Form 2 Revolving Loans Generic AOR Wireframes

AOR Wireframes

Contents

1. Page 1A 2

2. Page 1B 4

3. Page 2 4

4. Page 3 7

5. Page 4 11

6. Page 5 13

7. Page 6 14

8. AOR Sub-pages 17

8. Age and Gender 17

Public Burden Statement: The purpose of this information collection request is to obtain information for the administrative requirements pertaining to the Health Professions Student Loan (HPSL), Loans for Disadvantaged Students (LDS), Primary Care Loan (PCL) and Nursing Student Loan Programs (NSL). Participating HPSL, LDS, PCL and NSL schools are responsible for determining eligibility of applicants making loans, and collecting monies owed by borrowers on their outstanding loans. 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 0915-0047 and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit (HPSL – Sections 721-722 and 725-735 of the PHS Act; LDS – Sections 721-722 and 724-735 of the PHS Act; PCL – Sections 721-723 and 725-735 of the PHS Act; NSL – Sections 835-842 of the PHS Act). 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 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.

OMB #: 0915-0047

Expiration Date: xx/xx/202x

1. Page 1A

Student/Graduate Data	Cumulative ($) (Previous Years)	Cumulative ($) (Includes current year)	Current Year ($) (07/01/2020-06/30/2021)
1. Number of Loans for the <Discipline>	Prepopulated	Prepopulated
2. Total Dollar Amount of Loans Awarded for the <Discipline>	Prepopulated	Prepopulated
3. Total Full-Time Enrollment for the <Discipline> for the academic year (both non-HPSL and HPSL recipients)	Prepopulated	Prepopulated
4. Total Number of Defaulted Loans for the <Discipline>	Prepopulated	Prepopulated
5. Total Original Defaulted Principal Loaned for the <Discipline>	Prepopulated	Prepopulated
6a. Total Number of Students who dropped out of the <Discipline>	Prepopulated	Prepopulated
6b. Of the number above, how many of them were Health Careers Loans Branch student borrowers	Prepopulated	Prepopulated
7a. Total Number of Health Careers Loans Branch student borrowers for the <Discipline>	Prepopulated	Prepopulated
7b. Of the number of Health Careers Loans Branch student borrowers for the <Discipline> above, number of Active and Non Retired/Defaulted Borrowers	Prepopulated	Prepopulated and editable
8. Total Number of Health Careers Loans Students including those who graduated during the reporting period for the <Discipline> (Age and Gender details)	Prepopulated	Prepopulated
9. Total Graduates (HPSL- <Discipline> only)	Prepopulated	Prepopulated
10. Number of Health Careers Loans Branch students including those who graduated during this reporting period that indicate an intention to serve in a medically underserved community	Prepopulated	Prepopulated
11. Number of Health Careers Loans Branch students including those that graduated during this reporting period that indicate an intention to practice in primary care	Prepopulated	Prepopulated
12. Number of Health Careers Loans Branch students including those who graduated during this reporting period that are from rural backgrounds	Prepopulated	Prepopulated

Current Year Graduate Special Data	Number of Graduates
13. Total number of full time graduates (Health Career Loans recipients and Non-Health Careers Loans recipients) at your school during the current reporting period.
13a. Of the total number in question 1A-13, how many are URM graduates.
13b. Of the total number in question 1A-13, how many are non-URM graduates.
14. Total number of full time HPSL graduates during the current reporting period who indicate intent to serve in a rural area.

Prior Year Graduate Special Data for 2019-2020 Academic Year	Number of Graduates
15a. Total Number Recipients who graduated in academic year 2018-2019	0 – Warning: If number is zero, you must provide a justification.
15b. Of the Total Graduates reported in question 1A-15a, the Number of Full-Time and Half-Time Graduates in academic year 2019-2020 serving in Medically Underserved Communities	0 – Warning: If number is zero, you must provide a justification.
15c. Of the Total Graduates reported in question 1A-15a, the Number of Full-Time and Half-Time Graduates in academic year 2019-2020 serving in Primary Care	0 – Warning: If number is zero, you must provide a justification.
15d. Of the Total Graduates reported in question 1A-15a, the Number of Full-Time and Half-Time Graduates in academic year 2019-2020 who entered the field for which they received the degree	0 – Warning: If number is zero, you must provide a justification.
15e. Of the Total Graduates in question 1A-15a, the Number of Full-Time and Half-Time Graduates in academic year 2019-2020 who entered service in a rural area.	0 – Warning: If number is zero, you must provide a justification.
15f. Based on the graduates reported in 15e, what is the outstanding debt of the graduates in rural areas.	0 – Warning: If number is zero, you must provide a justification.

