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1.
Grant Purpose – Setup ..................................................................................................................................................................................................................................................................................................................................................................... 3
2.
Training Program – Setup ................................................................................................................................................................................................................................................................................................................................................................ 5
3.
PC: Program Characteristics ............................................................................................................................................................................................................................................................................................................................................................. 6
3.1.
PC-1: Program Characteristics – Degree/Diploma/Certificate Training Programs .................................................................................................................................................................................................................................................................. 6
3.2.
PC-2: Program Characteristics – Non-degree bearing Unstructured Training Programs ........................................................................................................................................................................................................................................................ 7
3.3.
PC-3: Program Characteristics – Non-degree bearing Structured Training Programs ............................................................................................................................................................................................................................................................. 8
3.4.
PC-4: Program Characteristics – Internship Programs ............................................................................................................................................................................................................................................................................................................. 9
3.5.
PC-5: Program Characteristics – One Year Retraining Programs ........................................................................................................................................................................................................................................................................................... 10
3.6.
PC-6: Program Characteristics – Fellowship Programs .......................................................................................................................................................................................................................................................................................................... 11
3.7.
PC-7: Program Characteristics – Practica and Field Placements ............................................................................................................................................................................................................................................................................................ 12
3.8.
PC-8: Program Characteristics – Residency Programs ........................................................................................................................................................................................................................................................................................................... 13
3.9.
PC-9: Program Characteristics –Positions Description........................................................................................................................................................................................................................................................................................................... 14
3.10.
4.
PC-10: Program Characteristics – Major Participating Sites/Rotation Sites ...................................................................................................................................................................................................................................................................... 15
LR-1: Legislatively Required ........................................................................................................................................................................................................................................................................................................................................................... 16
4.1
LR-1a: Trainees by Training Category..................................................................................................................................................................................................................................................................................................................................... 16
4.2
LR-2: Trainees by Age & Sex ................................................................................................................................................................................................................................................................................................................................................... 17
4.3
DV-1: Trainees by Racial & Ethnic Background ...................................................................................................................................................................................................................................................................................................................... 19
4.4
DV-2: Trainees from a Disadvantaged Background .............................................................................................................................................................................................................................................................................................................. 21
4.5
DV-3: Trainees from a Rural Background .............................................................................................................................................................................................................................................................................................................................. 22
5.
IND-GEN: Individual Characteristics ............................................................................................................................................................................................................................................................................................................................................... 23
6.
INDGEN-PY: Individual Prior Year................................................................................................................................................................................................................................................................................................................................................... 26
7.
EXP: Experiential Characteristics.................................................................................................................................................................................................................................................................................................................................................... 27
7.1.
EXP-1: Training Site Setup ...................................................................................................................................................................................................................................................................................................................................................... 27
7.2.
EXP-2: Experiential Characteristics - Trainees by Profession/Discipline ................................................................................................................................................................................................................................................................................ 28
7.3.
EXP-3: Experiential Characteristics - Team Based Care ......................................................................................................................................................................................................................................................................................................... 29
8.
RET: Retention Programs ............................................................................................................................................................................................................................................................................................................................................................... 29
9.
CDE: Course and Training Activity Development and Enhancement............................................................................................................................................................................................................................................................................................. 30
9.1.
CDE-1: Course Development and Enhancement - Course Information ................................................................................................................................................................................................................................................................................ 30
9.2.
CDE-2: Course Development and Enhancement - Trainees by Profession/Discipline ........................................................................................................................................................................................................................................................... 31
10.
CE: Continuing Education ........................................................................................................................................................................................................................................................................................................................................................... 32
10.1.
CE-1: Continuing Education - Course Characteristics and Content .................................................................................................................................................................................................................................................................................... 32
10.2.
CE-2: Continuing Education - Individuals Trained by Profession/Discipline ...................................................................................................................................................................................................................................................................... 33
11.
NA: Needs Assessment .............................................................................................................................................................................................................................................................................................................................................................. 34
11.1.
NA-1: Needs Assessment - Geographic Coverage Area ..................................................................................................................................................................................................................................................................................................... 34
11.2.
NA-2: Needs Assessment - Public Health Priorities ........................................................................................................................................................................................................................................................................................................... 35
Page 1 of 55
11.3.
12.
NA-3: Needs Assessment - Methods for Assessing Training Needs ................................................................................................................................................................................................................................................................................... 36
State Oral Health Workforce...................................................................................................................................................................................................................................................................................................................................................... 37
12.1.
