Form 4E NHHSP Change in Program Curriculum Form

Native Hawaiian Health Scholarship Program

U.S. Department of Health and Human Services

Health Resources and Services Administration

OMB No: 0915-0146

Expiration Date: xx/xx/xxxx

Form B - CHANGE in PROGRAM CURRICULUM -

The following information provides guidance for changes in your program curriculum.

Native Hawaiian Health Scholarship Program (NHHSP) keeps record of a Scholar’s entire Program Curriculum via the ‘Course Curriculum Worksheet’ that was submitted during the application process. This ‘Course Curriculum Worksheet’ remains in the Scholar’s file and is verified at the beginning of every academic period via the Scholar Enrollment Verification Form (SEVF).

In the event there are ANY changes to your program curriculum that is currently on file with NHHSP, such changes need to be reported to your Program Coordinator as soon as possible.

If your new course schedule does not align with the original ‘Course Curriculum Worksheet,’ the following process is required:

1. Scholar is to complete and submit a Change in Program Curriculum (CPC) document

2. Scholar is to request that the school verifies the new registration via an updated (SEVF) and attach the supplemental documentation, i.e., revised course schedule

3. Scholar must have Academic Advisor’s ‘concur’ signature on page 1 of the CPC document below.

To successfully complete the CPC document, indicate the semester and year in which the changes occurred. List all registered courses prior to the change in course schedule. A thorough explanation of the changes is required. Also, list below your revised course schedule in its entirety. Some examples of when this Form is needed, include:

• When a scholar has already registered and verified his/her enrollment, but there was a proceeding class change made before the Add/Drop Date.

• When a scholar is taking coursework that is out of sequence from what was projected on the original program ‘Course Curriculum Worksheet’ document.

Please communicate with your Program Coordinator if you have any questions or concerns about updates to your program Course Curriculum, and/or regarding the process of completing a CPC Form.

NOTE: Your completed Change in Program Curriculum (CPC) form must be submitted to NHHSP with an updated copy of the Scholar Enrollment Verification Form (SEVF).

U. S. Department of Health and Human Services HEALTH RESOURCES & SERVICES ADMINISTRATION Bureau of Health Workforce PAPA OLA LŌKAHI Title 42 Chapter 122 Section 11709– Native Hawaiian Health Scholarship Program Change in Program Curriculum
NAME	NHHSP Cohort Year:
COLLEGE / UNIVERSITY	PROJECTED Graduation MO/YR
In the event there are changes to your program curriculum, report the new course schedule below. This form MUST BE ACCOMPANIED with an updated Scholar Enrollment Verification Form (SEVF). Indicate your course schedule (prior to change): Fall Winter Spring Summer YEAR: COURSE NUMBER COURSE TITLE CREDIT HOURS Please explain the change: Indicate your REVISED course schedule: Fall Winter Spring Summer YEAR: COURSE NUMBER COURSE TITLE CREDIT HOURS Comments (if any):
Academic Advisor SIGNATURE		DATE

Indicate your remaining course schedule:

Fall

Winter

Spring

Summer YEAR:

COURSE NUMBER COURSE TITLE CREDIT HOURS

Fall

Winter

Spring

Summer YEAR:

COURSE NUMBER COURSE TITLE CREDIT HOURS

Fall

Winter

Spring

Summer YEAR:

COURSE NUMBER COURSE TITLE CREDIT HOURS

Fall

Winter

Spring

Summer YEAR:

COURSE NUMBER COURSE TITLE CREDIT HOURS

Scholar:

For questions on how/where to submit this form please contact the NHHSP at: 1-808-597-6550.

Public Burden Statement: Public Burden Statement: The purpose of this information collection is to obtain information through the Native Hawaiian Health Scholarship Program that is used to assess a scholarship applicant’s eligibility and qualifications for the NHHSP. Clinicians interested in participating in the NHHSP must submit an application to the Native Hawaiian Health Scholarship Program. 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 (The Native Hawaiian Health Care Improvement Act of 1992, as amended [42 U.S.C. 11709]). 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.