Virginia Department of Health-OMHHE
Nurse Educator Scholarship Program
2013 Application Revised 11-2012
1
“Nurse Educator Scholarship Program”
Checklist and Application Requirements
Program History
The Nurse Educator Scholarship Program pursuant to §23-35.9 and §32.1-122.6:01 of the Code of Virginia provides annual nursing
scholarships from the Nursing Scholarship and Loan Repayment Fund pursuant to §54.1-3011.1 and§54.1-3011.2 in Virginia Code for
part time and full time students enrolled in a graduate Nursing Educator Program that are residents of Virginia as determined by
Virginia Code section §23-7.4 for Instate Tuition eligibility. Graduate Nursing Educator Programs are defined as those programs
offering Master and Doctoral Degrees in Nursing Education and will complete in two years or less. This revolving Nursing
Scholarship and Loan Repayment Fund is maintained by fees authorized by Virginia Code section §54.1-2400 that charges one dollar
for every practical nurse and registered nurse obtaining a licensure or renewal in Virginia pursuant to §54.1-3011.1. This fund also
includes any funds appropriated by the General Assembly for the purposes of the fund; and any gifts, grants, or bequests received
from any private person or organization. All scholarship awards are made by an Advisory Committee appointed by the Virginia State
Board of Health. The Virginia Department of Health (VDH)-Office of Minority Health and Health Equity (OMHHE)-Health
Workforce serves as the staff element to the Advisory Committee and plays no role in the determination of scholarship recipients. The
Advisory Committee recommends to the State Commissioner of Health the award selection with due regard given to scholastic
attainment, financial need, and character. After final review and a decision is made by the Commissioner, selected Program
Recipients are notified by the Office of Minority Health and Health Equity.
This checklist has been provided to facilitate your application process. Please ensure that you read and
understand the following information prior to applying for a scholarship award. Please send us all documents
requested below to ensure that your application is complete. Failure to comply with these application
requirements will result in you being ineligible for a Virginia Nurse Educator Scholarship.
A current official transcript of grades must be submitted from undergraduate and/or graduate schools attended.
If you have a student identification number, please provide this number on the application (Section 2). This is
important so that our office can match your transcript with the application. The Office of Minority Health and
Health Equity prefer that you have the transcripts sent to you first, so that you can include them in your
application package to us. If this is not feasible by the institution, transcripts should be postmarked by June 30
for the academic year beginning in the fall of the calendar year that you are applying.
If you are already enrolled in a Nursing Education Graduate Program , you must demonstrate satisfactory
academic progress.
A current curriculum vitae or resume must be submitted with the application.
Two (2) letters of References in a sealed envelope with the reference’s signature across the seal are required as
part of the application. At least one reference must be from a former faculty member or teacher. Remember to
allow extra time for your references to send YOU the letters allowing enough time for you to be able to include
them in your application package to us.
Proof of US Citizenship must be provided by submitting a copy of your social security card.
Proof of Virginia Residency must be provided. To be considered a resident of Virginia for the Nurse Educator
Scholarship Program, you have to establish by clear and convincing evidence that for a period of at least one year
you have been domiciled in Virginia and have abandoned any previous domicile, if such existed. "Domicile"
means the present, fixed home of an individual to which he/she returns following temporary absences and at
which he/she intends to stay indefinitely. You must prove "Domiciliary intent" which means to present intent to
remain indefinitely. All of the following are acceptable methods to prove continuous residency for at least one (1)
year. Note: choose one of these that will be able to show or prove that you have lived here at least a year:
1. Previous years’ state income tax filings or statements verifying that you have lived in Virginia for at least a year
2. Driver's license with an issue date or a renewal date showing that you have lived in Virginia for at least a year
3. Motor vehicle registration with verification on it showing that you have lived in Virginia for at least a year
4. Voter registration with an issue date showing that you have lived in Virginia for at least a year
5. Employment records that include your home address verifying that you have lived in Virginia for at least a year
6. Property ownership records that state that the Virginia property is your primary residence verifying that you have
lived in Virginia for at least a year
7. Other sources of financial support statements such as student loans, spousal support, food stamp, SSI,
Unemployment or others verifying your address and showing that you have lived in Virginia for at least a year
Virginia Department of Health-OMHHE
Nurse Educator Scholarship Program
2013 Application Revised 11-2012
2
8. Military records including the Military Leave and Earning Statement (LES) verifying that you have been stationed in
Virginia
9. Other records proving social or economic relationships with the Commonwealth and other jurisdictions such as
County or City verifying that you have lived in Virginia for at least a year
Additional Information regarding residency:
Domiciliary status shall not ordinarily be conferred by the performance of acts which are auxiliary to fulfilling
educational objectives or are required or routinely performed by temporary residents of the Commonwealth. Mere
physical presence or residence primarily for educational purposes shall not confer domiciliary status.
