Form 1 Program Data Collection Tool

Program Data Collection Tool

Teaching Health Center Data Collection Tool

Please complete a separate data collection tool for each residency program receiving THCGME funding (for example, if your institution sponsors a Family Medicine and Dental program, please complete a data collection tool for each specialty).

General Program Information:

THC Name:
THC Contact Address:

Residency Program Director Name:
Residency Program Director Phone Number:
Residency Program Director Email:

THC Primary Contact Name:
THC Primary Contact Position:
THC Primary Contact Phone Number:
THC Primary Contact Email:

Residency Program Specialty:
Sponsoring Institution designated for Accreditation:
Primary Training Site designated for Accreditation:
Accrediting Body(ies), indicate all:

Is your THC sponsoring institution for Accreditation a GME consortium?	Yes/No
If yes, please list all members of the GME consortium and briefly describe their role in the consortium and residency program:
Name	Role

Which organization employs the residency director?
Which organization employs the residents?

Please list any medical schools or universities your residency program is affiliated with:

Residents:

Enter information for your current residency program classes. The current PGY-1 class is generally the class that entered training in July 2013.

	Total Number Residents	Number Male	Number Female	Number IMGs	Number THC Resident FTE
PGY-1 Class
PGY-2 Class
PGY-3 Class
PGY-4 Class or Graduates

	Number of Residents Matched Through Each:
	ACGME	AOA	ADA	Outside Match
PGY-1 Class
PGY-2 Class
PGY-3 Class
PGY-4 Class or Graduates

Please describe any pipeline or other special recruitment programs for your residency program.
Name of program	Description

Complete for each of the following Academic Years (Enter N/A if not applicable):
	2012-2013	2011-2012	2010-2011	2009-2010
Number of Graduates Who Started the Program Year 1 and Finished This Program Example, 2012-2013 would be the number who graduated during or at the end of this academic year
Number of Graduates Regardless of Whether they Began in this Program
Number of Residents Who Withdrew from the Program, for all training years
Number of Residents Who Transferred to Another Program, for all training years
Number of Residents Dismissed from the Program, for all training years
Number Residents Complete but not Promoted, for all training years

Curriculum:

Please briefly describe how each of the following has been incorporated into the operations of your health center and into the curriculum of your THC residency program (including how you evaluate residents in these areas if appropriate).
	Health Center Operations	Residency Curriculum and Evaluation
Patient Centered Medical Homes
Accountable Care Organizations
Health Information Technology
Quality Improvement
Interdisciplinary Teams
Health Policy
Health Advocacy
Community Medicine or Public Health
Research

Please list and briefly describe any accreditation or programs your health center and/or residency program participates in for any of the above areas. For example, NCQA accreditation for PCMH, Meaningful Use for HIT, or any regional or state practice transformation programs.
Name	Description

Please briefly describe how each of the following has been incorporated into the curriculum of your THC residency program (including how you evaluate residents in these areas if appropriate).
	Residency Curriculum	Resident Evaluation
Health Center Management Training
Leadership Training

Outpatient Training Sites:

Please indicate established outpatient clinical training sites, where all or the majority of your residents rotate for your THC residency program.

Outpatient Training Site:
Name:
Address:
Does this site fall into any of the following federally designated areas/practices? Check all that apply.	HPSA: Federally designated health professional shortage area MUA: Federally designated medically underserved area MHC: Federally designated migrant health center CHC: Federally designated community health center RHC: Federally designated rural health clinic NHSC: National Health Service Corps IHS: Indian Health Service site or tribal clinic FQHC: Federally Qualified Health Center FQHC Look Alike State qualified health center/clinic State or Local Health Department
Training objectives for site:
Indicate the time spent by residents in this site and whether the rotation is required or elective, indicate N/A if appropriate:
	Average number of weeks per year in this site	Average number of ½ day sessions per week	Average number of full time rotation weeks per year
Year 1
Year 2
Year 3
Year 4
Is there a written contract between the sponsoring institution and this site?
Is there a financial relationship with this site for the purposes or residency training? If yes, please describe.
Is there an exchange of resources with this site for the purposes or residency training? If yes, please describe. (Resources may include personnel.)
In what year did this site first become a training site for the residency program?