Student Special Data
16. Please indicate the recruitment activities for disadvantaged students your school uses for the LDS program by checking all box(s) that apply. (Recruitment Details)
16a. Are you a Community College.	The response will  be either Yes or No, provided by radio buttons or a drop down menu
16b. Are you a Historically Black College or University.	The response will  be either Yes or No, provided by radio buttons or a drop down menu
16c. Are you a Tribal Institution.	The response will  be either Yes or No, provided by radio buttons or a drop down menu
16d. Where is your institution located?	the response should be either Rural, Urban or Other, provided by radio buttons or a drop down menu
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. (Retention Details)
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. (Type of Retention Activities Details)
18. Please share in the box below any success stories about LDS recipients. (Maximum 250 characters)

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).
Description	Cumulative (Includes Current Year)	Current (New LDS Recipients)
HCOP	Pre-Populated
COE	Pre-Populated
Other	Pre-Populated
Other Program Titles	Pre-Populated

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. (Maximum 100 characters)
Clinic 1:
Clinic 2:
Clinic 3:

Student/Graduate Data	Academic Year		Cumulative (Previous Year)	Cumulative from 1993 to AY 2015-2016
	2014-2015	2015-2016
21. Total Graduates (<Discipline> Only)	Pre-populated		Pre-populated	Pre-populated
22. Of the number above, the number of Graduates in Primary Care Residencies & Practice	Pre-populated		Pre-populated	Pre-populated
23. Percentage of Graduates in Primary Health Care	Pre-populated
24. Percentage of Change from Prior Year	Pre-populated

2. Page 1B

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
C. Black or African-American
D. Native Hawaiian or Other Pacific Islander
E. White
A. Hispanic or Latino
B. Race Not Reported
Total (A + B)

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
C. Black or African-American
D. Native Hawaiian or Other Pacific Islander
E. White
F. More than one race
G. Race Not Reported
Total (A + B + C + D + E + F + G)

3. Page 2

Program Accounts Section
A. Federal Funds Awarded	Cumulative ($) (Previous Year)	Cumulative ($) (Includes Current Year)		Current Year ($)
1. Federal Funds Awarded	Prepopulated	Prepopulated		Prepopulated
B. Cash Balance – Start of Report Period				Current Year
1. Cash Balance – Start of Report Period				Prepopulated
2. Cash Balance – Start of Report Period Adjustment	.			This field is grayed out for grantee. This field is only available to POs to make adjustments
C. Cash Receipts	Cumulative ($) (Previous Year)	Cumulative ($) (Includes Current Year)		Current Year ($)
1. Federal Funds Received/Receivable	Prepopulated	Prepopulated
2. Institutional Contributions Deposited	Prepopulated	Prepopulated
3. Transferred from Scholarship Fund	Prepopulated	Prepopulated
4. Loan Principal Collected	Prepopulated	Prepopulated
5. Interest Income Collected on Loans	Prepopulated	Prepopulated
6. Penalty Charges Collected on Loans	Prepopulated	Prepopulated
7. Investment Income	Prepopulated	Prepopulated
8. Institutional Repayments of Bad Debts, Principal	Prepopulated	Prepopulated
9. Institutional Repayments of Bad Debts, Interest	Prepopulated	Prepopulated
10. Institutional Repayments of Bad Debts, Penalty charges	Prepopulated	Prepopulated
C. Total	Prepopulated	Prepopulated
D. Cash Disbursements
1. Loaned to Students	Prepopulated	Prepopulated
2. Transferred to Scholarship Fund	Prepopulated	Prepopulated
3. Repayments to Federal Government, Principal	Prepopulated	Prepopulated
4. Repayments to Federal Government, Interest	Prepopulated	Prepopulated
5. Repayments to Federal Government, Other Income	Prepopulated	Prepopulated
6. Repayments to Institution, Principal	Prepopulated	Prepopulated
7. Repayments to Institution, Interest	Prepopulated	Prepopulated
8. Repayments to Institution, Other Income	Prepopulated	Prepopulated
9. Collection Agent Costs, Principal	Prepopulated	Prepopulated
10. Collection Agent Costs, Interest	Prepopulated	Prepopulated
11. Litigation Costs, Principal	Prepopulated	Prepopulated
12. Litigation Costs, Interest	Prepopulated	Prepopulated
13. Credit Bureau Fees	Prepopulated	Prepopulated
14. Other Costs	Prepopulated	Prepopulated
D. Total	Total	Total
E. Cash Balance – End of Report Period				Current Year ($)
1. Cash Balance – End of Report Period	Total
2. Cash Balance – End of Report Period Adjustment			This field is grayed out for grantee. This field is only available to POs to make adjustments. This total should be carried over to the next years AOR as the Beginning Balance.

