Form 4 Confirmation of Interest Form

Bureau of Health Workforce
NC LRP Confirmation of Interest (COI) User Guide

Nurse Corps (NC)
Loan Repayment Program (LRP)
Confirmation of Interest (COI) User Guide
May 2024

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Bureau of Health Workforce
NC LRP Confirmation of Interest (COI) User Guide
CONTENTS
Part 1 | Introduction...................................................................................................................................................... 4
NC LRP Confirmation of Interest User Guide ........................................................................................................... 4
Part 2 | Applicant Confirms Interest and Accepts Award .............................................................................................. 4
Welcome Screen ....................................................................................................................................................... 4
Steps ...................................................................................................................................................................... 4
Business Rules ....................................................................................................................................................... 5
Review Screen – Contact Information ...................................................................................................................... 6
Steps ...................................................................................................................................................................... 6
Business Rules ....................................................................................................................................................... 6
Review Screen – Loan Verification ........................................................................................................................... 6
Steps ...................................................................................................................................................................... 6
Business Rules ....................................................................................................................................................... 7
REview Screen – Site Information ............................................................................................................................ 7
Steps ...................................................................................................................................................................... 7
Business Rules ....................................................................................................................................................... 8
REview Screen – Confirm Interest ............................................................................................................................ 9
Steps ...................................................................................................................................................................... 9
Business Rules ....................................................................................................................................................... 9
REview Screen – Banking Information ................................................................................................................... 10
Steps .................................................................................................................................................................... 10
Business Rules ..................................................................................................................................................... 10
Tax Withholdings Screen ........................................................................................................................................ 11
Steps .................................................................................................................................................................... 11
Business Rules ..................................................................................................................................................... 12
Sign Contract Screen ............................................................................................................................................... 13
Steps .................................................................................................................................................................... 13
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Bureau of Health Workforce
NC LRP Confirmation of Interest (COI) User Guide
Business Rules ..................................................................................................................................................... 13
Part 3 | Applicant Declines Interest............................................................................................................................. 15
Decline COI – Review Screen .................................................................................................................................. 15
Steps .................................................................................................................................................................... 15
Business Rules ..................................................................................................................................................... 15
Decline COI – Sign Contract Screen ........................................................................................................................ 16
Steps .................................................................................................................................................................... 16
Business Rules ..................................................................................................................................................... 17

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Bureau of Health Workforce
NC LRP Confirmation of Interest (COI) User Guide

PART 1 | INTRODUCTION
NC LRP CONFIRMATION OF INTEREST USER GUIDE
Purpose: The Nurse Corps (NC) Loan Repayment Program (LRP) Confirmation of Interest (COI) user guide serves as
the main to answer analyst questions regarding issues applicants may face when completing their COI Process. In
addition to this user guide, applicants must be familiar with the NC LRP Application Program & Guidance, as some
of the questions will be program based and will not be discussed in this user guide. The primary intent of this user
guide is to focus on the functionality developed for the NC LRP COI.
Roles: There are no roles associated with the NC online application. The Confirmation of Interest (COI) is on the
applicant portal and is only accessible to applicants that have been offered an award. Program will not have roles
or accounts for these screens.
Precondition: The applicant must be offered an Award and sent a Confirmation of Interest (COI).

PART 2 | APPLICANT CONFIRMS INTEREST AND ACCEPTS AWARD
The analyst will complete Verification Review and in some situations Exception Review as part of the NC LRP
modernized Application Review workflow. NC LRP Application Review will begin on the New Task Dashboard.

WELCOME SCREEN
During the Review Process, the Obligator Review sends the Confirmation of Interest email to applicants who have
been selected for award. The email provides the selected applicants a link to the portal notifying them that there
has been an update to their application. The applicant will need to log into his/her application to view the
Confirmation of Interest. Upon logging in, the applicant will be directed to the Welcome Screen.

STEPS
1.
2.
3.
4.
5.

Applicant receives their Confirmation of Interest email.
Applicant logs into NC LRP Application Portal.
Applicant is taken to the COI Welcome Screen.
Applicant reviews Welcome Screen content.
Applicant clicks “Start COI”.

