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pdfAppendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
Public Burden Statement: The BHW Performance Report for Grants and Cooperative Agreements (PRGCA) is an annual performance and progress report required from each health professions and nursing education grantee that has an approved, funded project with a project period of
one year or more. The report is required to determine the extent to which objectives of the project have been met so that a decision regarding continuation funding can be made. 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 0915-0061 and it is valid until 03/31/2025. This information collection is required to obtain or retain a benefit (Government Performance and Results Act (GPRA) of 1993 and
the GPRA Modernization Act of 2010). The information will be kept private to the extent permitted by law (see 42 USC 292 et seq). Public reporting burden for this collection of information is estimated to average 3.2 hours per response to the annual performance report, 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 14N39, Rockville, Maryland, 20857 or [email protected].
Table of Contents
1.
Grant Purpose – Setup ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 3
2.
Training Program – Setup ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 6
3.
PC: Program Characteristics ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. 8
3.1.
PC-1: Program Characteristics – Degree/Diploma/Certificate Training Programs ...................................................................................................................................................................................................................................................................................................................................................................................................................................................... 8
3.2.
PC-2: Program Characteristics – Non-degree bearing Unstructured Training Programs ............................................................................................................................................................................................................................................................................................................................................................................................................................................ 9
3.3.
PC-3: Program Characteristics – Non-degree bearing Structured Training Programs ............................................................................................................................................................................................................................................................................................................................................................................................................................................... 10
3.4.
PC-4: Program Characteristics – Internship Programs .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. 11
3.5.
PC-5: Program Characteristics – One Year Retraining Programs ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 12
3.6.
PC-6: Program Characteristics – Fellowship Programs .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. 13
3.7.
PC-7: Program Characteristics – Practica and Field Placements ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 14
3.8.
PC-8: Program Characteristics – Residency Programs ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 15
3.9.
PC-9: Program Characteristics –Positions Description .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. 16
3.10.
4.
PC-10: Program Characteristics – Major Participating Sites/Rotation Sites ......................................................................................................................................................................................................................................................................................................................................................................................................................................................... 17
LR-1: Legislatively Required ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 18
4.1
LR-1a: Trainees by Training Category ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 18
4.2
LR-2: Trainees by Age & Sex ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 19
4.3
DV-1: Trainees by Racial & Ethnic Background ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 21
4.4
DV-2: Trainees from a Disadvantaged Background .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. 23
4.5
DV-3: Trainees from a Rural Background ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. 24
5.
IND-GEN: Individual Characteristics ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 25
6.
INDGEN-PY: Individual Prior Year .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. 29
7.
EXP: Experiential Characteristics ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 30
7.1.
EXP-1: Training Site Setup ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 30
7.2.
EXP-2: Experiential Characteristics - Trainees by Profession/Discipline.................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 31
7.3.
EXP-3: Experiential Characteristics - Team Based Care ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. 32
8.
RET: Retention Programs ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 33
9.
CDE: Course and Training Activity Development and Enhancement ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................. 34
9.1.
CDE-1: Course Development and Enhancement - Course Information .................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 34
9.2.
CDE-2: Course Development and Enhancement - Trainees by Profession/Discipline ............................................................................................................................................................................................................................................................................................................................................................................................................................................... 35
10.
CE: Continuing Education............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 36
10.1.
CE-1: Continuing Education - Course Characteristics and Content ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 36
10.2.
CE-2: Continuing Education - Individuals Trained by Profession/Discipline.......................................................................................................................................................................................................................................................................................................................................................................................................................................................... 37
Page 1 of 66
Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
11.
NA: Needs Assessment .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. 38
11.1.
NA-1: Needs Assessment - Geographic Coverage Area ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 38
11.2.
NA-2: Needs Assessment - Public Health Priorities ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 39
11.3.
NA-3: Needs Assessment - Methods for Assessing Training Needs ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 40
12.
State Oral Health Workforce ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 41
12.1.
SOHWP-A: New Facilities ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 41
12.2.
SOHWP-B: Expanded Facilities .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. 42
12.3.
SOHWP-C: Teledentistry ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 43
12.4.
SOHWP-D: Prevention Services ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. 44
12.5.
SOHWP-E: Promotional Events ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. 45
12.6.
SOHWP-F: State Dental Offices ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. 46
12.7.
SOHWP-G: Other Activities ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 47
13.
Faculty Development ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 48
13.1.
Faculty Development – Setup ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 48
13.2.
FD-1a: Faculty Development - Structured Faculty Development Training Programs ........................................................................................................................................................................................................................................................................................................................................................................................................................................... 49
13.3.
FD-1b: Faculty Development - Faculty Trained By Profession/Discipline ............................................................................................................................................................................................................................................................................................................................................................................................................................................................. 50
13.4.
FD-2a: Faculty Development - Faculty Development Activities ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 51
13.5.
FD-2b: Faculty Development - Faculty Trained By Profession/Discipline ............................................................................................................................................................................................................................................................................................................................................................................................................................................................. 52
13.6.
FD-3: Faculty Development - Faculty-Student Collaboration Projects .................................................................................................................................................................................................................................................................................................................................................................................................................................................................. 53
13.7.
FD-4a: Faculty Development - Faculty Instruction ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 54
13.8.
FD-4b: Faculty Development - Faculty Trained by Profession/Discipline ............................................................................................................................................................................................................................................................................................................................................................................................................................................................. 55
13.9.
FD-5: Faculty Development - Faculty Recruitment ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 56
13.10.
FD-5: Faculty Development - Faculty Recruitment – T93 Only ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................. 57
13.11.
FD-5: Faculty Development - Faculty Recruitment – U3M Only ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 58
14.
CHGME Hospital Data .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 59
14.1.
CHD-1: CHGME Hospital Data – Hospital Discharge Data ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 59
14.2.
CHD-2: CHGME Hospital Data – Hospital Discharge and Safety Data ................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 60
14.3.
CHD-3: CHGME Hospital Data – Hospital Discharge Data by Zip Code ................................................................................................................................................................................................................................................................................................................................................................................................................................................................. 61
15.
PCC: Program Curriculum Changes ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 62
16.
State Primary Care Offices ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. 63
16.1.
PCO-1: State Primary Care Offices – Number of Forms Submitted ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 63
16.2.
PCO-2: State Primary Care Offices – OP Impact on Health Professional Shortage Areas ..................................................................................................................................................................................................................................................................................................................................................................................................................................... 64
16.3.
PCO-3a: State Primary Care Offices – Type of Clients Who Received Technical Assistance ................................................................................................................................................................................................................................................................................................................................................................................................................................. 65
16.4.