The domicile of a dependent student applicant shall be rebuttably presumed to be the domicile of the parent or legal
guardian claiming him as an exemption on federal or state income tax returns currently and for the previous tax year
providing him/her substantial financial support. For Military dependents, notwithstanding any other provision of law, all
dependents, as defined by 37 U.S.C. § 401, of active duty military personnel, or activated or temporarily mobilized
reservists or guard members, assigned to a permanent duty station or workplace geographically located in Virginia, or in
a state contiguous to Virginia or the District of Columbia, who reside in Virginia shall be deemed to be domiciled in
Virginia for purposes of eligibility of the Nurse Educator Program.
Domiciliary intent of active duty military personnel residing in the Commonwealth, retired military personnel residing in
the Commonwealth at the time of their retirement, or veterans, or the domiciliary intent of their dependent spouse or
children who claim domicile through them, who voluntarily elect to establish Virginia as their permanent residence for
domiciliary purposes, the requirement of one year shall be waived if all other conditions for establishing domicile are
satisfied.
One-Page Essay/Statement from the applicant-SECTION 7 describing personal and professional interest in
nursing and nursing education. Be sure to sign your name at the bottom of the page of your essay.
Include in this essay/statement:
1. What you hope to accomplish as a career
2. How the program will build on your current competencies
3. Cite leadership capabilities and/or describe your leadership experience(s)
4. Cite previous teaching opportunities (if any)
5. Describe your interest and willingness to teach in Virginia, including type of educational program/institution.
Proof of enrollment filled out by the School Director-SECTION 8. Make sure that your Nursing Education
School Directors are willing to comply with the annual reporting requirements that will be expected from them.
It is important if applicable, for you to have your Financial Aid Office of your institution fill out the Application
Financial Need Recommendation Form-SECTION 9. The recommendation of the Financial Aid Officer must
be based upon one of the three following referenced need analysis documents including a specific dollar amount
determined to be the applicant's financial need: Financial Aid Form (FAF) of the College Scholarship Service,
the Family Financial Statement (FFS) of the American College Testing, and/or the Free Application for Federal
Student Aid (FAFSA). The Virginia Nurse Educator Scholarship Program and the Nursing Scholarship Advisory
Committee that recommends its awards to the State Health Commissioner give due regard to the financial need of an
applicant. Financial Need is one of the many determining factors for award; it is not required for eligibility of the program.
Both the Dean/Director/Chair of the School of Nursing and the Financial Aid Officer/Authorized Person must
complete and provide original signatures in their sections of the application.
