Form 2 BHPr Program Applications

Attachment D: Revised Grant Application Forms Snapshot of Data Collected in BHPr Applications

PROGRAMS→ NOTE: Yellow highlight denote programs that have separate OMB clearance for collecting data.

Advanced Education Nursing Traineeship

Advanced Nursing Education Grants

Area Health Education Centers Infrastructure Development & Point of Service Maintenance & Enhancement

Centers of Excellence

Comprehensive Geriatric Education Program

Geriatric Academic Career Award

Geriatric Education Centers

Geriatric Training Program for Physicians, Dentists, and Behavioral and Mental Health Professions

Graduate Psychology Education Programs

Health Careers Opportunity Program

Nurse Anesthetist Traineeships

Nurse Education Practice, Quality and Retention

Nurse Faculty Loan Program

Nursing Assistant and Home Health Aide Program

Nursing Workforce Diversity

Primary Care Training and Enhancement Programs

Public Health Traineeship

Public Health Training Centers

Preventive Medicine Residencies

Scholarships for Disadvantaged Students

State Primary Care Office

Training in Gen, Ped & Public Health Dentistry

# Current and/or Projected Enrollment (generally and/or by many variables, field of study, education level, etc.)

X

X

X

X

X

X

X

X

X

X

X

X

# Current and/or Projected Participants/Students(headcount)/Grads

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

Faculty Data (Race/Ethnicity, FT/PT status, Discipline, etc.)

X

X

X

X

X

# Graduates (grant supported and/or not grant supported)

X

X

X

X

X

X

X

X

X

X

X

# Program Completers

X

X

X

X

# Participants/Graduates/Program Completers Serving in Medically Underserved Areas/Communities

X

X

X

X

X

X

X

X

X

X

X

X

# Trainees/Students/Participants/Graduates/Program Completers -Practice Setting

X

X

X

X

# Trainees/Students/Participants/Graduates/Program Completers -Disadvantaged/Underrepresented

X

X

X

X

X

X

# Trainees/Students/Participants/Graduates/Program Completers-- Demographic Data (race/ethnicity/gender/age, etc.)

X

X

X

X

X

X

X

X

X

# Trainees/Students/Participants by FT or PT status, level of support (prior and/or projected)

X

X

X

X

X

X

X

Information on Courses/Credit Hours

X

X

X

X

X

Information on Area Health Education Centers (# centers, population size, # medical and/or nursing students, etc.)

X

# Patients Served/# Client Encounters (current and/or projected)

X

X

Standardized test/boards pass rates (e.g. NCLEX)

X

X

X

Enrollment/Retention/Graduation Rates

X

X

X

Data Collected in Applications by Program

Below are data elements requesting grantees to provide information in the grant application. View the Bureau of Health Professions website for specific program application instructions http://bhpr.hrsa.gov/. Note: Programs are listed in alphabetical order except in the case of the following program clusters: Primary Care Training and Enhancement (PCTE) programs (Academic Administrative Units in Primary Care; Physician Faculty Development in Primary Care; Predoctoral Training in Primary Care; Residency Training in Primary Care; Physician Assistant Training), Training in General, Pediatric, and Public Health Dentistry programs (Pre-doctoral Training in General, Pediatric and Public Health Dentistry, and Dental Hygiene; Post-doctoral Training in General, Pediatric or Public Health Dentistry; Faculty Development Training in General, Pediatric or Public Health Dentistry and Dental Hygiene; and Dental Faculty Loan Repayment) and Nurse Traineeship Programs (Advanced Education Nursing Traineeships and Nurse Anesthetist Traineeships).

Advanced Education Nursing Traineeship and Nurse Anesthetist Traineeships

Rationale: The new tables proposed below are to capture more comprehensive data on the nursing traineeship programs to include the funding (award, stipend, tuition, by role, by degree), enrollees, students supported, graduates and graduates supported for both the Advanced Education Nursing Traineeship (AENT) and Nurse Anesthetist Traineeship (NAT) Programs.

The currently established AENT and NAT Tables were previously approved under OMB Approval Number 0915-0305 with an Expiration Date of 03/31/2010.  The approved renewal (revised AENT and NAT Tables) OMB Number is 0915-0305 with an Expiration Date of 03/31/2013. 

Table 1(To be completed by AENT applicants)

Dollar amount awarded per student?
Stipend amount awarded per student?
Tuition amount awarded per student?
Number of additional students you could fund if your institution received more traineeship funding?
What are the criteria used by your institution for selecting recipients and determining the amount of the award per student?
How would your institution use additional traineeship funds such as increase the award to current students, increasing the number of students who would be awarded funds or providing full educational costs and tuition to a few students?
What other sources of funding supplement the AENT funds?
What is the unmet need in terms of traineeship funding for students?
How does your institution track where students are working after graduation?

FULL-TIME AND PART-TIME STATUS (To be completed by AENT applicants)

Provide information on how the applicant institution defines the following:

(1) Full-Time graduate study: ____ (Indicate the number of credit hours or units required per term)

(2) Part-Time graduate study: ____ (Indicate the number of credit hours or units required per term)

IMPORTANT NOTE: Institutions are no longer required to provide Full-Time equivalent (FTE) calculations for Part-Time enrollees. 

TUITION, FEES AND STIPENDS (To be completed by AENT applicants)

(1) Provide the In-State and Out-of-State tuition costs for a Full-Time and Part-Time students. 

Tuition	Full-Time Students	Part-Time Students
Tuition: In-State
Tuition: Out-of-State

(2) Indicate the total cost of stipend support that would be required to support all the graduates eligible for support from July 1, 2010 - June 30, 2011 based on $21,180 for a 12-month period, if funds were available:  $_______________

(3) Based on the “Projected Student Enrollees” (Full-Time and Part-Time) reported on Tables 1-3, indicate the total cost of tuition and fees that would be required to support all the graduate students eligible for support from July 1, 2010 - June 30, 2011, if funds were available:  $_______________.

ACCREDITATION (To be completed by AENT and NAT applicants)

(1) Include the complete Accrediting Expiration Date (i.e. 02/31/2012 or March 20, 2017 for Spring 2017). 

(2) Include the actual accreditation documentation – accreditation letter, accreditation certificate, letter of reasonable assurance as Attachment 2.

Applicant Name	Application Tracking Number	Accrediting Expiration Date(s)	Accrediting Agency(ies)	Status (Full, Provisional)	Pending Site Visit	Compliance Concerns

AENT FUNDING BY ROLE (To be completed by AENT applicants)

Role	Amount Allocated	Number of Full-Time  Students Supported by Traineeship	Number of Part-Time  Students Supported by Traineeship	Number of Full-Time Graduates Supported by Traineeship	Number of Part-Time Graduates Supported by Traineeship

AENT FUNDING BY DEGREE (To be completed by AENT applicants)

Degree	Amount Allocated	Number of Full-Time  Students Supported by Traineeship	Number of Part-Time  Students Supported by Traineeship	Number of Full-Time Graduates Supported by Traineeship	Number of Part-Time Graduates Supported by Traineeship

FULL-TIME STATUS (To be completed by NAT applicants)

Note:  NAT supports Full-Time study only

Provide information on how the applicant institution defines the following:

(1) Full-Time graduate study: ____ (Indicate the number of credit hours or units required)

TUITION, FEES AND STIPENDS (To be completed by NAT applicants)

(1) Provide the In-State and Out-of-State tuition costs for Full-Time students. 

Tuition	Full-Time Students
	PER YEAR
Tuition:  In-State
Tuition:  Out-of-State

(2) Based on the “Projected Full-Time Student Enrollees” reported on Table 1, indicate the total cost of tuition and fees that would be required to support all the graduate students eligible for support from July 1, 2010 - June 30, 2011, if funds were available:  $_______________.

