BHW Program Specific Data Form.pdf

PDF 6 MB Posted Mar 7, 2024

Attached to: Opioid-Impacted Family Support Program
Opportunity number: HRSA-24-016
Issued by: Department of Health and Human Services Health Resources and Services Administration

About this file

Written by GovTribe AI · Mar 8, 2024

This document contains information on a federal grant opportunity from the Health Resources and Services Administration within the Department of Health and Human Services. The Opioid-Impacted Family Support Program seeks to support training programs that enhance the knowledge and skills of paraprofessionals such as peer support specialists working with children impacted by parental opioid use disorders and other substance use disorders. Eligible applicant types include nonprofits, local and tribal governments, higher education institutions, and small businesses. The funding will demonstrate understanding of the specific needs of at-risk children, adolescents, and transitional aged youth in areas with high substance use disorder prevalence. This grant opportunity falls under the Mental and Behavioral Health Education and Training Grants program, which aims to expand the behavioral healthcare workforce and address provider well-being through CFDA number 93.732.

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Appendix - BHW program specific data form

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File	Type	Posted
Cross-Form Error.pdf	PDF	Apr 5, 2024
HELP WITH GRANTS.GOV ERROR MESSAGES.pdf	PDF	Mar 22, 2024
HRSA BHW Program Specific Form (2).pdf	PDF	Mar 7, 2024
HRSA-24-016 OIFSP.pdf	PDF	Mar 7, 2024

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OMB Approval No: 0906-0073 Expiration Date: Updated 11.30.25

BHW Program Specific Data Form Note: To complete the form, please click on the Validate & Save button at the bottom of the form.

***Automatically tabulated

Grants.gov Application Tracking Number

Select Academic Year

Select Discipline for Trainees/Students

Others - Please Specify Discipline

A. STUDENTS/TRAINEES BY GENDER

STUDENTS/TRAINEES FOR THE THREE PREVIOUS CONSECUTIVE ACADEMIC YEARS AND THEIR GENDER Students/Trainees by Gender

Gender Number of Students/Trainees Enrolled for Academic Year

Number of Students/Trainees Enrolled for Academic Year

a. Female

b. Male

c. Not Reported **Subtotal https://11.30.25 https://11.30.25

B. STUDENTS/TRAINEES BY RACE AND ETHNICITY

STUDENTS/TRAINEES FOR THE THREE PREVIOUS CONSECUTIVE ACADEMIC YEARS AND THEIR RACIAL/ETHNIC BACKGROUNDS

1. Hispanic or Latino Students/Trainees

Did your program have students/trainees of "Hispanic or Latino Ethnicity"? Yes No

Hispanic or Latino Students/ Trainees by Race Number of Hispanic or Latino Students/

Trainees Enrolled for Academic Year Number of Hispanic or Latino Students/

Trainees Enrolled for Academic Year

a. American Indian/ Alaskan Native

b. Black or African A merican

c. Asian

d. Native Haw aiian or Other Pacific Islander

e. White

f. More Tha n One Race

g. Race Not Reported **Sub Total

2. Non-Hispanic or Non- Latino Students/Trainees

Non-Hispanic or Non-Latino Students/Trainees by Race

Number of Non-Hispanic or Non-Latino

Students/Trainees Enrolled for Academic Y ear Number of Non-Hispanic or Non-Latino

Students/Trainees Enrolled for Academic Yea r Numbe r o f Non-Hisp anic or No n-Latino

Students/Tra inees Enrolled for Academic Year

a. American Indian/ Alaskan Native

b. Black or African American

c. Asian

d. Native Hawaiian or Other Pacific Islander

e. White

f. More Than One Race

g. Race Not Reported **Sub Total

3. Ethnicity NOT REPORTED for Students/Trainees

Ethnicity NOT REPORTED Number of Students/Trainees

Enrolled for Academic Year Number of Students/Trainees

Enrolled for Academic Year

a. American Indian/ Alaskan Native

b. Black or African American

c. Asian

d. Native Hawaiian or Other Pacific Islander

e. White

f. More Than One Race

g. Race Not Reported **Sub Total

C. CLASS ENROLLMENT INFORMATION

**TOTAL CLASS ENROLLMENT AND DISADVANTAGED BACKGROUND ENROLLMENT BY CLASS YEAR FOR STUDENTS/TRAINEES FOR THE

THREE PREVIOUS CONSECUTIVE ACADEMIC YEARS

Class Year Total Class Enrollment Academic Year Academic Year Academic Year

Total Disadvantaged Background Enrollment Academic Year Academic Year Academic Year