PCO-3b: State Primary Care Offices – Groups Receiving Technical Assistance ..................................................................................................................................................................................................................................................................................................................................................................................................................................................... 66
Page 2 of 66
Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
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’. 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. 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
Program
D19
Program
D33
Program
D34
Program
D40
Program
D85
Program
D88
Program
E01
Grant Purpose
NWD-1: Assist underrepresented students throughout the educational pipeline to become registered nurses
NWD-2: Facilitate diploma or associate degree registered nurses becoming baccalaureate prepared registered nurses
NWD-3: Prepare practicing registered nurses for advanced nursing education
NWD-4: Nursing Workforce Diversity - Eldercare Enhancement
Grant Purpose
PMR-1: Support resident costs
PMR-2: Infrastructure and curriculum design
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
Grant Purpose
GPE-1: Faculty development
GPE-2: Curricula & Instructional Design / Program Enhancement
GPE-3: Practica
GPE-4: Internships
GPE-5: Post-doctorate fellowships
Grant Purpose
PD-1: Plan, develop, and operate or participate in an approved professional training program
PD-2: Support of an accredited master’s in public health program for dental and dental hygiene students
PD-3: Meet the costs of projects to establish, maintain, or improve pre-doctoral training in primary care
PD-4: Provide financial assistance to dental or dental hygiene students
Grant Purpose
PDD-1: Plan, develop, and operate or participate in an approved professional training program
PDD-2: Support of an accredited master’s degree in public health program for dental residents
PDD-3: Meet the costs of projects to establish, maintain, or improve post-doctoral training in primary care dentistry
programs
PDD-4: Provide financial assistance to dental residents or practicing dentists
Grant Purpose
Conduct Active Training Programs
Maintain and Administer NFLP Loan Fund
Page 3 of 66
Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
Program
M01
Program
T0B
Program
T12
Grant Purpose
BHWET-1: Professional Track- Add to existing, expand, and/or foster the development of (a) pre-degree internships
for psychology doctoral students (PhD/PsyD), or (b) field placement/practicum slots for graduate–level behavioral
health students
BHWET-2: Paraprofessional Track- Add to existing, expand, and/or foster the development of paraprofessional
certificate programs for students in behavioral health training programs
BHWET-3: Curriculum Development and Enhancement
Grant Purpose
PCTE-1: Plan, develop, and operate a degree, fellowship or residency program in addition to infrastructure activities
(curriculum development, faculty development, and/or continuing education)
PCTE-2: Faculty Development Programs and Activities Only (no degree, fellowship, or residency programs offered)
PCTE-IBHPC 3 (PCTE-Integrating Behavioral Health and Primary Care 3): Plan, develop, and operate a degree or
residency program in addition to infrastructure activities (curriculum development, faculty development, and/or
continuing education)
Grant Purpose
SOHWP-1: Loan forgiveness and repayment programs for dentists
SOHWP-3: Grants and low-interest or no-interest loans to help dentists who participate in the Medicaid program
SOHWP-4: The establishment or expansion of dental residency programs in coordination with accredited dental
training institutions in States without dental schools
SOHWP-5: Programs developed in consultation with State and local dental societies to expand or establish oral health
services and facilities in dental health professional shortage areas
SOHWP-6: Placement and support of dental students, dental residents, and advanced dentistry trainees
SOHWP-7: Continuing dental education, including distance-based education
SOHWP-10: Coordination with local education agencies within the State to foster programs that promote children
going into oral health or science professions
SOHWP-12: The development of a State dental officer position or the augmentation of a State dental office to
coordinate oral health and access issues in the State
SOHWP-13: Direct Financial Support
SOHWP-13: Training
SOHWP-14: Integrating oral and primary care medical delivery systems for underserved communities
SOHWP-15: Programs to support oral health providers practicing in advanced roles specifically designed to improve
oral health access in underserved communities
SOHWP-18: Programs to establish or expand oral health services and facilities in Dental HPSAs, such as the
establishment or expansion of community-based dental facilities, free-standing dental clinics, school-linked dental
facilities, and mobile or portable dental clinics
SOHWP-19: Grants and low-interest or no-interest loans to help dentists who participate in the Medicaid program to
enhance capacity, such as through equipment purchases or the sharing of overhead costs to allow for additional hours
of operation
Program
T97
Program
T98
Grant Purpose
OWEP-2: Paraprofessional Track- Add to existing, expand, and/or foster the development of paraprofessional
certificate programs for students in behavioral health training programs
OWEP-3: Curriculum Development and Enhancement
Grant Purpose
OWEP-1a: Professional Track- Add to existing, expand, and/or foster the development of (a) pre-degree internships
for psychology doctoral students (PhD/PsyD), or (b) field placement/practicum slots for graduate–level behavioral
health students
OWEP-1b: Professional Track- Add to existing, expand, and/or foster the development of (a) post-doc-degree
fellowships for psychology doctoral students (PhD/PsyD), or (b) Psychiatrist (MD).
OWEP-3: Curriculum Development and Enhancement
Page 4 of 66
Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
Program
U77
Grant Purpose
AHEC-1: Health careers recruitment of underrepresented minority populations or individuals from disadvantaged or
rural backgrounds
AHEC-2: Community-based training and education with emphasis on primary care
AHEC-3: Continuing education
AHEC-4: Public health careers exposure to youth
AHEC-5: Curriculum Development and Enhancement
AHEC-6: Active AHEC Scholar Program with participants
Page 5 of 66
Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
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. 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. 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)
Fellowship program
One-year retraining program (1 yr. Retraining)
Non-degree structured training program (Structured)
Practicum/Field Placement program
Residency program
Internship Program
Non-degree unstructured training program (Unstructured)
Residency - Accredited Rural Training Track
Residency - Rural Area
Residency - Rural Rotation
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
Select Delivery Mode Used to Offer Program
Single Select
Single Select
Single Select
Add Record
Page 6 of 66
Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
No.
Record Status
Training Program
(1)
Select Training Activity Status in the
Current Reporting Period
(2)
Option(s)
Page 7 of 66
Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
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. Please complete the required subforms for each program that was entered in the Training Program Setup form. The
PC-1 subform collects information specific to Degree/Diploma/Certificate Training Programs only. 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
Type of
Degree
Offered
Primary
Focus
Area
Select Delivery
Mode Used to
Offer Program
(1)
Block 1
(2)
Block 1j
(3)
Block 1k
(4)
Block 1k.1
Total
(7)
Block 3
PC-4
Select the
Primary
Purpose of
the Grant
Partnership(s)
Developed or
Enhanced
using BHW
Funding
(5a)
PC-5
(9)
Block 3b
PC-7
Select Secondary
Purpose(s) of the
Grant
Partnership(s)
Select Type of
Communitybased
Collaborator(s)
Select Primary
Discipline of
Collaborative
Training
Program
Select Status of
Preceptor
Competency
Assessment
(5b)
(5c)
(6b)
(6c)
(6d)
Enter Total # Graduated/Completed (whether funded by BHW or not)
Total
URM
(10)
Block 8
(11)
Block 8a
PC-9
PC-8
Select Types of
Partner
Organizations
for the Primary
Purpose
Enter Total # Enrolled
(whether funded by BHW or not)
URM
Disadvantaged Background and not URM
(8)
Block 3a
PC-6
Enter Total # Who left the Program Before Completion (whether
funded by BHW or not)
Total
URM
(12)
Block 9
(13)
Block 9a
Page 8 of 66
Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
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. The PC-2 subform collects information specific to Non-degree bearing Unstructured Training Programs only. 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
PC-4
PC-5
PC-6
PC-7
PC-8
PC-9
Type of Training Program
Type of Training Activity
Name of Training Activity
Select Education Level(s) of
Participants
Enter Length of Training
Activity in Clock Hours
Select the Primary Purpose
of the Grant Partnership(s)
Developed or Enhanced
using BHW Funding
(1)
Block 1
(2)
Block 1a
(3)
Block 1a.1
(4)
Block 1b
(5)
Block 1c
(5a)
Select Types of
Partner
Organizations
for the Primary
Purpose
(5b)
Select
Secondary
Purpose(s) of
the Grant
Partnership(s)
(5c)
Select Type of
Communitybased
Collaborator(s)
Select Training
Activity Status in
the Current
Reporting Period
(6a)
(7)
Page 9 of 66
Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
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. The PC-3 subform collects information specific to Non-degree bearing Structured Training Programs only. 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
View Prior Period Data
No.