SOHWP-A: New Facilities ................................................................................................................................................................................................................................................................................................................................................... 37
12.2.
SOHWP-B: Expanded Facilities ........................................................................................................................................................................................................................................................................................................................................... 38
12.3.
SOHWP-C: Teledentistry .................................................................................................................................................................................................................................................................................................................................................... 39
12.4.
SOHWP-D: Prevention Services.......................................................................................................................................................................................................................................................................................................................................... 39
12.5.
SOHWP-E: Promotional Events .......................................................................................................................................................................................................................................................................................................................................... 40
12.6.
SOHWP-F: State Dental Offices .......................................................................................................................................................................................................................................................................................................................................... 41
12.7.
SOHWP-G: Other Activities ................................................................................................................................................................................................................................................................................................................................................ 42
13.
Faculty Development ................................................................................................................................................................................................................................................................................................................................................................. 43
13.1.
Faculty Development – Setup ............................................................................................................................................................................................................................................................................................................................................ 43
13.2.
FD-1a: Faculty Development - Structured Faculty Development Training Programs ........................................................................................................................................................................................................................................................ 44
13.3.
FD-1b: Faculty Development - Faculty Trained By Profession/Discipline .......................................................................................................................................................................................................................................................................... 45
13.4.
FD-2a: Faculty Development - Faculty Development Activities ......................................................................................................................................................................................................................................................................................... 46
13.5.
FD-2b: Faculty Development - Faculty Trained By Profession/Discipline .......................................................................................................................................................................................................................................................................... 47
13.6.
FD-3: Faculty Development - Faculty-Student Collaboration Projects .............................................................................................................................................................................................................................................................................. 48
13.7.
FD-4a: Faculty Development - Faculty Instruction ............................................................................................................................................................................................................................................................................................................. 49
13.8.
FD-4b: Faculty Development - Faculty Trained by Profession/Discipline .......................................................................................................................................................................................................................................................................... 50
13.9.
FD-5: Faculty Development - Faculty Recruitment ............................................................................................................................................................................................................................................................................................................ 51
14.
CHGME Hospital Data ................................................................................................................................................................................................................................................................................................................................................................ 52
14.1.
CHD-1: CHGME Hospital Data – Hospital Discharge Data .................................................................................................................................................................................................................................................................................................. 52
14.2.
CHD-2: CHGME Hospital Data – Hospital Discharge and Safety Data ................................................................................................................................................................................................................................................................................ 53
14.3.
CHD-3: CHGME Hospital Data – Hospital Discharge Data by Zip Code .............................................................................................................................................................................................................................................................................. 54
15.
PCC: Program Curriculum Changes ............................................................................................................................................................................................................................................................................................................................................ 55
Page 2 of 55
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’. 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
Existing grantee who selected a planning year grant in the prior period (Note: Planning year has been selected for less than 12 months – one prior semi-annual period)
View Prior Period Data
Grant Purpose
PAT-1: Plan, develop and operate an education program to train physician assistants to practice in primary care settings
PAT-2: Planning year only
Select
☐
☒
Existing grantee who selected a planning year grant in the prior period (Note: Planning year has been selected for prior 2 semi-annual periods or 1 annual period)
View Prior Period Data
Grant Purpose
PAT-1: Plan, develop and operate an education program to train physician assistants to practice in primary care settings
PAT-2: Planning year only
Select
☐
☐
Existing grantee who did not select/did not have planning year grant in the prior period
View Prior Period Data
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
Select
☒
☐
☒
☐
☐
☐
Page 3 of 55
PROGRAM WITH SINGLE-SELECT GRANT PURPOSE (NEPQR)
Existing grantee
View Prior Period Data
Grant Purpose
E1: Expanding the enrollment in baccalaureate nursing programs
Select
E2: Providing education in the new technologies, including distance learning methodologies
P1: Establishing or expanding nursing practice arrangements in non-institutional settings (Nurse Managed Centers) to demonstrate
methods to improve access to primary health care in medically underserved communities
P2: Providing care for underserved populations and other high-risk groups such as the elderly, individuals with HIV/AIDS, substance
abusers, the homeless, and victims of domestic violence
P3: Providing quality coordinated care, and other skills needed to practice in existing and emerging organized health care systems
P4: Developing cultural competencies among nurses
R1: Career Ladder Program to promote career advancement for individuals, including licensed practical nurses, licensed vocational
nurses, certified nurse assistants, home health aides, diploma degree or associate degree nurses, to become baccalaureate prepared
registered nurses or advanced education nurses in order to meet the needs of the registered nurse workforce
R2: Developing and implementing internships and residency programs in collaboration with an accredited school of nursing to
encourage mentoring and the development of specialties
R4: Enhancing patient care delivery systems through improving the retention of nurses and enhancing patient care that is directly
related to nursing activities
Page 4 of 55
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. 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 autopopulate 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)
Non-degree structured training program (Structured)
Non-degree unstructured training program (Unstructured)
One-year retraining program (1 yr. Retraining)
Internship program
Practicum/Field Placement program
Residency program
Fellowship program
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
Single Select
Single Select
Add Record
No.