Applications must be typed; handwritten applications will be not accepted. It is the responsibility of you the
applicant to see that:
The application form and supporting documents are completed entirely;
All original signatures are obtained on the application form;
Maintain a copy of this application and supporting documents for your records;
Applications are to be mailed and postmarked prior to June 30 to:
Virginia Department of Health -Office of Minority Health and Health Equity
ATTN: Nurse Educator Scholarship Program
109 Governor Street, Suite 1016- East Richmond, Virginia 23219
Virginia Department of Health-OMHHE
Nurse Educator Scholarship Program
2013 Application Revised 11-2012
3
SECTION 1 – PERSONAL DATA
Date of Application:
Legal Name:
Last
Preferred Name
First
MI
Maiden
Address:
Street Number and Name
City
State
Zip
Day Phone Number:
(000) 000-0000
Evening Phone Number:
(000) 000-
0000
Email Address:
Preferred method of contact:
Social Security Number:
000-00-0000
Sex:
Please Select One
Date of Birth:
Place of
Birth:
Race/Ethnicity:
Please Select One
Other:
Are you a US Citizen or Naturalized Citizen?
How long have you been a resident of Virginia?
Congressional District:
(Please check with your voter registration office or visit
http://nationalatlas.gov/printable/congress.html)
Are you currently a Registered Nurse (RN)? Please Select One
Have you ever received a Nurse Educator Scholarship before?
Please Select One
If yes, in what year(s)?
What school of nursing were you attending during that time?
Do you speak another language other than English?
Please Select One If yes, please list:
ALTERNATIVE CONTACT PERSON
By providing a name in this section, you are giving us permission to contact this person if you cannot be reached
Name:
Last
First
MI
Address:
Street Number and Name
City
State
Zip
Phone Number:
(000) 000-0000
Relationship to
Applicant:
Virginia Department of Health-OMHHE
Nurse Educator Scholarship Program
2013 Application Revised 11-2012
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SECTION 2 – PROFESSIONAL NURSING EDUCATION
School of Graduate or Doctoral Nursing Program:
Is this an Online Program based in Virginia?
Student Identification Number
Address:
Street Number and Name
City
State
Zip
School Phone Number :
(000) 000-0000
Graduate school start date:
Date of expected
Graduation:
How many credits do you currently have if already started?
Full-time Student
Part-time Student; How many credit hours are you taking?
To the best of your ability, how many semester/quarters will you need to complete your studies?
How would this be translated into years?
Post-graduate Training (if any):
Degree being obtained:
M.S. or M.A. or MSN
Research (PhD, DNSc, DNS)
Practice (Doctor of Nursing Practice)
Current License and
Previous practice:
Currently a Registered Nurse
Previous Licensed Practical Nurse
Previous Certified Nursing Aide
Current
License
Number:
Certificate Number (if one):
Any license restrictions?
Yes No
If yes, please specify:
SECTION 3 – PRIOR EDUCATION
University/College
Diploma/Degree
City and State
Date of
Attendance
Reason for Leaving
1.
-
2.
-
3.
-
Virginia Department of Health-OMHHE
Nurse Educator Scholarship Program
2013 Application Revised 11-2012
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SECTION 4 – WORK EXPERIENCE
Check here if you have never been employed, and skip to Section 5
Type of Position
Name of Employer
City and State
Dates of
Employment
Reason for Leaving
1.
-
2.
-
3.
-
SECTION 5 – OTHER HEALTH-RELATED AND/OR CIVIC EXPERIENCES
Type of Position
Organization
City and State
Dates of Work
1.
-
2.
-
3.
-
SECTION 6 – OTHER FINANCIAL ASSISTANCE
Are you receiving any other type of financial aid for the upcoming school year?
Please Select One
If yes, please indicate:
Virginia Department of Health-OMHHE
Nurse Educator Scholarship Program
2013 Application Revised 11-2012
6
SECTION 7 – NARRATIVE SUMMARY (Required by the applicant)
Explain briefly, in 4,000 characters or less, the significance of the Virginia Nurse Educator Scholarship Program in
pursuing your educational goals. Describe your personal and professional interest in nursing and nursing
education. Be sure to include the following in this essay.
1. What you hope to accomplish as a career
2. How the program will build on your current competencies
3. Cite leadership capabilities and/or describe your leadership experience(s)
4. Cite previous teaching opportunities (if any)
5. Describe your interest and willingness to teach in Virginia, including type of educational program/institution.
All of the information in this narrative summary is true to the best of my knowledge. I realize that information from this
section will be used to determine scholarship awards if selected.
