Bureau of Health Workforce Application to Participate in the

1 |HPSL Application Page

U.S. Department of Health and Human Services

Health Resources and Services Administration

Bureau of Health Workforce

Application to Participate in the

HEALTH PROFESSIONS STUDENTS LOANS (HPSL) Program

Section I: INDICATIVE DATA

Institution: ______________________________________________________

Address: ______________________________________________________

______________________________________________________

Address:

City:

State:

Zip Code: _____________________ Zip 4 Code: ______________________

Telephone: _____________________ Fax: ____________________________

USSid: (If Exist) _____________________ DUNS: _________________________

Congressional District: ________________________________________________

Central Registry Entity Identification Number: _____________________________

Institution Code: _____________________________________________________

OPSID (leave blank):____________

A. PROGRAM DISCIPLINE:

Check the appropriate line

_________ Dentistry _________Optometry __________Pharmacy

_________Podiatric Medicine _________Veterinary Medicine

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(An application must be filled out for each discipline)

B. ACCREDITATION INFORMATION:

a. Name of Accrediting Association: _______________________________________________

b. Status of Accreditation (check the appropriate line)

_________

Full Accreditation

Provisional or Conditional Accreditation

c. Date (Month and Year) when current accreditation will expire _________________________ .

d. Is your institution a public or nonprofit institution? (Yes/No): __________________________

Section II: APPLICATION DATA

__________________

$_________________

________________

A. ENROLLMENT:

Full-time discipline student enrollment as of October 15, 2021

B. FUNDS REQUESTED:

a. Projected Need for the period 07/01/2022 - 06/30/2023

(NOTE: requested amount may not be the full amount received.)

b. Institutional Contribution (1/9

of line a)

c. Total Funds Requested for the period 07/01/2022 -06/30/2023

(Sum of a and b) $_

TERMS AND CONDITIONS OF AGREEMENT

The terms and conditions set forth represent the agreement between the applicant school and the

Secretary of Health and Human Services for the establishment and maintenance of a Health

Professions Student Loan (HPSL) fund, and are binding on all parties and personnel participating

in the program supported.

PROGRAM ADMINISTRATOR: Please indicate the person responsible for the day-to-day

administration of this program.

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SIGNATURE OF AUTHORIZING OFFICIAL: This agreement must be signed by the

Authorizing Official. The person designated as the Authorizing Official is legally responsible and

accountable for the use and disposition of any funds awarded on the basis of this agreement.

A. ASSURANCES AND PUBLIC POLICY REQUIREMENTS

Title VI of the Civil Rights Act of 1964 and 45CFR Part 80 states: ANo person in the United

States shall, on the grounds of race, color, or national origin, be excluded from participation in, be

denied the benefits of, or be subjected to discrimination under any program or activity receiving

financial assistance from the Department of Health and Human Services (DHHS), must be

operated in compliance with this law.

Attention is called to the requirements of Title IX of the Education Amendments of 1972 and in

particular to Section 901 of such Act and 45 CFR 86, which provide that no person in the United

States shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or be

subjected to discrimination under any educational program or activity receiving Federal financial

assistance.

Attention is called to Section 710 of the Public Health Service (PHS) Act which provides that no

contract, grant, cooperative agreement, loan guarantee, or interest subsidy payment may be

awarded under Titles VII and VIII to, or for the benefit of, any school program or training center

if the tuition level or educational fees at the school, program or training center are higher for certain

students solely on the basis those such students are the recipients of traineeships, loans, loan

guarantees, service scholarships, or interest subsidies from the Federal Government.

In accordance with 45 CFR, Part 83 of the DHHS Regulations issued under Section 704 and 855

of the PHS Act, no grant, loan guarantee, or interest subsidy payment under Titles VII or VIII of

the PHS Act shall be made to or for the benefit of any entity, and no contract under Titles VII or

VIII of the PHS Act shall be made with any entity, unless the entity will not discriminate on the

basis of sex in the admission of individuals to its training programs.

In accordance with 45 CFR Part 91, attention is called to the general rule that no person in the

United States shall, on the basis of age, be excluded from participation in, be denied the benefits

of, or be subjected to discrimination under any program or activity receiving financial assistance.

