Form 3G NHSC S2S LRP - Verification of Disadvantaged Background

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
VERIFICATION OF DISADVANTAGED BACKGROUND STATUS FORM
(For School Use Only - Must be Completed by a Financial Aid Official)

Name of Student:

Last 4 digits of SSN: XXX-XX-

The Financial Aid Official identified below certifies that the above-named student:
Is NOT

Is

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:

Phone:

Email:

Name of School:
Student may upload signed form to the NHSC S2S LRP Online Application: My BHW Account

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 scholarship applicant’s eligibility and qualifications. Clinicians interested in participating in the NHSC S2S LRP must submit an
application to the NHSC S2S LRP. 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.