Record Status
Training Program
(1)
Select Training Activity Status in the
Current Reporting Period
(2)
Option(s)
Page 5 of 55
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. Each of the subforms corresponds to a different type of training program. 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-1 subform collects information specific to Degree/Diploma/Certificate Training Programs only.
PC-1
PC-2
PC-3
PC-4
PC-5
PC-7
PC-6
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
Select
Primary
Discipline
Of Individuals
Trained
Select
Type(s) of
Partners/Co
nsortia
Used to
Offer this
Training
Select Type(s) of
Partners/
Consortia Used
for Job
Placement
Activities
Select Type of
Communitybased
Collaborator(s)
Select Primary
Discipline of
Collaborative
Training Program
Select Status of
Preceptor
Competency
Assessment
(1)
Block 1
(2)
Block 1j
(3)
Block 1k
(4)
Block 1k.1
(5)
Block 1l
(6)
Block 2
(6a)
(6b)
(6c)
(6d)
Total
(7)
Block 3
Enter Total # Enrolled
(whether funded by BHW or not)
URM
Disadvantaged Background and not URM
(8)
Block 3a
(9)
Block 3b
Enter Total # Graduated/Completed (whether funded by BHW or not)
Total
URM
(10)
Block 8
(11)
Block 8a
PC-9
PC-8
Enter Total # Who left the Program Before Completion (whether
funded by BHW or not)
Total
URM
(12)
Block 9
(13)
Block 9a
Page 6 of 55
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. Each of the subforms corresponds to a different type of training program. 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 Type(s) of
Partners/Consortia Used to
Offer this Training
Select Type of
Communitybased
Collaborator(s)
Select Training
Activity Status in
the Current
Reporting Period
(1)
Block 1
(2)
Block 1a
(3)
Block 1a.1
(4)
Block 1b
(5)
Block 1c
(6)
Block 2
(6a)
(7)
Page 7 of 55
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. Each of the subforms corresponds to a different type of training program. 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-7
PC-6
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 Type(s) of
Partners/Consortia
Used to Offer this
Training
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
(9)
Block 2
(9a)
(10)
Page 8 of 55
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. Each of the subforms corresponds to a different type of training program. 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
Select Type(s) of
Partners/Consorti
a Used to Offer
this Training
(3)
Block 2
PC-5
PC-7
PC-6
Enter Total # Enrolled (whether funded by BHW or not)
PC-8
Enter Total # Graduated/Completed
(whether funded by BHW or not)
PC-9
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
Page 9 of 55
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. Each of the subforms corresponds to a different type of training program. 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-2
PC-3
Type of Training Program
(1)
Block 1
PC-4
PC-5
Primary
Discipline of
Individuals
Trained
Select Type(s) of
Partners/Consort
ia Used to Offer
This Training
(2)
Block 1l
(3)
Block 2
PC-7
PC-6
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
PC-9
PC-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 10 of 55
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. Each of the subforms corresponds to a different type of training program. 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
PC-5
PC-7
PC-6
Select Type(s)
of
Partners/Conso
rtia Used to
Offer this
Training
Select Type of
Communitybased
Collaborator(s)
Select
Primary
Discipline of
Collaborative
Training
Program
(3)
Block 2
(3a)
(3b)
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
PC-9
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 11 of 55
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. Each of the subforms corresponds to a different type of training program. 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-2
PC-3
Type of Training Program
(1)
Block 1
PC-4
PC-5
PC-6
Primary
Discipline of
Individuals
Trained
Select Type(s) of
Partners/Consorti
a Used to Offer
this Training
Select Type of
Communitybased
Collaborator(s)
Select the Topic
Area(s)
Addressed by
this Activity
(2)
Block 1l
(3)
Block 2
(3a)
(3b)
PC-7
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 12 of 55
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. Each of the subforms corresponds to a different type of training program. 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
PC-5
PC-7
PC-6
Type of Training
Program
Primary Discipline
of Individuals
Trained
Type of
Dental
Residency
Program
Select Type(s)
of Partners/
Consortia Used
to Offer this
Training
Select Type(s)
of Communitybased
Collaborator(s)
Select Primary
Discipline of
Collaborative
Training
Program
(1)
Block 1
(2)
Block 1l
(3)
Block 1m
(4)
Block 2
(4a)
(4b)
Enter Total # Enrolled
(whether funded by BHW or not)
URM
