Form 1A Rural Underserved or PH practice settings; Graduate data

Appendix A

Table 1A - AENT: Rural, Underserved, or Public Health Practice Settings Data

Graduate Data from 7/01/20XX to 6/30/20XX

Practice Settings	PC-NP	PNMC	NMW Certificate	NMW Master’s	NMW Post- BSN to Doctoral	Grand Total
Community Health Centers
Migrant Health Centers
Health Care for the Homeless Grantees
Rural Health Clinics
National Health Service Corps Sites
Indian Health Service / Tribal Health Sites
Federally Qualified Health Centers
State or Local Health Departments
Ambulatory Practice Sites Designated by State Governors
Health Professional Shortage Areas (HPSAs)
Rural Populations / Settings
Underserved Populations / Settings
1. Total Number of Graduates Employed in these Settings (from 07/01/20XX – 06/30/20XX)
2. Total Number of Graduates (from 07/01/20XX – 06/30/20XX) 07/01/20XX – 06/3020/XX)
3. Percentage of Graduates Employed in these Settings (SFP) (Number 1 divided by Number 2)
4. Percentage of Graduates Employed in HPSAs (SPC) Total Number of HPSAs divided by Total Number of Graduates (from 07/01/20XX-06/30/20XX)

Post Nursing Master’s Certificate students who complete all program requirements are recognized as graduates.

OMB #: 0915-XXXX EXP: XX/XX/20XX

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-XXXX. Public reporting burden for this collection of information is estimated to average XX 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.

Instructions for Completing Table 1A. - AENT: Rural, Underserved, or Public Health Practice Settings Data - Graduate Data from 7/01/20XX to 6/30/20XX

In order to be eligible for the Funding Preference and/or the Special Considerations applicants must complete Table 1A (please see the Funding Preference and Special Consideration information in Section V.2 of this application).

Data on Table 1A should reflect graduate totals for the Master’s and Post Nursing Master’s Certificate Primary Care Nurse Practitioner, Nurse-Midwifery Certificate, Nurse-Midwifery Master’s, and Nurse-Midwifery Post-BSN to Doctoral students who completed program/degree requirements between 07/01/20XX and 6/30/20XX.

Complete Table 1A, as appropriate, providing data on the number of graduates in academic year 7/1/20XX-6/30/20XX who spend at least 50 percent of their employment in clinical practice sites substantially benefiting rural or underserved populations, or in State or local health departments. Each graduate is to be counted only once. Table 1A is used to determine if the institution meets the Statutory Funding Preference and also used to determine if the institution meets the Special Consideration.

In the “Total Number of Graduates Employed in These Settings” row, the system will automatically calculate the total number of graduates per specialty employed in these settings. The grand total will be system generated. This is a subset of “Total Number of Graduates”.

In the “Total Number of Graduates” row, enter the total number of graduates who completed degree requirements between 7/01/20XX and 6/30/20XX in the appropriate column. Enter the grand total: The Grand Total will be system generated. Numbers omitted in this row of Table 1A will not be counted.

In the “Percentage of Graduates Employed in these Settings” row, the system will automatically calculate this figure. Percentage of Graduates Employed in these Settings = Total Number of Graduates Employed in these Settings (from 07/01/20XX – 06/30/20XX) divided by Total Number of Graduates (from 07/01/20XX – 06/30/20XX).

In the “Percentage of Graduates Employed in HPSAs” row, the system will automatically calculate this figure. Percentage of Graduates Employed in HPSA’s = Total Number of HPSAs divided by Total Number of Graduates (from 07/01/20XX-06/30/20XX).

HRSA-14-067