First Year Second Year Third Year Fourth Year Fifth Year Sixth Year **Total

D. GRADUATES/COMPLETERS INFORMATION

**TOTAL GRADUATES/COMPLETERS AND DISADVANTAGED BACKGROUND GRADUATES/COMPLETERS FOR THE PREVIOUS THREE CONSECUTIVE

ACADEMIC YEARS

Total graduates/completers Academic Year Academic Year Academic Year

Total graduates/completers

Disadvantaged background graduates/completers daniel.ghazvini Sticky Note Accepted set by daniel.ghazvini daniel.ghazvini Sticky Note None set by daniel.ghazvini

**GRADUATES/COMPLETERS FROM YOUR PROGRAM SERVING IN PRIMARY CARE, MEDICALLY UNDERSERVED AND RURAL COMMUNITIES FOR THE

PREVIOUS THREE CONSECUTIVE ACADEMIC YEARS

Primary Care

Of the graduates/completers, enter the number of graduates/completers serving in primary care

Academic Year Academic Year Academic Year

Medically Underserved Communities

Of the graduates/completers in primary care, enter the number of graduates practicing/working in medically underserved communities.

Academic Year Academic Year Academic Year

Rural Communities

Of the graduates/completers in primary care, enter the number of graduates practicing/working in rural communities.

Academic Year Academic Year Academic Year

E. COMMUNITY COLLEGE

COMMUNITY COLLEGE QUESTION

Is your entity a community college? Yes No

F. RECRUITMENT A ND RETENTION

RECRUITMENT AND RETENTION ELIGIBILITY

Is your entity currently carrying out a program to recruit and retain students/trainees from disadvantaged backgrounds? Note: If selected, the grant must provide a recruitment and retention plan with the Standardized Work Plan (SWP) plan.

Yes No

Please indicate the data sources used to determine areas targeted for recruitment of students/trainees from disadvantaged backgrounds.

Health Professional Shortage Area (HPSA)

Medically Underserved Areas/Populations (MUA/P)

Other:

Is your entity currently carrying out a program to recruit and retain students/trainees from rural communities? Yes No

Please indicate the data sources used to determine areas targeted for recruitment of students/trainees from rural communities.

Health Professional Shortage Area (HPSA)

Medically Underserved Areas/Populations (MUA/P)

FACULTY QUESTIONS ARE ONLY FOR PROGRAMS WITH A FACULTY COMPONENT/FOCUS **Indicates automatic tabulation

G. FACULTY

FACULTY BY TENURE STATUS, GENDER, RACE, AND ETHNICITY

Does the BHW Notice of Funding Opportunity that you are applying for include funding for faculty? Yes No

Total Number of Faculty

Academic Year Academic Year Academic Year

Enter the Total Number of Tenured Faculty

Academic Year Academic Year Academic Year

2a. Total Faculty by Gender

Gender Number of Faculty for Academic Year Number of Faculty for Academic Year Number of Faculty for Academic Year

a. Female

b. Male

c. Not Reported **Subtotal 2b. Tenured Faculty by Gender

Gender Number of Faculty for Academic Year Number of Faculty for Academic Year Number of Faculty for Academic Year

a. Female

b. Male

c. Not Reported **Subtotal 3a. Total Faculty by Race

Race Number of Faculty for Academic Year Number of Faculty for Academic Year Number of Faculty for Academic Year

a. American Indian/ Alaskan Native

b. Black or African American

c. Asian

d. Native Hawaiian or Other Pacific Islander

e. White

f. More Than One Race

g. Race Not Reported **Sub Total

3b. Tenured Faculty by Race

Race Number of Faculty for Academic Year Number of Faculty for Academic Year Number of Faculty for Academic Year

a. American Indian/ Alaskan Native

b. Black or African American

c. Asian

d. Native Hawaiian or Other Pacific Islander

e. White

f. More Than One Race

g. Race Not Reported **Sub Total

Did your program have faculty of "Hispanic or Latino Ethnicity"? Yes No

4. Faculty by Ethnicity 4a. Total Number of Hispanic or Latino Faculty

Total Number of Hispanic or Latino Faculty Total Number of Hispanic or Latino Faculty Academic Year

