Grayed fields are provided here for identification purposes only.
Select whether status/employment data are available for the individual 1-year post graduation/completion: To select whether current training/employment data are available for each prior program completer click on the drop-down menu in Column 13 (Block 23) and choose one of the following options:
Select Individual's Current Training/Employment Status: Select the individual’s current training/employment status by clicking on the drop-down menu in Column 14 choosing all that apply from the options below. Please ensure applicable faculty employment is captured here. If employment data are not available for the individual, select “N/A.”
- Individual has applied to full-time faculty vacancies and has not obtained a full-time appointment
- Individual has applied to full-time faculty vacancies and has obtained a part-time appointment
- Individual has applied to full-time faculty vacancies and has obtained a part-time faculty position in combination with a clinical preceptor/educator position
- Individual has applied to full-time faculty vacancies and has obtained more than one part-time faculty position
- Individual has obtained a full-time faculty appointment
- Individual is currently employed or is pursuing further training in a medically underserved community
- Individual is currently employed or is pursuing further training in a primary care setting
- Individual is currently employed or is pursuing further training in a rural setting
- Individual is currently serving as a preceptor
- Individual is employed at a NHSC-approved site
- Individual is not currently employed
- Individual is providing behavioral health services
- Individual is providing maternal health care
- Individual is serving individuals with OUD/SUD
- Individual meets criteria for deferment status
- None of the above
- N/A
Select Individual's Type of Faculty Appointment: If current training/employment data are available, select the individual's type of faculty appointment by clicking on the drop-down menu under Column 15 and selecting one of the options below. If current training/employment data are not available, select 'N/A' in Column 15.
- Graduate level - Doctorate
- Graduate level - Masters
- Nursing Diploma School
- Two-year College
- Undergraduate level
- None of the above
- N/A
Select Whether Your Organization Hired this Individual - PY: Select whether your organization hired this individual following training program completion by clicking on the drop-down menu under Column 16 and choosing one of the options below. If employment data are not available for the individual, select “N/A.”
Select Whether a Partner Organization Hired this Individual - PY: Select whether a partner organization hired this individual following training program completion by clicking on the drop-down menu under Column 17 and choosing one of the options below. If employment data are not available for the individual, select “N/A.”
Select Employment Location - PY: Select the type of employment location where the individual was hired following training program completion by clicking on the drop-down menu under Column 18 and choosing one of the options below.
If faculty employment was obtained, please select 'Academic Institution'.
If employment data are not available for the individual, select 'N/A.'
- Academic Institution
- Academic Medical Center
- Area Health Education Center
- Certified Community Behavioral Health Clinic (CCBHC)
- Community Behavioral Health/Mental Health Center
- Community Health Center (CHC)
- Critical Access Hospital
- Federal Government
- FQHC or Look-Alike
- Health Department (local/state/tribal)
- Hospital (non-academic)
- Indian Health Service (IHS)/Tribal/Urban Indian Health Center
- Nursing Home
- Other Clinical Health Setting
- Other Community-Based Organization
- Other Long-term Care Facility
- Other Specialty Clinic
- Private Industry
- Private Practice
- Residential Living Facility (including independent and assisted living)
- Rural Health Clinic
- School-based Clinic
- State or Local Government
- US Armed Forces
- Veterans Affairs Healthcare (e.g. VA hospital or clinic)
- Pursuing Additional Education or Training
- Not Currently Employed
- N/A
Enter Zip Code PY: If ‘Yes’ was selected in column 13, enter the zip code (5 digits) of the employment site.
If ‘No’ was selected, leave column 18a blank.
City PY: Employment City (column 18b) will auto-populate based on Employment Location Zip Code (column 18c) after you save and validate the form.
State PY: Employment State (column 18c) will auto-populate based on Employment Location Zip Code (column 18a) after you save and validate the form.