Form 1 Program Data Collection Tool

Teaching Health Center Program Characteristics Survey
Please complete a separate data collection tool for each residency program receiving THCGME
funding (for example, if your institution sponsors a Family Medicine and Dental program, please
complete a data collection tool for each specialty).
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 0915-0376. Public reporting burden for this
collection of information is estimated to average 8 hours per response, including the time for
reviewing instructions, searching existing data sources, and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing this burden, to HRSA Reports
Clearance Officer, 5600 Fishers Lane, Room 10C-03I, Rockville, Maryland, 20857. OMB #
0915-0376 & Expiration Date 03/31/2017

General Program Information:
THC Name:
THC Contact Address:
Residency Program Director Name:
Residency Program Director Phone Number:
Residency Program Director Email:
THC Primary Contact Name:
THC Primary Contact Position:
THC Primary Contact Phone Number:
THC Primary Contact Email:
Residency Program Specialty:
Sponsoring Institution designated for Accreditation:
Primary Training Site designated for Accreditation:
Accrediting Body(ies), indicate all:
Is your THC sponsoring institution for Accreditation a
GME consortium?

Yes/No

If yes, please list all members of the GME consortium and briefly describe their role in the
consortium and residency program:
Name
Role

Which organization employs the residency director?
Which organization employs the residents?
Please list any medical schools or universities your
residency program is affiliated with:

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Residents:
Enter information for your current residency program classes. PGY-1 residents are currently enrolled but have not yet
completed their first year of training.
Total Number of
Residents

Number
Male

Number
Female

Number
IMGs

Number THC
Resident FTE

PGY-1 Class
PGY-2 Class
PGY-3 Class
PGY-4 Class or Graduates
Number of Residents Matched Through Each:
ACGME

AOA

ADA

Outside
Match

PGY-1 Class
PGY-2 Class
PGY-3 Class
PGY-4 Class or Graduates
Please describe any pipeline or other special recruitment programs for your residency program.
Name of Program

Description

Complete for each of the following Academic Years (Enter N/A if not applicable):
2014-2015

2013-2014

2012-2013

2011-2012

Number of Graduates Who Started the Program
Year 1 and Finished This Program
Example, 2012-2013 would be the number who
graduated during or at the end of this academic
year
Number of Graduates Regardless of Whether they
Began in this Program
Number of Residents Who Withdrew from the
Program, for all training years
Number of Residents Who Transferred to Another
Program, for all training years
Number of Residents Dismissed from the Program,
for all training years
Number Residents Complete but not Promoted, for
all training years

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Curriculum:
Please briefly describe how each of the following has been incorporated into the operations of your
health center and into the curriculum of your THC residency program (including how you evaluate
residents in these areas if appropriate).
Health Center Operations

Residency Curriculum and Evaluation

Patient Centered
Medical Homes

Accountable Care
Organizations

Health Information
Technology

Quality Improvement

Interdisciplinary
Teams

Health Policy

Health Advocacy

Community Medicine
or Public Health

Research

Please list and briefly describe any accreditation or programs your health center and/or residency
program participates in for any of the above areas. For example, NCQA accreditation for PCMH,
Meaningful Use for HIT, or any regional or state practice transformation programs.
Name

Description

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Please briefly describe how each of the following has been incorporated into the curriculum of your
THC residency program (including how you evaluate residents in these areas if appropriate).
Residency Curriculum

Resident Evaluation

Health Center Management
Training

Leadership Training

Outpatient Training Sites:
Please indicate established outpatient clinical training sites, where all or the majority of your residents
rotate for your THC residency program.
Outpatient Training Site Name:
Address:
Does this site fall into any of the following federally
designated areas/practices?
o HPSA: Federally designated health professional
shortage area
o MUA: Federally designated medically
underserved area
o MHC: Federally designated migrant health
center
o CHC: Federally designated community health
center
o RHC: Federally designated rural health clinic
o NHSC: National Health Service Corps
o IHS: Indian Health Service site or tribal clinic
o FQHC: Federally Qualified Health Center
o FQHC Look Alike
o State qualified health center/clinic
o State or Local Health Department

Write all the federally designated areas/practices
that apply to this site here:

Training objectives for site:
Indicate the time spent by residents in this site and whether the rotation is required or elective, indicate N/A
if appropriate:
Average
number of
weeks per year
in this site

Average
number of ½
day sessions
per week

Average
number of full
time rotation
weeks per
year

Year 1
Year 2
Year 3
Year 4

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Is there a written contract between the sponsoring
institution and this site?
Is there a financial relationship with this site for the
purposes or residency training? If yes, please
describe.
Is there an exchange of resources with this site for
the purposes or residency training? If yes, please
describe. (Resources may include personnel.)
In what year did this site first become a training site
for the residency program?

