Form 1 Performance Metrics 2023

BHW Performance Report for Grants and Cooperative Agreements

BHW_0906_0086_Master Wireframe - Performance Metrics 05092025

BHW Performance Measures Forms

OMB: 0906-0086

Document [docx]
Download: docx | pdf

Shape1

Appendix C: Program Mapping Document

==

OMB No. 0906-0086, Exp. Date 03/31/2027


Public Burden Statement: The BHW Performance Report for Grants and Cooperative Agreements (PRGCA) is an annual performance and progress report required from each health professions and nursing education grantee that has an approved, funded project with a project period of one year or more. The report is required to determine the extent to which objectives of the project have been met so that a decision regarding continuation funding can be made. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0906-0086 and it is valid until 03/31/2027. This information collection is required to obtain or retain a benefit (Government Performance and Results Act (GPRA) of 1993 and

the GPRA Modernization Act of 2010). The information will be kept private to the extent permitted by law (see 42 USC 292 et seq). Public reporting burden for this collection of information is estimated to average 3.2 hours per response to the annual performance report, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or paperwork@hrsa.gov.


Table of Contents

  1. Grant Purpose – Setup 3

  2. Training Program – Setup 6

  3. PC: Program Characteristics 8

    1. PC-1: Program Characteristics – Degree/Diploma/Certificate Training Programs 8

    2. PC-2: Program Characteristics – Non-degree bearing Unstructured Training Programs 9

    3. PC-3: Program Characteristics – Non-degree bearing Structured Training Programs 10

    4. PC-4: Program Characteristics – Internship Programs 11

    5. PC-5: Program Characteristics – One Year Retraining Programs 12

    6. PC-6: Program Characteristics – Fellowship Programs 13

    7. PC-7: Program Characteristics – Practica and Field Placements 14

    8. PC-8: Program Characteristics – Residency Programs 15

    9. PC-9: Program Characteristics –Positions Description 16

    10. PC-10: Program Characteristics – Major Participating Sites/Rotation Sites 17

  4. LR-1: Legislatively Required 18

    1. LR-1a: Trainees by Training Category 18

    2. LR-2: Trainees by Age & Sex 19

    3. DV-1: Trainees by Racial & Ethnic Background 21

    4. DV-2: Trainees from a Disadvantaged Background 23

    5. DV-3: Trainees from a Rural Background 24

  1. IND-GEN: Individual Characteristics 25

  2. INDGEN-PY: Individual Prior Year 29

  3. EXP: Experiential Characteristics 30

    1. EXP-1: Training Site Setup 30

    2. EXP-2: Experiential Characteristics - Trainees by Profession/Discipline 31

    3. EXP-3: Experiential Characteristics - Team Based Care 32

  4. RET: Retention Programs 33

  5. CDE: Course and Training Activity Development and Enhancement 34

    1. CDE-1: Course Development and Enhancement - Course Information 34

    2. CDE-2: Course Development and Enhancement - Trainees by Profession/Discipline 35

  6. CE: Continuing Education 36

    1. CE-1: Continuing Education - Course Characteristics and Content 36

    2. CE-2: Continuing Education - Individuals Trained by Profession/Discipline 37

  1. NA: Needs Assessment 38

    1. NA-1: Needs Assessment - Geographic Coverage Area 38

    2. NA-2: Needs Assessment - Public Health Priorities 39

    3. NA-3: Needs Assessment - Methods for Assessing Training Needs 40

  2. State Oral Health Workforce 41

    1. SOHWP-A: New Facilities 41

    2. SOHWP-B: Expanded Facilities 42

    3. SOHWP-C: Teledentistry 43

    4. SOHWP-D: Prevention Services 44

    5. SOHWP-E: Promotional Events 45

    6. SOHWP-F: State Dental Offices 46

    7. SOHWP-G: Other Activities 47

  3. Faculty Development 48

    1. Faculty Development – Setup 48

    2. FD-1a: Faculty Development - Structured Faculty Development Training Programs 49

    3. FD-1b: Faculty Development - Faculty Trained By Profession/Discipline 50

    4. FD-2a: Faculty Development - Faculty Development Activities 51

    5. FD-2b: Faculty Development - Faculty Trained By Profession/Discipline 52

    6. FD-3: Faculty Development - Faculty-Student Collaboration Projects 53

    7. FD-4a: Faculty Development - Faculty Instruction 54

    8. FD-4b: Faculty Development - Faculty Trained by Profession/Discipline 55

    9. FD-5: Faculty Development - Faculty Recruitment 56

    10. FD-5: Faculty Development - Faculty Recruitment – T93 Only 57

    11. FD-5: Faculty Development - Faculty Recruitment – U3M Only 58

  4. CHGME Hospital Data 59

    1. CHD-1: CHGME Hospital Data – Hospital Discharge Data 59

    2. CHD-2: CHGME Hospital Data – Hospital Discharge and Safety Data 60

    3. CHD-3: CHGME Hospital Data – Hospital Discharge Data by Zip Code 61

  5. PCC: Program Curriculum Changes 62

  6. State Primary Care Offices 63

    1. PCO-1: State Primary Care Offices – Number of Forms Submitted 63

    2. PCO-2: State Primary Care Offices – OP Impact on Health Professional Shortage Areas 64

    3. PCO-3a: State Primary Care Offices – Type of Clients Who Received Technical Assistance 65

    4. PCO-3b: State Primary Care Offices – Groups Receiving Technical Assistance 66

      1. Grant Purpose – Setup

Shape5 The Grant Purpose Setup form captures information about the types of activities conducted by grantees of multipurpose or hybrid programs during the reporting period. Please select the type(s) of activity(ies) that were conducted during the reporting period with BHW funds and then click ‘Save and Validate’. Selections on this form affect all subsequent forms. If you are unsure about which options to select, please refer to the instruction manual and/or contact your Government Project Officer. Also, if you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen.

PROGRAMS WITH MULTI-SELECT GRANT PURPOSES



Program

Grant Purpose

D19

NWD-1: Assist underrepresented students throughout the educational pipeline to become registered nurses

NWD-2: Facilitate diploma or associate degree registered nurses becoming baccalaureate prepared registered nurses

NWD-3: Prepare practicing registered nurses for advanced nursing education

NWD-4: Nursing Workforce Diversity - Eldercare Enhancement

Program

Grant Purpose

D33

PMR-1: Support resident costs

PMR-2: Infrastructure and curriculum design

Program

Grant Purpose

D34

COE-1: Increase the competitive applicant pool

COE-2: Enhance student performance

COE-3: Improve the capacity for faculty development

COE-4: Facilitate faculty and student research

COE-5: Carry out student training in providing health care services

COE-6: Improve information/curriculum design

Program

Grant Purpose

D40

GPE-1: Faculty development

GPE-2: Curricula & Instructional Design / Program Enhancement

GPE-3: Practica

GPE-4: Internships

GPE-5: Post-doctorate fellowships

Program

Grant Purpose

D85

PD-1: Plan, develop, and operate or participate in an approved professional training program

PD-2: Support of an accredited master’s in public health program for dental and dental hygiene students

PD-3: Meet the costs of projects to establish, maintain, or improve pre-doctoral training in primary care

PD-4: Provide financial assistance to dental or dental hygiene students

Program

Grant Purpose

D88

PDD-1: Plan, develop, and operate or participate in an approved professional training program

PDD-2: Support of an accredited master’s degree in public health program for dental residents

PDD-3: Meet the costs of projects to establish, maintain, or improve post-doctoral training in primary care dentistry

programs

PDD-4: Provide financial assistance to dental residents or practicing dentists

Program

Grant Purpose

E01

Conduct Active Training Programs

Maintain and Administer NFLP Loan Fund


Program

Grant Purpose

M01

BHWET-1: Professional Track- Add to existing, expand, and/or foster the development of (a) pre-degree internships

for psychology doctoral students (PhD/PsyD), or (b) field placement/practicum slots for graduate–level behavioral health students

BHWET-2: Paraprofessional Track- Add to existing, expand, and/or foster the development of paraprofessional

certificate programs for students in behavioral health training programs

BHWET-3: Curriculum Development and Enhancement

Program

Grant Purpose

T0B

PCTE-1: Plan, develop, and operate a degree, fellowship or residency program in addition to infrastructure activities

(curriculum development, faculty development, and/or continuing education)

PCTE-2: Faculty Development Programs and Activities Only (no degree, fellowship, or residency programs offered)

PCTE-IBHPC 3 (PCTE-Integrating Behavioral Health and Primary Care 3): Plan, develop, and operate a degree or residency program in addition to infrastructure activities (curriculum development, faculty development, and/or continuing education)

Program

Grant Purpose

T12

SOHWP-1: Loan forgiveness and repayment programs for dentists

SOHWP-3: Grants and low-interest or no-interest loans to help dentists who participate in the Medicaid program

SOHWP-4: The establishment or expansion of dental residency programs in coordination with accredited dental

training institutions in States without dental schools

SOHWP-5: Programs developed in consultation with State and local dental societies to expand or establish oral health

services and facilities in dental health professional shortage areas

SOHWP-6: Placement and support of dental students, dental residents, and advanced dentistry trainees

SOHWP-7: Continuing dental education, including distance-based education

SOHWP-10: Coordination with local education agencies within the State to foster programs that promote children going into oral health or science professions

SOHWP-12: The development of a State dental officer position or the augmentation of a State dental office to

coordinate oral health and access issues in the State

SOHWP-13: Direct Financial Support

SOHWP-13: Training

SOHWP-14: Integrating oral and primary care medical delivery systems for underserved communities

SOHWP-15: Programs to support oral health providers practicing in advanced roles specifically designed to improve

oral health access in underserved communities

SOHWP-18: Programs to establish or expand oral health services and facilities in Dental HPSAs, such as the establishment or expansion of community-based dental facilities, free-standing dental clinics, school-linked dental facilities, and mobile or portable dental clinics

SOHWP-19: Grants and low-interest or no-interest loans to help dentists who participate in the Medicaid program to enhance capacity, such as through equipment purchases or the sharing of overhead costs to allow for additional hours of operation

Program

Grant Purpose

T97

OWEP-2: Paraprofessional Track- Add to existing, expand, and/or foster the development of paraprofessional

certificate programs for students in behavioral health training programs

OWEP-3: Curriculum Development and Enhancement

Program

Grant Purpose

T98

OWEP-1a: Professional Track- Add to existing, expand, and/or foster the development of (a) pre-degree internships for psychology doctoral students (PhD/PsyD), or (b) field placement/practicum slots for graduate–level behavioral health students

OWEP-1b: Professional Track- Add to existing, expand, and/or foster the development of (a) post-doc-degree fellowships for psychology doctoral students (PhD/PsyD), or (b) Psychiatrist (MD).

