Memorandum
To:
Audiology Students (Masters)
From: Debbie Dahlquist, Institute of Rural Health
Date: 2/5/2016
Re:
Scholarship Announcement
The Institute of Rural Health has received scholarship funding (Scholarship for Disadvantaged
Students Program) from the U.S. Department of Health and Human Services, to assist students
for which cost of attendance would constitute a severe hardship. The fact sheet and application
are attached. Please note that you must come from an environmentally or economically
disadvantaged background in order to be eligible for the scholarship (definitions on following
pages). You must also be a full-time student during the 2006-2007 Academic year, and enrolled
in the Audiology (Masters) program (see additional eligibility criteria listed on page 1 of the
application).
The deadline is August 14, 2006. If you have any questions, please feel free to e-mail
Debbie Dahlquist at dahldebb@isu.edu or call 208-282-4560.
SCHOLARSHIP FOR DISADVANTAGED STUDENT PROGRAM
FACT SHEET & APPLICATION
WHAT IS IT? The Scholarship for Disadvantaged Students Program (SDS) is a federal program
designed to help students in the form of a scholarship who are considered disadvantaged, either
economically and/or environmentally.
WHAT ARE THE REQUIREMENTS? Students must come from a disadvantaged economic and/or
environmental background.
An individual from a disadvantaged background is defined as someone who:
•
•
Comes from an environment that has inhibited the individual from obtaining the knowledge, skill
and abilities required to enroll in and graduate from a school; or
Comes from a family with an annual income below a level based on low-income thresholds
according to family size published by the U.S. Bureau of the Census, adjusted annually for changes
in the Consumer Price Index, and adjusted by the Secretary of Health and Human Services for
adaptation to this program.
WHO DECIDES WHICH STUDENTS RECEIVE THE SCHOLARSHIPS? A scholarship
committee consisting of 3 or more individuals from various parts of the University meets and disperses
awards. Scholarships are awarded to eligible students in the order of greatest need. Preference is first
given to eligible disadvantaged students for whom the cost of attendance would constitute a severe
hardship.
HOW MUCH MONEY IS AWARDED? There is no statutory or regulatory dollar amount cap on SDS
awards to eligible disadvantaged students, however the amount may not exceed a recipient’s (student’s)
cost of tuition expenses, other reasonable educational expenses and reasonable living expenses. Awards
are made to best meet the student’s eligible needs.
SCHOLARSHIP CRITERIA: The Scholarship for Disadvantaged Students’ Program does not
discriminate based on race, sex, religion, or creed. Scholarships are awarded to students, who are
enrolled in one of the eligible programs, and who come from an environmentally and/or economically
disadvantaged background.
Scholarships are to be used for tuition, other reasonable educational expenses and living expenses.
Students also must be enrolled full-time in the Audiology (Masters) program at Idaho State University.
In addition, students are to remain in good academic standing.
Funding changes on a per annum basis. If you have any questions, please contact Debbie Dahlquist at:
Idaho State University
Institute of Rural Health
921 S. 8th Ave., Stop 8174
Pocatello, ID 83209-8174
Phone: 208-282-4560 Fax: 208-282-4074 E-Mail: dahldebb@isu.edu
Application
Scholarship for Disadvantaged Students Program
2006- 2007
Awards will be disbursed based on highest need. A scholarship committee will review all student
applications. The scholarship can be used for: tuition expenses, other reasonable educational expenses,
and reasonable living expenses. All 5 pages of the application must be completely filled out and all
appropriate attachments must be attached. Please submit your application to Debbie Dahlquist at the
Institute of Rural Health, Idaho State University, 921 S. 8th Ave. Stop 8174, Pocatello, ID 83209-8174 no
later than August 14, 2006 (Located in Graveley Hall North, Room 205). If you have any questions
regarding the application, please call Debbie at (208) 282-4560 or e-mail her at dahldebb@isu.edu.
Thank you!
