Form 4C NHHSP Acceptance Verification of Good Standing Form

OMB No: 0915-0146

Expiration Date: xx/xx/xxxx

U.S. Department of Health and Human Services

Health Resources & Services Administration Papa Ola Lōkahi

Title 42 USC Chapter 122 Section 11709 – Native Hawaiian Health Scholarship Program

Acceptance/Verification of Good Standing Form

APPLICANT’S/SCHOLAR’S NAME		DEGREE(i.e., masters of science in nursing)
COLLEGE/UNIVERSITY NAME		PROJECTED GRADUATION MO/YR

THIS Program Course Curriculum document MUST BE COMPLETED and RETURNED to NHHSP

APPLICANT applied for Admission or is Enrolled at above-mentioned College/University since/for the Academic Year 20 - 20 . APPLICANT will be enrolled OR is anticipated to be enrolled Full-Time in an undergraduate/graduate degree-seeking program (identified above) for the Academic Year 202x-202x. LIST Degree Program CURRICULUM from (start of) FIRST YEAR to COMPLETION e.g. FALL 2020 Months: August - December
Summer (Year)		Months:		Year One
Course Number		Credit Hours		Course Title
Fall (Year)		Months:
Course Number		Credit Hours		Course Title

Spring (Year)		Months:		Year One
Course Number		Credit Hours		Course Title
Summer (Year)		Months:		Year Two
Course Number		Credit Hours		Course Title
Fall (Year)		Months:
Course Number		Credit Hours		Course Title
Spring (Year)		Months:
Course Number		Credit Hours		Course Title

Summer (Year)		Months:		Year Three
Course Number		Credit Hours		Course Title
Fall (Year)		Months:
Course Number		Credit Hours		Course Title
Spring (Year)		Months:
Course Number		Credit Hours		Course Title
Summer (Year)		Months:		Year Four
Course Number		Credit Hours		Course Title

Fall (Year)		Months:		Year Four
Course Number		Credit Hours		Course Title
Spring (Year)		Months:
Course Number		Credit Hours		Course Title
(Term) (Year)		Months:
Course Number		Credit Hours		Course Title
(Term) (Year)		Months:
Course Number		Credit Hours		Course Title

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.

NHHSP Applicant Signature

Date