Form 1 BHPr Performance Measures Forms

BHPr Performance Report for Grants and Cooperative Agreements

Forms

BHPr Performance Measures Forms

OMB: 0915-0061

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Public Burden Statement: 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 project is 0915-0061. Public reporting burden
for this collection of information is estimated to average .15 hours per response, 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 10-29, Rockville, Maryland, 20857.

OMB Number 0915-0061
Expiration date XX/XX/201X

PERFORMANCE REPORT FOR GRANTS AND COOPERATIVE AGREEMENTS
FORM NAME:

Grant Purpose

Block 1. Select grant purpose(s) addressed. (Select all that apply)

[Drop-down]

Save & Continue

INSTRUCTIONS
Purpose. The Grant Purpose form captures information about
grant purpose(s) addressed during the reporting period by
grantees of specific BHPr-funded multipurpose grant
programs. Please complete the GP form using the instructions
below.
(Note: The Grant Purpose Form only pertains to grantees of
the AHEC, COE, CGEP, GPE, HCOP, IMP, NEPQR, NWD,
SOHWP, and PMR programs. Please note that selections in
this form will affect the number and types of forms you will
be required to complete.)
Block 1. Select the grant purpose(s) addressed during the
reporting period. You may select more than one option in this
block.
Selections:

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Comprehensive Geriatric Education Program
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Area Health Education Centers Program
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Health careers recruitment of underrepresented
minority populations or individuals from
disadvantaged or rural backgrounds
Community-based training and education with
emphasis on primary care
Field placements or preceptorships
Interdisciplinary/interprofessional education and
training
Continuing education
Public health careers exposure to youth

Improve information resources and cultural
competency
Facilitate faculty and student research
Carry out student training in providing health care
services
Provide stipends

Provide training to individuals who will provide
geriatric care for the elderly
Develop and disseminate curricula relating to the
treatment of the health problems of elderly
individuals
Train faculty members in geriatrics
Provide continuing education to individuals who
provide geriatric care
Establish traineeships for individuals who are
preparing for advanced education nursing degrees in
geriatric nursing, long-term care, gero-psychiatric
nursing or other nursing areas that specialize in the
care of the elderly population
Graduate Psychology Education

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Faculty development
Curriculum and instructional design
Program content enhancement
Program infrastructure development
Practicum
Pre-Degree Internships

Centers of Excellence Program
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Increase the competitive applicant pool
Enhance student performance
Improve the capacity for faculty development

OMB Number 0915-0061
Expiration date XX/XX/201X

Integrative Medicine Program
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Incorporate evidence-based integrative medicine
content into existing preventive medicine residency
programs
Provide faculty development to improve clinical
teaching in both preventive and evidence-based
integrative medicine
Facilitate delivery of related information that will be
measured through competency development and
assessment of the residents.
Nurse Education, Practice, Quality, and Retention
Program

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Expanding the enrollment in baccalaureate nursing
programs
Providing education in the new technologies,
including distance learning methodologies
Establishing or expanding nursing practice
arrangements in non-institutional settings (Nurse
Managed Centers) to demonstrate methods to
improve access to primary health care in medically
underserved communities
Providing care for underserved populations and other
high-risk groups such as the elderly, individuals with
HIV/AIDS, substance abusers, the homeless, and
victims of domestic violence
Providing quality coordinated care, and other skills
needed to practice in existing and emerging
organized health care systems
Developing cultural competencies among nurses
Career Ladder Program to promote career
advancement for individuals, including licensed
practical nurses, licensed vocational nurses, certified
nurse assistants, home health aides, diploma degree
or associate degree nurses, to become baccalaureate
prepared registered nurses or advanced education
nurses in order to meet the needs of the registered
nurse workforce
Developing and implementing internships and
residency programs in collaboration with an
accredited school of nursing to encourage mentoring
and the development of specialties
Career Ladder Program to assist individuals in
obtaining education and training required to enter the
nursing profession and advance within such
profession
Enhancing patient care delivery systems through
improving the retention of nurses and enhancing
patient care that is directly related to nursing
activities

Nursing Workforce Diversity
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Student scholarships or stipends for diploma or
associate degree nurses to enter a bridge or degree
completion program
Student scholarships or stipends for accelerated
nursing degree programs, pre-entry preparation,
advanced education preparation, and retention
activities.
Pre-doctoral Training in General, Pediatric, and
Public Health Dentistry and Dental Hygiene

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Plan, develop, and operate or participate in an
approved professional training program
Support of an accredited master’s in public health
program for dental and dental hygiene students
Meet the costs of projects to establish, maintain, or
improve pre-doctoral training in primary care
Provide financial assistance to dental or dental
hygiene students
Post-doctoral Training in General, Pediatric, and
Public Health Dentistry

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Plan, develop, and operate or participate in an
approved professional training program
Support of an accredited master’s degree in public
health program for dental residents
Meet the costs of projects to establish, maintain, or
improve post-doctoral training in primary care
dentistry programs
Provide financial assistance to dental residents or
practicing dentists
Residency Training in Primary Care
Plan, develop, and operate or participate in an
accredited residency or internship program
Plan, develop, and operate a program for the training
of physicians teaching in community-based settings
Provide need-based financial assistance in the form
of traineeships and fellowships to medical students,
interns, residents, practicing physicians, or other
medical personnel

OMB Number 0915-0061
Expiration date XX/XX/201X

State Oral Health Workforce Program
 Loan forgiveness and repayment programs for dentists
 Dental recruitment and retention efforts
 Grants and low-interest or no-interest loans to help
dentists who participate in the Medicaid program
under Title XIX of the Social Security Act to establish
or expand practices in designated dental health
professional shortage areas
 The establishment or expansion of dental residency
programs in coordination with accredited dental
training institutions in States without dental schools
 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, including services and facilities for
children with special needs.
 Placement and support of dental students, dental
residents, and advanced dentistry trainees
 Continuing dental education, including distance-based
education
 Practice support through teledentistry
 Community-based prevention services such as water
fluoridation and dental sealant programs
 Coordination with local educational agencies within
the state to foster programs that promote children
going into oral health or science professions
 The establishment of faculty recruitment programs at
accredited dental training institutions whose mission
includes community outreach and service and that
have a demonstrated record of serving the underserved
 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
 Any other activities determined to be appropriate by
the Secretary (provide a brief description)

Preventive Medicine Residency Program
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Support resident costs
Infrastructure and faculty development activities

When finished, click on "Save and Continue" to be routed
to the appropriate form(s).

Public Burden Statement: 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 project is 0915-0061. Public reporting burden
for this collection of information is estimated to average .25 hours per response, 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 10-29, Rockville, Maryland, 20857.

OMB Number 0915-0061
Expiration date XX/XX/201X

PERFORMANCE REPORT FOR GRANTS AND COOPERATIVE AGREEMENTS
FORM NAME:

Program Characteristics

SECTION A. Description of Training Program
Block 1. Select the type of training program supported:

[Drop-down]

Block 1a. If unstructured program, select type of training activity
Block 1a.1. If unstructured program, enter name of activity
Block 1b. If unstructured program, select education level of participants
Block 1c. If unstructured program, indicate length of activity in clock hours

[Drop-down]
[Drop-down]

Block 1d. If structured program, select type of training
Block 1d1. If structured program, enter name of activity
Block 1e. If structured program, select education level of participants
Block 1f. If structured program, indicate length of program in clock hours
Block 1g. If structured program, select whether public health careers content offered
Block 1h. If structured program, select whether clinical/practicum training offered
Block 1i. If structured program, select whether cultural competency training offered

[Drop-down]
[Drop-down]
Yes
Yes
Yes

No
No
No

Block 1j. If degree/diploma/certificate program, select type of degree
Block 1k. If degree/diploma/certificate program, select primary focus area

[Drop-down]
[Drop-down]

Block 1l. Select primary discipline of individuals trained

[Drop-down]

Block 1m. Select type of dental residency program:

New

Expanded

Previously Established

Previously Expanded

Block 2. Select the types of partners/consortia used, if any, for the purposes of offering this training program: [Drop-down]
(select all that apply)

SECTION B. Description of Enrollment (DIRECT FINANCIAL SUPPORT PROGRAMS/PURPOSES ONLY)
Block 3. Indicate the total number of individuals—whether funded by BHPr or not—enrolled in the program
Block 3a. Indicate the number of underrepresented minorities—whether funded by BHPr or not—enrolled in the program
Block 3b. Indicate number of individuals—whether funded by BHPr or not—who are from a disadvantaged background and are not
underrepresented minorities
Block 4. Indicate the total number of accredited positions by academic/training year:
Add Academic/Training Year

Number of Accredited Positions

Block 5. Indicate the total number of positions recruited for by academic/training year
Add Academic/Training Year

Number of Positions Recruited For

Block 6. Indicate the total number of positions filled by academic/training year:
Add Academic/Training Year

Number of Positions Filled

Block 7. Indicate the total number of positions expanded using BHPr funds by academic/training year
Add Academic/Training Year

Number of Positions Recruited For

OMB Number 0915-0061
Expiration date XX/XX/201X
Block 8. Indicate the total number of individuals—whether funded by BHPr or not—who graduated/completed the program:
Block 8a. Indicate the number of underrepresented minorities—whether funded by BHPr or not— who
graduated/completed the program
Block 9. Indicate the total number of individual—whether funded by BHPr or not—who permanently left the program before completion:
Block 9a. Indicate the number of underrepresented minorities—whether funded by BHPr or not—who permanently left the program before
completion

Add Another Training Program

Save & Continue

OMB Number 0915-0061
Expiration date XX/XX/201X

INSTRUCTIONS
Purpose. The Program Characteristics Form captures general
information about the various types of health professions
training programs that are supported with a BHPr-funded
grant. The form is divided into two sections: Section A
captures general information about each training program
supported with a BHPr-funded grant; Section B captures
enrollment-related information for training programs that
provide direct financial support (e.g., loans, stipends or
scholarships) to individuals. Please complete applicable
sections of the form using the instructions below.
(Note: Report each type of training program supported with a
BHPr grant separately by completing applicable sections and
clicking on "Add Training Program". Entries in this form will
affect the number and types of forms you will be required to
complete.)

Graduate—Master’s Degree
Graduate—Medical Degree
Graduate—Doctoral
Faculty
Administrator
Block 1c. For non-degree bearing unstructured programs
supported with a BHPr-funded grant during the reporting
period, indicate the length of the training activity in clock
hours.
Structured Training Programs Only
Block 1d. For non-degree bearing structured programs
supported with a BHPr-funded grant during the reporting
period, select the type of training activity from the options
below:

SECTION A
Block 1. Select the type of program supported with a BHPrfunded grant during the reporting period from the options
below:
Selections:
Degree/Diploma/Certificate Academic Training Program
Non-degree structured training program
Non-degree unstructured training program
One-year retraining program
Internship program
Practicum/Field Placement program
Residency program
Fellowship program
Unstructured Training Programs Only
Block 1a. For non-degree bearing unstructured programs
supported with a BHPr-funded grant during the reporting
period, select the type of training activity from the options
below:
Selections:
Pre-college Preparation
College Academic Support
Social Support
Socialization
Block 1b. For non-degree bearing unstructured programs
supported with a BHPr-funded grant during the reporting
period, select the education level of participants from the
options below:
Selections:
Primary level (K-8)
Secondary (9-12)
Post-Secondary/Pre-College
Nursing Diploma/Certificate
Undergraduate—Two Year College
Undergraduate—Baccalaureate Degree

Selections:
Summer Program (Pre-entry Preparation)
Summer Program (Academic Retention)
High School Academy
Saturday Academy (Pre-entry Preparation)
Saturday Academy (Academic Retention)
Pre-matriculation
Nursing Preparation Program (Pre-entry Preparation)
Nursing Preparation Program (Academic Retention)
Post Baccalaureate Program
Summer Program
Health Professions Academy
Faculty Development Program
Post-Baccalaureate Conditional Admissions Program
Health Careers Enrichment Activities
Block 1e. For non-degree bearing structured programs
supported with a BHPr-funded grant during the reporting
period, select the education level of participants from the
options below:
Selections:
Primary level (K-8)
Secondary (9-12)
Post-Secondary/Pre-College
Nursing Diploma/Certificate
Undergraduate—Two Year College
Undergraduate—Baccalaureate Degree
Graduate—Master’s Degree
Graduate—Medical Degree
Graduate—Doctoral
Faculty
Administrator
Block 1f. For non-degree bearing structured programs
supported with a BHPr-funded grant during the reporting
period, indicate the length of the training activity in clock
hours.

Block 1g. For non-degree bearing structured programs
supported with a BHPr-funded grant during the reporting
period, select whether the training program contained
information specific to careers in public health.
Block 1h. For non-degree bearing structured programs
supported with a BHPr-funded grant during the reporting
period, select whether the training program was a clinical
practicum.
Block 1i. For non-degree bearing structured programs
supported with a BHPr-funded grant during the reporting
period, select whether the training program offered
information on cultural competency.
Degree/Diploma/Certificate
Academic Training Programs Only
Block 1j. For degree-bearing supported with a BHPr-funded
grant during the reporting period, select the type of degree
offered from the options below:
Selections:
Certificate
Diploma
AA
AS
BA
BS
BSN
BSW
BPH
Bachelor's Not Otherwise Specified
DC
DDS
DDS/MPH
DDS/MSPH
DMD
DNAP
DNP
DNSc
DO
DO/MPH
DO/MSPH
DO/DrPH
DO/ScD
DrPH
DVM
EdD
MA
MEd
MHA
MD
MD/MPH
MD/MSPH
MD/DrPH
MD/ScD
MD/PhD

OMB Number 0915-0061
Expiration date XX/XX/201X

MS
MMS
MMS/MPH
MMS/MSPH
MMS/DrPH
MMS/ScD
MPAS
MPAS/MPH
MPAS/MSPH
MPAS/DrPH
MPAS/ScD
MPH
MSPH
MSCR
MS-CTS
MSN
MSN/MBA
MSN/MPH
MSW
MSSW
Master's Degree Not Otherwise Specified
Post-Masters Certificate
PhD
PharmD
PsyD
ScD
VMD

Dental, Nursing, Public Health, and Behavioral Health
Programs Only
Block 1k. For degree-bearing programs supported with a
BHPr-funded grant during the reporting period, select the
focus area from the options below:
Selections:
Dentistry-General
Dentistry-Pediatric Dentistry
Dentistry-Orthodontic Dentistry
Dentistry-Oral Surgery Dentistry
Dentistry-Radiology Dentistry
Dentistry-Periodontic Dentistry
Dentistry-Prosthodontic Dentistry
Dentistry-Pathology Dentistry
Dentistry-Dental Assistant
Dentistry-Dental Hygiene
Dentistry-Public Health Dentistry
Dentistry-Endodontic Dentistry
Nursing-General Practice
Nursing-Administration
Nursing-Anesthesia
Nursing-Education
Nursing-Informatics
Nursing-Midwifery
Nursing-Advanced Practice
Nursing-Public Health
Nursing-Acute care adult-gerontology nurse practitioner
Nursing-Acute-care pediatric nurse practitioner

Nursing-Adult Gerontology
Nursing-Adult-Gerontology Primary Care
Nursing-Family Nurse Practitioner
Nursing-Family/Individual Across Lifespan
Nursing-Geropsychiatric
Nursing-Neonatal
Nursing-Neonatal Nurse Practitioner
Nursing-Pediatric Primary Care
Nursing-Pediatrics
Nursing-Psychiatric nurse specialists
Nursing-Psychiatric/Mental Health
Nursing-Women’s Health/Gender Related And Psychiatric
Mental Health
Nursing-Women’s Health/Gender-Related
Nursing-Research
Psychology-Clinical
Psychology-Counseling
Psychology-School
Public Health-Epidemiology
Public Health-Biostatistics
Public Health-Health Policy and Management
Public Health-Environmental Health
Public Health-Social and Behavioral Health Sciences
Social Work-General
Social Work-Clinical
Residency & Dentistry Programs Only
Block 1l. Select the primary discipline(s) of individuals
enrolled in the training program supported with a BHPrfunded grant during the reporting period from the options
below:
Selections:
Dentistry
General Dentistry
Pediatric Dentistry
Orthodontic Dentistry
Oral Surgery Dentistry
Radiology Dentistry
Periodontic Dentistry
Prosthodontic Dentistry
Pathology Dentistry
Dental Assistant
Dental Hygiene
Public Health Dentistry
Endodontic Dentistry
Medicine
Aerospace Medicine
Allopathic Medicine, Alternative/Complementary
Medicine
Behavioral/Mental Health In School Of Medicine And
Osteopathic Medicine

OMB Number 0915-0061
Expiration date XX/XX/201X

Chiropractic
Family Medicine
General Internal Medicine
General Pediatrics
General Preventive Medicine
General Preventive Medicine/ Family Medicine
General Preventive Medicine/ Internal Medicine
General Preventive Medicine/ Public Health
Geriatric Medicine
Geriatric Psychiatry
Integrative Medicine
Internal Medicine /General Pediatrics
Internal Medicine/Family Medicine
Neurology
Obstetrics/Gynecology
Occupational Medicine
Osteopathic General Practice
Pediatrics/Family Medicine
Pharmacy
Podiatry
Psychiatry
Radiology
Veterinary Medicine
Other

State Oral Health Residency Programs Only
Block 1m. For dental residency programs supported by the
State with a BHPr-funded grant, select whether the residency
program was newly established or whether an existing
program was expanded.
All Training Programs
Block 2. Select the types of partners or consortia used, if any,
to deliver the training program supported with a BHPr-funded
grant during the reporting period from the options below:
Selections:
Academic department- within the institution
Academic department –outside the institution
Community Mental Health Center
Federal Government -Veterans Affairs
Federal Government- Department of Defense/Military
Federal Government-CDC
Federal Government-SAMHSA
Federal Government-IHS
Federal Government-NIH
Federal Government-AHRQ
Federal Government-FDA
Federal Government-Other HHS Agency/Office
Federal Government- Other HRSA Program
Federally-qualified health center or look-alikes
Federal Government –Other
Community-based health center (e.g., free clinic)
Health department- Local
Health department- State

Health department- Tribal
Health disparities research center
Health policy center
Hospital
Nonprofit organization (non-faith based)
State Governmental Programs
Professional Associations
Nonprofit organization (faith-based)
Private/For-profit organization
Local Government
Other
No partners/consortia used
SECTION B
Training Programs that Provide Direct Financial Support or
Conduct Field Placements/Practicums/Internships Only
Block 3. Indicate the total number of individuals—regardless
of whether they received BHPr funding—who are enrolled in
the training program. Include all trainees regardless of
completion status; however, do not count individuals who
permanently left the program before completion.
Block 3a. Of the number reported in Block 4,
indicate the number of underrepresented minorities
who are enrolled in the training program.
Block 3b. Of the number reported in Block 4,
indicate the number of individuals enrolled in the
program who are from a disadvantaged background
and are not underrepresented minorities.
Residency and Physician Assistant Programs Only
Block 4. Indicate the total number of accredited positions
during the reporting period by academic/training year. Click
on "Add Academic/Training Year" to select from the
following options:
Selections:
Training Year 1
Training Year 2
Training Year 3
Residency Year 1
Residency Year 2
Residency Year 3
Block 5. Indicate the total number of positions recruited for
during the reporting period by academic/training year. Click
on "Add Academic/Training Year" to select from the
following options:
Selections:
Training Year 1
Training Year 2
Training Year 3
Residency Year 1

Residency Year 2
Residency Year 3

OMB Number 0915-0061
Expiration date XX/XX/201X

Block 6. Indicate the total number of positions filled during
the reporting period by academic/training year. Click on "Add
Academic/Training Year" to select from the following
options:
Selections:
Training Year 1
Training Year 2
Training Year 3
Residency Year 1
Residency Year 2
Residency Year 3
Expansion Programs Only
Block 7. Indicate the total number of expanded positions
supported with BHPr funds during the reporting period by
academic/training year. Click on "Add Academic/Training
Year" to select from the following options:
Selections:
Training Year 1
Training Year 2
Training Year 3
Residency Year 1
Residency Year 2
Residency Year 3
All Training Programs that Provide Direct Financial Support
or Conduct Field Placements/Practicums/Internships Only
Block 8. Indicate the number of individuals—regardless of
whether they received BHPr funding— who graduated or
completed the program during the reporting period.
(Note: This number should be a subset of the number reported
in Block 4).
Block 8a. Of the number reported in Block 9,
indicate the number of underrepresented minorities
who graduated or completed the program during the
reporting period.
Block 9. Indicate the number of individuals—regardless of
whether they received BHPr funding— who permanently left
the program before completion during the reporting period.
Block 9a. Of the number reported in Block 10,
indicate the number of underrepresented minorities
who permanently left the program before completion
during the reporting period.