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Bureau of Health Workforce
NC LRP Confirmation of Interest (COI) User Guide

BUSINESS RULES
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Applicants will have the ability to view the left-hand navigation.
o The Welcome screen will be enabled in the left-hand navigation.
o All additional screens will be disabled in the left-hand navigation until the current screen is
completed.
Applicants have the ability to view their application status.
Applicants have the ability to download their submitted application (PDF).
Applicants have the ability to view the NC LRP Program Guidance.
Applicants have the ability to view the Paperwork Reduction Act Public Burden Statement.

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Bureau of Health Workforce
NC LRP Confirmation of Interest (COI) User Guide

REVIEW SCREEN – CONTACT INFORMATION
The applicant will need to ensure that their contact information is as up to date as possible. NC LRP uses primary
email addresses to communicate application status changes and requests for additional information regarding
applications.

STEPS
1.
2.

Upon clicking “Start COI” on the Welcome Screen, the applicant is navigated to the Review Screen.
Applicant completed Step 1 by reviews and updates his/her contact information by clicking on the
“Account Settings” link.

BUSINESS RULES
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System navigates user to account settings via the Step 1 link provided.
Applicant should make any updates to their account information within the account settings.

REVIEW SCREEN – LOAN VERIFICATION
The Loan Verification card allows the applicant to review Program’s verification results of loans submitted with the
application. Applicants with eligible debt that exceeds the maximum award will receive the maximum award.

STEPS
1.
2.
3.
4.

Applicant clicks “Continue” on the Contact Information card to be taken to Step 2, Loan Verification.
Applicant reviews their program information at the top of the card.
Applicant reviews and verifies their loan information.
If an applicant has questions or elects to dispute the information, he/she is suggested to contact NC LRP
via email.

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Bureau of Health Workforce
NC LRP Confirmation of Interest (COI) User Guide

BUSINESS RULES
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Applicant can view their program details.
Applicant can view their loan details.
Note: Only eligible loans will display on the loan information card.
The user will see the following values provided on the loan information card:
o Total Approved for Repayment = Total of all eligible loans.
o Projected Award Disbursement = Total of estimated award amount.

REVIEW SCREEN – SITE INFORMATION
The Site Information card allows the applicant to review Program’s verification results of applicant site(s).
Applicants will verify the accuracy of their site information and hours (full-time) for NC LRP.

STEPS
1.
2.

Applicant clicks “Continue” on the Loan Verification card to be taken to Step 3, Site Information.
Applicant reviews their site(s) information at the top of the card.
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Bureau of Health Workforce
NC LRP Confirmation of Interest (COI) User Guide
3.

Applicant reviews and verifies their site information is still accurate by answering “Yes” or “No”.

4.

If an applicant has questions or elects to dispute the information, he/she is suggested to contact NHSC
LRP via phone or email.

BUSINESS RULES
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Applicant can view their site(s) details.
Applicant will be required to answer the following (Y/N) question: “Are you currently working at the NC
verified and approved service site(s) and meeting NC's definition of full-time clinical practice and will to
the best of your knowledge continue to meet that definition at the NC-approved service site(s) listed
above?”
o Yes = The applicant will continue onto Step 4, the Confirm Interest card (see next section).
o No = The applicant will bypass Step 4 and continue onto Step 5, the Site Change / Change in
Work Hour card.
If the applicant responds “No” and populates the Site Change / Change in Work Hour card, the applicant
will be required to provide a reason/comment prior to clicking “Submit”.
o Once the applicant clicks “Submit” they will be directed to the Ineligible screen and their COI
process will be complete at this time.

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Bureau of Health Workforce
NC LRP Confirmation of Interest (COI) User Guide

REVIEW SCREEN – CONFIRM INTEREST
The Confirm Interest card is where the applicant will either accept or decline their NC LRP Award. Once the
applicant confirms or declines their interest in receiving the award, the NC Loan Repayment Program Award will
proceed without further notice based on the option they have selected.

STEPS
1.
2.
3.

Applicant clicks “Yes” on the Site Information card to be taken to Step 4, Confirm Interest.
If applicant confirms their interest by clicking “I ACCEPT”, the Banking Information card is displayed (see
next section).
If applicant declines their interest by clicking “I DECLINE”, the Decline COI card is displayed (see Part 3:
Applicant Declines Interest).

