4 Disadvantaged Background Form

OMB #: 0915-0150

Expiration Date: TBD

Certification Regarding

Disadvantaged Background

Faculty Loan Repayment Program

Institution Point of Contact Only: Please complete and return to the Bureau of Health Workforce, Faculty 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 Faculty Loan Repayment Program cannot accept faxed or emailed copies.

Applicant’s Name Application ID#

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Name of Applicant’s Institution of Employment

FACULTY LOAN REPAYMENT PROGRAM DISADVANTAGED BACKGROUND ELIGIBLITY PREFERENCE

For the applicant named above to receive disadvantaged background preference, the applicant must provide certification from a health professions school previously attended that identifies the individual as coming from an economically or environmentally disadvantaged background.

CRITERIA FOR DETERMINING WHETHER APPLICANT MEET DISADVANTAGED BACKGROUND STATUS

An individual certified by the health professions school (previously attended by the applicant) as having come from a “disadvantaged background” based on economic or environmental factors. These individuals can be either environmentally or economically disadvantaged as described below:

1. Environmentally Disadvantaged

The individual comes from an environment that has inhibited the person from obtaining the knowledge, skills, and abilities required to enroll in and graduate from an undergraduate or graduate school based on factors included, but not limited to the following:

• Graduated from (or last attended) a high school from which a low percentage of seniors received a high school diploma;

• Graduated from (or last attended) a high school at which, many of the enrolled students are eligible for free or reduced price lunches;

• Comes from a family that receives public assistance (e.g., Temporary Assistance to Needy Families, Supplemental Nutrition Assistance Program, Medicaid, public housing);

• Comes from a family that lives or lived in an area that is designated under section 332 of the Public Health Service Act as a Health Professional Shortage Area or is designated as a Medically Underserved Area;

• Participated in an academic enrichment program funded in whole or in part by the Health Careers Opportunity Program, authorized by section 739 of the Public Health Service Act;

• Participated in the Scholarships for Disadvantaged Students Program, authorized by section 737 of the Public Health Service Act;

• Did not complete high school but received an Adult High School (AHS) Diploma or General Educational Development or has received or is receiving public assistance;

• Comes from a school district where fifty (50) percent or less of graduates go to college or where college education is not encouraged;

• Is the first generation to attend college;

• Has a diagnosed physical or mental impairment that substantially limits the person’s participation in educational experiences and opportunities offered by the college;

• For whom English is not the primary language and took a Test of English as a Foreign Language (TOEFL) before entering health professions school;

• Was accepted to the health professions program after academic reassessment at the completion of remedial courses;

• Graduated from (or last attended) a high school from which a low percentage of seniors received a high school diploma;

• Other characteristics not listed above: --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

-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 according to family size published 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 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.

• Students who received a Pell grant while in school for a health profession degree.

• Other characteristics not listed above----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

CERTIFICATION BY INSTUTIONAL OFFICIAL

Place a check in the applicable box above indicating the disadvantaged background/s status for this applicant based on the criteria described above.

 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 the above named Faculty Loan Repayment Program applicant while a students at the above institution came from a disadvantaged background as indicated above.

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Signature Date

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Printed Name Phone Number

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Title

Public Burden Statement:

The purpose of this information collection is to obtain information through the Faculty Loan Repayment Program (FLRP), which is used to assess an applicant’s eligibility and qualifications for the FLRP. 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 0915-0150 and it is valid until xx/xx/20xx. This information collection is required to obtain or retain a benefit (Section 738(a) of the Public Health Service Act (42 USC 293b (a)). 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.