3 Aor - Hrsa 501 - Non-pcl

FINANCIAL DATA

1. Federal Agency and Organization Element to Which Report is Submitted	2. Federal Grant or Other Identifying Number Assigned by Federal Agency	3a. DUNS #		4. Reporting Period End Date
Health Resources and Services Administration (HRSA)	Grant #: Submission Tracking #: OPSID:	3b. EIN		06/30/2012
PAGE 1A - STUDENT BORROWER DATA SECTION

Student/Graduate Data	Cumulative (Includes current year)	Current Year (7/1/2011-6/30/2012)
1A-1. Number of Loans for the Dentistry discipline
1A-2. Total Dollar Amount of Loans Awarded for the Dentistry discipline
1A-3. Total Full-Time Enrollment for the Dentistry discipline for the academic year (both non-LDS and LDS recipients)
1A-4. Total Number of Defaulted Loans for the Dentistry discipline
1A-5. Total Original Defaulted Principal Loaned for the Dentistry discipline
1A-6a. Total Number of Students who dropped out of the Dentistry discipline
1A-6b. Total Number of Students who dropped out of the Dentistry discipline who were LDS borrowers
1A-7a. Total Number of LDS Borrowers for the Dentistry discipline		(First time recipients)
1A-7b. Of the number of LDS borrowers for the Dentistry discipline above, number of Active and Non Retired/Defaulted Borrowers
1A-8. Total Number of LDS students including those who graduated during the reporting period for the Dentistry discipline		(Age and Gender details)
1A-9. Total Graduates (LDS- Dentistry Only)
1A-10. Number of LDS students including those who graduated during this reporting period that indicate an intention to serve in a medically underserved community.
1A-11. Number of LDS students including those that graduated during this reporting period that indicate an intention to practice in primary care.
1A-12. Number of LDS students including those who graduated during this reporting period that are from rural backgrounds.

Current Year Graduate Special Data	Number of Graduates
1A-13. Total number of full time Underrepresented Minority (URM) graduates (LDS-Dentistry loan recipients and Non-LDS-Dentistry) at your school during the current reporting period.
1A-14. Total number of full time LDS-Dentistry graduates during the current reporting period who indicate intent to serve in a rural area.

Prior Years Graduate Special Data	Number of Graduates
1A-15a. Total Number of LDS – Dentistry Loan Recipients who graduated in academic year 2010-2011.
1A-15b. Of the Total Graduates reported in question 1A-15a, the Number of Full-Time LDS – Dentistry Graduates in academic year 2010-2011 serving in Medically Underserved Communities.
1A-15c. Of the Total Graduates reported in question 1A-15a, the Number of Full-Time LDS – Dentistry Graduates in academic year 2010-2011 serving in Primary Care
1A -15d. Of the Total Graduates in question 1A-15a, the Number of Full-Time LDS-Dentistry Graduates in academic year 2010-2011 who entered the field for which they received their degree
1A -15e. Of the Total Graduates in question 1A-15a, the Number of Full-Time LDS-Dentistry Graduates in academic year 2010-2011 who entered service in a rural area.

Student Special Data (For LDS programs Only)	Narrative
1A-16. Please indicate the recruitment activities for disadvantaged students your school uses for the LDS program by checking all box(s) that apply.	Check Boxes See Appendix A (These check boxes will be linked to the online form and appear as an integral part of the report rather than an appendix.)
1A-17a.  Please indicate the retention and/or mentoring activities for disadvantaged students that your school uses for the LDS program by checking all boxes that apply.	Check Boxes See Appendix B (These check boxes will be linked to the online form and appear as an integral part of the report rather than an appendix.)
1a-17b. Please indicate the type of retention and/or mentoring activities for disadvantaged students your school uses for the LDS program by checking all boxes that apply.	Check Boxes See Appendix B (These check boxes will be linked to the online form and appear as an integral part of the report rather than an appendix.)
1A-18. Please share in the box below any success stories about LDS recipients.	Narrative of up to 250 characters
1A-19. How many LDS students received pipeline training from other HRSA programs (i.e., Health Careers Opportunity Program (HCOP) Centers of Excellence (COE) at any period of time? (Data collection period starts July 1, 2011.)	Cumulative (including current year) HCOP __________ COE ___________ Other_________ Other Program Titles: ___________________	Current (New LDS Recipients) HCOP_________ COE___________ Other___________ Other Program Titles: _________________
1A-20. Please provide the name of at least one health clinic that provides service to a significant number of individuals who are from disadvantaged backgrounds including members of minority groups, that your school has an agreement with to provide students with experience in providing clinical services to such individuals.	Clinic 1: Clinic 2: Clinic 3:

OMB No.:0915-0044
Expiration Date:

FINANCIAL DATA

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration BUREAU OF HEALTH PROFESSIONS Annual Operating Report Page 1b - Student Race/Ethnicity Data Section	FOR HRSA USE ONLY
	Institution			Program
				LDS - Dentistry
	Submission Tracking Number	OPSID	Grant Number	Reporting Period
				07/01/2011 - 06/30/2012

1. Hispanic or Latino Students
Did your BHPr funded program have students of "Hispanic or Latino ethnicity" between 7/1/2011 and 6/30/2012?
Hispanic or Latino Students by Race	Enrollment of Discipline (A)	New Student Recipients (B)	Recipients Other Than New Who Did Not Graduate (C)	Recipients Other Than New Who Graduated (D)	Total Recipients (B+C+D)
A. American Indian or Alaska Native
B. Asian - All (including underrepresented)
B1. Asian - underrepresented, if Known
C. Black or African American
D. Native Hawaiian or Other Pacific Islander
E. White
F. More than one race (Race combinations)
TOTAL (A + B + C + D + E + F)
Hispanic or Latino Students All Races	Enrollment of Discipline (A)	New Student Recipients (B)	Recipients Other Than New Who Did Not Graduate (C)	Recipients Other Than New Who Graduated (D)	Total Recipients (B+C+D)
G. All races

2. Non-Hispanic or Non-Latino Students
Did your BHPr funded program have students of "Non-Hispanic or Non-Latino ethnicity" between 7/1/2011 and 6/30/2012?
Non-Hispanic or Non-Latino Students by Race	Enrollment of Discipline (A)	New Student Recipients (B)	Recipients Other Than New Who Did Not Graduate (C)	Recipients Other Than New Who Graduated (D)	Total Recipients (B+C+D)
A. American Indian or Alaska Native
B. Asian - All (including underrepresented)
B1. Asian - underrepresented, if known
C. Black or African American
D. Native Hawaiian or Other Pacific Islander
E. White
F. More than one race (Race combinations)
TOTAL (A + B + C + D + E + F)
Non-Hispanic or Non-Latino Students All Races	Enrollment of Discipline (A)	New Student Recipients (B)	Recipients Other Than New Who Did Not Graduate (C)	Recipients Other Than New Who Graduated (D)	Total Recipients (B+C+D)
G. All races

OMB No.:0915-0044
Expiration Date:

FINANCIAL DATA

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration BUREAU OF HEALTH PROFESSIONS Annual Operating Report Page 2 - PROGRAMS ACCOUNT SECTION	FOR HRSA USE ONLY
	Institution			Program
				LDS - Dentistry
	Submission Tracking Number	OPSID	Grant Number	Reporting Period
				07/01/2011 - 06/30/2012

Program Accounts

Cumulative
(includes current year)

Current Year

A.

FEDERAL FUNDS AWARDED

B.

CASH BALANCE - START OF REPORT PERIOD

C.

CASH RECEIPTS

1.

Federal Funds Received/Receivable

2.

Institutional Contributions Deposited

3.

Transferred from Scholarship Fund

4.

Loan Principal Collected

5.

Interest Income Collected on Loans

6.

Penalty Charges Collected on Loans

7.

Investment Income

8.

Institutional Repayments of Bad Debts, Principal

9.

Institutional Repayments of Bad Debts, Interest

10.

Institutional Repayments of Bad Debts, Penalty Charges

11.

Cash Receipts Total (sum of C.1 through C.10)

D.

CASH DISBURSEMENTS

1.

Loaned to Students

2.

Transferred to Scholarship Fund

3.

Repayments to Federal Government, Principal

4.

Repayments to Federal Government, Interest

5.

Repayments to Federal Government, Other Income

6.

Repayments to Institution, Principal

7.

Repayments to Institution, Interest

8.

Repayments to Institution, Other Income

9.

Collection Agent Costs, Principal

10.

Collection Agent Costs, Interest

11.

Litigation Costs, Principal

12.

Litigation Costs, Interest

13.