(3) Indicate the total cost of stipend support that would be required to support all the graduate students eligible for support from July 1, 2010 - June 30, 2011 based on $21,180 for a 12-month period, if funds were available:  $_______________

Advanced Nursing Education

Rationale: This data will provide the application reviewers with information regarding the proposed educational level, advanced nursing education role to be implemented along with the number of projected student enrollment and graduation based on the amount of funding that is requested by the applicant.

Proposed Project Specific Advanced Nursing Education Program Data Table

Project Title
Educational Level
Advanced Education Nursing Role
Nursing Specialty
Special Emphasis Area
Students	Most Recent as of 10/15/20xx	Projected Year 01	Projected Year 02	Projected Year 03
Continuing Enrolled Students
Full-Time
Part-Time
Newly Enrolled Students
Full-Time
Part-Time
Total Headcount
Graduates	7/1/xx – 6/30/xx	Projected 01	Projected 02	Projected 03

Curriculum Information

Rationale: This table will help the reviewers assess the curriculum/plan of study that proposed project will administer to ensure that based on the specialty and role there are enough clinical and didactic hours for the students.

Specialty:
Course Title	Course Description	Semester/ quarter offered (fall, spring, summer)	# of academic credits hours	# of clinical and didactic hours (if applicable)

Preference and Accreditation Data Tables

Rationale: As per the authorizing legislation, all nursing programs must be accredited by an agency recognized by the Department of Education. This table helps summarize accreditation documentation that must accompany the application.

Accreditation

Education Program	Name of Nursing Accrediting Agency	Expiration Date	Date of Next Site Visit (if applicable)

Preference Request Table (only one preference can be requested)

Preference	Requested Yes or No
Substantially benefit rural populations
Substantially benefit underserved populations
Help meet Public Health Nursing needs in state or local health departments

Area Health Education Centers Infrastructure Development and Area Health Education Centers Point of Service Maintenance and Enhancement

Note: The Area Health Education Centers Infrastructure Development and Area Health Education Centers Point of Service Maintenance and Enhancement Funding Opportunity Announcements (FOAs) are typically combined. The data requested for each program is the same.

Rationale: Applicants must provide data to demonstrate compliance with the legislative mandate that recipients conduct at least 10 percent of required medical student clinical education at community settings remote from the primary teaching facility of the contracting institution for awardees that operate a school of medicine or osteopathic medicine. In States in which a school of nursing, or its parent institution is the recipient, the nursing school or its parent institution shall submit data documenting that at least 10 percent of clinical education for nursing students is conducted in community settings that are remote from the primary teaching facility of the school.

MEDICAL/NURSING SCHOOL 10 PERCENT REQUIREMENT TABLE

	Awardee Medical/Nursing School	Cooperating Medical/Nursing School	Cooperating Medical/Nursing School	Cooperating Medical/Nursing School	Cooperating Medical/Nursing School
	Example
(A) Total Medical /Nursing Undergraduate Clinical Education Student-Weeks at or Sponsored by AHEC Each Year	953
	Example
(B) Total Medical/Nursing Undergraduate Clinical Education Student-Weeks of the School's 4 Year Curriculum	9530
A ÷ B	10 Percent

WORKSHEET EXAMPLE

EXAMPLE
Academic Year	# of Required Clinical Weeks	X	# of Students	Total Student Weeks	X	10%	AHEC Student Weeks
1	0	X	100	0	X	10%	0
2	20	X	95	1900	X	10%	190
3	30	X	91	2730	X	10%	273
4	50	X	98	4900	X	10%	490
	100	X	384	9530	X	10%	953
MINIMUM AHEC STUDENT WEEKS = 953

NOTE: A student week of clinical education totals 40 hours, completed in either five consecutive days or cumulatively over time.

AHEC Program and Center(s) Service Area Table

Rationale:  Applicants must provide descriptive data of their AHEC programs and centers. The use of a table provides a standardized format that will be required of and used by all AHEC programs as a strategy to collect uniform information across the entire network.

AHEC Program:			Date:		Grant #:
Program Office	Program Director (Include Credentials/Discipline)	Address, City, Zip Code	# of AHEC Programs in the State	# of Counties in the State	Total # of Counties Served by the Program	Population Size (State)
		(Street Address Where Possible)
# of Federally Funded AHEC Centers:
AHEC Center	Center Director (Include Credentials/Discipline)	Address, City, Zip Code	# of Counties Served	Names of Counties Served by the AHEC Center (List in Alpha Order)	Population Size of County	Reference # on Service Area Map*
		(Street Address Where Possible)

Centers of Excellence

Rationale: The applicant must clearly identify the trend in the actual enrollment of underrepresented minority (URM) students, as stated in the legislation and funding opportunity announcement, in order for the Objective Review Committee to determine whether application meets the criteria of URM Centers of Excellence.

Number of URM Students and Graduates in Health Professions School of Selected Discipline for COE

(Unduplicated Count)

	Total Number students in Entering Class					Total Number of Students in Graduating Class
	Class 2007	Class 2008	Class 2009	Class 2010	Class 2011	Class 2009	Class 2010	Class 2011
Hispanic/Latino and Black or African American
Hispanic/Latino and Native American
Hispanic/Latino and Other Pacific Islands
Hispanic/Latino and Asian, Under-represented *
Hispanic/Latino and Asian, Non-under-represented
Hispanic/Latino and White
Non-Hispanic/Latino and Black or African American
Non-Hispanic/Latino and Native American
Non-Hispanic/Latino and Other Pacific Islands
Non-Hispanic/Latino and Asian, Under-represented
Non-Hispanic/Latino and Asian, Non-under-represented
Non-Hispanic/Latino and White
Total URMs
Total Non-URMs
Total Number of Students

Total Number of Students and Graduates in School refers to the School applying and implementing the COE program for the students: Osteopathic, Allopathic, Dentistry, Pharmacy, graduate program in behavioral or mental health, or Veterinary Medicine

STUDENT CLINICAL TRAINING IN HEALTH CARE SERVICES

(Required of competing continuation applicants only)

How many COE Students participated in Health Services Clinical Training at sites located in Community Based Health Facilities in the past 3 years? Identify if it is a Health Professional Shortage Area (HPSA) with an asterisk (*). Please fill in the number of students, the name and location of the training site and the average number of days per student.

Number of Students	Name/Location of Training Site	Average # of days per student

Number of Hispanic and Latino Faculty in School¹

Total Number of Full-Time Faculty

Total Number of Full-Time Faculty

Total Number of Part-Time Faculty

Total Number of Part-Time Faculty

Academic Year 2009 - 2010

Academic Year 2010 to 2011

Academic Year 2009 - 2010

Academic Year 2010 - 2011

Osteo

Allo

Den

Pharm

Vet

B/M Health

Osteo

Allo

Dent

Pharm

Vet

B/M Health

Osteo

Allo

Dent.

Pharm

Vet

B/M Health

Osteo

Allo

Dent.

Pharm

Vet

B/M Health

African American

Native American

Asian

Caucasian

Unknown

>1 race

Total Faculty

Number of Vacancies

Number of Non-Hispanic and Non-Latino Faculty in School

Total Number of Full-Time Faculty

Total Number of Full-Time Faculty

Total Number of Part-Time Faculty

Total Number of Part-Time Faculty

Academic Year 2009 - 2010

Academic Year 2010 to 2011

Academic Year 2009 - 2010

Academic Year 2010 - 2011

Osteo

Allo

Dent

Pharm

Vet

B/M Health

Osteo

Allo

Dent

Pharm

Vet

B/M Health

Osteo

Allo

Dent

Pharm

Vet

B/M Health

Osteo

Allo

Dent

Pharm

Vet

B/M Health

African American

Native American

Asian

Caucasian

Unknown

>1 race

Total Faculty

Number of Vacancies

Comprehensive Geriatric Education Program

Project Specific Courses and Participants by Category

Rationale: The legislation requires applicants to train individuals who will provide geriatric care for the elderly, develop curricula relating to the treatment of health problems of elderly individuals, train faculty in geriatrics, or provide continuing education to individuals who provide geriatric care. The application must contain a projected list of courses to demonstrate the degree to which these statutory purposes may be addressed.