OMB Number 0915-0061
Expiration date XX/XX/201X

Click on "Add Another Training Program" to enter
information about another training program supported
with BHPr funds. Each training program must be
reported separately. You may add as many entries as
necessary.
When finished, click on "Save and Continue" to be routed
to the appropriate form(s).

Public Burden Statement: 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 project is 0915-0061. Public reporting burden
for this collection of information is estimated to average .25 hours per response, 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 10-29, Rockville, Maryland, 20857.

OMB Number 0915-0061
Expiration date XX/XX/201X

PERFORMANCE REPORT FOR GRANTS AND COOPERATIVE AGREEMENTS
FORM NAME:

LR-1

Select Training Program

SECTION A. Training Program Participants
Block 1. Total number of enrollees
Block 2. Total number of fellows
Block 3. Total number of residents
Block 4. Total number of graduates
Block 5. Total number of program completers
SECTION B. Attrition of Training Program Participants
Block 6. Total number of individuals who permanently left the program before completion
Block 6a. Number of underrepresented minorities who permanently left the program before completion
SECTION C. Training Programs with Interdisciplinary/Interprofessional Components
Block 7. Select whether program is interprofessional

Yes

Block 7a. Indicate the total number of individuals trained by profession and discipline
Add P rofession & Discipline
Add P rofession & Discipline

Number Trained
Number Trained

SECTION D. Continuing Education Providers
Block 8. Indicate the total unduplicated number of individuals trained through continuing education offerings
SECTION E. Nursing Aide Employment Status and Exam Outcomes
Block 9. Indicate the total number of individuals who are employed full-time
Block 10. Indicate the total number of individuals who are employed part-time
Block 11. Indicate the total number of individuals who are unemployed
Block 12. Select whether the exam assessed all competencies

Yes

Block 13. Indicate the total number of individuals who passed the final exam
Block 14. Indicate the total number of individuals who failed the final exam
Add Information about Another Training Program

Save & Continue

OMB Number 0915-0061
Expiration date XX/XX/201X

INSTRUCTIONS
Purpose. The LR-1 form captures data regarding the number
of individuals who participated in a training program
supported with a BHPr-funded grant. The LR-1 form contains
three sections: Section A captures enrollment and completionrelated information of training programs; Section B captures
information about interprofessional training programs; Section
C captures information about interprofessional or
interdisciplinary students trained through training programs;
and Section D captures information about individuals trained
through continuing education offerings. Please complete the
applicable sections of this form using the instructions below.
(Note: The "Select Training Program" button will only appear
if you reported supporting more than 1 non-direct financial
support training program in the Program Characteristics Form.
This will assist BHPr in associating the number of individuals
to specific types of non-direct financial support training
programs.)

Block 6a. Of the number reported in Block 6,
indicate the number of underrepresented minorities
who permanently left the training program before
completion.
SECTION C
Interprofessional Training Programs Only
(Note: Section C will appear only if "Yes" was selected in
Block 2 of the Program Characteristics Form)
Block 7. Select whether the training program was
interprofessional.
Block 7a. If yes, indicate the total number of students
trained by profession and discipline. Click on "Add
Profession" and select from the options below:

SECTION A
Block 1. Indicate the total number of individuals who received
training as a result of the grant during the reporting period.
Do not include fellows, residents, or individuals who either
completed/graduated or permanently left the program before
completion during the reporting period.
Block 2. Indicate the total number of fellows trained as a
result of the grant during the reporting period. Do not include
individuals who completed their fellowship or permanently
left the program before completion during the reporting
period.
Block 3. Indicate the total number of residents trained as a
result of the grant during the reporting period. Do not include
individuals who completed their residency or permanently left
the program before completion during the reporting period.
Block 4. Indicate the total number of individuals who were
trained as a result of the grant and earned an academic degree
during the reporting period. Do not include individuals who
permanently left the program before completion.
Block 5. Indicate the total number of individuals who were
trained as a result of the grant and completed program
requirements during the reporting period. Do not include
individuals who permanently left the program before
completion.
(Note: a program completer is an individual who successfully
meets all requirements of a training program that does not
confer an academic degree.)
SECTION B
Block 6. Indicate the total number of individuals who
permanently left the training program before completion.

Students
K-8 (primary)
9-12 (secondary)
Post-high school/Pre-college
Dental Student
Dental Hygiene Student
Dental Assistant Student
Medical Student
Physician Assistant Student
Medical Residents
Medical Fellows
Pre-licensure Nursing Students
Graduate-level Nursing Student
Undergraduate-level Public Health Student
Graduate-level Public Health Student
Graduate-level Psychology Student
Graduate-level Psychology Intern
Graduate-level Psychology Fellow
Faculty
Administrator
Other Undergraduate-level Student
Other Graduate-level Student
Other Fellow
Other Resident
Providers
Dentistry
General Dentistry
Pediatric Dentistry
Orthodontic Dentistry
Oral Surgery Dentistry
Radiology Dentistry
Periodontic Dentistry
Prosthodontic Dentistry
Pathology Dentistry
Dental Assistant

Dental Hygiene
Public Health Dentistry
Endodontic Dentistry

OMB Number 0915-0061
Expiration date XX/XX/201X

Medicine

Aerospace Medicine
Allopathic Medicine, Alternative/Complementary
Medicine
Behavioral/Mental Health In School Of Medicine And
Osteopathic Medicine
Chiropractic
Family Medicine
General Internal Medicine
General Pediatrics
General Preventive Medicine
General Preventive Medicine/ Family Medicine
General Preventive Medicine/ Internal Medicine
General Preventive Medicine/ Public Health
Geriatric Medicine
Geriatric Psychiatry
Integrative Medicine
Internal Medicine /General Pediatrics
Internal Medicine/Family Medicine
Neurology
Obstetrics/Gynecology
Occupational Medicine
Osteopathic General Practice
Pediatrics/Family Medicine
Pharmacy
Podiatry
Psychiatry
Radiology
Veterinary Medicine
Nursing
Alternative/Complementary Nursing
CNS-Adult gerontology
CNS-Family
CNS-Geropsychiatric
CNS-Neonatal
CNS-Pediatrics
CNS-Psychiatric/Mental health
CNS-Women’s health
Clinical Nurse Specialist (CNS)
Home Health Aide
Licensed Practical/Vocational Nurse (LPN/LVN)
NP - Other advanced nurse specialists
NP - Psychiatric/Mental health
NP –Adult gerontology
NP –Family
NP –Neonatal
NP –Pediatrics
NP –Women’s health
NP- Acute care adult gerontology
NP- Acute care pediatric
NP- Emergency care
NP- Geropsychiatric
Nurse Administrator
Nurse Anesthetist

Nurse Assistant/Patient Care Associate (PCA)
Nurse Educator
Nurse Generalist
Nurse Midwife
Nurse Practitioner (NP)
Nurse Researchers/Scientists
Nursing Informatics
Public Health Nurse
Registered Nurse
Behavioral Health

Counseling Psychology
Clinical Psychology
Clinical Social Work
Marriage and Family Therapy
Pastoral/Spiritual Care
Other Psychology
Other Social Work, Substance Abuse/Addictions
Counseling
Public Health
Biostatistics
Environmental Health
Epidemiology
Health Policy & Management
Social & Behavioral Sciences
Injury Control & Prevention
Disease Prevention & Health Promotion
Infectious Disease Control
Other
Indicate the total number of individuals trained in each
profession and discipline. You may add as many rows as
necessary.
SECTION D
Continuing Education Providers Only
Block 8. Indicate the unduplicated number of individuals
trained through continuing education offerings.
SECTION E
Nursing Assistant and Personal Home Health Aide Programs
Only
Block 9. Indicate the total number of individuals in the
training program who are employed full-time (i.e. 40 hours or
more each week).
Block 10. Indicate the total number of individuals in the
training program who are employed part-time (i.e. between 1
and 39 hours each week).

Block 11. Indicate the total number of individuals in the
training program who are unemployed.
Block 12. Select whether the final exam taken by individuals
enrolled in the program assessed all related competencies.
Block 13. Indicate the total number of individuals who
successfully passed the final exam.
Block 14. Indicate the total number of individuals who failed
the final exam.

OMB Number 0915-0061
Expiration date XX/XX/201X

If you reported supporting more than one training
program with BHPr funds in the Program Characteristics
Form, click on "Add Information about another Training
Program" to complete this form for each program.

When finished, click on "Save and Continue" to be routed
to the appropriate form(s).

Public Burden Statement: 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 project is 0915-0061. Public reporting burden
for this collection of information is estimated to average .25 hours per response, 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 10-29, Rockville, Maryland, 20857.

OMB Number 0915-0061
Expiration date XX/XX/201X

PERFORMANCE REPORT FOR GRANTS AND COOPERATIVE AGREEMENTS
FORM NAME:

LR-2

Select Training Program
ENROLLEES

GRADUATES

Block 1. Total Number of Male Enrollees Age 19 and Under
Block 2. Total Number of Male Enrollees Age 20 through 29
Block 3. Total Number of Male Enrollees Age 30 through 39
Block 4. Total Number of Male Enrollees Age 40 through 49
Block 5. Total Number of Male Enrollees Age 50 through 59
Block 6. Total Number of Male Enrollees Age 60 and Over

Block 37. Total Number of Male Graduates Age 19 and Under
Block 38. Total Number of Male Graduates Age 20 through 29
Block 39. Total Number of Male Graduates Age 30 through 39
Block 40. Total Number of Male Graduates Age 40 through 49
Block 41. Total Number of Male Graduates Age 50 through 59
Block 42. Total Number of Male Graduates Age 60 and Over

Block 7. Total Number of Female Enrollees Age 19 and Under
Block 8. Total Number of Female Enrollees Age 20 through 29
Block 9. Total Number of Female Enrollees Age 30 through 39
Block 10. Total Number of Female Enrollees Age 40 through 49
Block 11. Total Number of Female Enrollees Age 50 through 59
Block 12. Total Number of Female Enrollees Age 60 and Over

Block 43. Total Number of Female Graduates Age 19 and Under
Block 44. Total Number of Female Graduates Age 20 through 29
Block 45. Total Number of Female Graduates Age 30 through 39
Block 46. Total Number of Female Graduates Age 40 through 49
Block 47. Total Number of Female Graduates Age 50 through 59
Block 48. Total Number of Female Graduates Age 60 and Over

FELLOWS

PROGRAM COMPLETERS

Block 13. Total Number of Male Fellows Age 19 and Under
Block 14. Total Number of Male Fellows Age 20 through 29
Block 15. Total Number of Male Fellows Age 30 through 39
Block 16. Total Number of Male Fellows Age 40 through 49
Block 17. Total Number of Male Fellows Age 50 through 59
Block 18. Total Number of Male Fellows Age 60 and Over

Block 49. Total Number of Male Program Completers Age 19 and Under
Block 50. Total Number of Male Program Completers Age 20 through 29
Block 51. Total Number of Male Program Completers Age 30 through 39
Block 52. Total Number of Male Program Completers Age 40 through 49
Block 53. Total Number of Male Program Completers Age 50 through 59
Block 54. Total Number of Male Program Completers Age 60 and Over

Block 19. Total Number of Female Fellows Age 19 and Under
Block 20. Total Number of Female Fellows Age 20 through 29
Block 21. Total Number of Female Fellows Age 30 through 39
Block 22. Total Number of Female Fellows Age 40 through 49
Block 23. Total Number of Female Fellows Age 50 through 59
Block 24. Total Number of Female Fellows Age 60 and Over

Block 55. Total Number of Female Program Completers Age 19 and Under
Block 56. Total Number of Female Program Completers Age 20 through 29
Block 57. Total Number of Female Program Completers Age 30 through 39
Block 58. Total Number of Female Program Completers Age 40 through 49
Block 59. Total Number of Female Program Completers Age 50 through 59
Block 60. Total Number of Female Program Completers Age 60 and Over

RESIDENTS
Block 25. Total Number of Male Residents Age 19 and Under
Block 26. Total Number of Male Residents Age 20 through 29
Block 27. Total Number of Male Residents Age 30 through 39
Block 28. Total Number of Male Residents Age 40 through 49
Block 29. Total Number of Male Residents Age 50 through 59
Block 30. Total Number of Male Residents Age 60 and Over
Block 31. Total Number of Female Residents Age 19 and Under
Block 32. Total Number of Female Residents Age 20 through 29
Block 33. Total Number of Female Residents Age 30 through 39
Block 34. Total Number of Female Residents Age 40 through 49
Block 35. Total Number of Female Residents Age 50 through 59
Block 36. Total Number of Female Residents Age 60 and Over

Add Information about Another Training Program

Save & Continue

OMB Number 0915-0061
Expiration date XX/XX/201X

INSTRUCTIONS
Purpose. The LR-2 form captures information about the sex
and age of individuals who participated in a training program
supported with a BHPr-funded grant. Please complete the
applicable blocks of this form using the instructions below.
(Note: The "Select Training Program" button will only appear
if you reported supporting more than 1 non-direct financial
support training program in the Program Characteristics Form.
This will assist BHPr in associating the number of individuals
to specific types of non-direct financial support training
programs. Do not include information about individuals who
permanently left a program before completion during the
reporting period.)
ENROLLEES
Blocks 1 through 6. Indicate the total number of male
enrollees—by age group—who received training during the
reporting period as a result of the grant. Do not include
fellows, residents, or any individual who graduated/completed
the program during this reporting period.
Blocks 7 through 12. Indicate the total number of female
enrollees—by age group—who received training during the
reporting period as a result of the grant. Do not include
fellows, residents, or any individual who graduated/completed
the program during this reporting period.
FELLOWS
Blocks 13 through 18. Indicate the total number of male
fellows—by age group—who received training during the
reporting period as a result of the grant. Do not include
residents or any individual who graduated/completed the
program during this reporting period.

GRADUATES
Blocks 37 through 42. Indicate the total number of males—
by age group—who received training as a result of the grant
and earned an academic degree during the reporting period.
Blocks 43 through 48. Indicate the total number of females—
by age group—who received training as a result of the grant
and earned an academic degree during the reporting period.
PROGRAM COMPLETERS
Blocks 49 through 54. Indicate the total number of males—
by age group—who received training as a result of the grant
and completed all training requirements during the reporting
period. (Note: a program completer is an individual who met
all of the training requirements of a non-degree bearing
training program)
Blocks 55 through 60. Indicate the total number of females—
by age group—who received training as a result of the grant
and completed all training requirements during the reporting
period. (Note: a program completer is an individual who met
all of the training requirements of a non-degree bearing
training program)

When finished, click on "Save and Continue" to be routed
to the appropriate form(s).

Blocks 19 through 24. Indicate the total number of female
fellows—by age group—who received training during the
reporting period as a result of the grant. Do not include
residents or any individual who graduated/completed the
program during this reporting period.
RESIDENTS
Blocks 25 through 30. Indicate the total number of male
residents—by age group—who received training during the
reporting period as a result of the grant. Do not include any
individual who graduated/completed the program during this
reporting period.
Blocks 31 through 36. Indicate the total number of female
residents—by age group—who received training during the
reporting period as a result of the grant. Do not include any
individual who graduated/completed the program during this
reporting period.

Public Burden Statement: 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 project is 0915-0061. Public reporting burden
for this collection of information is estimated to average .25 hours per response, 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 10-29, Rockville, Maryland, 20857.

OMB Number 0915-0061
Expiration date XX/XX/201X

PERFORMANCE REPORT FOR GRANTS AND COOPERATIVE AGREEMENTS
FORM NAME:

DV-1

Select Training Program
SECTION A. Race of Hispanic Individuals Trained

SECTION B. Race of Non-Hispanic Individuals Trained

RACE OF HISPANIC ENROLLEES

RACE OF NON-HISPANIC ENROLLEES

Block 1. American Indian or Alaska Native
Block 2. Black or African American
Block 3. Asian
Block 4. Native Hawaiian or Pacific Islander
Block 5. White
Block 6. More than One Race
Block 7. Race Not Reported

Block 36. American Indian or Alaska Native
Block 37. Black or African American
Block 38. Asian
Block 39. Native Hawaiian or Pacific Islander
Block 40. White
Block 41. More than One Race
Block 42. Race Not Reported

RACE OF HISPANIC FELLOWS

RACE OF NON-HISPANIC FELLOWS

Block 8. American Indian or Alaska Native
Block 9. Black or African American
Block 10. Asian
Block 11. Native Hawaiian or Pacific Islander
Block 12. White
Block 13. More than One Race
Block 14. Race Not Reported

Block 43. American Indian or Alaska Native
Block 44. Black or African American
Block 45. Asian
Block 46. Native Hawaiian or Pacific Islander
Block 47. White
Block 48. More than One Race
Block 49. Race Not Reported

RACE OF HISPANIC RESIDENTS

RACE OF NON-HISPANIC RESIDENTS

Block 15. American Indian or Alaska Native
Block 16. Black or African American
Block 17. Asian
Block 18. Native Hawaiian or Pacific Islander
Block 19. White
Block 20. More than One Race
Block 21. Race Not Reported

Block 50. American Indian or Alaska Native
Block 51. Black or African American
Block 52. Asian
Block 53. Native Hawaiian or Pacific Islander
Block 54. White
Block 55. More than One Race
Block 56. Race Not Reported

RACE OF HISPANIC GRADUATES
Block 22. American Indian or Alaska Native
Block 23. Black or African American
Block 24. Asian
Block 25. Native Hawaiian or Pacific Islander
Block 26. White
Block 27. More than One Race
Block 28. Race Not Reported

RACE OF NON-HISPANIC GRADUATES
Block 57. American Indian or Alaska Native
Block 58. Black or African American
Block 59. Asian
Block 60. Native Hawaiian or Pacific Islander
Block 61. White
Block 62. More than One Race
Block 63. Race Not Reported

RACE OF HISPANIC PROGRAM COMPLETERS
Block 29. American Indian or Alaska Native
Block 30. Black or African American
Block 31. Asian
Block 32. Native Hawaiian or Pacific Islander
Block 33. White
Block 34. More than One Race
Block 35. Race Not Reported
Add Information about Another Training Program

RACE OF NON-HISPANIC PROGRAM COMPLETERS
Block 64. American Indian or Alaska Native
Block 65. Black or African American
Block 66. Asian
Block 67. Native Hawaiian or Pacific Islander
Block 68. White
Block 69. More than One Race
Block 70. Race Not Reported

Save & Continue

OMB Number 0915-0061
Expiration date XX/XX/201X

INSTRUCTIONS
Purpose. The DV-1 form captures information about the race
and ethnicity of individuals who participated in a training
program supported with a BHPr-funded grant. The form
contains two (2) sections: Section A captures information
about the racial background of individuals who were trained as
a result of the grant and are of Hispanic/Latino descent;
Section B captures information about the racial background of
individuals who were trained as a result of the grant and are
not of Hispanic/Latino descent. Please complete the applicable
sections and blocks of this form using the instructions below.
(Note: Categories for Race have been adjusted from the
previous reporting period to comply with standards set forth
by the Office of Management and Budget. The "Select
Training Program" button will only appear if you reported
supporting more than 1 non-direct financial support training
program in the Program Characteristics Form. This will assist
BHPr in associating the number of individuals to specific
types of non-direct financial support training programs. Do not
include information about individuals who permanently left a
program before completion during the reporting period.)