Record
Status
PC-2
PC-3
PC-4
PC-5
PC-6
PC-7
PC-9
PC-8
Type of
Training
Program
Type of
Training
Activity
Name of
Training
Activity
Select
Education
Level(s) of
Participants
Enter Length of
Training Program
in Clock Hours
Select Whether
Public Health
Careers Content
Was Offered
Select Whether
Clinical or
Practicum
Training Was
Offered
Select Whether
Cultural
Competency
Training Was
Offered
Select the Primary
Purpose of the
Grant
Partnership(s)
Developed or
Enhanced using
BHW Funding
Select Types of
Partner
Organizations for
the Primary
Purpose
Select Secondary
Purpose(s) of the
Grant
Partnership(s)
Select Type of
Communitybased
Collaborator(s)
Select Training
Activity Status in the
Current Reporting
Period
(1)
Block 1
(2)
Block 1d
(3)
Block 1d.1
(4)
Block 1e
(5)
Block 1f
(6)
Block 1g
(7)
Block 1h
(8)
Block 1i
(8a)
(8b)
(8c)
(9a)
(10)
Page 10 of 66
Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
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. The PC-4 subform collects information specific to Internship Programs only. 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
View Prior Period Data
No.
Record
Status
PC-2
PC-3
Type of
Training
Program
Primary Discipline of
Individuals Trained
(1)
Block 1
(2)
Block 1l
PC-4
PC-5
PC-7
PC-6
Select the Primary
Purpose of the
Grant
Partnership(s)
Developed or
Enhanced using
BHW Funding
Select Types of
Partner
Organizations for
the Primary
Purpose
Select Secondary
Purpose(s) of the
Grant
Partnership(s)
(3a)
(3b)
(3c)
PC-8
Enter Total # Enrolled (whether funded by BHW or not)
PC-9
Enter Total # Graduated/Completed
(whether funded by BHW or not)
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)
Block 3
(5)
Block 3a
(6)
Block 3b
(7)
Block 8
(8)
Block 8a
(9)
Block 9
(10)
Block 9a
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Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
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. The PC-5 subform collects information specific to 1-year Retraining Programs only. 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
View Prior Period Data
No.
Record
Status
PC-3
PC-2
Type of Training Program
(1)
Block 1
PC-4
PC-5
PC-7
PC-6
Primary
Discipline of
Individuals
Trained
Select the
Primary Purpose
of the Grant
Partnership(s)
Developed or
Enhanced using
BHW Funding
Select Types of
Partner Organizations
for the Primary
Purpose
Select
Secondary
Purpose(s) of
the Grant
Partnership(s)
(2)
Block 1l
(3a)
(3b)
(3c)
PC-9
PC-8
Enter Total # Enrolled
(whether funded by BHW or not)
Enter Total # Graduated/Completed (whether
funded by BHW or not)
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)
Block 3
(5)
Block 3a
(6)
Block 3b
(7)
Block 8
(8)
Block 8a
(9)
Block 9
(10)
Block 9a
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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. The PC-6 subform collects information specific to Fellowship Programs only. 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
View Prior Period Data
No.
Record
Status
PC-2
Type of Training
Program
(1)
Block 1
PC-3
Primary Discipline
of Individuals
Trained
(2)
Block 1l
PC-4
Select the
Primary
Purpose of the
Grant
Partnership(s)
Developed or
Enhanced using
BHW Funding
(2a)
PC-5
PC-6
PC-7
Select Types of
Partner
Organizations
for the Primary
Purpose
Select
Secondary
Purpose(s) of
the Grant
Partnership(s)
Select Type of
Communitybased
Collaborator(s)
(2b)
(2c)
(3a)
Select
Primary
Discipline of
Collaborative
Training
Program
(3b)
PC-9
PC-8
Enter Total # Enrolled
(whether funded by BHW or not)
Total
URM
Disadvantaged
Background
and not URM
(4)
Block 3
(5)
Block 3a
(6)
Block 3b
Enter Total #
Graduated/Completed
(whether funded by BHW or
not)
Total
URM
(7)
Block 8
(8)
Block 8a
Enter Total # Who left the
Program Before Completion
(whether funded by BHW or
not)
Total
URM
(9)
Block 9
(10)
Block 9a
Page 13 of 66
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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. The PC-7 subform collects information specific to Practicum and Field Placement Programs only. 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)
Block 1
PC-4
Primary
Discipline of
Individuals
Trained
(2)
Block 1l
PC-5
PC-7
PC-6
Select the Primary
Purpose of the
Grant
Partnership(s)
Developed or
Enhanced using
BHW Funding
Select Types of
Partner
Organizations
for the Primary
Purpose
Select
Secondary
Purpose(s) of
the Grant
Partnership(s)
Select Type of
Communitybased
Collaborator(s)
(2a)
(2b)
(2c)
(3a)
Select the Topic
Area(s)
Addressed by
this Activity
(3b)
PC-8
PC-9
Enter Total # Enrolled
(whether funded by BHW or not)
Enter Total #
Graduated/Completed (whether
funded by BHW or not)
Total
URM
Disadvantaged
Background and
not URM
Total
URM
(4)
Block 3
(5)
Block 3a
(6)
Block 3b
(7)
Block 8
(8)
Block 8a
Enter Total # Who left the
Program Before Completion
(whether funded by BHW or
not)
Total
URM
(9)
Block 9
(10)
Block 9a
Page 14 of 66
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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 The PC-8 subform collects information specific to Residency Programs only. 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
PC-2
View Prior Period Data
No.
Record Status
Total
(5)
Block 3
PC-3
PC-4
Type of Training
Program
Primary Discipline
of Individuals
Trained
Type of
Dental
Residency
Program
(1)
Block 1
(2)
Block 1l
(3)
Block 1m
Enter Total # Enrolled
(whether funded by BHW or not)
URM
Disadvantaged Background
and not URM
(6)
Block 3a
(7)
Block 3b
PC-5
Select the
Primary
Purpose of the
Grant
Partnership(s)
Developed or
Enhanced using
BHW Funding
(3a)
Block 2
PC-7
PC-6
Select Types of
Partner
Organizations
for the Primary
Purpose
Select
Secondary
Purpose(s) of
the Grant
Partnership(s)
Select Type of
Communitybased
Collaborator(s)
Select Primary
Discipline of
Collaborative
Training
Program
(3b)
(3c)
(4a)
(4b)
Enter Total # Graduated/Completed (whether funded
by BHW or not)
Total
URM
(8)
Block 8
PC-8
(9)
Block 8a
Enter Total # Who left the Program Before Completion
(whether funded by BHW or not)
Total
URM
(10)
Block 9
(11)
Block 9a
PC-9
Enter # of Core Physician Faculty as Reported to
ACGME
(12)
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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. The PC-9 subform collects information specific to positions or slots for certain types of primary care training programs. 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-6
PC-7
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
Training Year
Enter Total # of
Accredited Positions
Enter Total # of Positions
Recruited For
Enter Total # of
Positions Filled
Enter Total # of Positions
Expanded using BHW Funds
Enter # of Residents in
FTE Positions
(1)
Block 1
(2)
(3)
Block 4
(4)
Block 5
(5)
Block 6
(6)
Block 7
(7)
Option(s)
Page 16 of 66
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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-9
PC-10
Type of Training Program
Program Name
(1)
Block 1
(2)
Select the Primary
Purpose of the Grant
Partnership(s)
Developed or
Enhanced using BHW
Funding
(3a)
Select Types of
Partner
Organizations
for the Primary
Purpose
Select
Secondary
Purpose(s) of
the Grant
Partnership(s)
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
(3b)
(3c)
(4)
(5)
(6)
(7)
(8)
(9)
Page 17 of 66
Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
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
Enter # Enter # of
of
Enrollees
Ongoing
Trainees
(1a)
(2)
Block 1
Attrition
Enter #
of
Fellows
Enter # of
Residents
Enter # of
Graduates
Enter # of
Program
Completers
Enter # of
Graduates/
Program
Completers
(3)
Block 2
(4)
Block 3
(5)
Block 4
(6)
Block 5
(6a)
Enter # of
Individuals
who left the
Program
before
Completion
(7)
Block 6
Enter # of
URM who
left the
Program
before
Completion
(8)
Block 6a
Nursing Aide Employment Status and Exam Outcomes
Enter # of
Individuals
Employed
Full-Time
Enter
# of
Individuals
Employed
Part-Time
Enter # of
Individuals
Unemployed
(10)
Block 8
(11)
Block 9
(12)
Block 10
Select
Training
Select
Enter # of Enter # of Activity
Whether
Individuals Individuals Status in
the Current
Exam
who
who
Assessed All Passed the Failed the Reporting
Period
Competencies
Exam
Exam
(13)
Block 11
(14)
Block 12
(15)
Block 13
(16)
N/A
Page 18 of 66
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4.2
LR-2: Trainees by Age & Sex
The LR-2 form captures aggregate-level information about the age groups and gender 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. Record Status
Type of
Training
Program
(1)
Age Group of Trainees
(2)
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
6
7
8
9
10
11
12
13
14
Prior Record
Prior Record
New Record
New Record
New Record
New Record
New Record
New Record
New Record
60 and Over
Age Not Reported
19 and Under
20 – 29 years
30 – 39 years
40 – 49 years
50 – 59 years
60 and Over
Age Not Reported
Gender: Male
Gender: Female
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
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
(2a)
(3)
Blocks 1-6
(4)
Blocks 13-18
(5)
Blocks 25-30
(6)
Blocks 37-42
(6a)
(7)
Blocks 49-54
(7a)
(8)
Blocks 7-12
(9)
Blocks 19-24
(10)
Blocks 31-36
(11)
Blocks 43-48
(11a)
(12)
Blocks 55-60
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OMB No. 0915-0061, Exp. Date 03/31/2025
(Contd)
No.