Education Courses by Title	Academic Credit by Credit Hours	Continuing Education by Contact Hours	No. of times the Course will be offered each year	Lay and Family Caregivers Yes/No	Level of Nursing Personnel	Level of Health Professions (Other)
1
2
3

Ethnicity Data (one year projections)

	Hispanic/Latino	Non-Hispanic/Non-Latino	Unknown Ethnicity	Total
Participants Projected (July 1, 20xx thru June 30, 20xx)
Faculty Projected (July 1, 20xx thru June 30, 20xx)

Minority/Disadvantaged Status Data (one year projections)

	American Indian/ Alaska Native	Under-represented Asian subgroup*	Asian (Not under-represented)	Black or African American	Native Hawaiian or Other Pacific Islander	White: Disadvantaged	White: Non-Disadvantaged	More Than One Race	Total
Projected Participants (7/1/xx-6/30/xx)
Faculty Projected (7/1/xx-6/30/xx)

*Any Asian subpopulation other than Chinese, Filipino, Japanese, Korean, Asian Indian or Thai is considered underrepresented.

Geriatric Academic Career Award

Rationale: The purpose of the Geriatric Academic Career Award is to promote the career development of geriatric specialists in academia. This table provides information related to a previous Geriatric Academic Career Awardees’ promotion status.

Table 1

Information	Yes	No
1. Did the Awardee ever receive a GACA award before?	Provide the specific period of the previous GACA award:_____________________________________________________________________
2. Did the Awardee apply for promotion?	Date:______________________________________________________________________
	Outcome:___________________________________________________________________
3. Did the Awardee receive promotion during the last award period?	Instructor___________________________________________________________________
	Assistant professor:___________________________________________________________
	Associate professor:___________________________________________________________
4. If no to questions 2 and 3, when does the Awardee plan on applying for promotion?	Date:_______________________________________________________________________

Mentor Table

Rationale: The mentor plays a key role in the professional development of the Geriatric Academic Career Awardee. The table below provides information that addresses the requirements for the mentor.

Information	Yes	No
1. Is the mentor from the same discipline as the applicant?
2. Does the mentor hold a Full-Time academic appointment in an accredited school of medicine, osteopathic medicine, nursing, social work, psychology, dentistry, pharmacy or allied health at the same institution as the project director?
3. Does the mentor hold a position at the professor or associate professor level?
4. Is the mentor prepared at the doctoral level?
5. Did the mentor complete specialty training in geriatrics as required by the discipline and relevant certification in geriatrics as required by the discipline? (If yes, provide the expiration date for certification in geriatrics as required by the discipline).

Note: Physician mentors are required to have a current Certificate of Added Qualification in geriatrics.

Geriatric Education Centers

Statutory Funding Preference for Medically Underserved Communities Request Form

Sites	Number of Training Sites
	Academic Year 2011-2012	Academic Year 2012-2013
Community Health Centers
Migrant Health Centers
Health Care for the Homeless
Public Housing Primary Care
Rural Health Clinics
Indian Health Service Sites
State or Local Health Departments
Ambulatory Practice Sites Designated by State Governors
Governor Certified Areas
Total # of Graduates or Completers in these sites
Total # of Graduates or Completers
Percentage of Graduates or Completers in these sites

Settings	Number of Training Sites Per Setting
	Academic Year 2011-2012	Academic Year 2012-2013
Federally Qualified Health Centers (FQHC)
Health Professional Shortage Area and Dental (HPSA)
Medically Underserved Communities (MUC)
Rural
National Health Service Corps Sites
Total # of Graduates or Completers in these sites
Total # of Graduates or Completers
Percentage of Graduates or Completers in these sites

Rationale: This table provides quantitative documentation of the applicant’s projected commitment to this initiative and is used in evaluating the outputs of this initiative.

Faculty Development Data Table

	Number of Faculty Trained
Discipline	Projected Data	Projected Data	Projected Data	Projected Data	Projected Data
	Year 1	Year 2	Year 3	Year 4	Year 5
Art Therapy
Allopathic Medicine
Audiology
Chiropractic
Counseling
Dental Hygiene
Dentistry
Dietetic/ Nutrition
Gerontology
Health Care Admin
Health Education
Home Economics
Nursing
Occupational Therapy
Optometry
Osteopathic Medicine

Faculty Development Data Table (continued)

	Number of Faculty Trained
Discipline	Projected Data	Projected Data	Projected Data	Projected Data	Projected Data
	Year 1	Year 2	Year 3	Year 4	Year 5
Pharmacy
Physical Therapy
Physician Assistants
Podiatry
Psychology
Public Health
Recreational Therapy
Respiratory Therapy
Social Work
Sociology
Speech Pathology
Other
Other
Other
Other

Geriatric Training Programs for Physicians, Dentists, and Behavioral and Mental Health Professions

Statutory Funding Preference Request for Medically Underserved Communities (MUC) Form (Same as form for Geriatric Education Centers, p. 17)

Total Number of Completers/Graduates (for Competing Continuation Applicants)

Rationale: The applicant must provide trend data that demonstrates their recruitment of underrepresented minority individuals into the program and placing graduates in academic and Medically Underserved areas Areas (MUA).

Discipline/ Specialty (Complete separate tables per discipline/ specialty)	Year	Gender	Race/ Ethnicity	Number of Graduates in Academia Full-Time	Number of Graduates in Academia Part-Time	Number of Graduates Working in MUA	Number of URM Graduates Working in MUA	MUAs used for clinical training	Type of Patients Served
	2010-2011
	2009-2010
	2008-2009
	2007-2008
	2006-2007

Graduate Psychology Education Programs

Statutory Funding Preference Request for Medically Underserved Communities (MUC) Form

(Same as form for Geriatric Education Centers, p. 18)

Health Careers Opportunity Program (HCOP)

HCOP Discipline Identification (Associate Degree or above)

Rationale: The applicant must clearly identify the health disciplines to be targeted by the educational intervention in order for the Objective Review Committee to determine whether the project meets the needs of health professions shortages and diversity in the geographic area.

This is a sample list which provides some but not all of the HCOP Program discipline identifications in which students will have the opportunity to be trained through your program. Behavioral/Mental Health Clinical Psychology (Grad) Marriage & Family Therapy (Grad) Clinical Social Work Professional Counselor Gerontology Counselor Mental Health Counselor (Grad) Other Behavior/Mental Health Undecided

Chiropractic Dental

Medicine Allopathic Medicine Osteopathic Medicine

Optometry Pharmacy Physician Assistant Podiatry

Public Health Environmental Science Epidemiology Health Administration. (Grad) Public Health (Grad) Other Public Health Undecided

Veterinary Medicine

Allied Health Audiology (Bacc) Physical Therapy Assist. Audiology (Grad)) Radiologic Tech. (Bacc) Blood Bank Tech. Registered Dietician/Nutrition (Bacc) Dental Hygiene Registered Dietician/Nutrition (Grad) Dental Assistant/Lab Tech) Rehab. Counselor (Grad) Dental Ancillary Respiratory Therapy Emergency Med. Tech Speech-Lang. Path. (Bacc) Health Admin. (Bacc) Speech-Lang. Path. (Grad) Health Information Surgical Tech. Medical Laboratory Tech Veterinary Technician Occupat. Therapy (Grad) Technologist, Other Specify_______________ Occupat. Therapy (Bacc) Occupat. Therapy Assist. Other Health Professions Specify______ Physical Therapy (Bacc) Undecided Physical Therapy (Grad) Other, Rehab./ Restorative Specify_______________

Rationale: Tables A and B (below) provide three-year institutional enrollment trends for the target group, including the target population by school year as compared with total enrollment for the three previous years. These tables are used to determine the applicant institutions level of commitment to disadvantaged students, as well as create a baseline for disadvantaged student enrollment.