Disadvantaged Background
and not URM
(6)
Block 3a
(7)
Block 3b
Enter Total # Graduated/Completed (whether funded
by BHW or not)
Total
URM
(8)
Block 8
(9)
Block 8a
PC-8
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 or AOA
(12)
Page 13 of 55
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. Each of the subforms corresponds to a different type of training program. 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-2
PC-3
PC-4
PC-5
PC-7
PC-6
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 14 of 55
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-10
PC-9
Type of Training Program
Program Name
Select Type(s) of
Partners/Consortia
Used to Offer this
Training
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
(1)
Block 1
(2)
(3)
Block 2
(4)
(5)
(6)
(7)
(8)
(9)
Page 15 of 55
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
Attrition
Enter #
of
Ongoing
Trainees
Enter # of
Enrollees
Enter #
of
Fellows
Enter # of
Residents
Enter # of
Graduates
Enter # of
Program
Completers
Enter # of
Graduates/
Program
Completers
(1a)
(2)
Block 1
(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 16 of 55
4.2
LR-2: Trainees by Age & Sex
The LR-2 form captures aggregate-level information about the age groups and sex 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
Type of
Status
Training
Program
(1)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Age Group of
Trainees
(2)
Prior
Record
Prior
Record
Prior
Record
Prior
Record
Prior
Record
19 and Under
Prior
Record
Prior
Record
New
Record
New
Record
New
Record
New
Record
New
Record
New
Record
New
Record
60 and Over
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
20 – 29 years
30 – 39 years
40 – 49 years
50 – 59 years
Age Not
Reported
19 and Under
20 – 29 years
30 – 39 years
40 – 49 years
50 – 59 years
60 and Over
Age Not
Reported
Page 17 of 55
(Contd)
No.
Record Status
Type of Training Program
(1)
Age Group of
Trainees
(2)
Gender: Not Reported
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)
Select Training Activity
Status in the Current
Reporting Period
(18)
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
N/A
N/A
N/A
N/A
N/A
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
N/A
N/A
Complete
Complete
Complete
Complete
Complete
Complete
Complete
Page 18 of 55
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
Type of Training Program
(1)
1
Prior Record
2
Prior Record
3
4
Prior Record
Prior Record
5
6
7
8
Prior Record
Prior Record
Prior Record
New Record
9
New Record
10
11
New Record
New Record
12
13
14
New Record
New Record
New Record
Race Category
(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
Black or African
American
Asian
Native Hawaiian or
Pacific Islander
White
More than one Race
Race Not Reported
American Indian or
Alaska Native
Black or African
American
Asian
Native Hawaiian or
Pacific Islander
White
More than one Race
Race Not Reported
Page 19 of 55
(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
Black or African American
Asian
Native Hawaiian or Pacific Islander
White
More than one Race
Race Not Reported
American Indian or Alaska Native
Black or African American
Asian
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)
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
Page 20 of 55
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
No.
Record
Type of
Status
Training
Program
(1)
Enter Total # from
Disadvantaged
Background
(10)
Block 9
Enter Total # from
Disadvantaged
Background
Enrollees
Enter Total #
Where
Background is
Not Reported
(2)
Block 1
Program Completers
Enter Total # Where Background
is Not Reported
(10a)
Enter # from
Disadvantaged
Background who
are not URM
Enter Total # from
Disadvantaged
Background
(3)
Block 2
(4)
Block 3
(2a)
Fellows
Enter Total #
Where
Background is
Not Reported
(4a)
Enter # from
Disadvantaged
Background who are not
URM
Enter Total # from
Disadvantaged
Background
Ongoing Trainees
Enter Total # Where
Background is Not
Reported
(11)
Block 10
(13)
(13a)
Enter # from
Disadvantaged
Background who
are not URM
Enter Total # from
Disadvantaged
Background
(5)
Block 4
(6)
Block 5
Residents
Enter Total #
Where
Background is
Not Reported
(6a)
Enter # from
Disadvantaged
Background who are not
URM
Enter Total # from
Disadvantaged
Background
(14)
(15)
Enter # from
Disadvantaged
Background who
are not URM
Enter Total # from
Disadvantaged
Background
(7)
Block 6
(8)
Block 7
Graduates
Enter Total #
Where
Background is
Not Reported
(8a)
Graduates/Program Completers
Enter Total # Where
Enter # from Disadvantaged
Background is Not
Background who are not URM
Reported
(15a)
(16)
Enter # from
Disadvantaged
Background who
are not URM
(9)
Block 8
Select Training Activity
Status in the Current
Reporting Period
(12)
Page 21 of 55
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
No.
