HPEP Application, 2024-2025 Health Professional Education Program (HPEP) Funding Application, Academic Year 2024-2025 Step 1 of 7 14% HPEP Applicant QuestionaireWhich professional field are you applying for(Required) (Beginning 2024-2025)If you are applying for the RN to BSN stipend, do you plan, after earning your BSN, to pursue an Advanced Practice Registered Nursing (APRN) degree?(Required) Yes No I am not applying for RN to BSN stipend Define your program specialty(Required) Nurse Educator Family Nurse Practitioner Gerontology Psychiatric Mental Health Licensed Social Worker Other How did you hear about the Nevada Office of WICHE HPEP? Academic Advisor Website Friend Relative Employer Practitioner Other Is this your first time applying for Nevada Office of WICHE HPEP? Yes, This is my first time No Indicate the field and year you last applied Personal InformationName(Required) First Middle Last Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Birthplace(Required) (City/State)Date of Birth(Required) Educational InformationHigh School(Required) Location(Required) (City/State)Year Graduated College(Required) Location(Required) (City/State)Year Graduated Are you currently enrolled or admitted in a professional program?(Required) Yes No Name of the school where you are currently enrollled Field of Study Semester Started (Month and year you started your currently active program)Enrollment Type Full Time Part Time Certificate Estimated Graduation Date (Month and year of your estimated graduation date) Employment HistoryEmployer Name(Required) Job Title(Required) Employer Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Length of Employment(Required) (Years / Months)Is your employer also contributing funding towards the cost of your education?(Required) Yes No Amount contributed by employer, per year Nevada Residency InformationTo qualify for residency, you must have been a bona fide resident of Nevada for at least 12 consecutive months prior to submitting your HPEP application. You will be required to provide proof documenting Nevada residency such as a copy of your Nevada driver’s license. Additional documents may be requested to verify Nevada residency.Are you a United States citizen or permanent resident?(Required) Yes No Are you a legal resident of Nevada?(Required) Yes No State of legal residenceAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificStart date of current residence(Required) (mm/yyyy)End date of current residence(Required) (mm/yyyy)Driver's License No. Date Issued (MM/YYYY)State of IssueAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCounty of Legal Residence Start date of residence in this county (MM/YYYY) Please Upload Supporting DocumentsLetter of acceptance from your professional program(Required)To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your files Format: PDF • JPG • JPEG • PNGMaximum size: 256 MB Files Nevada Driver's License(Required)To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your files Format: PDF • JPG • JPEG • PNGMaximum size: 256 MB Files Please upload a photo of your valid Nevada Driver’s license for verification of residenceUnofficial Transcript(Required)To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your files Format: PDF • JPG • JPEG • PNGMaximum size: 256 MB Files Please upload your unofficial transcript Final StepApplication Certification & Statement of Intent To Provide Service(Required) I understand and agree to the following:Upon fulfillment of my professional studies, I will return, obtain my practice license (nursing or social work), and practice my profession (employment) in an underserved medical or health professional shortage area in the State of Nevada.Acknowledgement of Practice Duration in Nevada(Required) I understand and agree to the following:I will provide one (1) year of full-time practice in my profession for each year of Nevada HPEP stipend received.Acknowledgement of Intent to complete practice questionnaire(Required) I understand and agree to the following:I will notify the Nevada Office of WICHE of any changes related to my contact information and complete a Practice Questionnaire every six months with supporting documentation during school and out of school to demonstrate compliance with HPEP requirements.Acknowledgement of understanding for stipend requirements(Required) I understand and agree to the following:I further understand that if I do not complete my employment obligation, or do not complete my course of study the stipend amount I received will be converted to a loan, with interest, fees, and any applicable penalties. Acknowledgement of understanding for funding limitations(Required) I understand and agree to the following:I understand that continuation of Nevada HPEP funding is subject to legislative appropriation and funding limitations; therefore, support may not be guaranteed annually.Acknowledgement of public release(Required) I understand and agree to the following:I agree to