Table A: 1^st year enrollment of disadvantaged students in Health and/or Allied Health programs, by discipline, for which funding is requested.

Table B: Total School Enrollment of disadvantaged students in Health and/or Allied Health Professions schools, by discipline, for which funding is requested.

TABLE A

NUMBER AND PERCENT DISTRIBUTION OF FIRST-YEAR ENROLLMENT OF Disadvantaged HCOP Students BY RACE/ETHNICITY & YEAR

(FOR HEALTH/ALLIED HEALTH PROFESSIONS SCHOOLS ONLY)

*RACE/ETHNICITY	2008-2009		2009-2010		2010-2011
Hispanic/Latino and Black or African American	No.	%	No.	%	No.	%
Hispanic/Latino and Native American
Hispanic/Latino and Other Pacific Islands
Hispanic/Latino and Asian, Under-represented*
Hispanic/Latino and Asian, Non-under-represented
Hispanic/Latino and White
Non-Hispanic/Latino and Black or African American
Non-Hispanic/Latino and Native American
Non-Hispanic/Latino and Other Pacific Islands
Non-Hispanic/Latino and Asian, Under-represented
Non-Hispanic/Latino and Asian, Non-under-represented
Non-Hispanic/Latino and White
Total Disadvantaged Students
Total Non‑ Disadvantaged Students
Total First Year Enrollment		100%		100%		100%

TABLE B

NUMBER & PERCENT DISTRIBUTION OF TOTAL SCHOOL ENROLLMENT for DISADVANTAGED BY RACE/ETHNICITY & YEAR (FOR HEALTH/ALLIED HEALTH PROFESSIONS SCHOOLS ONLY)

*RACE/ETHNICITY	2008-2009		2009-2010		2010-2011
Hispanic/Latino and Black or African American	No.	%	No.	%	No.	%
Hispanic/Latino and Native American
Hispanic/Latino and Other Pacific Islands
Hispanic/Latino and Asian, Under-represented*
Hispanic/Latino and Asian, Non-under-represented
Hispanic/Latino and White
Non-Hispanic/Latino and Black or African American
Non-Hispanic/Latino and Native American
Non-Hispanic/Latino and Other Pacific Islands
Non-Hispanic/Latino and Asian, Under-represented
Non-Hispanic/Latino and Asian, Non-under-represented
Non-Hispanic/Latino and White
Total Disadvantaged Students
Total Non‑ Disadvantaged Students
Total School Enrollment		100%		100%		100%

Projected Number of HCOP Trainees and Number of Stipends per Structured Program

Rationale: This table is used to determine whether the applicant is meeting one of the legislative purposes of the program, providing stipends. It is also used by program to classify and quantify stipends of each grantee.

	Educational Level
Structured Programs	Middle School		High School		College/(2-4 yrs)		Post-College/ Pre-Professional		Graduate/ Professional
	# Students	# Stipends	# Students	# Stipends	# Students	# Stipends	# Students	# Stipends	# Students	# Stipends
Health Professions Academy
Summer Program
Saturday Academies
Pre-Matriculation Program
Post-Baccalaureate Program
Total

Nurse Education Practice, Quality and Retention

Rationale: The tables for NEPQR will be used to project retention and vacancy rates for the duration of the project. These rates will be compared to the actual rates as the project is completed and used to measure the program’s success with improving retention rates. The remainder of the data tables captures the needed student data for completion of performance measures.

Table 1: Current and Three Year Projected Enrollment of Students in Nursing Courses

	Current Year 2011-2012	Year 1 2012-2013	Year 2 2013-2014	Year 3 2014-2015	Years 1-3 2012-2015
Number of Students
Annual Percent Increase
Total increase in Number and Percent (%) increase

This table is to be completed by NEPQR E1, R1, R3, and E2 as appropriate; and other projects conferring degrees.

Table 2: Current and Three Year Projected Attrition of Students in Nursing Courses

	Current Year	Year 1	Year 2	Year 3
	2011-2012	2012-2013	2013-2014	2014-2015
Number Enrolled in Nursing Program
Attrition Number
Attrition Percentage

This table is to be completed by NEPQR E1, R1, R3, and E2 as appropriate; and other projects conferring degrees.

Table 3: Past, Current, and Projected Graduation Rates (2 or More Graduation Dates per Year)

	2008	2009	2011	2012	2013	2014	2015
January Graduates
May Graduates
Total

This table is to be completed by NEPQR E1, R1, R3, and E2 as appropriate; and other projects conferring degrees.

Table 4: NCLEX – RN Examination First Time Results for Graduates 2008 -2011

	Graduates
Calendar Year	2008	2009	2010	2011	Total
Number of Students Taking Exam
Number of Students Passing Exam
Percentage “Pass”
Percentage “Fail”

This table is to be completed by NEPQR E1, R1, R3, and E2 as appropriate; and other projects conferring degrees.

Table 5: NEPQR Projected Number of Project Participants, Type Participants, Requested Budget, and Certification for Each Project Year

	Year 1	Year 2	Year 3	Year 4	Year 5	Total
Number of Project Participants:
Target /Type Participant
Requested Budget:
Certification
Type Certification
CEU’s

This table is to be completed by all NEPQR applicants.

Table 6: NEPQR Practice Purposes Projected Numbers of Undergraduate and Graduate Students, and Patient Encounter Numbers for each year of the Project

	Year 1	Year 2	Year 3	Year 4	Year 5	Total
Undergraduate Students
Graduate Students
Patient Numbers
Patient Encounters

This table is to be completed by the NEPQR Practice Purposes – P1, P2, P3, and P4, as appropriate

Table 7: Internships and Residences

	Length of I & R program	Specialty	Career Role/Level	Number Supported -Projected	Number of Program Completers -Projected	Partners/Linkages
Year 1
Year 2
Year 3
Totals

To be completed by Nurse, Education Practice, Quality, and Retention Purpose R2 – Internships and Residences

Table 8: Nursing Retention and Vacancy Data

Core Retention Measures	Baseline (prior to start of project)	Year 1	Year 2		Year 3
		Projected		Projected			Projected
Nurse Retention Rate	%
Nurse Vacancy Rate	%

To be completed by Nurse Education Practice, Quality, and Retention (purpose R4 only)

Table 9: Patient Care Core Indicators

Patient Care Core Indicators	Baseline (prior to start of project)	YR. 1		YR. 2		YR. 3
		Projected		Projected		Projected
1.	%
2.	%
3.	%
4.	%

To be completed by Nurse Education Practice, Quality, and Retention (purpose R4 only)

Table 10: Application Data Collection

NEPQR APPLICATION DATA COLLECTION	Column1
Application /Fed ID #
Organization
Project Title
Project Director /w credentials
Org Address
State
Type of Organization, i.e. PH Dept,
Am Clinic, Hosp, etc.
Purpose	Drop down with E1, E2, P1, P2, P3, P4,
	R1, R2, R3, R4
Accrediting Body
Statutory Funding Preference	Drop down with underserved, rural, and public health

To be completed by all NEPQR applicants

Table 11: Application Data Collection

NEPQR Application Data Collection
Application Type	Yes	No	Other	Not Applicable
New
New Competing Continuation
Progress Report
Education Institution Type
Diploma School of Nursing
Community College
Four Year University/College
HealthCare Facility
Partnership SON/HCF
HBCU
HIS
Tribal College
Statutory Funding Preference
Business Plan included * P1 only
Project is operational by January 31

To be completed by all NEPQR applicants

Nurse Faculty Loan Program

Note: This is a revision of a Program Specific Data Form (OMB No. 0915-0321) with prior OMB approval for the Nurse Faculty Loan Program (NFLP).