Outpatient Training Site Name:
Address:
Does this site fall into any of the following federally
designated areas/practices?
o HPSA: Federally designated health professional
shortage area
o MUA: Federally designated medically
underserved area
o MHC: Federally designated migrant health
center
o CHC: Federally designated community health
center
o RHC: Federally designated rural health clinic
o NHSC: National Health Service Corps
o IHS: Indian Health Service site or tribal clinic
o FQHC: Federally Qualified Health Center
o FQHC Look Alike
o State qualified health center/clinic
o State or Local Health Department

Write all the federally designated areas/practices
that apply to this site here:

Training objectives for site:
Indicate the time spent by residents in this site and whether the rotation is required or elective, indicate N/A
if appropriate:
Average
number of
weeks per year
in this site

Average
number of ½
day sessions
per week

Average
number of full
time rotation
weeks per
year

Year 1
Year 2
Year 3
Year 4

Is there a written contract between the sponsoring
institution and this site?

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Is there a financial relationship with this site for the
purposes or residency training? If yes, please
describe.
Is there an exchange of resources with this site for
the purposes or residency training? If yes, please
describe. (Resources may include personnel.)
In what year did this site first become a training site
for the residency program?

Outpatient Training Site Name:
Address:
Does this site fall into any of the following federally
designated areas/practices?
o HPSA: Federally designated health professional
shortage area
o MUA: Federally designated medically
underserved area
o MHC: Federally designated migrant health
center
o CHC: Federally designated community health
center
o RHC: Federally designated rural health clinic
o NHSC: National Health Service Corps
o IHS: Indian Health Service site or tribal clinic
o FQHC: Federally Qualified Health Center
o FQHC Look Alike
o State qualified health center/clinic
o State or Local Health Department

Write all the federally designated areas/practices
that apply to this site here:

Training objectives for site:
Indicate the time spent by residents in this site and whether the rotation is required or elective, indicate N/A
if appropriate:
Average
number of
weeks per year
in this site

Average
number of ½
day sessions
per week

Average
number of full
time rotation
weeks per
year

Year 1
Year 2
Year 3
Year 4

Is there a written contract between the sponsoring
institution and this site?
Is there a financial relationship with this site for the
purposes or residency training? If yes, please
describe.

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Is there an exchange of resources with this site for
the purposes or residency training? If yes, please
describe. (Resources may include personnel.)
In what year did this site first become a training site
for the residency program?

Inpatient Training Sites:
Inpatient Training Site Name:
Address:
Does this site fall into any of the categories?
o Non-profit hospital
o For-profit hospital
o Children’s Hospital
o Rehabilitation Hospital
o Critical Access Hospital
Training objective for site:

Write all the categories that this site falls into here:

Indicate the duration of resident rotations and whether the rotation is required or elective, indicate N/A if
appropriate:
Average number of
Required/Elective
weeks per year
(weeks/weeks)
Year 1
Year 2
Year 3
Year 4

Is there a written contract between the sponsoring
institution and this site?
Is there a financial relationship with this site for the
purposes or residency training? If yes, please
describe.
Is there an exchange of resources with this site for
the purposes or residency training? If yes, please
describe. (Resources may include personnel.)
In what year did this site first become a training site
for the residency program?

Inpatient Training Site Name:
Address:
Does this site fall into any of the categories?
o Non-profit hospital
o For-profit hospital

Write all the categories that this site falls into here:

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o
o
o

Children’s Hospital
Rehabilitation Hospital
Critical Access Hospital
Training objective for site:

Indicate the duration of resident rotations and whether the rotation is required or elective, indicate N/A if
appropriate:
Average number of
Required/Elective
weeks per year
(weeks/weeks)
Year 1
Year 2
Year 3
Year 4

Is there a written contract between the sponsoring
institution and this site?
Is there a financial relationship with this site for the
purposes or residency training? If yes, please
describe.
Is there an exchange of resources with this site for
the purposes or residency training? If yes, please
describe. (Resources may include personnel.)
In what year did this site first become a training site
for the residency program?