Record
Type of
Status
Training
Program
(1)
Trainees from Rural Residential Background
Enter # of
Enrollees from
a Rural
Background
Enter # of
Enrollees
Where
Background is
Not Reported
Enter # of
Fellows from a
Rural
Background
Enter # of
Fellows Where
Background is
Not Reported
Enter # of
Residents from a
Rural Background
Enter # of
Residents Where
Background is Not
Reported
Enter # of
Graduates from a
Rural Background
Enter # of
Graduates
Where
Background is
Not Reported
Enter # of
Program
Completers
from a Rural
Background
Enter # of
Program
Completers
Where
Background is
Not Reported
Enter # of
Ongoing Trainees
from a Rural
Background
Enter # of
Ongoing
Trainees Where
Background is
Not Reported
Enter # of
Graduates/
Program
Completers from a
Rural Background
Enter # of
Graduates/
Program
Completers Where
Background is Not
Reported
(2)
Block 1
(2a)
(3)
Block 2
(3a)
(4)
Block 3
(4a)
(5)
Block 4
(5a)
(6)
Block 5
(6a)
(8)
(8a)
(9)
(9a)
Select
Training
Activity
Status in the
Current
Reporting
Period
(7)
Page 22 of 55
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 either have a) students or faculty who received direct financial support (e.g., scholarships,
stipends, loans, loan repayment) from a HRSA-funded grant and/or students who participated in
community-based primary care training during this reporting period; OR b) updates to provide for students
who received direct financial support and/or participated in community-based primary care training in a
previous reporting period Yes
View Prior Period Data
No.
Record
Status
(complete IND-GEN)
Yes
(click Save and Validate button to proceed to the next form)
No
Type of Training
Program
Trainee
Unique ID
NPI
Number
Select
Individual's
Training or
Awardee
Category
Select
Whether
Individual is an
International
Medical
Graduate
(IMG)
Select
Highest
Degree Held
by Individual
Select
Individual's
Enrollment /
Employment
Status
Select
Individual's
Gender
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)
(3)
Block 2
(3a)
(3b)
(4)
Block 3
(5)
Block 4
(6a)
(7)
Block 6
(8)
Block 7
(9)
Block 8
(10)
Block 9
(11)
Block 10
(Contd)
Select
Whether
Individual
Received
BHW
Financial
Award
(12)
Block 11
Enter Individual's Financial Award Amount (BHW funds only)
Salary
and
Benefits
Stipend
Tuition,
Fees,
and
Supplies
Traineeship
Scholarship
Loan
Career
Award
Loan
Repayme
nt
Grant
Fellowship
Direct
Financial
Support
Academic
Year Total
Cumulative
BHW
Financial
Award Total
(12a)
Block 11
(13)
Block 11
(13a)
Block 11
(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
Page 23 of 55
(Contd)
Enter # of
Academic
Years the
Individual
has
Received
BHW
Funding
(22)
Block 12
Enter
Balance of
Individual's
Loan
(23)
Block 13
Enter % of
Loan Paid
Off
(24)
Block 13a
Enter % FTE
paid for
through
BHW
Financial
Award
(25)
Block 14
% of
training
costs
covered
through
BHWfunded
financial
award
Select
Individual's
Academic
or Training
Year
(25a)
(26)
Block 15
Select
Topic
Area(s) on
which
Individual
was
Trained
(26a)
Select any
HHS
Priority
Topic Area
on which
an
Individual
Received
Training
Select
Individual'
s Primary
Discipline
(26b)
(27)
Block 16
Training in
Interprofessional
Education and/or
Practice
Select
Whether
Individual
Received
Training
Enter #
of
Contact
Hours
(27a)
(27b)
Enter
Total # of
Patients
Treated
by
Resident
During
Academic
Year
(27c)
Training in a Primary Care Setting
Select
Wheth
er
Individ
ual
Receive
d
Trainin
g
(28)
Block
17
Training in a Medically Underserved Community
Training in a Rural Area
Enter # of
Contact
Hours
Enter # of
Patient
Encounters
Select Whether
Individual
Received
Training
Enter # of
Contact Hours
Enter # of
Patient
Encounters
Select Whether
Individual
Received
Training
Enter # of
Contact
Hours
Enter # of
Patient
