by a discharge in bankruptcy under Title 11 of the United
States Code only if such discharge is granted after the expiration of
the 5-year period beginning on the first date that payment of such
damages is required, and only if the bankruptcy court finds that
nondischarge of the obligation would be unconscionable.
Section D - Credibility of Graduate Training Toward the Period
of Obligated Service
1. No period of residency will be counted toward satisfying the period of
obligated service incurred under this contract.
Section E - Cancellation, Suspension, Deferrment and Waiver of
Obligation

Keep a copy for your records. Please sign and return the one original contract. If you receive an
award, a copy of your contract, signed by a designee of the Secretary, DHHS, will be returned to you.

1. Any service or payment obligation incurred by the participant under
this contract will be canceled upon the participant’s death.
2. The Secretary may waive or suspend the participant’s service or
payment obligation, in whole or in part, incurred under this contract
if compliance by the participant with the obligation is impossible, or
would involve substantial hardship; and if enforcement of such
obligation would be unconscionable.

b. Requests a period of deferment to complete residency or other
advanced clinical training which the Secretary determines is
consistent with the needs of the Department. Deferments will not
be granted for postgraduate medical education conducted or
sponsored by a branch of the Armed Forces of the United States.
Section F - Contract Extension
1. The participant may annually request extension of this contract, for a
period not to exceed 12 months, if the request is submitted in accordance
with procedures established by the Secretary.
2. Subject to the availability of funds appropriated by the U.S. Congress,
the Secretary may approve a request for contract extension if:
a. The request does not extend the total period of scholarship beyond
4 years, and
b. The applicant is otherwise eligible for continued participation in
the UGSP.

3. The Secretary may defer performance of a participant’s period of
obligated service if appropriate, e.g., if the participant:
a. Pursues and ultimately obtains, within a reasonable period of time,
as determined by the Secretary, a degree from an accredited school
of medicine, osteopathy, dentistry or other school or program
approved by the Secretary; or

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

Applicant’s Name (Please Print)

Applicant’s Signature

Secretary of Health and Human Services, or designee

Date

Date
AMENDMENTS

This Undergraduate Scholarship Program for Individuals from Disadvantaged Backgrounds Scholarship Contract for the [
] school year
is hereby amended by the Secretary of Health and Human Services and the participant to provide the participant with additional scholarship support for
the school years indicated below, under the same terms and conditions set forth in the Scholarship Program contract for the [
] school
year except to the extent that the terms set forth in the [
] school year contract may be subsequently amended by statute or regulation.
Disbursements for each school year will begin at the start of that school year.
[
]
SCHOOL
YEAR
Participant’s Signature

Date

Secretary of Health and Human Services

Date

Participant’s Signature

Date

Secretary of Health and Human Services

Date

Participant’s Signature

Date

Secretary of Health and Human Services

Date

[
]
SCHOOL
YEAR

[
]
SCHOOL
YEAR

NIH 2762-4
PAGE 1 (BACK)
Revised 08/07

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