Form 2 Scholarships for Disadvantaged Students Program Specific

Scholarships for Disadvantaged Students Program Specific Data Forms

OMB Approval No: 0915-0149
Expiration Date: 11/30/2022

Fields marked with an asterisk (*) are required
Program Specific Information
*Note: The institution MUST be a public or non profit institution, in order to be eligible for SDS funds for any discipline. The following list of disciplines is the ONLY exception
to the rule
• Nursing (Associate, Baccalaureate, Diploma or Graduate)
• Physician Assistant (Associate, Baccalaureate or Graduate)
(For example: If the institution is applying for any of the disciplines mentioned above, it need NOT be public or non profit).
* To be eligible a school/program must be accredited by the relevant accrediting body approved for such purpose by the Secretary of Education.

Scholarships for Disadvantaged Students
* Current Fiscal Year
(Select the fiscal year date that is provided in the current SDS Funding Opportunity Announcement cover page)
* ADD DISCIPLINE
Select your Discipline

* A. PUBLIC OR NON PROFIT INSTITUTION
Is your school/program an accredited public or an accredited non profit institution?

Contact Information
* B. POINT OF CONTACT
Person Information
Title
* First Name
* Last Name
* Email Address
* Phone Number

(

)

-

Ext:

Yes

No

STUDENTS BY RACE AND ETHNICITY (DISCIPLINE: )
C. FULL-TIME STUDENTS IN YOUR PROGRAM FOR ACADEMIC YEARS 2016-2019 (7/1/2016 - 6/30/2019) AND THEIR RACIAL/ETHNIC BACKGROUNDS
1. Hispanic or Latino Students
* Did your program have full-time students of "Hispanic or Latino Ethnicity"?
Hispanic or Latino Students by Race

Number of Full-time Students Enrolled for
Academic Year (7/1/2016 - 6/30/2017)

Yes

No

Number of Full-time Students Enrolled for
Academic Year (7/1/2017 - 6/30/2018)

Number of Full-time Students Enrolled for
Academic Year (7/1/2018 - 6/30/2019)

a. American Indian/ Alaskan Native
b. Black or African American
c. Asian
d. Native Hawaiian or Other Pacific Islander
e. White
f. More Than One Race
g. Race Not Reported
Sub Total

2. Non-Hispanic or Non-Latino Students
* Did your program have full-time students of "Non-Hispanic or Non-Latino Ethnicity"?
Non-Hispanic or Non-Latino Students by
Race
a. American Indian/ Alaskan Native
b. Black or African American
c. Asian
d. Native Hawaiian or Other Pacific Islander
e. White
f. More Than One Race
g. Race Not Reported
Sub Total
Grand Total (Sum of Hispanic or Latino
Students and Non-Hispanic or Non-Latino
Students)

Number of Full-time Students Enrolled for
Academic Year (7/1/2016 - 6/30/2017)

Yes

No

Number of Full-time Students Enrolled for
Academic Year (7/1/2017 - 6/30/2018)

Number of Full-time Students Enrolled for
Academic Year (7/1/2018 - 6/30/2019)

PROGRAM INFORMATION (DISCIPLINE: )
* D. TOTAL FULL-TIME CLASS ENROLLMENT AND FULL-TIME DISADVANTAGED BACKGROUND ENROLLMENT BY CLASS YEAR FOR STUDENTS IN YOUR
PROGRAM FOR ACADEMIC YEARS 2016-2019 (7/1/2016 - 6/30/2019)
Total Full-Time Class Enrollment
Class Year

Academic Year
7/1/2016 - 6/30/2017

Academic Year
7/1/2017 - 6/30/2018

Total Full-Time Disadvantaged Background Enrollment
Academic Year
7/1/2018 - 6/30/2019

