Form 1 Program Specific Form

1
OMB Approval No:
Expiration Date:
Updated 3.31.22

Program Specific Data Forms
Fields marked with an asterisk (*) are required
Fields marked with an asterisk (**) are optional
Note: When it comes to reporting the data from academic partners, the applicant may (1) each partner into the system separately and have the
system aggregate the data for them or (2) create their own spreadsheet (or other means) to summarize the information, then input it into the system.
**Autom atically tabulated
Select Degrees/Certificates for Trainees/Students
(drop-dow n w ith multiple options
Allow ed)

A. STUDENTS/TRAINEES BY GENDER (DEGREE/CERTIFICATION: ____________________________________)
*STUDENTS/T RAINEES IN YOUR PROGRAM FOR THE THREE PREVIOUS CONSECUTIV E ACADEMIC YEARS AND THEIR GENDER
Students/Trainees By Gender
Numbe r of Stude nts /Tra ine es Enrolle d for
Acade mic Year [INSE RT YEAR]
a.

Female

b.

Male

c.

Not Provided

Numbe r of Stude nts /Tra ine es Enrolle d for
Acade mic Year [INSE RT YEAR]

Numbe r of Stude nts /Tra ine es Enrolle d for
Acade mic Year [INSE RT YEAR]

Numbe r of Stude nts /Tra ine es Enrolle d for
Acade mic Year [INSE RT YEAR]

**Subtotal

B. STUDENTS/TRAINEES BY RACE AND ETHNICITY (DEGREE/CERTIFICATION:____________________________________________)
*STUDENTS/T RAINEES IN YOUR PROGRAM FOR THE THREE PREVIOUS CONSECUTIV E ACADEMIC YEARS AND THEIR RACIAL/ETHNIC BACKGROUNDS
1. Hispanic or Latino Students/Trainees
Did your program have students/trainees of "Hispanic or Latino Ethnicity"?
Hispanic or Latino Students/Trainees by
Race
a. American Indian/ Alaskan Native
b. Black or African American

Numbe r of Hispanic or Latino
Students /Tra inee s Enrolle d for
Acade mic Year [INSE RT YEAR]

Yes

No
Numbe r of Hispanic or Latino
Students /Tra inee s Enrolle d for
Acade mic Year [INSE RT YEAR]

Numbe r of Hispanic or Latino
Students /Tra inee s Enrolle d for
Acade mic Year [INSE RT YEAR

2
c. Asian
d. Native Haw aiian or Other Pacific Islander
e. White
f. More Than One Race
g. Race Not Reported
**Sub Total

2. Non-Hispanic or Non-Latino Students/Trainees
Non-Hispanic or Non-Latino
Students/Trainees byRace

Numbe r of Non-Hispanic or Non-Latino
Students /Tra inee s Enrolle d for Acade m ic
Year [INSERT YEAR]

Numbe r of Non-Hispanic or Non-Latino
Students /Tra inee s Enrolle d for Acade mic
Year [INSERT YEAR]

Numbe r of Non-Hispanic or Non-Latino
Students /Tra inee s Enrolle d for Acade mic
Year [INSERT YEAR]

Numbe r of Enrolle d Students /Traine e s
Ethnicity NOT REPORTED for
Acade mic Year [INSE RT YEAR]

Numbe r of Enrolle d Students /Traine e s
Ethnicity NOT REPORTED for
Acade mic Year [INSE RT YEAR]

a. American Indian/ Alaskan Native
b. Black or African American
c. Asian
d. Native Haw aiian or Other Pacific Islander
e. White
f. More Than One Race
g. Race Not Reported
**Sub Total

3. Ethnicity Not reported for Students/Trainees
Ethnicity NOT REPORT ED
Students/Trainees byRace
a. American Indian/ Alaskan Native
b. Black or African American
c. Asian
d. Native Haw aiian or Other Pacific Islander
e. White

Numbe r of Enrolle d Students /Traine e s
Ethnicity NOT REPORTED for
Acade mic Year [INSE RT YEAR]