Credit Bureau Fees

14.

Other Costs

15.

Cash Disbursements Total (sum of D.1 through D.14)

E.

CASH BALANCE - END OF REPORT PERIOD
(CASH BALANCE START OF REPORT PERIOD + CASH RECEIPTS - CASH DISBURSEMENTS)

OMB No.:0915-0044
Expiration Date:

FINANCIAL DATA

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration BUREAU OF HEALTH PROFESSIONS Annual Operating Report Page 3 - PROGRAMS ACCOUNT SECTION (Continued)	FOR HRSA USE ONLY
	Institution			Program
				LDS - Dentistry
	Submission Tracking Number	OPSID	Grant Number	Reporting Period
				07/01/2011 - 06/30/2012

Program Accounts (Continued)

Cumulative
(includes current year)

Current Year

F.

LOAN CANCELLATIONS TO BORROWERS

Number of Borrowers

Principal

Interest

Number of Borrowers

Principal

Interest

1.

Professional Practice

a.	HP Practice-Shortage (10%)

b.	HP Practice-Rural Shortage (15%)

c.	Total (Sum of 1.a and 1.b)

2.

Nursing Employment

a.	Nursing Employment (10%)

b.	Nursing Employment (15%)

c.	Nursing Employment (20%)

d.	Nursing Employment (15%) on or after 03/23/2010

e.	Nursing Employment (20%) on or after 03/23/2010

f.	Nursing Employment (Other) on or after 03/23/2010

g.	Total (sum of 2.a through 2.f)

3.

Death

a.	On PCL Loans made on or after 10/22/85

b.	On Loans except those reported in F.3.a

c.	Total (Sum of 3.a and 3.b)

4.

Permanent & Total Disability Approved by HHS

a.	On PCL Loans made on or after 10/22/85

b.	On Loans except those reported in F.4.a

c.	Total (Sum of 4.a and 4.b)

PROGRAM ACCOUNTS (Continued)		Cumulative (includes current year)				Current Year
G.	BAD DEBTS APPROVED FOR WRITE-OFF BY HHS	Number of Borrowers	Principal	Interest	Penalty Charges	Number of Borrowers	Principal	Interest	Penalty Charges
	Total Approved

OMB No.:0915-0044
Expiration Date:

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration BUREAU OF HEALTH PROFESSIONS Annual Operating Report Page 4 - EXCESS CASH WORKSHEET	FOR HRSA USE ONLY
	Institution			Program
				LDS - Dentistry
	Submission Tracking Number	OPSID	Grant Number	Reporting Period
				07/01/2011 - 06/30/2012

A.

General Ledger Cash Balance as of 6/30/2011

B.

Actual Collections for 7/1/2011 - 6/30/2012

1.

Principal

2.

Interest

3.

Investment Income and Penalty Charges

4.

Institutional Repayments of Bad Debts (Principal, Interest & Penalty Charges)

C.

Federal Funds Received/Receivable 7/1/2011 - 6/30/2012

D.

Institutional Contribution for 7/1/2011 - 6/30/2012

E.

Projected Collections for 7/1/2012 - 6/30/2013

1.

Principal

2.

Interest

3.

Investment Income and Penalty Charges

F.

Projected Funds Available as of 6/30/2013 (A + B + C + D + E)

G.

Actual Expenditures for 7/1/2011 - 6/30/2012

1.

Loans to Students

2.

Costs (Collection, Litigation, Credit Bureau and Other)

3.

Repayments to Federal Government and Institution (Principal, Interest and Other Income)

H.

Projected Expenditures for 7/1/2012 - 6/30/2013

1.

Loans to Students

2.

Costs (Collection, Litigation and Credit Bureau)

I.

Projected Expenditures as of 6/30/2013 (G + H)

J.

Projected Cash Balance as of 6/30/2013 (F - I)

K.

Less Projected Expenditures for 7/1/2013 - 6/30/2015

L.

Excess Cash (J - K)

M.

General Ledger Ending Cash Balance as of 6/30/2012

OMB No.:0915-0044
Expiration Date:

FINANCIAL DATA

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration BUREAU OF HEALTH PROFESSIONS Annual Operating Report Page 5 - PROGRAMS ACCOUNT SECTION (Continued)	FOR HRSA USE ONLY
	Institution			Program
				LDS - Dentistry
	Submission Tracking Number	OPSID	Grant Number	Reporting Period
				07/01/2011 - 06/30/2012

Program Accounts (Continued)

H.