4. Page 3

Program Accounts Section
F.1. Loan Cancellations to Borrowers – Professional Practice
Description	Cumulative (Previous Year)				Cumulative (Includes Current Year)							Current Year
	Number of Borrowers	Principal ($)	Interest ($)		Number of Borrowers		Principal ($)		Interest ($)			Number of Borrowers		Principal ($)		Interest ($)
a. HP Practice – Shortage (10%)	Prepopulated	Prepopulated	Prepopulated		Prepopulated		Prepopulated		Prepopulated
b. HP Practice – Rural Shortage (15%)	Prepopulated	Prepopulated	Prepopulated		Prepopulated		Prepopulated		Prepopulated
F.1. Total					Total		Total		Total
F.2. Loan Cancellations to Borrowers – Nursing Employment
Description	Cumulative (Previous Year)				Cumulative (Includes Current Year)							Current Year
	Number of Borrowers	Principal ($)	Interest ($)		Number of Borrowers		Principal ($)		Interest ($)			Number of Borrowers		Principal ($)		Interest ($)
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
F.2. Total	Total	Total	Total		Total		Total		Total			Total		Total		Total
F.3. Loan Cancellations to Borrowers – Death
Description	Cumulative (Previous Year)				Cumulative (Includes Current Year)							Current Year
	Number of Borrowers	Principal ($)	Interest ($)		Number of Borrowers		Principal ($)		Interest ($)			Number of Borrowers		Principal ($)		Interest ($)
a. On HPSL Loans made on or after 10/22/85	Prepopulated	Prepopulated	Prepopulated		Prepopulated		Prepopulated		Prepopulated
b. On Loans except those made after F.3.a	Prepopulated	Prepopulated	Prepopulated		Prepopulated		Prepopulated		Prepopulated
F.3. Total	Total	Total	Total		Total		Total		Total			Total		Total		Total
F.4. Loan Cancellations to Borrowers – Permanent & Total Disability Approved by HHS
Description	Cumulative (Previous Year)				Cumulative (Includes Current Year)							Current Year
	Number of Borrowers	Principal ($)	Interest ($)		Number of Borrowers		Principal ($)		Interest ($)			Number of Borrowers		Principal ($)		Interest ($)
a. On Loans made on or after 10/22/85	Prepopulated	Prepopulated	Prepopulated		Prepopulated		Prepopulated		Prepopulated
b. On Loans except those reported after F.4.a	Prepopulated	Prepopulated	Prepopulated		Prepopulated		Prepopulated		Prepopulated
F.4. Total	Total	Total	Total		Total		Total		Total			Total		Total		Total
G. Bad Debts Approved For Write-Off By HHS
Description	Cumulative (Previous Year)					Cumulative (Includes Current Year)							Current Year
	Number of Borrowers	Principal	Interest	Penalty Charges ($)		Number of Borrowers		Principal ($)		Interest ($)	Penalty Charges ($)		Number of Borrowers		Principal ($)		Interest ($)	Penalty Charges ($)
Total Approved	Prepopulated	Prepopulated	Prepopulated	Prepopulated		Prepopulated		Prepopulated		Prepopulated	Prepopulated

5. Page 4

Excess Cash Worksheet Section
Description	Amount ($)
A. General Ledger Cash Balance as of 6/30/2020
B. Actual Collections for 07/01/2020-06/30/2021
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 07/01/2020-06/30/2021
1. Federal Funds Received/Receivable
D. Institutional Contribution for 07/01/2020-06/30/2021
1. Institutional Contribution
E. Projected Collections for 7/1/2021– 6/30/2022
1. Principal
2. Interest
3. Investment Income and Penalty Charges
F. Projected Funds Available as of 6/30/2022
1. Projected Funds Available (A+B+C+D+E)
G. Actual Expenditures for 07/01/2020-06/30/2021
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 7/1/2021 – 6/30/2022
1. Loans to Students
2. Costs (Collection, Litigation and Credit Bureau)
I. Projected Expenditures as of 6/30/2022
1. Projected Expenditures (G+H)
J. Projected Cash Balance as of 6/30/2022
1. Projected Cash Balance (F-I)
K. Less Projected Expenditures for 7/1/2022 – 6/30/2023
1. Less Projected Expenditures
L. Excess Cash
1. Excess Cash (J – K)
M. General Ledger Ending Cash Balance as of 6/30/2021
1. General Ledger Ending Cash Balance