HISPANIC GRADUATES
Blocks 22 through 27. Indicate the total number of
Hispanic/Latino graduates—by race—who received training
as a result of the grant and earned an academic degree during
the reporting period.
Block 28. Indicate the total number of Hispanic graduates
whose race was not reported.
Blocks 29 through 34. Indicate the total number of Hispanic
program completers—by race—who received training as a
result of the grant and completed all training requirements
during the reporting period. (Note: a program completer is an
individual who met all of the training requirements of a nondegree bearing training program)
Block 35. Indicate the total number of Hispanic program
completers whose race was not reported.
SECTION B
NON-HISPANIC ENROLLEES

SECTION A
HISPANIC ENROLLEES
Blocks 1 through 6. Indicate the total number of
Hispanic/Latino enrollees—by race—who received training
during the reporting period as a result of the grant. Do not
include fellows, residents, or any individual who
graduated/completed the program during this reporting period.
Block 7. Indicate the total number of Hispanic enrollees
whose race was not reported.
HISPANIC FELLOWS
Blocks 8 through 13. Indicate the total number of
Hispanic/Latino fellows—by race—who received training
during the reporting period as a result of the grant. Do not
include residents or any individual who graduated/completed
the program during this reporting period.
Block 14. Indicate the total number of Hispanic fellows whose
race was not reported.
HISPANIC RESIDENTS
Blocks 15 through 20. Indicate the total number of
Hispanic/Latino residents—by race—who received training
during the reporting period as a result of the grant. Do not
include any individual who graduated/completed the program
during this reporting period.

Blocks 36 through 41. Indicate the total number of NonHispanic/Non-Latino enrollees—by race—who received
training during the reporting period as a result of the grant. Do
not include fellows, residents, or any individual who
graduated/completed the program during this reporting period.
Block 42. Indicate the total number of Non-Hispanic enrollees
whose race was not reported.
NON-HISPANIC FELLOWS
Blocks 43 through 48. Indicate the total number of NonHispanic/Non-Latino fellows—by race—who received
training during the reporting period as a result of the grant. Do
not include residents or any individual who
graduated/completed the program during this reporting period.
Block 49. Indicate the total number of Non-Hispanic fellows
whose race was not reported.
NON-HISPANIC RESIDENTS
Blocks 50 through 55. Indicate the total number of NonHispanic/Non-Latino residents—by race—who received
training during the reporting period as a result of the grant. Do
not include any individual who graduated/completed the
program during this reporting period.
Block 56. Indicate the total number of Non-Hispanic residents
whose race was not reported.

Block 21. Indicate the total number of Hispanic residents
whose race was not reported.

OMB Number 0915-0061
Expiration date XX/XX/201X

NON-HISPANIC GRADUATES

NON-HISPANIC PROGRAM COMPLETERS

Blocks 57 through 62. Indicate the total number of NonHispanic/Non-Latino graduates—by race—who received
training as a result of the grant and earned an academic degree
during the reporting period.

Blocks 64 through 69. Indicate the total number of NonHispanic program completers—by race—who received
training as a result of the grant and completed all training
requirements during the reporting period. (Note: a program
completer is an individual who met all of the training
requirements of a non-degree bearing training program)

Block 63. Indicate the total number of Non-Hispanic
graduates whose race was not reported.

Block 70. Indicate the total number of Non-Hispanic program
completers whose race was not reported.

When finished, click on "Save and Continue" to be routed
to the appropriate form(s).

Public Burden Statement: 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 project is 0915-0061. Public reporting burden
for this collection of information is estimated to average .25 hours per response, 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 10-29, Rockville, Maryland, 20857.

OMB Number 0915-0061
Expiration date XX/XX/201X

PERFORMANCE REPORT FOR GRANTS AND COOPERATIVE AGREEMENTS
FORM NAME:

DV-2

Select Training Program
DISADVANTAGED STATUS OF ENROLLEES
Block 1. Total number of enrollees from a disadvantaged background
Block 2. Number of enrollees from a disadvantaged background who are not underrepresented minorities
DISADVANTAGED STATUS OF FELLOWS
Block 3. Total number of fellows from a disadvantaged background
Block 4. Number of fellows from a disadvantaged background who are not underrepresented minorities
DISADVANTAGED STATUS OF RESIDENTS
Block 5. Total number of residents from a disadvantaged background
Block 6. Number of residents from a disadvantaged background who are not underrepresented minorities
DISADVANTAGED STATUS OF GRADUATES
Block 7. Total number of graduates from a disadvantaged background
Block 8. Number of graduates from a disadvantaged background who are not underrepresented minorities
DISADVANTAGED STATUS OF PROGRAM COMPLETERS
Block 9. Total number of program completers from a disadvantaged background
Block 10. Number of program completers from a disadvantaged background who are not underrepresented
minorities

Add Information about Another Training Program

Save & Continue

OMB Number 0915-0061
Expiration date XX/XX/201X

INSTRUCTIONS
Purpose. The DV-2 form captures information about the
disadvantaged status of individuals who participated in a
training program supported with a BHPr-funded grant. Please
complete the applicable blocks of this form using the
instructions below.
(Note: For a definition of disadvantaged, please go to
http://www.hrsa.gov/loanscholarships/scholarships/disadvanta
ged.html. The "Select Training Program" button will only
appear if you reported supporting more than 1 non-direct
financial support training program in the Program
Characteristics Form. This will assist BHPr in associating the
number of individuals to specific types of non-direct financial
support training programs. Do not include information about
individuals who permanently left a program before completion
during the reporting period.))

ENROLLEES
Block 1. Indicate the total number of enrollees—regardless of
race—who received training as a result of the grant and
reported coming from a financial and/or educational
disadvantaged background. Do not include fellows, residents,
or any individual who graduated/completed the program
during this reporting period.
Block 2. Indicate the number of enrollees who received
training as a result of the grant, reported coming from a
financial and/or educational disadvantaged background and
are not underrepresented minorities. The number reported in
Block 2 should be a subset of the number reported in Block 1.
Do not include fellows, residents, or any individual who
graduated/completed the program during this reporting period.
FELLOWS
Block 3. Indicate the total number of fellows—regardless of
race—who received training as a result of the grant and
reported coming from a financial and/or educational
disadvantaged background. Do not include residents, or any
individual who graduated/completed the program during this
reporting period.
Block 4. Indicate the number of fellows who received training
as a result of the grant, reported coming from a financial
and/or educational disadvantaged background and are not
underrepresented minorities. The number reported in Block 4
should be a subset of the number reported in Block 3. Do not
include residents, or any individual who graduated/completed
the program during this reporting period.
RESIDENTS
Block 5. Indicate the total number of residents—regardless of
race—who received training as a result of the grant and
reported coming from a financial and/or educational

disadvantaged background. Do not include any individual
who graduated/completed the program during this reporting
period.
Block 6. Indicate the number of residents who received
training as a result of the grant, reported coming from a
financial and/or educational disadvantaged background and
are not underrepresented minorities. The number reported in
Block 6 should be a subset of the number reported in Block 5.
Do not include any individual who graduated/completed the
program during this reporting period.
GRADUATES
Block 7. Indicate the total number of graduates—regardless of
race—who received training as a result of the grant, earned an
academic degree during the reporting period, and reported
coming from a financial and/or educational disadvantaged
background.
Block 8. Indicate the number of graduates who received
training as a result of the grant, earned an academic degree
during the reporting period, reported coming from a financial
and/or educational disadvantaged and are not
underrepresented minorities. The number reported in Block 8
should be a subset of the number reported in Block 7.
PROGRAM COMPLETERS
Block 9. Indicate the total number of program completers—
regardless of race—who received training as a result of the
grant, completed all training requirements during the reporting
period, and reported coming from a financial and/or
educational disadvantaged background.
Block 10. Indicate the number of program completers who
received training as a result of the grant, completed all training
requirements during the reporting period, reported coming
from a financial and/or educational disadvantaged background
and are not underrepresented minorities. The number reported
in Block 10 should be a subset of the number reported in
Block 9. (Note: a program completer is an individual who
meets all of the requirements of a non-degree bearing training
program)

When finished, click on "Save and Continue" to be routed
to the appropriate form(s).

Public Burden Statement: 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 project is 0915-0061. Public reporting burden
for this collection of information is estimated to average .25 hours per response, 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 10-29, Rockville, Maryland, 20857.

OMB Number 0915-0061
Expiration date XX/XX/201X

PERFORMANCE REPORT FOR GRANTS AND COOPERATIVE AGREEMENTS
FORM NAME:

DV-3

Select Training Program
RURAL STATUS OF ENROLLEES
Block 1. Total number of enrollees from a rural residential background
RURAL STATUS OF FELLOWS
Block 2. Total number of fellows from a rural residential background
RURAL STATUS OF RESIDENTS
Block 3. Total number of residents from a rural residential background
RURAL STATUS OF GRADUATES
Block 4. Total number of graduates from a rural residential background
RURAL STATUS OF PROGRAM COMPLETERS
Block 5. Total number of program completers from a rural residential
background

Add Information about Another Training Program

Save & Continue

OMB Number 0915-0061
Expiration date XX/XX/201X

INSTRUCTIONS
Purpose. The DV-3 form captures information about the rural
status of individuals who participated in a training program
supported with a BHPr-funded grant. Please complete the
applicable blocks of this form using the instructions below.
(Note: A rural area is located in a county that is not part of a
Metropolitan Statistical Area. Refer to
http://datawarehouse.hrsa.gov/RuralAdvisor/RuralHealthAdvi
sor.aspx to determine if a county is considered rural. The
"Select Training Program" button will only appear if you
reported supporting more than 1 non-direct financial support
training program in the Program Characteristics Form. This
will assist BHPr in associating the number of individuals to
specific types of non-direct financial support training
programs. Do not include information about individuals who
permanently left a program before completion during the
reporting period.)
ENROLLEES
Block 1. Indicate the total number of enrollees who received
training as a result of the grant and are from a rural residential
background. Do not include fellows, residents, or any
individual who graduated/completed the program during this
reporting period.
FELLOWS
Block 2. Indicate the total number of fellows who received
training as a result of the grant and are from a rural residential
background. Do not include residents or any individual who
graduated/completed the program during this reporting period.

RESIDENTS
Block 3. Indicate the total number of residents who received
training as a result of the grant and are from a rural residential
background. Do not include any individual who
graduated/completed the program during this reporting period.
GRADUATES
Block 4. Indicate the total number of graduates who received
training as a result of the grant, earned an academic degree
during the reporting period, and are from a rural residential
background.
PROGRAM COMPLETERS
Block 5. Indicate the total number of program completers who
received training as a result of the grant, completed all training
requirements during the reporting period, and are from a rural
residential background. (Note: a program completer is an
individual who meets all of the requirements of a non-degree
bearing training program)

When finished, click on "Save and Continue" to be routed
to the appropriate form(s).

Public Burden Statement: 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 project is 0915-0061. Public reporting burden
for this collection of information is estimated to average 1.25 hours per response, 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 10-29, Rockville, Maryland, 20857.

OMB Number 0915-0061
Expiration date XX/XX/201X

PERFORMANCE REPORT FOR GRANTS AND COOPERATIVE AGREEMENTS
FORM NAME:

IND-GEN
Enter New Case

Select Training Program

Update Existing Case

SECTION A. ID & Training Category
Block 1. Indicate the individuals' unique identifier
Block 2. Select the individual's training category

Enrollee
Faculty

Fellow
Resident
Practicing Professional

Block 3. Select the individual's enrollment/employment status

Full-time

Part-time

On leave of absence

Block 4. Select the individual's sex

Male

Female

Not Reported

Block 5. Select the individual's age group

Under 20 years
20-29 years
30-39 years
40-49 years

Block 6. Select the individual's ethnicity

Hispanic/Latino

Block 7. Select the individual's race (Select All That Apply)

American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or Other Pacific Islander

SECTION B. Demographics

Block 8. Select whether the individual is from a rural residential background

Yes

50-59 years
60 years or older
Not Reported
Non-Hispanic/Non-Latino

Active Duty Military
Veteran--Retired

White
Not Reported

Not Reported

Block 9. Select whether the individual has reported coming from a disadvantaged background
Block 10. Select the individual's veteran status

Not Reported

Yes

Not Reported

Reservist
Veteran--Prior Service
Individual is not a Veteran
Not Reported

SECTION C. Financial Award
Block 11. Indicate the type(s) and amount(s) of BHPr financial awards provided
Add Type of BHP r Financial Award

Add Type of BHP r Financial Award

Amount
Amount

Block 12. Select the number of academic years the individual has received BHPr funding

5 or more

Block 13. Indicate balance of loan
Block 13a. Indicate percentage of loan paid off
Block 14. Indicate percent FTE paid for through BHPr financial award

OMB Number 0915-0061
Expiration date XX/XX/201X

SECTION D. Training Program
Block 15. Select the individual's academic/training year

Undergraduate—Year 1
Undergraduate—Year 2
Undergraduate—Year 4
Undergraduate—Year 5
Graduate—Year 2
Graduate—Year 3
Graduate—Year 5
Graduate—Year 6
Residency—Year 1
Residency—Year 2
Residency—Year 4
Fellowship—Year 1
Fellowship—Year 3
Internship—Year 1
Non-degree Training Program—Year 1
Non-degree Training Program—Year 2

Block 16. Select the individual's discipline or specialty

Undergraduate—Year 3
Graduate—Year 1
Graduate—Year 4
Graduate—Year 7
Residency—Year 3
Fellowship—Year 2
Internship—Year 2

[Drop-down]

Block 17. Select whether the individual received training in a primary care setting

Yes

Block 17a. If yes, indicate total number of contact hours in this setting
Block 17b. If yes, indicate total number of patient encounters in this setting
Block 18. Select whether the individual received training in a medically underserved area

Yes

Block 18a. If yes, indicate total number of contact hours in this setting
Block 19. Select whether the individual received training in a rural area

Yes

Block 19a. If yes, indicate total number of contact hours in this setting
Block 20. Select the type of setting where the individual was placed for the purposes of field placement

[Drop-down]

SECTION E. Attrition & Graduation
Block 21. Select whether the individual permanently left the program before completion:

Yes

Block 22. Select whether the individual graduated/completed the program:

Yes

Block 22a. If graduated, select degree earned

[Drop-down]

Block 22b. If graduated/completed, select whether the individual intends to pursue health professions training:
Block 22c. If graduated/completed, select whether the individual has applied to a residency program:

Yes
Yes

No
No

Block 22d. If graduated/completed, select whether the individual intends to teach

Yes

Block 22e. If graduated/completed, select whether the individual intends to conduct research

Yes

Block 22f. If graduated/completed, select whether the individual intends to practice in a Primary Care Setting
Block 22g. If graduated/completed, select whether the individual intends to practice in a Medically Underserved Area
Block 22h. If graduated/completed, select whether the individual intends to practice in a Rural Area

Yes
Yes
Yes

Block 23. Select whether employment data are available for the individual 1-year post graduation/completion

Yes

Block 23a. If yes, select whether the individual pursued health professions training
Block 23b. If yes, select whether the individual was accepted into the residency program

Yes
Yes

No
No

Block 23c.1. If graduated/completed, select whether the individual is currently teaching

Yes

Block 23.c.2. If yes, select level of teaching
Block 23d. If graduated/completed, select whether the individual is conducting research

No
No
No

[Drop-down]
Yes

Block 23e. If graduated/completed, select whether the individual currently practices in a Primary Care Setting
Block 23f. If graduated/completed, select whether the individual currently practices in a Medically Underserved Area
Block 23g. If graduated/completed, select whether the individual currently practices in a Rural Area

Yes
Yes
Yes

No
No
No

OMB Number 0915-0061
Expiration date XX/XX/201X

SECTION F. RESEARCH AND PUBLICATIONS
Block 24. Indicate the percent FTE spent on the following activities:
24a. Research
24b. Teaching
24c. Administration
24d. Clinical
Block 25. Indicate the total number of articles published in peer-reviewed journals
Block 26. Indicate the total number of peer-reviewed conference presentations
Block 27. Indicate the total number of awarded grants by type
Add Type of Grant Award

Add Size of Grant Award

Add Type of Grant Award

Add Size of Grant Award

Number of Grants Awarded

SECTION G. DENTAL PROVIDERS
Block 28. Indicate the total amount of time obligated to serve (in weeks):
Block 29. Select if the individual is currently practicing in a public health facility:

Yes

Block 30. Select if the individual is practicing in a dental HPSA:

Yes

Block 31. Select if the individual is practicing in a rural area:

Yes

Block 32. Select if the individual is enrolled in the Medicaid/CHIP program:

Yes

Block 32a. If enrolled, select whether the individual is accepting new Medicaid/CHIP patients:
Block 33. Indicate the total number of patient encounters:
Block 33a. Indicate your total number of Medicaid/CHIP patient encounters:

Add New Case

Add Information about Another Training Program

Update Existing Case

Save & Continue

OMB Number 0915-0061
Expiration date XX/XX/201X

INSTRUCTIONS
Purpose. The IND-GEN form captures information about
individuals who received direct financial support (e.g., loans,
stipends, scholarships) from training programs supported with
a BHPr-funded grant. The IND-GEN form is divided into six
sections: Section A captures identifying information for each
individual; Section B captures information about
demographics; Section C captures information about the type
and amount of financial support provided; Section D captures
information about the individual's training program; Section E
captures information specific to the completion of a training
program; Section F captures information about researchrelated activities; AND Section G captures information about
dental providers. Please complete the applicable sections and
blocks of this form using the instructions below.
(Note: The "Select Training Program" button will only appear
if you reported supporting more than 1 non-direct financial
support training program in the Program Characteristics Form.
This will assist BHPr in associating the number of individuals
to specific types of non-direct financial support training
programs.)
To enter a new case, click on "Add New Case". To update
information about an existing case, click on "Update Case"
and you will be routed to the list of cases reported in previous
reporting cycles.
SECTION A
Block 1. Indicate the individual's unique identifier. This
identifier must contain seven alphanumeric characters. Note:
The ID assigned to each individual will remain with student
until completion of/attrition from the program.
(Note: For medical residents, the ID number should be the
individual's provider number)
Block 2. Select the training category for the individual.
(Note: The "Faculty" option should only be selected if the
individual has completed a degree program and is currently an
appointed faculty member at a college or university)
Block 3.
For enrollees, fellows, and residents, select the individual's
enrollment status during the reporting period.
For faculty members, indicate the individual's employment
status during the reporting period.

Block 5. Select the age group that contains the individual's
current age. If not available, select "Not Reported".
Block 6. Select whether the individual is of Hispanic, Latino,
or Spanish descent. If not available, select "Not Reported".
Block 7. Select the individual's race. You may select more
than one option in this block for individuals of multiple races.
If not available, select "Not Reported".
Block 8. Select whether the individual is from a rural
residential background. A rural area is located in a county that
is not part of a Metropolitan Statistical Area. Refer to
http://datawarehouse.hrsa.gov/RuralAdvisor/RuralHealthAdvi
sor.aspx to determine if a county is considered rural.
Block 9. Select whether the individual reported coming from a
financial and/or educational disadvantaged background at the
time of matriculation into the program.
(Note: For a definition of disadvantaged, please go to
http://www.hrsa.gov/loanscholarships/scholarships/disadvanta
ged.html)
Block 10. Select the individual's veteran status from the
options below:
Active Duty Military: An individual serving in a full-time
capacity in one (1) of the seven (7) uniformed services.
Reservist: An individual serving in a part-time capacity in
one (1) of the seven (7) uniformed services.
Veteran (Prior service): An individual discharged from
one (1) of the seven (7) uniformed services after serving a
period of 90 days or more.
Veteran (Retired): An individual discharged from one (1)
of the seven (7) uniformed services after serving a period
of 20 years or more OR An individual discharged from
one (1) of the seven (7) uniformed services due to medical
status.
Individual is not a Veteran: An individual who has never
served in one (1) of the seven (7) uniformed services OR
An individual who was discharged from one (1) of the
seven (7) uniformed services before serving a total of 90
days or more.

(Note: If an individual is on a leave of absence, please select
"On leave of absence")
SECTION B
Block 4. Select whether the individual's biological sex is male
or female. If not available, select "Not Reported".