Record
Status
Type of
Training
Program
(1)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Age Group of Trainees
(2)
Gender: Transgender Nonbinary or Another Gender
Enter # of
Ongoing
Trainees
Enter # of
Enrollees
Enter # of
Fellows
Enter # of
Residents
Enter # of
Graduates
(12a)
(13)
(14)
(15)
(16)
Enter # of
Graduates/
Program
Completers
(16a)
Gender: Not Reported
Select Training Activity
Status in the Current
Reporting Period
Enter # of
Program
Completers
Enter # of
Ongoing
Trainees
Enter # of
Enrollees
Enter # of
Fellows
Enter # of
Residents
Enter # of
Graduates
(17)
(19)
(19a)
(19b)
(19c)
(19d)
Enter # of
Graduates/
Program
Completers
(19e)
Enter # of
Program
Completers
(19f)
(20)
Prior
Record
Prior
Record
Prior
Record
Prior
Record
Prior
Record
19 and Under
Ongoing
20 – 29 years
Ongoing
30 – 39 years
Ongoing
40 – 49 years
Ongoing
50 – 59 years
Ongoing
Prior
Record
Prior
Record
New
Record
New
Record
New
Record
New
Record
New
Record
New
Record
New
Record
60 and Over
Ongoing
Age Not Reported
Ongoing
19 and Under
Complete
20 – 29 years
Complete
30 – 39 years
Complete
40 – 49 years
Complete
50 – 59 years
Complete
60 and Over
Complete
Age Not Reported
Complete
Page 20 of 66
Appendix C: Program Mapping Document
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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 popup 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
Status
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Prior Record
Prior Record
Prior Record
Prior Record
Prior Record
Prior Record
Prior Record
New Record
New Record
New Record
New Record
New Record
New Record
New Record
Type of
Training
Program
Race Category
(1)
(2)
Ethnicity: Hispanic/Latino
Ethnicity: Non-Hispanic/Non-Latino
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
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
(2a)
(3)
Blocks 1-7
(4)
Blocks 8-14
(5)
Blocks 15-21
(6)
Blocks 22-28
(6a)
(7)
Blocks 29-35
(7a)
(8)
Blocks 36-42
(9)
Blocks 43-49
(10)
Blocks 50-56
(11)
Blocks 57-63
(11a)
(12)
Blocks 64-70
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
More than one Race
Race Not Reported
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
More than one Race
Race Not Reported
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Appendix C: Program Mapping Document
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(Contd)
No.
Record Status
Type of Training
Program
(1)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Prior Record
Prior Record
Prior Record
Prior Record
Prior Record
Prior Record
Prior Record
New Record
New Record
New Record
New Record
New Record
New Record
New Record
Race Category
(2)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
More than one Race
Race Not Reported
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
More than one Race
Race Not Reported
Ethnicity: Not Reported
Select Training Activity Status in
the Current Reporting Period
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)
(18)
Complete
Complete
Complete
Complete
Complete
Complete
Complete
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
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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
Enrollees
Type of
Record
No.
Training
Status
Program
(1)
Fellows
Residents
Graduates
Program Completers
Ongoing Trainees
Graduates/Program Completers
Select Training
Enter # from
Enter # from
Enter # from
Enter # from
Enter # from
Enter # from
Enter # from Activity Status in
Enter Total #
Enter Total #
Enter Total #
Enter Total #
Enter Total #
Enter Total #
Enter Total #
Disadvantaged
Disadvantaged
Disadvantaged
Disadvantaged
Disadvantaged
Disadvantaged
Disadvantaged the Current
from
from
from
from
from
from
from
Background
Background
Background
Background
Background
Background
Background
Reporting Period
Disadvantaged
Disadvantaged
Disadvantaged
Disadvantaged
Disadvantaged
Disadvantaged
Disadvantaged
who are not
who are not
who are not
who are not
who are not
who are not
who are not
Background
Background
Background
Background
Background
Background
Background
URM
URM
URM
URM
URM
URM
URM
(2)
Block 1
(3)
Block 2
(4)
Block 3
(5)
Block 4
(6)
Block 5
(7)
Block 6
(8)
Block 7
(9)
Block 8
(10)
Block 9
(11)
Block 10
(13)
(14)
(15)
(16)
(12)
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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
Trainees from Rural Residential Background
No.
Record
Status
Type of
Training
Program
(1)
Enter # of Enrollees
from a Rural
Background
Enter # of Fellows from a
Rural Background
Enter # of Residents from a
Rural Background
Enter # of Graduates from a
Rural Background
Enter # of Program Completers from a
Rural Background
Enter # of Ongoing Trainees from a
Rural Background
Enter # of Graduates/Program Completers
from a Rural Background
(2)
Block 1
(3)
Block 2
(4)
Block 3
(5)
Block 4
(6)
Block 5
(8)
(9)
Select Training
Activity Status
in the Current
Reporting
Period
(7)
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Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
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 have either a) new trainees OR b) updates to provide for trainees from a previous reporting
period? Yes
View Prior Period Data
No.
Record
Status
(complete IND-GEN)
Yes
No
(click Save and Validate button to proceed to the next form)
Type of Training
Program
Trainee
Unique ID
NPI
Number
Select Whether
T9C Funding
Was Used for
Resident or
Fellow
Select
Individual's
Training or
Awardee
Category
Select Whether
Individual is an
International
Medical
Graduate (IMG)
Select
Highest
Degree Held
by Individual
Select
Residency/Degree
Already
Completed by
Individual
Select
Individual's
Enrollment /
Employment
Status
Select
Individual's
Gender(s)
Enter Year
of Birth
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
(1)
(2)
Block 1
(2a)
(2b)
(3)
Block 2
(3a)
(3b)
(3c)
(4)
Block 3
(5a)
(6a)
(7)
Block 6
(8)
Block 7
(9)
Block 8
(10)
Block 9
(11)
Block 10
(Contd)
Select Whether
Individual
Received BHW
Financial
Award?