Academic Year
7/1/2016 - 6/30/2017

Academic Year
7/1/2017 - 6/30/2018

Academic Year
7/1/2018 - 6/30/2019

First Year
Second Year
Third Year
Fourth Year
Fifth Year
Sixth Year
Total
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
* E. TOTAL FULL-TIME GRADUATES AND FULL-TIME DISADVANTAGED BACKGROUND GRADUATES FOR ACADEMIC YEARS 2016-2019 (7/1/2016 - 6/30/2019)
Academic Year
7/1/2016 - 6/30/2017

Academic Year
7/1/2017 - 6/30/2018

Total full-time graduates
Full-time disadvantaged background graduates
Of the total full-time graduates for academic years (2016 - 2019), enter the number of graduates that received SDS or similar scholarships for students
from disadvantaged backgrounds
Of the total full-time graduates for academic years (2016 - 2019), enter the number of students who qualify as coming from a disadvantaged
background under the economic disadvantaged definition

Academic Year
7/1/2018 - 6/30/2019

* F. GRADUATES FROM YOUR PROGRAM SERVING IN PRIMARY CARE AND/OR MEDICALLY UNDERSERVED COMMUNITIES
Primary Care
Academic Year
7/1/15 - 6/30/16

Academic Year
7/1/16 - 6/30/17

Academic Year
7/1/17 - 6/30/18

Academic Year
7/1/16 - 6/30/17

Academic Year
7/1/17 - 6/30/18

Academic Year
7/1/18 - 6/30/19

Academic Year
7/1/15 - 6/30/16

Academic Year
7/1/16 - 6/30/17

Academic Year
7/1/17 - 6/30/18

Academic Year
7/1/16 - 6/30/17

Academic Year
7/1/17 - 6/30/18

Academic Year
7/1/18 - 6/30/19

Number of full-time graduates

Of the full-time graduates, enter the number of graduates serving in primary care

Of the full-time graduates serving in primary care (above), enter the number of graduates that
received SDS funds or similar scholarships from disadvantaged backgrounds
Medically Underserved Communities

Number of full-time graduates

Of the full-time graduates, enter the number of graduates practicing in medically underserved
communities
Of the full-time graduates practicing in medically underserved communities, enter the number of
graduates that received SDS funds or similar scholarships from disadvantaged backgrounds
* G. COST OF TUITION FOR FULL-TIME STUDENTS FOR THIS PROGRAM
$

Cost of Tuition for Full-Time Students for This Program
* H. LENGTH OF PROGRAM
Length of time (in years) necessary to complete this program
(Example: Nursing Baccalaureate, select 4)
* I. ACCREDITATION
Name of Accrediting Body

If 'Other' specify name:
Expiration Date (mm/dd/yyyy)

* J. REQUESTED AWARD AMOUNT
What is your total need amount?
(Requested amount cannot be less than $ 1000)

$

* K. STUDENTS SUPPORTED
How many students do you plan to support with the requested award amount?
* L. CERTIFICATION AND ELIGIBILITY QUESTIONS
Yes

Will preference be given to students for whom the cost of attendance would constitute a severe financial hardship?

No

Describe the school's methods and standards for setting the amount of the scholarships.
Select the method (including frequency) the program will use to disburse the SDS scholarships to students.
Check all that apply.

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

How will you use the SDS scholarship funds?

Tuition
Fees and Other Reasonable Educational Expenses
Reasonable Living Expenses

* M. COMMUNITY COLLEGE QUESTION
Is your school a community college?

Yes

No

Yes

No

* 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?

RECRUITMENT INFORMATION (DISCIPLINE: )
*Note: A school must have at least one recruiting activity to be eligible for SDS funding.
* O. Please indicate the recruitment activities for students from disadvantaged backgrounds that apply to your program. Check all that apply.
High School Recruitment
General

College Fairs
Summer camps/programs for high school students to receive information about programs offered
Other; Please Specify (Maximum 100 characters):
N/A

