Form 2 NC LRP Employment Verification Form

Nurse Corps Loan Repayment Program
U.S. Department of Health and Human Services
Health Resources and Services Administration
OMB No. 0915‐0140 Expiration Date: xx/xx/xxxx

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 Statement: The purpose of this information collection is to obtain information through the Nurse Corps Loan Repayment Program that is used to assess a
Loan Repayment Program applicant’s eligibility and qualifications for the Loan Repayment Program and to monitor a participant’s compliance with the program’s service
requirements. Applicants interested in participating in the Nurse Corps Loan Repayment Program must submit an application to the Nurse Corps. 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 0915-0140 and it is valid until xx/xx/xxxx. This information collection is required to obtain or retain a benefit (Section 846 of the
Public Health Service Act, as amended [42 U.S.C. 297n]). The information is protected by the Privacy Act, but it may be disclosed outside the U.S. Department of Health
and Human Services, as permitted by the Privacy Act and Freedom of Information Act, to Congress, the National Archives, and the Government Accountability Office, and
pursuant to court order and various routine uses as described in the System of Record Notice 09-15-0037.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 14NWH04, Rockville, MD 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
PARTICIPANT AND THE SITE MAY BE DEEMED INELIGIBLE AND THE SITE CHANGE REQUEST MAY NOT BE PROCESSED.
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 PARTICIPANT
Name: _____________________________________________

Email Address: _____________________________________

PLACE OF EMPLOYMENT
Name of Facility: ________________________________
Address: ____________________________________________

Phone Number: ____________________________________

Address Line 2: _______________________________________

Email Address: _____________________________________

City: ____________________ State: _____ Zip Code:________

Website: __________________________________________

Please note: Under the Nurse Corps LRP, participants must be RNs or APRNs providing full‐time service at a Critical Shortage Facility. Full‐time service is defined as
working as an RN or APRN for a minimum of 32 hours per week. Working as needed, as an LPN, PRN, as a Pool Nurse, a Vocational Nurse, as a Travel
Nurse, for a Nurse Staffing/Travel Agency, or being self employed are not eligible for the program. If the participant is working at more than one physical
location, please complete a form for each location and ensure that the hours worked at each location add up to the total hours worked by the participant.

I hereby certify that the individual identified above:
1.

Began working or will begin working as an RN or APRN at the healthcare facility identified above on _____________ and is
mm/dd/yyyy
currently working or will be working in the following capacity:
( ) a full‐time position (defined as working as an RN or APRN for a minimum of 32 hours per week); OR
( ) less than a full‐time position (defined as working as an RN or APRN for less than 32 hours per week)

2.

Is required to work ________ hours per week.

3.

Does or will the participant work as or for any of the following; As Needed, Licensed Practical/Vocational Nurse, Nurse
Staffing/Travel Agency, Pool Nurse, PRN, Travel Nurse, or Self Employed? ( ) Yes ( ) No
If yes, please select all that apply:
( ) As Needed ( ) Licensed Practical/Vocational Nurse ( ) Nurse Staffing/Travel Agency ( ) Pool Nurse ( ) PRN
( ) Travel Nurse ( ) Self Employed
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Nurse Corps Loan Repayment Program
U.S. Department of Health and Human Services
Health Resources and Services Administration
OMB No. 0915‐0140 Expiration Date: xx/xx/xxxx

4.

Is the participant currently licensed to practice as an RN or APRN without any restrictions or encumbrances? ( ) Yes ( ) No
Please provide the following:
License Number:________________

State:__________________

Expiration Date:___________________
(mm/dd/yyyy)

5.

Does or will the participant work as a self-employed worker? ( ) Yes ( ) No

6.

Is the place of employment listed on this form a healthcare faciltiy? ( ) Yes ( ) No

7.

Profit Status of the health care facility:
( ) For-Profit;
( ) Non-Profit; or
( ) Public/Government Owned

8.