Outpatient Training Site:
Name:
Address:
Does this site fall into any of the following federally designated areas/practices? Check all that apply.	HPSA: Federally designated health professional shortage area MUA: Federally designated medically underserved area MHC: Federally designated migrant health center CHC: Federally designated community health center RHC: Federally designated rural health clinic NHSC: National Health Service Corps IHS: Indian Health Service site or tribal clinic FQHC: Federally Qualified Health Center FQHC Look Alike State qualified health center/clinic State or Local Health Department
Training objectives for site:
Indicate the time spent by residents in this site and whether the rotation is required or elective, indicate N/A if appropriate:
	Average number of weeks per year	Average number of ½ day sessions per week	Required / Elective
Year 1
Year 2
Year 3
Year 4
Is there a written contract between the sponsoring institution and this site?
Is there a financial relationship with this site for the purposes or residency training? If yes, please describe.
Is there an exchange of resources with this site for the purposes or residency training? If yes, please describe. (Resources may include personnel.)
In what year did this site first become a training site for the residency program?

Outpatient Training Site:
Name:
Address:
Does this site fall into any of the following federally designated areas/practices? Check all that apply.	HPSA: Federally designated health professional shortage area MUA: Federally designated medically underserved area MHC: Federally designated migrant health center CHC: Federally designated community health center RHC: Federally designated rural health clinic NHSC: National Health Service Corps IHS: Indian Health Service site or tribal clinic FQHC: Federally Qualified Health Center FQHC Look Alike State qualified health center/clinic State or Local Health Department
Training objectives for site:
Indicate the time spent by residents in this site and whether the rotation is required or elective, indicate N/A if appropriate:
	Average number of weeks per year	Average number of ½ day sessions per week	Required / Elective
Year 1
Year 2
Year 3
Year 4
Is there a written contract between the sponsoring institution and this site?
Is there a financial relationship with this site for the purposes or residency training? If yes, please describe.
Is there an exchange of resources with this site for the purposes or residency training? If yes, please describe. (Resources may include personnel.)
In what year did this site first become a training site for the residency program?

Inpatient Training Sites:

Inpatient Training Site:
Name:
Address:
Does this site fall into any of the categories? Check all that apply.	Non-profit hospital For-profit hospital Children’s Hospital Rehabilitation Hospital Critical Access Hospital
Training objective for site:
Indicate the duration of resident rotations and whether the rotation is required or elective, indicate N/A if appropriate:
	Average number of weeks per year	Required/Elective (weeks/weeks)
Year 1
Year 2
Year 3
Year 4
Is there a written contract between the sponsoring institution and this site?
Is there a financial relationship with this site for the purposes or residency training? If yes, please describe.
Is there an exchange of resources with this site for the purposes or residency training? If yes, please describe. (Resources may include personnel.)
In what year did this site first become a training site for the residency program?

Inpatient Training Site:
Name:
Address:
Does this site fall into any of the categories? Check all that apply.	Non-profit hospital For-profit hospital Children’s Hospital Rehabilitation Hospital Critical Access Hospital
Training objective for site:
Indicate the duration of resident rotations and whether the rotation is required or elective, indicate N/A if appropriate:
	Average number of weeks per year	Required/Elective (weeks/weeks)
Year 1
Year 2
Year 3
Year 4
Is there a written contract between the sponsoring institution and this site?
Is there a financial relationship with this site for the purposes or residency training? If yes, please describe.
Is there an exchange of resources with this site for the purposes or residency training? If yes, please describe. (Resources may include personnel.)
In what year did this site first become a training site for the residency program?