Total Number of Hispanic or Latino Faculty Academic Year

a. American Indian/ Alaskan Native

b. Black or African American

c. Asian

d. Native Hawaiian or Other Pacific Islander

e. White

f. More Than One Race

g. Race Not Reported **Sub Total 4b. Total Number of Hispanic or Latino TENURED Faculty

Total Number of Tenured Hispanic or Latino Faculty

Total Number of Tenured Hispanic or Latino Faculty Academic Year

a. American Indian/ Alaskan Native

b. Black or African American

c. Asian

d. Native Hawaiian or Other Pacific Islander

e. White

f. More Than One Race

g. Race Not Reported **Sub Total 4c. Non-Hispanic or Non-Latino TENURED Faculty

Non-Hispanic or Non-Latino Tenured Total Number of Non-Hispanic or Non- Latino Tenured Faculty Academic Year

Total Number of Non-Hispanic or Non- Latino Tenured Faculty Academic Year

a. American Indian/ Alaskan Native

b. Black or African American

c. Asian

d. Native Hawaiian or Other Pacific Islander

e. White

f. More Than One Race

g. Race Not Reported **Sub Total 4d. Ethnicity Not Reported TENURED Faculty

Ethnicity Not Reported Number of Tenured Faculty Ethnicity

Not Reported Academic Year Number of Tenured Faculty Ethnicity

Not Reported Academic Year

a. American Indian/ Alaskan Native

b. Black or African American

c. Asian

d. Native Hawaiian or Other Pacific Islander

e. White

f. More Than One Race

g. Race Not Reported **Sub Total

Public Burden Statement: 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 0906-0073 and it is valid until 11/30/2025. This information collection is voluntary. If this information collection includes information protected by any form of confidentiality then explain this confidentiality and cite the authority. 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 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.

mailto:paperwork@hrsa.gov

HRSA EHBs Quick Reference Sheet Disparity and Diversity-BHW Program Specific Data Form: QRS for Applicants

HRSA EHBs Quick Reference Sheet

Diversity and Disparity- BHW Program Specific Data Form

A quick reference sheet for entering information to the Diversity and Disparity pdf form and attaching it to the application for HCOP funding opportunity package in Grants.gov

HRSA EHBs Quick Reference

Process Summary

You must be an applicant and have a Grants.gov account. You will be filling the Diversity and Disparity -BHW Program Specific Data Form as an applicant offline and will be attaching it to the application for HCOP funding opportunities in Grants.gov. To complete the form, you will have to validate the form and get rid of all the errors (if any) before attaching the form to the Grants.gov application.

Filling information in the Pdf form

The applicants should fill the Diversity and Disparity form offline and attach it to the application in Grants.gov. This form will be published as part of the NOFO for the applicants to fill. All fields in the form are required and cannot be left blank. Enter a ‘0’ if information is not available for a particular field.

The applicant will be able to save the PDF form at any time.

To ensure that the form is complete and free of any validation errors, the applicant must click on the ‘Validate & Save’ button and resolve any errors that may have occurred.

All the subtotal fields in the form will be auto calculated and will remain grayed out/not editable.

The name of the PDF form is ‘BHW Program Specific Data Form.’

1. Enter the Grants.gov Application Tracking Number.

2. Select the Academic Year from the drop down. The three previous academic years sections in the form will be auto populated throughout the form based on the option selected here.

3. Select the Discipline for Trainees/Students from the drop down. If ‘Other Accredited Public or Private Nonprofit Health or Educational Entity (including community colleges, technical colleges, and tribal colleges)’ is selected, then enter the discipline in the text box provided.

4. Section A. Students/Trainees By Gender. Enter number of Female, Male and Not reported students/trainees for the three previous consecutive academic years.

5. Section B. Students/Trainees By Race and Ethnicity. Enter information for students/trainees for the three previous consecutive academic years and their racial/ethnic backgrounds.

Select the Yes/No radio button for, Diddid your program have students/trainees of “Hispanic or Latino Ethnicity”?

a. If yes is selected, you must enter information in tables 1. Hispanic or Latino Students/ Trainees by Race, 2. Non-Hispanic or Non-Latino Students/Trainees by Race and 3. Ethnicity Not reported.

b. If No is selected, Table 1 Hispanic or Latino Students/ Trainees by Race will be disabled. You must enter information in 2. Non-Hispanic or Non-Latino Students/Trainees by Race and 3. Ethnicity Not reported.