OWEP-3: Curriculum Development and Enhancement


Program

Grant Purpose

U77

AHEC-1: Health careers recruitment of underrepresented minority populations or individuals from disadvantaged or

rural backgrounds

AHEC-2: Community-based training and education with emphasis on primary care

AHEC-3: Continuing education

AHEC-4: Public health careers exposure to youth

AHEC-5: Curriculum Development and Enhancement

AHEC-6: Active AHEC Scholar Program with participants

  1. Training Program – Setup

The Training Program Setup form captures general information about the types of training programs that were supported with BHW funds during the reporting period. Please complete this setup page for each training program that was offered during the reporting period and was supported with BHW funds. Enter each training program separately by selecting from the drop-down menu under the ‘Add Training Program’ section. Once selected, click the ‘Load Program Details’ button and complete the remaining follow-up question(s) related to your selection. Once you have answered all follow-up questions, click on ‘Add Record’ to save your entry. Do not include any information about faculty development or continuing education offerings in this form. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".

Shape6

View Prior Period Data

* Add Training Program

Select Type of Training Program Offered

(Click the ‘Load Program Details’ button after selecting your training program)


Select One V


Degree/Diploma/Certificate Academic Training Program (Degree/Diploma) Fellowship program

One-year retraining program (1 yr. Retraining)

Non-degree structured training program (Structured) Practicum/Field Placement program

Residency program Internship Program

Non-degree unstructured training program (Unstructured) Residency - Accredited Rural Training Track

Residency - Rural Area Residency - Rural Rotation

Major Participating Site/Rotation Site
Shape7

Load Program Details

For a Non-degree bearing Structured or Unstructured Training Program, Select Type of Training Activity

Single Select

For a Non-degree bearing Structured or Unstructured Training Program, Enter Name of Training Activity

Textbox

For a Degree/Diploma/Certificate Program, Select Type of Degree Offered

Single Select

For a Degree/Diploma/Certificate Program, Select Primary Focus Area

Single Select

For a Fellowship, Residency, Practicum/Field Placement, Internship or 1-year Retraining Program, Select the Primary

Discipline of Individuals Trained

Single Select

For a Major Participating Site/Rotation Site, Select the Program

Name

Single Select

Select Delivery Mode Used to Offer Program


Single Select




Shape8

Add Record


No.

Record Status

Training Program (1)

Select Training Activity Status in the Current Reporting Period

(2)

Option(s)











  1. PC: Program Characteristics

    1. PC-1: Program Characteristics – Degree/Diploma/Certificate Training Programs

The Program Characteristics (PC) subforms are designed to collect additional information about training programs that were offered during the reporting period and were supported with BHW funds. Please complete the required subforms for each program that was entered in the Training Program Setup form. The PC-1 subform collects information specific to Degree/Diploma/Certificate Training Programs only. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".

Shape9
Shape10


View Prior Period Data

No.

Record Status

Type of Training Program

Type of Degree Offered

Primary Focus Area

Select Delivery Mode Used to Offer Program

Select the Primary Purpose of the Grant Partnership(s) Developed or Enhanced using BHW

Funding

Select Types of Partner Organizations for the Primary Purpose

Select Secondary Purpose(s) of the Grant Partnership(s)

Select Type of Community- based Collaborator(s)

Select Primary Discipline of Collaborative Training Program

Select Status of Preceptor Competency Assessment



(1)

Block 1

(2)

Block 1j

(3)

Block 1k

(4)

Block 1k.1

(5a)

(5b)

(5c)

(6b)

(6c)

(6d)















Enter Total # Enrolled

(whether funded by BHW or not)

Enter Total # Graduated/Completed (whether funded by BHW or not)

Enter Total # Who left the Program Before Completion (whether

funded by BHW or not)

Total

URM

Disadvantaged Background and not URM

Total

URM

Total

URM

(7)

Block 3

(8)

Block 3a

(9)

Block 3b

(10)

Block 8

(11)

Block 8a

(12)

Block 9

(13)

Block 9a








    1. PC-2: Program Characteristics – Non-degree bearing Unstructured Training Programs

The Program Characteristics (PC) subforms are designed to collect additional information about training programs that were offered during the reporting period and were supported with BHW funds. The PC-2 subform collects information specific to Non-degree bearing Unstructured Training Programs only. Please complete the required subforms for each program that was entered in the Training Program Setup form. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".

Shape11
Shape12


View Prior Period Data

No.

Record Status

Type of Training Program

Type of Training Activity

Name of Training Activity

Select Education Level(s) of Participants

Enter Length of Training Activity in Clock Hours

Select the Primary Purpose of the Grant Partnership(s) Developed or Enhanced using BHW Funding

Select Types of Partner Organizations for the Primary

Purpose

Select Secondary Purpose(s) of the Grant

Partnership(s)

Select Type of Community- based Collaborator(s)

Select Training Activity Status in the Current Reporting Period



(1)

Block 1

(2)

Block 1a

(3)

Block 1a.1

(4)

Block 1b

(5)

Block 1c

(5a)

(5b)

(5c)

(6a)

(7)













    1. PC-3: Program Characteristics – Non-degree bearing Structured Training Programs

The Program Characteristics (PC) subforms are designed to collect additional information about training programs that were offered during the reporting period and were supported with BHW funds. The PC-3 subform collects information specific to Non-degree bearing Structured Training Programs only. Please complete the required subforms for each program that was entered in the Training Program Setup form. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".

Shape13
Shape14


View Prior Period Data

No.

Record Status

Type of Training Program

Type of Training Activity

Name of Training Activity

Select Education Level(s) of Participants

Enter Length of Training Program in Clock Hours

Select Whether Public Health Careers Content Was Offered

Select Whether Clinical or Practicum Training Was Offered

Select Whether Cultural Competency Training Was Offered

Select the Primary Purpose of the Grant Partnership(s) Developed or Enhanced using BHW Funding

Select Types of Partner Organizations for the Primary Purpose

Select Secondary Purpose(s) of the Grant Partnership(s)

Select Type of Community- based Collaborator(s)

Select Training Activity Status in the Current Reporting Period



(1)

Block 1

(2)

Block 1d

(3)

Block 1d.1

(4)

Block 1e

(5)

Block 1f

(6)

Block 1g

(7)

Block 1h

(8)

Block 1i

(8a)

(8b)

(8c)

(9a)

(10)
















    1. PC-4: Program Characteristics – Internship Programs

The Program Characteristics (PC) subforms are designed to collect additional information about training programs that were offered during the reporting period and were supported with BHW funds. The PC-4 subform collects information specific to Internship Programs only. Please complete the required subforms for each program that was entered in the Training Program Setup form. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".

Shape15
Shape16


View Prior Period Data

No.

Record Status

Type of Training Program

Primary Discipline of Individuals Trained

Select the Primary Purpose of the Grant Partnership(s) Developed or Enhanced using BHW Funding

Select Types of Partner Organizations for the Primary Purpose

Select Secondary Purpose(s) of the Grant Partnership(s)

Enter Total # Enrolled (whether funded by BHW or not)

Enter Total # Graduated/Completed (whether funded by BHW or not)

Enter Total # Who left the Program Before Completion (whether funded by BHW or not)

Total

URM

Disadvantaged Background and not URM

Total

URM

Total

URM



(1)

Block 1

(2)

Block 1l

(3a)

(3b)

(3c)

(4)

Block 3

(5)

Block 3a

(6)

Block 3b

(7)

Block 8

(8)

Block 8a

(9)

Block 9

(10)

Block 9a















    1. PC-5: Program Characteristics – One Year Retraining Programs

The Program Characteristics (PC) subforms are designed to collect additional information about training programs that were offered during the reporting period and were supported with BHW funds. The PC-5 subform collects information specific to 1-year Retraining Programs only. Please complete the required subforms for each program that was entered in the Training Program Setup form. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".

Shape17
Shape18


View Prior Period Data

No.

Record Status

Type of Training Program

Primary Discipline of Individuals Trained

Select the Primary Purpose of the Grant Partnership(s) Developed or Enhanced using BHW Funding

Select Types of Partner Organizations for the Primary Purpose

Select Secondary Purpose(s) of the Grant Partnership(s)

Enter Total # Enrolled (whether funded by BHW or not)

Enter Total # Graduated/Completed (whether funded by BHW or not)

Enter Total # Who left the Program Before Completion (whether funded by BHW or not)

Total

URM

Disadvantaged Background and not URM

Total

URM

Total

URM



(1)

Block 1

(2)

Block 1l

(3a)

(3b)

(3c)

(4)

Block 3

(5)

Block 3a

(6)

Block 3b

(7)

Block 8

(8)

Block 8a

(9)

Block 9

(10)

Block 9a















    1. PC-6: Program Characteristics – Fellowship Programs

The Program Characteristics (PC) subforms are designed to collect additional information about training programs that were offered during the reporting period and were supported with BHW funds. The PC-6 subform collects information specific to Fellowship Programs only. Please complete the required subforms for each program that was entered in the Training Program Setup form. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".

Shape19

Shape20

View Prior Period Data

No.