Inpatient Training Site:
Name:
Address:
Does this site fall into any of the categories? Check all that apply.	Non-profit hospital For-profit hospital Children’s Hospital Rehabilitation Hospital Critical Access Hospital
Training objective for site:
Indicate the duration of resident rotations and whether the rotation is required or elective, indicate N/A if appropriate:
	Average number of weeks per year	Required/Elective (weeks/weeks)
Year 1
Year 2
Year 3
Year 4
Is there a written contract between the sponsoring institution and this site?
Is there a financial relationship with this site for the purposes or residency training? If yes, please describe.
Is there an exchange of resources with this site for the purposes or residency training? If yes, please describe. (Resources may include personnel.)
In what year did this site first become a training site for the residency program?

*** Add more if needed ***

Community Experiences:

Please indicate any additional established community experiences for your THC residency program.

Experience:
Training Objectives:
Description of timing and duration of experience:

Experience:
Training Objectives:
Description of timing and duration of experience:

Experience:
Training Objectives:
Description of timing and duration of experience:

Experience:
Training Objectives:
Description of timing and duration of experience:

Experience:
Training Objectives:
Description of timing and duration of experience:

*** Add more if needed ***

Primary Care Clinical Service:

* Complete for all clinical sites where residents routinely provide primary care. Primary care may include general family medicine, internal medicine, pediatrics, geriatrics, ob-gyn, psychiatry, or dental services.

Clinical Site Name:
	Average number of patient visits per ½ day session	Average number of patient visits per year seen in health center	Average patient panel size
Year 1
Year 2
Year 3
What is the average preceptor to resident ratio in your health center?
How many patients do faculty physicians typically see during a half day session when supervising residents?
How many patients do faculty physicians typically see during a half day session when not supervising residents?

Clinical Site Name:
	Average number of patient visits per ½ day session	Average number of patient visits per year seen in health center	Average patient panel size
Year 1
Year 2
Year 3
What is the average preceptor to resident ratio in your health center?
How many patients do faculty physicians typically see during a half day session when supervising residents?
How many patients do faculty physicians typically see during a half day session when not supervising residents?

Clinical Site Name:
	Average number of patient visits per ½ day session	Average number of patient visits per year seen in health center	Average patient panel size
Year 1
Year 2
Year 3
What is the average preceptor to resident ratio in your health center?
How many patients do faculty physicians typically see during a half day session when supervising residents?
How many patients do faculty physicians typically see during a half day session when not supervising residents?

*** Add more if needed ***

Residency Program Financing:

Please list all funding sources for your THC residency program, including the amount and time period or funding. Funding sources may include THCGME and Medicare payments, as well as state funding and local, state, or national grants.
Funding Source	Annual Amount	Time Period (indicate funding cycle if recurrent funding or grant period for grants)
THCGME Payment Program
Medicare
Medicaid
Other (please specify):

Health Center Information:

Health centers include any community-based ambulatory health center systems affiliated with your Teaching Health Center program. These systems may include multiple clinical sites.

Health Center Name:
Please list all health center clinical sites and addresses.
Name	Address		Is this a residency teaching site? (yes/no)
Has your health center or is your health center planning to expand, either in operations or in sites? If yes, please describe.
Please list any additional health education students or residents training at your health center, and briefly describe the duration of their rotations (for example, 1 month rotations or weekly ½ day continuity clinics).
Name		Duration
For each of the following, please indicate the number of physicians currently participating in the program in your health center. Enter N/A if appropriate.
	Number of physicians		Number of dentists
NHSC scholarship
NHSC loan repayment
State loan repayment
J-1 visa waiver

Health Center Name:
Please list all health center clinical sites and addresses.
Name	Address		Is this a residency teaching site? (yes/no)
Has your health center or is your health center planning to expand, either in operations or in sites? If yes, please describe.
Please list any additional health education students or residents training at your health center, and briefly describe the duration of their rotations (for example, 1 month rotations or weekly ½ day continuity clinics).
Name		Duration
For each of the following, please indicate the number of physicians and dentists currently participating in the program in your health center. Enter N/A if appropriate.
	Number of physicians		Number of dentists
NHSC scholarship
NHSC loan repayment
State loan repayment
J-1 visa waiver