Form 6 Pre-Award Script

O.M.B.: 0915-0140

Expiration Date:

Nursing Education Loan Repayment Program (NELRP)

FY 2008 Pre-Award Script

**Note: Reference assigned listing of potential awardees; note Name, Employment State, Applicant Contact Tel #, and Analyst on this form.

1) Applicant Full Name: ___­­­­­­­­­­­­­__________________________ 3) Contact Telephone #: ________________________

2) Employment State: _______________________________ 4) Analyst: ­­­­­­­­__________________________________

**Prior to contact: Open Nursing Information System (NIS) Database, go to Applicant Record to readily have employer information, address, telephone number, and email address to reference and for verification.

GREETING: Good Morning/Afternoon: Is (Applicant) available? My name is (FocalPoint Staff member initiating call), and this call is in regards to the Nursing Education Loan Repayment Program application you submitted earlier this year. I am pleased to inform you that we are preparing to make award decisions. Before beginning the awarding phase, we will need to verify the residency, banking and employment information that you provided in your application. In addition, if an award is made to you, you will be bound by the conditions set forth in your contract including, but not limited to: a) Providing professional nursing services at least 32 hours per week at the facility designated in your application for a minimum of 45 weeks per year; and b) Compliance with semi-annual employment verification.

1. EMPLOYER INFORMATION:

1. Are you still currently employed at (See Employer Info Tab in NIS Database)? ( ) YES ( ) NO

2) If still employed at the same facility: Facility Name: _________________________________

Direct Work Phone #: ___________________________

3) Are you still employed in a full-time position which is defined as working as a nurse for a minimum of 32 hours per week? ( ) YES ( ) NO

**NOTE: If 'No' to either #1 or #3, inform the applicant that he/she is ineligible and will receive no further consideration.

**NOTE TO STAFF: If applicant is currently not FT, but plans to resume FT by effective date of contract, they're eligible for an award. Please provide explanation in “Additional Notes” section of this form, if applicant is not FT on date contacted but plans to resume FT status.

2. Although there's no guarantee you'll receive an award, do you still want to be considered to receive an award?

( ) Yes ( ) No, please withdraw my application from consideration

**NOTE: Confirm that NELRP will terminate processing based on this verbal request. Ask applicant to confirm their “request to withdraw” by e mail or fax (send one to them for faster turn-around)

3. RESIDENCY INFORMATION:

Please Verify Home Address, Daytime Telephone Number, and Email Address:

(Select ‘Addresses’ in PrimeCare Database to view applicant information):

( ) Same ( ) Changes, note below:

Address: ______________________________________

Home Phone: ______________________________________

Alternate Phone

(optional): _______________________________________

Email Address: _______________________________________

4. BANKING INFORMATION:

Please also verify whether banking information has changed or is the same: ( ) Same ( ) Changed

(Bank Name: _______________________)

If your Payment/Banking information has changed, a blank payment information form will need to be sent to you for completion. It can either be mailed or faxed.

***If changes, confirm how blank payment information form can be sent to the applicant.

__________________________________________________________________________

***CLOSING CALL, Advise of the following:

Also, please note that if you are selected as a NELRP participant, your assigned NELRP Analyst will be (Analyst Name), and they can be contacted by calling (Analyst Telephone Number) or via email at: (Analyst Email Address).

Also, it is important that prior to any changes in employment, residency, contact telephone number, payment information, or email address, you contact your NELRP Analyst to advise of such changes.

CALL STATUS:

( ) Unable to speak to the applicant, and

( ) Left a message, giving phone number and stating importance of contacting us ASAP

Name of Person, other than applicant, you left message with: ____________________________

(Annotate date and time you left a voice message if you left a message over answering machine)

Additional Notes:

Staff Signature __________________________

Date/Time ___________________________

NOTE: We cannot deny the application for failure to respond. Applicant remains eligible for award if there is no response to the phone call.