2 ANEW Form - Table 2

OMB No. 0915-0375

Expiration Date: xx/xx/202x

Public Burden Statement: HRSA uses the data from the ANEW Program-Specific Data Collection Forms as part of the process for determining the award amount, ensuring compliance with programmatic and grant requirements, and to provide information to the public and Congress. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0375 and it is valid until 05/31/2020. This information collection is required to obtain or retain benefit (Section 811 of the Public Health Service Act). Public reporting burden for this collection of information is estimated to average 7 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].

Table 2:  Projected Master’s and/or Doctoral and Post Masters Certificate Data

TRAINEESHIP DATA	NURSE PRACTITIONER		CLINICAL NURSE SPECIALIST		NURSE-MIDWIFE		CERTIFIED REGISTERED NURSE ANESTHETIST
	FT	PT	FT	PT	FT	PT	FT	PT
Total # of Master’s Degree Students Projected to Receive Traineeship – Support in Budget Year 1
Total # of Master’s Degree Students Projected to Receive Traineeship – Support in Budget Year 2
Total # of Master’s Degree Students Projected to Receive Traineeship – Support in Budget Year 3
Total # of Master’s Degree Students Projected to Receive Traineeship – Support in Budget Year 4
Total # of Doctoral Degree Students Projected to Receive Traineeship – Support in Budget Year 1
Total # of Doctoral Degree Students Projected to Receive Traineeship – Support in Budget Year 2
Total # of Doctoral Degree Students Projected to Receive Traineeship – Support in Budget Year 3
Total # of Doctoral Degree Students Projected to Receive Traineeship – Support in Budget Year 4
Total # Post-Master’s Certificate Students Projected to Receive Traineeship – Support in Budget Year 1
Total # Post-Master’s Certificate Students Projected to Receive Traineeship – Support in Budget Year 2
Total # Post-Master’s Certificate Students Projected to Receive Traineeship – Support in Budget Year 3
Total # Post-Master’s Certificate Students Projected to Receive Traineeship – Support in Budget Year 4

Instructions for Completing ANEW Table 2: Projected Master’s and/or Doctoral Degrees and Post Masters Certificate Data

• Enter the total number of Master’s and Doctoral Degree and Post-Master’s Certificate students projected to receive traineeship support in Budget Years 1 (July 1, 201X to June 30, 201X), 2, 3, and 4 as appropriate by their enrollment status (FT or PT) and their specialty role.

• If the ANEW FOA is a two-year funding opportunity, please indicate “N/A” for Budget Years 3 and 4.

HRSA-19-003 OMB ANEW Program Specific Data Forms Package.