Record Status

Type of Training Program

Primary Discipline of Individuals Trained

Select the Primary Purpose of the Grant Partnership(s) Developed or Enhanced using

BHW Funding

Select Types of Partner Organizations for the Primary Purpose

Select Secondary Purpose(s) of the Grant Partnership(s)

Select Type of Community- based Collaborator(s)

Select Primary Discipline of Collaborative Training Program

Enter Total # Enrolled (whether funded by BHW or not)

Enter Total # Graduated/Completed (whether funded by BHW or

not)

Enter Total # Who left the Program Before Completion (whether funded by BHW or

not)

Total

URM

Disadvantaged Background and not URM

Total

URM

Total

URM



(1)

Block 1

(2)

Block 1l

(2a)

(2b)

(2c)

(3a)

(3b)

(4)

Block 3

(5)

Block 3a

(6)

Block 3b

(7)

Block 8

(8)

Block 8a

(9)

Block 9

(10)

Block 9a

















    1. PC-7: Program Characteristics – Practica and Field Placements

The Program Characteristics (PC) subforms are designed to collect additional information about training programs that were offered during the reporting period and were supported with BHW funds. The PC-7 subform collects information specific to Practicum and Field Placement Programs only. Please complete the required subforms for each program that was entered in the Training Program Setup form. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".

Shape21
Shape22


View Prior Period Data

No.

Record Status

Type of Training Program

Primary Discipline of Individuals Trained

Select the Primary Purpose of the Grant Partnership(s) Developed or Enhanced using BHW Funding

Select Types of Partner Organizations for the Primary Purpose

Select Secondary Purpose(s) of the Grant Partnership(s)

Select Type of Community- based Collaborator(s)

Select the Topic Area(s) Addressed by this Activity

Enter Total # Enrolled (whether funded by BHW or not)

Enter Total # Graduated/Completed (whether funded by BHW or not)

Enter Total # Who left the Program Before Completion (whether funded by BHW or

not)

Total

URM

Disadvantaged Background and not URM

Total

URM

Total

URM



(1)

Block 1

(2)

Block 1l

(2a)

(2b)

(2c)

(3a)

(3b)

(4)

Block 3

(5)

Block 3a

(6)

Block 3b

(7)

Block 8

(8)

Block 8a

(9)

Block 9

(10)

Block 9a

















    1. PC-8: Program Characteristics – Residency Programs

The Program Characteristics (PC) subforms are designed to collect additional information about training programs that were offered during the reporting period and were supported with BHW funds The PC-8 subform collects information specific to Residency Programs only. Please complete the required subforms for each program that was entered in the Training Program Setup form. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".

Shape23
Shape24


View Prior Period Data

No.

Record Status

Type of Training Program

Primary Discipline of Individuals Trained

Type of Dental Residency Program

Select the Primary Purpose of the Grant Partnership(s) Developed or Enhanced using

BHW Funding

Select Types of Partner Organizations for the Primary Purpose

Select Secondary Purpose(s) of the Grant Partnership(s)

Select Type of Community- based Collaborator(s)

Select Primary Discipline of Collaborative Training Program



(1)

Block 1

(2)

Block 1l

(3)

Block 1m

(3a)

Block 2

(3b)

(3c)

(4a)

(4b)












Enter Total # Enrolled

(whether funded by BHW or not)

Enter Total # Graduated/Completed (whether funded

by BHW or not)

Enter Total # Who left the Program Before Completion

(whether funded by BHW or not)

Enter # of Core Physician Faculty as Reported to ACGME

Total

URM

Disadvantaged Background and not URM

Total

URM

Total

URM

(5)

Block 3

(6)

Block 3a

(7)

Block 3b

(8)

Block 8

(9)

Block 8a

(10)

Block 9

(11)

Block 9a

(12)









    1. PC-9: Program Characteristics –Positions Description

The Program Characteristics (PC) subforms are designed to collect additional information about training programs that were offered during the reporting period and were supported with BHW funds. The PC-9 subform collects information specific to positions or slots for certain types of primary care training programs. Please complete the required subforms for each program that was entered in the Training Program Setup form. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".

Shape25
Shape26


View Prior Period Data

* Add Academic/Training Year

Select Training Program

Single Select

Shape27

(only degree, fellowship and residency programs from setup page will be populated)

Select Training Year

 Shape28

Multi Select
Shape29

Add


No.

Record Status

Type of Training Program

Training Year

Enter Total # of Accredited Positions

Enter Total # of Positions Recruited For

Enter Total # of Positions Filled

Enter Total # of Positions Expanded using BHW Funds

Enter # of Residents in FTE Positions

Option(s)

(1)

Block 1

(2)

(3)

Block 4

(4)

Block 5

(5)

Block 6

(6)

Block 7

(7)












    1. PC-10: Program Characteristics – Major Participating Sites/Rotation Sites

The Program Characteristics (PC) subforms are designed to collect additional information about the training programs that were offered during the reporting period and were supported with BHW funds. The PC-10 subform collects information specific to the Major Participating Sites/Rotation Sites identified in the Training Program Setup form. Each line of this subform contains one of the training programs (rotation sites) that was entered in the Training Program Setup form. Please complete the information requested for each identified Major Participating Site/Rotation Site. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer.

Shape30

View Prior Period Data

No.

Record Status

Type of Training Program

Program Name

Select the Primary Purpose of the Grant Partnership(s) Developed or Enhanced using BHW

Funding

Select Types of Partner Organizations for the Primary Purpose

Select Secondary Purpose(s) of the Grant Partnership(s)

Enter # of Approved Positions

Enter # of Recruited Positions

Enter # of Approved Positions Filled

Enter # of Residents Rotating Through Programs

Enter # of Trainees Spending

>= 75% under Children’s Hospital Supervision

Enter # of Core Physician Faculty as Reported to ACGME or AOA



(1)

Block 1

(2)

(3a)

(3b)

(3c)

(4)

(5)

(6)

(7)

(8)

(9)














  1. LR-1: Legislatively Required

    1. LR-1a: Trainees by Training Category

The LR-1a subform captures aggregate-level information about the number of trainees who participated in specific types of programs or activities entered in the Training Program Setup form. Please complete this subform for each training program listed below. If you have any questions about how to complete this subform, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".



View Prior Period Data

No.

Record Status

Type of Training Program

Trainees by Training Category

Attrition

Nursing Aide Employment Status and Exam Outcomes

Select Training Activity Status in the Current Reporting Period

Enter # of Ongoing Trainees

Enter # of Enrollees

Enter # of Fellows

Enter # of Residents

Enter # of Graduates

Enter # of Program Completers

Enter # of Graduates/ Program Completers

Enter # of Individuals who left the Program

before Completion

Enter # of URM who left the Program

before Completion

Enter # of Individuals Employed Full-Time

Enter # of

Individuals Employed Part-Time

Enter # of Individuals Unemployed

Select Whether Exam Assessed All Competencies

Enter # of Individuals who Passed the Exam

Enter # of Individuals who Failed the Exam



(1)

(1a)

(2)

Block 1

(3)

Block 2

(4)

Block 3

(5)

Block 4

(6)

Block 5

(6a)

(7)

Block 6

(8)

Block 6a

(10)

Block 8

(11)

Block 9

(12)

Block 10

(13)

Block 11

(14)

Block 12

(15)

Block 13

(16)



















N/A

    1. LR-2: Trainees by Age & Sex

The LR-2 form captures aggregate-level information about the age groups and sex of trainees who participated in each of the training programs or activities entered in the Training Program Setup form. Please complete this form for each training program listed below. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".

View Prior Period Data

No.

Record Status

Type of Training Program

Age Group of Trainees

Sex: Male

Sex: Female

Enter # of Ongoing Trainees

Enter # of Enrollees

Enter # of Fellows

Enter # of Residents

Enter # of Graduates

Enter # of Graduates/ Program Completers

Enter # of Program Completers

Enter # of Ongoing Trainees

Enter # of Enrollees

Enter # of Fellows

Enter # of Residents

Enter # of Graduates

Enter # of Graduates/ Program Completers

Enter # of Program Completers



(1)

(2)

(2a)

(3)

Blocks 1-6

(4)

Blocks 13-18

(5)

Blocks 25-30

(6)

Blocks 37-42

(6a)

(7)

Blocks 49-54

(7a)

(8)

Blocks 7-12

(9)

Blocks 19-24

(10)

Blocks 31-36

(11)

Blocks 43-48

(11a)

(12)

Blocks 55-60

1

Prior Record


19 and Under















2

Prior Record


20 – 29 years















3

Prior Record


30 – 39 years















4

Prior Record


40 – 49 years















5

Prior Record


50 – 59 years















6

Prior Record


60 and Over















7

Prior Record


Age Not Reported















8

New Record


19 and Under















9

New Record


20 – 29 years















10

New Record


30 – 39 years















11

New Record


40 – 49 years















12

New Record


50 – 59 years















13

New Record


60 and Over















14

New Record


Age Not Reported
















(Contd)

No.

Record Status

Type of Training Program

Age Group of Trainees

Gender: Transgender Nonbinary or Another Gender

Sex: Not Reported

Select Training Activity Status in the Current Reporting Period

Enter # of Ongoing Trainees

Enter # of Enrollees

Enter # of Fellows

Enter # of Residents

Enter # of Graduates

Enter # of Graduates/ Program

Completers

Enter # of Program Completers

Enter # of Ongoing Trainees

Enter # of Enrollees

Enter # of Fellows

Enter # of Residents

Enter # of Graduates

Enter # of Graduates/ Program

Completers

Enter # of Program Completers




(1)

(2)

(12a)

(13)

(14)

(15)

(16)

(16a)

(17)

(19)

(19a)

(19b)

(19c)

(19d)

(19e)

(19f)

(20)

1

Prior

Record


19 and Under















Ongoing

2

Prior

Record


20 – 29 years















Ongoing

3

Prior

Record


30 – 39 years















Ongoing

4

Prior

Record


40 – 49 years















Ongoing

5

Prior Record


50 – 59 years















Ongoing

6

Prior

Record


60 and Over















Ongoing

7

Prior

Record


Age Not Reported















Ongoing

8

New

Record


19 and Under















Complete

9

New

Record


20 – 29 years















Complete

10

New

Record


30 – 39 years















Complete

11

New

Record


40 – 49 years















Complete

12

New

Record


50 – 59 years















Complete

13

New

Record


60 and Over















Complete

14

New

Record


Age Not Reported















Complete

    1. DV-1: Trainees by Racial & Ethnic Background

The DV-1 form captures aggregate-level information about the racial and ethnic background of trainees who participated in each of the training programs or activities entered in the Training Program Setup form. Please complete this form for each training program entered in the Training Program Setup form. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop- up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".

