Form 8 NC LRP Nurse Faculty Employment Verification Form - Revi

OMB No. 0915‐0140 Expiration Date: 05/31/2021

Nurse Corps Loan Repayment Program

U.S. Department of Health and Human Services Health Resources and Services Administration

NURSE CORPS LOAN REPAYMENT PROGRAM (Nurse Corps LRP) EMPLOYMENT VERIFICATION FOR NURSE FACULTY

FOR NURSE FACULTY ONLY

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 required to obtain or retain a benefit (Section 846 of the Public Health Service Act, as amended (42 U.S.C. 297n). 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.

TO BE COMPLETED BY THE AUTHORIZED PERSONNEL OFFICIAL OF THE EDUCATIONAL INSTITUTION. PLEASE NOTE: IF THIS FORM IS INCOMPLETE OR IF ANY INFORMATION IS INCORRECT, THE APPLICANT WILL BE DEEMED INELIGIBLE AND THE APPLICATION WILL NOT BE PROCESSED. INFORMATION ON THE ONLINE APPLICATION MUST MATCH THIS FORM.

Employee:

Employee SSN (Last 4 Digits Only):

Accredited School of Nursing:

Address:

Please note: Under the Nurse Corps LRP, participants must be registered nurses (RNs) who are employed full‐time (as defined by his or her employer) as nurse faculty at an accredited public or private nonprofit school of nursing.

Individuals who have an existing service obligation are not eligible to participate in the Nurse Corps LRP. An existing service obligation is defined as an obligation of the individual to work as nurse faculty for a certain period of time in exchange for receiving a financial recruitment or retention incentive from the school or institution (e.g., a sign‐on bonus, payment of moving expenses, funds to repay student loans). A basic employment contract which outlines the salary and benefits an individual earns in exchange for the work he/she performs does not constitute a service obligation.

( ) Yes or ( ) No: Does the individual identified above have an existing service obligation to remain employed/working as nurse faculty at the school of nursing in return for receiving educational benefits, a sign‐on bonus, or any other recruitment or retention incentive?

IF YES to the above question (the individual has an existing service obligation), will the existing service obligation be completely satisfied on or before mm/dd/yyyy ( ) Yes or ( ) No

I hereby certify that the individual identified above:

1. Began working as a full‐time nurse faculty member at the school of nursing identified above on and is currently working in: mm/dd/yyyy

( ) a full‐time position (as defined by the school of nursing) OR

( ) less than a full‐time position (as defined by the school of nursing)

2. Earns a current base annual salary (gross salary before deductions for taxes, insurance, etc.) of $ for the year. If the employee has worked at the school of nursing or educational institution for less than one year, report his/her negotiated base salary for the first year of employment. Listing of the hourly rate is not acceptable.

3. ( ) Yes or ( ) No: Is a tenured nurse faculty member.

IF NO, Is currently working under a nurse faculty appointment for: ( ) 9 months ( ) 12 months ( ) Other (please specify : ) with a start date of (mm/dd/yyyy) and end date of (mm/dd/yyyy).

5. Is currently licensed to practice as an RN without any restrictions or encumbrances.

Please provide the following: License Number: State: Expiration Date:

mm/dd/yyyy

5. Works at the following type of school of nursing:

( ) private nonprofit ( ) public / government owned ( ) private for profit

5. ( ) Yes or ( ) No: Works at a school of nursing with 50% enrollment of students from a disadvantaged background. If YES, please submit appropriate documentation.

Signature Date

Printed Name Title

Phone Fax

Employment Verification for Nurse Faculty

ONLY COMPLETE THIS FORM IF YOU ARE NURSE FACULTY

The educational institution where the applicant works as a nurse faculty must fill out this form completely and return it to the applicant for submission with the other application materials.

1. Name and Address of the Accredited School of Nursing is the name and location of the institution where the applicant is working.

2. Employment Date is the date the applicant started working as nurse faculty at the school of nursing.

3. The base annual salary of the applicant must be reported. Base salary does not include overtime or shift differential. Applicants working at the school of nursing for less than one year must report their negotiated base salary for the current year.

4. To determine if the School of Nursing has a student enrollment from disadvantaged backgrounds of at least 50%, please submit documentation confirming one or more of the following of its student population:

STUDENT CRITERIA FOR DISADVANTAGED BACKGROUND STATUS

1. Come from an environment that has inhibited them from obtaining the knowledge, skills, and abilities required to enroll in and graduate from a health professions or nursing school (Environmentally Disadvantaged). The following are provided as examples of “Environmentally Disadvantages” for guidance only and are not intended to be all‐ inclusive. Other circumstances may also be considered as examples of environmental disadvantages.

Examples:

• Person from high school with low average SAT/ACT scores compared to the national level or below average State test results.

• Person from a school district where 50 percent or less of graduates attend college.

• Person who has a diagnosed physical or mental impairment that substantially limits participation in educational experiences.

• Person for whom English is not his or her primary language and for whom language is still a barrier to academic performance.

• Person who is first generation to attend college.

• Person from a high school where at least 30 percent of enrolled students are eligible for free or reduced price lunches.

OR

2. 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 (Economically Disadvantaged).

The Secretary 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. A family is a group of two or more individuals related by birth, marriage, or adoption who live together or an individual who is not living with any relatives.

Employment Verification for Nurse Faculty

ONLY COMPLETE THIS FORM IF YOU ARE NURSE FACULTY

2019 Poverty Guidelines
Persons in Family	48 Contiguous States and D.C.	Alaska	Hawaii
1	$12,490	$15,600	$14,380
2	$16,910	$21,130	$19,460
3	$21,330	$26,660	$24,540
4	$25,750	$32,190	$29,620
5	$30,170	$37,720	$34,700
6	$34,590	$43,250	$39,780
7	$39,100	$48,780	$44,860
8	$43,430	$54,310	$49,940
For each additional person, add	$4,420	$5,530	$5,080

SOURCE: Federal Register, 83 FR 2642, January 18, 2018, pp. 2642-2644.

Please note that while the educational institution is responsible for completing the form in its entirety, the applicant is responsible for assuring that the form is complete and accurate, and the applicant is responsible for the timely submission of the completed form.

NURSE CORPS LOAN REPAYMENT PROGRAM (Nurse Corps LRP) CERTIFICATION of ACCREDITATION STATUS for SCHOOL of NURSING EDUCATION PROGRAMS

TO BE COMPLETED BY THE SCHOOL OF NURSING DEAN’S OFFICE OR PROGRAM CHAIR where you are

currently working (and returned to the applicant for submission with the other application materials)

PLEASE NOTE: Collegiate and associate degree schools of nursing are a department, division, or other administrative unit in the educational institution which provides primarily or exclusively a program of education in professional nursing. A diploma school of nursing means a school affiliated with a hospital or university, or an independent school, which provides primarily or exclusively a program of education in professional nursing.

19. Secretary of Education nationally recognized nursing accrediting agencies are the:

    • Commission on Collegiate Nursing Education

    • Accreditation Commission for Education in Nursing, Inc. (Formerly National League for Nursing Accrediting Commission);

    • American College of Nurse‐Midwives, Division of Accreditation;

    • National Association of Nurse Practitioners in Women’s Health, Council on Accreditation;

    • Council on Accreditation of Nurse Anesthesia Educational Programs;

    • Kansas State Board of Nursing;

    • Maryland Board of Nursing;

    • Missouri State Board of Nursing;

    • Montana State Board of Nursing;

    • North Dakota Board of Nursing; and

    • New York State Board of Regents and the Commissioner of Education.

SCHOOL OF NURSING

ADDRESS

**CERTIFICATION**

I hereby certify that all of the nursing education programs in the school of nursing identified above are accredited by a nationally recognized nursing accrediting agency listed above, and/or by a state nursing accrediting agency approved for such purposes by the Secretary of the U.S. Department of Education.

Name of Authorized Official (please print) Title Phone

Signature of Authorized Official Date

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