BHPr Performance Measures Forms

Table of Contents
1.

Grant Purpose – Setup ..................................................................................................................................................................................................................................................................................................................................................................... 3

2.

Training Program – Setup ................................................................................................................................................................................................................................................................................................................................................................ 5

3.

PC: Program Characteristics ............................................................................................................................................................................................................................................................................................................................................................. 6
3.1.

PC-1: Program Characteristics – Degree/Diploma/Certificate Training Programs .................................................................................................................................................................................................................................................................. 6

3.2.

PC-2: Program Characteristics – Non-degree bearing Unstructured Training Programs ........................................................................................................................................................................................................................................................ 7

3.3.

PC-3: Program Characteristics – Non-degree bearing Structured Training Programs ............................................................................................................................................................................................................................................................. 8

3.4.

PC-4: Program Characteristics – Internship Programs ............................................................................................................................................................................................................................................................................................................. 9

3.5.

PC-5: Program Characteristics – One Year Retraining Programs ........................................................................................................................................................................................................................................................................................... 10

3.6.

PC-6: Program Characteristics – Fellowship Programs .......................................................................................................................................................................................................................................................................................................... 11

3.7.

PC-7: Program Characteristics – Practica and Field Placements............................................................................................................................................................................................................................................................................................ 12

3.8.

PC-8: Program Characteristics – Residency Programs ........................................................................................................................................................................................................................................................................................................... 13

3.9.

PC-9: Program Characteristics –Positions Description........................................................................................................................................................................................................................................................................................................... 14

3.10.
4.

PC-10: Program Characteristics – Major Participating Sites/Rotation Sites ...................................................................................................................................................................................................................................................................... 15

LR-1: Legislatively Required ........................................................................................................................................................................................................................................................................................................................................................... 16
4.1

LR-1a: Trainees by Training Category..................................................................................................................................................................................................................................................................................................................................... 16

4.2

LR-2: Trainees by Age & Sex ................................................................................................................................................................................................................................................................................................................................................... 17

4.3

DV-1: Trainees by Racial & Ethnic Background ...................................................................................................................................................................................................................................................................................................................... 19

4.4

DV-2: Trainees from a Disadvantaged Background .............................................................................................................................................................................................................................................................................................................. 21

4.5

DV-3: Trainees from a Rural Background .............................................................................................................................................................................................................................................................................................................................. 22

5.

IND-GEN: Individual Characteristics ............................................................................................................................................................................................................................................................................................................................................... 23

6.

INDGEN-PY: Individual Prior Year................................................................................................................................................................................................................................................................................................................................................... 26

7.

EXP: Experiential Characteristics.................................................................................................................................................................................................................................................................................................................................................... 27

8.

9.

7.1.

EXP-1: Training Site Setup ...................................................................................................................................................................................................................................................................................................................................................... 27

7.2.

EXP-2: Training Site Characteristics ....................................................................................................................................................................................................................................................................................................................................... 28

7.3.

EXP-3: Experiential Characteristics - Trainees by Profession/Discipline ................................................................................................................................................................................................................................................................................ 29

7.4.

EXP-4: Experiential Characteristics - Team Based Care ......................................................................................................................................................................................................................................................................................................... 30

CDE: Course and Training Activity Development and Enhancement............................................................................................................................................................................................................................................................................................. 31
8.1.

CDE-1: Course Development and Enhancement - Course Information ................................................................................................................................................................................................................................................................................ 31

8.2.

CDE-1a: Course Development and Enhancement - Log of Courses/Training Activities Implemented .................................................................................................................................................................................................................................. 32

8.3.

CDE-2: Course Development and Enhancement - Trainees by Profession/Discipline ........................................................................................................................................................................................................................................................... 33

CE: Continuing Education ............................................................................................................................................................................................................................................................................................................................................................... 34
9.1.

CE-1: Continuing Education - Course Characteristics and Content........................................................................................................................................................................................................................................................................................ 34
Page 1 of 54

9.2.
10.

CE-2: Continuing Education - Individuals Trained by Profession/Discipline .......................................................................................................................................................................................................................................................................... 35
State Oral Health Workforce...................................................................................................................................................................................................................................................................................................................................................... 36

10.1.

SOHWP-A: New Facilities ................................................................................................................................................................................................................................................................................................................................................... 36

10.2.

SOHWP-B: Expanded Facilities ........................................................................................................................................................................................................................................................................................................................................... 37

10.3.

SOHWP-C: Teledentistry .................................................................................................................................................................................................................................................................................................................................................... 38

10.4.

SOHWP-D: Prevention Services.......................................................................................................................................................................................................................................................................................................................................... 38

10.5.

SOHWP-E: Promotional Events .......................................................................................................................................................................................................................................................................................................................................... 39

10.6.

SOHWP-F: State Dental Offices .......................................................................................................................................................................................................................................................................................................................................... 40

10.7.

SOHWP-G: Other Activities ................................................................................................................................................................................................................................................................................................................................................ 41

11.

Faculty Development ................................................................................................................................................................................................................................................................................................................................................................. 42

11.1.

Faculty Development – Setup ............................................................................................................................................................................................................................................................................................................................................ 42

11.2.

FD-1a: Faculty Development - Structured Faculty Development Training Programs ........................................................................................................................................................................................................................................................ 43

11.3.

FD-1b: Faculty Development - Faculty Trained By Profession/Discipline .......................................................................................................................................................................................................................................................................... 44

11.4.

FD-2a: Faculty Development - Faculty Development Activities ......................................................................................................................................................................................................................................................................................... 45

11.5.

FD-2b: Faculty Development - Faculty Trained By Profession/Discipline .......................................................................................................................................................................................................................................................................... 46

11.6.

FD-3: Faculty Development - Faculty-Student Collaboration Projects .............................................................................................................................................................................................................................................................................. 47

11.7.

FD-4a: Faculty Development - Faculty Instruction............................................................................................................................................................................................................................................................................................................. 48

11.8.

FD-4b: Faculty Development - Faculty Trained by Profession/Discipline .......................................................................................................................................................................................................................................................................... 49

11.9.

FD-5: Faculty Development - Faculty Recruitment ............................................................................................................................................................................................................................................................................................................ 50

12.

CHGME Hospital Data ................................................................................................................................................................................................................................................................................................................................................................ 51

12.1.

CHD-1: CHGME Hospital Data – Hospital Discharge Data .................................................................................................................................................................................................................................................................................................. 51

12.2.

CHD-2: CHGME Hospital Data – Hospital Discharge and Safety Data ................................................................................................................................................................................................................................................................................ 52

12.3.

CHD-3: CHGME Hospital Data – Hospital Discharge Data by Zip Code .............................................................................................................................................................................................................................................................................. 53

13.

