Form 2 NAT

OMB No. 0915-

Exp. Date:

Nurse Anesthetist Traineeship Program (NAT)

Public Burden Statement: 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 project is 0915-xxxx. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

• NAT Tables

Table 1 - NAT: Enrollment, Traineeship Support and Graduate Data

Table 2 - NAT: Graduate Data – Rural, Underserved, or Public Health

Table 3 - NAT: Minority/Disadvantaged Status Data

NAT PROGRAM TABLES 1-3

IMPORTANT NOTE: Applicants must adhere to the table instructions to ensure that the data provided is accurate and complete. All appropriate NAT Program Specific Tables must be submitted by the due date. If not, your grant application may be deemed non-responsive to the Program Guidance and the grant application will not be considered for funding. Schools are encouraged to consult with Program Staff for technical assistance prior to submitting the grant application.

• Specific instructions follow each table.

• Do not change the structure/format or elements of these tables.

• Review and confirm that all Grand Totals provided in each column of the tables are accurate.

Table 1 - NAT: Enrollment, Traineeship Support and Graduate Data

Complete Table 1 summarizing student enrollment, student support, graduates, graduates supported and projected student enrollment. Instructions for completing Table 1 are below.

STUDENTS	Total # of Full-time Students Enrolled As of 10/15/06	Total # of NAT Students Supported 7/1/05 – 6/30/06	Total # of Graduates 7/01/05-6/30/06	Total # of NAT Graduates Supported 7/01/05-6/30/06	Total # of NAT Students Projected As of 10/15/07
# Students in First 12 Months of Study		N/A	N/A	N/A
# Master’s Students Beyond First 12 Months of Study
# Doctoral Students Beyond First 12 Months of Study
GRAND TOTAL

Instructions for Completing Table 1 - NAT:

• All applicants should complete this table.

• Do not make any changes to this table.

• For “Total # of Full-time Students Enrolled”, enter the total number of full-time students enrolled as of 10/15/06.

• For “Total # of NAT Students Supported”, enter the total number of students (Master’s and Doctoral) supported from July 1, 2005 - June 30, 2006 who have received Nurse Anesthetist Traineeship support.

• For “Total # of Graduates”, enter the total number of graduates who completed degree requirements between July 1, 2005 and June 30, 2006. If this is a new program, enter “0" in the “Total # of Graduates” column.

• For “Total # of NAT Graduates Supported”, enter the total number of graduates who received NAT support and completed degree requirements between July 1, 2005 and June 30, 2006. If this is a new program, enter “0" in the “Total # of NAT Graduates” column.

• For “Total # of NAT Students Projected”, enter the total number of students projected to enroll by October 15, 2007.

Table 2 - NAT: Graduate Data - Rural, Underserved, or Public Health (7/01/05-6/30/06)

Complete Table 2, as appropriate, providing data on the number of graduates who completed degree requirements between 7/1/05-6/30/06 who spend at least 50 percent of their work-time in clinical practice sites substantially benefiting rural or underserved populations, or in State or local health departments. Instructions for completing Table 2 are below.

Practice Settings	Nurse Anesthetists
Community Health Centers
Migrant Health Centers
Health Care for the Homeless Grantees
Public Housing Primary Care Grantees
Rural Health Clinics
National Health Service Corps Sites
Indian Health Service Sites/Tribal Health Sites
Federally Qualified Health Centers
Health Professional Shortage Areas (HPSAs)
State or Local Health Departments
Ambulatory Practice Sites Designated by State Governors
Other Rural or Underserved Population – specify
Total # of Graduates in these Settings
Total # of Graduates
Percentage of Graduates in these Settings

Instructions for completing Table 2 - NAT:

• All applicant institutions requesting the Statutory Funding Preference must complete this table.

• Do not make any changes to this table.

• Data on this table should reflect only the number of nurse anesthetist graduates who completed degree requirements between 7/01/05 and 6/30/06.

• Although a graduate’s practice site may qualify under more than one category, each individual graduate should be reported only once.