SECTION C
Block 11. Select the type(s) and amount(s) of BHPr Financial
Award provided to the individual during the reporting period
using the options below. You may add more than one row in
this block if multiple BHPr awards were provided.
To enter a type of BHPr financial award, click on "Add Type
of BHPr Financial Award" and choose from the options
below:
Selections:
Stipend
Scholarship
Loan
Career Award
Loan Repayment
Traineeship
No Financial Award Provided
For each type of BHPr financial award, indicate the amount
provided to the individual during the reporting period.
Block 12. Select the total number of academic years the
individual has received one or more BHPr financial awards.
(Note: The number of academic years does not have to be
consecutive).
Loan Repayment Programs Only
Block 13. Indicate the individual's total loan balance at the
beginning of the agreement.
Block 13a. Of the amount entered in Block 13,
indicate the total percentage of the loan paid off with
BHPr funds during the reporting period.
Residency Programs Only
Block 14. Indicate the percent FTE paid for with BHPr funds
during the reporting period.
SECTION D
Block 15. Select the individual's current academic/training
year.
(Note: For non-degree bearing programs, select Non-degree
bearing Training Program—Year 1 through Non-degree
bearing Training Program—Year 2)
Residency & Dentistry Programs Only
Block 16. Select the individual's discipline/specialty from the
options below:
Dentistry

General Dentistry
Pediatric Dentistry
Orthodontic Dentistry
Oral Surgery Dentistry
Radiology Dentistry
Periodontic Dentistry
Prosthodontic Dentistry
Pathology Dentistry
Dental Assistant
Dental Hygiene
Public Health Dentistry
Endodontic Dentistry

OMB Number 0915-0061
Expiration date XX/XX/201X

Medicine
Aerospace Medicine
Allopathic Medicine, Alternative/Complementary
Medicine
Behavioral/Mental Health In School Of Medicine And
Osteopathic Medicine
Family Medicine
General Internal Medicine
General Pediatrics
General Preventive Medicine
General Preventive Medicine/ Family Medicine
General Preventive Medicine/ Internal Medicine
General Preventive Medicine/ Public Health
Geriatric Medicine
Geriatric Psychiatry
Integrative Medicine
Internal Medicine /General Pediatrics
Internal Medicine/Family Medicine
Neurology
Obstetrics/Gynecology
Occupational Medicine
Osteopathic General Practice
Pediatrics/Family Medicine
Pharmacy
Podiatry
Psychiatry
Radiology
Veterinary Medicine
Other
Clinical Training Programs Only
Block 17. Select whether the individual received training in a
primary care setting during the reporting period.
Block 17a. If yes, indicate the total number of
contact hours spent in this setting.
Block 17b. If yes, indicate the total number of patient
encounters in this setting.

Block 18. Select whether the individual received training in a
medically underserved area during the reporting period.
(Note: A medically underserved area includes a medically
underserved community and/or a health professional shortage
area. For definitions, please go to
http://datawarehouse.hrsa.gov/GeoAdvisor/ShortageDesignati
onAdvisor.aspx)
Block 18a. If yes, indicate the total number of
contact hours spent in this setting.
Block 19. Select whether the individual received training in a
rural area during the reporting period.
(Note: Refer to
http://datawarehouse.hrsa.gov/RuralAdvisor/RuralHealthAdvi
sor.aspx to determine if a county is considered rural.)
Block 19a. If yes, indicate the total number of
contact hours spent in this setting.
Public Health Training Centers Program Only
Block 20. Select the type of setting where the individual was
placed for the purposes of a field placement from the options
below:
Selections:
Academic institution
Acute care services
Aerospace operations setting
Ambulatory practice sites
Community Health Center (CHC) Other community
health center (i.e. free clinic)
Community Behavioral Health Center
Community care programs for elderly mentally
challenged individuals)
Community-based organization
Day and home care programs (i.e. Home Health)
Dental services
Extended care facilities
Federally-qualified Health Center
Federal and State Bureau of Prisons
Hospice
Hospital-academic center
Hospital-community
Hospital-federal
Hospital-non-profit
Hospital- for profit
Indian Health Service (IHS) site
International nonprofit/nongovernmental
organization
Local health department
National health association
Physician Office
Senior Centers
School-based clinic

OMB Number 0915-0061
Expiration date XX/XX/201X

Specialty clinics (e.g. mental health practice,
rehabilitation, substance abuse clinic)
State Health department
Surgery clinic
Tribal Health Department
Long-term Care Facility
Veterans Affairs Healthcare (e.g. VA hospital)
Other
SECTION D

Block 21. Select whether the individual permanently left the
program before completion.
(Note: If the individual is on a leave of absence, do not select
"Yes" here. Make sure "On leave of absence" is checked in
Block 3)
Block 22. Select whether the individual completed the
program during the reporting period.
(Note: If the individual did not graduate/complete the training
program during the reporting period, select "No")
Block 22a. For degree-bearing supported with a
BHPr-funded grant during the reporting period, select
the type of degree earned by the individual from the
options below:
Selections:
Certificate
Diploma
AA
AS
BA
BS
BSN
BSW
BPH
Bachelor's Not Otherwise Specified
DC
DDS
DDS/MPH
DDS/MSPH
DMD
DNP
DNSc
DO
DO/MPH
DO/MSPH
DO/DrPH
DO/ScD
DrPH
DVM
MA
MEd
MHA

MD
MD/MPH
MD/MSPH
MD/DrPH
MD/ScD
MD/PhD
MS
MMS
MMS/MPH
MMS/MSPH
MMS/DrPH
MMS/ScD
MPAS
MPAS/MPH
MPAS/MSPH
MPAS/DrPH
MPAS/ScD
MPH
MSPH
MSCR
MS-CTS
MSN
MSW
MSSW
Master's Degree Not Otherwise Specified
Post-Masters Certificate
PhD
PharmD
PsyD
ScD
VMD
Pipeline Training Programs Only
Block 22b. For pipeline programs, select whether the
individual intends to pursue health professions
training.

OMB Number 0915-0061
Expiration date XX/XX/201X

Block 22g. Select whether the individual intends to
practice in a medically underserved area.
Block 22h. Select whether the individual intends to
practice in a rural area.
Block 23. Select whether employment/training data are
available for the individual 1-year post program completion.
Pipeline Training Programs Only
Block 23a. For pipeline programs, indicate whether
the individual pursued health professions training.
Pre-doctoral Training Programs Only
Block 23b. For pre-doctoral programs, indicate
whether the individual was accepted into a residency
program.
Faculty Preparation/Research Awards Programs Only
Block 23c.1. For faculty preparation programs,
indicate whether the individual currently teaches.
Block 23.c.2. If yes, select level of teaching
from the options below:
Selections:
Nursing Diploma School
Two-year College
Undergraduate-level
Graduate-level Masters
Graduate-level Doctorate

Pre-doctoral Training Programs Only

Research Awards Programs Only

Block 22c. For pre-doctoral programs, select whether
the individual has applied to a residency program.

Block 23d. Select whether the individual is currently
conducting research.

Faculty Preparation/Research Awards Programs Only
Block 22d. For faculty preparation programs,
indicate whether the individual intends to teach.
Research Awards Programs Only
Block 22e. Select whether the individual intends to
conduct research.
All Other Training Programs

All Other Training Programs
Block 23e. For all other training programs, select
whether the individual practices in a primary care
setting.
Block 23f. For all other training programs, select
whether the individual practices in a medically
underserved area.
Block 23g. For all other training programs, select
whether the individual practices in a rural area.

Block 22f. Select whether the individual intends to
practice in a primary care setting.

OMB Number 0915-0061
Expiration date XX/XX/201X

SECTION F

SECTION G
Research Awards Programs Only

Blocks 24a through 24d. Indicate the percent FTE spent on
each of the activities listed during the reporting period. Totals
must add up to 100%.
Block 25. Indicate the total number of articles published in
peer-reviewed journals during the reporting period.
(Note: You may count articles that have been accepted by the
journal, but have not been physically published (i.e. "in press")
Block 26. Indicate the total number of conference
presentations given during the reporting period.
Block 27. Indicate the total number of awarded grants by type
and size from the options below.
For type of grant, click on "Add Type of Grant Award" and
select from the options below:
Selections:
Research
Education
For size of grant award, click on "Add Size of Grant Award"
and select from the options below:
Selections:
<$100,000
>$100,000
For each grant type, indicate the total number of grants
awarded during the reporting period.

State Oral Health Programs Only
Block 28. Indicate the number of weeks the individual is
obligated to serve during the reporting period.
Block 29. Select whether the individual is currently practicing
in a public health facility.
Block 30. Select whether the individual is currently practicing
in a dental health professional shortage area.
Block 31. Select whether the individual is currently practicing
in a rural area.
Block 32. Select whether the individual is currently enrolled
as a provider in the Medicaid/CHIP program.
Block 32a. If enrolled, select whether the individual
is currently accepting new patients.
Block 33. Indicate the total number of patient encounters
during the reporting period.
Block 33a. Of the number reported in Block 33,
indicate the total number of patients enrolled in the
Medicaid/CHIP program.
Click on "Add Another New Case" to enter new cases of
individuals supported during the reporting period.
Click on "Update Another Existing Case" to be routed to a
list of cases reported in previous reporting cycles.
If you reported supporting more than one training
program with BHPr funds in the Program Characteristics
Form, click on "Add Information about another Training
Program" to complete this form for each program.
When finished, click on "Save and Continue" to be routed
to the appropriate form(s).

Public Burden Statement: 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 project is 0915-0061. Public reporting burden
for this collection of information is estimated to average .25 hours per response, 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 10-29, Rockville, Maryland, 20857.

OMB Number 0915-0061
Expiration date XX/XX/201X

PERFORMANCE REPORT FOR GRANTS AND COOPERATIVE AGREEMENTS
FORM NAME:

EXP-1

Select Training Program
SECTION A. Training Site Characteristics
Block 1. Indicate the name of the training site
Block 1a. Select the type of site used to provide training:
Block 2. Select the type of setting the training site was located in:
(Select all that apply)

[Drop-down]
Medically underserved community
Rural area

Health professional shortage area
None of the above

Block 3. Indicate the number of students trained by profession/discipline
Add P rofession & Discipline
Add P rofession & Discipline

Number of Students Trained
Number of Students Trained

Block 4. Select, if any, the partners/consortia used for purpose of delivering clinical/experiential training (Select all that apply)

[Drop-down]

SECTION B. Content Area(s) Covered
Block 5. Select the primary competency addressed through this training site
Block 5a. Select, if any, the secondary competency addressed through this training site

[Drop-down]
[Drop-down]

SECTION C. Team-based Care
Block 6. Indicate the total number of interprofessional teams used to provide care
Block 7. For each team, indicate the number of team members by profession and discipline
Add Team Number

Add P rofession & Discipline
Add P rofession & Discipline

Add Team Number

Add P rofession & Discipline
Add P rofession & Discipline

Number of Team Members
Number of Team Members
Number of Team Members
Number of Team Members

SECTION D. Populations Served & Services Provided through Training
Block 8. Indicate the total number of vulnerable populations served by population type:
Add Vulnerable P opulation
Add Vulnerable P opulation

Number of Patients Served
Number of Patients Served

Add Information about Another Training Program

Save & Continue

OMB Number 0915-0061
Expiration date XX/XX/201X

INSTRUCTIONS
Purpose. The EXP-1 form captures information about the
types of sites used to provide individuals with clinical or
experiential trainings through BHPr-funded grant programs.
The EXP-1 form is divided into four sections: Section A
captures general information about sites used to provide
individuals with clinical or experiential training; Section B
captures information about the competency(ies) addressed
through training; Section C captures information about teambased care; and Section D captures information specific to
populations served by individuals participating in clinical
training. Please complete applicable sections and blocks of
this form using the instructions below.
(Note: Complete the EXP-1 form for each training site used to
provide training during the reporting period. The "Select
Training Program" button will only appear if you reported
supporting more than 1 non-direct financial support training
program in the Program Characteristics Form. This will assist
BHPr in associating the number of individuals to specific
types of non-direct financial support training programs.)

SECTION A
Block 1a. Select the type of site used to provide training
during the reporting period from the options below:
(Note: you will be required to complete this form for each site
used to provide training)
Selections:
Academic institution
Acute care services
Aerospace operations setting
Ambulatory practice sites
Community Health Center (CHC) Other community
health center (i.e. free clinic)
Community Behavioral Health Center
Community care programs for elderly mentally
challenged individuals)
Community-based organization
Day and home care programs (i.e. Home Health)
Dental services
Extended care facilities
Federally-qualified Health Center
Federal and State Bureau of Prisons
Hospice
Hospital-academic center
Hospital-community
Hospital-federal
Hospital-non-profit
Hospital- for profit
Indian Health Service (IHS) site
International nonprofit/nongovernmental
organization
Local health department
Mobile Clinic/Site

National health association
Physician Office
Senior Centers
School-based clinic
Specialty clinics (e.g. mental health practice,
rehabilitation, substance abuse clinic)
State Health department
Surgery clinic
Tribal Health Department
Long-term Care Facility
Veterans Affairs Healthcare (e.g. VA hospital)
Other
Block 2. Select the type of designated setting the training site
is located in. You may select more than one option in this
block.
Block 3. Indicate the total number of students trained by
profession and discipline. Click on "Add Profession" and
select from the options below:
Selections:

Students

K-8 (primary)
9-12 (secondary)
Post-high school/Pre-college
Dental Student
Dental Hygiene Student
Dental Assistant Student
Medical Student
Physician Assistant Student
Medical Residents
Medical Fellows
Pre-licensure Nursing Students
Graduate-level Nursing Student
Undergraduate-level Public Health Student
Graduate-level Public Health Student
Graduate-level Psychology Student
Graduate-level Psychology Intern
Graduate-level Psychology Fellow
Faculty
Administrator
Other Undergraduate-level Student
Other Graduate-level Student
Other Fellow
Other Resident
Providers
Dentistry
General Dentistry
Pediatric Dentistry
Orthodontic Dentistry
Oral Surgery Dentistry
Radiology Dentistry
Periodontic Dentistry

OMB Number 0915-0061
Expiration date XX/XX/201X

Prosthodontic Dentistry
Pathology Dentistry
Dental Assistant
Dental Hygiene
Public Health Dentistry
Endodontic Dentistry
Medicine
Aerospace Medicine
Allopathic Medicine, Alternative/Complementary
Medicine
Behavioral/Mental Health In School Of Medicine And
Osteopathic Medicine
Chiropractic
Family Medicine
General Internal Medicine
General Pediatrics
General Preventive Medicine
General Preventive Medicine/ Family Medicine
General Preventive Medicine/ Internal Medicine
General Preventive Medicine/ Public Health
Geriatric Medicine
Geriatric Psychiatry
Integrative Medicine
Internal Medicine /General Pediatrics
Internal Medicine/Family Medicine
Neurology
Obstetrics/Gynecology
Occupational Medicine
Osteopathic General Practice
Pediatrics/Family Medicine
Pharmacy
Podiatry
Psychiatry
Radiology
Veterinary Medicine
Nursing
Alternative/Complementary Nursing
CNS-Adult gerontology
CNS-Family
CNS-Geropsychiatric
CNS-Neonatal
CNS-Pediatrics
CNS-Psychiatric/Mental health
CNS-Women’s health
Clinical Nurse Specialist (CNS)
Home Health Aide
Licensed Practical/Vocational Nurse (LPN/LVN)
NP - Other advanced nurse specialists
NP - Psychiatric/Mental health
NP –Adult gerontology
NP –Family
NP –Neonatal
NP –Pediatrics
NP –Women’s health
NP- Acute care adult gerontology
NP- Acute care pediatric

NP- Emergency care
NP- Geropsychiatric
Nurse Administrator
Nurse Anesthetist
Nurse Assistant/Patient Care Associate (PCA)
Nurse Educator
Nurse Generalist
Nurse Midwife
Nurse Practitioner (NP)
Nurse Researchers/Scientists
Nursing Informatics
Public Health Nurse
Registered Nurse
Behavioral Health

Counseling Psychology
Clinical Psychology
Clinical Social Work
Marriage and Family Therapy
Pastoral/Spiritual Care
Other Psychology
Other Social Work, Substance Abuse/Addictions
Counseling
Public Health
Biostatistics
Environmental Health
Epidemiology
Health Policy & Management
Social & Behavioral Sciences
Other
Indicate the total number of individuals trained in each
profession and discipline. You may add as many rows as
necessary.
Block 4. Select, if any, the partners/consortia used for the
purposes of delivering clinical or experiential training during
the reporting period from the options below. You may select
more than one option in this block.
Selections:
Academic department- within the institution
Academic department –outside the institution
Community Mental Health Center
Federal Government -Veterans Affairs
Federal Government- Department of Defense/Military
Federal Government-CDC
Federal Government-SAMHSA
Federal Government-IHS
Federal Government-NIH
Federal Government-AHRQ
Federal Government-FDA
Federal Government-Other HHS Agency/Office
Federal Government- Other HRSA Program
Federally-qualified health center or look-alikes

Federal Government –Other
Community-based health center (e.g., free clinic)
Health department- Local
Health department- State
Health department- Tribal
Health disparities research center
Health policy center
Hospital
Nonprofit organization (non-faith based)
State Governmental Programs
Professional Associations
Nonprofit organization (faith-based)
Private/For-profit organization
Local Government
Other
No partners
SECTION B
Public Health Training Centers Program Only
Block 5. Select the primary competency addressed through the
training site from the options below:
Selections:
Analytical/assessment skills
Policy development program planning skills
Communication skills
Cultural competency skills
Community dimensions of practice skills
Public health sciences skills
Financial planning and management skills
Leadership and systems thinking skills
Block 5a. Select the secondary competency, if any,
addressed through the training site from the options
below:

OMB Number 0915-0061
Expiration date XX/XX/201X

Block 7. Indicate the profession and discipline composition of
each team reported in Block 7. Report each team separately by
assigning each team a number from 1 to 20.
To begin entering a team, click on "Add Team Number" and
select a value from 1 to 20.
To begin entering a profession and discipline, click on "Add
Profession & Discipline" and select from the following
options:
Selections:
Students
K-8 (primary)
9-12 (secondary)
Post-high school/Pre-college
Dental Student
Dental Hygiene Student
Dental Assistant Student
Medical Student
Physician Assistant Student
Medical Residents
Medical Fellows
Pre-licensure Nursing Students
Graduate-level Nursing Student
Undergraduate-level Public Health Student
Graduate-level Public Health Student
Graduate-level Psychology Student
Graduate-level Psychology Intern
Graduate-level Psychology Fellow
Faculty
Administrator
Other Undergraduate-level Student
Other Graduate-level Student
Other Fellow
Other Resident

Selections:

Providers

Analytical/assessment skills
Policy development program planning skills
Communication skills
Cultural competency skills
Community dimensions of practice skills
Public health sciences skills
Financial planning and management skills
Leadership and systems thinking skills
No secondary competency addressed

Dentistry

SECTION C
Collaborative/Team-based Training Activities Only

Block 6. Indicate the total number of teams used to provide
care at the training site.

Nurse Midwife
Nurse Practitioner (NP)
Nurse Researchers/Scientists
Nursing Informatics
Public Health Nurse
Registered Nurse

OMB Number 0915-0061
Expiration date XX/XX/201X

Behavioral Health
Counseling Psychology
Clinical Psychology
Clinical Social Work
Marriage and Family Therapy
Pastoral/Spiritual Care
Other Psychology
Other Social Work, Substance Abuse/Addictions
Counseling
Public Health
Biostatistics
Environmental Health
Epidemiology
Health Policy & Management
Social & Behavioral Sciences
Other
Indicate the total number of individuals trained in each
profession and discipline. You may add as many rows as
necessary.

