3D-Preceptor NHSC S2S LRP - Preceptor Instructions

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

Students to Service Loan Repayment Program

Preceptor Letter of Recommendation – Instructions

This letter may be from a primary care preceptor or another individual who has worked with the applicant in a primary care setting and can discuss the applicant’s interest and commitment to a career in primary care and service to underserved populations and communities.

All recommendations must be submitted by the recommender through the application portal. To complete and submit the letter of recommendation, please click on the link you received via email and submit the recommendation. The letter must have a handwritten signature and/or be on letterhead from the preceptor’s organization/institution and include the following:

1. Applicant’s first initial, last name, and Application ID;

2. Applicant’s discipline;

3. Your Name (printed) and Title or Organization;

4. Your Address (unless already on letterhead);

5. Your Contact Information (phone number & email address)

6. Signature;

7. A description of your relationship to the applicant and length of time you have known the applicant; and

8. A discussion of the following items:

a. The applicant’s community/civic or other non-academic achievements,;

b. The applicant’s ability to work and communicate constructively with other people, and;

c. An assessment of the applicant’s particular characteristics, interest and motivation to serve populations in areas of greatest need in health professional shortage areas. This assessment should include your knowledge of the applicant’s, work experiences, pertinent course work, special projects, research, or other activities that demonstrate an interest and commitment to serving underserved populations.

For questions on how/where to submit this form please contact the Customer Care Center at: 1-800-221-9393.

Public Burden Statement: The purpose of this information collection is to obtain information through the National Health Service Corps Students to Service Loan Repayment Program (NHSC S2S LRP) that is used to assess a loan repayment applicant’s eligibility and qualifications. Clinicians interested in participating in the NHSC S2S LRP must submit an application to the NHSC S2S LRP 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 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 required to obtain or retain a benefit [Section 338B of the Public Health Service Act (42 USC 254l-1), as amended; Section 331(i) of the Public Health Service Act (42 USC 254d(i)), 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 HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14NWH04, Rockville, Maryland, 20857.