3
f. More Than One Race
g. Race Not Reported
***Sub Total

C. CLASS ENROLLMENT INFORMATION (DEGREE/CERTIFICATION: _________________________________________________ )
* TOTAL CLASS ENROLLM ENT AND DISADVANTAGED BACKGROUND ENROLLMENT BY CLASS YEAR FOR STUDENTS/T RAINEES IN YOUR PROGRAM
FOR THE THREE PREVIOUS CONSECUTIV E ACADEMIC YEARS
Class Year

Total Class Enrollm ent

Total Disadvantaged Background Enrollm ent

Acade mic Year

Acade mic Year

Acade mic Year

Acade mic Year

[ENTER
ACADEMIC YEAR]

[ENTER
ACADEMIC YEAR]

[ENTER
ACADEMIC YEAR]

[ENTER
ACADEMIC
YEAR]

Acade mic Year
[ENTER
ACADEMIC YEAR]

Acade mic Year
[ENTER
ACADEMIC
YEAR]

*Total

D. GRADUATES/COMPLETERS INFORMATION
* TOTAL GRADUAT ES/COMPL ET ERS AND DISADVANTAGED BACKGROUND GRADUATES/COMPL ET ERS FOR THE PREVIOUS THREE CONSECUTIV E ACADEMIC
YEARS ACADEMIC YEARS
Acade mic Year
Acade mic Year
Acade mic Year
[ENTER
[ENTER
[ENTER
ACADEMIC
ACADEMIC
ACADEMIC
YEAR]
YEAR]
YEAR]
Total graduates/com pleters
Disadvantaged background graduates/completers
* GRADUAT ES/COMPL ET ERS FROM YOUR PROGRAM SERVING IN PRIMARY CARE, MEDICALLY UNDERSERV ED AND RURAL COMMUNITIES FOR THE PREVIOUS
THREE CONSECUTIV E ACADEMIC YEARS
Prim ary Care
[ENTE R ACADE M IC YEAR] [ENTE R ACADE M IC YEAR] [ENTE R ACADE M IC YEAR]
Of the graduates/completers, enter the number of graduates/completers serving in primary care

Medically Underserved Com munities
[Enter Acade mic Year]
Of the graduates/completers in primary care, enter the number of graduates practicing/w orking in
medically underserved communities.

[Enter Acade mic Year]

[Enter Acade mic Year]

4

Rural Com m unities
[Enter Acade mic Year]

[Enter Acade mic Year]

[Enter Acade mic Year]

Of the graduates/completers in primary care, enter the number of graduates
practicing/w orking in rural communities.
Select Health Workforce
Occupations for Graduates/Completers
(drop-down with multiple options
Allowed)
E. COMMUNITY COLLEGE
*COMMUNITY COLLEGE QUESTION
Is your entity a community college?

Yes

No

Yes

No

F. RECRUITM ENT AND RETENTION
*RECRUITMENT AND RETENTION ELIGIBILITY
Is your entity currently carrying out a program to recruit and retain students/trainees from disadvantaged backgrounds? Note: The
applicant m ust provide their recruitment and retention plan w ith the Standardized Work Plan (SWP) plan.
Please indicate the data sources used to determine areas targeted for recruitment of students/trainees from disadvantaged backgrounds.

☐ Health Professional Shortage
Area (HPSA)
☐ Medically Underserved
Areas/Populations (MUA/P)
☐Other:__________

Is your entity currently carrying out a program to recruit and retain students/trainees from rural communities?

Yes

No

Please indicate the data sources used to determine areas targeted for recruitment of students/trainees from rural communities.

☐ Health Professional Shortage
Area (HPSA)
☐ Medically Underserved
Areas/Populations (MUA/P)
☐Other:__________

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FACULTY QUESTIONS ARE ONLY FOR PROGRAMS WITH A FACULTY COMPONENT/FOCUS
**Indicates automatic tabulation
G. FACULTY
FACULTY BY TENURE STATUS, GENDER, RACE AND ETHNICITY
1.

*Total Num ber of Faculty
Enter Total Num ber of Faculty: ___

2a.

Enter Total Num ber of Tenured Faculty:____
Faculty by Gende r

Total Faculty by Gender
a.

Female

b.

Male

c.

