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Application {% if request.params.id %} {% assign applvn = entities.eapp_applvn[request.params.id] %}{% endif %}{{ applvn.eapp_name }} – Bachelor of Science Nursing Loan Repayment Program

Application – Bachelor of Science Nursing Loan Repayment Program

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Eligibility

General Information

Program

*

Applicant Name

*

Please list any other names you go by such as maiden names, nicknames, etc.

*

Do you have a current and unrestricted Professional License to practice your profession?*

*

Current License or Registration NoCurrent License or Registration Yes

Are you a prior or current Office of Statewide Health Planning and Development (OSHPD) or Health Care Access and Information (HCAI) Awardee?*

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Prior Awardee NoPrior Awardee Yes

As defined by Scholarship for Disadvantaged Students program, have you been identified as having a disadvantaged background based on environmental and/or economic factors, or did you receive a federal Exception Financial Need Scholarship?*

*

disadvantaged or receive financial need Nodisadvantaged or receive financial need Yes

What percent of your time currently is spent working in reproductive health?*

Are you willing to continue or begin providing abortion-related care?*

Abortion-related Care NoAbortion-related Care Yes

Are you currently working at or are you willing to commit to serve for three years in at least one of these population areas?*

Commit to serve population NoCommit to serve population Yes

Have you had abortion training or certification?*

Have you had abortion training or certification?* NoHave you had abortion training or certification?* Yes

If yes, from where?*

*

If awarded with reproductive health funds, awardees will be contacted by HCAI and a partner organization regarding opportunities related to Reproductive Health Service Corps (RHSC). Award information will be used to evaluate the effectiveness of the RHSC, unless awardees choose not to participate by selecting the option below. If awardee chooses to participate, their information including name, email, profession, grant type, and award date will be used to contact awardees regarding these opportunities and assist with RHSC evaluation. Your information will not be shared with anyone else other than the partner organization conducting outreach and program evaluation. That entity will dispose of your information once outreach and evaluation are complete.*

Please respond according to your preference.

BSN Share Reproductive Corps Opportunities Yes, I agree to the sharing of this information as it relates to Reproductive Health Service Corps opportunities and evaluation.BSN Share Reproductive Corps Opportunities No, I do not agree to sharing of this information as it relates to Reproductive Health Service Corps opportunities and evaluation.