PCC: Program Curriculum Changes ............................................................................................................................................................................................................................................................................................................................................ 54

Page 2 of 54

1. Grant Purpose – Setup
The Grant Purpose Setup form captures information about the types of activities conducted by grantees of multipurpose or hybrid programs during the reporting period. Please select the type(s) of activity(ies) that were conducted during the
reporting period with BHW funds and then click ‘Save and Validate’. Also, if you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior
performance report will pop-up in a new screen.

Selections on this form affect all subsequent forms. If you are unsure about which options to select, please refer to the instruction manual and/or contact your Government Project Officer.
PROGRAMS WITH MULTI-SELECT GRANT PURPOSES
Existing grantee who selected a planning year grant in the prior period (Note: Planning year has been selected for less than 12 months – one prior semi-annual period)
View Prior Period Data
Grant Purpose
PAT-1: Plan, develop and operate an education program to train physician assistants to practice in primary care settings
PAT-2: Planning year only

Select
☐
☒

Existing grantee who selected a planning year grant in the prior period (Note: Planning year has been selected for prior 2 semi-annual periods or 1 annual period)
View Prior Period Data
Grant Purpose
PAT-1: Plan, develop and operate an education program to train physician assistants to practice in primary care settings
PAT-2: Planning year only

Select
☐
☐

Existing grantee who did not select/did not have planning year grant in the prior period
View Prior Period Data
Grant Purpose
COE-1: Increase the competitive applicant pool
COE-2: Enhance student performance
COE-3: Improve the capacity for faculty development
COE-4: Facilitate faculty and student research
COE-5: Carry out student training in providing health care services
COE-6: Improve information/curriculum design

Select
☒
☐
☒
☐
☐
☐

Page 3 of 54

PROGRAM WITH SINGLE-SELECT GRANT PURPOSE (NEPQR)
Existing grantee
View Prior Period Data
Grant Purpose

Select

E1: Expanding the enrollment in baccalaureate nursing programs
E2: Providing education in the new technologies, including distance learning methodologies
P1: 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
P2: 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
P3: Providing quality coordinated care, and other skills needed to practice in existing and emerging organized health care systems
P4: Developing cultural competencies among nurses
R1: 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
R2: Developing and implementing internships and residency programs in collaboration with an accredited school of nursing to
encourage mentoring and the development of specialties
R4: Enhancing patient care delivery systems through improving the retention of nurses and enhancing patient care that is directly
related to nursing activities

Page 4 of 54

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

Select One
V
Degree/Diploma/Certificate Academic Training Program (Degree/Diploma)
Non-degree structured training program (Structured)
Non-degree unstructured training program (Unstructured)
One-year retraining program (1 yr. Retraining)
Internship program
Practicum/Field Placement program
Residency program
Fellowship program
Major Participating Site/Rotation Site

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

Single Select

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

Textbox

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

Single Select

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

Single Select

For a Fellowship, Residency, Practicum/Field Placement,
Internship or 1-year Retraining Program, Select the Primary
Discipline of Individuals Trained
For a Major Participating Site/Rotation Site, Select the Program
Name

Single Select

Single Select

Add Record

No.

Record Status

Training Program
(1)

Select Training Activity Status in the
Current Reporting Period
(2)

Option(s)

Page 5 of 54

3. PC: Program Characteristics
3.1.

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

The PC-1 subform collects information specific to Degree/Diploma/Certificate Training Programs only.

PC-1

PC-3

PC-2

View Prior Period Data
No. Record Type of
Status
Training
Program

(1)

Type of
Degree
Offered

(2)

Primary
Focus
Area

(3)

PC-4

Select Delivery
Mode Used to
Offer Program

(4)

PC-5

PC-6

Select
Primary
Discipline
Of Individuals
Trained

Select
Type(s) of
Partners/Co
nsortia
Used to
Offer this
Training

Select Type(s) of
Partners/
Consortia Used
for Job
Placement
Activities

Select
Type of
Collaborat
or

(5)

(6)

(6a)

(6b)

PC-7

PC-8

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

Total

URM

Disadvantaged
Background and
not URM

(7)

(8)

(9)

PC-9

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

(10)

(11)

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

(12)

(13)

Page 6 of 54

3.2.

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

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

The PC-2 subform collects information specific to Non-degree bearing Unstructured Training Programs only.

PC-1
View Prior Period Data
No.
Record
Status

PC-3

PC-2

Type of Training Program

(1)

PC-4

PC-5

PC-6

PC-7

Type of Training Activity

Name of Training Activity

Select Education Level(s) of
Participants

Enter Length of Training
Activity in Clock Hours

(2)

(3)

(4)

(5)

PC-8

PC-9

Select Type(s) of
Partners/Consortia Used to
Offer this Training

(6)

Select Type of
Collaborator

(6a)

Select Training
Activity Status in
the Current
Reporting Period
(7)

Page 7 of 54

3.3.

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

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

The PC-3 subform collects information specific to Non-degree bearing Structured Training Programs only.

PC-1

PC-2

PC-3

View Prior Period Data
No.
Record Type of
Status
Training
Program

(1)

Type of Training Activity

(2)

PC-4

Name of Training
Activity

(3)

PC-5

Select Education
Level(s) of
Participants

(4)

PC-6

Enter Length of
Training Program in
Clock Hours

(5)

PC-7

Select Whether
Public Health
Careers Content
Was Offered

(6)

PC-9

PC-8

Select Whether
Clinical or
Practicum
Training Was
Offered

Select Whether
Cultural Competency
Training Was
Offered

Select Type(s) of
Partners/Consortia
Used to Offer this
Training

Select Training
Activity Status in
the Current
Reporting Period

(7)

(8)

(9)

(10)

Page 8 of 54

3.4.

PC-4: Program Characteristics – Internship Programs

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

The PC-4 subform collects information specific to Internship Programs only.

PC-1

PC-2

PC-3

View Prior Period Data
No.
Record
Type of
Status
Training
Program

(1)

Primary Discipline of
Individuals Trained

(2)

PC-4

PC-5

Select Type(s) of
Partners/Consorti
a Used to Offer
this Training

(3)

PC-7

PC-6

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

PC-8

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

PC-9

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

Total

URM

Disadvantaged
Background and
not URM

Total

URM

Total

URM

(4)

(5)

(6)

(7)

(8)

(9)

(10)

Page 9 of 54

3.5.

PC-5: Program Characteristics – One Year Retraining Programs

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

The PC-5 subform collects information specific to 1-year Retraining Programs only.

PC-1

PC-2

PC-3

View Prior Period Data
No.
Record
Type of Training Program
Status

(1)

PC-4

Primary
Discipline of
Individuals
Trained

(2)

PC-5

Select Type(s) of
Partners/Consort
ia Used to Offer
This Training

(3)

PC-7

PC-6

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

Total

URM

Disadvantaged
Background
and not URM

(4)

(5)

(6)

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

(7)

PC-9

PC-8

(8)

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

URM

(9)

(10)

Page 10 of 54

3.6.

