Form 1 ANE Program Specific Data Forms

OMB #: 0915-0375

Expiration Date: xx/xx/xxxx

ANE Programs Specific Data Forms (Tables)

As part of the application submitted through Grants.gov, applicants must also complete and electronically submit the ANE Program Specific Data Forms. Copies of the ANE Program Specific Data Forms (Tables) are included in the Notice of Funding Opportunity (NOFO) for your reference. The Tables must be completed electronically and submitted by the established application due date as part of the official electronic application package for ANE Programs. These tables are not included in the application page count.

The data are essential in making award determinations in accordance with the legislative statute:

• Statutory Funding Preference is given to applicants, who meet the Notice of Funding Opportunity requirements, with projects that will substantially benefit rural or underserved populations or help meet public health nursing needs in state or local health departments.

• Special Consideration is given to an eligible entity, who meets the Notice of Funding Opportunity requirements, that agrees to expend the award to train advanced education nurses who will practice in health professional shortage areas designated under section 332.

Applicant organizations must adhere to the Table instructions to ensure that the data provided are accurate and complete. Applicant organizations are encouraged to consult with Program Staff for technical assistance prior to submitting the grant application.

Refer to HRSA’s SF-424 R&R Application Guide for instructions on the document submission process for Grants.gov.

Appendix A

LIST OF ADVANCED NURSING EDUCATION (ANE) ProgramS Specific DATA FORMS (TABLES)

ANE Programs Specific Data Forms (Tables) and Instructions - Office of Management and Budget (OMB) Approved

Table 1: Graduate Data – Rural, Underserved, Public Health Practice Settings and Health Professional Shortage Areas (HPSAs)

Table 2: Projected Traineeship Data for Master’s, Post Master’s Certificate, Doctoral, and Post-Graduate Residency Programs

Project Period of Performance

Year 1 = (July 1, 202X to June 30, 202X)

Year 2 = (July 1, 202X to June 30, 202X)

Year 3 = (July 1, 202X to June 30, 202X)

Year 4 = (July 1, 202X to June 30, 202X)

Year 5 = (July 1, 202X to June 30, 202X)

Table 1: Graduate Data - Rural, Underserved, Public Health Practice Settings and Health Professional Shortage Areas (HPSAs) (Used by Advanced Nursing Education Workforce Program (ANEW), Nurse Anesthetist Traineeship Program (NAT), Advanced Nursing Education Nurse Practitioner Residency

and Fellowship Program, Advanced Nursing Education Sexual Assault Nurse Examiners Program (ANE-SANE), and Maternity Care Nursing Workforce Expansion (MatCare) Program)

Graduate Data from 7/01/202X to 6/30/202X

Practice Settings	Nurse Practitioner	Nurse Midwife	Clinical Nurse Specialist	Nurse Anesthetist	Additional Specialty (See NOFO Table 1 Instructions)	Total
Statutory Funding Preference
1a. Total Number of Graduates Employed in Rural Settings
1b. Total Number of Graduates Employed in Medically Underserved Communities
1c. Total Number of Graduates Employed in State or Local Health Departments						Autopop-ulate
2. Total Number of Graduates Employed in these Funding Preference Settings [Rows 1a + 1b + 1c = Row 2]
3. Total Number of Graduates
] 4. Percentage of Graduates Employed in these Funding Preference Settings [Row 2 divided by Row 3, multiplied by 100]			Autopopulate
Special Consideration
5a. Total Number of Graduates Employed in Health Professional Shortage Areas (HPSAs)
5b. Total Number of Graduates Employed in the Additional Settings specified in the NOFO (Refer to Table 1, Row 5b Instructions in the NOFO).
6. Total Number of Graduates Employed in these Special Consideration Settings [Rows 5a + 5b = Row 6]
7. Total Number of Graduates (Same number as in Row 3)			Autopopulate
8. Percentage of Graduates Employed in these Special Consideration Settings [Row 6 divided by Row 7, multiplied by 100]			Autopopulate

The ANEW, NAT, ANE-NPRF, ANE-SANE and MatCare programs align with the Table 1, because the data collected describes the most recent applicant graduation/completion numbers for type of employment practice setting (rural, underserved and/or state or local health department, and/or HPSAs). This information is used by HRSA to determine the applicant Funding Preference and Special Consideration.

Instructions for Completing Table 1: Graduate Data - Rural, Underserved, Public Health Practice Settings and HPSA Data - Graduate Data from 7/01/202X to 6/30/202X

For all programs, refer to the program Notice of Funding Opportunity (NOFO) for specific instructions.

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

Graduates are to be counted only once in Table 1.

Data on Table 1 should reflect graduate totals for nurse practitioners (NPs), certified nurse-midwives (CNMs), clinical nurse specialists (CNSs), certified registered nurse anesthetists (CRNAs) and other Registered Nurse specialties (as outlined in the NOFO) who completed program/degree requirements between 07/01/202X and 06/30/202X. Ensure to enter the correct specialty under the correct column. For example, CNMs should not be entered in the NP column, or vice versa. Additionally, the “Additional Specialty” Column should only be completed if specified in the NOFO. Complete Table 1, as appropriate, providing data on the cumulative number of graduates from your institution (whether supported with HRSA grant Funds or not) in the previous academic year, who obtained employment and spend at least 50 percent of their employment in clinical practice sites substantially benefiting rural or medically underserved populations, state or local health departments, health professional shortage areas, and other specified settings as outlined in the NOFO.

If the applicant organization is a health facility or other entity (as outlined in the Notice of Funding Opportunity), the data that should be entered in Table 1 is to be obtained from the applicant’s academic partner.

The system will automatically calculate the Total for each row and the percentage of Graduates Employed in these Settings.

