Form 3 NCLRP CSF Verification

NURSE Corps Loan Repayment Program

U.S. Department of Health and Human Services Health Resources and Services Administration

NURSE CORPS LOAN REPAYMENT PROGRAM (Nurse Corps LRP) EMPLOYMENT VERIFICATION AND CRITICAL SHORTAGE FACILITY FORM

FOR NURSES WORKING AT CRITICAL SHORTAGE FACILITIES ONLY (Not Nurse Faculty)

Public Burden Estimate: OMB No. 0915‐0140 Expiration Date: 04/30/2017 An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current valid OMB control number. Public reporting burden for this collection of information is estimated to average 30 minutes 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 Office, 5600 Fishers Lane, Room 11A‐33, Rockville, Maryland 20857.

TO BE COMPLETED BY THE AUTHORIZED PERSONNEL OFFICIAL OF THE FACILITY. PLEASE NOTE: IF THIS FORM IS INCOMPLETE OR IF ANY INFORMATION IS INCORRECT, THE APPLICANT WILL BE DEEMED INELIGIBLE AND THE APPLICATION WILL NOT BE PROCESSED. INFORMATION ON THE ONLINE APPLICATION MUST MATCH THIS FORM.

Advanced practice registered nurses (NPs, CRNAs, CNMs, CNSs) employed by a professional group should have this form filled out by the administrator of the health care facility, not by the professional group.

NURSE Corps LRP Applicant:

Applicant’s SSN (Last 4 Digits Only): XXX‐XX‐

Name of Health Care Facility:

Address:

Please note: Under the NURSE Corps LRP, participants must be registered nurses (RNs) providing full‐time service at a Critical Shortage Facility. Full‐time service is defined as working as an RN for a minimum of 32 hours per week. No more than 7 weeks (35 work days) per service year can be spent away from the facility for vacation, holidays, continuing education, illness, maternity/paternity/adoption, or any other reason.

RNs working PRN, or as Pool Nurses, or for Travel or Nurse Staffing Agencies are not eligible for the program.

Individuals who have an existing service obligation are not eligible to participate in the Nurse Corps LRP. An existing service obligation is defined as an obligation of the individual to work as an RN for a certain period of time in exchange for receiving a financial recruitment or retention incentive from the facility (e.g., a sign‐on bonus, payment of moving expenses, funds to repay student loans). A basic employment contract which outlines the salary and benefits an individual earns in exchange for the work he/she performs does not constitute a service obligation.

( ) Yes or ( ) No: Does the individual identified above have an existing service obligation to remain employed/working at the facility in return for receiving educational benefits, a sign‐on bonus, or any other recruitment or retention incentive?

If YES to the above question (the individual has an existing service obligation), will the existing service obligation be completely satisfied on or before February 25, 2018 ( ) Yes or ( ) No

I hereby certify that the individual identified above:

1. Began working as an RN at the health care facility identified above on and is currently working in:

mm/dd/yyyy

( ) a full‐time position (defined as working as an RN for a minimum of 32 hours per week) OR ( ) less than a full‐time position (defined as working as an RN for less than 32 hours per week)

2. Earns a base annual salary (gross salary before deductions for taxes, insurance, etc.) of $ for the year (please calculate full‐time base salary if the individual is paid on an hourly basis). Base salary does not include Overtime or Shift Differential Pay. Listing of the hourly rate is not acceptable.

3. Is required to work hours per week.

4. Is currently licensed to practice as an RN without any restrictions or encumbrances.

Please provide the following: License Number: State: Expiration Date:

(mm/dd/yyyy)

5. If practicing as a NP, is NP‐certified by: ( ) AANP ( ) ANCC ( )NCC ( )ONCC ( )PNCB

6. Works at the following type of facility: ( ) private nonprofit;

( ) public / government owned; or ( ) private for profit.