PC-6: Program Characteristics – Fellowship Programs

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

PC-1

PC-3

PC-2

View Prior Period Data
No.
Record Type of Training
Status Program

(1)

Primary Discipline
of Individuals
Trained

(2)

PC-4

PC-5

Select Type(s)
of
Partners/Conso
rtia Used to
Offer this
Training

Select Type of
Collaborator

(3)

(3a)

PC-7

PC-6

PC-9

PC-8

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

Total

URM

Disadvantaged
Background
and not URM

(4)

(5)

(6)

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

(7)

(8)

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

(9)

(10)

Page 11 of 54

3.7.

PC-7: Program Characteristics – Practica and Field Placements

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

PC-1
View Prior Period Data
No.
Record Status

PC-3

PC-2
Type of Training Program

(1)

PC-4

Primary Discipline of Individuals Trained

(2)

PC-5

PC-7

PC-6

Select Type(s) of
Partners/Consortia Used to
Offer this Training

(3)

PC-8

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

PC-9

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

Total

URM

Disadvantaged
Background and
not URM

Total

URM

(4)

(5)

(6)

(7)

(8)

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

(9)

(10)

Page 12 of 54

3.8.

PC-8: Program Characteristics – Residency Programs

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

The PC-8 subform collects information specific to Residency Programs only.

PC-1
View Prior Period Data
No.
Record Status

PC-2
Type of Training
Program

(1)

PC-3

PC-4

Primary Discipline
of Individuals
Trained

Type of Dental
Residency Program

(2)

(3)

PC-5

Select Type(s) of
Partners/Consortia
Used to Offer this
Training

(4)

PC-7

PC-6

Select
Type of
Collab
orator

(4a)

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

Total

URM

(5)

(6)

Disadvantag
ed
Background
and not
URM
(7)

PC-8

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

(8)

(9)

PC-9

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

(10)

(11)

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

(12)

Page 13 of 54

3.9.

PC-9: Program Characteristics –Positions Description

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

The PC-9 subform collects information specific to positions or slots for certain types of primary care training programs.

PC-1

PC-3

PC-2

PC-4

PC-5

PC-7

PC-6

PC-8

PC-9

View Prior Period Data
* Add Academic/Training Year
Select Training Program

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

Select Training Year

Multi Select

Add

No.

Record Status

Type of Training Program

(1)

Training Year

(2)

Enter Total # of Accredited
Positions

Enter Total # of Positions
Recruited For

Enter Total # of Positions
Filled

Enter Total # of Positions
Expanded using BHW Funds

(3)

(4)

(5)

(6)

Enter # of
Residents in FTE
Positions
(7)

Option
(s)

Page 14 of 54

3.10. PC-10: Program Characteristics – Major Participating Sites/Rotation Sites
The Program Characteristics (PC) subforms are designed to collect additional information about the training programs that were offered during the reporting period and were supported with BHW funds. The PC-10 subform collects information
specific to the Major Participating Sites/Rotation Sites identified in the Training Program Setup form. Each line of this subform contains one of the training programs (rotation sites) that was entered in the Training Program Setup form. Please
complete the information requested for each identified Major Participating Site/Rotation Site. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer.
PC-6
View Prior Period Data
No.
Record
Status

PC-8

PC-10

PC-9

Type of Training Program

Program Name

Select Type(s) of
Partners/Consortia
Used to Offer this
Training

Enter # of
Approved
Positions

Enter # of
Recruited
Positions

Enter # of
Approved
Positions
Filled

Enter # of
Residents Rotating
Through Programs

Enter # of Trainees Spending
>= 75% under Children’s
Hospital Supervision

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

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

Page 15 of 54

4. LR-1: Legislatively Required
4.1

LR-1a: Trainees by Training Category

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

View Prior Period Data
No. Record Type of
Status
Training
Program

(1)

Trainees by Training Category

Attrition

Nursing Aide Employment Status and Exam Outcomes

Enter #
of
Ongoing
Trainees

Enter #
of
Enrollees

Enter #
of
Fellows

Enter # of
Residents

Enter # of
Graduates

Enter # of
Program
Completers

Enter # of
Graduates/
Program
Completers

Enter # of
Individuals
who left the
Program
before
Completion

Enter # of
URM who
left the
Program
before
Completion

Enter # of
Individuals
Employed
Full-Time

Enter
# of
Individuals
Employed
Part-Time

Enter # of
Individuals
Unemployed

(1a)

(2)

(3)

(4)

(5)

(6)

(6a)

(7)

(8)

(10)

(11)

(12)

Select
Training
Select
Enter # of Enter # of Activity
Whether
Individuals Individuals Status in
the
Exam
who
who
Assessed All Passed the Failed the Current
Reporting
Competencies
Exam
Exam
Period
(13)

(14)

(15)

(16)
N/A

Page 16 of 54

4.2

LR-2: Trainees by Age & Sex

The LR-2 form captures aggregate-level information about the age groups and sex of trainees who participated in each of the training programs or activities entered in the Training Program Setup form. Please complete this form for each training
program listed below. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period,
click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will autopopulate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".
View Prior Period Data
No. Record Type of
Status
Training
Program

(1)

1
2
3
4
5
6
7

Age Group
of
Trainees

(2)

Prior
Record
Prior
Record
Prior
Record
Prior
Record
Prior
Record

19 and
Under
20 – 29
years
30 – 39
years
40 – 49
years
50 – 59
years

Prior
Record
Prior
Record

60 and
Over
Age Not
Reported

Sex: Male

Sex: Female

Enter # of
Ongoing
Trainees

Enter # of
Enrollees

Enter #
of
Fellows

Enter # of
Residents

Enter # of
Graduates

(2a)

(3)

(4)

(5)

(6)

Enter # of
Graduates/
Program
Completers
(6a)

Enter # of
Program
Completers

Enter # of
Ongoing
Trainees

Enter # of
Enrollees

Enter #
of
Fellows

Enter # of
Residents

Enter # of
Graduates

(7)

(7a)

(8)

(9)

(10)

(11)

Enter # of
Graduates/
Program
Completers
(11a)

Enter # of
Program
Completers
(12)

Page 17 of 54

(Contd)
No.