Specifically Targeting/Recruiting
Students from Disadvantaged
Backgrounds

Attending college fairs in areas with high percentages of students from disadvantaged backgrounds locally or on a broader
scale
Training recruiters specifically to answer questions and provide information to students from disadvantaged backgrounds
Providing specifically designed information packets on programs and accommodations your school offers for students from
disadvantaged backgrounds
Prep Courses for high school students from disadvantaged backgrounds interested in careers in the health professions
Other; Please Specify (Maximum 100 characters):
N/A

College Level Recruitment
General

Recruitment from community colleges in disadvantaged areas
Community College joint admissions programs for students from disadvantaged backgrounds
Other; Please Specify (Maximum 100 characters):
N/A

Specifically Targeting/Recruiting
Students from Disadvantaged
Backgrounds

Attending college fairs in areas with high percentages of students from disadvantaged backgrounds locally or on a broader scale
Training recruiters specifically to answer questions and provide information to students from disadvantaged backgrounds
Providing specifically designed information packets on programs and accommodations your school offers for students from
disadvantaged backgrounds
Prep Courses for high school students from disadvantaged backgrounds interested in careers in the health professions
Other; Please Specify (Maximum 100 characters):
N/A

Application Services

Online programs that waive or assist with application fees for students from disadvantaged backgrounds
Other; Please Specify (Maximum 100 characters):
N/A

Open Houses

Booths or presentations on resources for students from disadvantaged backgrounds
Targeted advertisements for open houses or other programs in areas with high percentage of students from disadvantaged
backgrounds
Other; Please Specify (Maximum 100 characters):
N/A

RETENTION INFORMATION (DISCIPLINE: )
*Note: A school must have at least one retention activity to be eligible for SDS funding.
* P. Please indicate the retention activities for students from disadvantaged backgrounds that apply to your program. Check all that apply.
Individual or Group Peer Mentor Program
(Big Brother/Big Sister)

Open to all
Specifically designed for students from disadvantaged backgrounds
Placing students in peer support or networks and groups
Other; Please Specify (Maximum 100 characters):
N/A

Individual Staff/Advisor Mentor Program

Open to all
Specifically designed for students from disadvantaged backgrounds
Other; Please Specify (Maximum 100 characters):
N/A

Specialized Pre-attendance Orientation
for Students from Disadvantaged
Backgrounds

Team and camaraderie building activities to help students feel included in the school
Educate students from disadvantaged backgrounds on how to best use the accommodations and resources the school provides
Introduce and build contacts between students from disadvantaged backgrounds and faculty/staff (ex: Heads of departments,
Tutors, Financial aid and/or advisors)
Specialized welcome packets for students from disadvantaged backgrounds with additional information on available
resources and programs that will help them succeed
Other; Please Specify (Maximum 100 characters):
N/A

College Skills Development and Review
Programs

Summer or pre-matriculation sessions in a classroom setting teaching students from disadvantaged backgrounds skills that
they will need to be successful (e.g.: study skills, note taking skills, test taking skills, and/or time management skills)
Summer or pre-matriculation classes for students from disadvantaged backgrounds to review and strengthen prerequisite
knowledge of the course work
Individual assessment and profile of students from disadvantaged backgrounds strengths and weaknesses with advisor and
plan for development of skills
Other; Please Specify (Maximum 100 characters):
N/A

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 students from disadvantaged backgrounds to ensure success/coordination
support
Provide learning specialists for students from disadvantaged backgrounds who can identify possible learning disabilities or
assess strengths and weaknesses
Seminars and lectures specifically for students from disadvantaged backgrounds
Other; Please Specify (Maximum 100 characters):
N/A

Group or Individual Tutoring Services

Provide faculty or peer tutors to students from disadvantaged backgrounds
Tutors specifically trained to help students faced with difficulties and are from a disadvantaged background
Financial mentoring/tutoring
Other; Please Specify (Maximum 100 characters):
N/A

Child Care Support

Free
Partially Subsidized
Other; Please Specify (Maximum 100 characters):
N/A

Professional Opportunities

Shadowing health professional
Interviewing health professional
Other; Please Specify (Maximum 100 characters):
N/A