Form 1 Blank NFLP Application Data Form 0378

OMB Approval No.: 0915-0378; Expiration: xx/xx/20xx

Nurse Faculty Loan Program - Program Specific Data Form

CURRENT FISCAL YEAR? (Formatted DATE Field) Instruction: Enter the fiscal year date that is provided in the current NFLP Funding Opportunity Announcement cover page.
PREVIOUS NFLP APPLICANT? ____Yes ____No Instruction: Select ‘YES’ if your school has ever received past NFLP funding. Enter ‘NO’ if your school has never received NFLP funding.
A. Program Information
Select Type of Institution:			[_]Public [ ]Private
Select Type of Entity:			[ ]School/College of Nursing [_]Other Entity/Department within the Institution that offers a Graduate Nursing Degree Program
Provide Educator Component/Course Offered:			Applicants may add new educator courses offered or edit/delete previous educator courses specified.
B. Accreditation
State the applicable accreditation for the graduate nursing program(s) offered and provide the required documentation:
C. Federal Funds Requested
Indicate the total Federal Capital Contribution (FCC) Amount Requested.
D1. NFLP Loan Fund Balance/Unused Accumulation
Indicate the institution’s NFLP loan fund balance as of the past reporting period end date.
D2. NFLP Loan Fund Default Rate
Does the institution’s NFLP default rate exceed the threshold (>5%)?						___Yes ___No
If yes, has a corrective action plan been included as part of your application?						___Yes ____No
D3. Last NFLP Student Loan Award
Has an NFLP loan been disbursed from the institution’s NFLP loan fund within the last two academic years?						___Yes ____No
E.1 NFLP Enrollees Information by Degree – Continuing Students Expected to Request NFLP Support
Type of Institution	Master’s Degree			Doctoral Degree
	FT	PT		FT	PT
Public – In-state
Public – Out-of-state
Private
TOTALS:

E.2 NFLP Enrollees Information by Degree - New Students Expected to Request NFLP Support
Type of Institution	Master’s Degree		Doctoral Degree
	FT	PT	FT	PT
Public – In-state
Public – Out-of-state
Private
TOTALS:

E.3 NFLP Graduates Information (Prior Year)
	Total Number of NFLP Graduates		Total Number of NFLP Graduates Employed as Nursing Faculty
	Master’s Degree	Doctoral Degree	Master's Degree	Doctoral Degree
TOTALS:

E.4 NFLP Enrollees by Nurse Practice Role
Nurse Practice Role	NFLP Enrollees (07/01/20XX - 06/30/20XX)
	Master’s Degree	Doctoral Degree
Primary Care Nurse Practitioner
Acute Care Nurse Practitioner
Nurse – Midwife
Nurse Anesthetist
Clinical Nurse Specialist
Public Health Nurse
Nurse Administrator
Nurse Educator
Other Nurse Specialty 1 (Insert):
TOTALS:

F. Tuition, Terms and Credit Hours
	Master's Program				Doctoral Program
Tuition	In-State		Out-of-State		In-State		Out-of-State
	FT	PT	FT	PT	FT	PT	FT	PT
Program Degree Level (Select From List):
Tuition Costs per TERM : Private Institution
Type of Term
# of Terms/Quarters per year
Minimum Credit Hours Required for Full-time Status

NFLP PROGRAM SPECIFIC DATA FORM

Instructions

CURRENT FISCAL YEAR? Enter the fiscal year date that is provided in the current NFLP Funding Opportunity Announcement cover page.

PREVIOUS NFLP APPLICANT? Instruction: Select ‘YES’ if your school has ever received past NFLP funding. Enter ‘NO’ if your school has never received NFLP funding.

PART 1 – PROGRAM INFORMATION

1. Applicant and Program Information

Type of Institution

Public and private institutions are eligible to apply. The selection will enable the applicable data fields to be completed under Sections E.1-E.2 (Enrollee Information) and F. (Tuition Information).

Eligible Entity

An eligible entity is an accredited collegiate school of nursing that offer advanced graduate (master’s and doctoral) nursing degree programs that prepare nurse faculty/educators.

Educator Component/Course Offered?

For each course entered, details such as the number of credits, whether it is a required or elective course, if it includes distance learning, and the competencies it addresses should be provided.

Of the six educator competencies listed (below), at least two of the first four Nurse Educator Competencies must be selected for all courses added in this section.

• Use of educational theory and evidence-based teaching practices.

• Identification of individual learning styles and unique learning needs of traditional and non-traditional students.

• Assessment, measurement, and evaluation strategies.

• Curriculum design and evaluation of program outcomes.

• Design and implementation of scholarly activities in an established area of expertise.

• Balancing teaching, scholarship, and service demands inherent in the role of nurse educator.

