Form 7 Emp Verification Form

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.

6-MONTH VERIFICATION OF EMPLOYMENT

FOR PARTICIPANTS IN THE

NURSING EDUCATION LOAN REPAYMENT PROGRAM (NELRP)

TO BE COMPLETED BY THE AUTHORIZED PERSONNEL OFFICIAL OF THE FACILITY

Applicant's Name (your employee): _______________________________________

Applicant's Social Security Number: _______________________________________

Name of Health Care Facility: ____________________________________________

Address of Health Care Facility: ___________________________________________

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. RN’s working PRN or as Pool Nurses, or for Travel or Nurse Staffing Agencies are not eligible for the program.

I hereby certify that, during the period from through ________, (or through his/her last day worked as specified below), the individual identified above:

1. Was employed by the facility identified above in:

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

(a) ( ) the entire period, or

(b) ( ) part of the period from through ; and/or

MM/DD/YYYY MM/DD/YYYY

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

(a) ( ) the entire period, or

(b) ( ) part of the period from through ;

MM/DD/YYYY MM/DD/YYYY

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

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

3. Did not work the following number of hours due to vacation, holidays, continuing education, illness, maternity, or any

other reason: ;

4. Is required to work the following number of hours per week ______, or bi-weekly______;

5. (if applicable) terminated employment on (last day worked); and

MM/DD/YYYY

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