4C NHHSP Acceptance Verification of Good Standing Form

OMB Number: 0915-0146
Expiration Date: XX/XX/20XX

U.S. Department of Health and Human Services
Health Resources & Services Administration
Papa Ola Lōkahi

Title 42 USC Chapter 122 Section 11709 – Native Hawaiian Health Scholarship
Acceptance/Verification of Good Standing Form - Program Course Curriculum

APPLICANTS’ NAME

DEGREE(i.e., masters of science in nursing)

COLLEGE/UNIVERSITY NAME

PROJECTED GRADUATION MO/YR

THIS Program Course Curriculum document MUST BE COMPLETED and RETURNED to NHHSP
APPLICANT applied for Admission or is Enrolled at above-mentioned College/University since/for the Academic Year 20____ 20____. APPLICANT will be enrolled OR is anticipated to be enrolled Full-Time in an undergraduate/graduate degree-seeking program
(identified above) for the Academic Year 202x-202x.
LIST Degree Program CURRICULUM from (start of) FIRST YEAR to COMPLETION
e.g. FALL 2020
Summer _________ (Year)
Course Number

Fall _________ (Year)
Course Number

NHHSP Applicant Signature

Months: August - December

Months: _______________
Credit Hours

Year One
Course Title

Months: _______________
Credit Hours

Course Title

Date

Spring _________ (Year)
Course Number

Summer _________ (Year)
Course Number

Fall _________ (Year)
Course Number

Spring _________ (Year)
Course Number

NHHSP Applicant Name

OMB Number: 0915-0146
Expiration Date: XX/XX/20XX

Months: _______________
Credit Hours

Year One

Course Title

Months: _______________
Credit Hours

Year Two
Course Title

Months: _______________
Credit Hours

Course Title

Months: _______________
Credit Hours

Course Title

Summer _________ (Year)
Course Number

Fall _________ (Year)
Course Number

Spring _________ (Year)
Course Number

Summer _________ (Year)
Course Number

NHHSP Applicant Name

OMB Number: 0915-0146
Expiration Date: XX/XX/20XX

Months: _______________
Credit Hours

Year Three

Course Title

Months: _______________
Credit Hours

Course Title

Months: _______________
Credit Hours

Course Title

Months: _______________
Credit Hours

Year Four
Course Title

Fall _________ (Year)
Course Number

Spring _________ (Year)
Course Number

_______ (Term) _________ (Year)
Course Number

_______ (Term) _________ (Year)
Course Number

NHHSP Applicant Name

OMB Number: 0915-0146
Expiration Date: XX/XX/20XX

Months: _______________
Credit Hours

Year Four

Course Title

Months: _______________
Credit Hours

Course Title

Months: _______________
Credit Hours

Course Title

Months: _______________
Credit Hours

Course Title

OMB Number: 0915-0146
Expiration Date: XX/XX/20XX

Public Burden Statement: The purpose of the NHSC SP, NHSC S2S LRP, and the NHHSP is to provide scholarships or loan repayment
to qualified students who are pursuing primary care health professions education and training. In return, students agree to provide primary
health care services at approved facilities located in designated Health Professional Shortage Areas (HPSAs) once they are fully trained
and licensed health professionals. 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 0915-0146
and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit (NHSC SP: Section 338A of the PHS Act
and Section 338C-H of PHS Act; NHSC S2S LRP: Section 338B of the PHS Act and Section 331(i) of the PHS Act; NHHSP: The Native
Hawaiian Health Care Improvement Act of 1992, as amended [42 U.S.C. 11709]. 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.

NHHSP Applicant Name