HRSA Intune Traineeship Grant

HRSA Intune Traineeship Grant

SPRING 2019 APPLICATION

Please complete this form in its entirety (no blanks, please) and return to

Melinda Morris, Grant Coordinator,

DEADLINE NOVEMBER 1, 2018

Name: ______

Student ID: ______

Address: ______

Phone: ______

Email- School: ______Personal:______

Status: Full-Time______or Part-Time______

At any point in programLast 12 Months of program**REQUIRED

Estimated Tuition Cost for Semester in which applying for monies: ______

Semester/level in program:______

Anticipated graduation date: ______

Current employment, if any:______

(Once you have been notified that you have been preliminarily selected to continue the applicationprocess, you may begin gathering supporting documentation for submission to Ms. Morris, Grant Coordinator.)

Preliminary Eligibility Criteria:

Points
Yes / No / Are you fully enrolled in good standing in FNP study and in their 12 months of study?(unofficial transcript; not more than one C)
Yes / No / Are you enrolled in >8 hours in the fall or spring in which you are applying for monies?
Yes / No / Do you work in a rural area? (Definition of Rural Area see below)
Yes / No / Do you live in a rural area? (see link for rural areas in Texas or use urban area data below)
Yes / No / Is your race other than Caucasian? If yes, please specify:______
Yes / No / Are you a male?
Yes / No / Are you medically fluent multilingual? List languages in which you are fluent:______Answer no if you require an interpreter >50% of the time you deal with non-English speaking patients.
Yes / No / Are you a veteran, active or reserved member of the United States military or discharged honorably?
Yes / No / Do you currently work in a medically underserved area (MUA), health care provider shortage area (HPSA), underserved community, and/or public health clinic? (see definitions below)
Yes / No / Do you agree to sign contract that you will work in a medically underserved area (MUA), health care provider shortage area (HPSA), underserved community, or public health clinic post-graduation? (See definitions below)
Yes / No / Do you agree to sign contract that you will perform greater than 50% of clinicals in a MUA, rural, or HPSA site, and/or among underserved populations?
Yes / No / Do you agree to complete post-graduation surveys?
Yes / No / Do you come from any of the following disadvantaged backgrounds? (Check yes if any of these apply and check all that apply):
____Receive supplemental nutritional assistance?
____Do you live below the 200% 2015 HRHS poverty guidelines per size of family?
(Per W2)
____Medicaid?
____Public housing?
____Are you first generation to attend college?
____Graduated from a high school with low graduation rates/SAT scores?
Total point: 1 point per positive response

Definitions:

**HRSA(Health Resources & Services Administration)

Several definitions are helpful when determining whether areas are known as rural, MUA, HPSA, underserved, etc. Use the following links to try to determine if your workplace and/or home are located in one of these areas. Do your best to determine this, based on the physical address of your home and/or clinic. You can also ask the leadership at your clinic whether they qualify as rural, MUA, HPSA, or underserved. But, if you are unsure, please apply anyway. We can help you determine these qualifications. If you have questions about this, please contact Ms. Melinda Morris, , or Dr. Carol Rizer, .

Rural Area -a geographic area that is located outside towns and cities The Health Resources and Services Administration of the U.S. Department of Health and Human Services defines the word "rural" as encompassing "...all population, housing, and territory not included within anurban area. Whatever is not urban is considered rural. You can also use 2010 urban area file containing a list of all texas counties. (Areas not specified as urban will be classified as rural.)

MUA: Medically Underserved Area;

HPSA: Health Professional Shortage Area;

Underserved area: Generally determined through a review of client base. Sometimes based on # of Medicaid/subsidized patients seen in the clinic.

If you have trouble with this form, please contact us. We would be glad to assist you!