Form 4F NHHSP Graduation Documentation 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

Native Hawaiian Health Scholarship Program Graduation Documentation

To Be COMPLETED by a SCHOOL OFFICIAL

Date:
Name of Participant:
Institution:
Participant Unique ID:
Entrance Date into the NHHSP:
Graduation Date:
Withdrawal/Dismissal Date:
NHHSP Balance Owed:	□ Yes □ No

School Stamp/Seal

If yes, what is the balance:

• I have attached copy of invoice: □ Yes □ No

School Representative Signature: Date:

For questions on how/where to submit this form please contact the NHHSP at: nhhsp@papaolalokahi.org.

Public Burden Statement: The purpose of this information collection is to obtain information through the Native Hawaiian Health Scholarship Program, which is used to assess an applicant’s eligibility and qualifications for the NHHSP. Clinicians interested in participating in the NHHSP must submit an application to the NHHSP, which is administered by Papa Ola Lokahi. 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 hour 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.