• Enter the total number of “Nurse Anesthetist” graduates employed in each of the “Practice Settings” listed.

• Enter the “Total # of Graduates in these Settings” working in the identified settings.

• Enter the “Total # of Graduates” completing degree requirements between 7/01/05 and 6/30/06.

• Enter the “Percentage of Graduates in these Settings” working in the identified settings.

TABLE 3 - NAT: Minority/Disadvantaged Status Data

On the following Table 3, provide the total number of enrollees, students supported, graduates and graduates supported reported on Table 1 by each ethnicity/disadvantaged category. Enrollees, students supported, graduates and graduates supported that do not report ethnicity/race or those for which data is unavailable must be reported in the “Unreported / Unavailable Student Ethnicity / Race” column. Instructions for completing Table 3 are below.

	American Indian or Alaska Native	Underrepresented Asian Subgroup*	Asian (Not Under- Represented)	Black or African American	Hispanic or Latino	Native Hawaiian or Other Pacific Islander	White: Disadvantaged	White: Not- Disadvantaged	More than one race	Unreported/Unavailable Student Ethnicity / Race	GRAND TOTAL
ENROLLEES (As of 10/15/06)
STUDENTS SUPPORTED (As of 10/15/06)
GRADUATES (7/1/05-6/30/06)
GRADUATES SUPPORTED (7/1/05-6/30/06)

*Any Asian other than Chinese, Filipino, Japanese, Korean, Asian Indian, or Thai.

Instructions for completing Table 3:

• Enter the total number of “Enrollees” by category and the “grand total” for students enrolled as of 10/15/2006. Include only full-time, second-year and beyond nurse anesthetist enrollees on this table.

• Enter the total number of “Students Supported” by category and the “grand total” for students supported as of 10/15/2006. Include only full-time, second-year and beyond nurse anesthetist supported students on this table.

• Enter the total number of “Graduates” by category and the “grand total” for graduates

who completed degree requirements between 7/01/2005 and 6/30/2006.

Enter the total number of “Graduates” by category and the “grand total” for graduates

who completed degree requirements between 7/01/2005 and 6/30/2006.

• Enter the total number of “Graduates Supported” by category and the “grand total” for graduates supported that completed degree requirements between 7/01/2005 and 6/30/2006.

• IMPORTANT NOTE: These figures should reconcile with data reported on TABLE 1 for the total number of master’s and doctoral students (enrollees, supported, graduates) beyond first 12 months of study.

Use the following definitions from the OMB standards for the classification of Federal data on race and ethnicity for the identified racial/ethnic categories:

American Indian or Alaska Native: a person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Asian: a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American: a person having origins in any of the black racial groups of Africa.

Hispanic or Latino: a person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin regardless of race. The term “Spanish Origin” can be used in addition to “Hispanic or Latino”.

Native Hawaiian or Other Pacific Islander: a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White: a person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

More than one race: a person reporting more than one race.

Use the following definition for low-income populations to determine Disadvantaged status:

Low-income populations are defined as individuals who come from a family with an annual income below a level based on low-income thresholds according to family size, published by the U.S. Bureau of the Census, and adjusted annually for changes in the Consumer Price Index, and by the Secretary for use in health professions and nursing programs. Low-income populations are considered to be at risk of poor health outcomes. A family is a group of two or more individuals related by birth, marriage, or adoption who live together or an individual who is not living with any relatives. Most HRSA programs use the income of the student’s parents to compute low income status, while a few programs, depending upon the legislative intent of the program, programmatic purpose of the low income level, as well as the age and circumstances of the average participant, will use the student’s family as long as he or she is not listed as a

dependent upon the parents’ tax form. The figures to be used to determine low-income eligibility for purposes of this grant program are:

Size of parents’ family * Income Level **

1 $19,600

2 $26,400

3 $33,200

4 $40,000

5 $46,800

6 $53,600

7 $60,400

8 $67,200

* Includes only dependents listed on Federal

income tax forms. Some programs will use the

student’s family rather than his or her parents’

family.

** Adjusted gross income for calendar year

2005.

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