This clearance request is for approval of the modified NFLP Program Specific Data Form which is used by applicants to provide the information required to determine eligibility and the award level. The web-based (online) version of the NFLP Program Specific Data Form was developed and integrated into the existing HRSA Electronic Handbook (EHBs) application module in fiscal year 2009. The online form will be modified to collect minimal additional data from NFLP applicants that will include information on the total number of enrollees, graduates and graduates employed by, the type of nursing degree program, and the nurse practice role. Program wishes to collect additional data on: (1) the educational level; (2) the nursing role, and (3) the age and gender for NFLP student participants and the number of NFLP graduates that obtain nurse faculty employment. The additional data will be used to determine program-specific information related to the advanced nursing degree programs supported under NFLP.

The NFLP Program Data Specific Form will capture program-related information provided by the applicant. NFLP applicants will complete and submit the Program Specific Data Form as an electronic attachment with the required application materials. The form will provide the Federal Government with specific data from the applicant to specify: (1) the amount of the Federal funds requested by the applicant, (2) the expected contribution from the applicant, (3) the student enrollment and graduation data based on current and prospective NFLP loan recipients, (4) the advanced nursing degree programs supported under NFLP, (5) the program accreditation status, (6) the current tuition and fee information for graduate nursing education programs, and (7) the projected NFLP loan fund balance that may be considered as part of the award determination. The data provided in the form are essential for the formula-based criteria used to determine eligibility of the applicant school of nursing, the nursing degree programs offered by the school, and the award amount to the applicant schools. The current electronic data collection capability within the HRSA EHBs is established to streamline the application submission process, enable an efficient award determination process, and serve as a data repository to facilitate reporting on the use of funds and analysis of program outcomes. Additionally, the data will be used to ensure programmatic compliance with the legislative authority and program guidance, to report program accomplishments to policy makers, and to formulate and justify the appropriation to the Office of Management and Budget and Congress.

TABLE 1

Nursing Degree Levels	NFLP Recipients Enrolled – Did Not Graduate	NFLP Graduates	NFLP Graduates Employed as Faculty
Masters
Post BSN-PhD/DNSc
Post BSN-DNP
Post MSN-PhD/DNSc
Post MSN-DNP
TOTAL:

TABLE 2

Role	NFLP Recipients Enrolled – Did Not Graduate	NFLP Graduates
Primary Care Nurse Practitioner
Acute Care Nurse Practitioner
Nurse-Midwife
Nurse Anesthetist
Clinical Nurse Specialist
Public Health Nurse
Nurse Administrator
Nurse Educator
“Other” Nurse Specialty
TOTAL:

TABLE 3

Ages	NFLP Recipients Enrolled (Did Not Graduate)		NFLP Graduates		NFLP Graduates Employed as Faculty
	Males	Females	Males	Females	Males	Females
Under 20
20-29
30-39
40-49
50-59
60 or older
TOTAL:

UNDERREPRESENTED/DISADVANTAGED STATUS TABLE

Race/Ethnicity

Black or African-American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

American Indian or Alaska Native

Asian Subpopulations

Asian Disadvantaged (not subpopulations)

White e Disadvantaged (not Hispanic)

Other Disadvantaged

Underrepresented/Disadvantaged Subtotal

Asian (not subpopulation)

White (not Hispanic)

Other

TOTALS

Total Percent Underrepresented/Disadvantaged

UNDERREPRESENTED

DISADVANTAGED

NON-DISADV.

NFLP Borrowers Enrolled (did not graduate)

%

NFLP Graduates

%

NFLP Graduates employed as nurse faculty

Table 4 is data that we plan to collect when the formula change is made to the NFLP program.

Nursing Assistant and Home Health Aide Program

Rationale: The FOA requested data from the applicants to project the number of students or project participant pool for each year of the study.

Table 1

	Number of Participants
Year 1
Year 2
Year 3

Nursing Workforce Diversity

Rationale: Proposed projects are required, during each year of the three-year project, to include one of the Pre-Entry Preparation Cohorts, one of the Academic Retention Cohorts, and the provision of student support in the form of scholarships and/or stipends to eligible participants. These data capture target of project and amount/allocation of student support.

Table 1: Type of Nursing Program Offered to Participants

Student population in each nursing program offered in project		Associate Degree	Nursing Diploma	Bachelors Degree in Nursing	Graduate Degrees
Enrollment rate	All students
	Disadvantaged/URM
Retention rate	All students
	Disadvantaged/URM
NCLEX pass rate	All students
	Disadvantaged/URM

Table 2

Number of Participants	Year 1	Year 2	Year 3	Total
Pre-Entry Preparation Cohort
MS, HS, HS graduates
CNA/LPN/LVN
Pre-Nursing/ Pre-College
College graduates/ Second Degree
Diploma/ AD nurses
BS nurses
Total Pre-Entry Prep
Academic Retention Cohort
Pre-licensure nursing
RN-BSN
Second Degree BSN or MSN
Bridge or Degree Completion
Total Retention
Total Pre-Entry + Academic Retention
Outreach Only Cohort

Table 3

Total # Participants Receiving Stipends or Scholarships	Year 1	Year 2	Year 3	Total
Stipends
MS, HS, HS graduates
CNA/LPN/LVN
Pre-Nursing/ Pre-College
College graduates/ Second Degree
Diploma/ AD nurses
BS nurses
Other (specify)
Total Number Stipends
Scholarships
Pre-licensure nursing
RN-BSN
Second Degree BSN or MSN
Bridge or Degree Completion
Other (specify)
Total Number Scholarships
Total Number Stipends + Scholarships

Table 4

Total Budgeted Amount for Stipends or Scholarships	Year 1	Year 2	Year 3	Total
Stipends
MS, HS, HS graduates
CNA/LPN/LVN
Pre-Nursing/ Pre-College
College graduates/ Second Degree
Diploma/ AD nurses
BS nurses
Total Stipend Budget
Scholarships
Pre-licensure nursing
RN-BSN
Second Degree BSN or MSN
Bridge or Degree Completion
Total Scholarship Budget
Total Stipends + Scholarships Budget

Type of Applicant Institution

• Diploma School of Nursing

• Community College/Technical School

• 4-yr College/University

• Other: (please describe) ____________________________________________

Primary Care Training and Enhancement (PCTE) Programs

PCTE Programs: Academic Administrative Units in Primary Care, Physician Faculty Development in Primary Care, Predoctoral Training in Primary Care, Residency Training in Primary Care, Physician Assistant Training in Primary Care.

Table PPA1: MUC Preference

Cascades from Trainee Level.