Encounter
s
(29)
Block 17a
(30)
Block 17b
(31)
Block 18
(32)
Block 18a
(32a)
(33)
Block 19
(34)
Block 19a
(34aa)
Enter # of
Patient
Encounte
rs Across
All
Settings
Including
Inpatient
s
Student Servic
Select
Social
Support
services
used by
Trainee
(34ab)
(Contd)
Select
Individual's
Field
Placement
Setting
Select
Whether
Individual
Left the
Program
Before
Completion
Select
Reason
for
Attrition
or
Inactive
Status
Select
Whether
Individual
Graduated/
Completed
the
Program
(35)
Block 20
(36)
Block 21
(36a)
(37)
Block 22
Select
Whether
Individual
Graduated
from their
residency
or
fellowship
by the end
of the
academic
year
(37a)
Select
Degree
Earned
(38)
Block
22a
Select
whether
individual
earned
degree
onschedule/
on-time
Select
whether
individual
took and
passed a
certifying
examination
on the first
attempt
Enter the
Number of
Education
Courses
Taken
Select
Individual's
PostGraduation/
Completion
Intentions
(38a)
(38b)
(38c)
(39)
Block 22b
Enter the % FTE Individual Spent on the Following
Roles
Research
Teaching
Administration
Clinical
(40)
Block
24a
(41)
Block 24b
(42)
Block 24c
(43)
Block
24d
Enter # of
Articles
Published
in PeerReviewed
Journals
Enter # of
PeerReviewed
Conference
Presentations
Enter # of
Trainees
Precepted
(44)
Block 25
(45)
Block 26
(45a)
Enter # of Hours
Spent Precepting
(45b)
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
Page 24 of 55
(34a)
Sel
Acad
Sup
serv
use
Tra
(34
(Contd)
Enter Total Time
Obligated to Serve (in
weeks)
(50)
Block 28
Select Individual's
Current Designated
Practice Settings
(51)
Blocks 29-31
Select Whether
individual is Enrolled
in Medicaid/CHIP
Program
(52)
Block 32
Select Whether
individual is
Accepting new
Medicaid/CHIP
Patients
(53)
Block 32a
Enter Total # of
Patient Encounters
(54)
Block 33
Enter # of
Medicaid/CHIP
Patient Encounters
Select whether
Employment Data is
available?
City
State
Zip Code
Type of Employment
Select Individual’s
Employment Location
Settings
(56)
(57)
(58)
(59)
(60)
(61)
Option(s)
(55)
Block 33a
Page 25 of 55
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
(1)
Trainee
Unique
ID
Select
Individual's
Training or
Awardee
Category
Select
Individual's
Enrollment /
Employment
Status
Select
Individual's
Gender
Select
Individual's
Age
Enter
Year
of
Birth
Select
Individual's
Ethnicity
Select
Individual's
Race
Select Whether
Individual is from
a Rural
Residential
Background
(2)
Block 1
(3)
Block 2
(4)
Block 3
(5)
Block 4
(6)
Block 5
(6a)
(7)
Block 6
(8)
Block 7
(9)
Block 8
Select Whether
Individual is from a
Disadvantaged
Background
Select Degree
Earned
Select Individual's
Post-Graduation/
Completion Intentions
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
Select Whether Your
Organization Hired
this Individual
Select Whether a
Partner Organization
Hired this Individual
Select
Employment
Location
(10)
Block 9
(11)
Block 22a
(12)
Block 22b
(13)
Block 23
(14)
Block 23a
(15)
Block 23b
(16)
(17)
(18)
Page 26 of 55
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-1
EXP-2
EXP-3
View Prior Period Data
* Add Site
Enter the Site's Name
Textbox, 200 characters
Add Record
No.
Record Status
Site Name
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 Type(s)
of Partners/
Consortia used
to Offer
Training at this
Site
Select
Primary
Training
Competency
Addressed
at this Site
Select
Type(s) of
Vulnerable
Population
Served at
this Site
Zip
Cod
e
City
State
Four Digit
Zip Code
Extension
Paymen
t Model
Select whether
the training site
implements
interprofessional
education and/or
practice
Select any
HHS
Priorities
Addressed
at this Site
(1)
Block 1
(2)
(3)
(4)
(5)
Block 5
(6)
Block 6
(7)
Block 4
(8)
(9)
(10)
(11)
(12)
(13)
(14)
Opti
on(s)
Page 27 of 55
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.