Attention is called to the requirements of OMB circular M-87-32 which provide that an applicant

institution receiving a loan must not be delinquent on any Federal debt.

The applicant institution must comply with the requirements of 45 CFR, Part 76, Subpart F, which

requires certification that grantees will provide and maintain a drug-free workplace.

The Drug-Free Schools and Communities Act Amendments of 1989, P.L. 101-226, require that

any public or private institution of higher education (including independent hospitals conducting

training programs for health care personnel), State educational agency, or local educational agency

receiving Federal financial assistance must certify to the Secretary of Education, as a condition for

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funding, that it has adopted and implemented a drug prevention program as described in 34CFR,

Part 86, (55FR 33580), August 16, 1990. The provisions of the regulations also apply to

subgrantees which receive Federal funds from any Federal grantee regardless of whether or not

the primary grantee is an institution of higher education, State educational agency, or local

educational agency.

The applicant organization must certify, among other things, that neither it nor its principals are

presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily

excluded from covered transactions by any Federal department or agency. Subawardees, (i.e, other

corporations, partnerships, or other legal entities called Alower tier@ participants), must make the

same certification to the applicant organization concerning their covered transactions. The

pertinent DHHS regulations are found in 45 CFR Part 76.

B. ELIGIBILITY CRITERIA

Institutions must meet certain criteria in order to be eligible to participate in the HPSL program,

which fall into the following categories:

•

discipline and degree programs;

•

location of the institution;

•

accreditation;

•

written agreement between the institution and the Secretary of Health and

Human Services;

•

default rate performance standard;

•

non-discrimination requirements;

•

non-delinquency of the institution on Federal debt;

•

drug-free workplace, schools and campuses requirements;

•

lobbying and disclosure of lobbying requirements; and

•

debarment and suspension provisions.

DISCIPLINE AND DEGREE PROGRAMS

Any public or other nonprofit institution that offers degrees to full-time students in disciplines

as specified below may apply to participate in the HPSL program:

•

doctor of dentistry;

•

bachelor or doctor of science in pharmacy;

•

doctor of podiatric medicine;

•

doctor of optometry; and

•

doctor of veterinary medicine.

Note: With the enactment of the Health Professions Education Extension Amendments of 1992,

schools of allopathic medicine and osteopathic medicine will be phasing their HPSL funds into

Primary Care Loan (PCL) funds. Effective July 1, 1993, new borrowers must train and practice

as primary health care physicians. Only borrowers who obtained HPSL loans prior to July 1,

1993 will be eligible to receive HPSLs without meeting the requirements under the PCL

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program. Information on the PCL program appears in Primary Care Loan.

[Section 721(b)(4) of the Public Health Service Act]

LOCATION OF THE INSTITUTION

The health professions school must be located in a State, the District of Columbia, the

Commonwealth of Puerto Rico, the Northern Mariana Islands, the Virgin Islands, Guam,

American Samoa or the Trust Territory of the Pacific.

[Section 799(9) of the Public Health Service Act]

ACCREDITATION

A health professions school that is interested in participating in the HPSL program must be

accredited by an appropriate accrediting body that is recognized by the Secretary of Education.

The approved accrediting bodies for health professions schools are as follows:

• dentistry: Commission on Dental Accreditation

• optometry: Council on Optometric Education of the American Optometric

Association

• pharmacy: American Council on Pharmaceutical Education

• podiatric medicine: Council on Education of the American Podiatric Association

• veterinary medicine: American Veterinary Medical Association

[Section 799(1)(A) of the Public Health Service Act]

WRITTEN AGREEMENT

Health professions schools must enter into an agreement with the Secretary of Health and Human

Services as a criterion for participation. The agreement requires that the institution:

•

establish a fund for the HPSL program;

•

deposit in the fund Federal Capital Contribution, Institutional Capital

Contribution, collections from loans in repayment, and any other

earnings;

•

provide an ICC of at least one-ninth of the FCC;

•

permit the funds only to be used for student loans and the costs associated

with collection;

•

award funds only to students who are studying full-time in eligible discipline

and degree programs;

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•

inform borrowers of the terms and conditions of HPSLs; and

•

submit an annual operating report that describes the use of the fund.