Trainee Level	Discipline	Required Year 1		Required Year 2
May enter multiple	Not for medical or PA students	Total Graduates or Program Completers	Graduates or Program Completers practicing in MUC	Total Graduates or Program Completers	Graduates or Program Completers practicing in MUC

Table PPA2: Primary Care Priority

Trainee Level	Discipline	Required Year 1		Required Year 2
May enter multiple	Not for medical or PA students	Total Graduates or Program Completers	Graduates or Program Completers practicing primary care	Total Graduates or Program Completers	Graduates or Program Completers practicing in primary care

Table PPA3: Underrepresented Minority Priority

Trainee Level	Discipline	Required Year 1		Required Year 2
May enter multiple	Not for medical or PA students	Total Graduates or Program Completers	Graduates or Program Completers practicing who are URM	Total Graduates or Program Completers	Graduates or Program Completers practicing who are URM

Public Health Traineeship

Rationale: Distribution of Public Health Traineeship grant funds is based on a formula and certain data is needed at the time of application to determine the award amount. The following tables with data variables are requested at the time of application to populate the formula:

Graduate Education Field	Column 1	Column 2
	Full-Time Enrollment (10/15/11)	Credit-Hours of Part-Time Students (10/15/11)
Epidemiology
Environmental Health
Biostatistics
Toxicology
Nutrition
Maternal and Child Health
Others
TOTAL

Public Health Traineeship Trainees Supported from FY 2008 (7/1/11 – 6/30/12)

Col. 1	Col. 2	Col. 3	Col. 4	Col. 5	Col. 6	Col. 7	Col. 8	Col. 9
					LEVEL OF SUPPORT
Area of Specialization	Race/ Ethnicity	Enroll-ment Status FT/PT	Target Degree	Period of Support	Stipend	Tuition and Fees	Transportation	Total
Biostatistics
1
2
Sub-Total
Epidemiology
1
2
Sub-Total
Other
(not listed above)
1
2
Average total award per trainee $_______________________________
Number of Part-Time trainees supported: ________

Graduates Serving in Medically Underserved Communities (MUCs) Trained in Public Health Disciplines

Type of Setting/ Discipline	Biostatistics	Epidemiology	Environmental Health	Toxicology	Nutrition	Maternal & Child Health	Other	Total
Community Health Center
Migrant Health Center
Health Care for the Homeless Center
Public Housing Primary Care Grantees
Rural Health Clinic
NHSC
FQHC
HPSA
Health Departments
Sites Designated By State Governors
Total # of Grads in Settings
Total # of Grads

Public Health Training Centers

Rationale: The applicant must clearly identify the trend in the data as stated in the legislation and funding opportunity announcement in order for the Objective Review Committee to determine the extent to which the applicant has addressed these areas. For competing continuation applicants only.	Year 1	Year 2	Year 3	Year 4
Total Number of Participants trained (excluding student placements)
Of the total Number of Participants, indicate those involved in Distance Learning only
Total Number of field placement for students in public or nonprofit private health agencies or organizations
Of the total number of field placements, indicate the number of participants in medically underserved population.
Range of amount award to students in field placement (low – high)
Average amount of stipend awarded to students in field placement
Total Number of Courses offered
Total Number of Courses offered (Non-Distance Learning)
Total Number of Courses offered (Distance Learning)
Total Number of Health Department Employees trained

Preventive Medicine Residency

Rationale: The information requested in the tables below will be used to assist the Objective Review Committee in their evaluation of the application.

Preventive Medicine Residency Program Applicant Specialty

Preventive Medicine Specialty		Yes	No
1	Preventive Medicine/Public Health
2	Occupational Medicine
3	Aerospace Medicine

Preventive Medicine Residency Program Accreditation Status

Accreditation Status:		Yes	No
1	Not accredited but application for accreditation has been submitted to ACGME
2	Not accredited but application for accreditation has been submitted to AOA
3	Accredited by ACGME
4	Accredited by AOA

Preventive Medicine Residency Program Applicant Type

Applicant Type		Select all that that apply
1	Medical school
2	Osteopathic school
3	Public Health school
4	State, local or tribal health department
5	Private or public nonprofit hospital
6	Consortium

Preventive Medicine Residency Financial Assistance (estimated)

	Year 1	Year 2	Year 3
Estimated # of Trainees for entire program
Estimated # of Trainees that will receive grant support
	Total Amount	Total Amount	Total Amount
Stipends
Tuition/Fees
Travel to Professional Conferences
Other Costs

Scholarships for Disadvantaged Students

Rationale: The currently established Scholarships for Disadvantaged Students (SDS) data elements were previously approved under OMB Approval Number 0915-0149 with an Expiration Date of 11/30/2013.  The SDS application has been revised to be consistent with other pipeline and diversity programs within the Bureau.

If the student is at least 24 years of age and not listed on his or her parents’ income tax for 3 years or more, use the students’ family income rather than his or her parents’ family income.

