Form 3 Attachment D Additional Data Elements

Provide the following information about all personnel (faculty, staff, and others) contributing to your Division of MCH Workforce Development grant project, including those listed in the budget form and budget narrative and others that your program considers to have a central and ongoing role in the leadership training program whether they are supported or not supported by the grant. Do not list trainees.

A ‘central’ role refers to those that regularly participate in ongoing training activities such as acting as preceptors, teaching core courses, and participating in other core leadership training activities that would be documented in the progress reports.

Definitions:

Ethnicity

Hispanic or Latino is defined as a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. People who identify as Hispanic, Latino, or Spanish may be any race.

Race

American Indian or Alaska Native: The category “American Indian or Alaska Native” includes all individuals who identify with any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment. It includes people who identify as “American Indian” or “Alaska Native” and includes groups such as Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, and Nome Eskimo Community.
Asian: The category “Asian” includes all individuals who identify with one or more nationalities or ethnic groups originating in the Far East, Southeast Asia, or the Indian subcontinent. Examples of these groups include, but are not limited to, Chinese, Filipino, Asian Indian, Vietnamese, Korean, and Japanese. The category also includes groups such as Pakistani, Cambodian, Hmong, Thai, Bengali, Mien, etc.
Black or African American: The category “Black or African American” includes all individuals who identify with one or more nationalities or ethnic groups originating in any of the black racial groups of Africa. Examples of these groups include, but are not limited to, African American, Jamaican, Haitian, Nigerian, Ethiopian, and Somali. The category also includes groups such as Ghanaian, South African, Barbadian, Kenyan, Liberian, and Bahamian.
Native Hawaiian and Pacific Islander: The category “Native Hawaiian or Other Pacific Islander” includes all individuals who identify with one or more nationalities or ethnic groups originating in Hawaii, Guam, Samoa, or other Pacific Islands. Examples of these groups include, but are not limited to, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, and Marshallese. The category also includes groups such as Palauan, Tahitian, Chuukese, Pohnpeian, Saipanese, Yapese, etc.
White: The category “White” includes all individuals who identify with one or more nationalities or ethnic groups originating in Europe, the Middle East, or North Africa. Examples of these groups include, but are not limited to, German, Irish, English, Italian, Lebanese, Egyptian, Polish, French, Iranian, Slavic, Cajun, and Chaldean.
More than One Race: This category includes individuals who identify with more than one race.

Gender

Cisgender Man: Describes a person who was assigned male at birth and whose gender identity is a man/male.
Cisgender Woman: Describes a person who was assigned female at birth and whose gender identity is a woman/female.
Transgender Man: Describes a person who is transgender and whose gender identity is man/male.
Transgender Woman: Describes a person who is transgender and whose gender identity is woman/female.
A different term (specify): A gender identity that does not fit into the above categories, such as nonbinary (a person whose gender identity falls outside of the gender binary structure of woman/female and man/male), agender (a person who identifies as having no gender, or who does not experience gender as a primary identity component), or another identity.

Year Work Began with MCH Leadership Training Program: Please specify the year the individual began work with the MCH Training Program, not the year they were hired by the organization, if different. For example, if a faculty member began mentoring trainees in 2005 and was then hired in 2007, list 2005 as the year work began.

Personnel (Do not list trainees)
Name	Ethnicity (Hispanic or Latino, Not Hispanic or Latino, Unrecorded)	Race (American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, White, More than One Race, Unrecorded)	Gender (Cisgender Man, Cisgender Women, Transgender Man, Transgender Woman, A different term (specify), Choose not to disclose/Unrecorded)	Discipline	Year Work Began with MCH Leadership Training Program	Former MCHB Trainee? (Yes/No)
Faculty

Staff

Other

Comments:

Short-Term Trainees

Short-Term Trainees

Instructions

Provide the following information for short-term trainees in your training program.

Definitions:

Short-term trainees are trainees with less than 40 contact hours in the reporting period. Continuing Education participants are not counted in this category.

Total number of short term trainees during the past 12-month grant period________

Indicate disciplines (check all that apply)

Applied Behavior Analysis

Audiology

Community Health Worker

Community Member/Person with Lived Experience

Dentistry-Pediatric

Dentistry – Other

Dietetics

Disability Studies

Doula

Education/Special Education

Family Member

Genetics/Genetic Counseling

Health Administration

Law

Medicine-General

Medicine-Adolescent Medicine

Medicine-Adult Providers

Medicine-Developmental-Behavioral Pediatrics

Medicine-Neurodevelopmental Disabilities

Medicine-Pediatrics

Medicine-Pediatric Pulmonology

Medicine- Sleep

Medicine – Other

Nursing-General

Nursing-Family/Pediatric Nurse Practitioner

Nursing-Midwife

Nursing – Other

Nutrition

Occupational Therapy

Pharmacy

Physician Assistant

Physical Therapy

Psychiatry

Psychology

Public Health

Respiratory Therapy

School Psychology/School Counseling

Self-Advocate/Person with a Disability or Special Health Care Need

Social Work

Speech-Language Pathology

Other (Specify)

Comments:

Medium-Term Trainees

Medium-Term Trainees

Instructions

Provide the following information for medium-term trainees in your training program. Medium-term trainees are trainees with 40 – 299 contact hours in the reporting period and include the following sub-categories:

Medium-Term Trainee I: 40 – 149 contact hours during the reporting period
Medium-Term Trainee II: 150 – 299 contact hours during the reporting period
TOTAL number of medium-term trainees: 40 – 299 contact hours during the reporting period

Definitions:

Ethnicity

Hispanic or Latino is defined as a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. People who identify as Hispanic, Latino, or Spanish may be any race.