2. Accreditation and Approvals

Accreditation documentation for your program should be provided either in the form of a letter or certificate from CCNE, NLNAC, COA, or ACME. A letter from the United States Department of Education providing reasonable assurance of accreditation for your Program(s) is also accepted. Failure to provide documentation of each applicable accreditation with the application will render the application non-responsive and the application will not be considered for funding under this announcement.

Each letter(s) or certificate of accreditation, or letter(s) of Reasonable Assurance from the U.S. Department of Education, must be uploaded as Attachment 1. The filename attachment should specify the accreditation name (i.e., Attachment1_CCNE.doc, Attachment1_COA.doc).

Other Attachments

All ‘other’ attachments must not be uploaded in this form. Please upload attachments 2-11 below under the Other Project Information section of the HRSA EHBs application.

• Biographical Sketch – Required, upload as Attachment 2

• Sample plan for Full and Part-Time Students – Required, upload as Attachment 3

• Educator Component/Coursework Description – Required, upload as Attachment 4

• Maintenance of Effort Documentation – Required, upload as Attachment 5

• Loan Disbursement Plan – Required, upload as Attachment 6

• Sample NFLP Loan Commitment Letter – Required, upload as Attachment 7

• Statement of Employment Partnership – Required, upload as Attachment 8

• Documentation of Collaborative Agreement – If Applicable, upload as Attachment 9

• Default Rate Action Plan – If Applicable, upload as Attachment 10

Documentation of Private or Public Non-Profit Status – Required, upload as Attachment 11

PART 2 – FUND INFORMATION

3. Federal Funds Requested

Applicants may determine the Federal Capital Contribution (FCC) amount requested by calculating the tuition and other educational fees for the academic year multiplied by the number of continuing NFLP students and prospective new students expected to receive NFLP loan support. The Federal funds requested in this section should consider the enrollee data that will be provided under Sections E.1-E.2.

Example:

FCC Amount Requested = (Tuition costs plus other educational fees/expenses for an academic year multiplied by the number of continuing NFLP students plus the number of prospective new NFLP students expected to request NFLP)

= $(25,000 + 2000) * (15 + 5)

= $540,000

IMPORTANT NOTE: Applicant should consider the required 1/9 institutional capital contribution when providing the information.

D1. NFLP Loan Fund Balance/Unused Accumulation

Verify the NFLP loan fund balance with the appropriate officials at your institution. New applicants must enter “$0”.

D2. NFLP Loan Fund Default Rate

Verify the NFLP loan fund default rate with the appropriate officials at your institution. New applicants must select “No”.

D3. Last NFLP Student Loan Award

Verify the last NFLP student loan fund award from the NFLP loan fund. New applicants must select “No”.

PART 3 – NFLP ENROLLEE AND GRADUATE INFORMATION

This section will enable data fields based on the selection for “Type of Institution” (Public or Private) under Section A.

E.1 NFLP Enrollees (Continuing) by Degree Level – Provide the number of continuing NFLP enrollees expected to receive NFLP support during the current academic year (Fall/Spring/Summer). All data fields must be completed. Enter “0” if not reporting data in the fields.

E.2 NFLP Enrollee (New) by Degree Level – Provide the number of projected new enrollees expected to receive NFLP support during the current academic year (Fall/Spring/Summer). All data fields must be completed. Enter “0” if not reporting data in the fields.

E.3 NFLP Graduates and Graduates Employed as Nurse Faculty – Provide the number of NFLP students that graduated during the previous academic year. Provide the number of NFLP graduates that reported employment as full-time faculty during the previous academic year. All data fields must be completed. Enter “0” if not reporting data in the fields.

E.4 NFLP Enrollees by Practice Role – Provide the total number of continuing and projected new NFLP enrollees by practice. All data fields must be completed. Enter “0” if not reporting data in the fields.

• The total Master's enrollees for all Nurse Practice Roles listed should reconcile with the sum of total Master’s Degree (FT and PT) under Sections E.1 and E.2.

• The total Doctoral enrollees for all Nurse Practice Roles listed should reconcile with the sum of total Doctoral Degree (FT and PT) under Sections E.1 and E.2.

PART 4 – TUITION INFORMATION

F. Tuition, Required Terms and Credit Hours

Provide the required tuition information for each distinct graduate nursing degree program for which enrollee information is provided under Sections E.1-E.2.

• Program Degree – Select each program degree level and provide the number of terms, the number of credits and the tuition data.

• Tuition Costs Per Term – For “Full-time” tuition costs per TERM, enter total amount for one term with fees and expenses based on the required full-time credit hours (or average full-time credit hours).  For “Part-time” tuition costs per TERM, enter total amount for one single credit hour with fees and expenses (Example, $2,500 full-time tuition per term divided by 9 credit hours equals $277 for a single credit hour).   NOTE:  If you are a PRIVATE institution, enter tuition data under in-state only.

Public 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 0915–0378. Public reporting burden for this collection of information is estimated to average 8 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 14N39, Rockville, MD 20857.