Individuals reported in this subform should be those captured in LR-1a or IND-GEN.
.
EXP-3
EXP-2
EXP-1
View Prior Period Data
No.
Type of Training
Program
(1)
Site Name
Select Profession
and Discipline of
Individuals Trained
Enter # Trained in this
Profession and Discipline
Enter # of Other Trainees in this
Profession and Discipline Who
Participated in Interprofessional
Team-based care
(2)
Block 1
(3)
Block 3
(4)
Block 3
(5)
Block 8
Select Type Select Type
of Site
of Setting
Used
Where the
Site was
Located
(6)
Option(s)
(7)
Page 28 of 55
7.3.
EXP-3: Experiential Characteristics - Team Based Care
The EXP-3 subform captures information about the number and types of interprofessional teams used at each site that was entered in the EXP-1 Setup form. Please complete this subform for each training site 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.
Individuals reported in this subform should not be captured in EXP-3.
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
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)
Block 7b
(5)
Block 7b
(6)
(7)
Option(s)
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
Enter # of Targeted Vacant Dentist/Dental
Provider Positions (Block 5)
Text Box (4 digits)
Enter # of Filled Dentist/Dental Provider
Positions (Block 6)
Text Box (4 digits)
Enter # of Dentist/Dental Provider Positions
Retained (Block 7)
Text Box (4 digits)
Page 29 of 55
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 the
Primary
Competency
Addressed by
the Course
Select Delivery Mode
Used to Offer this Course
or Training Activity
Select which
training
programs are
associated
with this
course or
training
activity
Select
Primary
Topic Area
Select
Whether the
Course or
Training
Activity was
Offered in
the Current
Reporting
Period
(2)
Block 2
(3)
Block 3
(4)
Block 4
(7a)
(8)
Block 6
(10)
(11)
(12)
Option(s)
Page 30 of 55
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".
Although you were allowed to report courses or training activities developed or enhanced in previous academic years, only report individuals who participated in these courses or training activities during the current academic year.
CDE-1
CDE-2
View Prior Period Data
* Add Profession/Discipline
Name of Course or Training Activity
Profession and Discipline 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)
Add Record
No.
Name of Course or Training Activity
(1)
Block 1
Profession and Discipline of Individuals
Trained
(2)
Block 7
Enter # Trained in this Profession and
Discipline
Select Type of Course
or Training Activity
(3)
Block 7
(4)
Select whether
Course or Training
Activity was Newly
Developed or
Enhanced
(5)
Select the Primary
Competency
Addressed by the
Course
Select Delivery Mode
Used to Offer this
Course or Training
Activity
Select Primary Topic
Area
(6)
(7)
(8)
Select Whether the
Course or Training
Activity was Offered
in the Current
Reporting Period
(9)
Option(s)
Page 31 of 55
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. 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".
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 Whether the
Course was Offered in
the Current Reporting
Period
Yes
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
(2)
Block 2
(3)
Block 3
(4)
Block 4
(5)
Block 5
(1a)
Select the Primary Competency
Addressed by the Course
(13)
Block 12
(complete CE-1 and CE-2)
Select Type(s) of Partnership(s)
Established for the Purposes of
Delivering this Course
Select Whether Employment
Location Data are Available
for Individuals Trained
(6)
Block 6
(8)
Block 9
Select the Competency Tier for this Course
Select Whether Supplemental Funding for Alzheimer's
Disease-Related Training was used for this Course
(14)
Block 13
(15)
Block 14
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)
Page 32 of 55
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.
CE-1
CE-2
View Prior Period Data
No.