APPLICANT PLEASE SIGN BELOW
Print Name of Applicant
Date
Signature of Applicant
Virginia Department of Health-OMHHE
Nurse Educator Scholarship Program
2013 Application Revised 11-2012
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SECTION 8 –SCHOOL OF NURSE EDUCATOR PROGRAM RECOMMENDATION
This section is to be completed by the Dean/Director of the Graduate School of Nursing.
1. Name of applicant:
2. Student Identification or Social Security Number:
3. This applicant is: Attending Approved for Admission
4. Date of entrance: Month Year
5. During this award period, the applicant will be attending: Full Time Part Time
6. Cumulative Grade Point Average if already attending: (Applicants must have at least a satisfactory
cumulative GPA in Required Courses, not electives)
7. Please provide a brief recommendation below in 2,000 characters or less describing the applicant in regards to
scholastic attainment, character, and adaptability to the nurse educator profession if applicable.
I recommend
(Full Name of Applicant)
for a Nurse Educator Scholarship Award.
Name of Authorized Person Completing This Section
Title
Signature
Date
Full Name of School of Nursing
Phone Number
E-Mail Address
Virginia Department of Health-OMHHE
Nurse Educator Scholarship Program
2013 Application Revised 11-2012
8
SECTION 9 – FINANCIAL NEED RECOMMENDATION
This section is to be completed and signed by the Financial Aid Officer or Program Director of your instistution if
applicable.
The Virginia Nurse Educator Scholarship Program and the Nursing Scholarship Advisory Committee that recommends its
awards to the State Health Commissioner give due regard to the financial need of an applicant. Financial Need is one of
the many determining factors for award; it is not required for eligibility of the program. If applicable, document by
one of the accepted uniform methodology needs analysis systems. Please use the most recent needs analysis on file for
this student to recommend the amount of scholarship required to meet the calculated need, after taking
into consideration other financial aid already received by the applicant.
1. Applicant Name:
2. Student Identification or Social Security Number
3.
Student Costs and Resources:
Student Aid Budget for Applicant
Expected Family Contribution (EFC)
Financial Aid Received (excluding loans)
Remaining Need
Cost of Program for One Year
(including tuition, fees, books, uniforms, etc.)
4.
Scholarship Recommendation:
The Nursing Scholarship Committee does not make their award selection based solely on the financial
need recommendation. Award range for a graduate varies depending on the number of applicants and
the Appropriation by the Virginia General Assembly.
Based upon a review of this applicant’s financial situation,
I recommend a Virginia Nurse Educator Scholarship award of
(check one):
$5,000 to $9,999
$10,000 to $14,999
$15,000 and up
5. If your recommendation is less than both the "remaining need" above and the maximum allowable reflected in the
award range above, please explain:
6. Needs Analysis Method Used:
Please indicate which of the following methods was used in determining
the applicant's financial need and the academic
year for which the form was filed. (Financial Aid Officers are encouraged to use the need analysis for the year in
which the student is applying for assistance.)
CSS
ACT
PELL
FAFSA
Academic Year from to
Name of Financial Aid Officer/Authorized Person (Please Print)
Phone Number
Signature of Financial Aid Officer/Authorized Person
Date
E-Mail Address
Virginia Department of Health-OMHHE
Nurse Educator Scholarship Program
2013 Application Revised 11-2012
9
SECTION 10 – CERTIFICATION STATEMENT
All of the information on this scholarship application is true and complete to the best of my knowledge. I realize that
information from this application will be used to determine scholarship eligibility. I understand that it may be investigated
and that any willful false representation is sufficient cause for rejection of this application. If asked by the Nursing
Scholarship Advisory Committee, I agree to provide documentation verifying any information on this application. I have
read and accept the conditions of the Nurse Educator Scholarship Program.
Signature of Applicant
Date
Full Name (Please Print)
For marketing purposes, how did you learn about this scholarship opportunity?
Thank you for your interest in this program!
