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HRSA Electronic Handbooks

National Health Service Corps- State Loan Repayment Program (NHSC-SLRP)

pdf
  • Health Resources and Services Administration
  • Academic Year: 2022-2023
  • Bureau of Health Workforce
  • OMB Number: 0915-0061
  • Annual Performance Report
  • OMB Expiration Date: 01/31/2025

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 StatusTrainee Unique ID
(2)
Block 1
NPI Number
(2a)
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 AmountEnter Original Qualifying Educational Loan Amount
(22a)
Select Individual's Primary Discipline/Specialty
(26d)
Select Individual's Specialty
(27aa)
Select Any Key Services Provided by Individual
(34c)
Select Whether Individual Graduated/Completed the Program
(37)
Block 22
Select Whether Individual is a First Time Participant
(80)
Select Whether this is a Continuation Award
(81)
Select Whether Provider is in default of service obligation
(82)
Enter Service Obligation Start Date
(84)
Enter Service Obligation End Date
(85)
Select Any HRSA/BHW program Individual Participated In Prior to Entering NHSC SLRP
(86)
Select Medication Assisted Treatment (MAT) Services Provided by Individual
(88)
Select If Individual Holds a Substance Use Disorder License or Certificate
(89)
Select Primary Site Name
(91)
Select Other Site Name(s)
(92)
Option(s)
Federal Contribution to Loan Repayment
(21d)
State Contribution to Loan Repayment
(21e)
Total Contribution to Loan Repayment (Auto-Populates)
(21h)
Page Total
Form Total

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