Alternative/Complementary Nursing
CNS-Adult gerontology
CNS-Family
CNS-Geropsychiatric
CNS-Neonatal
CNS-Pediatrics
CNS-Psychiatric/Mental health
CNS-Women’s health
Clinical Nurse Specialist (CNS)
Home Health Aide
Licensed Practical/Vocational Nurse (LPN/LVN)
NP - Other advanced nurse specialists
NP - Psychiatric/Mental health
NP –Adult gerontology
NP –Family
NP –Neonatal
NP –Pediatrics
NP –Women’s health
NP- Acute care adult gerontology
NP- Acute care pediatric
NP- Emergency care
NP- Geropsychiatric
Nurse Administrator
Nurse Anesthetist
Nurse Assistant/Patient Care Associate (PCA)
Nurse Educator
Nurse Generalist

OMB Number 0915-0061
Expiration date XX/XX/201X

SECTION D
Clinical/Patient Care Training Programs Only
Block 8. Indicate the type(s) and number of vulnerable
populations served by individuals receiving training. Report
each vulnerable population separately using options below.
You may add as many rows as you need.
To enter a vulnerable population, click on "Add Vulnerable
Population" and select from the options below:
Selections:
Adolescents
Children
Chronically ill
College students
Homeless individuals
Individuals with HIV/AIDS
Individuals with mental health or substance abuse
disorders
Migrant workers
Military and/or military families
Older adults
People with disabilities
Pregnant women and infants
Unemployed
Returning war veterans (Iraq or Afghanistan)
Veterans
Victims of abuse or trauma

For each type of vulnerable population selected, indicate the
total number patients served by individuals participating in the
training program.
If you reported supporting more than one training
program with BHPr funds in the Program Characteristics
Form, click on "Add Information about another Training
Program" to complete this form for each program.

When finished, click on "Save and Continue" to be routed
to the appropriate form(s).

Public Burden Statement: 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 project is 0915-0061. Public reporting burden
for this collection of information is estimated to average .25 hours per response, 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 10-29, Rockville, Maryland, 20857.

OMB Number 0915-0061
Expiration date XX/XX/201X

PERFORMANCE REPORT FOR GRANTS AND COOPERATIVE AGREEMENTS
FORM NAME:

EBP

A. Characteristics of Evidence-based Practices Implemented
Block 1. Select the focus area for the evidence-based practice

[Drop-down]

Block 2. Select the type of evidence-based practice

Assessment

Block 3. Select the type of setting designated for the evidence-based practice

Intervention

[Drop-down]

Block 4. Indicate the total number of sites implementing evidence-based practice

B. Characteristics of Providers Implementing Evidence-based Practice
Block 5. Indicate the total number of providers trained in the evidence-based practice
Block 6. Select the primary discipline/specialty of individuals trained in the evidence-based practice
Block 7a. Select whether providers of other professions/disciplines were trained

[Drop-down]
Yes

Block 7b. If yes, indicate the total number of individuals trained by profession/discipline
Add P rofession & Discipline
Add P rofession & Discipline

Number Trained
Number Trained

C. Characteristics of Patient Populations
Block 8a. Indicate the number of patients who received the evidence-based practice before training
Block 8b. Indicate the total number of patients before the training
Block 9a. Indicate the number of patients who received the evidence-based practice after training
Block 9b. Indicate the total number of patients after the training

Add Additional Evidence-base P ractices

Save & Continue

OMB Number 0915-0061
Expiration date XX/XX/201X

INSTRUCTIONS
Purpose. The EBP form captures information about evidencebased practices implemented by grantees of select BHPrfunded multipurpose grant programs. Please complete
applicable sections of this form using the instructions below.
Geriatric Education Centers Program Only
Block 1. Select the focus area for the evidence-based practice
implemented during the reporting period from the options
below:
Selections:
Delirium
Depression
Diabetes
Falls prevention
Palliative care

Dental Hygiene Student
Dental Assistant Student
Medical Student
Physician Assistant Student
Medical Residents
Medical Fellows
Pre-licensure Nursing Students
Graduate-level Nursing Student
Undergraduate-level Public Health Student
Graduate-level Public Health Student
Graduate-level Psychology Student
Graduate-level Psychology Intern
Graduate-level Psychology Fellow
Faculty
Administrator
Other Undergraduate-level Student
Other Graduate-level Student
Other Fellow
Other Resident

Block 2. Select the type of evidence-based practice
implemented during the reporting period.
Block 3. Select the type of setting designated for the evidencebased practice implemented during the reporting period from
the list provided.
Selections:
Assisted living
Continuing care retirement community
Ambulatory care
Hospice
Nursing home
Home care
Hospital
Senior center
Other
Block 4. Indicate the total number of sites implementing the
evidence-based practice during the reporting period.
SECTION B
Block 5. Indicate the total number of providers trained in the
evidence-based practice during the reporting period.
Block 6. Select the primary profession and discipline of
providers trained during the reporting period from the options
below:
Selections:
Students
K-8 (primary)
9-12 (secondary)
Post-high school/Pre-college
Dental Student

Providers
Dentistry
General Dentistry
Pediatric Dentistry
Orthodontic Dentistry
Oral Surgery Dentistry
Radiology Dentistry
Periodontic Dentistry
Prosthodontic Dentistry
Pathology Dentistry
Dental Assistant
Dental Hygiene
Public Health Dentistry
Endodontic Dentistry
Medicine
Aerospace Medicine
Allopathic Medicine, Alternative/Complementary
Medicine
Behavioral/Mental Health In School Of Medicine And
Osteopathic Medicine
Chiropractic
Family Medicine
General Internal Medicine
General Pediatrics
General Preventive Medicine
General Preventive Medicine/ Family Medicine
General Preventive Medicine/ Internal Medicine
General Preventive Medicine/ Public Health
Geriatric Medicine
Geriatric Psychiatry
Integrative Medicine
Internal Medicine /General Pediatrics
Internal Medicine/Family Medicine
Neurology

Obstetrics/Gynecology
Occupational Medicine
Osteopathic General Practice
Pediatrics/Family Medicine
Pharmacy
Podiatry
Psychiatry
Radiology
Veterinary Medicine
Nursing
Alternative/Complementary Nursing
CNS-Adult gerontology
CNS-Family
CNS-Geropsychiatric
CNS-Neonatal
CNS-Pediatrics
CNS-Psychiatric/Mental health
CNS-Women’s health
Clinical Nurse Specialist (CNS)
Home Health Aide
Licensed Practical/Vocational Nurse (LPN/LVN)
NP - Other advanced nurse specialists
NP - Psychiatric/Mental health
NP –Adult gerontology
NP –Family
NP –Neonatal
NP –Pediatrics
NP –Women’s health
NP- Acute care adult gerontology
NP- Acute care pediatric
NP- Emergency care
NP- Geropsychiatric
Nurse Administrator
Nurse Anesthetist
Nurse Assistant/Patient Care Associate (PCA)
Nurse Educator
Nurse Generalist
Nurse Midwife
Nurse Practitioner (NP)
Nurse Researchers/Scientists
Nursing Informatics
Public Health Nurse
Registered Nurse
Behavioral Health
Counseling Psychology
Clinical Psychology
Clinical Social Work
Marriage and Family Therapy
Pastoral/Spiritual Care
Other Psychology
Other Social Work, Substance Abuse/Addictions
Counseling
Public Health

OMB Number 0915-0061
Expiration date XX/XX/201X

Biostatistics
Environmental Health
Epidemiology
Health Policy & Management
Social & Behavioral Sciences
Other
Block 7a. Select whether this training was interprofessional or
interdisciplinary.
Block 7b. If the training was interprofessional or
interdisciplinary, indicate the total number of
individuals trained by profession/discipline. Click on
"Add Profession & Discipline" and select from the
options below. You may add as many rows as you
need.
Selections:
Students
K-8 (primary)
9-12 (secondary)
Post-high school/Pre-college
Dental Student
Dental Hygiene Student
Dental Assistant Student
Medical Student
Physician Assistant Student
Medical Residents
Medical Fellows
Pre-licensure Nursing Students
Graduate-level Nursing Student
Undergraduate-level Public Health Student
Graduate-level Public Health Student
Graduate-level Psychology Student
Graduate-level Psychology Intern
Graduate-level Psychology Fellow
Faculty
Administrator
Other Undergraduate-level Student
Other Graduate-level Student
Other Fellow
Other Resident
Providers
Dentistry
General Dentistry
Pediatric Dentistry
Orthodontic Dentistry
Oral Surgery Dentistry
Radiology Dentistry
Periodontic Dentistry
Prosthodontic Dentistry

OMB Number 0915-0061
Expiration date XX/XX/201X

Pathology Dentistry
Dental Assistant
Dental Hygiene
Public Health Dentistry
Endodontic Dentistry
Medicine
Aerospace Medicine
Allopathic Medicine, Alternative/Complementary
Medicine
Behavioral/Mental Health In School Of Medicine And
Osteopathic Medicine
Chiropractic
Family Medicine
General Internal Medicine
General Pediatrics
General Preventive Medicine
General Preventive Medicine/ Family Medicine
General Preventive Medicine/ Internal Medicine
General Preventive Medicine/ Public Health
Geriatric Medicine
Geriatric Psychiatry
Integrative Medicine
Internal Medicine /General Pediatrics
Internal Medicine/Family Medicine
Neurology
Obstetrics/Gynecology
Occupational Medicine
Osteopathic General Practice
Pediatrics/Family Medicine
Pharmacy
Podiatry
Psychiatry
Radiology
Veterinary Medicine
Nursing
Alternative/Complementary Nursing
CNS-Adult gerontology
CNS-Family
CNS-Geropsychiatric
CNS-Neonatal
CNS-Pediatrics
CNS-Psychiatric/Mental health
CNS-Women’s health
Clinical Nurse Specialist (CNS)
Home Health Aide
Licensed Practical/Vocational Nurse (LPN/LVN)
NP - Other advanced nurse specialists
NP - Psychiatric/Mental health
NP –Adult gerontology
NP –Family
NP –Neonatal
NP –Pediatrics
NP –Women’s health
NP- Acute care adult gerontology
NP- Acute care pediatric

Click on "Add Additional Evidence-based Practices" to
add additional practices implemented during the reporting
period.
When finished, click on "Save and Continue" to be routed
to the appropriate form(s).

Public Burden Statement: 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 project is 0915-0061. Public reporting burden
for this collection of information is estimated to average .25 hours per response, 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 10-29, Rockville, Maryland, 20857.

OMB Number 0915-0061
Expiration date XX/XX/201X

PERFORMANCE REPORT FOR GRANTS AND COOPERATIVE AGREEMENTS
FORM NAME:

RET

Block 1. Indicate the projected retention rate by funding year
Add Year (Baseline)
Add Year (Year 1 of Funding)
Add Year (Year 2 of Funding)
Add Year (Year 3 of Funding)

Block 4. Indicate the actual vacancy rate by funding year
Projected Rate

Projected Rate

Add Year (Baseline)
Add Year (Year 1 of Funding)
Add Year (Year 2 of Funding)
Add Year (Year 3 of Funding)

Block 2. Indicate the actual retention rate by funding year
Add Year (Baseline)
Add Year (Year 1 of Funding)
Add Year (Year 2 of Funding)
Add Year (Year 3 of Funding)

Actual Rate

Block 5. Indicate the targeted vacant dentist/dental provider
positions

Actual Rate

Block 6. Indicate the number of filled dentist/dental provider
positions
Block 7. Indicate the number of dentist/dental provider
positions retained

Block 3. Indicate the projected vacancy rate by funding year
Add Year (Baseline)
Add Year (Year 1 of Funding)
Add Year (Year 2 of Funding)
Add Year (Year 3 of Funding)

Projected Rate

Save & Continue

OMB Number 0915-0061
Expiration date XX/XX/201X

INSTRUCTIONS
Purpose. The RET form captures information about retentionrelated activities from grantees of select BHPr-funded
multipurpose grant programs. Please complete the RET form
using the instructions below.
Nurse Education, Practice, Quality and Retention Program
Only)
Block 1. Indicate the projected retention rate by funding year.
Baseline should be the academic year before you received the
BHPr grant. Rates for projected retention should be calculated
and reported at the beginning of each academic year.
To enter projected retention rate at baseline, click on "Add
Year (Baseline)" and select from the options below:
Selections:
Academic Year 2009-2010
Academic Year 2010-2011
Academic Year 2011-2012
Academic Year 2012-2013
Academic Year 2013-2014
Academic Year 2014-2015
Academic Year 2015-2016
To enter projected retention rates for subsequent academic
years, click on "Add Year" and select from the following
options:
Selections:
Academic Year 2009-2010
Academic Year 2010-2011
Academic Year 2011-2012
Academic Year 2012-2013
Academic Year 2013-2014
Academic Year 2014-2015
Academic Year 2015-2016
Block 2. Indicate the actual retention rate by funding year.
Baseline should be the academic year before you received the
BHPr grant. Rates for actual retention should be calculated
and reported at the end of each academic year.
To enter actual retention rate at baseline, click on "Add Year
(Baseline)" and select from the options below:

To add actual retention rate for subsequent years, click on
"Add Year" and select from the options below:
Selections:
Academic Year 2009-2010
Academic Year 2010-2011
Academic Year 2011-2012
Academic Year 2012-2013
Academic Year 2013-2014
Academic Year 2014-2015
Academic Year 2015-2016
Block 3. Indicate the projected vacancy rate by funding year.
Baseline should be the academic year before you received the
BHPr grant. Rates for projected retention should be calculated
and reported at the beginning of each academic year.
To add projected vacancy rate for baseline, click on "Add
Year" and select from the options below:
Selections:
Academic Year 2009-2010
Academic Year 2010-2011
Academic Year 2011-2012
Academic Year 2012-2013
Academic Year 2013-2014
Academic Year 2014-2015
Academic Year 2015-2016
Block 4. Indicate the actual vacancy rate by funding year.
Baseline should be the academic year before you received the
BHPr grant. Rates for actual retention should be calculated
and reported at the end of each academic year.
To add actual vacancy rate for subsequent years, click on
"Add Year" and select from the options below:
Selections:
Academic Year 2009-2010
Academic Year 2010-2011
Academic Year 2011-2012
Academic Year 2012-2013
Academic Year 2013-2014
Academic Year 2014-2015
Academic Year 2015-2016

Selections:
Academic Year 2009-2010
Academic Year 2010-2011
Academic Year 2011-2012
Academic Year 2012-2013
Academic Year 2013-2014
Academic Year 2014-2015
Academic Year 2015-2016

State Oral Health Workforce Program Only
Block 5. Indicate the number of targeted vacant dentist and/or
dental provider positions located within a Dental HPSA or a
government recognized, dental underserved population or
community.

OMB Number 0915-0061
Expiration date XX/XX/201X

When finished, click on "Save and Continue" to be routed
to the appropriate form(s).

Block 6. Indicate the targeted number of vacant dentist/dental
provider positions in a dental HPSA or governmentrecognized dental underserved population or community that
were filled during the reporting period.
Block 7. Indicate the number of dentist and/or dental provider
positions located within a dental HPSA or a governmentrecognized dental underserved population or community that
were retained as a result of activities undertaken through the
grant.

Public Burden Statement: 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 project is 0915-0061. Public reporting burden
for this collection of information is estimated to average .25 hours per response, 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 10-29, Rockville, Maryland, 20857.

OMB Number 0915-0061
Expiration date XX/XX/201X

PERFORMANCE REPORT FOR GRANTS AND COOPERATIVE AGREEMENTS
FORM NAME:

PCI

Block 1. Select a patient core indicator and indicate projected
outcomes by funding year

Block 2. Indicate the actual outcome for the patient core
indicator
P atient Core Indicator

Add P atient Core Indicator

(Auto-populated)
Add Year (Baseline)
Add Year (Year 1 of Funding)
Add Year (Year 2 of Funding)
Add Year (Year 3 of Funding)

Add Additional P atient Core Indicators

Projected Rate

Add Year (Year 1 of Funding)

Projected Rate

Add Year (Year 2 of Funding)

Projected Rate

Add Year (Baseline)

Add Year (Year 3 of Funding)

Actual Rate

Save & Continue

OMB Number 0915-0061
Expiration date XX/XX/201X

INSTRUCTIONS
Purpose. The PCI form captures information about patient
core indicators that are targeted by grantees of select BHPrfunded multipurpose grant programs. Please complete the PCI
form using the instructions below.
Nurse Education, Practice, Quality and Retention Program
Only
Block 1. Select a patient core indicator and indicate projected
outcomes by funding year. Baseline should be the academic
year before you received the BHPr grant. Rates for projected
outcomes should be calculated and reported at the beginning
of each academic year.
To select patient core indicator, click on "Add Patient Core
Indicator" and select from the options below:
Selections:
Nurse Satisfaction NDNQI Scale
Blood stream infections (infections/1000 device days)
Ventilator Assisted Pneumonia (Infections/1000
ventilator days)
Urinary Track Infections (UTI: infections/1000 foley
days
% of RNs reporting occasional or frequent patient and
family complaints with care over the past year
% of RNs rating the quality of nursing care delivered to
patients on their units as poor or fair
% of RNs reporting being somewhat or not at all
confident that their patients can manage their care
% of RNs occasionally or frequently reporting wrong
med or wrong dose given to one of their patients
% Children (0-24 mo.) fully immunized
% clients with high satisfaction
%PNC in 1st Trimester
Chlamydia Cases/100,000
Patient Satisfaction (Overall Quality of Care)
Behavioral Health
Safety Climate Survey (Neurosciences)
Falls (Neurosciences)
Patient Satisfaction Nurse-to-Patient Communication
(Neurosciences)
To enter projected outcomes at baseline, click on "Add Year
(Baseline)" and select from the options below:
Selections:
Academic Year 2009-2010
Academic Year 2010-2011
Academic Year 2011-2012
Academic Year 2012-2013
Academic Year 2013-2014

Academic Year 2014-2015
Academic Year 2015-2016
To enter projected outcomes for subsequent academic years,
click on "Add Year" and select from the following options:
Selections:
Academic Year 2009-2010
Academic Year 2010-2011
Academic Year 2011-2012
Academic Year 2012-2013
Academic Year 2013-2014
Academic Year 2014-2015
Academic Year 2015-2016
Block 2. Indicate the actual outcome by funding year.
Baseline should be the academic year before you received the
BHPr grant. Rates for actual outcomes should be calculated
and reported at the end of each academic year.
To enter actual outcomes at baseline, click on "Add Year
(Baseline)" and select from the options below:
Selections:
Academic Year 2009-2010
Academic Year 2010-2011
Academic Year 2011-2012
Academic Year 2012-2013
Academic Year 2013-2014
Academic Year 2014-2015
Academic Year 2015-2016
To enter actual outcomes for subsequent academic years, click
on "Add Year" and select from the following options:
Selections:
Academic Year 2009-2010
Academic Year 2010-2011
Academic Year 2011-2012
Academic Year 2012-2013
Academic Year 2013-2014
Academic Year 2014-2015
Academic Year 2015-2016
Click on "Add Additional Patient Core Indicators" to
select additional patient core indicators targeted during
the reporting period.

When finished, click on "Save and Continue" to be routed
to the appropriate form(s).

OMB Number 0915-0061
Expiration date XX/XX/201X

PERFORMANCE REPORT FOR GRANTS AND COOPERATIVE AGREEMENTS
FORM NAME:

Curriculum Development and Enhancement

Block 1. Select the type of curriculum development or enhancement activity: (select all that apply)

[Drop-down]

Block 2. For each course, select the type of content, class, and number of students trained by profession.

Course Name

Add Year Implemented

Add Delivery Mode

Add P rofession/Discipline
Add P rofession/Discipline

Course Name

Add Year Implemented

Add Delivery Mode

Add P rofession/Discipline
Add P rofession/Discipline

Add Another Curriculum Activity

Number Trained
Number Trained

Save & Continue

OMB Number 0915-0061
Expiration date XX/XX/201X

INSTRUCTIONS
Purpose. The Curriculum Development & Enhancement Form
captures information about courses and curriculum developed
or enhanced through BHPr-funded grant programs. Please
complete this form using the instructions below.

and select from the options below. You may add as many rows
as necessary.
Selections:
Students

SECTION A
Block 1. Select the type of curriculum development or
enhancement activity conducted during the reporting period
from the options below. You may select more than one option
in this block.
Selections:
Developed new course
Developed new curriculum/program
Enhanced existing course
Enhanced existing curriculum/program
(Note: If you developed or enhanced multiple courses that are
not part of the same curriculum, complete this form for each
course individually. For 2 or more courses that were
developed or enhanced and are part of the same curriculum,
click on the appropriate "Curriculum/Program" selections and
complete only 1 form for the entire curriculum. You may add
as many rows as necessary to capture all courses developed or
enhanced)
Block 2. For each course/curriculum developed or enhanced,
indicate its name, year implemented, delivery mode, and
professions and disciplines of students trained. You may add
as many rows as necessary.