[Sections 721(a) and 721(b) of the Public Health Service Act]

DEFAULT RATE PERFORMANCE STANDARDS

Each June 30, a school must have an HPSL default rate that does not exceed five percent.

Schools that exceed the five percent performance standard are subject to probation, suspension

or termination from program participation.

The regulations require a school to meet a performance standard for participation in the Primary

Care HPSL Loan Programs.

On June 30 each year a school must have a default rate of not more than five percent. The default

rate is the ratio (stated as a percentage) that the defaulted principal amount outstanding of the

school bears to the matured loans of the school. For this purpose:

•

the term "defaulted principal amount outstanding" means the total amount borrowed

from the loan fund of a school that has reached the repayment stage (minus any principal

amount repaid or cancelled) on loans in default for 120 days or more.

•

the term "matured loans" means the total principal amount of all loans made by a school

minus the total principal amount of loans made by the school to students who are enrolled

in a full-time course of study at the school or are in their grace period.

The worksheet for calculating the default rate in the Primary Care FCC Loan Programs can be

found on the internet at http://bhpr.hrsa.gov/dsa/ratecalc/html.

Any school that has a default rate greater than five percent on June 30 of any year will be

required to:

•

reduce its default rate by fifty percent (or a school with a default rate below 10 percent

must reduce its rate to five percent) by the close of the following six-month period;

and

•

by the end of each succeeding six-month period, reduce its default rate to 50 percent

of the required rate for the previous six-month period until it reaches five percent.

Refer to Fiscal Management, Program Monitoring, Chapter 2 for additional information on the

default rate performance standard.

[Section 721(c)(1) of the Public Health Service Act; 42 CFR Part 57.216a]

NON-DISCRIMINATION REQUIREMENTS

Participating health professions institutions must adhere to statutes and regulations addressing

non-discrimination. These include:

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•

Section 794 of the Public Health Service Act and its implementing regulations

45 CFR Part 83, which prohibit discrimination in the admissions process on the

basis of sex;

•

Title VI of the Civil Rights Act of 1964 and its implementing regulations 45

CFR Part 80, which prohibit discrimination in federally assisted programs on

the basis of race, color or national origin;

•

Title IX of the Education Amendments of 1972 and its implementing

regulations 45 CFR Part 86, which prohibit discrimination in federally assisted

education programs on the basis of sex;

•

Section 504 of the Rehabilitation Act of 1973 and its implementing regulation,

45 CFR Part 84, which prohibit discrimination in federally assisted programs on

the basis of handicap;

•

Section 798(C) of the Public Health Service Act, which prohibits institutions

from charging higher tuition to students that benefit from Federal financial aid

funds; and

•

45 CFR Part 91, which prohibits discrimination on the basis of age.

In addition, institutions may not discriminate on the basis of religion in the admissions process.

[42 CFR Part 57.216]

DRUG-FREE WORKPLACE, SCHOOLS AND CAMPUSES

Participating schools must comply with the requirements in 45 CFR Part 76, Subpart F. This

section of the regulations stipulates that institutions must certify that they will provide and

maintain a drug-free workplace.

The Drug-Free Schools and Communities Act Amendments of 1989 and its implementing

regulations 34 CFR Part 86 apply to any public or private institution of higher education

(including independent hospitals conducting training programs for health care personnel), State

educational agency, or local educational agency. As a condition of funding from Federal

financial assistance programs, the statute requires these entities to certify to the Secretary of

Education that they have adopted and implemented a drug prevention program. These

provisions also apply to subgrantees of Federal funds whether or not the primary grantee is an

institution of higher education, a State educational agency, or a local educational agency.

NON-DELINQUENCY OF THE INSTITUTION ON FEDERAL DEBT

Participating institutions must comply with non-delinquency on Federal debt requirements.

