OMB Number: 0915-0149
Exp Date: XX/XX/201X
U. S. DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH RESOURCES AND SERVICES ADMINISTRATION
BUREAU OF HEALTH PROFESSIONS
INSTRUCTIONS FOR SCHOLARSHIPS FOR DISADVANTAGED STUDENTS APPLICATION PROGRAM SPECIFIC FORM
Academic Year 20XX-XX
PUBLIC REPORTING BURDEN STATEMENT
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 project is 0915-0149. Public reporting burden for the applicant for this collection of information is estimated to average 13 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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 10C-031, Rockville, Maryland, 20857.
GENERAL INFORMATION
You are required to complete a program specific form for each discipline for which you are seeking support.
To be eligible to participate in the SDS program, all data must be submitted online as part of the application process. (If your school receives SDS funding, you will be required to provide to HRSA program and fiscal data and submit reports electronically via the Electronic Handbooks (EHBs). The two required reports are the annual Federal Financial Report (FFR) also known as the SF 425 (formerly the SF 269 FSR) and the annual SDS Performance Report
(SDSPR).
Your submission of the SDS Application represents an agreement between the applicant school and the Secretary of the Department of Health and Human Services (HHS) for the management and administration of the SDS Program, and is binding on all parties participating in the program.
ELIGIBILITY CRITERIA: A school must meet all of the criteria listed below to be eligible to be considered for SDS funds for FY 20XX. All requirements refer to full-time students (using the school’s requirements for full-time):
Full-time students from disadvantaged backgrounds must be:
1) At least 20 percent of the total enrollment (full-time enrolled) of your program during
Academic Year (AY) 20XX-20XX and
2) At least 20 percent of the total graduates (who were full-time students) of your program during AY 20XX-20XX, and
In addition to the above, if your school is a newly established school, as long as you have students enrolled for the SDS program reporting year (20XX – 20XX) you may apply. Since newly established schools have not yet graduated students, and do not have graduate data, schools may complete the "graduates" data on the application using the data on the class year of expected first graduating class in place of the graduate data. For example, if your program is a 4-year program and you have students enrolled only in the first 2 years, you must use the second year data in providing the "graduates" information. In other words, the data for the second year and the data for the "graduates" will be the same.
Program Specific Instructions
PUBLIC OR NON-PROFIT INSTITUTION
Enter Yes or No.
POINT OF CONTACT
The person responsible for the application data.
FULL-TIME STUDENTS ENROLLED IN YOUR PROGRAM FOR ACADEMIC YEAR XXXX-XX AND THEIR RACIAL/ETHNIC BACKGROUNDS
You must include all full-time students (using your school's definition of full-time) enrolled in your program. Complete this table showing the enrollment and racial/ethnic background of full- time students enrolled in the program for which your school is applying for SDS funds (i.e., health professions, baccalaureate nursing, public health, clinical psychology, etc.) during Academic Year 20XX-XX.
Select the category of racial/ethnic background using the following definitions.
Race:
American Indian or Alaska Native: A person having origins in any of the original peoples of
North America, and who maintains cultural identification through tribal affiliation or community recognition.
Black or African American: A person having origins in any of the Black racial groups of Africa.
Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.
Native Hawaiian or Pacific Islander: A person having origins in any of the original peoples
of Hawaii, Guam, Samoa, or other Pacific Islands.
White: A person having origins in any of the original peoples of Europe, North America, the
Middle East or North Africa.
More than One Race: A person having origins from more than one race.
Race Not Reported: Race unknown
Ethnicity:
Hispanic or Latino: A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race.
Non-Hispanic/Non-Latino: A person not having origins of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race.
TOTAL FULL-TIME ENROLLMENT AND FULL-TIME DISADVANTAGED ENROLLMENT BY CLASS YEAR FOR STUDENTS IN YOUR PROGRAM FOR ACADEMIC YEAR 20XX-20XX
CLASS YEAR - Enter full-time enrollment by class year (using the school’s definition for full time). Space on the application is available for programs up to six years in length. Enter only Class Year data that is appropriate for the length of your program. For example, if your program is four years in length, the Fifth and Sixth years on the application would be left blank.
For the graduate degree programs with more than one type of degree (e.g. masters and doctorate, or pharmacy baccalaureate and graduate), all the students who are in the last year of their program should be included in the same year. For example, if a school has a one year program and a two year program, the students in the one year program would be included in the same year as the students in the second year of the two year program.
