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HRSA Electronic Handbooks

Opioid-Impacted Family Support Program

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 StatusType of Training Program
(1)
Trainee Unique ID
(2)
Block 1
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 AreaEnter Total # of Contact Hours Across All Settings Including Inpatients
(34ac)
Select Whether Individual Left the Program Before Completion
(36)
Block 21
Select Reason for Attrition or Inactive Status
(36a)
Select Whether Individual Graduated/Completed the Program
(37)
Block 22
Select Degree Earned
(38)
Block 22a
Select whether individual passed a certifying examination on the first attempt
(38b)
Enter Certification Number
(38f)
Select Individual's Post-Graduation/Completion Intentions
(39)
Block 22b
Employment DataApprenticeship DataOption(s)
Stipend
(13)
Block 11
Tuition, Fees, and Supplies
(13a)
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)
Select Whether Program Sponsoring Employer Hired the Apprentice After the Apprenticeship
(56c)
Enter Zip Code
(57)
City (Auto-Populates)
(58)
State (Auto-Populates)
(59)
Select Type of Employment
(60)
Select Individual's Employment Location Settings
(61)
Select Apprenticeship Program Status
(93)
Program Entry Date for Apprenticeship Participant
(94)
Program Exit Date for Apprenticeship Participant
(95)
Employment Status at Apprenticeship Entry
(96)
Type of Credential Attained During Or At Apprenticeship Exit
(107)
Page Total
Form Total

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