Enter Individual's Financial Award Amount (BHW funds only)
Stipend
(12)
Block 11
(13)
Block 11
Tuition,
Fees,
and
Supplies
(13a)
Block 11
Enter Individual's Financial Award Amount
Traineeship
Scholarship
Loan
Career
Award
Loan
Repayment
Grant
Fellowship
Direct
Financial
Support
Academic Year Total
Cumulative BHW
Financial Award
Total
Federal
Contribution to
Loan Repayment
State
Contribution to
Loan Repayment
Total
Contribution to
Loan Repayment
(14)
Block 11
(15)
Block 11
(16)
Block 11
(17)
Block 11
(18)
Block 11
(19)
Block 11
(20)
Block 11
(20a)
Block 11
(21b)
Block 11
(21c)
Block 11
(21d)
(21e)
(21h)
Page 25 of 66
Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
(Contd)
Enter # of
Academic Years
the Individual
has Received
BHW Funding
Select
Enter
Whether
Original
Enter
Loan Remains
Qualifying Balance of
in Good
Educational Individual's
Standing and
Loan
Loan
is not in
Amount
Default
(22)
Block 12
(22a)
(23a)
(23)
Block 13
Enter %
Select
Enter FTE paid
Enter % of
Select
Topic
% of
for
Training Costs
Individual's
Area(s)
Loan through Covered through Academic on which
Paid
BHW
BHW-funded
or Training Individual
Off Financial Financial Award
Year
was
Award
Trained
(24)
Block
13a
(25)
Block 14
(25a)
(26)
Block 15
Select any HHS
Priority Topic
Area on which
an Individual
Received
Training
(26a)
(26b)
Training in
Interprofessional
Education and/or
Practice
Select
Select
Select Individual's
Individual's
Individual's
Primary
Profession Discipline/Specialty Specialty
(26c)
(26d)
(27aa)
Select
Enter #
Whether
of
Individual
Contact
Received
Hours
Training
(27a)
(27b)
Training in a Telehealth
Enter Total #
of Patients
Treated during
Academic Year
(27c)
Training in a Primary Care Setting
Select
Select
Enter #
Enter #
Whether
Enter # of
Whether
Enter # of
of
of
Individual
Patient
Individual
Patient
Contact
Contact
Received
Encounters Received
Encounters
Hours
Hours
Training
Training
(27d)
(27e)
(27f)
(28)
Block 17
(29)
Block
17a
(30)
Block 17b
(Contd)
Training in a Medically
Underserved Community
Select
Whether
Individual
Received
Training
(31)
Block 18
Training in a Rural Area
Select
Enter #
Enter #
Enter # of
Whether
Enter # of
of
of
Patient
Individual
Patient
Contact
Contact
Encounters Received
Encounters
Hours
Hours
Training
(32)
Block
18a
(32a)
(33)
Block 19
(34)
Block
19a
(34aa)
Block 19
Student Services
Enter Total # of
Patient Encounters
Across All Settings
Including Inpatients
(34ab)
Block 19
Enter Total # of
Contact Hours
Across All
Settings
Including
Inpatients
(34ac)
Select Social
Support services
used by Trainee
Select
Academic
Support
services used
by Trainee
(34a)
(34b)
Page 26 of 66
Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
(Contd)
Select Any Key
Services Provided
by Individual
Select Individual's
Field Placement
Setting
Select Whether
Individual Left the
Program Before
Completion
Select Reason
for Attrition or
Inactive Status
(34c)
(35)
Block 20
(36)
Block 21
(36a)
Select Whether
Individual
Graduated/
Completed the
Program
(37)
Block 22
Select
Degree
Earned
(38)
Block 22a
Select whether
individual earned
degree onschedule/ ontime
(38a)
Select whether
individual passed a
certifying
examination on the
first attempt
(38b)
Enter the
Number of
Education
Courses Taken
Did Medical
Student Match to
a Residency
Program?
Select Type of
Residency
Program
Enter Certification
Number
Select Individual's
Post-Graduation/
Completion
Intentions
Select Competencies the
Individual is Highly
Ready to Perform
Select Factors
Individual
was Highly
Satisfied with
(38c)
(38d)
(38e)
(38f)
(39)
Block 22b
(39a)
(
(39b)
(Contd)
Enter the % FTE Individual Spent on the Following Roles
Enter # of Articles
Published in PeerReviewed Journals
Research
Teaching
Administration
Clinical
(40)
Block 24a
(41)
Block 24b
(42)
Block 24c
(43)
Block 24d
(44)
Block 25
Enter # of PeerReviewed Conference
Presentations
(45)
Block 26
Enter # of
Trainees
Precepted
Enter # of Hours
Spent Precepting
(45a)
Block 26
Enter # of Grants Awarded by Type and Amount
Research (<$100,000)
Research
(>=$100,000)
Education
(<$100,000)
Education
(>=$100,000)
(46)
Block 27
(47)
Block 27
(48)
Block27
(49)
Block 27
(45b)
Block 26
(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
(50)
Block 28
(51)
Blocks 29-31
(52)
Block 32
(53)
Block 32a
(54)
Block 33
(55)
Block 33a
Select whether
Select Whether
Employment
Your
Data is available?
Organization
Hired this
Individual
(56)
(56a)
Select Whether a
Partner
Organization
Hired this
Individual
Select Whether
Program Sponsoring
Employer Hired the
Apprentice After the
Apprenticeship
Hired
Hourly
Wage
Enter
Zip
Code
Enter
City
Enter
State
Select Type of
Employment
Select
Individual’s
Employment
Location Settings
Select
Individual’s
Primary Role at
Employment
Setting
Select
Individual's
Other Role(s) at
Employment
Setting
Select Type(s) of
Vulnerable
Populations
Served at
Employment
Setting
(56b)
(56c)
(56d)
(57)
(58)
(59)
(60)
(61)
(62)
(63)
(64)
Page 27 of 66
Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
(Contd)
Select Whether
Individual is a First
Time Participant
Select Whether this
is a Continuation
Award
Select Whether
Provider is in
default of service
obligation
(80)
(81)
(82)
Enter Service
Obligation Start
Date
Enter
Service
Obligation
End Date
(84)
(85)
Select Any
HRSA/BHW
program
Individual
Participated In
Prior to Entering
NHSC SLRP
(86)
Select
Medication
Assisted
Treatment
(MAT) Services
Provided by
Individual
(88)
Select If
Individual Holds
a Substance Use
Disorder License
or Certificate
Select
Primary
Site Name
Select Other
Site Name(s)
(89)
(91)
(92)
(Contd)
Apprenticeship Data
Select
Apprenticeship
Program Status
Program Entry
Date for
Apprenticeship
Participant
Program Exit
Date for
Apprenticeship
Participant
(93)
(94)
(95)
Employment
Status at
Apprenticeship
Entry
Hourly Wage At
Apprenticeship
Entry
Select
Apprentice
Role(s) at Site
(96)
(97)
(98)
Options
Select Skills the
Apprentice is
Developing
Select Support
Received During
Apprenticeship
Apprenticeship
Minimum
Term Length
Total Number of
Apprenticeship
Training Hours
Apprenticeship
Street
Apprenticeship
City
Apprenticeship
State
Apprenticeship
Zip Code
Type of
Credential
Attained
During Or At
Apprenticeship
Exit
(99)
(100)
(101)
(102)
(103)
(104)
(105)
(106)
(107)
Hourly Wage
At
Apprenticeship
Exit
(108)
Page 28 of 66
Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
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 readonly 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
Trainee
Unique
ID
NPI
Number
Select
Individual's
Training or
Awardee
Category
Select Individual's
Enrollment /
Employment
Status
Select
Individual's
Genders
Enter
Year of
Birth
Select
Individual's
Ethnicity
Select
Individual's
Race
Select Whether
Individual is from a
Rural Residential
Background
(2)
Block 1
(2a)
(3)
Block 2
(4)
Block 3
(5a)
Block 4
(6a)
(7)
Block 6
(8)
Block 7
(9)
Block 8
(1)
Select Whether
Individual is from
a Disadvantaged
Background
Select
Degree
Earned
Select
Individual's
PostGraduation/
Completion
Intentions
Enter Zip
Code
(10)
Block 9
(11)
Block 22a
(12)
Block 22b
(12a)
Select Type
Select
of
Individual's
Employment Employment
Location
Settings
(12b)
(12c)
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
(13)
Block 23
(14)
Block 23a
(15)
Block 23b
Select
Whether a
Partner
Organization
Hired this
Individual PY
Select
Employment
Location PY
Enter Zip
Code PY
City PY
Select
Whether Your
Organization
Hired this
Individual PY
State
PY
Select Whether
individual is
Enrolled in
Medicaid/CHIP
Program
Select Whether
individual is
Accepting new
Medicaid/CHIP
Patients
Select Individual’s
Primary Role at
Employment
Setting PY
Select Individual's
Other Role(s) at
Employment
Setting PY
(16)
(17)
(18)
(18a)
(18b)
(18c)
(19)
(20)
(21)
(22)
Page 29 of 66
Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
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 auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".