Inpatient Training Site Name:
Address:
Does this site fall into any of the categories?
o Non-profit hospital
o For-profit hospital
o Children’s Hospital
o Rehabilitation Hospital
o Critical Access Hospital
Training objective for site:

Write all the categories that this site falls into here:

Indicate the duration of resident rotations and whether the rotation is required or elective, indicate N/A if
appropriate:
Average number of
Required/Elective
weeks per year
(weeks/weeks)
Year 1
Year 2
Year 3
Year 4

Is there a written contract between the sponsoring
institution and this site?

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Is there a financial relationship with this site for the
purposes or residency training? If yes, please
describe.
Is there an exchange of resources with this site for
the purposes or residency training? If yes, please
describe. (Resources may include personnel.)
In what year did this site first become a training site
for the residency program?

*** Add more if needed ***

Community Experiences:
Please indicate any additional established community experiences for your THC residency program.
Experience:
Training Objectives:
Description of timing and duration of experience:
Experience:
Training Objectives:
Description of timing and duration of experience:
Experience:
Training Objectives:
Description of timing and duration of experience:
Experience:
Training Objectives:
Description of timing and duration of experience:
Experience:
Training Objectives:
Description of timing and duration of experience:

*** Add more if needed ***

Primary Care Clinical Service:
Complete for all clinical sites where residents routinely provide primary care. Primary care may include
general family medicine, internal medicine, pediatrics, geriatrics, ob-gyn, psychiatry, or dental services.
Clinical Site Name:
Average number of patient
visits per ½ day session

Average number of patient
visits per year seen in
health center

Average patient panel size

Year 1
Year 2

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Year 3

What is the average preceptor to resident ratio in your health center?
How many patients do faculty physicians typically see during a half-day
session when supervising residents?
How many patients do faculty physicians typically see during a half-day
session when not supervising residents?

Clinical Site Name:
Average number of patient
visits per ½ day session

Average number of patient
visits per year seen in
health center

Average patient panel size

Year 1
Year 2
Year 3

What is the average preceptor to resident ratio in your health center?
How many patients do faculty physicians typically see during a half-day
session when supervising residents?
How many patients do faculty physicians typically see during a half-day
session when not supervising residents?

Clinical Site Name:
Average number of patient
visits per ½ day session

Average number of patient
visits per year seen in
health center

Average patient panel size

Year 1
Year 2
Year 3

What is the average preceptor to resident ratio in your health center?
How many patients do faculty physicians typically see during a half-day
session when supervising residents?
How many patients do faculty physicians typically see during a half-day
session when not supervising residents?

*** Add more if needed ***

Health Center Information:
Health centers include any community-based ambulatory health center systems affiliated with your
Teaching Health Center program. These systems may include multiple clinical sites.

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Health Center Name:
Please list all health center clinical sites and addresses.
Name

Address

Is this a residency
teaching site? (yes/no)

Has your health center or is your health center
planning to expand, either in operations or in sites?
If yes, please describe.

Please list any additional health education students or residents training at your health center, and
briefly describe the duration of their rotations (for example, 1 month rotations or weekly ½ day
continuity clinics).
Name

Duration

For each of the following, please indicate the number of physicians currently participating in the
program in your health center. Enter N/A if appropriate.
Number of physicians

Number of dentists

NHSC scholarship
NHSC loan repayment
State loan repayment
J-1 visa waiver

Health Center Name:
Please list all health center clinical sites and addresses.
Name

Address

Is this a residency
teaching site? (yes/no)

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OMB # 0915-0376 & Expiration Date 03/31/2017

Has your health center or is your health center
planning to expand, either in operations or in sites?
If yes, please describe.

Please list any additional health education students or residents training at your health center, and
briefly describe the duration of their rotations (for example, 1 month rotations or weekly ½ day
continuity clinics).
Name

Duration

For each of the following, please indicate the number of physicians currently participating in the
program in your health center. Enter N/A if appropriate.
Number of physicians

Number of dentists

NHSC scholarship
NHSC loan repayment
State loan repayment
J-1 visa waiver

*** Add more if needed ***

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