View Prior Period Data

No.

Record Status

Type of Training Program

Race Category

Ethnicity: Hispanic/Latino

Ethnicity: Non-Hispanic/Non-Latino

Enter # of Ongoing Trainees

Enter # of Enrollees

Enter # of Fellows

Enter # of Residents

Enter # of Graduates

Enter # of Graduates/ Program Completers

Enter # of Program Completers

Enter # of Ongoing Trainees

Enter # of Enrollees

Enter # of Fellows

Enter # of Residents

Enter # of Graduates

Enter # of Graduates/ Program Completers

Enter # of Program Completers



(1)

(2)

(2a)

(3)

Blocks 1-7

(4)

Blocks 8-14

(5)

Blocks 15-21

(6)

Blocks 22-28

(6a)

(7)

Blocks 29-35

(7a)

(8)

Blocks 36-42

(9)

Blocks 43-49

(10)

Blocks 50-56

(11)

Blocks 57-63

(11a)

(12)

Blocks 64-70

1

Prior Record


American Indian or Alaska Native















2

Prior Record


Asian















3

Prior Record


Black or African American















4

Prior Record


Native Hawaiian or Pacific Islander















5

Prior Record


White















6

Prior Record


More than one Race















7

Prior Record


Race Not Reported















8

New Record


American Indian or Alaska Native















9

New Record


Asian















10

New Record


Black or African American















11

New Record


Native Hawaiian or Pacific Islander















12

New Record


White















13

New Record


More than one Race















14

New Record


Race Not Reported
















(Contd)


No.

Record Status

Type of Training Program

Race Category

Ethnicity: Not Reported

Select Training Activity Status in the Current Reporting Period

Enter # of Ongoing Trainees

Enter # of Enrollees

Enter # of Fellows

Enter # of Residents

Enter # of Graduates

Enter # of Graduates/ Program Completers

Enter # of Program Completers



(1)

(2)

(12a)

(13)

(14)

(15)

(16)

(16a)

(17)

(18)

1

Prior Record


American Indian or Alaska Native








Complete

2

Prior Record


Asian








Complete

3

Prior Record


Black or African American








Complete

4

Prior Record


Native Hawaiian or Pacific Islander








Complete

5

Prior Record


White








Complete

6

Prior Record


More than one Race








Complete

7

Prior Record


Race Not Reported








Complete

8

New Record


American Indian or Alaska Native








Ongoing

9

New Record


Asian








Ongoing

10

New Record


Black or African American








Ongoing

11

New Record


Native Hawaiian or Pacific Islander








Ongoing

12

New Record


White








Ongoing

13

New Record


More than one Race








Ongoing

14

New Record


Race Not Reported








Ongoing

    1. DV-2: Trainees from a Disadvantaged Background

The DV-2 form captures aggregate-level information about the disadvantaged background status of trainees who participated in each of the training programs or activities entered in the Training Program Setup form. Please complete this form for each training program listed below. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".

View Prior Period Data






No.





Record Status





Type of Training Program

Enrollees

Fellows

Residents

Graduates

Program Completers

Ongoing Trainees

Graduates/Program Completers




Select Training Activity Status in the Current Reporting Period



Enter Total # from Disadvantaged Background



Enter # from Disadvantaged Background who are not URM



Enter Total # from Disadvantaged Background



Enter # from Disadvantaged Background who are not URM



Enter Total # from Disadvantaged Background



Enter # from Disadvantaged Background who are not URM



Enter Total # from Disadvantaged Background



Enter # from Disadvantaged Background who are not URM



Enter Total # from Disadvantaged Background



Enter # from Disadvantaged Background who are not URM



Enter Total # from Disadvantaged Background



Enter # from Disadvantaged Background who are not URM



Enter Total # from Disadvantaged Background



Enter # from Disadvantaged Background who are not URM




(1)


(2)

Block 1


(3)

Block 2


(4)

Block 3


(5)

Block 4


(6)

Block 5


(7)

Block 6


(8)

Block 7


(9)

Block 8


(10)

Block 9


(11)

Block 10


(13)


(14)


(15)


(16)


(12)



















    1. DV-3: Trainees from a Rural Background

The DV-3 form captures aggregate-level information about the number of trainees who participated in each of the training programs or activities entered in the Training Program Setup form and are from a rural background. Please complete this form for each training program entered in the Training Program Setup form. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".

View Prior Period Data





No.





Record Status




Type of Training Program



Trainees from Rural Residential Background



Select Training Activity Status in the Current Reporting Period

Enter # of Enrollees from a Rural Background


Enter # of Fellows from a Rural Background


Enter # of Residents from a Rural Background


Enter # of Graduates from a Rural Background


Enter # of Program Completers from a Rural Background


Enter # of Ongoing Trainees from a Rural Background


Enter # of Graduates/Program Completers from a Rural Background




(1)

(2)

Block 1

(3)

Block 2

(4)

Block 3

(5)

Block 4

(6)

Block 5

(8)

(9)

(7)












  1. IND-GEN: Individual Characteristics

The IND-GEN form captures individual-level information about students, faculty, or other types of awardees who either received direct financial support (e.g., loans, loan repayment, scholarships, or stipends) through a HRSA grant or participated in specific types of HRSA-supported training. Please complete this form in its entirety. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".

Shape31


View Prior Period Data

No.

Record Status

Type of Training Program

Trainee Unique ID

NPI

Number

Select Whether T9C Funding Was Used for Resident or Fellow

Select Individual's Training or Awardee Category

Select Whether Individual is an International Medical Graduate (IMG)

Select Highest Degree Held by Individual

Select Residency/Degree Already Completed by Individual

Select Individual's Enrollment / Employment Status

Select Individual's Sex

Enter Year of Birth

Select Individual's Ethnicity

Select Individual's Race

Select Whether Individual is from a Rural Residential Background

Select Whether Individual is from a Disadvantaged Background

Select Individual's Veteran Status



(1)

(2)

Block 1

(2a)

(2b)

(3)

Block 2

(3a)

(3b)

(3c)

(4)

Block 3

(5a)

(6a)

(7)

Block 6

(8)

Block 7

(9)

Block 8

(10)

Block 9

(11)

Block 10




















(Contd)


Select Whether Individual Received BHW Financial Award?

Enter Individual's Financial Award Amount (BHW funds only)

Enter Individual's Financial Award Amount

Stipend

Tuition, Fees, and

Supplies

Traineeship

Scholarship

Loan

Career Award

Loan Repayment

Grant

Fellowship

Direct Financial Support

Academic Year Total

Cumulative BHW Financial Award Total

Federal Contribution to Loan Repayment

State Contribution to Loan Repayment

Total Contribution to Loan Repayment

(12)

Block 11

(13)

Block 11

(13a)

Block 11

(14)

Block 11

(15)

Block 11

(16)

Block 11

(17)

Block 11

(18)

Block 11

(19)

Block 11

(20)

Block 11

(20a)

Block 11

(21b)

Block 11

(21c)

Block 11

(21d)

(21e)

(21h)



















(Contd)





Enter # of Academic Years the Individual has Received BHW Funding




Enter Original Qualifying Educational Loan Amount





Enter Balance of Individual's Loan



Select Whether Loan Remains in Good Standing and is not in Default




Enter

% of Loan Paid Off



Enter % FTE paid for through BHW

Financial Award




Enter % of Training Costs Covered through BHW-funded Financial Award




Select Individual's Academic or Training Year



Select Topic Area(s) on which Individual was Trained



Select any HHS Priority Topic Area on which an Individual Received Training





Select Individual's Profession





Select Individual's Primary Discipline/Specialty





Select Individual's Specialty

Training in Interprofessional Education and/or Practice





Enter Total # of Patients Treated during Academic Year


Training in a Telehealth


Training in a Primary Care Setting


Select Whether Individual Received Training


Enter # of Contact Hours


Select Whether Individual Received Training


Enter # of Contact Hours



Enter # of Patient Encounters


Select Whether Individual Received Training


Enter # of Contact Hours



Enter # of Patient Encounters

(22)

Block 12

(22a)

(23)

Block 13

(23a)

(24)

Block 13a

(25)

Block 14

(25a)

(26)

Block 15

(26a)

(26b)

(26c)

(26d)

(27aa)

(27a)

(27b)

(27c)

(27d)

(27e)

(27f)

(28)

Block 17

(29)

Block 17a

(30)

Block 17b






















(Contd)




Training in a Medically Underserved Community


Training in a Rural Area





Enter Total # of Patient Encounters Across All Settings Including Inpatients




Enter Total # of Contact Hours Across All Settings Including Inpatients


Student Services


Select Whether Individual Received Training


Enter # of Contact Hours



Enter # of Patient Encounters


Select Whether Individual Received Training


Enter # of Contact Hours



Enter # of Patient Encounters



Select Social Support services used by Trainee


Select Academic Support services used by Trainee

(31)

Block 18

(32)

Block 18a

(32a)

(33)

Block 19

(34)

Block 19a

(34aa) Block 19

(34ab) Block 19

(34ac)

(34a)

(34b)












Select Any Key Services Provided by Individual

Select Individual's Field Placement Setting

Select Whether Individual Left the Program Before Completion

Select Reason for Attrition or Inactive Status

Select Whether Individual Graduated/ Completed the

Program

Select Degree Earned

Select whether individual earned degree on- schedule/ on-

time

Select whether individual passed a certifying examination on the

first attempt

Enter the Number of Education Courses Taken

Did Medical Student Match to a Residency Program?