EXP-2
EXP-1
View Prior Period Data
No.
Record
Site
Status
Name
(1)
Block 1
EXP-3
Select
Whether the
Site was Used
in the Current
Reporting
Period
Select Type of
Site Used
Select Type of
Setting Where
the Site was
Located
Select the
Primary Purpose
of the Grant
Partnership(s)
Developed or
Enhanced using
BHW Funding
Select Types of
Partner
Organizations
for the
Primary
Purpose
Select
Secondary
Purpose(s) of
the Grant
Partnership(s)
Select Primary
Training
Competency
Addressed at this
Site
Select Type(s) of
Vulnerable
Population Served
at this Site
Street
Address
1
Street
Address
2
Zip
Code
City
State
Four Digit
Zip Code
Extension
Payment
Model
Select whether
the training site
implements
interprofessional
education and/or
practice
Select any
HHS
Priorities
Addressed
at this Site
Select
Provider
HPSA
Type for
Site
Dental
HPSA
Score
Mental
Health
HPSA
Score
Primary
Care
HPSA
Score
(2)
(3)
Block 1a
(4)
Block 2
(5a)
(5b)
(5c)
(6)
(7)
(7a)
(7b)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
Page 30 of 66
Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
7.2.
EXP-2: Experiential Characteristics - Trainees by Profession/Discipline
The EXP-2 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.
.
EXP-1
EXP-2
View Prior Period Data
No.
Type of Training
Program
(1)
EXP-3
Site Name
Select
Profession and
Discipline of
Individuals
Trained
Select
Discipline/Specialty of
Individuals Trained
Enter # Trained in this
Profession and Discipline
Enter # of Other Trainees in
this Profession and
Discipline Who Participated
in Interprofessional Teambased care
Select
Type of
Site Used
Select Type
of Setting
Where the
Site was
Located
(2)
Block 1
(3)
(3a)
(4)
Block 3
(5)
Block 8
(6)
(7)
Page 31 of 66
Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
7.3.
EXP-3: Experiential Characteristics - Team Based Care
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.
EXP-1
EXP-2
View Prior Period Data
No.
Type of Training Program
(1)
EXP-3
Site Name
Select Team
Number
Select Profession and
Discipline of Team
Members
Select Discipline/Specialty
of Team Members
Enter # of Team Members
in this Profession and
Discipline
Select Type of
Site Used
Select Type of
Setting Where
the Site was
Located
(2)
Block 1
(3)
Block 7b
(4)
(4a)
(5)
Block 7b
(6)
(7)
Page 32 of 66
Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
8. RET: Retention Programs
The RET form captures information about recruitment and retention-related efforts for specific types of BHW-supported initiatives. Please complete this form for any recruitment and retention-related efforts conducted 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.
View Prior Period Data
* Retention Information
Indicate # of Targeted Vacant Dentist/Dental
Provider Positions (Block 5)
Text Box (4 digits)
Indicate # of Filled Dentist/Dental Provider
Positions (Block 6)
Text Box (4 digits)
Indicate # of Dentist/Dental Provider Positions
Retained (Block 7)
Text Box (4 digits)
Page 33 of 66
Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
9. CDE: Course and Training Activity Development and Enhancement
9.1.
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-2
CDE-1
* 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)
Block 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
Select Primary
Competency
Addressed by
the Course
Select Delivery Mode
Used to Offer this Course
or Training Activity
Select Primary
Topic Area
Select Whether
the Course or
Training Activity
was Offered in
the Current
Reporting Period
Was
Supplement
Funding
Used?
(2)
Block 2
(3)
Block 3
(4)
Block 4
(7a)
(8)
Block 6
(11)
(12)
(13)
Select Status of
Development or
Enhancements
Prior Year
Option(s)
Page 34 of 66
Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
9.2.
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".
View Prior Period Data
* Add Profession/Discipline
Name of Course or Training Activity
Select Profession of Individuals Trained
Populated with the following:
- Courses in CDE-1 where Column 4 = Implemented and Column 2 =
‘Academic Course’ or ‘Training/Workshop for health professions
students, fellows or residents’ and column 12 = ‘Offered’ or ‘Reoffered’
(Multi-Select)
Select Discipline/Speciality of Individuals Trained
(Multi-Select)
Add Record
No.
Name of Course or Training Activity
(1)
Block 1
Profession and Discipline of
Individuals Trained
(2)
Select
Discipline/Specialty
of Individuals
Trained
Enter # Trained in this
Profession and Discipline
Select Type of
Course or Training
Activity
Select whether
Course or Training
Activity was
Newly Developed
or Enhanced
Select Primary
Competency
Addressed by the
Course
Select Delivery
Mode Used to
Offer this Course
or Training
Activity
Select Primary
Topic Area
(2a)
(3)
Block 7
(4)
Block 2
(5)
Block 3
(6)
(7)
Block 6
(8)
Select Whether
the Course or
Training Activity
was Offered in
the Current
Reporting Period
(9)
Was Supplement
Funding Used?
Option(s)
(10)
Page 35 of 66
Appendix C: Program Mapping Document
OMB No. 0915-0061, Exp. Date 03/31/2025
10. CE: Continuing Education
10.1. 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. Report each individual course only once and indicate the number of times offered within this
subform. 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".
To add more than 50 records, click the arrow icon (>) displayed next to the page number in the left side of the page navigation bar below. 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 Status
Course Title
(1)
Block 1
Select the Course's Primary Topic Area
(12)
Block 11
Select Type of Course or
Training Activity
(1b)
Select the Primary Competency
Addressed by the Course
(13)
Block 12
Yes
(complete CE-1 and CE-2)
No
(Click Save and Validate to proceed to the next form)
Select Whether Course is
Approved for Continuing
Education Credit
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
(2)
Block 2
(3)
Block 3
(4)
Block 4
(5)
Block 5
(6)
Block 6
(8)
Block 9
Select the Competency Tier for this Course
Select Whether this Course Covers
Alzheimer's Disease-Related Training
Was Supplement
Funding Used?