Statutory Funding Preference

In Table 1 Rows 1a, 1b and 1c, enter the “Total Number of Graduates Employed” for Rural Settings (Row 1a), Medically Underserved Communities (Row 1b) and State or Local Health Departments (Row 1c) by Specialty, as applicable. The data in each row (Rows 1a, 1b, 1c) is a subset of “Total Number of Graduates” (Row 3).

In Row 2, the sum for “Total Number of Graduates Employed in these Funding Preference Settings” will be automatically calculated by the system from numbers entered for Rows 1a, 1b, and 1c.

In Row 3, enter “Total Number of Graduates” (whether supported with HRSA grant funds or not) who completed degree requirements and graduated from your institution in the previous academic year between 7/01/202X and 06/30/202X in the appropriate column. This number will be system populated into Special Consideration Row 6.

In Row 4, the “Percentage of Graduates Employed in these Settings” will be automatically calculated. “Percentage of Graduates Employed in these Settings” equals the “Total Number of Graduates Employed in these Settings” (from 07/01/202X – 06/30/202X) divided by “Total Number of Graduates” (from 07/01/202X – 06/30/202X) multiplied by 100, or Row 2 divided by Row 3 multiplied by 100. Row 4 is a component of determining if the Statutory Funding Preference is met (refer to the Notice of Funding Opportunity for further details and criteria).

Special Consideration

In Row 5a, enter the “Total Number of Graduates Employed in Health Professional

Shortage Areas (HPSAs)” by Specialty, as applicable.

Row 5b is reserved for additional data entry for other settings as specified in the NOFO.

In Row 6, the sum for “Total Number of Graduates Employed in these Special Consideration Settings” will be automatically calculated by the system from numbers entered for Rows 5a and 5b.

In Row 7, the “Total Number of Graduates” will be system populated from Statutory Funding Preference Row 3, as the data is identical.

In Row 8, the “Percentage of Graduates Employed in these Special Consideration Settings”, the system will automatically calculate this figure. “Percentage of Graduates Employed in these Special Consideration Settings” equals the “Total Number of Graduates Employed in these Special Consideration Settings” divided by “Total Number of Graduates” (from 07/01/202X - 06/30/202X), or Row 6 divided by Row 7, multiplied by 100. Row 8 is a component of determining if the Special Consideration is met (see the Notice of Funding Opportunity for further details and criteria).

Table 2:  Projected Traineeship Data for Master’s, Post Master’s Certificate, Doctoral, and Post-Graduate Residency Programs (Used by Advanced Nursing Education Workforce (ANEW) Program, Nurse Anesthetist Traineeship Program (NAT), Advanced Nursing Education Nurse Practitioner Residency and Fellowship Program, Advanced Nursing Education Sexual Assault Nurse Examiners Program (ANE-SANE), and Maternity Care Nursing Workforce Expansion (MatCare) Program)

Projected Traineeship Support Data

Traineeship Data	Budget Year	Nurse Practitioner		Nurse Midwife		Clinical Nurse Specialist		Nurse Anesthetist		Additional Specialty (See NOFO Instructions Table 2)		Total
		FT	PT	FT	PT	FT	PT	FT	PT	FT	PT
Total # of Master’s Degree Participants/ Trainees Projected to Receive Traineeship Support by Budget Year	1
	2
	3
	4
	5
Total # of Doctoral Degree Participants/ Trainees Projected to Receive Traineeship Support by Budget Year	1
	2											Autopopulate
	3
	4
	5
Total # Post-Master’s Certificate Participants/ Trainees Projected to Receive Traineeship Support by Budget Year	1
	2
	3
	4
	5
Additional Degree/Certificate	1
	2
	3
	4
	5
Total						Autopopulate

The ANEW, NAT, ANE-NPRF, ANE-SANE, and MatCare programs align with the use Table 2, because the data collected describes the applicant projected number of trainees by project year. This information is used by HRSA to confirm the applicant number of trainees planned for the awarded period of performance and standardizes a key data set in one location of the application. For the NAT program, this data is also used in the formula calculation process. In addition, thisdata is used by HRSA when analyzing awardee annual performance data.

Instructions for Completing Table 2: Projected Traineeship Data for Master’s, Post Master’s Certificate, Doctoral and Post-Graduate Residency Programs.

For all programs, refer to the program Notice of Funding Opportunity for specific instructions.

All applicants must complete Table 2.

The system will automatically calculate the Total for each row and column.

Participants/Trainees to be supported are to be counted only once in a given budget year and for a specific specialty or degree/certificate.

Only complete for the applicable budget years. For example, complete only Budget Years 1 and 2 for a two year funding announcement. In other words, if the application is for a two-year funding announcement, do not enter numbers in Table 2 boxes for Budget Years 3, 4 and 5.

Enter the “Total Number of Master’s, Post-Master’s Certificate, Doctoral Degree, and Post-Graduate Residency Participants/Trainees Projected to Receive Traineeship Support” in Budget Years 1, 2, 3, 4 and 5 as appropriate by their enrollment status (FT or PT) and their specialty role.

Public Burden Statement

The purpose of the ANE Program Specific Form is to support the enhancement of advanced nursing education and creating opportunities for individuals in advanced nursing education programs by collecting information during the application process that is necessary for determining eligibility for funding preferences, special considerations, and award amounts. 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 XX/XX/202X. This information collection is required to obtain or retain a benefit (Section 811 of the Public Health Service (PHS) Act (42 U.S.C. 296j). Public reporting burden for this collection of information is estimated to average xx 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 14N39, Rockville, Maryland, 20857 or paperwork@hrsa.gov.

OMB ANE Programs Specific Data Forms Package