Form 1 ANEW Form - Table 1

OMB No. 0915-0375

Expiration Date: xx/xx/202x

Public Burden Statement: HRSA uses the data from the ANEW Program-Specific Data Collection Forms as part of the process for determining the award amount, ensuring compliance with programmatic and grant requirements, and to provide information to the public and Congress. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0375 and it is valid until 05/31/2020. This information collection is required to obtain or retain a benefit (Section 811 of the Public Health Service Act). Public reporting burden for this collection of information is estimated to average 7 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.

Table 1 - ANEW: Rural, Underserved, and/or Public Health Practice Settings Data

Graduate Data from 7/01/201X to 6/30/201X

Practice Settings	NP	CNS	NM	CRNA	Grand Total
State or Local Health Departments
Rural Populations / Settings
Medically Underserved Populations / Settings
1. Total Number of Graduates Employed in these Settings (from 07/01/201X – 06/30/201X)
2. Total Number of Graduates (from 07/01/201X – 06/30/201X)
3. Percentage of Graduates Employed in these Settings (SFP) (Number 1 divided by Number 2)
Health Professional Shortage Areas
4. Percentage of Graduates Employed in HPSAs (SPC) Total Number of Graduates Employed in HPSAs divided by Total Number of Graduates (from 07/01/201X-06/30/201X)

Instructions for Completing Table 1 - ANEW: Rural, Underserved, and/or Public Health Practice Settings & HPSA Data - Graduate Data from 7/01/201X to 6/30/201X

In order to be eligible for the Funding Preference and/or the Special Consideration, applicants must complete Table 1.

Data on Table 1 should reflect graduate totals for nurse practitioners (NP), clinical nurse specialists (CNS), nurse-midwives (NM) and certified registered nurse anesthetists (CRNA) who completed program/degree requirements between 07/01/201X and 6/30/201X.

Complete Table 1, as appropriate, providing data on the number of graduates in academic year 7/1/201X-6/30/201X who spend at least 50 percent of their employment in clinical practice sites substantially benefiting rural or medically underserved populations, or in State or local health departments. Each graduate is to be counted only once. Table 1 is used to determine if the institution meets the Statutory Funding Preference and also used to determine if the institution meets the Special Consideration.

In the “Total Number of Graduates Employed in These Settings” row, the system will automatically calculate the total number of graduates per specialty employed in these settings. The grand total will be system generated. This is a subset of “Total Number of Graduates”.

In the “Total Number of Graduates” row, enter the total number of graduates who completed degree requirements between 7/01/201X and 6/30/201X in the appropriate column. Enter the grand total: The Grand Total will be system generated. Numbers omitted in this row of Table 1 will not be counted.

In the “Percentage of Graduates Employed in these Settings” row, the system will automatically calculate this figure.  Percentage of Graduates Employed in these Settings = Total Number of Graduates Employed in these Settings (from 07/01/201X– 06/30/201X) divided by Total Number of Graduates (from 07/01/201X – 06/30/201X).

In the “Percentage of Graduates Employed in HPSAs” row, the system will automatically calculate this figure.  Percentage of Graduates Employed in HPSA’s = Total Number of graduates employed in HPSAs divided by Total Number of Graduates (from 07/01/201X-06/30/201X).