7. Works at the following type of Health Care Facility (check only one)

Ambulatory Surgical Center – An entity that operates exclusively for the purpose of furnishing surgical services to patients who do not require hospitalization and in which the expected duration of services does not exceed 24 hours following admission.	Critical Access Hospital (CAH) – A facility certified by the Centers for Medicare & Medicaid Services (CMS) under section 1820 of the Social Security Act. In general, a CAH must be located in a rural area in a state that has a Medicare Rural Hospital Flexibility Program, maintain no more than 25 inpatient beds and an average annual length of stay of 96 hours or less, furnish 24‐hour emergency care services 7 days a week, and be located either more than a 35‐mile drive from the nearest hospital or CAH, or more than a 15‐mile drive in areas with mountainous terrain or only secondary roads.”
Certified Community Behavioral Health Clinic (CCBHC) ‐ A clinic that is certified as a CCBHC by a State in accordance with criteria published by the Secretary of Health and Human Services and with the requirements of the Protecting Access to Medicare Act of 2014. The criteria include requirements for staffing, availability and accessibility of services, care coordination, scope of services, quality and other reporting, and organizational authority. Certified Community Mental Health Centers (CMHCs) would also fall under this category. A CMHC is an entity that meets applicable licensing or certification requirements for CMHCs in the State in which it is located and provides (1) outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically mentally ill, and residents of its mental health service area who have been discharged from inpatient treatment at a mental health facility; (2) 24‐hour‐a‐day emergency care services; (3) day treatment, or other partial hospitalization services, or psychosocial rehabilitation services; and (4) screening for patients being considered for admission to State mental health facilities to determine the appropriateness of such admission.	Disproportionate Share Hospital (DSH) – A hospital that has a disproportionately large share of low‐income patients and receives an augmented payment from the State under Medicaid or a payment adjustment from Medicare. Hospital‐based outpatient clinics are included under this definition.
End Stage Renal Disease (ESRD) Dialysis Centers ‐ An ESRD facility is an entity that provides outpatient maintenance dialysis services, or home dialysis training and support services, or both. ESRD facilities are classified in Section 1881 of the Social Security Act and codified in 42 CFR 413.174 as being either hospital‐based or independent facilities.	Federally Qualified Health Center – FQHCs include: (1) nonprofit entities that receive a grant, or funding from a grant, under section 330 of the Public Health Service Act to provide primary health services and other related services to a population that is medically underserved; (2) FQHC “Look‐Alikes” which are nonprofit entities that are certified by the Secretary of HHS as meeting the requirements for receiving a grant under section 330 of the Public Health Service Act but are not grantees; and (3) outpatient health programs or facilities 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. FQHCs include Community Health Centers, Migrant Health Centers, Health Care for the Homeless Health Centers, and Public Housing Primary Care Health Centers.
Home Health Agency – An agency or organization, certified under section 1861(o) of the Social Security Act that is primarily engaged in providing skilled nursing care and other therapeutic services.	Hospice Program – An agency or organization, certified under section 1861(dd)(2) of the Social Security Act, that provides 24‐hour care and treatment services (as needed) to terminally ill individuals and bereavement counseling for their immediate family members. This care is provided in individuals’ homes, on an outpatient basis, and on a short‐term inpatient basis, directly or under arrangements made by the agency or organization.
Indian Health Service Health Center – A health care facility (whether operated directly by the Indian Health Service or by a tribe or tribal organization, contractor or grantee under the Indian Self‐ Determination Act, as described in 42 Code of Federal Regulations (CFR) Part 136, Subparts C and H, or by an urban Indian organization receiving funds under Title V of the Indian Heath Care Improvement Act) that is physically separated from a hospital, and which provides clinical treatment services on an outpatient basis to persons of Indian or Alaskan Native descent as described in 42 CFR Section 136.12.	Native Hawaiian Health Center – An entity as defined in 42 U.S.C. § 11711(4): (a) which is organized under the laws of the State of Hawaii; (b) which provides or arranges for health care services through practitioners licensed by the State of Hawaii, where licensure requirements are applicable; (c) which is a public or nonprofit private entity; and, (d) in which Native Hawaiian health practitioners significantly participate in the planning, management, monitoring, and evaluation of health services.

Nurse Managed Health Clinic/Center – An entity as defined in 42 U.S.C. § 254c‐1a(a)(2) which is a nurse‐practice arrangement, managed by advanced practice nurses, that provides primary care or wellness services to underserved or vulnerable populations and that is associated with a school, college, university or department of nursing, federally qualified health center, or independent nonprofit health or social services agency.	Public Hospital – Any hospital that is owned by a government (Federal, State, or Local), receives government funding, and is primarily engaged in providing the following care, by or under the supervision of physicians, to inpatients: (a) diagnostic and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons; or (b) rehabilitation of injured, disabled, or sick persons. Hospital‐based outpatient clinics are included under this definition.
Private Hospital ‐ A hospital in a State that is a private nonprofit entity and is primarily engaged in providing the following care, by or under the supervision of physicians, to inpatients: (a) diagnostic and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (b) rehabilitation of injured, disabled, or sick persons. Hospital‐based outpatient clinics and hospitals contracted with the U.S. Department of Veterans Affairs are included under this definition.	Residential Nursing Home – An institution that is primarily engaged in providing, on a regular basis, health related care and service to individuals who because of their mental or physical condition require care and service (above the level of room and board) that can be made available to them only through institutional facilities. This category includes a “skilled nursing facility,” which is an institution (or distinct part of an institution), certified under section 1819(a) of the Social Security Act, that is primarily engaged in providing skill nursing care and related services to residents requiring medical, rehabilitation, or nursing care and is not primarily for the care and treatment of mental diseases; transitional facilities; assisted living; and group homes.
Rural Health Clinic – An entity that the Centers for Medicare and Medicaid Services has certified as a rural health clinic under section 1861(aa)(2) of the Social Security Act. A rural health clinic provides outpatient services to a non‐urban area with an insufficient number of health care practitioners.	State or Local Public Health or Human Services Department – The State, county, parish, or district entity that is responsible for providing healthcare services which include health promotion, disease prevention, and intervention services in clinics or other health care facilities that are funded and operated by the Public Health or Human Services Department.
Urgent Care Center ‐ Urgent Care centers provide acute episodic care on a walk‐in basis to assist patients with an illness or injury that does not appear to be limb or life–threatening and is either beyond the scope or availability of the typical primary care practice.	Free and Charitable Clinics – Free and Charitable Clinics are safety-net health care organizations that utilize a volunteer/staff model to provide a range of medical, dental, pharmacy, vision and/or behavioral health services to economically disadvantaged individuals. Such clinics are 501(c)(3) tax-exempt organizations, or operate as a program component or affiliate of a 501(c)(3) organization. Please note: volunteer staff are not eligible for loan repayment awards.

POC Signature Date

Printed Name Title

Phone Fax

Email Phone

1

OMB No. 0915‐0140 Expiration 04/30/2017