Enter the name of the course in the text box provided.
To select the academic year that the course was first
implemented, click on "Add Academic Year" and select from
the options below:
Selections:
Academic Year 2011-2012
Academic Year 2012-2013
Academic Year 2013-2014
Academic Year 2014-2015
To select the delivery mode of the course, click on "Add
Delivery Mode" and select from the options below:
Selections:
Classroom-based
Distance learning (Online, Webinar)
Hybrid (mostly classroom)
Hybrid (mostly distance learning)
To indicate the professions and disciplines of individuals
trained in each course, click on "Add Profession & Discipline"

Dentistry
General Dentistry
Pediatric Dentistry
Orthodontic Dentistry
Oral Surgery Dentistry
Radiology Dentistry
Periodontic Dentistry
Prosthodontic Dentistry
Pathology Dentistry
Dental Assistant
Dental Hygiene
Public Health Dentistry
Endodontic Dentistry
Medicine
Aerospace Medicine
Allopathic Medicine, Alternative/Complementary
Medicine
Behavioral/Mental Health In School Of Medicine And
Osteopathic Medicine
Chiropractic
Family Medicine
General Internal Medicine

General Pediatrics
General Preventive Medicine
General Preventive Medicine/ Family Medicine
General Preventive Medicine/ Internal Medicine
General Preventive Medicine/ Public Health
Geriatric Medicine
Geriatric Psychiatry
Integrative Medicine
Internal Medicine /General Pediatrics
Internal Medicine/Family Medicine
Neurology
Obstetrics/Gynecology
Occupational Medicine
Osteopathic General Practice
Pediatrics/Family Medicine
Pharmacy
Podiatry
Psychiatry
Radiology
Veterinary Medicine
Nursing
Alternative/Complementary Nursing
CNS-Adult gerontology
CNS-Family
CNS-Geropsychiatric
CNS-Neonatal
CNS-Pediatrics
CNS-Psychiatric/Mental health
CNS-Women’s health
Clinical Nurse Specialist (CNS)
Home Health Aide
Licensed Practical/Vocational Nurse (LPN/LVN)
NP - Other advanced nurse specialists
NP - Psychiatric/Mental health
NP –Adult gerontology
NP –Family
NP –Neonatal
NP –Pediatrics
NP –Women’s health
NP- Acute care adult gerontology

OMB Number 0915-0061
Expiration date XX/XX/201X

NP- Acute care pediatric
NP- Emergency care
NP- Geropsychiatric
Nurse Administrator
Nurse Anesthetist
Nurse Assistant/Patient Care Associate (PCA)
Nurse Educator
Nurse Generalist
Nurse Midwife
Nurse Practitioner (NP)
Nurse Researchers/Scientists
Nursing Informatics
Public Health Nurse
Registered Nurse
Behavioral Health

Public Burden Statement: 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 project is 0915-0061. Public reporting burden
for this collection of information is estimated to average .25 hours per response, 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 10-29, Rockville, Maryland, 20857.

OMB Number 0915-0061
Expiration date XX/XX/201X

PERFORMANCE REPORT FOR GRANTS AND COOPERATIVE AGREEMENTS
FORM NAME:

Faculty Development, Instruction and Recruitment

SECTION A. Type of Faculty Development, Instruction, and Recruitment Activities
Block 1. Select the type of faculty development activities:

[Drop-down]

SECTION B. Structured Faculty Development Training Programs
Block 2. Select whether the training program will culminate in faculty earning a new degree
Block 2a. If degree-bearing program, select type of degree
Block 2b. If degree-bearing program, select primary focus area

Yes

[Drop-down]
[Drop-down]

Block 3. If non-degree bearing program, indicate length of program in clock hours
Block 4. Indicate the total number of faculty trained by profession and disciplines
Add P rofession & Discipline
Add P rofession & Discipline

Number Trained
Number Trained

Block 5. Indicate the percent of time in the training program dedicated to develop competencies for each of the following roles:
Clinician
Administrator
Educator
Researcher
Block 6. Indicate the number of faculty who completed the training program
Block 7. Select whether any faculty received a BHPr-funded stipend during the training program

Yes

SECTION C. Faculty Development Activities
Block 8. Select the type of faculty development activity

[Drop-down]

Block 8a. If training course or workshop, select whether it is accredited for continuing education purposes:
Yes
Block 8b. If training course or workshop, select whether attendance was to acquire or maintain professional certification Yes

No
No

Block 9. Indicate the duration of the faculty development activity in clock hours:
Block 10. Select the delivery mode(s) used to deliver this training:

[Drop-down]

Block 11. Indicate the faculty roles addressed at this training (select all that apply):

Administrator
Researcher

Clinician
Educator

Block 12. Indicate the total number of faculty trained by profession and disciplines
Add P rofession & Discipline
Add P rofession & Discipline

Number Trained
Number Trained

OMB Number 0915-0061
Expiration date XX/XX/201X

SECTION D. Faculty-Student Collaboration Projects
Block 13. Select the type of faculty-student collaboration project

Research-based project

Block 13a. If research-based, select the content area of the project

[Drop-down]

Block 13b. If non-research based, select purpose of project

[Drop-down]

Non-research based project

Block 14. Indicate the number of faculty members involved in the project
Block 14a. Indicate the total number of underrepresented minority faculty members involved in the project
Block 15. Indicate the number of students involved in the project
Block 15a. Indicate the total number of underrepresented minority students involved in the project
SECTION E. Faculty Instruction
Block 16. Indicate the name of the course/workshop offered
Block 17. Select the content area of the course/workshop offered

[Drop-down]

Block 18. Indicate the length of the course/workshop in clock hours
Block 19. Indicate the number of times the course/workshop was offered
Block 20. Indicate the total number of individuals trained by profession and discipline
Add P rofession & Discipline
Add P rofession & Discipline

Number Trained
Number Trained

Block 21. Indicate the education level(s) of individuals trained

[Drop-down]

Block 22. Select the delivery mode(s) used to train individuals

[Drop-down]

SECTION F. Faculty Recruitment
Block 23. Indicate if your institution established a faculty recruitment program:

Yes

Block 23a. If yes, indicate the total number of dental faculty recruited through the program:
Block 23b. If yes, indicate the number of underrepresented minority dental faculty recruited:
Block 23c. If yes, indicate the number of dental faculty positions retained:

Add Another Faculty Development Activity

Save & Continue

OMB Number 0915-0061
Expiration date XX/XX/201X

INSTRUCTIONS
Purpose. The Faculty Development form captures information
about faculty-related activities conducted through BHPrfunded grant programs. The faculty form is divided into five
sections: Section A captures general information about the
type of faculty activities conducted; Section B captures
information about structured faculty development training
programs; Section C captures information about various types
of faculty development activities; Section D captures
information about faculty-student collaboration and research
projects; Section E captures information about courses and
workshops taught by faculty; and Section F captures
information about faculty recruitment activities. Please
complete the applicable sections and blocks using the
instructions below.
(Note: Each type of faculty development, instruction and
recruitment activity must be reported separately)
SECTION A
Block 1. Select the type of faculty development, instruction or
recruitment activity conducted during the reporting period
from the options below:
Selections:
Structured Faculty Development Training Program
Faculty Development Activity
Faculty-Student Research or Collaboration Project
Faculty Instruction
Faculty Recruitment Activities
SECTION B
Structured Faculty Development Training Programs Only
Block 2. Select whether faculty will earn a n ew degree by
completing the program.
Block 2a. If yes, select the type of degree faculty will
earn from the options below:
Selections:
Certificate
Diploma
AA
AS
BA
BS
BSN
BSW
BPH
Bachelor's Not Otherwise Specified
DC
DDS
DDS/MPH

DDS/MSPH
DMD
DNP
DNSc
DO
DO/MPH
DO/MSPH
DO/DrPH
DO/ScD
DrPH
DVM
MA
MEd
MHA
MD
MD/MPH
MD/MSPH
MD/DrPH
MD/ScD
MD/PhD
MS
MMS
MMS/MPH
MMS/MSPH
MMS/DrPH
MMS/ScD
MPAS
MPAS/MPH
MPAS/MSPH
MPAS/DrPH
MPAS/ScD
MPH
MSPH
MSCR
MS-CTS
MSN
MSW
MSSW
Master's Degree Not Otherwise Specified
Post-Masters Certificate
PhD
PharmD
PsyD
ScD
VMD
Dental, Nursing, Public Health, and Behavioral Health
Programs Only
Block 2b. For degree-bearing programs supported with a
BHPr-funded grant during the reporting period, select the
focus area from the options below:
Selections:
Dentistry-General
Dentistry-Pediatric Dentistry

Dentistry-Orthodontic Dentistry
Dentistry-Oral Surgery Dentistry
Dentistry-Radiology Dentistry
Dentistry-Periodontic Dentistry
Dentistry-Prosthodontic Dentistry
Dentistry-Pathology Dentistry
Dentistry-Dental Assistant
Dentistry-Dental Hygiene
Dentistry-Public Health Dentistry
Dentistry-Endodontic Dentistry
Nursing-General Practice
Nursing-Administration
Nursing-Anesthesia
Nursing-Education
Nursing-Informatics
Nursing-Midwifery
Nursing-Advanced Practice
Nursing-Public Health
Nursing-Acute care adult-gerontology nurse practitioner
Nursing-Acute-care pediatric nurse practitioner
Nursing-Adult Gerontology
Nursing-Adult-Gerontology Primary Care
Nursing-Family Nurse Practitioner
Nursing-Family/Individual Across Lifespan
Nursing-Geropsychiatric
Nursing-Neonatal
Nursing-Neonatal Nurse Practitioner
Nursing-Pediatric Primary Care
Nursing-Pediatrics
Nursing-Psychiatric nurse specialists
Nursing-Psychiatric/Mental Health
Nursing-Women’s Health/Gender Related And Psychiatric
Mental Health
Nursing-Women’s Health/Gender-Related
Nursing-Research
Psychology-Clinical
Psychology-Counseling
Psychology-School
Public Health-Epidemiology
Public Health-Biostatistics
Public Health-Health Policy and Management
Public Health-Environmental Health
Public Health-Social and Behavioral Health Sciences
Social Work-General
Social Work-Clinical
Block 3. If the training program will not result in a new degree
for faculty, indicate the length of the training program in clock
hours.
Block 4. Indicate the professions and disciplines of faculty
members trained. Click on "Add Profession" and select from
the options below. You may add as many rows as necessary.

OMB Number 0915-0061
Expiration date XX/XX/201X

Selections:
Students
K-8 (primary)
9-12 (secondary)
Post-high school/Pre-college
Dental Student
Dental Hygiene Student
Dental Assistant Student
Medical Student
Physician Assistant Student
Medical Residents
Medical Fellows
Pre-licensure Nursing Students
Graduate-level Nursing Student
Undergraduate-level Public Health Student
Graduate-level Public Health Student
Graduate-level Psychology Student
Graduate-level Psychology Intern
Graduate-level Psychology Fellow
Faculty
Administrator
Other Undergraduate-level Student
Other Graduate-level Student
Other Fellow
Other Resident
Providers
Dentistry
General Dentistry
Pediatric Dentistry
Orthodontic Dentistry
Oral Surgery Dentistry
Radiology Dentistry
Periodontic Dentistry
Prosthodontic Dentistry
Pathology Dentistry
Dental Assistant
Dental Hygiene
Public Health Dentistry
Endodontic Dentistry
Medicine
Aerospace Medicine
Allopathic Medicine, Alternative/Complementary
Medicine
Behavioral/Mental Health In School Of Medicine And
Osteopathic Medicine
Chiropractic
Family Medicine
General Internal Medicine
General Pediatrics
General Preventive Medicine
General Preventive Medicine/ Family Medicine

General Preventive Medicine/ Internal Medicine
General Preventive Medicine/ Public Health
Geriatric Medicine
Geriatric Psychiatry
Integrative Medicine
Internal Medicine /General Pediatrics
Internal Medicine/Family Medicine
Neurology
Obstetrics/Gynecology
Occupational Medicine
Osteopathic General Practice
Pediatrics/Family Medicine
Pharmacy
Podiatry
Psychiatry
Radiology
Veterinary Medicine
Nursing
Alternative/Complementary Nursing
CNS-Adult gerontology
CNS-Family
CNS-Geropsychiatric
CNS-Neonatal
CNS-Pediatrics
CNS-Psychiatric/Mental health
CNS-Women’s health
Clinical Nurse Specialist (CNS)
Home Health Aide
Licensed Practical/Vocational Nurse (LPN/LVN)
NP - Other advanced nurse specialists
NP - Psychiatric/Mental health
NP –Adult gerontology
NP –Family
NP –Neonatal
NP –Pediatrics
NP –Women’s health
NP- Acute care adult gerontology
NP- Acute care pediatric
NP- Emergency care
NP- Geropsychiatric
Nurse Administrator
Nurse Anesthetist
Nurse Assistant/Patient Care Associate (PCA)
Nurse Educator
Nurse Generalist
Nurse Midwife
Nurse Practitioner (NP)
Nurse Researchers/Scientists
Nursing Informatics
Public Health Nurse
Registered Nurse
Behavioral Health

OMB Number 0915-0061
Expiration date XX/XX/201X

Clinical Social Work
Marriage and Family Therapy
Pastoral/Spiritual Care
Other Psychology
Other Social Work, Substance Abuse/Addictions
Counseling
Public Health
Biostatistics
Environmental Health
Epidemiology
Health Policy & Management
Social & Behavioral Sciences
Other

Block 5. Indicate the percent of time in the training program
dedicated to develop competencies in each of the roles listed.
Block 6. Indicate the number of faculty who completed the
training program during the reporting period.
Block 7. Select whether any faculty received a B HPr-funded
stipend during the training program .
(Note: Grantees will be required to complete the IND-GEN form for
faculty members who received a stipend during the reporting period)

SECTION C
Faculty Development Activities Only
Block 8. Select the type of faculty development activity
supported through the grant during the reporting period from
the options below:
Selections:
Professional Conference
Academic Course for Continuing Education
Training/Workshop for Continuing Education
(Note: Each activity must be reported separately)
Block 8a. If training/workshop, select whether
accredited for continuing education purposes.
Block 8b. Select whether faculty attended the
training/workshop for the purposes of acquiring or
maintain a professional certification.
Block 9. Indicate the length of the training activity in clock
hours.

Counseling Psychology
Clinical Psychology

Block 10. Select the delivery mode used to provide the faculty
training activity from the options below:
Selections:
Classroom-based
Distance learning (Online, Webinar)
Hybrid (mostly classroom)
Hybrid (mostly distance learning)
Block 11. Select the type(s) of faculty roles addressed in the
training. You may select more than one option in this block.
Block 12. Indicate the professions and disciplines of faculty
members trained. Click on "Add Profession" and select from
the options below. You may add as many rows as necessary.
Selections:
Students
K-8 (primary)
9-12 (secondary)
Post-high school/Pre-college
Dental Student
Dental Hygiene Student
Dental Assistant Student
Medical Student
Physician Assistant Student
Medical Residents
Medical Fellows
Pre-licensure Nursing Students
Graduate-level Nursing Student
Undergraduate-level Public Health Student
Graduate-level Public Health Student
Graduate-level Psychology Student
Graduate-level Psychology Intern
Graduate-level Psychology Fellow
Faculty
Administrator
Other Undergraduate-level Student
Other Graduate-level Student
Other Fellow
Other Resident
Providers
Dentistry
General Dentistry
Pediatric Dentistry
Orthodontic Dentistry
Oral Surgery Dentistry
Radiology Dentistry
Periodontic Dentistry
Prosthodontic Dentistry
Pathology Dentistry
Dental Assistant

Dental Hygiene
Public Health Dentistry
Endodontic Dentistry

OMB Number 0915-0061
Expiration date XX/XX/201X

Medicine
Aerospace Medicine
Allopathic Medicine, Alternative/Complementary
Medicine
Behavioral/Mental Health In School Of Medicine And
Osteopathic Medicine
Chiropractic
Family Medicine
General Internal Medicine
General Pediatrics
General Preventive Medicine
General Preventive Medicine/ Family Medicine
General Preventive Medicine/ Internal Medicine
General Preventive Medicine/ Public Health
Geriatric Medicine
Geriatric Psychiatry
Integrative Medicine
Internal Medicine /General Pediatrics
Internal Medicine/Family Medicine
Neurology
Obstetrics/Gynecology
Occupational Medicine
Osteopathic General Practice
Pediatrics/Family Medicine
Pharmacy
Podiatry
Psychiatry
Radiology
Veterinary Medicine
Nursing
Alternative/Complementary Nursing
CNS-Adult gerontology
CNS-Family
CNS-Geropsychiatric
CNS-Neonatal
CNS-Pediatrics
CNS-Psychiatric/Mental health
CNS-Women’s health
Clinical Nurse Specialist (CNS)
Home Health Aide
Licensed Practical/Vocational Nurse (LPN/LVN)
NP - Other advanced nurse specialists
NP - Psychiatric/Mental health
NP –Adult gerontology
NP –Family
NP –Neonatal
NP –Pediatrics
NP –Women’s health
NP- Acute care adult gerontology
NP- Acute care pediatric
NP- Emergency care

NP- Geropsychiatric
Nurse Administrator
Nurse Anesthetist
Nurse Assistant/Patient Care Associate (PCA)
Nurse Educator
Nurse Generalist
Nurse Midwife
Nurse Practitioner (NP)
Nurse Researchers/Scientists
Nursing Informatics
Public Health Nurse
Registered Nurse
Behavioral Health
Counseling Psychology
Clinical Psychology
Clinical Social Work
Marriage and Family Therapy
Pastoral/Spiritual Care
Other Psychology
Other Social Work, Substance Abuse/Addictions
Counseling
Public Health
Biostatistics
Environmental Health
Epidemiology
Health Policy & Management
Social & Behavioral Sciences
Other
SECTION D
Faculty-Student Collaboration Projects Only
Block 13. Select the type of faculty-student collaboration
project conducted during the reporting period.
Block 13a. For research-based projects, select the
primary content area of the project from the options
below:
Selections:
Aerospace medicine
Clinical preventive services
Communicable diseases
Community health planning/assessments
Cultural Competencies
Health Promotion and disease prevention
Environmental health
Epidemiology
Evidence-based medicine
Food safety and inspection

OMB Number 0915-0061
Expiration date XX/XX/201X

Health administration and management
Health communications (media)
Health disparities reduction
Informatics
Injury prevention
Interprofessional integrated models of care
Leadership advocacy
Occupational medicine
Policy development/analysis
Program planning and evaluation
Public health systems and services research
Quality improvement/assurance
Risk assessment and communication
Surveillance
Other

Block 13b. For non-research based projects, select
the type of project from the options below:
Selections:
Materials supporting health department accreditation
Grant application for community organization
Environmental health assessments
Community health assessments
Development of evidence-based programs for
community partner
Other
Block 14. Indicate the total number of faculty members who
participated in the project.
Block 14a. Of the number reported in Block 12,
indicate the number of underrepresented minority
faculty who participated in the project.
Block 15. Indicate the total number of students who
participated in the project.
Block 15a. Of the number reported in Block 13,
indicate the number of underrepresented minority
students who participated in the project.