STUDENTS FROM DISADVANTAGED BACKGROUNDS ENROLLMENT - Complete the table, showing full-time student enrollment from disadvantaged backgrounds (using your school’s requirements for full time) by class year.
Enter Class Year data that is applicable for the length of your program.
An individual from a disadvantaged background is defined as someone who:
[Part I - educational/environmental] comes from an environment that has inhibited the individual from obtaining the knowledge, skill, and abilities required to enroll in and graduate from a school, or from a program providing education or training in an allied health profession.
The Department expects that eligible students who meet these criteria will
(1) Have the abilities needed to succeed in a health career, but come from backgrounds and educational environments that have made it difficult for them to reach and fully demonstrate their academic potential; and
(2) Are more likely than other students to provide care to underserved areas and populations following completion of their degree.
EXAMPLES - schools are not limited to these examples only:
(1) The individual graduated from (or last attended) a high school with low SAT score based on most recent data available:
(2) The individual graduated from (or last attended) a high school from which, based on most recent data available:
(a) low percentage of seniors receive a high school diploma; or
(b) low percentage of graduates go to college during the first year after graduation.
(3) The individual graduated from (or last attended) a high school with low per capita funding.
(4) The individual graduated from (or last attended) a high school from which, based on most recent data available, many of the enrolled students are eligible for free or reduced price lunches.
(5) The individual comes from a family that receives public assistance (e.g., Aid to Families with Dependent Children, food stamps, Medicaid, public housing). (6) First generation in family to attend college
OR
[Part II - economic] comes from a family with an annual income below a level based on low- income thresholds according to family size published by the U.S. Bureau of the Census, adjusted annually for changes in the Consumer Price Index, and adjusted by the Secretary of Health and Human Services for use in all health professions programs.
Of the Total Full-Time Students from Disadvantaged Backgrounds, enter the number of students who qualify as coming from a disadvantaged background under the economic (Part II) definition.
Please NOTE: When identifying students from disadvantaged backgrounds, minority status in
itself is NOT A FACTOR for determining disadvantaged status.
For income levels that determine what constitutes a low income family for determining economically disadvantaged students enrolled/graduated during AY 20XX-20XX see the “Eligible Participants” section of the most recent Funding Opportunity Announcement.
The parental income will be used to determine a student’s eligibility for economically disadvantaged in all cases except in those cases where the student is considered independent by being at least 24 years old and has not been listed as a dependent on his or her parents’ income tax for 3 or more years. In those cases, the students' family income will be used instead of parental family income (for parental income and students' family income use the historical poverty income level)).
Documentation must be provided to the school for age and independent status. Schools may use whichever documentation they choose, such as the students’ last three years income tax or the parents’ last three years income taxes or other sources of proof of independency. For proof of age, some examples are, a drivers’ license, birth certificate, or passport.
However, the school will be held accountable for the accuracy of the students’ independent status.
If a student is at least 24 years old, and cannot prove independent status then he or she would be considered dependent and schools should use the parental income for economically disadvantaged.
TOTAL NUMBER OF FULL-TIME STUDENTS GRADUATED AND NUMBER OF FULL- TIME DISADVANTAGED STUDENTS FROM DISADVANTAGED BACKGROUNDS GRADUATED FROM YOUR PROGRAM FOR ACADEMIC YEAR 20XX-20XX.
* Total Full-Time Graduates:
Enter the total Full-time Students (using your school’s requirements for full time) Graduated for the academic year 20XX-20XX
• Of the number of full time graduates, number of graduates that received scholarships for disadvantaged students from disadvantaged backgrounds (SDS):
Of the number full time graduates above, enter the total number of Full-time students graduated that received SDS funds regardless of when they received the funds.
*Full-Time Disadvantaged Graduates from Disadvantaged Backgrounds:
Enter total full-time disadvantaged students from disadvantaged backgrounds graduated for the academic year 20XX-20XX
For newly established schools or programs that had full-time students enrolled in AY 20XX-20XX, but had not been in existence long enough to have had a graduating class in AY 20XX-20XX, provide the data from the table in Section B. that represents the first graduating class, in place of graduate data. For example, if a four year program had students enrolled in the first, second and third years during AY 20XX-20XX, the school would provide data on the third year full-time students in place of the graduate data requested.
* Of the number of full-time disadvantagedstudents from disadvantaged backgrounds, how many are economically disadvantaged:
Of the number of full-time disadvantaged students from disadvantaged backgrounds above, enter the number of students who qualify as coming from a disadvantaged background under the economic (Part II) definition for the academic year 20XX-20XX.