Record Status

Type of Training Program

(1)

Age Group of
Trainees

(2)

Sex: Not Reported
Enter # of
Ongoing
Trainees
(12a)

Enter # of
Enrollees

Enter # of
Fellows

Enter # of
Residents

Enter # of
Graduates

(13)

(14)

(15)

(16)

Enter # of
Graduates/ Program
Completers
(16a)

Enter # of Program
Completers

Select Training
Activity Status in
the Current
Reporting Period

(17)

(18)

1
2
3
4
5

Prior Record
Prior Record
Prior Record
Prior Record
Prior Record

19 and Under
20 – 29 years
30 – 39 years
40 – 49 years
50 – 59 years

N/A
N/A
N/A
N/A
N/A

6
7

Prior Record
Prior Record

60 and Over
Age Not
Reported

N/A
N/A

Page 18 of 54

4.3

DV-1: Trainees by Racial & Ethnic Background

The DV-1 form captures aggregate-level information about the racial and ethnic background of trainees who participated in each of the training programs or activities entered in the Training Program Setup form. Please complete this form for each
training program entered in the Training Program Setup form. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were
submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the
prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".
View Prior Period Data
No.
Record
Type of Training
Status
Program

(1)

1
2
3
4

5
6
7

Prior
Record
Prior
Record
Prior
Record
Prior
Record
Prior
Record
Prior
Record
Prior
Record

Race Category

(2)

Ethnicity: Hispanic/Latino
Enter # of
Ongoing
Trainees

Enter #
of
Enrollees

Enter #
of
Fellows

Enter # of
Residents

Enter # of
Graduates

(2a)

(3)

(4)

(5)

(6)

Ethnicity: Non-Hispanic/Non-Latino
Enter # of
Enter # of
Graduates/
Program
Program
Completers
Completers

(6a)

(7)

Enter # of
Ongoing
Trainees

Enter # of
Enrollees

Enter # of
Fellows

Enter # of
Residents

Enter # of
Graduates

(7a)

(8)

(9)

(10)

(11)

Enter # of
Enter # of
Graduates/
Program
Program
Completers
Completers

(11a)

(12)

American Indian
or Alaska Native
Black or African
American
Asian
Native Hawaiian
or Pacific
Islander
White
More than one
Race
Race Not
Reported

Page 19 of 54

(Contd)
No.

Record Status

Type of Training Program

(1)

1

Prior Record

2
3
4

Prior Record
Prior Record
Prior Record

5
6
7

Prior Record
Prior Record
Prior Record

Race Category

(2)

American Indian or Alaska
Native
Black or African American
Asian
Native Hawaiian or Pacific
Islander
White
More than one Race
Race Not Reported

Ethnicity: Not Reported
Enter # of
Ongoing
Trainees

Enter # of
Enrollees

Enter # of
Fellows

Enter # of
Residents

Enter # of
Graduates

Enter # of Graduates/
Program Completers

Enter # of
Program
Completers

(12a)

(13)

(14)

(15)

(16)

(16a)

(17)

Select Training Activity
Status in the Current
Reporting Period

(18)

N/A
N/A
N/A
N/A
N/A
N/A
N/A

Page 20 of 54

4.4

DV-2: Trainees from a Disadvantaged Background

The DV-2 form captures aggregate-level information about the disadvantaged background status of trainees who participated in each of the training programs or activities entered in the Training Program Setup form. Please complete this form for
each training program listed below. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior
reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period
will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".
View Prior Period Data
No Recor Type of
.
d
Trainin Enter Total #
Status g
from
Progra
Disadvantag
m
ed
Background

(1)

(2)

Enrollees
Enter
Total #
Where
Backgroun
d is Not
Reported

Enter # from
Disadvantag
ed
Background
who are not
URM

(2a)

(3)

Enter Total #
from
Disadvantag
ed
Background

Fellows
Enter
Total #
Where
Backgroun
d is Not
Reported

Enter # from
Disadvantag
ed
Background
who are not
URM

(4)

(4a)

(5)

Enter Total #
from
Disadvantag
ed
Background

Residents
Enter
Total #
Where
Backgroun
d is Not
Reported

Enter # from
Disadvantag
ed
Background
who are not
URM

(6)

(6a)

(7)

Enter Total #
from
Disadvantag
ed
Background

Graduates
Enter
Total #
Where
Backgroun
d is Not
Reported

Enter # from
Disadvantag
ed
Background
who are not
URM

(8)

(8a)

(9)

Program Completers
Enter Total #
Enter
Enter # from
from
Total #
Disadvantag
Disadvantag
Where
ed
ed
Backgroun Background
Background
d is Not
who are not
Reported
URM
(10)

(10a)

(11)

(Contd)
No.

Record Status

Type of Training
Program

(1)

Program Completers
Enter Total #
Enter Total #
Enter # from
from
Where
Disadvantaged
Disadvantaged Background is
Background
Background
Not Reported
who are not
URM
(10)

(10a)

(11)

Enter Total #
from
Disadvantaged
Background

Ongoing Trainees
Enter Total #
Where
Background is
Not Reported

Enter # from
Disadvantaged
Background who
are not URM

(12)

(12a)

(13)

Graduates/Program Completers
Enter Total #
Enter Total #
Enter # from
from
Where
Disadvantaged
Disadvantaged
Background is
Background who
Background
Not Reported
are not URM

(14)

(14a)

(15)

Select Training
Activity Status
in the Current
Reporting
Period

(12)

Page 21 of 54

4.5

DV-3: Trainees from a Rural Background

The DV-3 form captures aggregate-level information about the number of trainees who participated in each of the training programs or activities entered in the Training Program Setup form and are from a rural background. Please complete this
form for each training program entered in the Training Program Setup form. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view
data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or
activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".
View Prior Period Data
No. Record Type of
Status Training
Program

(1)

Trainees from Rural Residential Background
Enter # of
Enter # of
Enter # of
Enter # of
Enrollees
Enrollees
Fellows
Fellows
from a
Where
from a
Where
Rural
Background
Rural
Background
Background
is Not
Background
is Not
Reported
Reported

(2)

(2a)

(3)

(3a)

Enter # of
Residents
from a Rural
Background

Enter # of
Residents
Where
Background
is Not
Reported

Enter # of
Graduates
from a Rural
Background

(4)

(4a)

(5)

Enter # of
Enter # of
Enter # of
Graduates
Program
Program
Where
Completers Completers
Background
from a
Where
is Not
Rural
Background
Reported Background
is Not
Reported
(5a)

(6)

(6a)

Enter # of
Ongoing
Trainees
from a Rural
Background

Enter # of
Ongoing
Trainees
Where
Background
is Not
Reported

Enter # of
Graduates/
Program
Completers
from a Rural
Background

Enter # of
Graduates/
Program
Completers
Where
Background is
Not Reported

(7)

(7a)

(8)

(8a)

Select
Training
Activity
Status in
the
Current
Reporting
Period

(7)

