Skip to Main Content

HRSA Electronic Handbooks

Value-Based Medical Student Education Training Program

pdf
  • Health Resources and Services Administration
  • Academic Year: 2023-2024
  • Bureau of Health Workforce
  • OMB Number: 0906-0086
  • Annual Performance Report
  • OMB Expiration Date: 03/31/2027

IND-GEN: Individual Characteristics

The IND-GEN form captures individual-level information about students, faculty, or other types of awardees who either received direct financial support (e.g., loans, loan repayment, scholarships, or stipends) through a HRSA grant or participated in specific types of HRSA-supported training. Please complete this form in its entirety. If you have any questions about how to complete this form, please refer to the instruction manual and/or contact your Government Project Officer. If you wish to view data that were submitted in the prior reporting period, click on the ‘View Prior Period Data’ link and a read-only version of your most recent prior performance report will pop-up in a new screen. Also, records about ongoing training programs or activities from the prior reporting period will auto-populate into this form and are identified as ‘Prior Records’ under the column labeled "Record Status".


Do you have either a) new trainees OR b) updates to provide for trainees from a previous reporting period?
(complete IND-GEN)(click Save and Validate button to proceed to the next form)
No.Record StatusType of Training Program
(1)		Trainee Unique ID
(2)
Block 1		NPI Number
(2a)		Select Individual's Training or Awardee Category
(3)
Block 2		Select Individual's Enrollment / Employment Status
(4)
Block 3		Select Individual's Gender(s)
(5a)		Enter Year of Birth
(6a)		Select Individual's Ethnicity
(7)
Block 6		Select Individual's Race
(8)
Block 7		Select Whether Individual is from a Rural Residential Background
(9)
Block 8		Select Whether Individual is from a Disadvantaged Background
(10)
Block 9		Select Individual's Veteran Status
(11)
Block 10		Select Whether Individual Received BHW Financial Award?
(12)
Block 11		Enter Individual's Financial Award Amount (BHW funds only)Enter # of Academic Years the Individual has Received BHW Funding
(22)
Block 12		Select Individual's Academic or Training Year
(26)
Block 15		Select any HHS Priority Topic Area on which an Individual Received Training
(26b)
Block 15		Select Individual's Profession
(26c)		Select Individual's Primary Discipline/Specialty
(26d)		Training in TelehealthTraining in a Primary Care SettingTraining in a Medically Underserved CommunityTraining in a Rural AreaSelect Whether Individual Left the Program Before Completion
(36)
Block 21		Select Whether Individual Graduated/Completed the Program
(37)
Block 22		Select Degree Earned
(38)
Block 22a		Did Medical Student Match to a Residency Program?
(38d)		Select Type of Residency Program
(38e)		Select Individual's Post-Graduation/Completion Intentions
(39)
Block 22b		Employment DataOption(s)
Direct Financial Support
(20a)
Block 11		Academic Year Total (Auto-Populates)
(21b)
Block 11		Select Whether Individual Received Training
(27d)		Enter # of Contact Hours
(27e)		Select Whether Individual Received Training
(28)
Block 17		Enter # of Contact Hours
(29)
Block 17a		Select Whether Individual Received Training
(31)
Block 18		Enter # of Contact Hours
(32)
Block 18a		Select Whether Individual Received Training
(33)
Block 19		Enter # of Contact Hours
(34)
Block 19a		Select whether Employment Data is available?
(56)		Select Whether Your Organization Hired this Individual
(56a)		Select Whether a Partner Organization Hired this Individual
(56b)		Enter Zip Code
(57)		City (Auto-Populates)
(58)		State (Auto-Populates)
(59)		Select Type of Employment
(60)		Select Individual's Employment Location Settings
(61)
Page Total
Form Total

Scroll to top