GRADUATES FROM YOUR PROGRAM SERVING IN PRIMARY CARE AND/OR MEDICALLY UNDERSERVED COMMUNITIES: If the graduated student is in Primary Care as well as working in Medically Underserved Communities, include this graduate in both categories.
PRIMARY CARE
Definition: Primary Care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. (Institute of Medicine. Primary Care: America’s Health in a New Era. Washington, D.C.: National Academy Press, 1996).
For the SDS program, primary care fields are limited to Allopathic Medicine, Osteopathic Medicine, Dentistry, Dental Hygiene, Behavioral and Mental Health, Graduate Nursing, and Physician Assistants. Disciplines other than those listed above are not eligible for providing Primary Care data.
1. Number of full - time graduates in Primary Care:
1.1 For schools of allopathic and osteopathic medicine: enter the total number of full-time students graduated in academic year 20XX-20XX serving in Primary Care (residency included) during 20XX-20XX.
1.2 For schools of dentistry, dental hygiene, behavioral and mental health, nursing (graduate degree), and physician assistants: enter the total number of full-time students graduated in academic year 20XX-20XX serving in primary care (residency included) during 20XX-20XX.
2. Of the Number of Full-Time Graduates in Primary Care (above), Number of Graduates that
Received SDS:
2.1 For schools of allopathic and osteopathic medicine: Of the number of full-time graduates in primary care (item 4.1 above), enter the total number of students who received SDS funds, regardless of when they received them.
2.2 For schools of dentistry, dental hygiene, mental and behavioral health, nursing (graduate degree), and physician assistants: Of the number of full-time graduates in primary care (item 4.2 above), enter the total number of students who received SDS funds, regardless of when they received them.
3. Total Number of Full-Time Graduates:
3.1 For schools of allopathic and osteopathic medicine: will be pre-populated from item 3.1 above.
3.2 For disciplines other than allopathic and osteopathic medicine: will be pre-populated from item 3.2 above.
MEDICALLY UNDERSERVED COMMUNITIES (MUC)
Definition of Medically Underserved Community:
The term “Medically Underserved Community” means an urban or rural area or population that:
(A) is eligible for designation under Section 332 of the PHS Act as a health professional shortage area (HPSA);
(B) is eligible to be served by a migrant health center under Section 329 [now 330(g)] of the PHS Act, a community health center under Section 330 of the PHS Act, a grantee under Section 330(h) of the PHS Act, (relating to homeless individuals), or a grantee under Section 340A [now 330(i)] of the PHS Act (relating to residents of public housing);
(C) has a shortage of personal health services, as determined under criteria issued by the Secretary under Section 1861(aa)(2) of the Social Security Act (relating to rural health clinics); or
(D) is designated by a State Governor (in consultation with the medical community) as a shortage area or medically underserved community.
In keeping with the Congressional intent that eligible entities should not be limited to formally designated Health Professional Shortage Areas (HPSAs) and populations serviced by CHCs, MHCs, or homeless health centers, the list of types of practice sites that can be claimed under this provision includes the following:
• Community Health Centers (CHC) (section 330 of the PHS Act)
• Migrant Health Centers (MHC) (section 330(g) of the PHS Act)
• Health Care for the Homeless Grantees (section 330(h) of the PHS Act)
• Public Housing Primary Care Grantees (section 330(i) of the PHS Act)
• Rural Health Clinics, federally designated (section 1861(aa)(2) of the Social Security
Act)
• National Health Service Corps (NHSC) Sites (section 333 of the PHS Act)
• An outpatient health program or facility operated by a tribe or tribal organization under the Indian Self-Determination Act or by an urban Indian organization receiving funds under Title V of the Indian Health Care Improvement Act (25 U.S.C. § 450 et seq. and 25 U.S.C. § 1601 et seq.)
• Federally Qualified Health Centers (section 1861(aa)(2) of the Social Security Act)
• Primary Medical Care Health Professional Shortage Areas (HPSAs) (section 332 of the PHS Act)
• Mental Health HPSA
• Dental HPSAs (section 332 of the PHS Act)
• Nurse Shortage Areas (section 846 of the PHS Act)
• State or Local Health Departments (regardless of sponsor - for example, local health departments who are funded by the state would qualify)
• Practice sites designated by State Governors as serving medically underserved communities
4. Number of Full-Time Graduates in Medically Underserved
Communities:
4.1 For schools of allopathic and osteopathic medicine: enter the total number of full-time students graduated in academic year 20XX-20XX serving (residency included) during 20XX-20XX in medically underserved communities.