Select Type of Residency Program

Enter Certification Number

Select Individual's Post-Graduation/ Completion Intentions

Select Competencies the Individual is Highly Ready to Perform

Select Factors Individual was Highly Satisfied with

(34c)

(35)

Block 20

(36)

Block 21

(36a)

(37)

Block 22

(38)

Block 22a

(38a)

(38b)

(38c)

(38d)

(38e)

(38f)

(39)

Block 22b

(39a)

(39b)

















(Contd)


Enter the % FTE Individual Spent on the Following Roles

Enter # of Articles Published in Peer- Reviewed Journals

Enter # of Peer- Reviewed Conference Presentations

Enter # of Trainees Precepted

Enter # of Hours Spent Precepting

Enter # of Grants Awarded by Type and Amount

Research

Teaching

Administration

Clinical





Research (<$100,000)

Research (>=$100,000)

Education (<$100,000)

Education (>=$100,000)

(40)

Block 24a

(41)

Block 24b

(42)

Block 24c

(43)

Block 24d

(44)

Block 25

(45)

Block 26

(45a)

Block 26

(45b)

Block 26

(46)

Block 27

(47)

Block 27

(48)

Block27

(49)

Block 27














(Contd)


Enter Total Time Obligated to Serve (in weeks)

Select Individual's Current Designated Practice Settings

Select Whether individual is Enrolled in Medicaid/CHIP Program

Select Whether individual is Accepting new Medicaid/CHIP Patients

Enter Total # of Patient Encounters

Enter # of Medicaid/CHIP Patient Encounters

Select whether Employment Data is available?

Select Whether Your Organization Hired this Individual

Select Whether a Partner Organization Hired this Individual

Select Whether Program Sponsoring Employer Hired the Apprentice After the Apprenticeship

Hired Hourly Wage

Enter Zip Code

Enter City

Enter State

Select Type of Employment

Select Individual’s Employment Location Settings

Select Individual’s Primary Role at Employment Setting

Select Individual's Other Role(s) at Employment Setting

Select Type(s) of Vulnerable Populations Served at Employment Setting

(50)

Block 28

(51)

Blocks 29-31

(52)

Block 32

(53)

Block 32a

(54)

Block 33

(55)

Block 33a

(56)

(56a)

(56b)

(56c)

(56d)

(57)

(58)

(59)

(60)

(61)

(62)

(63)

(64)






















Select Whether Individual is a First Time Participant


Select Whether this is a Continuation Award


Select Whether Provider is in default of service obligation


Enter Service Obligation Start Date


Enter Service Obligation End Date

Select Any HRSA/BHW

program Individual Participated In Prior to Entering

NHSC SLRP

Select Medication Assisted Treatment (MAT) Services Provided by

Individual

Select If Individual Holds a Substance Use Disorder License or Certificate


Select Primary Site Name



Select Other Site Name(s)

(80)

(81)

(82)

(84)

(85)

(86)

(88)

(89)

(91)

(92)














(Contd)


Apprenticeship Data

Options


Select Apprenticeship Program Status

Program Entry Date for Apprenticeship Participant

Program Exit Date for Apprenticeship Participant


Employment Status at Apprenticeship Entry


Hourly Wage At Apprenticeship Entry


Select Apprentice Role(s) at Site


Select Skills the Apprentice is Developing


Select Support Received During Apprenticeship


Apprenticeship Minimum Term Length


Total Number of Apprenticeship Training Hours


Apprenticeship Street


Apprenticeship City


Apprenticeship State


Apprenticeship Zip Code

Type of Credential Attained During Or At Apprenticeship Exit

Hourly Wage At Apprenticeship Exit


(93)

(94)

(95)

(96)

(97)

(98)

(99)

(100)

(101)

(102)

(103)

(104)

(105)

(106)

(107)

(108)



















  1. INDGEN-PY: Individual Prior Year

The INDGEN-PY subform captures 1-year follow-up information about individuals who received direct financial support (e.g., loans, loan repayment, scholarships, or stipends) through a HRSA grant or participated in specific types of HRSA-supported training programs and have since graduated or completed their training. Please complete this form for each individual listed below. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read- only version of your most recent prior performance report will pop-up in a new screen.

View Prior Period Data

No.

Record Status

Type of Training Program

Trainee Unique ID

NPI

Number

Select Individual's Training or Awardee Category

Select Individual's Enrollment / Employment Status

Select Individual's Sex

Enter Year of Birth

Select Individual's Ethnicity

Select Individual's Race

Select Whether Individual is from a Rural Residential Background

(1)

(2)

Block 1

(2a)

(3)

Block 2

(4)

Block 3

(5a)

Block 4

(6a)

(7)

Block 6

(8)

Block 7

(9)

Block 8














Select Whether Individual is from a Disadvantaged Background

Select Degree Earned

Select Individual's Post- Graduation/ Completion Intentions

Enter Zip Code

Select Type of Employment

Select Individual's Employment Location Settings

Select whether status/employment data are available for the individual 1-year post graduation/ completion

Select Individual's Current Training/ Employment Status

Select Individual's Type of Faculty Appointment

Select Whether Your Organization Hired this Individual PY

Select Whether a Partner Organization Hired this Individual PY

Select Employment Location PY

Enter Zip Code PY

City PY

State PY

Select Whether individual is Enrolled in Medicaid/CHIP Program

Select Whether individual is Accepting new Medicaid/CHIP Patients

Select Individual’s Primary Role at Employment Setting PY

Select Individual's Other Role(s) at Employment Setting PY

(10)

Block 9

(11)

Block 22a

(12)

Block 22b

(12a)

(12b)

(12c)

(13)

Block 23

(14)

Block 23a

(15)

Block 23b

(16)

(17)

(18)

(18a)

(18b)

(18c)

(19)

(20)

(21)

(22)




















  1. EXP: Experiential Characteristics

    1. EXP-1: Training Site Setup

The EXP-1 Setup form captures information about the names of sites used by grantees to provide trainees with clinical or experiential training. Please enter each site used separately by typing in a site's name and clicking the ‘Add Record’ button. Please complete this setup form for each training site used. If you have any questions about how to complete this setup form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about sites used in a prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".


Shape37

EXP-1

EXP-2

EXP-3



View Prior Period Data

No.

Record Status

Site Name

Select Whether the Site was Used in the Current Reporting Period

Select Type of Site Used

Select Type of Setting Where the Site was Located

Select the Primary Purpose of the Grant Partnership(s) Developed or Enhanced using BHW Funding

Select Types of Partner Organizations for the Primary Purpose

Select Secondary Purpose(s) of the Grant Partnership(s)

Select Primary Training Competency Addressed at this Site

Select Type(s) of Vulnerable Population Served at this Site

Street Address 1

Street Address 2

Zip Code

City

State

Four Digit Zip Code Extension

Payment Model

Select whether the training site implements interprofessional education and/or practice

Select any HHS

Priorities Addressed at this Site

Select Provider HPSA

Type for Site

Dental HPSA

Score

Mental Health HPSA

Score

Primary Care HPSA

Score

(1)

Block 1

(2)

(3)

Block 1a

(4)

Block 2

(5a)

(5b)

(5c)

(6)

(7)

(7a)

(7b)

(8)

(9)

(10)

(11)

(12)

(13)

(14)

(15)

(16)

(17)

(18)

























    1. EXP-2: Experiential Characteristics - Trainees by Profession/Discipline

The EXP-2 subform collects information about the profession and discipline of individuals trained at each site that was entered in the EXP-1 Setup form. Please complete this subform for each site listed below. If you have any questions about how to complete this subform, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen.

Shape38


View Prior Period Data

No.

Type of Training Program

Site Name

Select Profession and Discipline of Individuals Trained

Select Discipline/Specialty of Individuals Trained

Enter # Trained in this Profession and Discipline

Enter # of Other Trainees in this Profession and Discipline Who Participated in Interprofessional Team- based care

Select Type of Site Used

Select Type of Setting Where the Site was Located

(1)

(2)

Block 1

(3)

(3a)

(4)

Block 3

(5)

Block 8

(6)

(7)










    1. EXP-3: Experiential Characteristics - Team Based Care

The EXP-3 subform collects information about the profession and discipline of individuals trained at each site that was entered in the EXP-1 Setup form. Please complete this subform for each site listed below. If you have any questions about how to complete this subform, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen.

Shape39


View Prior Period Data

No.

Type of Training Program

Site Name

Select Team Number

Select Profession and Discipline of Team Members

Select Discipline/Specialty of Team Members

Enter # of Team Members in this Profession and Discipline

Select Type of Site Used

Select Type of Setting Where the Site was Located


(1)

(2)

Block 1

(3)

Block 7b

(4)

(4a)

(5)

Block 7b

(6)

(7)










  1. RET: Retention Programs

The RET form captures information about recruitment and retention-related efforts for specific types of BHW-supported initiatives. Please complete this form for any recruitment and retention-related efforts conducted during this reporting period. If you have any questions about how to complete this subform, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen.

View Prior Period Data

* Retention Information

Indicate # of Targeted Vacant Dentist/Dental Provider Positions (Block 5)

 Shape40

Text Box (4 digits)

Indicate # of Filled Dentist/Dental Provider Positions (Block 6)

 Shape41

Text Box (4 digits)

Indicate # of Dentist/Dental Provider Positions Retained (Block 7)

 Shape42

Text Box (4 digits)

  1. CDE: Course and Training Activity Development and Enhancement

    1. CDE-1: Course Development and Enhancement - Course Information

The CDE-1 subform captures information about courses or other training activities that have been developed or enhanced by grantees using BHW funds during their project period. Please complete an entry for each course or other training activity that was developed or enhanced. If you have any questions about how to complete this subform, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".

