2 01292024 Institution Loan Repayment Form

Faculty Loan Repayment Program

OMB No. 0915-0150, Expiration: TBD

Institution Employment/Loan Repayment Verification Form

(To be completed by institution)

Section 1 – Institution Information
Name of institution		School of (e.g., medicine, nursing, allied health)
The institution is accredited by		Profit status (select one) ¨ Private non-profit ¨ Public/government owned ¨ Private for-profit
Optional: The institution is (select all that apply): ¨ Historically Black ¨ Hispanic Serving ¨ Tribal		Optional: The institution is located in a (select all that apply): ¨ Medically Underserved Area ¨ Health Professional Shortage Area
Section 2 – Applicant Employment Information
Applicant name		(Select one) ¨ Full Time ¨ Part Time		(Select one) ¨ Tenured ¨Non-tenured
Teaching discipline		Number of hours/week
Initial Employment start date (must be on or before June 27, 2024)		Fall term start date
Number of months in an academic year		Number of months in an academic year that applicant serves as faculty
This institution intends to employ the applicant indicated above for a minimum of 2 years after June 27, 2024 as able (select one): To be eligible for the Faculty Loan Repayment Program, applicants must have an employment commitment from an eligible health professions school for a faculty position for a minimum of two years. ¨ Yes ¨ No
Section 3 – Institutional Match Agreement
Regardless of selection below, the school must provide a letter detailing their award match agreement or waiver request and supporting documentation of undue financial hardship. Details of the award match requirement are found in the Application and Program Guidance. The institution (select one)*:
¨ Full match The institution has agreed to make payments of principal and interest on the educational loans of the applicant in an amount equal to the amount of such payments(s) made by the Health & Human Services Secretary (maximum $40,000 total for 2-year contract period). These payments will be in addition to the applicant’s faculty salary and the applicant’s salary will be determined without regard to the amount paid by Health & Human Services/Faculty Loan Repayment Program
¨ Partial match Match amount from institution: ________________ The institution is able to make payments of principal and interest on the educational loans of the applicant in the amount less than the amount of such payment(s) made by the Health & Human Services Secretary (maximum $40,000 total for 2-year period) and requests a partial waiver, on the basis of undue financial hardship, of the requirement that it fully match the Health & Human Services Secretary’s payment(s).
¨ Full waiver The institution is unable to make any payments of principal and interest on the educational loans of the applicant and requests a full waiver, on the basis of undue financial hardship, of the requirement that the institution make loan repayments equal to the amount of such payment(s) made by the Health & Human Services Secretary.
*Institutions who fail to comply with their specific match agreement indicated above will be held liable for default, and all future applicants employed at their institution will be deemed ineligible for the Faculty Loan Repayment Program.
Please submit this form, the match letter/waiver, and the supporting documentation to the applicant for submission with their application.
Institution official’s name	Title	Signature	Date
Mailing address		Phone/Fax/Email

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/202x. This information collection is required to obtain or retain a benefit (Section 738(a) of the Public Health Service Act (42 USC 293b (a)). Any datasets made available to the public with regards to the Faculty Loan Repayment Program (42 U.S.C. 293b(a) (Sec. 738(a) of the PHS Act), would be de-identified, limited to information the disclosure of which would not constitute a clearly unwarranted invasion of personal privacy under the Freedom of Information Act and the Privacy Act. A Privacy Act Notification Statement is included on the FLRP website which describes the purpose of the information collection and the potential disclosures. A Privacy Act System of Records, #09–15–0037, have been established for the FLRP, HHS/HRSA/BHW. Public reporting burden or 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or paperwork@hrsa.gov.