SECTION E
Faculty Instruction Activities
Block 16. Indicate the title of the course taught by the faculty
during the reporting period.
(Note: Report each course separately)

Block 17. Select the content area of the course taught by the
faculty from the options below:
Selections:
Aerospace medicine
Clinical preventive services
Communicable diseases
Community health planning/assessments
Cultural Competencies
Health Promotion and disease prevention
Environmental health
Epidemiology
Evidence-based medicine
Food safety and inspection
Health administration and management
Health communications (media)
Health disparities reduction
Informatics
Injury prevention
Interprofessional integrated models of care
Leadership advocacy
Occupational medicine
Policy development/analysis
Program planning and evaluation
Public health systems and services research
Quality improvement/assurance
Risk assessment and communication
Surveillance
Other
Block 18. Indicate the length of the course in clock hours.
Block 19. Indicate the number of times the course was offered
during the reporting period.
Block 20. Indicate the total number of individuals trained by
profession and discipline. Click on "Add Profession" and
select from the options below:
Selections:
Students
K-8 (primary)
9-12 (secondary)
Post-high school/Pre-college
Dental Student
Dental Hygiene Student
Dental Assistant Student
Medical Student
Physician Assistant Student
Medical Residents
Medical Fellows
Pre-licensure Nursing Students
Graduate-level Nursing Student
Undergraduate-level Public Health Student
Graduate-level Public Health Student

OMB Number 0915-0061
Expiration date XX/XX/201X

Graduate-level Psychology Student
Graduate-level Psychology Intern
Graduate-level Psychology Fellow
Faculty
Administrator
Other Undergraduate-level Student
Other Graduate-level Student
Other Fellow
Other Resident
Providers
Dentistry
General Dentistry
Pediatric Dentistry
Orthodontic Dentistry
Oral Surgery Dentistry
Radiology Dentistry
Periodontic Dentistry
Prosthodontic Dentistry
Pathology Dentistry
Dental Assistant
Dental Hygiene
Public Health Dentistry
Endodontic Dentistry
Medicine

Nursing
Alternative/Complementary Nursing
CNS-Adult gerontology
CNS-Family
CNS-Geropsychiatric
CNS-Neonatal
CNS-Pediatrics
CNS-Psychiatric/Mental health
CNS-Women’s health
Clinical Nurse Specialist (CNS)
Home Health Aide
Licensed Practical/Vocational Nurse (LPN/LVN)
NP - Other advanced nurse specialists
NP - Psychiatric/Mental health
NP –Adult gerontology
NP –Family
NP –Neonatal
NP –Pediatrics
NP –Women’s health
NP- Acute care adult gerontology
NP- Acute care pediatric
NP- Emergency care
NP- Geropsychiatric
Nurse Administrator
Nurse Anesthetist
Nurse Assistant/Patient Care Associate (PCA)
Nurse Educator
Nurse Generalist
Nurse Midwife
Nurse Practitioner (NP)
Nurse Researchers/Scientists
Nursing Informatics
Public Health Nurse
Registered Nurse
Behavioral Health
Counseling Psychology
Clinical Psychology
Clinical Social Work
Marriage and Family Therapy
Pastoral/Spiritual Care
Other Psychology
Other Social Work, Substance Abuse/Addictions
Counseling
Public Health
Biostatistics
Environmental Health
Epidemiology
Health Policy & Management
Social & Behavioral Sciences
Other

OMB Number 0915-0061
Expiration date XX/XX/201X

Indicate the total number of individuals trained in each
profession and discipline. You may add as many rows as
necessary.
Block 21. Select the education level(s) of individuals trained
by the faculty from the options below:
Selections:
Primary level (K-8)
Secondary (9-12)
Post-Secondary/Pre-College
Nursing Diploma/Certificate
Undergraduate—Two Year College
Undergraduate—Baccalaureate Degree
Graduate—Master’s Degree
Graduate—Medical Degree
Graduate—Doctoral
Faculty
Administrator
Block 22. Select the delivery mode used to provide the
training from the options below:
Selections:
Classroom-based
Distance learning (Online, Webinar)
Hybrid (mostly classroom)
Hybrid (mostly distance learning)

SECTION F
State Oral Health Programs Only
Block 23. Select whether a faculty recruitment program was
established during the reporting period.
Block 23a. If yes, indicate the total number of faculty
recruited.
Block 23b. Of the number reported in Block 23a,
indicate the number of underrepresented minority
faculty recruited.
Block 23c. Of the number reported in Block 23a,
indicate the number of faculty retained during the
reporting period.
Click on "Add Another Faculty Development Activity" to
enter additional faculty development, instruction and
recruitment activities conducted during the reporting
period.
When finished, click on "Save and Continue" to be routed
to the appropriate form(s).

OMB Number 0915-0061
Expiration date XX/XX/201X

Public Burden Statement: 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 project is 0915-0061. Public reporting burden
for this collection of information is estimated to average .25 hours per response, 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 10-29, Rockville, Maryland, 20857.

PERFORMANCE REPORT FOR GRANTS AND COOPERATIVE AGREEMENTS
FORM NAME:

CE-1

SECTION A. Course Characteristics
Block 1. Indicate the title of the course offered:
Block 2. Select whether the course is approved for continuing education purposes:

Yes

Block 3. Indicate the duration of the course offering in clock hours
Block 4. Indicate the number of times this course was offered
Block 5. Select the delivery mode used to deliver this course

[Drop-down]

Block 6. Select, if any, the partnership(s) established for the purposes of delivering this course

[Drop-down]

SECTION B. Trainee Characteristics
Block 7. Indicate the total number of individuals who participated in the course
Block 8. Indicate the total number of individuals trained by profession and discipline
Add P rofession/Discipline
Add P rofession/Discipline

Number Trained
Number Trained

Block 9. Select whether employment location data are available for individuals trained:

Yes

Block 9a. If yes, indicate the total number of individuals trained who are employed in a primary care setting
Block 9b. If yes, indicate the total number of individuals trained who are employed in a medically underserved community
Block 9c. If yes, indicate the total number of individuals trained who are employed in a rural area
Block 10. Indicate the number of individuals who applied this course to initial certification or continuing education requirements
SECTION C. Course Content
Block 11. Select the primary topic covered by this course
Block 11a. Select, if any, the secondary topic covered by this course
Block 12. Select the primary competency addressed through this course
Block 12a. Select, if any, the secondary competency addressed through this course
Block 13. Select the competency tier addressed through this course.

[Drop-down]
[Drop-down]
[Drop-down]
[Drop-down]
Tier 1

Tier 2

Block 14. Select whether supplemental funding for Alzheimer's Disease-related training was used to offer this course:

Add Additional Courses

Tier 3
Yes

Save & Continue

OMB Number 0915-0061
Expiration date XX/XX/201X

INSTRUCTIONS
Purpose. The Continuing Education Form captures
information about continuing education offerings provided
through BHPr-funded grant programs. The Continuing
Education Form is divided into three sections: Section A
captures general information about each continuing education
course offered during the reporting period; Section B captures
information about the trainees participating in each continuing
education offering; and Section C captures information about
the content and competencies addressed through each course.
Please complete applicable sections and blocks of this form
using the instructions below.
(Note: Each course must be reported separately)
SECTION A
Block 1. Indicate the title of the course offered.
Block 2. Select whether the course is accredited for continuing
education purposes. Courses accredited are those that provide
participants with certificates of completion that can be applied
to continuing education requirements for the health
professions.
Block 3. Indicate the duration of the course offering in clock
hours. For courses less than one (1) hour, provide a decimal
value by dividing the total number of minutes the course
lasted by 60. Example: a 15-minute course would entered as
15/60 = .25.
Block 4. Indicate the total number of times the course was
offered during the reporting period.
Block 5. Select the delivery mode used to deliver the course
from the list provided.
Selections:
Classroom-based
Distance learning (Online, Webinar)
Hybrid (mostly classroom)
Hybrid (mostly distance learning)
Block 6. Select, if any, the partnership(s) established for the
purposes of delivering this course from the list provided. You
may select more than one option in this block.
Selections:
Academic department- within the institution
Academic department –outside the institution
Community Mental Health Center
Federal Government -Veterans Affairs
Federal Government- Department of Defense/Military
Federal Government-CDC
Federal Government-SAMHSA
Federal Government-IHS

Federal Government-NIH
Federal Government-AHRQ
Federal Government-FDA
Federal Government-Other HHS Agency/Office
Federal Government- Other HRSA Program
Federally-qualified health center or look-alikes
Federal Government –Other
Community-based health center (e.g., free clinic)
Health department- Local
Health department- State
Health department- Tribal
Health disparities research center
Health policy center
Hospital
Nonprofit organization (non-faith based)
State Governmental Programs
Professional Associations
Nonprofit organization (faith-based)
Private/For-profit organization
Local Government
Other
No partners/consortia used

SECTION B
Block 7. Indicate the total number of participants. Example: If
the course was offered two (2) times with 15 participants each
time, the number reported in Block 7 would be 30.
Block 8. Indicate the total number of individuals trained by
profession and discipline. Click on "Add Profession" and
select from the options below:
Selections:

Students

OMB Number 0915-0061
Expiration date XX/XX/201X

Other Fellow
Other Resident
Providers
Dentistry
General Dentistry
Pediatric Dentistry
Orthodontic Dentistry
Oral Surgery Dentistry
Radiology Dentistry
Periodontic Dentistry
Prosthodontic Dentistry
Pathology Dentistry
Dental Assistant
Dental Hygiene
Public Health Dentistry
Endodontic Dentistry
Medicine
Aerospace Medicine
Allopathic Medicine, Alternative/Complementary
Medicine
Behavioral/Mental Health In School Of Medicine And
Osteopathic Medicine
Chiropractic
Family Medicine
General Internal Medicine
General Pediatrics
General Preventive Medicine
General Preventive Medicine/ Family Medicine
General Preventive Medicine/ Internal Medicine
General Preventive Medicine/ Public Health
Geriatric Medicine
Geriatric Psychiatry
Integrative Medicine
Internal Medicine /General Pediatrics
Internal Medicine/Family Medicine
Neurology
Obstetrics/Gynecology
Occupational Medicine
Osteopathic General Practice
Pediatrics/Family Medicine
Pharmacy
Podiatry
Psychiatry
Radiology
Veterinary Medicine
Nursing
Alternative/Complementary Nursing
CNS-Adult gerontology
CNS-Family
CNS-Geropsychiatric
CNS-Neonatal

CNS-Pediatrics
CNS-Psychiatric/Mental health
CNS-Women’s health
Clinical Nurse Specialist (CNS)
Home Health Aide
Licensed Practical/Vocational Nurse (LPN/LVN)
NP - Other advanced nurse specialists
NP - Psychiatric/Mental health
NP –Adult gerontology
NP –Family
NP –Neonatal
NP –Pediatrics
NP –Women’s health
NP- Acute care adult gerontology
NP- Acute care pediatric
NP- Emergency care
NP- Geropsychiatric
Nurse Administrator
Nurse Anesthetist
Nurse Assistant/Patient Care Associate (PCA)
Nurse Educator
Nurse Generalist
Nurse Midwife
Nurse Practitioner (NP)
Nurse Researchers/Scientists
Nursing Informatics
Public Health Nurse
Registered Nurse
Behavioral Health
Counseling Psychology
Clinical Psychology
Clinical Social Work
Marriage and Family Therapy
Pastoral/Spiritual Care
Other Psychology
Other Social Work, Substance Abuse/Addictions
Counseling
Public Health
Biostatistics
Environmental Health
Epidemiology
Health Policy & Management
Social & Behavioral Sciences
Other

Block 9. Select whether employment data are available for
individuals who participated in this course.
Block 9a. If yes, indicate the total number of
participants who currently work in a p rimary care
setting.
Block 9b. If yes, indicate the total number of

participants who currently work in a medically
underserved community.
Block 9c. If yes, indicate the total number of
participants who currently work in a r ural area. A
rural area is located in a county that is not part of a
Metropolitan
Statistical
Area.
Refer
to
http://datawarehouse.hrsa.gov/RuralAdvisor/RuralHe
althAdvisor.aspx to determine if a co unty is
considered rural.
(Note: Blocks 9a through 9c are not meant to be
mutually exclusive. Totals may exceed those reported
in block 7).
Block 10. Indicate the number of individuals who applied this
course to initial certification or continuing education
requirements for their profession.
SECTION C
Block 11. Select the primary topic covered by the course from
the options below:
Selections:
Acute care
Adolescent Health
Advanced 3D graphics
Advocacy/health policy
African-Americans
Alcohol and substance misuse/prevention
Alternative/complementary medicine
Alzheimer's disease
Alzheimer's disease/dementia
Ambulatory care
American Indian/Alaska Natives
Asthma
Basic restorative skills
Behavioral assessment and consultation in primary
care
Behavioral health
Behavioral interventions for primary care
Bioterrorism/preparedness
Border Health
Border health activities
Cancer
Chronic Disease
Chronic disease management
Clinical Practice Information
Clinical preventive services
Communication Skills
Communications
Community collaboration
Community health nursing
Community needs assessment
Community-Based Care
Community-based continuity of care

OMB Number 0915-0061
Expiration date XX/XX/201X

Computer-based instructions
Consumers' rights
Crisis intervention
Cultural competence in nursing
Cultural competencies
Data collection and analysis
Delirium
Dementia
Depression
Diabetes
Domestic Violence
Domestic Violence/Interpersonal violence
Drug-resistant diseases
Elder abuse
E-Learning technology
Emergency preparedness
Emergency training
Environmental health
Epidemiology
Ethics and confidentiality
Ethics/bioethics
Evidence Based Medicine
Evidence Based Medicine/Practice
Evidence-Based Practices
Experiences
Extended care
Financial planning and management (including
budgeting)
Focus groups
Food borne Disease
Genetics
Genomics
Geriatric education for direct care providers
Geriatric medicine
Geriatrics
Gerontological nursing
Grant writing
Health care and older adults
Health Disparities
Health information technology
Health literacy
Health promotion
Health promotion and disease prevention
Healthy aging
Heart disease
Hepatitis
Hispanics
HIV/AIDS
HIV/AIDS and other infectious diseases
Home health
Home health care
Homeless
Homelessness
Hypertension
Improving communication skills
Infant Health
Infection control
Influenza

Informatics
Information Technology
Injury prevention
Interactive simulated case studies
Interdisciplinary training
Interpersonal skills
Interprofessional Education
Interprofessional integrated models of care
Interprofessional team training
Leadership Training
Leadership/Management
Lesbian, gay, bisexual, transgender individuals
Long-Term Care
Long-term care nursing
Managed Care
Mannequin-based and patient simulators
Maternal and child health
Medical economics
Medication basics
Medications/drugs
Meeting facilitation
Mental health
Mental health and older adults
Migrant health initiatives
Minority Health
Minority health issues
Native Hawaiian/Pacific Islander
Needs-specific training
Negotiations
Nursing care for vulnerable populations
Nursing leadership and management
Nutrition
Nutrition/healthy eating
Obesity
Oral health
Other (Specify)
Other simulated or virtual methods
Pain management
Palliative and end of life care
Palliative care
Pastoral/Spiritual Care
Patient safety (medical errors)
Perioperative care
Personal care skills
Pharmacology
Physical activity/active lifestyles
Prevention/Primary care
Primary care
Professional development
Program design
Program evaluation
Program management
Program planning
Project management
Public health infrastructure
Public health law
Public health policy development
Public health science

OMB Number 0915-0061
Expiration date XX/XX/201X

Quality Improvement
Quality improvement and patient safety
Rehabilitation
Rehabilitation Therapies
Research
Rural Health
Secondary care Technology
Sexual health
Sexually transmitted infections
Skills-based training (including coalition building)
Social marketing
Stroke
Substance Abuse
Suicide
Survey design
Sustainability
Teledentistry
Telehealth
Telemedicine/telehealth
Tertiary care
Tobacco cessation
Training
Transitional care
Trauma
Tuberculosis
Urban health
Urgent care
Veteran Related
Veterans Health
Virtual simulation
Women's health
Women's health issues
Worker and patient safety
Workforce development
Wound care
Youth development

Block 11a. Select, if any, the secondary topic
covered by the course from options below:
Selections:
Acute care
Adolescent Health
Advanced 3D graphics
Advocacy/health policy
African-Americans
Alcohol and substance misuse/prevention
Alternative/complementary medicine
Alzheimer's disease
Alzheimer's disease/dementia
Ambulatory care
American Indian/Alaska Natives
Asthma
Basic restorative skills
Behavioral assessment and consultation in primary
care
Behavioral health

Behavioral interventions for primary care
Bioterrorism/preparedness
Border Health
Border health activities
Cancer
Chronic Disease
Chronic disease management
Clinical Practice Information
Clinical preventive services
Communication Skills
Communications
Community collaboration
Community health nursing
Community needs assessment
Community-Based Care
Community-based continuity of care
Computer-based instructions
Consumers' rights
Crisis intervention
Cultural competence in nursing
Cultural competencies
Data collection and analysis
Delirium
Dementia
Depression
Diabetes
Domestic Violence
Domestic Violence/Interpersonal violence
Drug-resistant diseases
Elder abuse
E-Learning technology
Emergency preparedness
Emergency training
Environmental health
Epidemiology
Ethics and confidentiality
Ethics/bioethics
Evidence Based Medicine
Evidence Based Medicine/Practice
Evidence-Based Practices
Experiences
Extended care
Financial planning and management (including
budgeting)
Focus groups
Food borne Disease
Genetics
Genomics
Geriatric education for direct care providers
Geriatric medicine
Geriatrics
Gerontological nursing
Grant writing
Health care and older adults
Health Disparities
Health information technology
Health literacy
Health promotion

OMB Number 0915-0061
Expiration date XX/XX/201X

Health promotion and disease prevention
Healthy aging
Heart disease
Hepatitis
Hispanics
HIV/AIDS
HIV/AIDS and other infectious diseases
Home health
Home health care
Homeless
Homelessness
Hypertension
Improving communication skills
Infant Health
Infection control
Influenza
Informatics
Information Technology
Injury prevention
Interactive simulated case studies
Interdisciplinary training
Interpersonal skills
Interprofessional Education
Interprofessional integrated models of care
Interprofessional team training
Leadership Training
Leadership/Management
Lesbian, gay, bisexual, transgender individuals
Long-Term Care
Long-term care nursing
Managed Care
Mannequin-based and patient simulators
Maternal and child health
Medical economics
Medication basics
Medications/drugs
Meeting facilitation
Mental health
Mental health and older adults
Migrant health initiatives
Minority Health
Minority health issues
Native Hawaiian/Pacific Islander
Needs-specific training
Negotiations
Nursing care for vulnerable populations
Nursing leadership and management
Nutrition
Nutrition/healthy eating
Obesity
Oral health
Other (Specify)
Other simulated or virtual methods
Pain management
Palliative and end of life care
Palliative care
Pastoral/Spiritual Care
Patient safety (medical errors)

Perioperative care
Personal care skills
Pharmacology
Physical activity/active lifestyles
Prevention/Primary care
Primary care
Professional development
Program design
Program evaluation
Program management
Program planning
Project management
Public health infrastructure
Public health law
Public health policy development
Public health science
Quality Improvement
Quality improvement and patient safety
Rehabilitation
Rehabilitation Therapies
Research
Rural Health
Secondary care Technology
Sexual health
Sexually transmitted infections
Skills-based training (including coalition building)
Social marketing
Stroke
Substance Abuse
Suicide
Survey design
Sustainability
Teledentistry
Telehealth
Telemedicine/telehealth
Tertiary care
Tobacco cessation
Training
Transitional care
Trauma
Tuberculosis
Urban health
Urgent care
Veteran Related
Veterans Health
Virtual simulation
Women's health
Women's health issues
Worker and patient safety
Workforce development
Wound care
Youth development

OMB Number 0915-0061
Expiration date XX/XX/201X

Public Health Training Centers Program Only

Block 12. Select the primary competency addressed through
the course from the options below:
Selections:
Analytical/assessment skills
Policy development program planning skills
Communication skills
Cultural competency skills
Community dimensions of practice skills
Public health sciences skills
Financial planning and management skills
Leadership and systems thinking skills
No secondary competency addressed
Block 12a. Select, if any, the secondary competency
addressed through the course from the options below:
Selections:
Analytical/assessment skills
Policy development program planning skills
Communication skills
Cultural competency skills
Community dimensions of practice skills
Public health sciences skills
Financial planning and management skills
Leadership and systems thinking skills
No secondary competency addressed
Block 13. Select the competency tier addressed through the
course. Tier 1 is entry-level; Tier 2 is management; Tier 3 is
senior-level leadership.
Geriatric Education Centers Program Only
Block 14. Select whether supplemental funding for
Alzheimer's Disease-related training was used to offer this
course.