Shape43


View Prior Period Data

* Add Course

Enter the Name of the Course of Training Activity that was Developed or Enhanced

(text 200 chars)
Shape44

Add Record


No.

Record Status

Name of Course or Training Activity

Select Type of Course or Training Activity

Select whether Course or Training Activity was Newly Developed or Enhanced

Select Status of Development or Enhancements

Select Primary Competency Addressed by the Course

Select Delivery Mode Used to Offer this Course or Training Activity

Select Primary Topic Area

Select Whether the Course or Training Activity was Offered in the Current Reporting Period

Was Supplement Funding Used?

Select Status of Development or Enhancements Prior Year

Option(s)

(1)

Block 1

(2)

Block 2

(3)

Block 3

(4)

Block 4

(7a)

(8)

Block 6

(11)

(12)

(13)


















    1. CDE-2: Course Development and Enhancement - Trainees by Profession/Discipline

The CDE-2 subform captures information about individuals who participated in courses or other types of training activities that were developed or enhanced using BHW funds. Please complete this subform for each type of course or training activity that was developed or enhanced using BHW funds and has been implemented either in the current or in a previous academic year. If you have any questions about how to complete this subform, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".

View Prior Period Data

* Add Profession/Discipline

Name of Course or Training Activity

Populated with the following:

- Courses in CDE-1 where Column 4 = Implemented and Column 2 = ‘Academic Course’ or ‘Training/Workshop for health professions students, fellows or residents’ and column 12 = ‘Offered’ or ‘Reoffered’

Select Profession of Individuals Trained

(Multi-Select)

Select Discipline/Speciality of Individuals Trained

(Multi-Select)
Shape45

Add Record


No.

Name of Course or Training Activity

Profession and Discipline of Individuals Trained

Select Discipline/Specialty of Individuals Trained

Enter # Trained in this Profession and Discipline

Select Type of Course or Training Activity

Select whether Course or Training Activity was Newly Developed or Enhanced

Select Primary Competency Addressed by the Course

Select Delivery Mode Used to Offer this Course or Training Activity

Select Primary Topic Area

Select Whether the Course or Training Activity was Offered in the Current

Reporting Period

Was Supplement Funding Used?

Option(s)


(1)

Block 1

(2)

(2a)

(3)

Block 7

(4)

Block 2

(5)

Block 3

(6)

(7)

Block 6

(8)

(9)

(10)















  1. CE: Continuing Education

    1. CE-1: Continuing Education - Course Characteristics and Content

The CE-1 subform captures information about continuing education courses developed and/or offered by grantees using BHW funds during this reporting period. Please complete an entry for each individual course that was offered. Report each individual course only once and indicate the number of times offered within this subform. If you have any questions about how to complete this subform, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".

Shape46

View Prior Period Data

No.

Record Status

Course Title

Select Type of Course or Training Activity

Select Whether Course is Approved for Continuing Education Credit

Enter the Duration of the Course in Clock Hours

Enter # of Times Course was Offered

Select Delivery Mode Used to Offer Course

Select Type(s) of Partnership(s) Established for the Purposes of Delivering this Course

Select Whether Employment Location Data are Available for Individuals Trained

Enter # of Individuals Trained by Employment Location (not mutually exclusive)

Primary Care Setting

Medically Underserved Community

Rural Area

(1)

Block 1

(1b)

(2)

Block 2

(3)

Block 3

(4)

Block 4

(5)

Block 5

(6)

Block 6

(8)

Block 9

(9)

Block 9a

(10)

Block 9b

(11)

Block 9c
















Select the Course's Primary Topic Area

Select the Primary Competency Addressed by the Course

Select the Competency Tier for this Course

Select Whether this Course Covers Alzheimer's Disease-Related Training

Was Supplement Funding Used?

Option(s)

(12)

Block 11

(13)

Block 12

(14)

Block 13

(15)

Block 14

(16)








    1. CE-2: Continuing Education - Individuals Trained by Profession/Discipline

The CE-2 subform captures information about the profession and discipline of individuals participating in continuing education offerings supported with BHW funds. Please complete this subform for each course entered in CE-1. If you have any questions about how to complete this subform, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen.

Shape47

View Prior Period Data



No.

Course Title

Select Profession and Discipline of Individuals

Trained

Select Discipline/Specialty of Individuals Trained

Enter # Trained in this Profession and Discipline

Primary Topic Area

Select Whether this Course Covers Alzheimer's Disease-Related Training

Was Supplement Funding Used

Option(s)

(1)

Block 1

(2)

Block 8

(2a)

(3)

Block 8

(4)

(5)

(6)











  1. NA: Needs Assessment

    1. NA-1: Needs Assessment - Geographic Coverage Area

The NA-1 subform captures information about your geographically designated service area. Please select the state(s) covered by your project and identify the specific counties that are also covered in your service area. You must report each state separately. If you have any questions about how to complete this subform, please refer to the instruction manual and/or contact your Government Project Officer.

Shape48



* Add Geographically Designated Coverage Area

Select the State(s) Covered in Your Geographically Designated Service Area

(Click the ‘Load Counties’ button after selecting the State)


Select One V


Shape49

Load Counties

Select the County(ies) covered in Your Geographically Designated Service Area

Multi-Select
Shape50

Add Record


No.

State

County

Option(s)

(1)

Block 1

(2)

Block 1






    1. NA-2: Needs Assessment - Public Health Priorities

The NA-2 subform captures information about the trends of the public health priorities and related training needs in a geographically designated service area. Complete the ‘Add Public Health Priority’ section and click the ‘Add Record’ button. In the data table, provide particulars related to this public health priority. If you have any questions about how to complete this subform, please refer to the instruction manual and/or contact your Government Project Officer.


NA-1

 Shape51

NA-2

NA-3


* Add Public Health Priority

Enter the Public Health Priority


Textbox 200 characters



Shape52

Add Record


No.

Public Health Priority

Select the State(s) for Which this is a Priority

Enter the Data Source Used to Document this Priority

Enter the Current Rate

Select the Type of Observed Trend

Select the Type(s) of Competency(ies) that Need to be Addressed related to this Priority

Option(s)

(1)

Block 2

(2)

Block 1

(3)

Block 2

(4)

Block 2

(5)

Block 2

(6)

Block 2










    1. NA-3: Needs Assessment - Methods for Assessing Training Needs

The NA-3 subform captures information about the method(s) used to assess training needs among public health workers in a geographically designated service area. If several methods are used, each must be reported separately. Please complete this form in its entirety. If you have any questions about how to complete this subform, please refer to the instruction manual and/or contact your Government Project Officer.

Shape53


* Add Methods to Assess Training Needs

Method Used to Assess Training Needs in Geographically Designated Service Area


Multi-Select V



Shape54

Add Record


No.

Methods Used

Enter the Types of Participants Queried using this Method

Option(s)

(1)

Block 3

(2)

Block 3






  1. State Oral Health Workforce

    1. SOHWP-A: New Facilities

If your program established new dental facilities in a HPSA/underserved area, select ‘Yes’ and complete the table below, otherwise select ‘No’ and proceed to the next form. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen.

Shape55
Shape56



View Prior Period Data

* Add Facility

Facility name

(Textbox 100 chars)
Shape57

Add Record


No.

Facility Name

Select the Type of Facility

Select Type(s) of Oral Health Services Provided

Enter # of Patient Encounters

Select whether this is a Mobile/Portable Facility

Option(s)


(1)

Block 1b

(2)

Block 1a

(3)

Block 1c

(4)

Block 1d

(5)

Block 1e









    1. SOHWP-B: Expanded Facilities

If your program expanded existing dental facilities in a HPSA/underserved area, select ‘Yes’ and complete the table below, otherwise select ‘No’ and proceed to the next form. If you wish to view data that were submitted in the prior reporting period, click on the 'View Prior Period Data' link and a read-only version of your most recent prior performance report will pop-up in a new screen.

Shape58
Shape59



View Prior Period Data

* Add Facility

Facility name

(Textbox 100 chars)
Shape60

Add Record


No.

Facility Name

Select the Type of Facility

Select Type(s) of Oral Health Services Provided

Enter Average # of Patient Encounters Prior to Expansion

Enter Actual # of Patient Encounters Post Expansion

Enter Average # of Patient Encounters Facility can Accommodate

Select whether this is a Mobile/Portable Facility

Option(s)


(1)

Block 2b

(2)

Block 2a

(3)

Block 2c

(4)

Block 2d

(5)

Block 2e

(6)

Block 2f

(7)

Block 2g











    1. SOHWP-C: Teledentistry

Provide information on the teledentistry education training particulars for the program offered by you. If you wish to view data that were submitted in the prior reporting period, click on the 'View Prior Period Data' link and a read-only version of your most recent prior performance report will pop-up in a new screen.

Shape61

View Prior Period Data

* Add Teledentistry Program Details

Number of Dental Facilities with Teledentistry Capabilities (Block 3)

3 digits

Number of Teledentistry Encounters Involving Patient Care (Block 4)

3 digits

Number of Teledentistry Sessions Involving Training (Block 5)

3 digits

    1. SOHWP-D: Prevention Services

Provide information on the types of community-based preventive services provided by your program in the table below. If you wish to view data that were submitted in the prior reporting period, click on the 'View Prior Period Data' link and a read-only version of your most recent prior performance report will pop-up in a new screen.

Shape62

View Prior Period Data

* Community-Based Prevention Services Details

Enter # of New Water Systems with Fluoridated Water (Block 6)

(text 3 digits)

Enter # of Replaced Water Systems with Fluoridated Water (Block 7)

(text 2 digits)

Enter Estimated # of Residents Served (Block 8)

(text 7 digits)

Enter # of Children Receiving Dental Sealants (Block 9)

(text 5 digits)

Enter # of Individuals Receiving Topical Fluoride (Block 10)

(text 5 digits)

Enter # of Individuals Receiving Diagnostic or Preventive Dental Services (Block 11)

(text 5 digits)

Enter # of Recipients of Oral Health Education (Block 12)

(text 5 digits)

Enter # of Individuals Receiving an Oral Screening

(text 5 digits)

Enter # of Individuals Receiving a Referral for Dental Services

(text 5 digits)

Enter # of Individuals Receiving any other Type of Preventive Services

(text 5 digits)

    1. SOHWP-E: Promotional Events

In the table below, describe the programs that encourage children going into oral health and science professions. Select a promotional event in the dropdown list and click ‘Add Record’. In the data table, provide particulars related to this promotional event. If you wish to view data that were submitted in the prior reporting period, click on the 'View Prior Period Data' link and a read-only version of your most recent prior performance report will pop-up in a new screen.