BUSINESS RULES
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If applicant confirms their interest by clicking: “I ACCEPT the FY 2024 NC Loan Repayment Program
Award”, the Banking Information card is displayed (see next section).
If applicant declines their interest by clicking “I DECLINE the FY 2024 NC Loan Repayment Program Award.
I understand that I will no longer be considered for the FY 2024 NC Loan Repayment Program Award”, the
Decline COI card is displayed (see Part 3: Applicant Declines Interest).
The alert will notify the user of their COI Expiration date.
o Important: The applicant will be required to provide a response to their Confirm Interest and
completed their COI by this expiration in order to still be considered for an award.

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Bureau of Health Workforce
NC LRP Confirmation of Interest (COI) User Guide

REVIEW SCREEN – BANKING INFORMATION
The Banking Information card allows the applicant to provide their banking information for the account in which
the FY 2024 NC LRP funds should be deposited. Note: Release of award funds is contingent on a fully executed FY
2024 NC LRP contract (i.e. signed by both parties) and your satisfactory performance of at least 90 days of service.

STEPS
1.
2.
3.
4.
5.

Applicant clicks “I ACCEPT” on the Confirm Interest card, they’re taken to Step 5, Banking Information.
Applicant enters the Bank Name.
Applicant enters the Account Type (checking or savings).
Applicant confirms and enters his/her Bank’s Routing and Account numbers.
Applicant selects Submit.

BUSINESS RULES
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Routing #’s must be:
o 9 digits
o Start with 0, 1, 2, or 3 digit.
Applicant will be required to complete all fields.
The Routing Number and Re-enter Routing number fields must match.
The Account Number and Re-enter Account number fields must match.

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Bureau of Health Workforce
NC LRP Confirmation of Interest (COI) User Guide

TAX WITHHOLDINGS SCREEN
The Tax Withholdings screen allows the applicant to provide their W4 tax information via the Electronic
Withholding Allowance Certificate. Applicants will verify the accuracy of their tax information and electronically
sign their certificate.

STEPS
1.
2.
3.
4.
5.

Applicant completes their banking information on the Review screen and clicks “Continue” to be taken to
the Tax Withholdings screen.
Applicant reviews and verifies the ‘Tax Withholdings’ statement section.
Applicant provides their tax information on the Electronic Withholding Allowance Certificate.
Applicant certifies their tax information.
Applicant completes their electronic signature.

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Bureau of Health Workforce
NC LRP Confirmation of Interest (COI) User Guide

BUSINESS RULES
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The Total Award Amount will be displayed above Step 1
Applicants are required to provide their federal tax withholding selections for:
o Filing Status
o Exactly Two Jobs
o Amount Claimed for Dependents
o Other Income (optional)
o Deductions (optional)
o Extra Withholding Amount (optional)
o Exemption status
Applicants are required to certify they have provided correct tax withholding information.
After self-certification, applicants will be required to enter the following information, which will qualify as
signing the contract:
o SSN
o Confirm SSN
o Security answer
o Password
The SSN and Confirm SSN numbers must match for the applicant to submit
The SSN and Confirm SSN numbers must match the SSN entered by the applicant on the online application
for the applicant to submit
If the SSN entered on COI does not match the SSN entered on the application, the applicant can either reenter the SSN on COI, or contact the Call Center to reach out to Program if they believe the SSN they have
entered on COI is correct, and the SSN they had entered on their application is incorrect
The system will generate and store an electronically signed electronic federal tax withholdings document
(W4) to the applicant profile upon full submission of the COI.
Once the applicant is converted to a participant, the PDF is accessible from the Participant profile, Tax
information tab.
If the applicant does not complete the COI, or is deemed ineligible, the tax selections will not be saved.

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Bureau of Health Workforce
NC LRP Confirmation of Interest (COI) User Guide

SIGN CONTRACT SCREEN
The Sign Contract screen is the final step of the applicant’s COI process. The applicant will download the contract,
self-certify that they have read the contract, and electronically sign the contract. Note: Release of award funds is
contingent on a fully executed FY 2024 NC LRP contract (i.e. signed by both parties) and your satisfactory
performance of at least 90 days of service.

STEPS
1.
2.
3.

4.

5.
6.

Applicant completes their tax information on the Tax Withholdings screen and clicks “Continue” to be
taken to the Sign Contract screen.
Applicant downloads their NCLRP contract for review.
Applicant completes the self-certification question.
a. If applicant declines certification by answering “No”, the Decline COI card is displayed (see Part 3:
Applicant Declines Interest).
After self-certification, applicants will be required to enter the following information, which will qualify as
signing the contract:
a. SSN
b. Confirm SSN
c. Security answer
d. Password
Applicant selects Submit.
System displays Accepted Award landing page.