Race

American Indian or Alaska Native: The category “American Indian or Alaska Native” includes all individuals who identify with any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment. It includes people who identify as “American Indian” or “Alaska Native” and includes groups such as Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, and Nome Eskimo Community.
Asian: The category “Asian” includes all individuals who identify with one or more nationalities or ethnic groups originating in the Far East, Southeast Asia, or the Indian subcontinent. Examples of these groups include, but are not limited to, Chinese, Filipino, Asian Indian, Vietnamese, Korean, and Japanese. The category also includes groups such as Pakistani, Cambodian, Hmong, Thai, Bengali, Mien, etc.
Black or African American: The category “Black or African American” includes all individuals who identify with one or more nationalities or ethnic groups originating in any of the black racial groups of Africa. Examples of these groups include, but are not limited to, African American, Jamaican, Haitian, Nigerian, Ethiopian, and Somali. The category also includes groups such as Ghanaian, South African, Barbadian, Kenyan, Liberian, and Bahamian.
Native Hawaiian and Pacific Islander: The category “Native Hawaiian or Other Pacific Islander” includes all individuals who identify with one or more nationalities or ethnic groups originating in Hawaii, Guam, Samoa, or other Pacific Islands. Examples of these groups include, but are not limited to, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, and Marshallese. The category also includes groups such as Palauan, Tahitian, Chuukese, Pohnpeian, Saipanese, Yapese, etc.
White: The category “White” includes all individuals who identify with one or more nationalities or ethnic groups originating in Europe, the Middle East, or North Africa. Examples of these groups include, but are not limited to, German, Irish, English, Italian, Lebanese, Egyptian, Polish, French, Iranian, Slavic, Cajun, and Chaldean.
More than One Race: This category includes individuals who identify with more than one race.

Gender

Cisgender Man: Describes a person who was assigned male at birth and whose gender identity is a man/male.
Cisgender Woman: Describes a person who was assigned female at birth and whose gender identity is a woman/female.
Transgender Man: Describes a person who is transgender and whose gender identity is man/male.
Transgender Woman: Describes a person who is transgender and whose gender identity is woman/female.
A different term (specify): A gender identity that does not fit into the above categories, such as nonbinary (a person whose gender identity falls outside of the gender binary structure of woman/female and man/male), agender (a person who identifies as having no gender, or who does not experience gender as a primary identity component), or another identity.

Medium-term Trainees with 40-149 contact hours during the reporting period

Total Number ______

Disciplines (check all that apply):

Applied Behavior Analysis

Audiology

Community Health Worker

Community Member/Person with Lived Experience

Dentistry-Pediatric

Dentistry – Other

Dietetics

Disability Studies

Doula

Education/Special Education

Family Member

Genetics/Genetic Counseling

Health Administration

Law

Medicine-General

Medicine-Adolescent Medicine

Medicine-Adult Providers

Medicine-Developmental-Behavioral Pediatrics

Medicine-Neurodevelopmental Disabilities

Medicine-Pediatrics

Medicine-Pediatric Pulmonology

Medicine-Sleep

Medicine – Other

Nursing-General

Nursing-Family/Pediatric Nurse Practitioner

Nursing-Midwife

Nursing – Other

Nutrition

Occupational Therapy

Pharmacy

Physician Assistant

Physical Therapy

Psychiatry

Psychology

Public Health

Respiratory Therapy

School Psychology/School Counseling

Self-Advocate/Person with a Disability or Special Health Care Need

Social Work

Speech-Language Pathology

Other (Specify)

Medium-Term Trainees with 150-299 contact hours

The totals for gender, ethnicity, race and discipline must equal the total number of medium-term trainees with 150-299 contact hours

Total Number of Medium-Term Trainees with 150-299 hours during the reporting period:	____________________
Gender:	Cisgender Man: ______ Cisgender Woman: ______ Transgender Man: ______ Transgender Woman: ______ A different term(s) (specify): ______ Choose not to disclose/Unrecorded: ______
Ethnicity:	Hispanic or Latino: ______ Not Hispanic or Latino: _____ Choose not to disclose/Unrecorded: ______
Race:	American Indian or Alaska Native: _____ Asian: _____ Black or African American: _____ Native Hawaiian or Other Pacific Islander: ______ White: ______ More than One Race: ______ Choose not to disclose/Unrecorded:______

Discipline (MTTs with 150-299 contact hours during the reporting period)

DISCIPLINE	NUMBER
Applied Behavior Analysis
Audiology
Community Health Worker
Community Member/Person with Lived Experience
Dentistry-Pediatric
Dentistry – Other
Dietetics
Disability Studies
Doula
Education/Special Education
Family Member
Genetics/Genetic Counseling
Health Administration
Law
Medicine-General
Medicine-Adolescent Medicine
Medicine-Adult Providers
Medicine-Developmental-Behavioral Pediatrics
Medicine-Neurodevelopmental Disabilities
Medicine-Pediatrics
Medicine-Pediatric Pulmonology
Medicine-Sleep
Medicine – Other
Nursing-General
Nursing-Family/Pediatric Nurse Practitioner
Nursing-Midwife
Nursing – Other
Nutrition
Occupational Therapy
Pharmacy
Physician Assistant
Physical Therapy
Psychiatry
Psychology
Public Health
Respiratory Therapy
School Psychology/School Counseling
Self-Advocate/Person with a Disability or Special Health Care Need
Social Work
Speech-Language Pathology
Other (Specify)
TOTAL NUMBER

TOTAL Number of Medium-term Trainees (40-299 hours): _________

Comments:

Long-Term Trainees

Long-Term Trainee Form

Instructions

Provide the following information for each long-term trainee (LTT) in your training program. Long-term trainees are those with greater than or equal to 300 contact hours within the training program in the reporting period who benefit from the training grant, including those who received MCH funds and those who did not.

MCH Public Health Catalyst Programs (T1C) Instructions: MCH Public Health Catalyst programs utilize a combination of MCH coursework, practicum, and student interest group participation to define long-term trainee participation and may or may not meet the 300 contact hour threshold for LTT. On this form, Catalyst Programs should report information about Catalyst Program LTTs based on the definition established by each program. The same definition should be used consistently over time and the requirements and definition of LTTs should be included in the Comments section.

Definitions:

Ethnicity

Hispanic or Latino is defined as a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. People who identify as Hispanic, Latino, or Spanish may be any race.

Race

American Indian or Alaska Native: The category “American Indian or Alaska Native” includes all individuals who identify with any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment. It includes people who identify as “American Indian” or “Alaska Native” and includes groups such as Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, and Nome Eskimo Community.
Asian: The category “Asian” includes all individuals who identify with one or more nationalities or ethnic groups originating in the Far East, Southeast Asia, or the Indian subcontinent. Examples of these groups include, but are not limited to, Chinese, Filipino, Asian Indian, Vietnamese, Korean, and Japanese. The category also includes groups such as Pakistani, Cambodian, Hmong, Thai, Bengali, Mien, etc.
Black or African American: The category “Black or African American” includes all individuals who identify with one or more nationalities or ethnic groups originating in any of the black racial groups of Africa. Examples of these groups include, but are not limited to, African American, Jamaican, Haitian, Nigerian, Ethiopian, and Somali. The category also includes groups such as Ghanaian, South African, Barbadian, Kenyan, Liberian, and Bahamian.
Native Hawaiian and Pacific Islander: The category “Native Hawaiian or Other Pacific Islander” includes all individuals who identify with one or more nationalities or ethnic groups originating in Hawaii, Guam, Samoa, or other Pacific Islands. Examples of these groups include, but are not limited to, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, and Marshallese. The category also includes groups such as Palauan, Tahitian, Chuukese, Pohnpeian, Saipanese, Yapese, etc.
White: The category “White” includes all individuals who identify with one or more nationalities or ethnic groups originating in Europe, the Middle East, or North Africa. Examples of these groups include, but are not limited to, German, Irish, English, Italian, Lebanese, Egyptian, Polish, French, Iranian, Slavic, Cajun, and Chaldean.
More than One Race: This category includes individuals who identify with more than one race.

Gender

Cisgender Man: Describes a person who was assigned male at birth and whose gender identity is a man/male.
Cisgender Woman: Describes a person who was assigned female at birth and whose gender identity is a woman/female.
Transgender Man: Describes a person who is transgender and whose gender identity is man/male.
Transgender Woman: Describes a person who is transgender and whose gender identity is woman/female.
A different term (specify): A gender identity that does not fit into the above categories, such as nonbinary (a person whose gender identity falls outside of the gender binary structure of woman/female and man/male), agender (a person who identifies as having no gender, or who does not experience gender as a primary identity component), or another identity.

First-generation college students are students who are enrolled in postsecondary education and whose parents do not have any postsecondary education experience.

Trainees who are not enrolled in a formal degree program may include non-degree seeking students and post-graduate trainees who are completing a fellowship.

Data Element	Response Options
Name:	_____________________________________
Email address:	_____________________________________
Gender:	Cisgender Man Cisgender Woman Transgender Man Transgender Woman A different term (specify)_________ Choose not to disclose/unrecorded
Ethnicity:	Hispanic or Latino Not Hispanic or Latino Choose not to disclose/unrecorded
Race:	American Indian or Alaska Native Asian Black or African American Native Hawaiian and Other Pacific Islander White More than One Race Choose not to disclose/unrecorded
First-generation college student?	Yes No Choose not to disclose/unrecorded
Zip Code where trainee lives:
Primary discipline of study (during MCH Training Program):	Applied Behavior Analysis Audiology Community Health Worker Community Member/Person with Lived Experience Dentistry-Pediatric Dentistry – Other Dietetics Disability Studies Doula Education/Special Education Family Member Genetics/Genetic Counseling Health Administration Law Medicine-General Medicine-Adolescent Medicine Medicine-Adult Providers Medicine-Developmental-Behavioral Pediatrics Medicine-Neurodevelopmental Disabilities Medicine-Pediatrics Medicine-Pediatric Pulmonology Medicine-Sleep Medicine – Other Nursing-General Nursing-Family/Pediatric Nurse Practitioner Nursing-Midwife Nursing – Other Nutrition Occupational Therapy Pharmacy Physician Assistant Physical Therapy Psychiatry Psychology Public Health Respiratory Therapy School Psychology/School Counseling Self-Advocate/Person with a Disability or Special Health Care Need Social Work Speech-Language Pathology Other (Specify)
Level of training currently being completed through MCHB Training Program:	Undergraduate Masters Pre-doctoral Doctoral Postdoctoral Non-Degree Seeking
Is the trainee currently enrolled in a degree program:	Part-time Full-time Not Enrolled
Did the trainee receive financial support through the MCH Training grant?	Yes No If Yes, amount of financial support received: $_______ If Yes, type of financial support received: Stipend Tuition Stipend and Tuition Other (specify)
Postdoctoral Fellows and MCH Epidemiology Doctoral Program Fellows, please specify:	Length of time receiving support to date: _________________ Research topic or title: ___________________

Comments:

Former Long-Term Trainees

FORMER LONG-TERM TRAINEE FORM

Former Long-Term Trainee Form

Instructions

Provide the following information for former long-term trainees in your training program. Former trainees are long-term trainees who completed a long-term (greater than or equal to 300 contact hours) MCH Training Program 2 and 5 years ago, including those who received MCH funds and those who did not.

Former long-term trainees should be tracked based on when they complete their MCH Training Program. For example, if a trainee completes a one-year training experience in 2020, 2-year follow-up should be collected and reported to MCHB in 2022 and 5-year follow-up should be collected and reported in 2025.

SECTION 1: Indicate if the training program has trainees that completed the training program at least 2 and/or 5 years ago. Indicate the number of trainees that completed the program 2 years ago and 5 years ago.

SECTION 2: Complete this section for each long-term trainee who completed the MCHB-funded training program 2 or 5 years ago.

Definitions:

Ethnicity

Hispanic or Latino is defined as a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. People who identify as Hispanic, Latino, or Spanish may be any race.

Race

American Indian or Alaska Native: The category “American Indian or Alaska Native” includes all individuals who identify with any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment. It includes people who identify as “American Indian” or “Alaska Native” and includes groups such as Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, and Nome Eskimo Community.
Asian: The category “Asian” includes all individuals who identify with one or more nationalities or ethnic groups originating in the Far East, Southeast Asia, or the Indian subcontinent. Examples of these groups include, but are not limited to, Chinese, Filipino, Asian Indian, Vietnamese, Korean, and Japanese. The category also includes groups such as Pakistani, Cambodian, Hmong, Thai, Bengali, Mien, etc.
Black or African American: The category “Black or African American” includes all individuals who identify with one or more nationalities or ethnic groups originating in any of the black racial groups of Africa. Examples of these groups include, but are not limited to, African American, Jamaican, Haitian, Nigerian, Ethiopian, and Somali. The category also includes groups such as Ghanaian, South African, Barbadian, Kenyan, Liberian, and Bahamian.
Native Hawaiian and Pacific Islander: The category “Native Hawaiian or Other Pacific Islander” includes all individuals who identify with one or more nationalities or ethnic groups originating in Hawaii, Guam, Samoa, or other Pacific Islands. Examples of these groups include, but are not limited to, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, and Marshallese. The category also includes groups such as Palauan, Tahitian, Chuukese, Pohnpeian, Saipanese, Yapese, etc.
White: The category “White” includes all individuals who identify with one or more nationalities or ethnic groups originating in Europe, the Middle East, or North Africa. Examples of these groups include, but are not limited to, German, Irish, English, Italian, Lebanese, Egyptian, Polish, French, Iranian, Slavic, Cajun, and Chaldean.
More than One Race: This category includes individuals who identify with more than one race.

Gender

Cisgender Man: Describes a person who was assigned male at birth and whose gender identity is a man/male.
Cisgender Woman: Describes a person who was assigned female at birth and whose gender identity is a woman/female.
Transgender Man: Describes a person who is transgender and whose gender identity is man/male.
Transgender Woman: Describes a person who is transgender and whose gender identity is woman/female.
A different term (specify): A gender identity that does not fit into the above categories, such as nonbinary (a person whose gender identity falls outside of the gender binary structure of woman/female and man/male), agender (a person who identifies as having no gender, or who does not experience gender as a primary identity component), or another identity.

First-generation college students are students who are enrolled in postsecondary education and whose parents do not have any postsecondary education experience.

Leadership activities

Academic leadership activities
- Disseminated information on MCH Issues (e.g., Peer-reviewed publications, key presentations, training manuals, issue briefs, best practices documents, standards of care)
- Conducted research or quality improvement on MCH issues
- Provided consultation or technical assistance in MCH areas
- Taught/mentored in their discipline or other MCH related field
- Served as a reviewer (e.g., for a journal, conference abstracts, grant, quality assurance process)
- Procured grant and other funding in MCH areas
- Conducted strategic planning or program evaluation
Clinical leadership activities
- Participated as a group leader, initiator, key contributor or in a position of influence/authority on any of the following: committees of State, national, or local organizations; task forces; community boards; advocacy groups; research societies; professional societies; etc.
- Served in a clinical leadership position (e.g. director, senior therapist, team leader, etc)
- Taught/mentored in their discipline or other MCH related field
- Conducted research or quality improvement on MCH issues
- Disseminated information on MCH Issues (e.g., Peer-reviewed publications, key presentations, training manuals, issue briefs, best practices documents, standards of care)
- Served as a reviewer (e.g., for a journal, conference abstracts, grant, quality assurance process)
Public health leadership activities
- Provided consultation, technical assistance, or training in MCH areas
- Procured grant or other funding in MCH areas
- Conducted strategic planning or program evaluation
- Conducted research or quality improvement on MCH issues
- Served as a reviewer (e.g., for a journal, conference abstracts, grant, quality assurance process)
- Collaborated with community partners
Public policy leadership activities
- Participated in public policy development activities at local, state, or national levels (e.g., participated in community engagement or coalition building efforts, written policy or guidelines, influenced MCH related legislation, provided testimony, educated legislators)
- Participated on any of the following as a group leader, initiator, or key contributor: committees of State, national, or local organizations; task forces; community boards; research societies; professional societies; etc.
- Presented or disseminated information on MCH public policy issues to a legislative body, key decision makers, foundations, or the general public (e.g., Peer-reviewed publications, key presentations, training manuals, issue briefs, best practices documents, standards of care, commentaries, and chapters)

Interdisciplinary/Interprofessional: the skills and expertise of team members from different disciplines, including a variety of professionals, MCH populations, and community partners, are acknowledged and seen as essential and synergistic. Input from each team member is elicited and valued in making collaborative, outcome-driven decisions to address individual, community-level, or systems-level problems.

Does your program have any long-term trainees who have completed the Training Program at least 2 and/or 5 years prior to the reporting period?	Yes No
How many trainees completed the Training Program 2 years prior to the reporting period?	Number of trainees:______
How many trainees completed the Training Program 5 years prior to the reporting period?	Number of trainees:______

Complete the following section for each long-term trainee who completed the MCHB-funded Training Program 2 or 5 years prior to the reporting period.

Name	_________
Email address	_________
When did the trainee complete the MCHB-funded Training Program? (select one)	2 years prior to the current reporting year 5 years prior to the current reporting year
What was the trainee’s primary discipline while participating in your Training Program?	Applied Behavior Analysis Audiology Community Health Worker Dentistry – Pediatric Dentistry – Other Dietetics Disability Studies Doula Education/Special Education Family Member Genetics/Genetic Counseling Health Administration Law Medicine – General Medicine – Adolescent Medicine Medicine – Adult Providers Medicine – Developmental Behavioral Pediatrics Medicine – Neurodevelopmental Disabilities Medicine – Pediatrics Medicine – Pediatric Pulmonology Medicine - Sleep Medicine – Other Nursing – General Nursing – Family/Pediatric Nurse Practitioner Nursing – Midwife Nursing – Other Nutrition Occupational Therapy Person with Lived Experience Pharmacy Physician Assistant Physical Therapy Psychiatry Psychology Public Health Respiratory Therapy Self-Advocate/Person with a disability or special health care need Social Work Speech-Language Pathology Other (specify)
Gender (select one)	Cisgender Man Cisgender Woman Transgender Man Transgender Woman A different term (specify) _______________ Choose not to disclose/unrecorded
Ethnicity (select one)	Hispanic or Latino Not Hispanic or Latino Choose not to disclose/unrecorded
Race (select one)	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White More than One Race Choose not to disclose/unrecorded
First-generation college student?	Yes No Choose not to disclose/unrecorded
Do you have follow-up data to report on the trainee (e.g. former trainee survey)?	Yes No
What is the trainee’s current employment setting? (select one)	Student Elementary or secondary school or school system Undergraduate or graduate-level institution State health department, including Title V Other government agency (e.g. Federal, state or local) Clinical health care setting (includes hospitals, health centers and clinics) Community-based organization or non-profit Other private sector organization Not currently working or retired Other, please specify: ____________
Zip code of employment setting selected
Does the trainee’s current work support or serve any of the following Maternal and Child Health (MCH) populations? (select all that apply)	Women or people who have given birth Infants Children Adolescents and young adults Fathers or other caregivers Children and youth with special health care needs, including children with autism spectrum disorder or other developmental disabilities None or unknown
Does the trainee’s current work support or serve populations that have been historically underserved or marginalized? (select all that apply)	Racially/ethnically diverse populations Indigenous populations LGBTQ+ populations Rural populations Children and youth with special healthcare needs People with disabilities People living in poverty People experiencing homelessness Military veterans None or unknown
Has the trainee done any of the following leadership activities since completing their training program? (select all that apply)	Academic leadership activities Clinical leadership activities Public health leadership activities Public policy leadership activities None or unknown
Has the trainee participated in or led any of the following interdisciplinary/interprofessional⁵activities since completing your training program? (select all that apply)	Sought input or information from other professions, disciplines, people with lived experience, or self-advocates to address a need in their work Provided input or information to other professions or disciplines Developed a shared vision, roles and responsibilities across disciplines Utilized shared vision, roles or responsibilities to develop a coordinated, prioritized plan across disciplines to address a need in their work Established decision-making procedures in an interdisciplinary group Collaborated with various disciplines across agencies/entities Advanced policies & programs that promote collaboration with other disciplines or professions Engaged in clinical practice working in collaboration across disciplines and with the patient None or unknown

Comments:

Proposed Survey Questions

Contact / Background Information

*Name (first, middle, last):
Previous Name (if used while enrolled in the training program):
*Address:

	City	State	Zip
If tribal nation, specify:
Phone:
Primary Email:

Permanent Contact Information (someone at a different address who will know how to contact you in the future, e.g., parents)

*Name of Contact:
Relationship:
Email address:
*Address:

	City	State	Zip
Phone:

Primary discipline while participating in the MCH Training Program:

Applied Behavior Analysis
Audiology
Community Health Worker
Community Member/Person with Lived Experience
Dentistry-Pediatric
Dentistry – Other
Dietetics
Disability Studies
Doula
Education/Special Education
Family Member
Genetics/Genetic Counseling
Health Administration
Law
Medicine-General
Medicine-Adolescent Medicine
Medicine-Adult Providers
Medicine-Developmental-Behavioral Pediatrics
Medicine-Neurodevelopmental Disabilities
Medicine-Pediatrics
Medicine-Pediatric Pulmonology
Medicine-Sleep
Medicine – Other
Nursing-General
Nursing-Family/Pediatric Nurse Practitioner
Nursing-Midwife
Nursing – Other
Nutrition
Occupational Therapy
Pharmacy
Physician Assistant
Physical Therapy
Psychiatry
Psychology
Public Health
Respiratory Therapy
School Psychology/School Counseling
Self-Advocate/Person with a Disability or Special Health Care Need
Social Work
Speech-Language Pathology
Other (Specify)

Gender: (choose one)

__Cisgender Man

__Cisgender Woman

__Transgender Man

__Transgender Woman

__A different term (specify):_______________________________________

__Choose not to disclose

Are you a first-generation college student?

__ Yes

__ No

__ Prefer not to say

Ethnicity: (choose one)

Hispanic is an ethnic category for people whose origins are in the Spanish-speaking countries of Latin America or who identify with a Spanish-speaking culture. Individuals who are Hispanic may be of any race.

__ Hispanic or Latino

__ Not Hispanic or Latino

__ Prefer not to say

Race: (choose one)

__ American Indian or Alaska Native includes all individuals who identify with any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment. It includes people who identify as “American Indian” or “Alaska Native” and includes groups such as Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, and Nome Eskimo Community.

__ Asian includes all individuals who identify with one or more nationalities or ethnic groups originating in the Far East, Southeast Asia, or the Indian subcontinent. Examples of these groups include, but are not limited to, Chinese, Filipino, Asian Indian, Vietnamese, Korean, and Japanese. The category also includes groups such as Pakistani, Cambodian, Hmong, Thai, Bengali, Mien, etc.

__ Black or African American includes all individuals who identify with one or more nationalities or ethnic groups originating in any of the black racial groups of Africa. Examples of these groups include, but are not limited to, African American, Jamaican, Haitian, Nigerian, Ethiopian, and Somali. The category also includes groups such as Ghanaian, South African, Barbadian, Kenyan, Liberian, and Bahamian.

__ Native Hawaiian and Other Pacific Islander includes all individuals who identify with one or more nationalities or ethnic groups originating in Hawaii, Guam, Samoa, or other Pacific Islands. Examples of these groups include, but are not limited to, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, and Marshallese. The category also includes groups such as Palauan, Tahitian, Chuukese, Pohnpeian, Saipanese, Yapese, etc.

__ White includes all individuals who identify with one or more nationalities or ethnic groups originating in Europe, the Middle East, or North Africa. Examples of these groups include, but are not limited to, German, Irish, English, Italian, Lebanese, Egyptian, Polish, French, Iranian, Slavic, Cajun, and Chaldean.

__ More than One Race includes individuals who identify with more than one racial designation.

__ Prefer not to say.

Survey

Please answer all of the following questions to help us understand the impact of the MCH Training Program on your post-training activities. Thank you for taking the time to complete this survey. When you have filled out the entire survey, return it to your MCH Training Program Director.

1. What best describes your current employment setting:

__ Student

__ Elementary or secondary school or school system

__ Undergraduate or graduate-level institution

__ State health department, including Title V

__ Other government agency (e.g. Federal, state or local)

__ Clinical health care setting (includes hospitals, health centers and clinics)

__ Community-based organization or non-profit

__ Other private sector organization

__ Not currently working or retired

__ Other (please specify): ____________________________________

2. Does your current work support or serve any of the following Maternal and Child Health (MCH) populations? (select all that apply)

__ Women or people who have given birth

__ Infants
__ Children

__ Adolescents and young adults

__ Fathers or other caregivers

__ Children and youth with special health care needs, including children with autism spectrum disorder or other developmental disabilities

__ None or unknown

3. Does your current work support or serve populations that have been historically underserved or marginalized? (select all that apply)

__ Racially/ethnically diverse populations

__ Indigenous populations

__ LGBTQ+ populations

__ Rural populations

__ Children and youth with special health care needs

__ People with disabilities

__ People living in poverty

__ People experiencing homelessness

__ Military veterans

__ None or unknown

4. Have you done any of the following leadership activities since completing your training program? (select all that apply)

__ Academic leadership activities

Disseminated information on MCH issues (e.g., peer-reviewed publications, key presentations, training manuals, issue briefs, best practices documents, standards of care)
Conducted research or quality improvement on MCH issues
Provided consultation or technical assistance in MCH areas
Taught/mentored in MCH discipline or other MCH related field
Served as a reviewer (e.g., for a journal, conference abstracts, grant, quality assurance process)
Procured grant and other funding in MCH areas
Conducted strategic planning or program evaluation

__ Clinical leadership activities

Participated as a group leader, initiator, key contributor or in a position of influence/authority on any of the following: committees of state, national, or local organizations; task forces; community boards; advocacy groups; research societies; professional societies; etc
Served in a leadership position in a clinical setting (e.g., director, senior therapist, team leader)
Taught/mentored in MCH discipline or other MCH related field
Conducted research or quality improvement on MCH issues
Disseminated information on MCH Issues (e.g., peer-reviewed publications, key presentations, training manuals, issue briefs, best practices documents, standards of care)
Served as a reviewer (e.g., for a journal, conference abstracts, grant, quality assurance process)

__ Public health leadership activities

Provided consultation, technical assistance, or training in MCH areas
Procured grant or other funding in MCH areas
Conducted strategic planning or program evaluation
Conducted research or quality improvement on MCH issues
Served as a reviewer (e.g., for a journal, conference abstracts, grant, quality assurance process)

__ Public policy leadership activities

Participated in public policy development activities at local, state, or national levels (e.g., participated in community engagement or coalition building efforts, written policy or guidelines, influenced MCH related legislation, provided testimony, educated legislators)
Participated on any of the following as a group leader, initiator, or key contributor: committees of state, national, or local organizations; task forces; community boards; research societies; professional societies; etc
Presented or disseminated information on MCH public policy issues to a legislative body, key decision makers, foundations, or the general public (e.g., peer-reviewed publications, key presentations, training manuals, issue briefs, best practices documents, standards of care, commentaries, and chapters)

__ None or unknown

5. Have you participated or led any of the following interdisciplinary/interprofessional activities since completing your training program? (select all that apply)

Sought input or information from other professions, disciplines, people with lived experience, or self-advocates to address a need in their work
Provided input or information to other professions or disciplines
Developed a shared vision, roles and responsibilities across disciplines
Utilized shared vision, roles or responsibilities to develop a coordinated, prioritized plan across disciplines to address a need in their work
Established decision-making procedures in an interdisciplinary group
Collaborated with various disciplines across agencies/entities
Advanced policies and programs that promote collaboration with other disciplines or professions
Engaged in clinical practice working in collaboration across disciplines and with the patient
None or unknown

(end of survey)

Confidentiality Statement

Thank you for agreeing to provide information that will enable your training program to follow up with you after the completion of your training. Your input is critical to our own improvement efforts and our compliance with Federal reporting requirements. Please know that your participation in providing information is entirely voluntary. The information you provide will only be used for monitoring and improvement of the training program. Please also be assured that we take the confidentiality of your personal information very seriously. We very much appreciate your time and assistance in helping to document outcomes of the Training Program. We look forward to learning about your academic and professional development.¹

LEAP Trainee Information

Maternal and Child Health Leadership, Education, and Advancement in Undergraduate Pathways (LEAP) Training Program: Trainee Information Form

LEAP Trainee Information Form

Instructions

Provide aggregate data on medium- and long-term LEAP trainees who are participating in the LEAP training program in the reporting period. LEAP programs are expected to collect trainee data annually. Aggregate data are reported on this form based on trainee self-report of data elements.

Definitions:

LEAP trainees: Medium-term (40 – 299 program hours) and long-term (300+ program hours) trainees enrolled in the LEAP training program

Ethnicity

Hispanic or Latino is defined as a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. People who identify as Hispanic, Latino, or Spanish may be any race.

Race

American Indian or Alaska Native: The category “American Indian or Alaska Native” includes all individuals who identify with any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment. It includes people who identify as “American Indian” or “Alaska Native” and includes groups such as Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, and Nome Eskimo Community.
Asian: The category “Asian” includes all individuals who identify with one or more nationalities or ethnic groups originating in the Far East, Southeast Asia, or the Indian subcontinent. Examples of these groups include, but are not limited to, Chinese, Filipino, Asian Indian, Vietnamese, Korean, and Japanese. The category also includes groups such as Pakistani, Cambodian, Hmong, Thai, Bengali, Mien, etc.
Black or African American: The category “Black or African American” includes all individuals who identify with one or more nationalities or ethnic groups originating in any of the black racial groups of Africa. Examples of these groups include, but are not limited to, African American, Jamaican, Haitian, Nigerian, Ethiopian, and Somali. The category also includes groups such as Ghanaian, South African, Barbadian, Kenyan, Liberian, and Bahamian.
Native Hawaiian and Pacific Islander: The category “Native Hawaiian or Other Pacific Islander” includes all individuals who identify with one or more nationalities or ethnic groups originating in Hawaii, Guam, Samoa, or other Pacific Islands. Examples of these groups include, but are not limited to, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, and Marshallese. The category also includes groups such as Palauan, Tahitian, Chuukese, Pohnpeian, Saipanese, Yapese, etc.
White: The category “White” includes all individuals who identify with one or more nationalities or ethnic groups originating in Europe, the Middle East, or North Africa. Examples of these groups include, but are not limited to, German, Irish, English, Italian, Lebanese, Egyptian, Polish, French, Iranian, Slavic, Cajun, and Chaldean.
More than One Race: This category includes individuals who identify with more than one race.

Gender

Cisgender Man: Describes a person who was assigned male at birth and whose gender identity is a man/male.
Cisgender Woman: Describes a person who was assigned female at birth and whose gender identity is a woman/female.
Transgender Man: Describes a person who is transgender and whose gender identity is man/male.
Transgender Woman: Describes a person who is transgender and whose gender identity is woman/female.
A different term (specify): A gender identity that does not fit into the above categories, such as nonbinary (a person whose gender identity falls outside of the gender binary structure of woman/female and man/male), agender (a person who identifies as having no gender, or who does not experience gender as a primary identity component), or another identity.

First-generation college students are students who are enrolled in postsecondary education and whose parents do not have any postsecondary education experience.

Work full time includes LEAP trainees who have worked full-time (>35 hours/week) at any point during the reporting period.

Total Number of LEAP Trainees in the reporting period: _____

Ethnicity:

Number of LEAP trainees who identify as:

Hispanic/Latino: ______
Non-Hispanic/Latino: _____
Choose not to disclose/Unrecorded: _____

Race:

Number of LEAP trainees who identify as:

American Indian or Alaska Native: ______
Asian: _____
Black or African American: _____
Native Hawaiian or Pacific Islanders: _____
White: ____
More than one race:____
Choose not to disclose/Unrecorded: ____

Gender:

Number of LEAP trainees who identify as:

Cisgender Man: _____
Cisgender Woman: _____
Transgender Man: _____
Transgender Woman: _____
A different term (specify): _____
Choose not to disclose/Unrecorded: _____

Age:

15 – 19: _____
20 – 24: _____
25 – 29: _____
30 – 34: _____
35 and older: ____

Number of LEAP trainees who are enrolled in college:

Part-time: _____
Full-time: _____
Unrecorded: _____

Number of LEAP trainees who:

Are first-generation college student: _____

Work full-time (>35 hours/week) while enrolled in college:⁵ _____

Have a dependent(s) other than spouse: ______

Comments:

Healthy Start Site Form

HEALTHY START SITE FORM

Healthy Start Site Form

Instructions

Section I: Grantee Primary Organization Information

The Grantee Primary Organization is the grantee site location that is noted in the grant records as the main address for your grantee organization. It may be considered the headquarters (HQ) and may/may not be a site that also provides Healthy Start (HS) services. For example, an organization may have an administrative HQ site located in Maryland and has locations providing services to areas in the U.S. Virgin Islands. In this example, the grantee would submit the address for the HQ site in Maryland in Section I and enter the addresses for the U.S. Virgin Islands sites in Section II.

Grant # and Grantee Name will be pre-populated.
Enter the street address, city, state, and 5-digit ZIP code for the primary site in the fields provided.
Indicate whether HS services are provided at the primary location by checking “Yes” or “No.” Note: Most HS grantees provide services at their primary location.

Service Area

Using the dropdown menu, indicate which state(s) are in your organization’s service area (as a whole). For example, if your service area covers seven counties across two states, select both states in this dropdown menu.
Indicate how your organization’s service area is primarily defined (as indicated in your grantee application): by county, ZIP code, or census tract. Your selection informs the menu for the next question.
After you select how your service area is primarily defined, the next field, “Please select all of the [counties OR ZIP codes OR census tracts] covered by this organization’s service area,” will become activated for that particular selection (i.e., counties, ZIP codes, or census tract). Use the dropdown menu to select which [counties OR ZIP codes OR census tracts] are in your organization’s HS service area. Please note that you will have access to only one mode of reporting: county, ZIP code, or census tract; it is not possible to select more than one type of service area.

HS Services – Respond to this section for your HS organization as a whole. For example, if HS Site 1 provides doula services and HS Site 2 provides care to incarcerated persons, indicate that these services are provided by your grantee organization. Note: Only indicate services that are provided through the Healthy Start program.

Indicate which type(s) of services your project provides, checking all that apply.

Section 2: Healthy Start Sites

For each HS service delivery site:

Enter the Project Manager’s name.
Enter the name of the project.

Enter the street address, city, state, and 5-digit ZIP code for the primary site in the fields provided

Section 1. Grantee Primary Organization Information

Grant #____________________________________________

Grantee Name _______________________________________

Street Address_______________________________________

City_______________________________________ State _________ ZIP Code______________

Are HS services provided at the primary location? ☐ Yes ☐ No

State(s) in this organization’s service area:_______________________________________________

Service area for this organization primarily defined by:  County  ZIP Code  Census Tract

Please select all the names of all of the counties covered by this organization’s service area:_________________________________________________________________

Please select all the ZIP codes covered by this organization’s service area:_____________________________________________________________

Please select all Census Tracts covered by this organization’s service area:_____________________________________________________________

Please check all services provided by this grantee organization as a whole:

	Adolescent Population		Doula Services		Interconception
	Breastfeeding Support		Fatherhood – Case Management		Mental & Behavioral Health (beyond screening)
	Case Management/ Care Coordination		Fatherhood – Group Services/Health Education		Outreach
	Children/Youth w/Special Health Care Needs		Food Insecurity Services		Preconception
	Children/Youth w/Special Health Care Needs		Health Education		Prenatal
	Direct Clinical Services		Incarcerated/Justice-System Involved Population		Telehealth Services

(Complete section below for each service delivery site)

Section 2. Healthy Start Sites

Site 1

Project Manager Name_______________________________________________________________

Project Name_______________________________________________________________________

Street Address______________________________________________________________________

City__________________________________ State__________ ZIP Code______________________

Site 2

Project Manager Name_______________________________________________________________

Project Name_______________________________________________________________________

Street Address______________________________________________________________________

City__________________________________ State__________ ZIP Code______________________

Comments:

Attachment D

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	DGIS OMB_SSA_Attachment D_Additional Data Elements
Author	Alexandra Joraanstad
File Modified	0000-00-00
File Created	2023-08-20