6. Page 5

   Program Accounts Section
   H. Default Rate (Pre-populated. No entry required)
   1. Default Rate (%)	Prepopulated
   For Active Schools
   2. Excess cash($) from report page 4 that was or will be returned to PMS	Change the Verification Warning on this field to a regular Warning and make it editable.
   3. Excess cash($) from report page 4 that was or will be returned to the Division of Financial Operations	Eliminate the auto-population for this field and make it editable
   For Closing Schools
   4. Amount of cash($) determined to be due the Federal Government and remitted separately to the Division of Financial Operations	Prepopulated
   I Checklist/Questions
   1. What is the total amount ($) of interest that is past due?
   2. Does your institution provide for a biennial audit of the loan and/or scholarship funds by a qualified independent auditor?
   Audits	MM	YYYY
   a. Period of last audit – Start Date
   b. Period of last audit – End Date
   c. Date audit submitted to Regional Audit Agency

7. Page 6

Program Accounts Section
1. Fully Retired
	Number of Borrowers (1)	Principal Loaned (2)	Principal Repaid (3)	Principal Cancelled		Principal Delinquent (6)	Principal Uncollectible Not Past Due (7)	Principal Outstanding but Not Due (8)	Principal Written Off (9)	Capitalized Interest (10)	Reconciling Difference (Column 2 + 10 – Sum of Columns 3 through 9)
				Employment as Nurse Faculty (4)	Description
A. Repayment/Cancellation				Prepopulated
B. Cancellation/Death				Prepopulated
C. Cancellation/Disability				Prepopulated
D. Discharged in Bankruptcy				Prepopulated
E. HHS Approved Write-Off				Prepopulated
F. Uncollectible per P.L. 107-205				Prepopulated
1. Total (Sum of A through F)	Total	Total	Total	Total	Total	Total	Total	Total	Total	Total
2. Current
Description	Number of Borrowers (1)	Principal Loaned (2)	Principal Repaid (3)	Principal Cancelled		Principal Delinquent (6)	Principal Uncollectible Not Past Due (7)	Principal Outstanding but Not Due (8)	Principal Written Off (9)	Capitalized Interest (10)	Reconciling Difference (Column 2 + 10 – Sum of Columns 3 through 9)
				Employment as Nurse Faculty (4)	Death/Disability (5)
A. Student Status
B. Grace Period
C. Deferment Status				Prepopulated
D. Postponement/Cancellation				Prepopulated
E. Repayment – Not Past Due				Prepopulated
F. Past Due 1-119 Days				Prepopulated
2. Total (Sum of A through f)	Total	Total	Total	Total	Total	Total	Total	Total	Total	Total
3. In Bankruptcy
Description	Number of Borrowers (1)	Principal Loaned (2)	Principal Repaid (3)	Principal Cancelled		Principal Delinquent (6)	Principal Uncollectible Not Past Due (7)	Principal Outstanding but Not Due (8)	Principal Written Off (9)	Capitalized Interest (10)	Reconciling Difference (Column 2 + 10 – Sum of Columns 3 through 9)
				Employment as Nurse Faculty (4)	Death/Disability (5)
A. Pending Discharge/Wage Earners Agreement				Prepopulated
4. In Default
Description	Number of Borrowers (1)	Principal Loaned (2)	Principal Repaid (3)	Principal Cancelled		Principal Delinquent (6)	Principal Uncollectible Not Past Due (7)	Principal Outstanding but Not Due (8)	Principal Written Off (9)	Capitalized Interest (10)	Reconciling Difference (Column 2 + 10 – Sum of Columns 3 through 9)
				Employment as Nurse Faculty (4)	Death/Disability (5)
A. 120 Days and Over				Prepopulated
5. Forbearance
Description	Number of Borrowers (1)	Principal Loaned (2)	Principal Repaid (3)	Principal Cancelled		Principal Delinquent (6)	Principal Uncollectible Not Past Due (7)	Principal Outstanding but Not Due (8)	Principal Written Off (9)	Capitalized Interest (10)	Reconciling Difference (Column 2 + 10 – Sum of Columns 3 through 9)
				Employment as Nurse Faculty (4)	Death/Disability (5)
A. Forbearance				Prepopulated
Total	Total	Total	Total	Total	Total	Total	Total	Total	Total	Total

8. AOR Sub-pages

8. Age and Gender

Students by Age and Gender
Age	Males	Females	Total
Under 20
20-29
30-39
40-49
50-59
60 or Older
Unreported/Unavailable
Total

17