BUSINESS RULES

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Bureau of Health Workforce
NC LRP Confirmation of Interest (COI) User Guide
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Applicants are required to certify that they have read the contract.
If the applicant indicates “No” to having read the contract, they will be directed to the Ineligible landing
page upon selecting Sign and Submit
If the applicant indicates “Yes” to having read the contract, they will be required to enter the following
information, which will qualify as signing the contract:
o SSN
o Confirm SSN
o Security answer
o Password
The SSN and Confirm SSN numbers must match for the applicant to submit.
The SSN and Confirm SSN numbers must match the SSN entered by the applicant on the online application
for the applicant to submit.
If the SSN entered on COI does not match the SSN entered on the application, the applicant can either reenter the SSN on COI, or contact the Call Center to reach out to Program if they believe the SSN they have
entered on COI is correct, and the SSN they had entered on their application is incorrect.
Accepted Award landing page will display a link to applicant’s submitted application on the
Applicants have the ability to view their application status from the Accepted Award landing page.
Applicants have the ability to download their submitted application (PDF) from the Accepted Award
landing page.
Applicants have the ability to download their signed contract from the Accepted Award landing page.
o Note: Once the contract is signed and approved in Obligation, the newly signed document will be
updated).

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Bureau of Health Workforce
NC LRP Confirmation of Interest (COI) User Guide

PART 3 | APPLICANT DECLINES INTEREST
The applicant will either accept or decline their NC LRP award through the Confirmation of Interest (COI) process.
The above section walks through the acceptance process. This section details the two opportunities an applicant has
to decline their award.

DECLINE COI – REVIEW SCREEN
The first opportunity to decline COI is on the Review screen, Step 4, Confirm Interest card. The user will end their
COI process here if they choose to decline and will be navigated to the Declined Award landing page.

STEPS
1.
2.
3.
4.
5.
6.

Applicant completes the Welcome Screen and is taken to the Review Screen.
Applicant completes Steps 1-3 on the Review Screen.
Applicant selects “I DECLINE…” and sees the Decline COI card.
Applicant enters reason why he/she is declining award.
Applicant selects Decline.
Applicant is navigated to the Declined Award landing page.

BUSINESS RULES
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Once COI is declined, the COI process will end and the system updates applicant’s external and internal
status to Declined Award.
Applicants have the ability to download their submitted application (PDF) from the Declined Award
landing page.

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Bureau of Health Workforce
NC LRP Confirmation of Interest (COI) User Guide

DECLINE COI – SIGN CONTRACT SCREEN
The second opportunity to decline COI is on the Sign Contract screen, certification question. The user will end their
COI process here if they choose to decline and will be navigated to the Declined Award landing page.

STEPS
1.
2.
3.
4.
5.
6.
7.

Applicant completes the Welcome Screen and is taken to the Review Screen.
Applicant completes Steps 1-5 on the Review Screen.
Applicant completes and signs the Tax Withholdings screen.
Applicant selects “No” to the self-certification question on the Sign Contract screen.
Applicant enters reason why he/she is declining award.
Applicant selects Decline.
Applicant is navigated to the Declined Award landing page.

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Bureau of Health Workforce
NC LRP Confirmation of Interest (COI) User Guide

BUSINESS RULES
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Once COI is declined, the COI process will end and the system updates applicant’s external and internal
status to Declined Award.
Applicants have the ability to download their submitted application (PDF) from the Declined Award
landing page.

OMB No. 0915-0140 Expiration Date: xx/xx/xxxx
Public Burden Statement: The purpose of this information collection is to obtain information through the Nurse Corps
Loan Repayment Program that is used to assess a Loan Repayment Program applicant’s eligibility and qualifications for the
Loan Repayment Program and to monitor a participant’s compliance with the program’s service requirements. Applicants
interested in participating in the Nurse Corps Loan Repayment Program must submit an application to the Nurse Corps. 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/xxxx. 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]). The information is protected by the Privacy Act, but it may be disclosed
outside the U.S. Department of Health and Human Services, as permitted by the Privacy Act and Freedom of Information
Act, to Congress, the National Archives, and the Government Accountability Office, and pursuant to court order and
various routine uses as described in the System of Record Notice 09-15-0037.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 14NWH04, Rockville, Maryland, 20857.
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