Page 22 of 54

5. IND-GEN: Individual Characteristics
The IND-GEN form captures individual-level information about students, faculty, or other types of awardees who either received direct financial support (e.g., loans, loan repayment, scholarships, or stipends) through a HRSA grant or participated in
specific types of HRSA-supported training. Please complete this form in its entirety. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to
view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs
or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".
* Do you either have a) students or faculty who received direct financial support (e.g., scholarships,
stipends, loans, loan repayment) from a HRSA-funded grant and/or students who participated in
community-based primary care training during this reporting period; OR b) updates to provide for students
who received direct financial support and/or participated in community-based primary care training in a
previous reporting period Yes
View Prior Period Data
No.
Record
Type of Training
Status
Program

(1)

(complete IND-GEN)

Yes

No

(click Save and Validate button to proceed to the next form)

Trainee
Unique ID

NPI Number

Select Individual's
Training or
Awardee Category

Select Whether
Individual is an
International
Medical
Graduate (IMG)

Select Individual's
Enrollment /
Employment
Status

Select
Individual's
Sex

Select
Individual's
Age Group

Select
Individual's
Ethnicity

Select
Individual's
Race

Select Whether
Individual is
from a Rural
Residential
Background

Select Whether
Individual is from
a Disadvantaged
Background

Select
Individual's
Veteran
Status

(2)

(2a)

(3)

(3a)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(11)

(Contd)
Select
Whether
Individual
Received
BHW
Financial
Award
(12)

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

Stipend

Tuition,
Fees,
and
Supplies

Traineeship

Scholarship

Loan

Career
Award

Loan
Repayme
nt

Grant

Fellowship

Direct
Financial
Support

Current
Reporting
Period
Total

Academic
Year Total

Cumulative
BHW
Financial
Award Total

(12a)

(13)

(13a)

(14)

(15)

(16)

(17)

(18)

(19)

(20)

(20a)

(21a)

(21b)

(21c)

Page 23 of 54

(Contd)
Enter # of
Academic
Years the
Individual
has
Received
BHW
Funding

(22)

Enter
Balance of
Individual's
Loan

Enter % of
Loan Paid
Off

(23)

(24)

Enter % FTE
paid for
through
BHW
Financial
Award

(25)

% of training
costs
covered
through
BHWfunded
financial
award

Select
Individual's
Academic or
Training
Year

(25a)

(26)

Select
Individual'
s Primary
Discipline

(27)

Training in a Primary Care Setting

Training in a
Medically
Underserved Area

Training in a Rural
Area

Student Services

Select
Whether
Individual
Received
Training

Enter #
of
Contact
Hours

Enter # of
Patient
Encounter
s

Select
Whether
Individual
Received
Training

Enter # of
Contact
Hours

Select
Whether
Individual
Received
Training

Enter #
of
Contact
Hours

Select Social
Support
services
used by
Trainee

(28)

(29)

(30)

(31)

(32)

(33)

(34)

(34a)

Select
Individual's
Field
Placement
Setting

Select
Academic
Support
services
used by
Trainee
(34b)

(35)

(Contd)
Select
Select
Select
Select
Select
Select
Whether
Whether
Degree whether
whether
Individual's
Individual
Individual Earned individual
individual
PostLeft the
Graduated/
earned
took and
Graduation/
Program
Completed
degree
passed a
Completion
Before
the
oncertifying
Intentions
Completion
Program
schedule/ examination
on-time
on the first
attempt

(36)

(37)

(38)

(38a)

(38b)

(39)

Enter the % FTE Individual Spent on the Following Roles

Research

Teaching

Administration

Clinical

(40)

(41)

(42)

(43)

Enter # of
Enter # of
Articles
PeerPublished
Reviewed
in PeerConference
Reviewed Presentations
Journals

Enter # of Grants Awarded by Type and Amount

Research
Research
Education
Education
(<$100,000) (>=$100,000) (<$100,000) (>=$100,000)
(44)

(45)

(46)

(47)

(48)

(49)

Page 24 of 54

(Contd)
Enter Total
Time Obligated
to Serve (in
weeks)

Select
Individual's
Current
Designated
Practice
Settings

Select Whether
individual is
Enrolled in
Medicaid/CHIP
Program

Select Whether
individual is
Accepting new
Medicaid/CHIP
Patients

Enter Total # of
Patient
Encounters

Enter # of
Medicaid/CHIP
Patient
Encounters

Select whether
Employment
Data is
available?

City

State

Zip Code

Type of Employment

(50)

(51)

(52)

(53)

(54)

(55)

(56)

(57)

(58)

(59)

(60)

Option(s)

Page 25 of 54

6. INDGEN-PY: Individual Prior Year
The INDGEN-PY subform captures 1-year follow-up information about individuals who received direct financial support (e.g., loans, loan repayment, scholarships, or stipends) through a HRSA grant or participated in specific types of HRSA-supported
training programs and have since graduated or completed their training. Please complete this form for each individual listed below. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact
your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen.
View Prior Period Data
No. Record Type of
Status Training
Program

(1)

Trainee
Unique
ID

Select
Individual's
Training or
Awardee
Category

Select
Individual's
Enrollment /
Employment
Status

Select
Individual's
Sex

Select
Individual's
Age Group

Select
Individual's
Ethnicity

Select
Individual's
Race

Select
Whether
Individual is
from a Rural
Residential
Background

Select Whether
Individual is
from a
Disadvantaged
Background

Select
Degree
Earned

Select
Individual's
PostGraduation/
Completion
Intentions

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

Select
Individual's
Current
Training/
Employment
Status

Select
Individual's
Type of
Faculty
Appointment

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(11)

(12)

(13)

(14)

(15)

Page 26 of 54

7. EXP: Experiential Characteristics
7.1.

EXP-1: Training Site Setup

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

EXP-2

EXP-3

EXP-4

View Prior Period Data

* Add Site
Enter the Site's Name

Textbox, 200 characters

Add Record

No.

Record Status

Site Name

(1)

Select Whether the Site
was Used in the Current
Reporting Period
(2)

Select Type of Site
Used
(3)

Select Type of
Setting Where the
Site was Located
(4)

City

State

Zip Code

(8)

(9)

(10)

Four Digit
Zip Code
Extension
(11)

Delivery Model

Payment Model

(12)

(13)

Option(s)

Page 27 of 54

7.2.

EXP-2: Training Site Characteristics

The EXP-2 subform collects general information about each site that was entered in the EXP-1 Setup form. Please complete this subform for each training site listed below. If you have any questions about how to complete this subform, please refer to
the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior
performance report will pop-up in a new screen. Also, records about sites used in a prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".
EXP-1
View Prior Period Data
No.
Record
Status

EXP-2

Type of
Training
Program

(1)

EXP-3

EXP-4

Site Name

Select Type of
Site Used

Select Type of
Setting Where
the Site was
Located

Select Type(s) of
Partners/Consortia
used to Offer Training
at this Site

Select Primary
Training
Competency
Addressed at this
Site

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

City

State

Zip Code

Four Digit
Zip Code
Extension

Delivery
Model

Payment
Model

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(11)

(12)

(13)

Option(s)

Page 28 of 54

7.3.