Shape63

View Prior Period Data

* Add Type of Promotional Event

Promotional Event

 Shape64

Multi select
Shape65

Add Record



No.

Type of Promotional Event

Enter # Promotional Events Held

Select Type(s) of Local Organizations Involved in Promotional Events

Enter Total # of Children Who Attended Promotional Events

Select Type(s) of Materials Created for Promotional Events

Option(s)


(1)

Block 13a

(2)

Block 13b

(3)

Block 13c

(4)

Block 13d

(5)

Block 13e









    1. SOHWP-F: State Dental Offices

Answer each question below for the reporting period. If you wish to view data that were submitted in the prior reporting period, click on the 'View Prior Period Data' link and a read-only version of your most recent prior performance report will pop-up in a new screen

Shape66

View Prior Period Data

Select whether a new state dental office was created

Select whether a new state dental officer position was created

Enter # of new support staff members hired

Select whether staff members hired in a previous reporting period have been retained

Administrative

Dentists, Dental Hygienists, Oral Health Coordination

Fluoridation expert

Epidemiologist

Statistician

Other

Administra tive

Dentist, Dental Hygienist Oral Health Coordination

Fluoridation expert

Epidemiologist

Statistician

Other

(1)

Block 14

(2)

Block 15

(3)

Block 16

(4)

Block 17

(5)

Block 18

(6)

Block 19

(7)

Block 20

(8)

Block 21

(9)

Block 16a

(10)

Block 17a

(11)

Block 18a

(12)

Block 19a

(13)

Block 20a

(14)

Block 21a















    1. SOHWP-G: Other Activities

Describe activities conducted. If you wish to view data that were submitted in the prior reporting period, click on the 'View Prior Period Data' link and a read-only version of your most recent prior performance report will pop-up in a new screen.

Shape67

View Prior Period Data

Policy (Block 22)

 Shape68

Multi-line text box (5000 chars)

Grants Contracts (Block 22)


Shape69

Multi-line text box (5000 chars)

Strategic Efforts (Block 22)


Shape70

Multi-line text box (5000 chars)

Partnerships (Block 22)


Shape71

Multi-line text box (5000 chars)

Training (Block 22)


Shape72

Multi-line text box (5000 chars)

Prevention Activity (Block 22)


Shape73

Multi-line text box (5000 chars)

Workforce Development (Block 22)


Shape74

Multi-line text box (5000 chars)

Direct Financial Support (Block 22)


Shape75

Multi-line text box (5000 chars)

Other (Block 22)


Shape76

Multi-line text box (5000 chars)

  1. Faculty Development

    1. Faculty Development – Setup

The Faculty development Setup form captures information about the specific types of faculty development activities conducted by grantees using BHW funds Please select the type(s) of faculty development activities supported that took place during the reporting period and were supported with BHW funds. Selections in this form will affect all subsequent faculty-related forms. If you have any questions about how to complete this subform, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen.

Shape77


View Prior Period Data

Faculty Development Activities

Structured Faculty Development Training Program

□

Faculty Development Activity

□

Faculty-Student Research or Collaboration Project

□

Faculty Instruction

□

Faculty Recruitment Activities

□

No faculty-related activities conducted

□

    1. FD-1a: Faculty Development - Structured Faculty Development Training Programs

The FD-1a subform captures general information about structured faculty development programs offered by grantees using BHW funds. Please complete this subform for each structured faculty development program offered during the reporting period and supported with BHW funds. If you have any questions about how to complete this subform, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".

Shape78

View Prior Period Data

* Add Structured Faculty Development Program

Program Name

 Shape79

Textbox (200 char)


Shape80

Add Record



No.

Record Status

Program Name

Select Program Status in the Current Reporting Period

Select Whether this was a Preceptor Training Program

Select Whether this was a Degree Bearing Program

For Degree-Bearing Programs

For Non- Degree Bearing Program, Enter Length of Training Program in Clock Hours

Enter the % of Time Spent Developing Competencies for the Following Roles

Enter # of Faculty Who Completed the Program

Select whether any Faculty Received any type of BHW- Funded Financial Award during the Training Program

Was Supplement Funding Used?

Option(s)

Select Type of Degree Offered

Select Primary Focus Area

Clinician

Administrator

Educator

Researcher

(1)

(1a)

(1b)

(2)

Block 2

(3)

Block 2a

(4)

Block 2b

(5)

Block 3

(6)

Block 5

(7)

Block 5

(8)

Block 5

(9)

Block 5

(10)

Block 6

(11)

Block 7

(12)



















    1. FD-1b: Faculty Development - Faculty Trained By Profession/Discipline

The FD-1b subform captures information about the profession and discipline of faculty who participated in a structured faculty development program that was offered by grantees using BHW funds. If you have any questions about how to complete this subform, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen.

Shape81


Fields with * are required


View Prior Period Data

* Add Training Program and Discipline

Program Name

Only newly added programs from FD-1a will be populated in this single select dropdown box.

Select Profession of Faculty Trained

Multi-Select

Select Discipline/Speciality of Faculty Trained

Multi-Select
Shape82

Add Record


No.

Program Name

Profession and Discipline of Faculty Trained

Select Discipline/Specialty of Faculty Trained

Enter # Trained in this Profession and Discipline

Option(s)

(1)

(2)

Block 4

(2a)

(3)

Block 4








    1. FD-2a: Faculty Development - Faculty Development Activities

The FD-2a subform captures general information about unstructured faculty development training activities offered by grantees using BHW funds. Please complete this subform for each faculty development activity offered during the reporting period and supported with BHW funds. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen.

Shape83

View Prior Period Data

* Add Faculty Development Activities

Activity Name


Shape84

Textbox (200 char)
Shape85

Add Record


No.

Activity Name

Select Type of Faculty Development Activity Offered

For Courses or Workshops

Enter Duration of Training Activity in Clock Hours

Select Delivery Mode Used to Offer Training Activity

Select the Faculty Role(s) Addressed at Training Activity

Was Supplement Funding Used?

Option(s)

Select Whether Activity is Accredited for Continuing Education Credit

Select Whether Attendance was to

Acquire or Maintain Professional Certification

(1)

(2)

Block 8

(3)

Block 8a

(4)

Block 8b

(5)

Block 9

(6)

Block 10

(7)

(8)












    1. FD-2b: Faculty Development - Faculty Trained By Profession/Discipline

The FD-2b subform captures information about the profession and discipline of faculty who participated in unstructured faculty development activities offered by grantees using BHW funds. If you have any questions about how to complete this subform, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen.

Shape86

View Prior Period Data Fields with *are required

* Add Activity Name and Discipline

Activity Name

Values populated from Activity Name col. in previous tab (single-select)

Select Profession of Faculty Trained

Multi-Select

Select Discipline/Speciality of Faculty Trained

Multi-Select
Shape87

Add Record


No.

Activity Name

Select Profession of Faculty Trained

Select Discipline/Specialty of Faculty Trained

Enter # Trained in this Profession and Discipline

Option(s)

(1)

(2)

(2a)

(3)

Block 12








    1. FD-3: Faculty Development - Faculty-Student Collaboration Projects

The FD-3 subform captures information about faculty-student collaborations that are supported by grantees using BHW funds. Please complete this subform for each faculty-student collaboration project supported during this reporting period. If you have any questions about how to complete this subform, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".

View Prior Period Data

* Add Collaboration Projects

Project Name

 Shape88

Textbox (200 char)


Shape89

Add Record



No.

Record Status

Project Name

Select Project Status in the Current Reporting Period

Describe the Faculty- Student Project

Select the Purpose of the Project

Enter # of Faculty Members Involved in the Project

Enter # of Students Involved in the Project

Select whether any Faculty Received any type of BHW-Funded Financial Award

Select Type(s) of Vulnerable Population Studied in this Project

Was Supplement Funding Used?

Option(s)

Total

URM

Total

URM


(1)

(1a)

(2)

Block 13

(3)

Block 13a

(4)

Block 14

(5)

Block 14a

(6)

Block 15

(7)

(8)

Block 16

(9)

(10)


















    1. FD-4a: Faculty Development - Faculty Instruction

The FD-4a subform captures information about the courses or trainings offered by faculty that receive direct financial support from a BHW grant. Please complete this subform for each course or workshop offered during this reporting period. If you have any questions about how to complete this subform, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".

Shape90


View Prior Period Data

* Add Courses/Workshops

Enter the Name of the Course or Workshop Offered by the Faculty

 Shape91

Textbox (200 char)
Shape92

Add Record


No.

Record Status

Name of the Course or Workshop Offered by the Faculty

Select Whether the Course/Workshop was Offered in the Current Reporting Period

Select the Content Area Of the Course or Workshop

Enter the Length of the Course or Workshop

in Clock Hours

Enter # of Times the Course or Workshop was Offered

Select the Delivery Mode Used to Offer the Course or Workshop

Option(s)

(1)

Block 17

(1a)

(2)

Block 18

(3)

Block 19

(4)

Block 20

(5)

Block 22











    1. FD-4b: Faculty Development - Faculty Trained by Profession/Discipline

The FD-4b subform captures information about the profession and discipline of individuals who participated in courses or workshops offered by faculty receiving direct financial support from a BHW grant during the reporting period. Please complete this subform for each course or workshop listed below. If you have any questions about how to complete this subform, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen.