(14)
Block 13
(15)
Block 14
(16)
Enter # of Individuals Trained by Employment Location
(not mutually exclusive)
Primary Care
Setting
Medically Underserved
Community
Rural Area
(9)
Block 9a
(10)
Block 9b
(11)
Block 9c
Option(s)
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10.2. 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.
To add more than 50 records, click the arrow icon (>) displayed next to the page number in the left side of the page navigation bar below.
CE-2
CE-1
View Prior Period Data
No.
Course Title
(1)
Block 1
Select Profession and
Discipline of Individuals
Trained
(2)
Block 8
Select Discipline/Specialty of
Individuals Trained
Enter # Trained in this Profession
and Discipline
Primary Topic Area
Select Whether this Course Covers
Alzheimer's Disease-Related Training
Was Supplement
Funding Used
(2a)
(3)
Block 8
(4)
(5)
(6)
Option(s)
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11. NA: Needs Assessment
11.1. NA-1: Needs Assessment - Geographic Coverage Area
The NA-1 subform captures information about your geographically designated service area. Please select the state(s) covered by your project and identify the specific counties that are also covered in your service area. You must report each state separately. If you have any questions about how to complete this subform, please
refer to the instruction manual and/or contact your Government Project Officer.
NA-2
NA-1
NA-3
* Add Geographically Designated Coverage Area
Select the State(s) Covered in Your
Geographically Designated Service Area
(Click the ‘Load Counties’ button after selecting
the State)
Select the County(ies) covered in Your
Geographically Designated Service Area
Select One
V
Load Counties
Multi-Select
Add Record
No.
State
County
Option(s)
(1)
(2)
Block 1
Block 1
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11.2. NA-2: Needs Assessment - Public Health Priorities
The NA-2 subform captures information about the trends of the public health priorities and related training needs in a geographically designated service area. Complete the ‘Add Public Health Priority’ section and click the ‘Add Record’ button. In the data table, provide particulars related to this public health priority. If you have
any questions about how to complete this subform, please refer to the instruction manual and/or contact your Government Project Officer.
NA-1
NA-2
NA-3
* Add Public Health Priority
Enter the Public Health Priority
Textbox 200 characters
Add Record
No.
Public Health Priority
(1)
Block 2
Select the State(s)
for Which this is a
Priority
(2)
Block 1
Enter the Data
Source Used to
Document this
Priority
Enter the Current
Rate
Select the Type of
Observed Trend
(3)
Block 2
(4)
Block 2
(5)
Block 2
Select the Type(s) of
Competency(ies) that Need to
be Addressed related to this
Priority
Option(s)
(6)
Block 2
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11.3. NA-3: Needs Assessment - Methods for Assessing Training Needs
The NA-3 subform captures information about the method(s) used to assess training needs among public health workers in a geographically designated service area. If several methods are used, each must be reported separately. Please complete this form in its entirety. If you have any questions about how to complete this
subform, please refer to the instruction manual and/or contact your Government Project Officer.
NA-1
NA-2
NA-3
* Add Methods to Assess Training Needs
Method Used to Assess Training Needs in
Geographically Designated Service Area
Multi-Select
V
Add Record
No.
Methods Used
(1)
Block 3
Enter the Types of
Participants Queried using
this Method
Option(s)
(2)
Block 3
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12. State Oral Health Workforce
12.1. 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
(complete table below)
SOHWP-F
No
SOHWP-G
(proceed to the next form)
View Prior Period Data
* Add Facility
Facility name
(Textbox 100 chars)
Add Record
No.
Facility Name
(1)
Block 1b
Select the Type of Facility
(2)
Block 1a
Select Type(s) of
Oral Health
Services Provided
(3)
Block 1c
Enter # of Patient
Encounters
(4)
Block 1d
Select whether
this is a
Mobile/Portable
Facility
Option(s)
(5)
Block 1e
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12.2. 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 table below)
SOHWP-F
No
SOHWP-G
(proceed to the next form)
View Prior Period Data
* Add Facility
Facility name
(Textbox 100 chars)
Add Record
No.
Facility Name
(1)
Block 2b
Select the Type
of Facility
Select Type(s) of
Oral Health
Services
Provided
Enter Average # of Patient
Encounters Prior to Expansion
Enter Actual # of Patient
Encounters Post
Expansion
Enter Average # of
Patient Encounters
Facility can
Accommodate
(2)
Block 2a
(3)
Block 2c
(4)
Block 2d
(5)
Block 2e
(6)
Block 2f
Select whether
this is a
Mobile/Portable
Facility
Option(s)
(7)
Block 2g
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12.3. 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)
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12.4. 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 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
* 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 # of Individuals Receiving Diagnostic or Preventive Dental Services (Block 11)
(text 5 digits)
Enter # of Recipients of Oral Health Education (Block 12)
(text 5 digits)
Enter # of Individuals Receiving an Oral Screening
(text 5 digits)
Enter # of Individuals Receiving a Referral for Dental Services
(text 5 digits)
Enter # of Individuals Receiving any other Type of Preventive Services
(text 5 digits)
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12.5. 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-E
SOHWP-D
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)
Block 13a
Enter #
Promotional
Events Held
(2)
Block 13b
Select Type(s) of Local
Organizations
Involved in
Promotional Events
Enter Total # of Children
Who Attended
Promotional Events
(3)
Block 13c
(4)
Block 13d
Select Type(s) of
Materials Created for
Promotional Events
Option(s)
(5)
Block 13e
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12.6. 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 pop-up in a new screen
SOHWP-A
SOHWP-B
View Prior Period Data
Select whether a Select whether a
new state dental new state dental
office was created officer position
was created
(1)
Block 14
(2)
Block 15
SOHWP- C
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)
Block 16
(4)
Block 17
(5)
Block 18
(6)
Block 19
(7)
Block 20
(8)
Block 21
(9)
Block 16a
(10)
Block 17a
(11)
Block 18a
(12)
Block 19a
(13)
Block 20a
(14)
Block 21a
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12.7. 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)
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13. Faculty Development
13.1. 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. Selections in this
form will affect all subsequent faculty-related forms. 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
☐
☐
☐
☐
☐
☐
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13.2. 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
Select
Whether
this was a
Preceptor
Training
Program
Select
Whether this
was a
Degree
Bearing
Program
(1a)
(1b)
(2)
Block 2
For Degree-Bearing
Programs
Select
Select Primary
Type of
Focus Area
Degree
Offered
(3)
Block 2a
(4)
Block 2b
For NonDegree
Bearing
Program,
Enter Length
of Training
Program in
Clock Hours
(5)
Block 3
Enter the % of Time Spent Developing Competencies for the
Following Roles
Clinician
Administrator
Educator
Researcher
(6)
Block 5
(7)
Block 5
(8)
Block 5
(9)
Block 5
Enter # of
Faculty Who
Completed
the Program
Select whether
any Faculty
Received any
type of BHWFunded Financial
Award during
the Training
Program
Was Supplement
Funding Used?
(10)
Block 6
(11)
Block 7
(12)
Option(s)
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13.3. 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
Fields with * are required
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 of Faculty Trained
Multi-Select
Select Discipline/Speciality of Faculty Trained
Multi-Select
Add Record
No.
