Form 1G NHSC SP - Verification of Disadvantaged Background Statu

OMB No. 0915-0146
Expiration Date: xx/xx/xxxx
Bureau of Health Workforce
U.S. Department of Health and Human Services
Health Resources and Services Administration

National Health Service Corps Scholarship Program
VERIFICATION OF DISADVANTAGED BACKGROUND STATUS FORM
(From School Use Only - Must be Completed by a Financial Aid Official)

Last 4 digits of SSN: XXX-XX-

Name of Student:

The Financial Aid Official identified below certifies that the above-named student:
Is

Is NOT

from a disadvantaged background (criteria described below). Students from a disadvantaged background have either
participated in or would have been eligible to participate in Federal Programs such as the “Scholarships for
Disadvantaged Students”. As defined by the Scholarship for Disadvantaged Students Program (Sec. 737 of the Public
Health Service Act, 42 U.S.C. § 293(a)), this term refers to individuals who have been identified by their schools or can
document having come from a “disadvantaged background” based on educational, environmental, and/or economic
factors.)
CRITERIA FOR DISADVANTAGED BACKGROUND STATUS
1. An individual comes from an environment that has inhibited the individual 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 for guidance only and are not intended to be all-inclusive.
•
•
•
•
•
•

The individual graduated from (or last attended) a high school with low SAT score based on most recent data
available.
The individual graduated from (or last attended) a high school from which, based on most recent data available, low
percentage of seniors receive a high school diploma; or low percentage of graduates go to college during the first year
after graduation.
The individual graduated from (or last attended) a high school with low per capita funding.
The individual graduated from (or last attended) a high school at which, based on most recent data available, many of
the enrolled students are eligible for free or reduced price lunches.
The individual comes from a family that receives public assistance (e.g., Aid to Families with Dependent Children,
food stamps, Medicaid, public housing).
First generation in family to attend college
OR

2. An individual comes from a family with an annual income below a level based on low-income thresholds according to
family size established by the U.S. Census Bureau, adjusted annually for changes in the Consumer Price Index, and
adjusted by the Secretary of Health and Human Services (HHS) for adaptation to this program (Economically
Disadvantaged). The Secretary defines a ‘‘low income family/household’’ 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. A household may be only one person.
SUBMITTED BY
Signature:
Name & Title:
Email:

Phone Number:
Name of School:

Student may upload signed form to the NHSC SP Online Application: My BHW Account

OMB No. 0915-0146
Expiration Date: xx/xx/xxxx
Bureau of Health Workforce
U.S. Department of Health and Human Services
Health Resources and Services Administration

Public Burden Statement: The purpose of this information collection is to obtain information through the National Health Service
Corps Scholarship Program (NHSC SP), which is used to assess an applicant’s eligibility and qualifications for the NHSC SP.
Clinicians interested in participating in the NHSC SP must submit an application to the NHSC SP through the My BHW online
portal. 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 Office of Management and Budget control number. The Office of Management and Budget control
number for this information collection is 0915-0146 and it is valid until xx/xx/xxxx. This information collection is required to
obtain or retain a benefit (National Health Service Corps Scholarship Program: Section 338A of the Public Health Service Act and
Section 338C-H of Public Health Service Act.). 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 Health Resources and Services Administration Reports Clearance Officer, 5600
Fishers Lane, Room 14NWH04, Rockville, Maryland 20857.