4.2 For disciplines other than allopathic and osteopathic medicine: enter the total number of full-time students graduated in academic year 20XX-20XX serving in medically underserved communities (residency included) during 20XX-20XX.
5. Of the Number of Full-Time Graduates in Medically Underserved Communities (above), Number of Graduates that Received SDS:
5.1. For schools of allopathic and osteopathic medicine: Of the number of full-time graduates in medically underserved communities (item 1.1 above) enter the number of graduates that received SDS funds regardless of when they received them.
5.2. For disciplines other than allopathic and osteopathic medicine: Of the Number of full-time graduates in medically underserved communities (item 1.2 above) enter the number of graduates that received SDS funds regardless of when they received them.
6. Total number of Full-Time Graduates:
6.1: For schools of allopathic and osteopathic medicine: enter the total number of full- time students graduated in academic year 20XX-20XX.
6.2. For disciplines other than allopathic and osteopathic medicine: enter the total number of full-time students graduated in academic year 20XX-20XX.
COST OF TUITION FOR FULL-TIME STUDENTS FOR THIS PROGRAM: Enter the average cost of tuition for one year (average of in-state and out-state) for full-time students for the program you are applying for.
LENGTH OF PROGRAM: Enter the length of time (in years) necessary to complete this program (Nursing Baccalaureate, enter 4).
ACCREDITATION: Health professions and nursing schools that are interested in participating in the SDS program must be accredited by a recognized body approved for such purpose by the Secretary of Education.
Each program/discipline must be accredited by the specialized accrediting body approved for the health discipline applying for program participation.
Enter the Name of Accrediting Body (American Osteopathic Association, Commission on Dental Accreditation, Council on Education of the American Podiatric Association, National League for Nursing, etc.) that your discipline (Osteopathic Medicine, Dentistry, Podiatric Medicine,
Graduate Nursing, etc.) is accredited by and accreditation expiration date, mm/yy.
Provide proof of accreditation for the discipline(s) that you are applying for as Attachment
1 in Grants.gov.
REQUESTED AWARD AMOUNT
Enter the amount needed for your school to provide one-half of all your financially needy, students from disadvantaged students’ background’s average cost of tuition. This amount is not necessarily the amount requested in the budget, but is the amount actually needed, so the “need” amount may exceed the $650,000 cap that has been placed on the requested amount you identified in the budget.
STUDENTS SUPPORTED
Enter the number of students the school plans to support with the requested award amount.
L. CERTIFICATION AND ELIGIBILITY QUESTIONS (Narrative Questions):
• Please certify that you will give preference to students for whom the cost of attendance would constitute a severe financial hardship.
Enter Yes or No.
• Please describe in the text box your program’s methods and standards for setting the amounts of scholarships.
• Select the method (including frequency) the program will use to disburse the
SDS scholarships to students:
□ Disburse funds directly to students
□ Apply funds towards tuition expenses
□ Disburse funds to students monthly
□ Disburse funds to students quarterly
□ Disburse funds to students per semester
□ Disburse funds to students annually
• Check box(s) that reflect(s) how the SDS scholarships will be used:
□ Tuition
□ Fees and other reasonable educational expenses
□ Reasonable living expenses
M. COMMUNITY COLLEGE QUESTION
Please indicate if your school is a community college.
N. RECRUITMENT AND RETENTION ELIGIBILITY
Is your school currently carrying out a program to recruit and retain students from disadvantaged backgrounds, including students who are members of racial and ethnic minority groups?
O. RECRUITMENT ACTIVITIES
Please indicate what retention activities for disadvantaged students from disadvantaged backgrounds apply to your program by checking all boxes that apply:
Recruitment:
□ High School Recruitment
□ Specifically targeting/recruiting disadvantaged students
□ College Level Recruitment
□ Application Services
□ Open Houses
P. RETENTION AND/OR MENTORING ACTIVITIES
Please indicate what mentoring activities for disadvantaged students from disadvantaged backgrounds apply to your program by checking all boxes that apply:
Retention and/or mentoring activities:
□ Individual or Group Peer Mentor Program (big brother/big sister)
□ Individual Staff/Advisor Mentor Program
□ Specialized pre-attendance orientation for disadvantaged students from disadvantaged backgrounds
□ College Skills Development and Review Programs
□ Early identification for students at risk
□ Group or Individual Tutoring Services
□ Child Care Support
□ Professional Opportunities
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Andrea Stampone |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |