Form 1A Fielding Tracker

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Overview

Instructions
Fielding Tracker

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Sheet 1: Instructions

INSTRUCTIONS: The [HPSWRTP/PRMHW] Healthcare Workforce Fielding Tracker will gather information about survey data collection methods and progress. The information is required for the [HPSWRTP/PRMHW] evaluation and for NORC to provide assistance as needed. "Target population," here means the individuals that have been targeted/invited to participate in any aspect of your program since funding began (regardless of whether they have participated to date). Refer to the following definitions below for more information on how to complete each required field.
Population that received the survey	Definition
Checkbox options	For this question, please indicate if all target population individuals (to date) received the survey or only individuals who participated in at least one activity (select one).
Notes on who received the survey	Any information or questions about who received an email invitation to the survey. This is useful for data analysis. (E.g., Email outreach does not include students. We were unable to obtain email addresses for students in the target population.)
Survey Fielding information	Definition
Date Sent	MM/DD/YY that the email was sent to the target population
Time of Day Sent	Time of day (morning, afternoon, evening) that the email was sent to the target population
Number of Email Addresses Sent To	Total number of target population email addresses that the email was sent to. Please plan to send the initial email and all follow-up reminder emails to all members of the target population.
Number of Bounceback Emails Received	Total number of emails that were returned to sender with an error message (e.g., undeliverable)
Number in Target Population Without Email Info	Total number in the target population who were not emailed (e.g., if you do not have email addresses for these individuals)
Total Number of People in Target Population	Total number in the target population. This needs to be the sum of 'Number of Email Addresses Sent To' (D4) and 'Number of Target Population Without Email Info' (F4). (D4+F4=G4)
Notes
Target Population Demographics	Definition
Please report the demographics of those invited to participate in the survey (the total program target population). To allow for us to adjust findings to reflect the target population, each individual should be reported in only one category).
Age	Number of individuals in the program target population by age group - across all sites (15-24, 25-34, 35-44, 45-54, 55-64, 65+)
Gender	Number of individuals in the program target population by gender - across all sites (male, female, or transgender/non-binary/another gender)
Race	Number of individuals in the program target population by race- across all sites (American Indian or Alaska Native, Asian, Black or African-American, Native Hawaiian or Other Pacific Islander, White, More than one race, Other)
Ethnicity	Number of individuals in the program target population by ethnicities - across all sites (Hispanic or Latino/a, Non-Hispanic or Non-Latino/a)
Type of Primary Discipline/Profession	Number of individuals in the total program target population by discipline/profession across all sites.
OMB Control Number: 0915-XXXX Expiration Date: MM/DD/20XX
Public Burden Statement: The purpose of this information collection is to evaluate federal programs designed to support the mental health and resiliency of the healthcare and public safety workforce. 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-XXXX and is valid until MM/DD/20XX. Public reporting burden for this collection of information is estimated to average xx hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].

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Sheet 2: Fielding Tracker

	[Health and Public Safety Workforce Resiliency Training Program (HPSWRTP)/ Promoting Resilience and Mental Health Among Health Professional Workforce (PRMHW)] The Healthcare Workforce Fielding Tracker
Organization Name:
Please indicate whether the population that is receiving the survey most closely matches (select one)
Everyone in target population to date (This option is preferred if applicable)
Only those who have participated in one or more activities (to date)
Enter any notes on who received the survey
Survey Fielding Information
	Date Sent	Time of Day Sent	Number of Email Addresses Sent To	Number of Bounceback Emails Received	Number in Target Population Without Email Info	Total Number of People in Target Population	Notes
Initial Email Invitation						0
Reminder 1						0
Reminder 2						0
Reminder 3						0
Last chance 1						0
Last chance 2						0
Target Population Demographics
Please report the demographics of those that received the survey (this will allow us to determine if responses are representative). For each demographic variable, individuals should be reported only in one category.
Age	19 and younger	20-29	30-39	40-49	50-59	60 and Over	Not provided	Total	Notes
								0
Gender	Male	Female	Transgender, non-binary, or another gender	Not provided	Total	Notes
					0
Race	American Indian or Alaska Native	Asian	Black or African-American	Native Hawaiian or Other Pacific Islander	White	More than One Race	Other	Not Provided	Total	Notes
									0
Ethnicity	Hispanic or Latina/o	Non-Hispanic or Non-Latina/o	Not provided	Total	Notes
				0
Type of Primary Discipline/Profession	Number of Workers	Number of Students
Nurse (registered nurse, licensed practical nurse)
Advance Practice Registered Nurse (nurse practitioner, clinical nurse specialist, nurse anesthetist, and nurse midwive)
Physician
Medical or other resident
Physician assistant
Professional counselor, social worker, or psychologist
Dentist
Pharmacist
Physical therapist, occupational therapist, or speech-language therapist
Emergency responder/Public safety
Community health worker/Peer support
Technician/Assistant (e.g., nursing assistant, medical assistant, pharmacy technician, dental assistant; phlebotomist)
Environmental support (e.g., custodial, medical equipment)
Administrator
Other medical staff
Other non-medical staff
Total	0	0
Notes
OMB Control Number: 0915-XXXX Expiration Date: MM/DD/20XX
Public Burden Statement: The purpose of this information collection is to evaluate federal programs designed to support the mental health and resiliency of the healthcare and public safety workforce. 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-XXXX and is valid until MM/DD/20XX. Public reporting burden for this collection of information is estimated to average xx hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].