P ROGRAM SPECIFIC
Fiscal Year:					Application Tracking #:
Program Type:
A. FULL-TIME STUDENTS IN YOUR PROGRAM FOR ACADEMIC YEAR XX/XX/XXXX AND THEIR RACIAL/ETHNIC BACKGROUNDS
Race/Ethnicity	Full-Time Students Enrolled
	1. Hispanic/Latino			2. Non-Hispanic/Non-Latino
a. American Indian/Alaskan Native
b. Asian - all
b1. Asian Underrepresented
c. Black or African American
d. Native Hawaiian or Other Pacific Islander
e. White
f. Unknown
g. More than one race
Sub Total
Grand Total (Sum of Hispanic/Latino Students and Non-Hispanic/Non-Latino Students)
B. TOTAL FULL-TIME ENROLLMENT AND FULL-TIME DISADVANTAGED ENROLLMENT BY CLASS YEAR FOR STUDENTS IN YOUR PROGRAM FOR ACADEMIC YEAR XX/XX/XXXX
Class Year	Total Full-Time Class Enrollment			Total Full-Time Disadvantaged Enrollment
First Year
Second Year
Third Year
Fourth Year
Fifth Year
Sixth Year
Total
Of the number of full-time disadvantaged, how many are economically disadvantaged?
C. TOTAL NUMBER OF FULL-TIME STUDENTS GRADUATED, TOTAL NUMBER OF FULL-TIME STUDENTS GRADUATED THAT RECEIVED SDS FUNDS, AND NUMBER OF FULL-TIME DISADVANTAGED STUDENTS GRADUATED FROM YOUR PROGRAM FOR ACADEMIC YEAR XX/XX/XXXX
Total Full-Time Graduates
Of the number of full time graduates, number of graduates that received SDS
Full-Time Disadvantaged Graduates
Of the number or Full-Time Disadvantaged, how many are economically disadvantaged?
D. GRADUATES FROM YOUR PROGRAM SERVING IN PRIMARY CARE AND/OR MEDICALLY UNDERSERVED COMMUNITIES
Medically Underserved Communities
Total number of Full-Time Graduates during XXXX- XXXX (for discipline 10 and 20)
Total number of Full-Time Graduates during XXXX- XXXX (for non discipline 10 and 20)
Number of Full-Time Graduates in Medically Underserved Communities
Of the Number of Full-Time Graduates in Medically Underserved Communities (above), number of Graduates that received SDS
Primary Care
Total number of Full-Time Graduates during XXXX- XXXX (for discipline 10 and 20)
Total number of Full-Time Graduates during XXXX- XXXX (for non discipline 10 and 20)
Number of Full time graduates in Primary Care
Of the Number of Full - Time Graduates in Primary Care (above), number of graduates that received SDS
E. COST OF TUITION FOR FULL-TIME STUDENTS FOR THIS PROGRAM
Average cost of tuition for one year (average of in-state and out-state) for full-time students for the program
F. LENGTH OF PROGRAM
Length of time (in years) necessary to complete this program
G. ACCREDITATION
Name of Accrediting Body
Expiration Date (mm/dd/yyyy)
H. POINT OF CONTACT
Name
Title
Phone Number
Email
*Note: This form is used to collect additional SDS information.
PERFORMANCE PROGRESS REPORT (SF-PPR-2)
1. Federal Agency and Organization Element to Which Report is Submitted			2. Federal Grant or Other Identifying Number Assigned by Federal Agency	3a. DUNS#		4. Reporting Period End Date
Health Resources and Services Administration (HRSA)			Application #:	3b. EIN
I. REQUESTED AWARD AMOUNT
Award amount requested this budget period
J. STUDENTS SUPPORTED
How many students do you plan to support with the requested award amount
K. PUBLIC OR ANY OTHER NON PROFIT ACCREDITED INSTITUTION
Is your school/program public or any other nonprofit accredited institution?
L. CERTIFICATION AND ELIGIBILITY QUESTIONS
L1. Will preference be given to students for whom the cost of attendance would constitute a severe financial hardship?
L2. Does your program have methods and standards for setting the amounts of scholarships?
L3. Describe the method the program will use to disburse the SDS scholarships to students.
L4. How will you use the SDS scholarship funds?
Codes for question L4.
[X]Tuition
[X]Fees and other reasonable educational expenses
[X]Reasonable living expenses
M. Please indicate what recruitment activities for disadvantaged students that apply to your program by checking all box(s) that apply.
High School Recruitment
General
*	College Fairs
*	Summer camps/programs for high school students to receive information about programs offered
Specifically targeting/recruiting disadvantaged students
*	Attending college fairs in areas with high percentages of disadvantaged students locally or on a broader scale
*	Training recruiters specifically to answer questions and provide information to disadvantaged students.
*	Providing specifically designed information packets on programs and accommodations your school offers for disadvantaged students
*	Prep Courses for disadvantaged high school students interested in careers in the health professions
College Level Recruitment
*	Recruitment from community colleges in disadvantaged areas
*	Community College joint admissions programs for disadvantaged students
Application Services
*	Online programs that wave or assist with application fees for disadvantaged students
Open Houses
*	Booths or presentations on resources for disadvantaged students
*	Targeted advertisements for open houses or other programs in areas with high percentage of disadvantaged students
N. Please indicate what retention and/or mentoring activities for disadvantaged students apply to your program by checking all boxes that apply:
Individual or Group Peer Mentor Program (big brother/big sister)
*	Open to all
*	Specifically designed for disadvantaged students
*	Placing students in peer support or networks and groups
*	Other. Please describe
Individual Staff/Advisor Mentor Program
*	Open to all
*	Specifically designed for disadvantaged students
*	Other. Please describe
Specialized pre-attendance orientation for disadvantaged students
*	Team and camaraderie building activities to help students feel included in the school
*	Educate disadvantaged students on how to best use the accommodations and resources the school provides
*	Introduce forge contacts between disadvantaged students and faculty/staff (ex: Heads of departments, Tutors, Financial aid and/or advisors)
*	Specialized welcome packets for disadvantaged students with additional information on available recourses and programs that will help them succeed
*	Other. Please describe
College Skills Development and Review Programs
*	Summer or pre-matriculation sessions in a classroom setting teaching disadvantaged students skills that they will need to be successful (eg: study skills, note taking skills, test taking skills, and/or time management skills)
*	Summer or pre-matriculation classes for disadvantaged students to review and strengthen prerequisite knowledge of the course work
*	Individual assessment and profile of disadvantaged students strengths and weaknesses with advisor and plan for development of skills
*	Other. Please describe
Early identification for students at risk
*	Identify students who are falling behind early and provide assistance for them in furthering their academic career
*	Develop individualized plans for struggling disadvantaged students to ensure success/coordination support
*	Provide learning specialists for disadvantaged students who can identify possible learning disabilities or assess strengths and weaknesses.
*	Seminars and lectures specifically for disadvantaged students
*	Other. Please describe
Group or Individual Tutoring Services
*	Provide faculty or peer tutors to disadvantaged students
*	Tutors specifically trained to help students faced with struggles from a disadvantaged background.
*	Financial mentoring/tutoring
*	Other. Please describe
Child Care Support
*	Free
*	Partially subsidized
*	Other. Please describe
Professional Opportunities
*	Shadowing health professional
*	Interviewing health professional
*	Other. Please describe
O. Provide a detailed description of your recruitment and retention activities for students of disadvantaged backgrounds, including minority students who enter into the health professions. Discuss activities that provide educational preparation and clinical services preparation.
P. Provide a description of how your school intends to improve the performance of recruiting and retaining students of disadvantaged student including minority students, to enter into the health professions.
Age	Males		Females		Total
	Enrollees		Enrollees
Under 20
20-29
30-39
40-49
50-59
60 or older
Total

State Primary Care Office Program

Question	Number
How many ARRA-funded National Health Service Corp (NHSC) Student Loan Repayment Program (SLRP) clinicians are currently serving within your State?

Training in General, Pediatric, and Public Health Dentistry

Training in General, Pediatric, and Public Health Dentistry programs: Pre-doctoral Training in General, Pediatric and Public Health Dentistry, and Dental Hygiene; Post-doctoral Training in General, Pediatric or Public Health Dentistry; Faculty Development Training in General, Pediatric or Public Health Dentistry and Dental Hygiene; and Dental Faculty Loan Repayment

Rationale: This table offers a standardized reference for reviews of the number and types of trainees proposed to be trained through grant activities.

		NUMBER OF TRAINEES (select one)  student (Predoctoral Training program)  resident (Postdoctoral Training program)  faculty (Faculty Development program)  faculty (Dental Faculty Loan Repayment program -DFLRP)
Discipline	Type of Trainee	Year 1	Year 2	Year 3	Year 4	Year 5
General Dentistry	Total number of trainees
	Target number of underrepresented minority trainees
	Number of trainees receiving direct financial support (if applicable)
	Support for Masters Degree (direct and/or indirect support, if applicable)
Pediatric Dentistry	Total number of trainees
	Target number of underrepresented minority trainees
	Number of trainees receiving direct financial support (if applicable)
	Support for Masters Degree (direct and/or indirect support, if applicable)
Public Health Dentistry	Total number of trainees
	Target number of underrepresented minority trainees
	Number of trainees receiving direct financial support (if applicable)
	Support for Masters Degree (direct and/or indirect support, if applicable)
Dental Hygiene	Total number of trainees
	Target number of underrepresented minority trainees
	Number of trainees receiving direct financial support (if applicable)
	Support for Masters Degree (direct and indirect support, if applicable)

Authority: Title VII, Section 748 (d), Public Health Service Act, as amended by the Affordable Care Act of 2010, Pub. L. 111-148

Student Recruitment Table: Record of Training Individuals from Underrepresented Minority Groups, Rural, or Disadvantaged Backgrounds

Rationale: This table provides a uniform presentation of data to aid in the review of Student Recruitment Priority requests.

1. Category of Program Completers/Graduates		2010 Completers / Graduates	2011 Completers / Graduates	Total 2010 & 2011 Completers / Graduates	2011-2012 Current Trainees / Students
2. Underrepresented Minority Group	American Indian or Alaska Native
	Asian Subgroup (any Asian other than Chinese, Filipino, Japanese, Korean, Asian Indian or Thai)
	Black or African/American
	Hispanic or Latino
	Native Hawaiian or Other Pacific Islander
3. Rural Background
4. Disadvantaged Background	Educational
	Economic
5. Total Underrepresented, Rural, and Disadvantaged Program Completers (Rows 1-4)
6. Total of All Program Completers or Current Trainees
7. Percentage of Program Completers from Underrepresented, Rural, and Disadvantaged (Divide Row 5 by Row 6 and multiply by 100)

See the Grant Program Guidance to determine which Section is appropriate for your program.

Instructions: Student Recruitment Table:

1. For each row enter the number of Graduates or Program Completers in the appropriate column

2. In the Total 2010 & 2011 Completers / Graduates column enter the sum of the 2010 Completers / Graduates and 2011 Completers / Graduates columns.

3. In Row 5 enter the column total

4. In Row 6 enter the total of all Program Completers in the appropriate column. For the last column enter in the number of all Program Completers.