Click on "Add Additional Courses" to enter additional
courses offered during the reporting period.

When finished, click on "Save and Continue" to be routed
to the appropriate form(s).

Public Burden Statement: 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 project is 0915-0061. Public reporting burden
for this collection of information is estimated to average .5 hours per response, 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 10-29, Rockville, Maryland, 20857.

OMB Number 0915-0061
Expiration date XX/XX/201X

PERFORMANCE REPORT FOR GRANTS AND COOPERATIVE AGREEMENTS
FORM NAME:

Needs Assessment

SECTION A. Geographic Coverage Area
Block 1. Indicate the geographically designated coverage area.
Add State

Add Counties (Select All that Apply)

Add State

Add Counties (Select All that Apply)

SECTION B. Public Health Priorities & Related Training Needs
Block 2. Select and describe the trends of the top three (3) public health priorities and related training needs in the geographically
designated coverage area.
a. Public Health Priority Area

b. Data Source

c. Current Rate

a. Public Health Priority Area

b. Data Source

c. Current Rate

a. Public Health Priority Area

b. Data Source

c. Current Rate

Add Trend Direction

Add Competency Training Needs

SECTION C. Methodology for Assessing Training Needs
Block 3. Select the method(s) and types of participants used to assess training needs of the public health workforce in the
geographically designated coverage area.
a.
a.

Add Method

b. Types of participants queried

b. Types of participants queried
Save & Continue

OMB Number 0915-0061
Expiration date XX/XX/201X

INSTRUCTIONS
Purpose. The Needs Assessment Form captures information
about the required assessment of training needs in the
geographically designated coverage area. The Needs
Assessment Form is divided into three sections: Section A
captures information about your geographically designated
coverage area; Section B captures information about the
prevailing public health issues and related training needs in
your geographically designated coverage area; Section C
captures information about the types of methods and
participants used to assess training needs in your
geographically designated coverage area. Please complete this
form using the instructions below.
SECTION A
Block 1. Indicate your geographically designated coverage
area by selecting a State and applicable counties. You may add
as many rows as you need.
Selections:
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS

MT
NC
ND
NE
NH
NM
NJ
NY
NV
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY

(Note: Block 1b will auto-populate with a list of counties for
the State selected in Block 1a.)

Block 2. Select, in rank order, the public health priority areas
and related training needs of public health personnel in your
geographically designated area.
For Block 2a, indicate the public health priority area.
For Block 2b, indicate the data source used to document the
public health priority reported in Block 2a.
For Block 2c, indicate the current rate of the public health
priority area using the most recent data point from the source
selected in Block 2b.
For Block 2d, select the direction of the trend over the past 3
data points from the following:
Selections:
Increasing
Decreasing
No Change
For Block 2e, select the training need(s) specific to the priority
area reported in Block 2a from the following:
Selections:
Analytical/assessment skills
Policy development program planning skills
Communication skills
Cultural competency skills
Community dimensions of practice skills
Public health sciences skills
Financial planning and management skills
Leadership and systems thinking skills
(Note: You may select more than one option in this block.)
SECTION C
Block 3. Select the method(s) and types of participants used to
assess training needs of the public health workforce in the
geographically designated coverage area.
For Block 3a, select from the following:
Selections:
Surveys
Focus Groups
Key Informant Interviews
Delphi Panel
Secondary Data Sources
For Block 3b, enter the types of participants queried.

SECTION B
When finished, click on "Save and Continue" to be routed
to the appropriate form(s).

Public Burden Statement: 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 project is 0915-0061. Public reporting burden
for this collection of information is estimated to average .5 hours per response, 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 10-29, Rockville, Maryland, 20857.

OMB Number 0915-0061
Expiration date XX/XX/201X

PERFORMANCE REPORT FOR GRANTS AND COOPERATIVE AGREEMENTS
FORM NAME:

State Oral Health Workforce

SECTION A. New Facilities
Block 1. Select whether the program established new dental facilities in a HPSA/Underserved area:
Block 1a. If yes, select type of facility

Yes

[Drop-down]

Block 1b. If yes, indicate name of facility
Block 1c. If yes, select types of oral health services

[Drop-down]

Block 1d. If yes, indicate number of patient encounters
Block 1e. If yes, select if this facility is mobile/portable

Yes

Add New Facility

SECTION B. Expanded Facilities
Block 2. Select whether the program expanded existing dental facilities in a HPSA/Underserved area:
Block 2a. If yes, select type of facility

[Drop-down]

Block 2b. If yes, indicate name of facility
Block 2c. If yes, select types of oral health services (select all that apply)

[Drop-down]

Block 2d. If yes, indicate average number of patient encounters prior to expansion
Block 2e. If yes, indicate actual number of patient encounters post expansion
Block 2f. If yes, indicate average number of patient encounters facility can accommodate
Block 2g. If yes, select if this facility is mobile/portable

Yes

Add Expanded Facility

SECTION C. Teledentistry
Block 3. Indicate number of dental facilities with teledentistry capabilities
Block 4. Indicate number of teledentistry encounters involving patient care
Block 5. Indicate number of teledentistry sessions involving training

OMB Number 0915-0061
Expiration date XX/XX/201X

SECTION D. Prevention Services
Block 6. Indicate number of new water systems with fluoridated water:
Block 7. Indicate number of replaced water systems with fluoridated water:
Block 8. Indicate estimated number of residents served:
Block 9. Indicate the number of children receiving dental sealants:
Block 10. Indicate the number of individuals receiving topical fluoride:
Block 11. Indicate the number of individuals receiving diagnostic or preventive dental services:
Block 12. Indicate the number of recipients of oral health education:

SECTION E. Events
Block 13. Select whether the program provided promotional events for children:
Block 13a. Select type of promotional event:

Yes

[Drop-down]

Block 13b. Number of promotional events of that type:
Block 13c. Select types of local organizations involved in events:

[Drop-down]

Block 13d. Number of children attending events:
Block 13e. Select types of promotional materials created for event:

[Drop-down]

Add New Event Type

OMB Number 0915-0061
Expiration date XX/XX/201X

SECTION F. State Dental Offices
Block 14. Select whether a new state dental office was created:

Yes

Block 15. Select whether a new state dental officer position was created:

Yes

Block 16. Indicate number of new administrative support staff members hired:
Block 17. Indicate number of new dentists, dental hygienists, oral health coordination staff members hired:
Block 17a. Select whether a dentist, dental hygienist, or oral health coordination staff member hired in a previous reporting period has been
Yes
No
retained
Block 18. Indicate number of new fluoridation expert staff members hired:
Block 18a. Select whether a fluoridation expert staff member hired in a previous reporting period has been retained

Yes

Block 19. Indicate number of new epidemiologist staff members hired:
Block 19a. Select whether an epidemiologist staff member hired in a previous reporting period has been retained
Block 20. Indicate number of new statistician staff members hired:
Block 20a. Select whether a statistician staff member hired in a previous reporting period has been retained

Yes

Block 21. Indicate number of new other staff members hired:
Block 21a. Select whether any other staff member hired in a previous reporting period has been retained

Save & Continue

OMB Number 0915-0061
Expiration date XX/XX/201X

INSTRUCTIONS
Purpose. The State Oral Health Workforce Form captures
information about the various types of State Oral Health
projects that are supported with a BHPr-funded grant. The
form is divided into six sections: Section A captures
information about new dental facilities established in dental
HPSAs or underserved areas; Section B captures information
about expanded existing dental facilities in a dental HPSA or
underserved area; Section C captures information about
teledentistry; Section D captures information about dental
prevention services; Section E captures information about
promotional dental events for children; and Section F captures
information about state dental offices. Please complete
applicable sections of the form using the instructions below.
(Note: The "Select Training Program" button will only appear
if you reported supporting more than 1 non-direct financial
support training program in the Program Characteristics Form.
This will assist BHPr in associating the number of individuals
to specific types of non-direct financial support training
programs.)
SECTION A
Block 1. If your program established new dental facilities in a
HPSA/underserved area, select ‘Yes’, otherwise select ‘No.’
Block 1a. If yes, select the type of new facility that
was established as a result of activities undertaken by
the grant from the options below:
Selections:
Community health centers
Departments of health
Migrant health centers
Private
Rural health centers
School-based clinic
Other health center
Block 1b. Indicate the name of the new dental
facility established in a designated Dental HPSA or
government-recognized underserved
population/community as a result of activities
undertaken by the grant.
Block 1c. Select the type(s) of oral health services
offered at the newly established facility as a result of
activities undertaken by the grant from the options
below:
Selections:
Prevention
Restoration
Education
Interprofessional training
Block 1d. Indicate the number of patient encounters
in the new dental facility established in a designated

Dental HPSA or government-recognized underserved
population/community as a result of activities
undertaken by the grant.
Block 1e. Select ‘Yes’ if this facility is
mobile/portable. Select ‘No’ if this facility is in a
permanent structure.
Click on "Add New Facility" to enter new cases of a new
facility established during the reporting period.

SECTION B
Block 2. If your program expanded existing dental facilities in
a HPSA/underserved area, select ‘Yes’, otherwise select ‘No.’
Block 2a. If yes, select the type of facility that was
expanded as a result of activities undertaken by the
grant from the options below:
Selections:
Community health centers
Departments of health
Migrant health centers
Private
Rural health centers
School-based clinic
Other health center
Block 2b. Indicate the name of the dental facility that
was expanded in a designated Dental HPSA or
government-recognized underserved
population/community as a result of activities
undertaken by the grant.
Block 2c. Select the type(s) of oral health services
offered at the expanded facility as a result of
activities undertaken by the grant from the options
below (select all that apply):
Selections:
Prevention
Restoration
Education
Interprofessional training
Block 2d. Indicate the average number of patient
encounters for the entire prior reporting period that
occurred prior to the expansion.
Block 2e. Indicate the actual number of patient
encounters during the current reporting period that
occurred after expansion in the dental facility.
Block 2f. Indicate the average number of patient
encounters during a typical reporting period that the
newly expanded facility can accommodate.

OMB Number 0915-0061
Expiration date XX/XX/201X

Block 2g. Select ‘Yes’ if this facility is
mobile/portable. Select ‘No’ if this facility is in a
permanent structure.
Click on "Add Expanded Facility" to enter new cases of an
expanded facility funded during the reporting period.

SECTION E
Block 13. If your program sponsored/conducted oral health
promotion events through the grant, select ‘Yes’, otherwise
select ‘No.’
Block 13a. If yes, select the type of event offered that
promoted oral health and science professions from
the options below:

SECTION C
Block 3. Indicate the number of dental facilities that have
teledentistry capabilities that were/are supported by the grant.
Block 4. Indicate the number of teledentistry encounters
involving patient care that occurred during the reporting
period.
Block 5. Indicate the number of teledentistry sessions
involving training that occurred during the reporting period.
SECTION D
Block 6. Indicate the number of new water systems that were
installed to provide optimally fluoridated water as a result of
activities funded through the grant during the current reporting
period.
Block 7. Indicate the number of water systems that were
replaced to provide optimally fluoridated water as a result of
activities funded through the grant during the current reporting
period.
Block 8. Indicate the estimated number of residents served by
community water systems with optimally fluoridated water as
a result of activities funded through the grant during the
current reporting period.
Block 9. Indicate the number of children that received a
sealant on at least one permanent molar tooth during the
current reporting period as a result of activities funded through
the grant.
Block 10. Indicate the number of individuals who received
topical fluoride during the current reporting period as a result
of activities funded through the grant.
Block 11. Indicate the number of individuals who received
diagnostic or preventive dental services during the current
reporting period as a result of activities funded through the
grant.
Block 12. Indicate the number of individuals who received
oral health education during the current reporting period as a
result of activities funded through the grant.

Selections:
School/career fair
Community fair
For-profit organization sponsored event
Government-sponsored event
Nonprofit organization sponsored event
Lecture
Presentation
Other type of event
Block 13b. Indicate the number of events held of the
type indicated in block 13a during the reporting
period as a result of activities undertaken by the
grant.
Block 13c. Select all applicable type(s) of local
organizations involved in promoting oral health and
science professions of the type indicated in block 13a
during the reporting period from the options below:
Selections:
Social organization
Non-profit organization
School
Recreational Facility
For-profit organization
Other type of local organization
Block 13d. Indicate the estimated number of children
reached by oral health and science professions events
of the type indicated in block 13a during the
reporting period.
Block 13e. Select all applicable types of promotional
materials that were created as a result of activities
taken through the grant from the options below:
Selections:
Posters
Brochures
Curricula
Public service announcements
Other materials
Click on "Add New Event Type" to enter a new type of
promotional event during the reporting period.

OMB Number 0915-0061
Expiration date XX/XX/201X

SECTION F
Block 14. Select whether a new State dental office was
established as a result of activities taken through the grant
during the current reporting period.
Block 15. Select whether a new State dental officer position
was established as a result of activities taken the through the
grant during the current reporting period.
Block 16. Indicate the number of new administrative support
staff members (.5 FTE or greater) hired to support the State
dental officer and office as a result of activities taken through
the grant during the reporting period.
Block 17. Indicate the number of new dentists, dental
hygienists and/or oral health coordination staff members (.5
FTE or greater) hired to support the State dental officer and
office as a result of activities taken through the grant during
the reporting period.
Block 17a. Select dentist, dental hygienist, or oral
health coordination staff member hired in a previous
reporting period has been retained.
Block 18. Indicate the number of new fluoridation expert staff
members (.5 FTE or greater) hired to support the State dental
officer and office as a result of activities taken through the
grant during the reporting period.
Block 18a. Select whether fluoridation staff member
hired in a previous reporting period has been
retained.

Block 19. Indicate the number of new epidemiologist staff
members (.5 FTE or greater) hired to support the State dental
officer and office as a result of activities taken through the
grant during the reporting period.
Block 19a. Select whether epidemiological staff
hired in a previous reporting period has been
retained.
Block 20. Indicate the number of new statistician staff
members (.5 FTE or greater) hired to support the State dental
officer and office as a result of activities taken through the
grant during the reporting period.
Block 20a. Select whether statistical staff member
hired in a previous reporting period has been
retained.
Block 21. Indicate the number of new other staff members (.5
FTE or greater) hired to support the State dental officer and
office as a result of activities taken through the grant during
the reporting period.
Block 21a. Select whether other staff member hired
in a previous reporting period has been retained.

When finished, click on "Save and Continue" to be routed
to the appropriate form(s).

Public Burden Statement: 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 project is 0915-0061. Public reporting burden
for this collection of information is estimated to average .25 hours per response, 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 10-29, Rockville, Maryland, 20857.

OMB Number 0915-0061
Expiration date XX/XX/201X

PERFORMANCE REPORT FOR GRANTS AND COOPERATIVE AGREEMENTS
FORM NAME:

State Primary Care Offices (PCOs)

SECTION A. Obligated Health Professional (OHP) Providing Care
Block 1. Indicate the number of Obligated Health Professionals (OHP) currently providing care:

Number Trained

Block 2. Indicate the number of Obligated Health Professionals (OHP) working in National Health Service Corps’ (NHSC) sites:
Number Trained
Block 3. Indicate the number of Obligated Health Professionals (OHP) participating in State Loan Repayment Program (SLRP):
Number Trained
Block 4. Indicate the number of Obligated Health Professionals (OHP) participating in Non-State Loan Repayment Program (SLRP):
Number Trained
Block 5. Indicate the number of Obligated Health Professionals (OHP) practicing on a J-1 Waiver:

Number Trained

Block 6. Indicate the number of Obligated Health Professionals (OHP) receiving other incentives or benefits:

Number Trained

Block 7. Indicate the number of Obligated Health Professionals (OHP) working in Community Health Centers:

Number Trained

Block 8. Indicate the number of Obligated Health Professionals (OHP) working in Health Professional Shortage Areas (HPSAs):
Number Trained
Block 9. Indicate the number of Obligated Health Professionals (OHP) working in other settings:

Number Trained

SECTION B. Number of NHSC Site Application State Recommendation Forms Submitted
Block 10. Indicate the total number of National Health Service Corps' (NHSC) Site application state recommendation forms submitted by the state
Primary Care Office to the NHSC within 14 days (10 business days).
Number of Forms
Block 10a. Indicate the number of National Health Service Corps' (NHSC) Site application state recommendation forms submitted by the
State Primary Care Office to the NHSC.
Number of Forms
SECTION C. New Safety Net Sites Developed or Expanded
Block 11. Select the Type of New Safety Net Site
Block 11a. Select type of site developed or expanded

New Safety Net Sites Developed

Safety Net Sites Expanded

[Drop-down]

Block 12. Indicate the total number of New Safety Net Sites

SECTION D. Number of Clients Who Received Technical Assistance

OMB Number 0915-0061
Expiration date XX/XX/201X

Block 13. Indicate the type of clients who received technical assistance by type of site
Add P rofession & Discipline

Number Trained
Add P rofession & Discipline

Number Trained
Save & Continue

OMB Number 0915-0061
Expiration date XX/XX/201X

INSTRUCTIONS
Purpose. The State Primary Care Offices form captures
information about State Primary Care Offices conducted
through BHPr-funded grant programs. The State Primary Care
Offices form is divided into four sections: Section A captures
information about the type of Obligated Health Professional
(OHP) providing care; Section B captures information about
Number of NHSC Site Application State Recommendation
Forms Submitted; Section C captures information about New
Safety Net Sites Developed or Expanded; Section D captures
information about Number of Clients Who Received
Technical Assistance. Please complete the applicable sections
and blocks using the instructions below.

SECTION A
Block 1. Enter the total number of Obligated Health
Professionals (OHP) currently providing care by discipline in
column A for the current reporting period. Enter value greater
than zero. At least one discipline is required during the
reporting period from the options below:
Discipline
Non-psychiatric Physician (MD or DO)
Dentist (DDS/DMD)
Nurse Practitioner (NP)
Nurse Midwife
(NM)
Physician Assistant (PA)
Dental Hygienist (DH)
Psychiatrist (MD&DO)
Clinical Psychologist (CP)
Licensed Clinical Social Worker (LCSW)
Psychiatric Nurse Specialist (PNS)
Other Mental Health Clinician (specify)
Licensed Professional Counselor (LPC)
Marriage and Family Therapist (MFT)
Other (specify)
Only count OHP that were obligated as of June 30, 2013. This
measure does not have a start and end data collection date.
This measure ONLY has an end date.
Block 2 through Block 6. Of the number reported in Block 1,
indicate the total number of OHP by type.
(Note: Do NOT count Nursing and Education Loan
Repayment (NELRP) Participants)
Block 7 through Block 9. Of the number reported in Block 1,
indicate the total number of OHP by practice setting.

SECTION B
Number of Site Application Recommendation State
Recommendation Forms Submitted
Block 10. Indicate the total number of National Health Service
Corps' (NHSC) Site application state recommendation forms
submitted by the state Primary Care Office to the NHSC
within 14 days (10 business days).
Block 10a. Indicate the l number of National Health
Service Corps' (NHSC) Site application state
recommendation forms submitted by the State
Primary Care Office to the NHSC.

SECTION C
New Safety Net Sites Developed or Expanded
Block 11. Indicate the total number of newly developed or
expanded safety net sites for each type of new safety net site.
If more than one type is offered, expand the table to include all
types of clients. Leave blank if type of new safety net site is
not applicable.
Block 11a. Select the type of safety net sites developed or
expanded from the options below:
330 Sites
RHC
FQHC Look-a-Like
Free Clinics
School Based Health Centers
Faith Based Clinics
Other (specify)
Block 12. Indicate the total number of New Safety Net Sites
SECTION D
Number of Clients Who Received Technical Assistance
Block 13. Indicate the number of clients who received
technical assistance by profession and discipline from the
options below:

When finished, click on "Save and Continue" to be routed
to the appropriate form(s).

File Type	application/pdf
Author	Windows User
File Modified	2013-03-18
File Created	2013-03-14