Works at the following type of Health Care Facility:

(Please check all of the site types you believe your site is. Final determination will be made by the Nurse Corps)

Ambulatory Surgical Center
An entity that operates exclusively for the purpose of furnishing surgical
services to patients who do not require hospitalization and for which the
expected duration of services does not exceed 24 hours following admission.
Community Mental Health Center
Behavioral and mental health facilities must be located in or serve in a HPSA
and must offer comprehensive primary behavioral health services to all
residents in the defined HPSA. The site must offer comprehensive primary
behavioral health care services including, but not limited to:
• Core Comprehensive Behavioral Health Service Elements:
1) screening and assessment; 2) treatment plans; and 3) care coordination;
• Non-Core Behavioral Health Service Elements:
1) diagnosis; 2) therapeutic services (including psychiatric medication
prescribing and management, chronic disease management, and substance
use disorder treatment); 3) crisis/emergency services (including 24-hour crisis
call access); 4) consultative services; and 5) case management.
Birth Centers
Also known as a birthing center, is a licensed facility staffed by certified
nurse midwives and/or physicians that provides a home-like setting for
people with low-risk pregnancies to pro Policy Workgroup Kick off meeting
vide comprehensive care throughout pregnancy, including prenatal care,
labor and delivery services, and postpartum care for both mother and
newborn. Birth centers can be free-standing buildings or attached to a
hospital.

Federally Qualified Health Center (FQHC)
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American Indian Health Facilities
A health care facility (whether operated directly by the IHS; or by a tribe or tribal
organization contracting with the IHS pursuant to the Indian Self‐Determination
and Education Assistance Act, codified at 25 U.S.C. 450 et seq.; or by an urban
Indian organization receiving funds under Subchapter IV of the Indian Heath Care
Improvement Act, codified at 25 U.S.C. 1651 et seq.), which provides clinical
treatment services to eligible American Indians and Alaska Natives on an
outpatient basis.
School Based Clinic
A health clinic that is located in or near a school facility of a school district or
board or of an Indian tribe or tribal organization.
Community Outpatient Facility
Outpatient facilities mean a health care facility, other than a hospital, or a
separate facility operated by or in conjunction with a hospital, which provides
outpatient services including, but not limited to, prescheduled surgical
service, emergency care, urgent care, laboratory or diagnostic services.
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 described under section 1881 of the Social Security Act and 42 CFR 413.174
as being either hospital-based or independent facilities.
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Nurse Corps Loan Repayment Program
U.S. Department of Health and Human Services
Health Resources and Services Administration
OMB No. 0915‐0140 Expiration Date: xx/xx/xxxx

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Native Hawaiian Health Center
An entity: (1) which is organized under the laws of the state of Hawaii; (2)
which provides or arranges for health care services through practitioners
licensed by the state of Hawaii, where licensure requirements are
applicable; (3) which is a public or nonprofit private entity; and (4) in which
Native Hawaiian health practitioners significantly participate in the planning,
management, monitoring, and evaluation of health services. For more
information, see the Native Hawaiian Health Care Act of 1992, as amended.
Private Hospital
A hospital or affiliated outpatient clinics that are private entities and are
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.
Residential Nursing Home
A institution that is primarily engaged in providing, on a regular basis, healthrelated 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 skilled 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.
Small Rural Hospital
A non-Federal, short–term general acute care hospital that is located in a rural
area (as defined for purposes of section 1886(d)); and (ii) has less than 50 beds.
Critical Access Hospitals are included as eligible within this Critical Shortage
Facility.

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Nurse Managed Health Clinic/Center
An entity 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, FQHC, or independent health or social services
agency. These clinics must serve the general public.
Public Hospital
Any hospital or hospital-based outpatient clinics that are owned by a
government (federal, state, or local), receives government funding, and are
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. U.S. Department of Veterans
Affairs hospitals and military treatment facility hospitals are also included under
this definition. State psychiatric hospitals must use facility HPSAs to determine
site eligibility, population and geographic HPSAs cannot be used.
Rural Health Clinic
An entity that the Centers for Medicare & Medicaid Services (CMS) 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 Health 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 state or local Public Health, Health, or Human Services
Departments.
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 lifethreatening and is either beyond the scope or availability of the typical primary
care practice. Urgent care centers primarily treat injuries or illnesses requiring
immediate care but not serious enough to require an emergency room visit.

____________________________________________________
Point Of Contact Signature

____________________________________________________
Date

____________________________________________________
Point Of Contact Printed Name

____________________________________________________
Point Of Contact Title

____________________________________________________
Point Of Contact Phone Number

____________________________________________________
Point Of Contact Email Address

For questions on how/where to submit this form please submit an inquiry through your My BHW account.
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