EXP-3: Experiential Characteristics - Trainees by Profession/Discipline

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

Individuals reported in this subform should be those captured in LR-1a or IND-GEN.

.

EXP-1

EXP-3

EXP-2

View Prior Period Data
No.
Type of Training
Program

(1)

EXP-4

Site Name

Select Profession
and Discipline of
Individuals Trained

Enter # Trained in this
Profession and Discipline

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

(2)

(3)

(4)

(5)

Option(s)

Page 29 of 54

7.4.

EXP-4: Experiential Characteristics - Team Based Care

The EXP-4 subform captures information about the number and types of interprofessional teams used at each site that was entered in the EXP-1 Setup form. Please complete this subform for each training site below. If you have any questions about
how to complete this subform, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a readonly version of your most recent prior performance report will pop-up in a new screen.

Individuals reported in this subform should not be captured in EXP-3.

EXP-1

EXP-2

View Prior Period Data
No.
Type of Training Program

(1)

EXP-3

EXP-4

Site Name

Select Team
Number

(2)

(3)

Select Profession and
Discipline of Team
Members
(4)

Enter # of Team Members
in this Profession and
Discipline
(5)

Option(s)

Page 30 of 54

8. CDE: Course and Training Activity Development and Enhancement
8.1.

CDE-1: Course Development and Enhancement - Course Information

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

CDE-1

CDE-2

* Have you used BHW resources or received in-kind support to develop or
enhance a course or other training activity associated with the grant Yes

Yes

(complete CDE-1 and CDE-2)

No

(Click Save and Validate to proceed to the next form)

View Prior Period Data

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

(text 200 chars)

Add Record

No.

Record
Status

Name of
Course or
Training
Activity

(1)

Select Type of
Course or Training
Activity

Select whether Course
or Training Activity
was Newly Developed
or Enhanced

Select Status of
Development
or
Enhancements

(2)

(3)

(4)

For Courses or Training
Activities Implemented,
Enter Academic Year of
First Implementation
From
To Year
Year
(5)

(6)

Enter the
Curriculum
the Course or
Training
Activity is
Associated
With
(7)

Select the
Primary
Competency
Addressed
by the
Course

Select Delivery Mode
Used to Offer this
Course or Training
Activity

Enter Site Name
from EXP-1 Where
Implemented

Select which
training
programs are
associated with
this course or
training activity

(7a)

(8)

(9)

(10)

Option(s)

Page 31 of 54

8.2.

CDE-1a: Course Development and Enhancement - Log of Courses/Training Activities Implemented

The CDE-1a subform stores a running log of courses or training activities that were developed or enhanced using BHW funds and have been implemented in a prior reporting period. Information regarding each course or training activity that was
developed or enhanced using BHW and implemented in a prior reporting period has been auto-populated from the CDE-1 table. Please complete this subform regarding the continued use of each course or training activity in your institution. If you
wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training
programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".

CDE-1a

CDE-1
View Prior Period Data
No. Record
Name of
Status
Course or
Training
Activity

(1)

CDE-2

Select Type of
Course or Training
Activity

Select whether Course
or Training Activity
was Newly Developed
or Enhanced

Select Status of
Development
or
Enhancements

(2)

(3)

(4)

For Courses or Training
Activities Implemented,
Enter Academic Year of
First Implementation
From
To Year
Year
(5)

(6)

Enter the
Curriculum
the Course or
Training
Activity is
Associated
With
(7)

Select the
Primary
Competency
Addressed
by the
Course

Select Delivery Mode
Used to Offer this
Course or Training
Activity

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

Enter Site Name
from EXP-1
Where
Implemented

Select which training
programs are
associated with this
course or training
activity

(7a)

(8)

(9)

(10)

(11)

Page 32 of 54

8.3.

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

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

Although you were allowed to report courses or training activities developed or enhanced in previous academic years, only report individuals who participated in these courses or training activities during the current academic year.

CDE-1

CDE-2

CDE-1a

View Prior Period Data

* Add Profession/Discipline
Name of Course or Training Activity

Populated with CDE-1 Data

Profession and Discipline of Individuals Trained

(Multi-Select)

Add Record

No.

Name of Course or Training
Activity
(1)

Profession and Discipline of
Individuals Trained
(2)

Enter # Trained in this Profession
and Discipline
(3)

Option(s)

Page 33 of 54

9. CE: Continuing Education
9.1.

CE-1: Continuing Education - Course Characteristics and Content

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

Report each individual course only once and indicate the number of times offered within this subform.
CE-1

CE-2

* Did you use BHW funds to support one or more continuing education
offerings Yes
View Prior Period Data
No. Record
Course
Status
Title

(1)

Select the Course's Primary
Topic Area
(12)

Select Whether
the Course was
Offered in the
Current Reporting
Period

(1a)

Select
Whether
Course is
Approved for
Continuing
Education
Credit
(2)

Select the Primary
Competency Addressed
by the Course
(13)

Yes

(complete CE-1 and CE-2)

No

(Click Save and Validate to proceed to the next form)

Enter the
Duration of
the Course in
Clock Hours

Enter # of
Times
Course was
Offered

Select Delivery
Mode Used to
Offer Course

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

Select Whether
Employment Location
Data are Available for
Individuals Trained

(3)

(4)

(5)

(6)

(8)

Select the Competency Tier for this
Course

Select Whether Supplemental Funding for
Alzheimer's Disease-Related Training was
used for this Course

(14)

(15)

Enter # of Individuals Trained by
Employment Location
(not mutually exclusive)
Primary Care
Medically
Rural
Setting
Underserved
Area
Community
(9)

(10)

(11)

Option(s)

Page 34 of 54

9.2.

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

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

CE-2

View Prior Period Data
No.
Course Title

Select Profession and Discipline of
Individuals Trained
(1)

(2)

Enter # Trained in this Profession and Discipline

Option(s)

(3)

Page 35 of 54

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

SOHWP-B

SOHWP- D

SOHWP-C

* Did your program establish new dental facilities in a
HPSA/Underserved area (Block 1)

Yes

SOHWP-E

SOHWP-F

(complete SOHWP-A)

No

SOHWP-G

(Click Save and Validate to proceed to the next form)

View Prior Period Data

* Add Facility
Facility name

(Textbox 100 chars)

Add Record

No.