Examples of Federal debt or possible sources include delinquent taxes, audit disallowances, FHA

loans, and other unpaid administrative debts. Specific examples include:

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•

a scheduled payment on a direct loan that is more than 31 days past due;

•

the unpaid disallowed amount in a "Notice of Grants Cost Disallowance"

unless otherwise unresolved; and

•

unpaid Social Security tax payment or other administrative payment owed to

the Federal Government.

LOBBYING AND DISCLOSURE OF LOBBYING

Institutions must adhere to restrictions on lobbying and provide a disclosure statement about

lobbying activities for each Federal award to the institution in excess of $100,000. The Office of

Management and Budget published guidance for restrictions on lobbying in the Federal Register.

DEBARMENT AND SUSPENSION OF CAMPUSES

According to regulations in 45 CFR Part 76, an institution must certify that neither it nor any of

its principals are debarred, suspended, proposed for debarment, declared ineligible, or

voluntarily excluded from covered transactions by any Federal dependent or agency.

Subawardees (e.g., other corporations, partnerships, or other legal entities) also must provide the

same certification to the institution.

C. FEDERAL CAPITAL CONTRIBUTION (FCC)

1. Monies paid to the institution, pursuant to this application in the form of FCC shall be

maintained by the institution in a separate account, hereafter referred to as the AFCC

Fund.@ In addition to Federal Capital Contributions, the institution shall maintain in the

FCC Fund:

a) an amount equal to not less than one-ninth of such FCC, contributed by the

institution;

b) collections of principal and interest on loans made to students from the FCC Fund;

c) collections of charges pursuant to 42 CFR Part 57 Section 205;

d) any other earnings of the FCC Fund.

2. The FCC Fund shall be used by the institution only for:

a) loans to eligible students pursuing a full-time course of study;

b) costs of litigation arising in connection with the collection of any obligations to the

FCC Fund, and interest thereon; and

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c) other collection costs that are in excess of the usual expenses incurred in the

collection of student loans to the extent specifically approved by the Secretary.

3. The Secretary, DHHS shall pay to the institution its proportionate share of the amount of

principal and interest which is canceled with respect to student loans pursuant to Section

722(d) of the Public Health Service Act.

4. The FCC Fund must be maintained by the institution in an insured, interest bearing account

at all times, unless it is not cost effective, and all earnings must become a part of the FCC

Fund. If the account is not federally insured, the institution will be liable for any loss that

may occur.

5. Capital distributions shall be made as provided under Section 728 of the PHS Act.

6. Institutions must submit an Annual Operating Report as required By the Secretary of

Health and Human Services. The report accounts for the money in the FCC account and

its use and the student’s outcome.

INSTITUTION: ________________________________________________________________

PROGRAM: _____________________________________EIN#: _________________________

OPSID (leave blank): ____________

Program Director: ____________________________________________________________

NAME (print)

Title: ____________________________________________________________

Address: ____________________________________________________________

____________________________________________________________ Address2:

City/State: ______________________________Zip Code: _____________________

Telephone: ______________________________Fax: _________________________

E-mail address: _________________________________________________________________

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Financial Aid Official: ___________________________________________________________

Title: ____________________________________________________________

Address: ____________________________________________________________

____________________________________________________________ Address2:

City/State: ______________________________Zip Code: _____________________

Telephone: ______________________________Fax: _________________________

E-Mail Address: ____________________________________________________________

CERTIFICATION AND ACCEPTANCE: The undersigned official of the applicant institution

accepts, as to any Federal funds allocated and paid as a result of this application, the obligation to

comply with the applicable provisions of the PHS Act as amended, regulations, and with the PHS

policies in effect at the time of such allocation and payment.

Signature of Authorizing Official:

_______________________________________Title __________________________________

Name (print)

Signature: ______________________________Date: __________________________________

E-mail address: __________________________Telephone Number: ______________________

ANY PERSON WHO KNOWINGLY MAKES A FALSE STATEMENT OR

MISREPRESENTATION IN OBTAINING THESE FUNDS IS SUBJECT TO PENALTIES

WHICH MAY INCLUDE FINES AND IMPRISONMENT UNDER FEDERAL STATUTE.