allow the State of Nevada to release my name, address, and school to allow the State of Nevada to use my name in publicizing the WICHE HPEP. The State may use information about my participation for internal or public reports, research studies, or statistical analysis on program effectiveness.Acknowledgement of consent for Transfer Student Records Through the Nevada Office of Western Interstate Commission for Higher Education (WICHE)(Required) I understand and agree to the following: PURPOSE FOR REQUESTING STUDENT SIGNATURE ON CONSENT AND WAIVER FORM: Public Law 93-380, the Federal Family Education Rights and Privacy Act of 1974, requires all who hold custody of student records to insure protection of personally identifiable information. Administration of Nevada Office of WICHE Health Profession Education Program requires the exchange of educational information about student applicants in order to provide for consideration of enrollment and transfer of funds by the state in the case of admission by the school. In order to facilitate exchange of necessary documents, the student application is asked to sign a “Consent and Waiver” statement. DESCRIPTION OF USE OF PERSONAL RECORDS: The program collects and uses information concerning student eligibility for the program; admission; enrollment; academic progress; graduation and/or termination from the professional program; and payment of fees by the State of Nevada through Nevada Office of WICHE to the receiving school. This information is exchanged between and among the Nevada Office of WICHE staff; Nevada System of Higher Education administrative staff assisting the Nevada Office of WICHE and the professional school(s) to which the student makes an application and is admitted. Periodic accounting for the Nevada Office of WICHE programs may result in publication of reports which contain year of enrollment, enrolling institution, and money spent by the Nevada Office of WICHE to support the student’s effort to reach an educational objective. NOTIFICATION CONCERNING STUDENT ACCESS TO PERSONAL RECORDS: Any student participant or applicant for participation in the Nevada Office of WICHE Health Profession Education Program has access to their personal records maintained as a part of the exchange activity. If you want to review your record, contact the Nevada Office of WICHE that maintains the record to make appropriate arrangements. Nevada Office of WICHE has 45 calendar days to comply. The student participant may inspect and/or receive copies at a cost not to exceed the actual cost of reproduction. Per Nevada Revised Statute 239.080 the Nevada WICHE Commission/Nevada Office of WICHE state record retention schedule for applicant files that are unfunded are retained five (5) years and recipient files are retained for twenty (20) fiscal years after contract satisfaction. After the retention period has ended the records can be destroyed securely. Consent and Waiver I understand that it is necessary to process student records in order to carry out the purpose of the Nevada Office of WICHE Health Profession Education Program, providing access to educational opportunities for Nevada residents. I understand that the record-keeping process requires preparation, transmission, receipt, filing, and reporting of information appropriate to the effectiveness and continuity of the program. I hereby consent to the transfer of personally identifiable educational records between and among the participants in the Nevada Office of WICHE Health Profession Education Program to include the following: Information concerning student eligibility, acceptance, and educational attainment. Information concerning fees paid by the Nevada Office of WICHE to the receiving school. Lists of applicants certified as eligible for support. Admissions reports, withdrawal reports, and annual reports for Nevada Office of WICHE Health Profession Education Program Participants. I understand that the information referred to herein will be available only to Nevada Office of WICHE Program staff members, Nevada System of Higher Education staff supporting Nevada Office of WICHE; designated institutional officials as required to carry out their official duties. E-Signature Acknowledgement(Required) I Agree to sign this application electronicallyBy selecting the “I AGREE” button, you acknowledge that you have read, understand and agree to the following: You are voluntarily choosing to sign your HPEP Application electronically You understand and agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and The Nevada Office of WICHE You understand that you have the right to withhold your consent to the use of electronic documents and signatures and that you have the right to withdraw your consent at any time prior to completing the e-sign process. Please be aware, however, that withdrawal of consent may result in the termination of your HPEP application. Signature(Required)HiddenSignature Date MM slash DD slash YYYY