Facility Name

(1)

Select the Type of Facility

(2)

Select Type(s) of
Oral Health
Services Provided

(3)

Enter # of Patient
Encounters

(4)

Select whether
this is a
Mobile/Portable
Facility

Option(s)

(5)

Page 36 of 54

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

SOHWP-B

SOHWP-C

SOHWP-D

* Did your program expand existing dental facilities in a
HPSA/Underserved area (Block 2)

Yes

SOHWP-E

(complete SOHWP-B)

SOHWP-F

No

SOHWP-G

(Click Save and Validate to proceed to the next form)

View Prior Period Data

* Add Facility
Facility name

(Textbox 100 chars)

Add Record

No.

Facility Name

(1)

Select the Type
of Facility

(2)

Select the
Type(s) of Oral
Health Services
Provided

(3)

Enter Average # of Patient
Encounters Prior to Expansion

Enter Actual # of Patient
Encounters Post
Expansion

Enter Average # of
Patient Encounters
Facility can
Accommodate

(4)

(5)

(6)

Select whether
this is a
Mobile/Portable
Facility

Option(s)

(7)

Page 37 of 54

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

SOHWP-A

SOHWP-B

SOHWP-C

SOHWP- D

SOHWP-E

SOHWP-F

SOHWP-G

5b
View Prior Period Data
* Add Teledentistry Program Details

Number of Dental Facilities with Teledentistry Capabilities (Block 3)

3 digits
3 digits

Number of Teledentistry Encounters Involving Patient Care (Block 4)
3 digits
Number of Teledentistry Sessions Involving Training (Block 5)

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

SOHWP-A

SOHWP-B

SOHWP- C

SOHWP-D

SOHWP-E

SOHWP-F

SOHWP-G

View Prior Period Data
* Community-Based Prevention Services Details
Enter # of New Water Systems with Fluoridated Water (Block 6)

(text 3 digits)

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

(text 2 digits)

Enter Estimated # of Residents Served (Block 8)

(text 7 digits)

Enter # of Children Receiving Dental Sealants (Block 9)

(text 5 digits)

Enter # of Individuals Receiving Topical Fluoride (Block 10)

(text 5 digits)

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

(text 5 digits)

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

(text 5 digits)

Page 38 of 54

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

SOHWP-A

SOHWP-B

SOHWP- C

SOHWP-D

SOHWP-E

SOHWP-F

SOHWP-G

View Prior Period Data

* Add Type of Promotional Event
Promotional Event

Multi select

Add Record

No.

Type of
Promotional
Event

(1)

Enter #
Promotional
Events Held

(2)

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

(3)

Enter Total # of Children
Who Attended
Promotional Events

(4)

Select Type(s) of
Materials Created for
Promotional Events

Option(s)

(5)

Page 39 of 54

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

SOHWP-A

View Prior Period Data
Select whether a Select whether a
new state dental new state dental
office was created officer position
was created

(1)

SOHWP- C

SOHWP-B

(2)

SOHWP-D

SOHWP-E

SOHWP-G

SOHWP-F

Enter # of new support staff members hired

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

Administrative

Dentists, Dental
Hygienists, Oral
Health Coordination

Fluoridation
Expert

Epidemiologist

Statistician

Other

Administra
tive

Dentist, Dental
Hygienist Oral
Health Coordination

Fluoridation
Expert

Epidemiologist

Statistician

Other

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(11)

(12)

(13)

(14)

Page 40 of 54

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

SOHWP-A

SOHWP-B

SOHWP- C

SOHWP-D

SOHWP-E

SOHWP-F

SOHWP-G

View Prior Period Data
Policy (Block 22)

Multi-line text box (5000 chars)

Grants Contracts (Block 22)

Multi-line text box (5000 chars)

Strategic Efforts (Block 22)

Multi-line text box (5000 chars)

Partnerships (Block 22)

Multi-line text box (5000 chars)

Training (Block 22)

Multi-line text box (5000 chars)

Prevention Activity (Block 22)

Multi-line text box (5000 chars)

Workforce Development (Block 22)

Multi-line text box (5000 chars)

Direct Financial Support (Block 22)

Multi-line text box (5000 chars)

Other (Block 22)

Multi-line text box (5000 chars)

Page 41 of 54

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

Selections in this form will affect all subsequent faculty-related forms.
View Prior Period Data
Faculty Development Activities
Structured Faculty Development Training Program
Faculty Development Activity
Faculty-Student Research or Collaboration Project
Faculty Instruction
Faculty Recruitment Activities
No faculty-related activities conducted

☐
☒
☒
☒
☐
☐

Page 42 of 54

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

FD-1a

FD-1b

View Prior Period Data

* Add Structured Faculty Development Program
Program Name

Textbox (200 char)

Add Record
No.

Record Status

Program
Name

(1)

Select
Program
Status in
the
Current
Reporting
Period
(1a)

Select
Whether this
was a Degree
Bearing
Program

(2)

For Degree-bearing
Programs
Select
Select Primary
Type of
Focus Area
Degree
Offered
(3)

(4)

For NonDegree
Bearing
Program,
Enter Length
of Training
Program in
Clock Hours
(5)

Enter the % of Time Spent Developing Competencies for the
Following Roles
Clinician
Administrator
Educator
Researcher

(6)

(7)

(8)

(9)

Enter # of
Faculty Who
Completed
the Program

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

(10)

(11)

Option(s)

Page 43 of 54

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

FD-1b

View Prior Period Data

* Add Training Program and Discipline
Program Name

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

Select Profession and Discipline of
Faculty Trained

Multi-Select

Add Record

No.

Program Name

Profession and Discipline of Faculty Trained

(1)

(2)

Enter # Trained in this Profession and Discipline

Option(s)

(3)

Page 44 of 54

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

FD-2a

FD-2b

View Prior Period Data

* Add Faculty Development Activities
Activity Name
Textbox (200 char)

Add Record

No.

Activity
Name

(1)

Select Type of
Faculty
Development
Activity Offered

(2)

For Courses or Workshops
Select Whether Activity is
Accredited for Continuing
Education Credit
(3)

Select Whether
Attendance was to
Acquire or Maintain
Professional Certification
(4)

Enter Duration
of Training
Activity in Clock
Hours

(5)

Select Delivery
Mode Used to
Offer Training
Activity

(6)

Select the
Faculty Role(s)
Addressed at
Training
Activity

Option(s)

(7)

Page 45 of 54

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

FD-2a

FD-2b

View Prior Period Data

* Add Activity Name and Discipline
Activity Name

Select Profession and Discipline of
Faculty Trained

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

Add Record

No.

Activity Name

(1)

Profession and Discipline of
Faculty Trained
(2)

Enter # Trained
in this Profession
and Discipline

Option(s)

(3)

Page 46 of 54

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

* Add Collaboration Projects
Project Name

Textbox (200 char)

Add Record

No.