5. In Row 7 enter the result of the following calculations Divide Row 5 by Row 6 and multiply by 100.

“Rural” For the purposes of applying for this priority means either a jurisdiction that is not located in a metropolitan statistical area (MSA), as defined by the Office of Management and Budget http://www.whitehouse.gov/omb/inforeg_statpolicy/ or any jurisdiction located in an MSA, but in a county or tribal jurisdiction that has a population less than 50,000. Special rules apply for independent cities and townships.

“Under-represented minority” is defined as racial and ethnic populations that are underrepresented in the health profession relative to their proportion of the population involved. This definition would include Black or African American, American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, Hispanic or Latino, and any Asian other than Chinese, Filipino, Japanese, Korean, Asian Indian or Thai.

“Disadvantaged background” is applicable to an individual who comes from 1) an environment that has inhibited the individual from obtaining the knowledge, skill, and abilities required to enroll in and graduate from a graduate or undergraduate school or 2) a family with an annual income below a level based on low-income thresholds established by the U.S. Census Bureau, adjusted annually for changes in the Consumer Price Index documented in http://edocket.access.gpo.gov/2011/pdf/2011-6110.pdf. It is the responsibility of each applicant to clearly delineate the criteria used to classify student participants as educationally disadvantaged.

Placement In Practice Settings Priority Table

Purpose: This table provides a uniform presentation of data to aid in the review of Placement in Practice Settings Priority request.

CHC

MHC

Health Care for the Homeless

Public Housing Primary Care Grantees

Rural Health Clinics

NHSC Sites

IHS Sites

FQHCs

Dental HPSAs

Health Depts.

Sites Designated by State Gov.

Total Grads or Prog Comp in MUC settings

Total Grads or Prog Comp

% Grads or Prog Comp in MUC settings

Section A: Program Completers

A: 2009 Program Completers as of July 2009

B: 2010 Program Completers as of July 2010

C: Percentage Increase:

Section B: Graduates (each program completer must devote at least 50% of clinical time in the MUC setting to be counted in that setting)

A: 2006 Graduates as of July 2009

B: 2007 Graduates as of July 2010

C: Percentage Increase:

See the Grant Program Guidance to determine which Section is appropriate for your program.

Authority: Title VII, Section 748(c) (7) and Section 748 (d), Public Health Service Act, as amended by the Affordable Care Act of 2010, Pub. L. 111-148

Placement In Practice Settings Priority Table Instructions

1. Fill out only the appropriate section for your program (see the program guidance for further details).

2. Fill out Line A and/or Line B if you are seeking to qualify under the “High Rate” option.

3. Fill out Lines A, B, and C if you are seeking to qualify under the “Significant Increase” option.

4. For each MUC practice setting column enter the number of program completer/graduates who devoted at least 50% of their clinical time in that setting.

5. Count each individual (program completer/graduate) only once

   1. To be counted as working in a MUC a program completer/graduate must devote at least 50% of their clinical time in an MUC setting

   2. If a program completer/graduate works in multiple MUC settings that combined is a least 50% of their clinical time reporting them in the MUC setting where they spend the most time (if equal choose one).

   3. If a particular work site qualifies as multiple MUC settings (e.g., CHC and HPSA) you may only count the time a program completer/graduate works there once.

6. Enter the sum of the MUC practice Setting Columns in the Total Grads or Prog Comp in MUC settings column.

7. Enter the total number of program completer/graduate for your program into the Total Grads or Prog Comp column. This must be the actual number and not limited to those responding to a survey or questionnaire.

8. % Grads or Prog Comp in MUC settings Column (Lines A and B only): Divide the Total Grads or Prog Comp in MUC settings column by the Total Grads or Prog Comp and multiply the result by 100

9. Line C: If you are seeking to qualify under “Significant Increase”, in the % Grads or Prog Comp in MUC settings column, Subtract Line A from Line B and divide the difference by Line B. Multiply this result by 100 and enter it in Line C

Acronyms Used on this Table:

CHC: Community Health Centers

MHC: Migrant Health Centers

NHSC: National Health Service Corps

HIS: Indian Health Service

FQHC: Federally Qualified Health Centers

DHPSA: Dental Health Professional Shortage Area

MUC: Medically underserved community

Discipline Retention Priority Table

Rationale: This table provides a uniform presentation of data to aid in the review of Placement in Practice Settings Priority requests.

	2007 Program Completers			2008Program Completers
	Total # Program Completers	# Program Completers in general, pediatric, or public health dentistry or dental hygiene as of 7/10	% Program Completers in general, pediatric, or public health dentistry or dental hygiene as of 07/10	Total # Program Completers	# Program Completers in general, pediatric, or public health dentistry or dental hygiene as of 7/11	% Program Completers in general, pediatric, or public health dentistry or dental hygiene as of 7/11
General Dentistry
Pediatric Dentistry
Public Health Dentistry
Dental Hygiene
TOTALS

Instructions:

1. An applicant must report on their two most recent program completer cohorts three years following their completion of training.

2. Report only on the discipline(s) relevant to your program

3. Enter the Total # Program Completers for each cohort

4. For each cohort enter the Total Program Completers who remained in general, pediatric, or public health dentistry or dental hygiene practice three years after their completion or graduation from the program.

5. For each cohort enter the percentage of Program Completers who remained in general, pediatric, or public health dentistry or dental hygiene practice three years after their completion or graduation from the program. Calculate this by dividing the Total Program Completers who remained in general, pediatric, or public health dentistry or dental hygiene practice three years after their completion or graduation from the program by the Total # Program Completers for each cohort and multiply by 100.

State Oral Health Workforce

Rationale: Applications for the State Oral Health Workforce program must address one or more of the following 13 activities. This form provides standardized reference for reviewers to determine which activities are being proposed.

ACTIVITIES
loan forgiveness and repayment programs for dentists who:
A. agree to practice in designated dental health professional shortage areas;
B. are dental school graduates who agree to serve as public health dentists for the Federal, State, or local government; and
C. agree to:
I provide services to patients regardless of such patients’ ability to pay; and
II. use a sliding payment scale for patients who are unable to pay the total cost of services;
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 (42 U.S.C. 1396 et. seq.) to establish or expand practices in designated dental health professional shortage areas by equipping dental offices or sharing in the overhead costs of such practices;
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, such as:
A. the expansion or establishment of a community-based dental facility, free-standing dental clinic, consolidated health center dental facility, school-linked dental facility, or United States dental school-based facility
B. the establishment of a mobile or portable dental clinic; and
C. the establishment or expansion of private dental services to enhance capacity through additional equipment or hours of operation;
D. Other: Specify
placement and support of dental students, dental residents, and advanced dentistry trainees
continuing dental education, including distance-based education
practice support through teledentistry in accordance with State laws;
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 underserved States;
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;
and any other determined to be appropriate by the Secretary: Specify:

Instructions: For each activity being proposed under your application enter an X in the right-hand column. Where sub-categories are available select the appropriate sub-categories. If Activities 5D and 13 are selected enter a brief description of the proposed activities where prompted to “specify”.

Hispanic/Latino and Native American*Any Asian sub-population other than Chinese, Filipino, Japanese, Korean, Asian Indian, or Thai is underrepresented.

1 Choose only one discipline within the School applying and implementing the COE program for the students: Osteopathic, Allopathic, Dentistry, Pharmacy, Veterinary, or graduate School in Behavior and mental Health.

Hispanic/Latino and Native American*Any Asian sub-population other than Chinese, Filipino, Japanese, Korean, Asian Indian, or Thai is underrepresented.

Hispanic/Latino and Native American*Any Asian sub-population other than Chinese, Filipino, Japanese, Korean, Asian Indian, or Thai is underrepresented.

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