Form 2A NHSC SP Awardees - Data Collection Worksheet Form

BHW Management Information System Solution
OMB No: 0915-0146
Expiration Date: xx/xx/xxxx

2025-2026 School Data Collection Worksheet
Program

School

Discipline

Degree

NHSC Scholarship Program

Data Collection Worksheets
Thank you for creating a DCW! The form can be completed in 4 easy steps. For any questions on filling out this information
please contact NHSC SP at nhscsp@hrsa.gov.

1. Tuition
Enter the Resident (In-State) and Non-resident (Out-of-State) tuition for the entire ACADEMIC year for 1st, 2nd, 3rd, and 4th Year
Students. If your school's degree program is less than 4 years, only enter amounts for each year of your program. For example,
two year programs would only enter values in the first two columns for 1st and 2nd Year Students. You MUST enter values for
every year of your program, even if your costs are estimated to be the same for students regardless of which year they are in the
program.
All fields are required unless noted as optional.
1ST YEAR STUDENT

2ND YEAR STUDENT

3RD YEAR STUDENT

4TH YEAR STUDENT

2. School Incurred Fees (Optional)
Review and enter amounts for the list of items grouped under School Incurred Fees. These fees are incurred by the school as
part of the tuition and required fees. The NHSC SP would expect items defined as Fees to be included in the tuition invoice
submitted by the school and reimbursed by NHSC SP directly to the school.
The following fields are optional.
1ST YEAR STUDENT

2ND YEAR STUDENT

3RD YEAR STUDENT

4TH YEAR STUDENT

1ST YEAR STUDENT

2ND YEAR STUDENT

3RD YEAR STUDENT

4TH YEAR STUDENT

1ST YEAR STUDENT

2ND YEAR STUDENT

3RD YEAR STUDENT

4TH YEAR STUDENT

3. Student Expenses (Optional)
Review and enter amounts for the list of items grouped under Student Expenses. The Student Expenses or Other Reasonable
Costs (ORC) amount is paid by the NHSC SP directly to the student to cover additional reasonable expenses incurred by the
student that are not covered under the tuition and fees billed by the school. The NHSC SP will disburse a one-time Other
Reasonable Cost (ORC) payment to the student when they receive their first monthly stipend.
The following fields are optional.
1ST YEAR STUDENT

2ND YEAR STUDENT

3RD YEAR STUDENT

4TH YEAR STUDENT

4. Insurance (Optional)
Review and enter amounts for the list of items grouped under Insurance. Insurance items may be incurred by the school as part
of the tuition and required fees or incurred as an ORC by the Student. Please complete the form based on if the cost of insurance
is incurred by the school or incurred by the student.
The following fields are optional.

1ST YEAR STUDENT

2ND YEAR STUDENT

3RD YEAR STUDENT

4TH YEAR STUDENT

Comments (Optional)
Add New Comment

Enter text here...

Upload Documents (Optional)



Approve DCW

Questions?

Submit DCW

Select or Drop File Here

Cancel

202508.0.0

Contact your BMISS expert for help.

Resources

Quick Links

Virtual Job Fairs

BHW FAQ Library

Learn more about the
NHSC

HRSA.gov

Health Workforce
Connector

BMISS Status Glossary

User Guides

Learn more about the
Nurse Corps

HRSA Data Warehouse

HHS Privacy Act

About HRSA

Contact Us

Viewers & Players

Privacy Policy

Disclaimers

Accessibility

U.S. Department of Health and Human Services

Freedom of Information Act

USA.gov

EEO/No Fear Act

WhiteHouse.gov

Public Burden Statement: The purpose of this information collection is to obtain information through the NHSC SP
and the NHSC S2S LRP, that is used to assess an applicant’s eligibility, qualifications as well as monitor program
participants’ enrollment in school, postgraduate training, and compliance with program requirements. 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/xxxx. This information collection is mandatory (Sections 338A-H of the Public Health Service Act [42
USC 254l-q], as amended). 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.