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HRSA Electronic Handbooks

Community Health Worker 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		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 Patient Encounters Across All Settings Including Inpatients
(34ab)
Block 19		Enter Total # of Contact Hours Across All Settings Including Inpatients
(34ac)		Select Any Key Services Provided by Individual
(34c)		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 Individual's Post-Graduation/Completion Intentions
(39)
Block 22b		Select Competencies the Individual is Highly Ready to Perform
(39a)		Select Factors Individual was Highly Satisfied with
(39b)		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)		Enter # of Patient Encounters
(27f)		Select Whether Individual Received Training
(28)
Block 17		Enter # of Contact Hours
(29)
Block 17a		Enter # of Patient Encounters
(30)
Block 17b		Select Whether Individual Received Training
(31)
Block 18		Enter # of Contact Hours
(32)
Block 18a		Enter # of Patient Encounters
(32a)
Block 19		Select Whether Individual Received Training
(33)
Block 19		Enter # of Contact Hours
(34)
Block 19a		Enter # of Patient Encounters
(34aa)
Block 19		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)		Hired Hourly Wage
(56d)		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 Individual’s Primary Role at Employment Setting
(62)		Select Individual's Other Role(s) at Employment Setting
(63)		Select Type(s) of Vulnerable Populations Served at Employment Setting
(64)		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)		Hourly Wage At Apprenticeship Entry
(97)		Select Apprentice Role(s) at Site
(98)		Select Skills the Apprentice is Developing
(99)		Select Support Received During Apprenticeship
(100)		Apprenticeship Minimum Term Length
(101)		Total Number of Apprenticeship Training Hours
(102)		Apprenticeship Street
(103)		Apprenticeship City
(104)		Apprenticeship State
(105)		Apprenticeship Zip Code
(106)		Type of Credential Attained During Or At Apprenticeship Exit
(107)		Hourly Wage At Apprenticeship Exit
(108)
Page Total
Form Total

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