Form 4 NC LRP - DAB Form - Revised

OMB Number: 0915-0140

Expiration Date: 5/31/2021

Public Burden Statement:

The purpose of the Nurse Corps Loan Repayment Program (NURSE CORPS LRP) is to assist in the recruitment and retention of professional Registered Nurses (RNs) dedicated to working in health care facilities with a critical shortage of nurses or working as nurse faculty in eligible schools of nursing, by decreasing the economic barriers associated with pursuing careers at such critical shortage facilities or in academic nursing. 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. The OMB control number for this information collection is 0915-0140 and it is valid until XX/XX/202X. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average xx hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.

Certification Regarding Disadvantaged Background

Loan Repayment Program

Institution Point of Contact Only: Please complete and return this form to the Nurse Corps Loan Repayment Program applicant for submission with their program application.

Applicant: Upload this completed form to your application when prompted to do so for consideration of Disadvantaged Background preference. The Nurse Corps cannot accept faxed or emailed copies.

Applicant’s Name Application ID#

Name of Applicant’s Institution of Employment

NURSE CORPS DISADVANTAGED BACKGROUND ELIGIBILITY PREFERENCE

For the applicant named above to receive disadvantaged background preference, the institution where they serve as a faculty member must certify that at least 50 percent of the student body at that institution is from a disadvantaged background.

CRITERIA FOR DETERMINING WHETHER STUDENTS AT YOUR INSTITUTION

MEET DISADVANTAGED BACKGROUND STATUS

Individuals from a disadvantaged background have either participated in, or would have been eligible to participate in, federal programs such as the Scholarships for Disadvantaged Students, Loans to Disadvantaged Students, or the Nursing Workforce Diversity Grant Program. These individuals can be either environmentally or economically disadvantaged as described below:

1. Environmentally Disadvantaged

The individual/student comes from an environment that has inhibited them from obtaining the knowledge, skills, and abilities required to enroll in and/or graduate from a health professions or nursing school is considered as being Environmentally Disadvantaged.

The following are provided as examples of "Environmentally Disadvantaged" criteria, which are for guidance only and are not intended to be all-inclusive:

• The individual/student graduated from (or last attended) a high school with low average SAT scores based on most recent data available.

• The individual/student graduated from (or last attended) a high school which, based on most recent data available, has a:

  • Low percentage of seniors receive a high school diploma; or

  • Low percentage of graduates go to college during the first year after graduation

• The individual/student graduated from (or last attended) a high school with low per capital funding.

• The individual/student graduated from (or last attended) a high school where, based on most recent data available, at least 30 percent of the enrolled students are eligible for free or reduced price lunches.

• The individual/student comes from a family that receives public assistance (e.g., Aid to Families with Dependent Children, food stamps, Medicaid, public housing).

• The individual is the first generation in their family to attend college.

_{– OR –}

2. Economically Disadvantaged

The following characteristics describe individuals who are considered Economically Disadvantaged:

• Individuals who come from a family with an annual income below a level based on low-income thresholds established by the U.S. Census Bureau, adjusted annually for changes in the Consumer Price Index.

• Individuals who are considered as coming from a ‘low income family’. The Secretary of HHS defines a ‘low income family’ for various health professions and nursing programs included in Titles III, VII and VIII of the Public Health Service Act as having an annual income that does not exceed 200 percent of the Department’s poverty guidelines.

• Receipt of the Pell grant is considered proof of an economic disadvantaged background.

CERTIFICATION BY INSTUTIONAL OFFICIAL

Place a check in the applicable box below regarding the disadvantaged background status for this applicant’s institution based on the Criteria described in the previous section.

• I certify that I am a responsible institutional official at _____________________________, and that because of my official duties, I am knowledgeable about the demographics of the students enrolled here and can certify whether they meet the criteria stated above.

• I further certify that at least 50 percent of students at my institution come from a disadvantaged background.

OR

• I further certify that less than 50 percent of students at my institution come from a disadvantaged background.

Signature Date

Printed Name Phone Number

Title

5600 Fishers Lane

Rockville, MD 20857