Course Title
Select Profession and Discipline of Individuals
Trained
(1)
Block 1
(2)
Block 8
Enter # Trained in this Profession and Discipline
Primary Topic Area
(3)
Block 8
(4)
Select Whether Supplemental Funding
for Alzheimer’s Disrease-Related
Training was used fort his Course
(5)
Option(s)
Page 33 of 55
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
Page 34 of 55
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-2
NA-1
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
Page 35 of 55
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-2
NA-1
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
Page 36 of 55
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 SOHWP-A)
SOHWP-F
No
SOHWP-G
(Click Save and Validate to 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
Page 37 of 55
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 SOHWP-B)
SOHWP-F
No
SOHWP-G
(Click Save and Validate to 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
(2)
Block 2a
Select the
Type(s) of Oral
Health Services
Provided
(3)
Block 2c
Enter Average # of Patient
Encounters Prior to Expansion
Enter Actual # of Patient
Encounters Post
Expansion
Enter Average # of
Patient Encounters
Facility can
Accommodate
(4)
Block 2d
(5)
Block 2e
(6)
Block 2f
Select whether
this is a
Mobile/Portable
Facility
Option(s)
(7)
Block 2g
Page 38 of 55
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
View Prior Period Data
* Add Teledentistry Program Details
Number of Dental Facilities with Teledentistry Capabilities (Block 3)
Number of Teledentistry Encounters Involving Patient Care (Block 4)
Number of Teledentistry Sessions Involving Training (Block 5)
3 digits
3 digits
3 digits
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 # Individual Receiving Diagnostic or Preventive Dental Services (Block 11)
(text 5 digits)
Enter # of Recipients of Oral Health Education (Block 12)
(text 5 digits)
Page 39 of 55
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
Page 40 of 55
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
Page 41 of 55
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)
Page 42 of 55
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. 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 popup 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
☐
☒
☒
☒
☐
☐
Page 43 of 55
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-1b
FD-1a
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
Perceptor
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
(10)
Block 6
(11)
Block 7
Option(s)
Page 44 of 55
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
View Prior Period Data
FD-1b
* 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 and Discipline of Faculty
Trained
Multi-Select
Add Record
No.
Program Name
Profession and Discipline of Faculty Trained
Enter # Trained in this Profession and Discipline
(1)
(2)
Block 4
(3)
Block 4
Option(s)
Page 45 of 55
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
(5)
Block 9
(6)
Block 10
(7)
Option(s)
Page 46 of 55
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
* Add Activity Name and Discipline
Activity Name
Values populated from Activity Name
col. in previous tab (single-select)
Select Profession and Discipline of Faculty
Trained
Multi-Select
Add Record
No.
Activity Name
(1)
Profession and Discipline of
Faculty Trained
(2)
Block 12
Enter # Trained
in this Profession
and Discipline
Option(s)
(3)
Block 12
Page 47 of 55
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
(1)
Select Project
Status in the
Current Reporting
Period
(1a)
Describe the FacultyStudent Project
(2)
Block 13
Select the
Purpose of
the Project
(3)
Block 13a
Enter # of Faculty
Members Involved in
the Project
Enter # of Students
Involved in the Project
Total
URM
Total
URM
(4)
Block 14
(5)
Block
14a
(6)
Block 15
(7)
Block 15a
Select whether any
Faculty Received any
type of BHW-Funded
Financial Award
(8)
Block 16
Select Type(s) of
Vulnerable
Populations Studied
in this Project
Option(s)
(9)
Page 48 of 55
13.7. FD-4a: Faculty Development - Faculty Instruction
The FD-4 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-4b
FD-4a
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
Page 49 of 55
13.8. FD-4b: Faculty Development - Faculty Trained by Profession/Discipline
The FD-4 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)
Profession and Discipline 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)
Block 21
Enter # Trained in
this Profession and
Discipline
Option(s)
(3)
Block 21
Page 50 of 55
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) 12
Enter # of URM Faculty Recruited through the Program (Block 23b)
(text 3 digits) 5
Enter # of Faculty Positions Retained (Block 23c)
(text 3 digits) 10
Page 51 of 55
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
Yes
(complete table below)
* Hospital Discharge Data by Payor
No.
1
2
3
4
5
6
Payor
(1)
Private Insurance
Medicaid and/or CHIP
Medicare
Other Public (TRICARE, Indian Health Service)
Self-Pay
Uncompensated Care
Total
Enter # of Inpatient Discharges
(2)
Enter # of Outpatient Visits
(3)
No
(Click Save and Validate to
proceed to the next form)
Enter # of Emergency Department Visits
(4)
Page 52 of 55
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
All 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)
View Prior Period Data
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)
1
2
3
Root cause or error analysis
Chart audits
Mandatory error disclosure
4
Reducing hand-offs
5
Other: test initiative
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)
Page 53 of 55
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.
CHD-3
CHD-2
CHD-1
Zip Code
(1)
City
State
Number of Inpatient
Discharges
(2)
(3)
(4)
Option(s)
Page 54 of 55
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.
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 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)
Page 55 of 55
| File Type | application/pdf |
| File Title | Master Wireframe 2017-2018 FInal |
| Author | Swetha Vijayakumar |
| File Modified | 2019-02-04 |
| File Created | 2019-02-04 |