FROM WORKSHEET CALCULATIONS

1.

Default Rate

FOR ACTIVE SCHOOLS

2.

Excess Cash from report page 4 that was or will be returned to PMS

3.

Excess Cash from report page 4 that was or will be returned to the Division of Financial Operations

FOR CLOSING SCHOOLS

4.

Amount of cash determined to be due the Federal Government and remitted separately to the Division of Financial Operations

I.

CHECK LIST/QUESTIONS

1.

What is the total amount of interest that is past due?

AUDITS

2.

Does your institution provide for a biennial audit of the loan and/or scholarship funds by a qualified independent auditor?

a. Period of last audit

OMB No.:0915-0044
Expiration Date:

FINANCIAL DATA

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration BUREAU OF HEALTH PROFESSIONS Annual Operating Report Page 6a - BORROWER ACCOUNTS WORKSHEET	FOR HRSA USE ONLY
	Institution			Program
				LDS - Dentistry
	Submission Tracking Number	OPSID	Grant Number	Reporting Period
				07/01/2011 - 06/30/2012

Borrower Accounts

Number of Borrowers
(1)

Principal Loaned
(2)

Principal Repaid
(3)

1.

FULLY RETIRED

A.

Repayment/Prof Pract/Cancel

B.

Cancellation/Death

C.

Cancellation/Disability

D.

Discharged in Bankruptcy

E.

HHS Approved Write-off

F.

Uncollectible per P.L. 100-607

G.

Total (sum of 1.A through 1.F)

2.

CURRENT

A.

Student Status

B.

Grace Period

C.

Deferment Status

D.

Postponement/Cancellation

E.

Repayment - Not Past Due

F.

Past Due 1-119 Days

G.

Total (sum of 2.A through 2.F)

3.

IN BANKRUPTCY

A.

Pending Discharge/Wage Earners Agreement

4.

IN DEFAULT

A.

120 Days and Over

5.

FORBEARANCE

A.

Forbearance

TOTAL

OMB No.:0915-0044
Expiration Date:

FINANCIAL DATA

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration BUREAU OF HEALTH PROFESSIONS Annual Operating Report Page 6b - BORROWER ACCOUNTS WORKSHEET	FOR HRSA USE ONLY
	Institution			Program
				LDS - Dentistry
	Submission Tracking Number	OPSID	Grant Number	Reporting Period
				07/01/2011 - 06/30/2012

Borrower Accounts

PRINCIPAL CANCELED

Employment/
Prof Pract
(4)

Death/
Disability
(5)

Principal Delinquent
(6)

1.

FULLY RETIRED

A.

Repayment/Prof Pract/Cancel

B.

Cancellation/Death

C.

Cancellation/Disability

D.

Discharged in Bankruptcy

E.

HHS Approved Write-off

F.

Uncollectible per P.L. 100-607

G.

Total (sum of 1.A through 1.F)

2.

CURRENT

A.

Student Status

B.

Grace Period

C.

Deferment Status

D.

Postponement/Cancellation

E.

Repayment - Not Past Due

F.

Past Due 1-119 Days

G.

Total (sum of 2.A through 2.F)

3.

IN BANKRUPTCY

A.

Pending Discharge/Wage Earners Agreement

4.

IN DEFAULT

A.

120 Days and Over

5.

FORBEARANCE

A.

Forbearance

TOTAL

OMB No.:0915-0044
Expiration Date:

FINANCIAL DATA

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration BUREAU OF HEALTH PROFESSIONS Annual Operating Report Page 6c - BORROWER ACCOUNTS WORKSHEET	FOR HRSA USE ONLY
	Institution			Program
				LDS - Dentistry
	Submission Tracking Number	OPSID	Grant Number	Reporting Period
				07/01/2011 - 06/30/2012

Borrower Accounts

Principal Uncollectible Not Past Due
(7)

Principal Outstanding but Not Due
(8)

Principal Written Off
(9)

Capitalized Interest
(10)

1.

FULLY RETIRED

A.

Repayment/Prof Pract/Cancel

B.

Cancellation/Death

C.

Cancellation/Disability

D.

Discharged in Bankruptcy

E.

HHS Approved Write-off

F.

Uncollectible per P.L. 100-607

G.