Record
Status

Project
Name

Select Project
Status in the
Current Reporting
Period

Describe the FacultyStudent Project

Select the
Purpose of
the Project

Enter # of Faculty
Members Involved in
the Project

Total
(1)

(1a)

(2)

(3)

(4)

URM
(5)

Enter # of Students
Involved in the Project

Total
(6)

URM
(7)

Select whether
any Faculty
Received any
type of BHWFunded
Financial Award

Option(s)

(8)

Page 47 of 54

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

FD-4b

View Prior Period Data

* Add Courses/Workshops
Enter the Name of the Course or
Workshop Offered by the Faculty

Textbox (200 char)

Add Record

No.

Record Status

Name of the
Course or
Workshop
Offered by the
Faculty
(1)

Select Whether
the
Course/Workshop
was Offered in
the Current
Reporting Period
(1a)

Select the
Content Area
Of the
Course or
Workshop
(2)

Enter the Length
of the Course or
Workshop
in Clock Hours

(3)

Enter # of Times
the Course or
Workshop was
Offered

(4)

Select the Delivery
Mode Used to Offer
the Course or
Workshop

Option(s)

(5)

Page 48 of 54

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

FD-4b

View Prior Period Data

* Add Profession/Discipline
Name of the Course or Workshop
Offered by the Faculty
Profession and Discipline of
Individuals Trained

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

Add Record

No.

Name of the Course or
Workshop Offered by
the Faculty
(1)

Profession and
Discipline of
Individuals Trained
(2)

Enter # Trained in
this Profession and
Discipline

Option(s)

(3)

Page 49 of 54

11.9. FD-5: Faculty Development - Faculty Recruitment
Answer each question below for the reporting period. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will popup in a new screen.
View Prior Period Data

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

(text 3 digits) 12

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

(text 3 digits) 5

Enter # of Faculty Positions Retained (Block 23c)

(text 3 digits) 10

Page 50 of 54

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

CHD-2

CHD-3

View Prior Period Data
General Information
Medicare Provider Number

* Year hospital first received funding

Text Box

* How many outside institutions send residents to your hospital?

Text Box

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

Yes

(complete table below)

No

(Click Save and Validate to
proceed to the next form)

* Hospital Discharge Data by Payor
No.
1
2
3
4
5
6

Payor
(1)

Enter # of Inpatient Discharges
(2)

Enter # of Outpatient Visits
(3)

Enter # of Emergency Department Visits
(4)

Private Insurance
Medicaid and/or CHIP
Medicare
Other Public (TRICARE, Indian Health Service)
Self-Pay
Uncompensated Care
Total

Page 51 of 54

12.2. CHD-2: CHGME Hospital Data – Hospital Discharge and Safety Data
Please answer the lead question below. If your children’s hospital has any patient safety initiatives in place during the most recently completed academic year, answer ‘Yes’ and proceed to complete this form. If not, please answer ‘No’ and click ‘Save
and Validate’ to proceed to the next required form. If ‘Yes’ was answered, please select all patient safety initiatives your children’s hospital utilized. You may add additional ones not listed. Please click ‘Add Record’ after each selection. Each selected
initiative will form a line on the table. Then indicate whether your children’s hospital utilized the selected initiatives in the most recently completed academic year (July 1 – June 30) and if any changes in the initiatives have occurred since the previous
academic year. Also, please select all applicable reasons for the change and resulting benefits from any change(s) in the following columns. Please refer to the instruction manual and/or contact your Government Project Officer if you have any
questions about how to complete this form.
CHD-1

CHD-2

CHD-3

All fields with * are required

* Did your children’s hospital have any patient safety initiatives in place in
the most recently completed academic year? Yes

Yes

(complete CHD-2)

No

(Click Save and Validate to proceed to the next form)

View Prior Period Data
Add Patient Safety Initiative (add all that apply)

* Patient Safety Initiative

Single Select Dropdown Box

If Other, specify

Text Box

Add Record

No.

Patient Safety Initiative

(1)
1
2
3

Root cause or error analysis
Chart audits
Mandatory error disclosure

4

Reducing hand-offs

5

Other: test initiative

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

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

Reasons for
Change

Benefits of
Initiative

(2)

(3)

(4)

(5)

Option(s)

Page 52 of 54

12.3. CHD-3: CHGME Hospital Data – Hospital Discharge Data by Zip Code
Please complete the following steps to enter locality data identifying the number of hospital discharges by zip code. First, download the excel template to enter the required data (see link below; alternatively, you can contact your Government
Project Officer to acquire this template). Note that the structure of the Excel template must not be altered (i.e., do not add/remove/edit/rearrange columns or column headers). Complete each row of data entry by reporting (a) each zip code used
by your program and (b) the corresponding number of hospital discharges. If you are reporting an overseas zip code, use code “88888”. If the zip code is unknown, enter “00000”.
When you have completed data entry using the template, save your work to a local folder and follow the instructions to upload this file into BPMH (e.g., using the browse function to select your file from your local folder). Once your file has been
uploaded, select the “Process Data” button, which will populate the table below with the data you entered into the excel template (i.e., zip codes and discharge counts). Next, select the “Save” button to automatically populate the city and state
fields (based on the zip codes you have provided) and run the form validations. Errors in editable fields will be identified with a “Row” number and can be corrected either (a) within the BMPH system or (b) corrected in the original excel template and
then re-uploaded. (Note- once uploaded into BMPH, template data cannot be downloaded back into an Excel format). After you have verified that all data are present and accurate, select the Save/Validate button to proceed to the next subform.
Please refer to the instruction manual and/or contact your Government Project Officer if you have any questions about how to complete this form.

No.

CHD-3

CHD-2

CHD-1

Zip Code

City

State

Number of
Inpatient
Discharges

(1)

(2)

(3)

(4)

Option(s)

Page 53 of 54

13. PCC: Program Curriculum Changes
Please list all courses and training activities implemented by your residency or fellowship program as part of its training/curriculum in the most recent academic year. Be sure to list all courses and training activities related to quality improvement and
measurement, cultural competency, primary care, underserved populations, oral health, community health, diversity, etc. You do not need to list standard curriculum mandated for accreditation unless it falls into a category mentioned above. For all
identified training activities/curriculum, indicate whether the topic was newly developed or enhanced since the previous year, select the standard topic area, and delivery mode. Also, please select the training sites where the curriculum was
implemented from the list you indicated on the EXP form.
View Prior Period Data
No.

Select Residency Program Name

(1)

Enter the Name of
Course or Training
Activity

(2)

Select Type of
Course or
Training Activity

Select whether
Course or Training
Activity was Newly
Developed or
Enhanced

Select Topic
Area

Select Topics in
Quality Improvement
and Measurement

Enter the
Curriculum the
Course or Training
Activity is
Associated With

Select Delivery
Mode Used to Offer
this Course or
Training Activity

Select Site Name
from EXP-1 Where
Implemented

(3)

(4)

(5)

(6)

(7)

(8)

(9)

Option(s)

Page 54 of 54