Name:
(Last)
(First)
Social Security Number:
(Middle)
E-mail:
Present Mailing Address:
(City)
(State)
(Zip)
E-mail:
Bengal ID # ____________________________
Home Telephone #
Work Telephone #
(Optional): Date of Birth
Race
(For statistical purposes only)
Sex
Name of High School from which you graduated:
(Or last attended if completed GED:)
City
Current Educational Status:
ISU Program enrolled in:
Start date:
State
End date:
 Audiology (Masters)
Student Eligibility Criteria
(All 3 answers must be checked yes, to be eligible for this program)
YES
NO
1. Are you enrolled full-time in the above program for the 2006-2007 academic year?
2. Are you a citizen or national of the United States, or a lawful permanent resident of
the United States, the Commonwealth of Puerto Rico, the Northern Marian Islands, the
Virgin Islands, Guam, American Samoa or the Trust Territory of the Pacific? A
student who remains in this country on a student or visitors visa is not eligible!
3. Do you come from a low income OR environmentally disadvantaged background?
Please see definitions on following page!
Page 1 of 5
Eligibility Requirements for the Scholarship for Disadvantaged Students Program
Awards will be allocated and disbursed based on highest need. A scholarship committee will review all
student applications. ALL APPLICANTS MUST PROVIDE A COPY OF THEIR PARENTS’
FINANCIAL INFORMATION (2005 tax forms) REGARDLESS OF AGE, MARITAL, OR
INDEPENDENT/DEPENDENT STATUS. This is a requirement of the Federal Government, and is
used in order to give scholarships to those students in highest need. Students who do not send in a copy
of their parents’ tax forms will not be eligible for this program.
In order to be eligible for the SDS scholarship, you must be considered either low income according
to the guidelines below, or must answer yes to at least one of the statements under the
Environmentally/ Disadvantaged Background definition. PLEASE CIRCLE ALL THAT APPLY.
Awards will be disbursed to students based on a scoring system using a combination of (1) eligibility
under the low-income guidelines, (2) Eligibility under the environmentally disadvantaged background,
and (3) Financial need of the student.
1.
Low Income Guidelines:
Students coming from a family with an annual income below the level determined by the U.S.
Census Bureau guidelines will be considered. This is based on the student’s parents’ income
regardless of independent/dependent or marital status. All students applying must submit their
parents’ latest income tax forms regardless of age, independent/dependent, or marital status.
Size of
Parents’
Family *1
1
2
3
4
5
6
7
8
Income Level
*2
$19,600
$26,400
$33,200
$40,000
$46,800
$53,600
$60,400
$67,200
For each additional person add: $6,800
*1 Size of Parent’s family means the number of exemptions listed on the parent’s Federal
Income tax form. (e.g. family size of 4 might include two parents and 2 dependents; OR 1
parent and 3 dependents)
*2 Income level is Adjusted gross income for calendar year 2005.
OR
2.
Comes from an Environmentally/Disadvantaged Background:
(PLEASE CIRCLE ALL THAT APPLY) - Questions A and B will be verified based on the high
school information provided on page 1.
A. I graduated from (or last attended) a high school from which a low percentage of seniors received
a high school diploma.
% (ask for the current % of high school seniors receiving a high school diploma.)
B.
I graduated from (or last attended) a high school from which many of the enrolled students were
eligible for free or reduced price lunches (based on most recent data available).
Page 2 of 5
% (ask for the current % of high school students receiving free or reduced price
lunches.)
The answer to question C can be found on the following website:
http://www.bphc.hrsa.gov/dsd. (Once in, click on HPSA database, enter your appropriate state &
city & verify. Note: if you see a date in the column labeled designation status, this means your
county is designated.)
C.
I come from a family that lives/lived in an area that is designated as a Health Professional
Shortage Area (HPSA), Medically Underserved Area (MUA), or Dental Health Professional
Shortage Area (DPSA).
Please state City/County/State you are from:
City
County
State
D. I come from a family that received/receives public assistance, (e.g., Aid to Families with
Dependent Children, food stamps, Medicaid, public housing).
E.
I participated in an academic enrichment program funded, in whole or in part, by the Health
Career Opportunity Program, (HCOP) or Nursing Workforce Diversity (NWD) Program formerly
Nursing Education Opportunities Program (NEOP).
F.
I received an AHS diploma or GED and am from a rural area/public assistance.
Note: You must have both received an AHS or GED and have grown up in a rural area.