Shape93

View Prior Period Data

* Add Profession/Discipline

Name of the Course or Workshop Offered by the Faculty

Course/Workshop Name from FD-4a where Column 1a = ‘Yes’ (single-select)

Select Profession of Individuals Trained

Multi-Select

Select Discipline/Specialty of Individuals Trained

Multi-Select
Shape94

Add Record


No.

Name of the Course or Workshop Offered by the Faculty

Profession and Discipline of Individuals Trained

Select Discipline/Specialty of Individuals Trained

Enter # Trained in this Profession and Discipline

Option(s)

(1)

Block 17

(2)

(2a)

(3)

Block 21








    1. FD-5: Faculty Development - Faculty Recruitment

Shape95

* Faculty Recruitment Details

Enter # of Faculty Recruited through the Program (Block 23a)

(text 3 digits)

Enter # of URM Faculty Recruited through the Program (Block 23b)

(text 3 digits)

Enter # of Faculty Positions Retained (Block 23c)

(text 3 digits)


Answer each question below for the reporting period. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. View Prior Period Data

    1. FD-5: Faculty Development - Faculty Recruitment – T93 Only

Shape96

* Faculty Recruitment Details

Individuals participating in both Loan Repayment and Faculty Development

Individuals Participating in Faculty Development Programs/Activities Only

Total

Enter # of Faculty Participants in the current reporting period

(text 7 digits)

(text 7 digits)


Enter # of Faculty Recruited (new participants) in the current reporting period

(text 7 digits)

(text 7 digits)


Enter # of Faculty Retained (existing participants) in the current reporting period

(text 7 digits)

(text 7 digits)



Answer each question below for the reporting period. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. View Prior Period Data

    1. FD-5: Faculty Development - Faculty Recruitment – U3M Only

Shape97

Profession

Number Employed at Start of Project Year

Number of Positions Recruited for

Number of New Staff Hired

Number that Left the Organization

Number of Employees that Participated in the Program

Number of Employees that Left the Program

Number of Employees that Participated in the Program and Left the

Organization

Number of Employees that Did Not Participate in the Program and Left

the Organization

Nurses









Physicians









Physician Assistants









Behavioral Health Providers









Other Medical Staff









Non-Medical Staff









Total










Answer each question below for the reporting period. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. View Prior Period Data

  1. CHGME Hospital Data

    1. CHD-1: CHGME Hospital Data – Hospital Discharge Data

Please provide the requested general information and answer the lead question below. If your children’s hospital has any residency program where at least one resident spent greater than or equal to 75% time under children’s hospital supervision, please answer ‘Yes’ and complete the table below with hospital-level data. If not, please answer ‘No’, and click ‘Save and Validate’ to proceed to the next required form. If ‘Yes’ was answered, please provide the number of hospital discharges for the most recently completed academic year (July 1 – June 30) for each of the following payment groups. Include all Medicaid payments including Medicaid managed care and any other Medicaid payments under the Medicaid and/or CHIP category. Self-pay refers to patients who have made out-of-pocket payments for services. Uncompensated care means care for which the hospital receives no payment. Do not include lab services under Outpatient visits. Please refer to the instruction manual and/or contact your Government Project Officer if you have any questions about how to complete this form.

Shape98


View Prior Period Data

* General Information

Medicare Provider Number




Year hospital first received funding


Text Box


How many outside institutions send residents to your hospital?


Text Box



* Did any of your residency programs have at least one resident spending >= 75% under Children’s Hospital Supervision? Yes

 Shape99

Yes (complete table below) No (Click Save and Validate to

Shape100

proceed to the next form)

No.

Payor

(1)

Enter # of Inpatient Discharges

(2)

Enter # of Outpatient Visits

(3)

Enter # of Emergency Department Visits

(4)

1

Private Insurance




2

Medicaid and/or CHIP




3

Medicare




4

Other Public (TRICARE, Indian Health Service)




5

Self-Pay




6

Uncompensated Care




Total




    1. CHD-2: CHGME Hospital Data – Hospital Discharge and Safety Data

Please answer the lead question below. If your children’s hospital has any patient safety initiatives in place during the most recently completed academic year, answer ‘Yes’ and proceed to complete this form. If not, please answer ‘No’ and click ‘Save and Validate’ to proceed to the next required form. If ‘Yes’ was answered, please select all patient safety initiatives your children’s hospital utilized. You may add additional ones not listed. Please click ‘Add Record’ after each selection. Each selected initiative will form a line on the table. Then indicate whether your children’s hospital utilized the selected initiatives in the most recently completed academic year (July 1 – June 30) and if any changes in the initiatives have occurred since the previous academic year. Also, please select all applicable reasons for the change and resulting benefits from any change(s) in the following columns. Please refer to the instruction manual and/or contact your Government Project Officer if you have any questions about how to complete this form.

Shape101


View Prior Period Data

Fields with * are required

Shape102


* Add Patient Safety Initiative (add all that apply)

Patient Safety Initiative

 Shape103 Shape104

Single Select Dropdown Box



If Other, specify Text Box
Shape105

Add Record


No.

Patient Safety Initiative

Select Whether Initiative is Part of the Hospital’s Patient Safety Program in Most Recent Academic Year

Select Whether the Hospital has made Changes in Initiative since the Previous Academic Year

Reasons for Change

Benefits of Initiative

Option(s)

(1)

(2)

(3)

(4)

(5)









    1. CHD-3: CHGME Hospital Data – Hospital Discharge Data by Zip Code

Please complete the following steps to enter locality data identifying the number of hospital discharges by zip code. First, download the excel template to enter the required data (see link below; alternatively, you can contact your Government Project Officer to acquire this template). Note that the structure of the Excel template must not be altered (i.e., do not add/remove/edit/rearrange columns or column headers). Complete each row of data entry by reporting (a) each zip code used by your program and (b) the corresponding number of hospital discharges. If you are reporting an overseas zip code, use code “88888”. If the zip code is unknown, enter “00000”.

When you have completed data entry using the template, save your work to a local folder and follow the instructions to upload this file into BPMH (e.g., using the browse function to select your file from your local folder). Once your file has been uploaded, select the “Process Data” button, which will populate the table below with the data you entered into the excel template (i.e., zip codes and discharge counts). Next, select the “Save” button to automatically populate the city and state fields (based on the zip codes you have provided) and run the form validations. Errors in editable fields will be identified with a “Row” number and can be corrected either (a) within the BMPH system or (b) corrected in the original excel template and then re-uploaded. (Note- once uploaded into BMPH, template data cannot be downloaded back into an Excel format). After you have verified that all data are present and accurate, select the Save/Validate button to proceed to the next subform. Please refer to the instruction manual and/or contact your Government Project Officer if you have any questions about how to complete this form.

Shape106



No.

Record Status

Zip Code

City

State

Number of Inpatient Discharges

Option(s)

(1)

(2)

(3)

(4)























  1. PCC: Program Curriculum Changes

Please list all courses and training activities implemented by your residency or fellowship program as part of its training/curriculum in the most recent academic year. Be sure to list all courses and training activities related to quality improvement and measurement, cultural competency, primary care, underserved populations, oral health, community health, diversity, etc. You do not need to list standard curriculum mandated for accreditation unless it falls into a category mentioned above. For all identified training activities/curriculum, indicate whether the topic was newly developed or enhanced since the previous year, select the standard topic area, and delivery mode. Also, please select the training sites where the curriculum was implemented from the list you indicated on the EXP form.


View Prior Period Data



No.

Record Status

Select Residency Program Name

Enter the Name of Course or Training Activity

Select Type of Course or Training Activity

Select whether Course or Training Activity was Newly Developed or Enhanced

Select Primary Topic Area

Select Topics in Quality Improvement and Measurement

Enter the Curriculum the Course or Training Activity is Associated With

Select Delivery Mode Used to Offer this Course or Training Activity

Option(s)

(1)

(2)

Block 1

(3)

Block 2

(4)

Block 3

(5)

(6)

(7)

Block 5

(8)

Block 6






































  1. State Primary Care Offices


    1. PCO-1: State Primary Care Offices – Number of Forms Submitted

Please provide the total number of NHSC site application and recertification forms submitted by the State Primary Care Office to the NHSC.


*Number of Forms Submitted

Total number of NHSC Site Application and Recertification recommendation forms submitted by the State Primary Care Office to the NHSC


Total number of NHSC Site Application and Recertification recommendation forms submitted by the State Primary Care Office to the NHSC within 21 calendar days (15 business days)


    1. PCO-2: State Primary Care Offices – OP Impact on Health Professional Shortage Areas

Please complete the following steps to enter the OP impact on HPSAs.

HPSA Name

HPSA ID#

OP NPI#

State OP Placements by Specialty

per HPSA

If Other Specialty, specify

State OP hours per week in

direct patient care

State OP Program

Sponsor

If Other Program, specify

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

1









2









3









    1. PCO-3a: State Primary Care Offices – Type of Clients Who Received Technical Assistance

Please enter the type of clients who received technical assistance.


Type of Clients Who Received Technical Assistance

(1)

NHSC

(2)

Expansion

(3)

Data Sharing

(4)

Designation

(5)

Needs Assessment

(6)

Other Technical Assistance Type

Clients Specify

(7) (8)

Community








Provider








J1-Waiver








Community Health Center








Health Department








State Agency








Office of Regional Operations








Medicaid








Primary Care Association








State Loan Repayment Program








Rural Health Clinic








NHSC








Other (specify)








Total








    1. PCO-3b: State Primary Care Offices – Groups Receiving Technical Assistance

Please enter the groups receiving technical assistance.

Date of Event

Name of Outreach Event

Define Audience Reached

If Multiple or Other Audience,

Specify

Total #’s Reached at Each

Outreach Event

Describe Audience Reached

Option(s)

(1)

(2)

(3)

(4)

(5)

(6)

1








2








3









Shape2

Page 1 of 66


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Modified0000-00-00
File Created0000-00-00
© 2025 OMB.report | Privacy Policy