Total (sum of 1.A through 1.F)

2.

CURRENT

A.

Student Status

B.

Grace Period

C.

Deferment Status

D.

Postponement/Cancellation

E.

Repayment - Not Past Due

F.

Past Due 1-119 Days

G.

Total (sum of 2.A through 2.F)

3.

IN BANKRUPTCY

A.

Pending Discharge/Wage Earners Agreement

4.

IN DEFAULT

A.

120 Days and Over

5.

Forbearance

A.

Forbearance

TOTAL

OMB No.:0915-0044
Expiration Date:

COMMENTS AND CERTIFICATION

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration BUREAU OF HEALTH PROFESSIONS	FOR HRSA USE ONLY
	Institution		Program
			LDS - Dentistry
	Submission Tracking Number	Grant Number	Reporting Period
			07/01/2011 - 06/30/2012

1. Facility (Name and complete address, including ZIP code)
2. Contact Information	Primary Point Of Contact
	Alternate Point Of Contact
Certification: I certify to the best of my knowledge and belief that this Annual Operating report is true and correct.
Typed or Printed Name and Title			Telephone (Area code, number and extension)
Signature of Authorized Certifying Official			Date Report Submitted

Comments

Appendix A Question 1A-12 Check Boxes

1A-12 Please indicate what recruitment activities for disadvantaged students that apply to your program by checking all box(s) that apply.
High School Recruitment
General
*	College Fairs
*	Summer camps/programs for high school students to receive information about programs offered
Specifically targeting/recruiting disadvantaged students
*	Attending college fairs in areas with high percentages of disadvantaged students locally or on a broader scale
*	Training recruiters specifically to answer questions and provide information to disadvantaged students.
*	Providing specifically designed information packets on programs and accommodations your school offers for disadvantaged students
*	Prep Courses for disadvantaged high school students interested in careers in the health professions
College Level Recruitment
*	Recruitment from community colleges in disadvantaged areas
*	Community College joint admissions programs for disadvantaged students
Application Services
*	Online programs that wave or assist with application fees for disadvantaged students
Open Houses
*	Booths or presentations on resources for disadvantaged students
*	Targeted advertisements for open houses or other programs in areas with high percentage of  disadvantaged students

Appendix B

1A-13  Please indicate what retention and/or mentoring activities for disadvantaged students apply to your program by checking all boxes that apply:
Individual or Group Peer Mentor Program (big brother/big sister)
*	Open to all
*	Specifically designed for disadvantaged students
*	Placing students in peer support or networks and groups
*	Other. Please describe
Individual Staff/Advisor Mentor Program
*	Open to all
*	Specifically designed for disadvantaged students
*	Other. Please describe
Specialized pre-attendance orientation for disadvantaged students
*	Team and camaraderie building activities to help students feel included in the school
*	Educate disadvantaged students on how to best use the accommodations and resources the school provides
*	Introduce or forge contacts between disadvantaged students and faculty/staff (ex: Heads of departments, Tutors, Financial aid and/or advisors)
*	Specialized welcome packets for disadvantaged students with additional information on available recourses and programs that will help them succeed
*	Other. Please describe
College Skills Development and Review Programs
*	Summer or pre-matriculation sessions in a classroom setting teaching disadvantaged students skills that they will need to be successful  (eg: study skills, note taking skills, test taking skills, and/or time management skills)
*	Summer or pre-matriculation classes for disadvantaged students to review and strengthen prerequisite knowledge of the course work
*	Individual assessment and profile of disadvantaged students strengths and weaknesses with advisor and plan for development of skills
*	Other. Please describe
Early identification for students at risk
*	Identify students who are falling behind early and provide assistance for them in furthering their academic career
*	Develop individualized plans for struggling disadvantaged students to ensure success/coordination support
*	Provide learning specialists for disadvantaged students who can identify possible learning disabilities or assess strengths and weaknesses.
*	Seminars and lectures specifically for disadvantaged students
*	Other. Please describe
Group or Individual Tutoring Services
*	Provide faculty or peer tutors to disadvantaged students
*	Tutors specifically trained to help students faced with struggles from a disadvantaged background.
*	Financial mentoring/tutoring
*	Other. Please describe
Child Care Support
*	Free
*	Partially subsidized
*	Other. Please describe
Professional Opportunities
*	Shadowing health professional
*	Interviewing health professional
*	Other. Please describe