Please state City/County/State you are from:
City
County
State
G. I am the first generation in my family to attend college and I am from a rural area/public
assistance area. Note: You must be both a first generation student and have grown up in a rural
area. Please state City/County/State you are from:
City
County
State
H. I come from a rural area or poverty/public assistance area.
Please state City/County/State you are from:
City
County
State
I.
I have a diagnosed physical or mental impairment that substantially limits my participation in the
educational experiences and opportunities offered by the college. Please attach verification.
J.
I am a student for whom English is not my primary language and I must take a Test of English as
Foreign Language (TOEFL) before entering health professions/nursing school.
TOEFL Score
K. I have been accepted to the program after academic reassessment at the completion of remedial
courses.
Page 3 of 5
FINANCIAL NEED INFORMATION
Finances: Please be aware that receiving this scholarship may affect other financial aid awards you
receive. Applicants must complete a budget, which reflects approximate costs for attending ISU. Please
attach a written statement expressing your need/reasons for this scholarship, and any unusual
circumstances, which cannot be adequately reflected in this budget!
PLEASE READ CAREFULLY AND COMPLETE ACCURATELY
FOR THE 2006-2007 ACADEMIC YEAR.
ESTIMATED MONTHLY EXPENSES
ESTIMATED MONTHLY RESOURCES
Housing
$
Your Salary
$
Gas/Electric
$
Spouse Salary
$
Clothing
$
Aid from Family
$
Phone
$
VA, DVA Benefits
$
Water
$
Unemployment
$
Food
$
Child Support
$
Dental/Med.
$
TOTAL MONTHLY RESOURCES $
Car Payment
$
Car Insurance
$
OTHER RESOURCES:
Gas & Oil
$
Have you ever applied for Federal Student Aid?
(Please circle)
Yes
No
Car Repairs
$
Debt Payments
$
Childcare
$
Child Support
$
Please list make, model, and year of vehicles
you own/operate:
Other Expenses (Specify):
$
$
$
$
TOTAL MONTHLY EXPENSES
HOUSEHOLD SIZE:
How many people are in your (and your spouse’s)
household?
$
Page 4 of 5
PUBLIC ASSISTANCE:
Do you receive Public Assistance from the Idaho Department of Health & Welfare?
If yes, in what form? (Please check all that apply.)
Health Care Coverage for Children
Telephone Service Assistance
TAFI & AABD
Child Care Assistance
Food Stamps
Health Coverage for Adults
If no, are you financially eligible to do so?
(Please circle.)
1.
No
Don’t Know
Please list all sources and the amounts you will be using to pay for tuition, books, and reasonable
living expenses, for the 2006-2007 academic year. (Sources should include all loans,
scholarships, grants, help from parents, savings from part-time or full-time jobs, help from
spouse, other family members, etc.) PLEASE BE VERY SPECIFIC & LIST ALL SOURCES
USED FOR THE ACADEMIC YEAR (be sure to include your fall and spring semester ONLY)!
This information is needed for the scholarship committee to determine financial need.
SOURCE
2.
Yes
$ AMOUNT
SOURCE
$ AMOUNT
Please list all outstanding debts: (be sure to include all PAST students loans, only balance
amounts are needed & must be included for each debt listed).
LOAN #1
LOAN #2
LOAN #3
LOAN #4
Owe to:
Purpose:
Balance:
Monthly Pmt:
(ATTACH ADDITIONAL SHEET(S) IF NECESSARY)
I hereby certify that all of the above statements are true and correct. Further, I give the Scholarship for
Disadvantaged Students Committee permission to verify my financial need status with the ISU Financial
Aid and Scholarship Office.
Name - Please Print
(Signature of Applicant)
(Date)
Page 5 of 5
PLEASE BE SURE TO ATTACH ALL FORMS AND SEND TO THE ADDRESS LISTED
ON THE COVER PAGE OF THIS APPLICATION.
LETTERS WILL BE SENT OUT TO ALL APPLICANTS TO INFORM YOU OF YOUR
AWARD STATUS.
REMEMBER THE DEADLINE IS August 14, 2006.
SDS CHECKLIST
_____
I have completed all 5 pages of the application.
_____
I have attached a copy of my parents’ 2005 tax forms.
I have completed a written statement in regards to my need/reasons for the
scholarship.
_____
Page 6 of 5