Program Name
Profession and Discipline of Faculty Trained
Select Discipline/Specialty of Faculty Trained
Enter # Trained in this Profession and Discipline
(2)
Block 4
(2a)
(1)
(3)
Block 4
Option(s)
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13.4. 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)
Block 8
For Courses or Workshops
Select Whether Activity is
Accredited for Continuing
Education Credit
(3)
Block 8a
Select Whether
Attendance was to
Acquire or Maintain
Professional Certification
(4)
Block 8b
Enter Duration
of Training
Activity in Clock
Hours
Select Delivery
Mode Used to
Offer Training
Activity
Select the
Faculty Role(s)
Addressed at
Training
Activity
Was Supplement
Funding Used?
(5)
Block 9
(6)
Block 10
(7)
(8)
Option(s)
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13.5. 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
Fields with *are required
* Add Activity Name and Discipline
Activity Name
Values populated from Activity Name
col. in previous tab (single-select)
Select Profession of Faculty Trained
Multi-Select
Select Discipline/Speciality of Faculty Trained
Multi-Select
Add Record
No.
Activity Name
(1)
Select Profession of Faculty
Trained
(2)
Select
Discipline/Specialty
of Faculty Trained
Enter # Trained
in this Profession
and Discipline
(2a)
(3)
Block 12
Option(s)
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13.6. 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
Enter # of Students
Involved in the Project
Total
URM
Total
(4)
Block 14
(5)
Block
14a
(6)
Block 15
Select whether any
Faculty Received any
type of BHW-Funded
Financial Award
(1)
(2)
Block 13
(3)
Block 13a
Was Supplement
Funding Used?
(9)
(10)
Option(s)
URM
(7)
(1a)
Select Type(s) of
Vulnerable Population
Studied in this Project
(8)
Block 16
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13.7. FD-4a: Faculty Development - Faculty Instruction
The FD-4a 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)
Block 17
Select Whether
the
Course/Workshop
was Offered in
the Current
Reporting Period
(1a)
Select the
Content Area
Of the
Course or
Workshop
(2)
Block 18
Enter the Length
of the Course or
Workshop
in Clock Hours
(3)
Block 19
Enter # of Times
the Course or
Workshop was
Offered
(4)
Block 20
Select the Delivery
Mode Used to Offer
the Course or
Workshop
Option(s)
(5)
Block 22
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13.8. FD-4b: Faculty Development - Faculty Trained by Profession/Discipline
The FD-4b 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
Course/Workshop Name from FD-4a
where Column 1a = ‘Yes’ (single-select)
Select Profession of Individuals Trained
Multi-Select
Select Discipline/Specialty of Individuals
Trained
Multi-Select
Add Record
No.
Name of the Course or
Workshop Offered by the
Faculty
(1)
Block 17
Profession and
Discipline of
Individuals Trained
(2)
Select
Discipline/Specialty
of Individuals
Trained
Enter # Trained in
this Profession and
Discipline
(2a)
(3)
Block 21
Option(s)
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13.9. 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 pop-up in a new screen.
View Prior Period Data
* Faculty Recruitment Details
Enter # of Faculty Recruited through the Program (Block 23a)
(text 3 digits)
Enter # of URM Faculty Recruited through the Program (Block 23b)
(text 3 digits)
Enter # of Faculty Positions Retained (Block 23c)
(text 3 digits)
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13.10.
FD-5: Faculty Development - Faculty Recruitment – T93 Only
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 pop-up in a new screen.
View Prior Period Data
* Faculty Recruitment Details
Individuals participating in both Loan
Repayment and Faculty Development
Individuals Participating
in Faculty Development
Programs/Activities Only
Enter # of Faculty Participants in the current reporting period
(text 7 digits)
(text 7 digits)
Enter # of Faculty Recruited (new participants) in the current reporting period
(text 7 digits)
(text 7 digits)
Enter # of Faculty Retained (existing participants) in the current reporting period
(text 7 digits)
(text 7 digits)
Total
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13.11.
FD-5: Faculty Development - Faculty Recruitment – U3M Only
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 pop-up in a new screen.
View Prior Period Data
Profession
Number Employed at
Start of Project Year
Number of
Positions
Recruited for
Number of New
Staff Hired
Number that Left the
Organization
Number of Employees
that Participated in the
Program
Number of
Employees that
Left the Program
Number of Employees
that Participated in the
Program and Left the
Organization
Number of Employees
that Did Not Participate
in the Program and Left
the Organization
Nurses
Physicians
Physician Assistants
Behavioral Health Providers
Other Medical Staff
Non-Medical Staff
Total
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14. CHGME Hospital Data
14.1. 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. Self-pay 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
No.
1
2
3
4
5
6
Payor
(1)
Enter # of Inpatient Discharges
(2)
Yes
(complete table below)
Enter # of Outpatient Visits
(3)
No
(Click Save and Validate to
proceed to the next form)
Enter # of Emergency Department Visits
(4)
Private Insurance
Medicaid and/or CHIP
Medicare
Other Public (TRICARE, Indian Health Service)
Self-Pay
Uncompensated Care
Total
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14.2. 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
View Prior Period Data
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)
* 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)
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)
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14.3. 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.
Record
Status
CHD-3
CHD-2
CHD-1
Zip Code
City
State
Number of Inpatient
Discharges
(1)
(2)
(3)
(4)
Option(s)
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15. 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.
Record
Status
Select Residency Program Name
(1)
Enter the Name of
Course or Training
Activity
(2)
Block 1
Select Type of Course or Training Activity
Select whether Course or Training
Activity was Newly Developed or
Enhanced
Select Primary 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
(3)
Block 2
(4)
Block 3
(5)
(6)
(7)
Block 5
(8)
Block 6
Option(s)
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16. State Primary Care Offices
16.1. PCO-1: State Primary Care Offices – Number of Forms Submitted
Please provide the total number of NHSC site application and recertification forms submitted by the State Primary Care Office to the NHSC.
*Number of Forms Submitted
Total number of NHSC Site Application and Recertification recommendation forms submitted by the State Primary Care Office to the NHSC
Total number of NHSC Site Application and Recertification recommendation forms submitted by the State Primary Care Office to the NHSC within 21 calendar days (15 business days)
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16.2. PCO-2: State Primary Care Offices – OP Impact on Health Professional Shortage Areas
Please complete the following steps to enter the OP impact on HPSAs.
HPSA Name
(1)
HPSA ID#
(2)
OP NPI#
(3)
State OP Placements by Specialty
per HPSA
(4)
If Other Specialty, specify
(5)
State OP hours per week in
direct patient care
(6)
State OP Program
Sponsor
(7)
If Other Program, specify
(8)
1
2
3
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16.3. PCO-3a: State Primary Care Offices – Type of Clients Who Received Technical Assistance
Please enter the type of clients who received technical assistance.
Type of Clients Who Received Technical Assistance
(1)
NHSC
(2)
Expansion
(3)
Data Sharing
(4)
Designation
(5)
Needs Assessment
(6)
Other Technical Assistance Type
Clients
(7)
Specify
(8)
Community
Provider
J1-Waiver
Community Health Center
Health Department
State Agency
Office of Regional Operations
Medicaid
Primary Care Association
State Loan Repayment Program
Rural Health Clinic
NHSC
Other (specify)
Total
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16.4. PCO-3b: State Primary Care Offices – Groups Receiving Technical Assistance
Please enter the groups receiving technical assistance.
Date of Event
(1)
Name of Outreach Event
(2)
Define Audience Reached
If Multiple or Other Audience,
Specify
Total #’s Reached at Each
Outreach Event
Describe Audience Reached
(3)
(4)
(5)
(6)
Option(s)
1
2
3
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| File Type | application/pdf |
| File Title | Master Wireframe 2019-2020 (Working Copy) |
| Author | Swetha Vijayakumar |
| File Modified | 2024-03-08 |
| File Created | 2023-12-21 |