Not Provided

Numbe r of Faculty
Acade mic Year [INSE RT YEAR]

Numbe r of Faculty
Acade mic Year [INSE RT YEAR]

Numbe r of Faculty
Acade m ic Year [INSERT YEAR]

Numbe r of Tenure d Faculty
Acade mic Year [INSE RT YEAR]

Numbe r of Tenure d Faculty
Acade mic Year [INSE RT YEAR]

Numbe r of Tenure d Faculty
Acade m ic Year [INSERT YEAR]

**Subtotal

2b. Tenure d Faculty by Gende r
Tenured Faculty by Gender
a.

Female

b.

Male

c.

Not Provided

**Subtotal

3a.

Faculty by Race

Total Faculty by Race
a. American Indian/ Alaskan Native
b. Black or African American
c. Asian
d. Native Haw aiian or Other Pacific
Islander

Numbe r of Faculty for
Acade mic Year: [YEAR]

Numbe r of Faculty
Acade mic Year: [ENTER]

Numbe r of Faculty
Acade mic Year: [ENTER]

6
e. White
f. More Than One Race
g. Race Not Reported
**Total

3b. Tenured Faculty by Race
Tenured Faculty by Race

Numbe r of Tenure d Faculty for

Numbe r of Tenure d Faculty

Numbe r of Tenure d Faculty

Acade mic Year: [YEAR]

Acade mic Year: [ENTER]

Acade mic Year: [ENTER]

a. American Indian/ Alaskan Native
b. Black or African American
c. Asian
d. Native Haw aiian or Other Pacific
Islander
e. White
f. More Than One Race
g. Race Not Reported
**Subtotal

4.

Faculty by Ethnicity

* Did your program have faculty members of "Hispanic or Latino Ethnicity"?

Yes

No

* Did your program have faculty members that did not report their ethnicity?

Yes

No

4a. Total Num ber of Hispanic or Latino Faculty
Total Num ber of Hispanic or Latino
Faculty
a. American Indian/ Alaskan Native
b. Black or African American
c. Asian
d. Native Haw aiian or Other Pacific Islander
e. White

Total Num ber of Hispanic or Latino
Ethnicity Faculty for
Acade m ic Year: [YEAR]

Total Numbe r of Hispanic or Latino
Ethnicity Faculty
Acade mic Year: [ENTER]

Total Num ber of Hispanic or Latino
Ethnicity Faculty
Acade mic Year: [ENTER]

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f. More Than One Race
g. Race Not Reported
**Sub Total

4b. Total Num ber of Hispanic or Latino Faculty
Hispanic or Latino Tenured Faculty by
Race

Numbe r of Tenure d Hispanic or Latino
Ethnicity Faculty for
Acade mic Year: [YEAR]

Numbe r of Tenure d Hispanic or Latino
Ethnicity Faculty
Acade mic Year: [ENTER]

Numbe r of Tenure d Hispanic or Latino
Ethnicity Faculty
Acade mic Year: [ENTER]

Numbe r of Tenure d Non-Hispanic or NonLatino Faculty
Acade mic Year: [ENTER]

Numbe r of Tenure d Non-Hispanic or NonLatino Faculty
Acade mic Year: [ENTER]

a. American Indian/ Alaskan Native
b. Black or African American
c. Asian
d. Native Haw aiian or Other Pacific Islander
e. White
f. More Than One Race
g. Race Not Reported
**Sub Total

4c. Non-Hispanic or Non-Latino Tenured Faculty
Non-Hispanic or Non-Latino Tenured
Faculty
a. American Indian/ Alaskan Native
b. Black or African American
c. Asian
d. Native Haw aiian or Other Pacific Islander
e. White
f. More Than One Race
g. Race Not Reported
**Sub Total

Numbe r of Tenure d Non-Hispanic or NonLatino Faculty
Acade mic Year: [ENTER]

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4d. Ethnicity Not Reported Tenured Faculty
Ethnicity Not Reported

Numbe r of Tenure d Faculty
Ethnicity Not Reported
Acade mic Year: [ENTER]

Numbe r of Tenure d Faculty
Ethnicity Not Reported
Acade mic Year: [ENTER]

Numbe r of Tenure d Faculty
Ethnicity Not Reported
Acade mic Year: [ENTER]

a. American Indian/ Alaskan Native
b. Black or African American
c. Asian
d. Native Haw aiian or Other Pacific Islander
e. White
f. More Than One Race
g. Race Not Reported
**Sub Total
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information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].