Validation on Section B

· The sum of the subtotals in Section B (For tables 1,2 and 3) must be less than or equal to the value of the subtotal in Section A for a given academic year.

6. Section C. Class Enrollment Information. Enter the total class enrollment and disadvantaged background enrollment by class year (first year, second year, third year, fourth year, fifth year and sixth year) for students/trainees for the three previous consecutive academic years.

Validations on Section C

· The total number of enrollees must be less than or equal to the Total number of students in Section A for a given academic year.

· The number of Disadvantaged enrollees cannot be greater than the Total number of enrollees for a given academic year.

7. Section D. Graduates/Completers Information.

Enter total graduates/completers and disadvantaged background graduates/completers for the previous three consecutive academic years.

Enter graduates/completers from your program serving in primary care, medically underserved and rural communities for the previous three consecutive academic years.

Validations on Section D

· The number of Disadvantaged background graduates/completers cannot be greater than the total graduates/completers for a given academic year.

· The number of graduates/completers serving in Primary care cannot be greater than the total graduates/completers for a given academic year.

· The value entered under Medically Underserved Communities cannot exceed the number entered under Primary Care for a given academic year.

· The value entered under Rural Communities cannot exceed the number entered under Primary Care for a given academic year.

· The sum of the values entered in Primary Care, Medically Underserved Communities, and Rural Communities cannot exceed the Total graduates/completers for a given academic year.

8. Section E. Community College. Choose Yes/No radio button for Is your entity a community college?

9. Section F. Recruitment and Retention.

· Yes/No must be selected for the question by choosing the appropriate radio button- Is your entity currently carrying out a program to recruit and retain students/trainees from disadvantaged backgrounds? Note: If selected, the grant must provide a recruitment and retention plan with the Standardized Work Plan (SWP) plan.

· Select one or multiple checkboxes for - Please indicate the data sources used to determine areas targeted for recruitment of students/trainees from disadvantaged backgrounds. If ‘other’ is selected, then enter the information in the textbox provided.

· Yes/No must be selected for the question by choosing the appropriate radio button- Is your entity currently carrying out a program to recruit and retain students/trainees from rural communities?

· Select one or multiple checkboxes for - Please indicate the data sources used to determine areas targeted for recruitment of students/trainees from rural communities.

10. Section G. Faculty by Tenure status, Gender, Race and Ethnicity

Does the BHW Notice of Funding Opportunity that you are applying for include funding for faculty?

Yes/No must be selected for the question by choosing the appropriate radio button.

a. If No is selected, Section G will be disabled, and users will be not required to fill any data.

b. If Yes is selected, Section G will be enabled, and users will be required to fill data in section G.

Enter Total number of faculty and Total number of tenured faculty for the three previous academic years.

2a. Total Faculty by Gender: Enter number of females, males and gender not reported faculty for the three previous academic years.

2b. Tenured Faculty by Gender: Enter number of females, males and gender not reported tenured faculty for the three previous academic years.

3a. Total Faculty by Race: Enter number of American Indian/ Alaskan Native, Black or African American, Asian, Native Hawaiian or other Pacific Islander, White, more than one race, race not required faculty for the three previous academic years.

3b. Tenured Faculty by Race: Enter number of American Indian/ Alaskan Native, Black or African American, Asian, Native Hawaiian or other Pacific Islander, White, more than one race, race not required tenured faculty for the three previous academic years.

Did your program have faculty of "Hispanic or Latino Ethnicity"? Yes/No must be selected for the question by choosing the appropriate radio button.

a. If No is selected, sections 4a and 4b will be disabled and the user is required to provide information in sections 4c and 4d.

b. If Yes is selected, section 4c will be disabled and the user is required to provide information for sections 4a, 4b and 4d.

Validate and Save the Form

To ensure that the form is complete and free of any validation errors, the applicant must click on the ‘Validate & Save’ button and resolve any errors that may have occurred.

When the Validate and Save button is clicked, a pop-up window will display the errors which need to be resolved before the form can be marked as complete and saved.

Once all the errors and resolved, the pdf can be saved to the local system.

Attach the D&D form to Grants.gov

1. Login to Grants.gov as an applicant.

2. Navigate to Manage Workspaces and Search for the Funding Opportunity Number

3. Navigate to the application for that funding opportunity.

4. For Research & Related Other project Information [V1.4] click on Webform under Actions.

Stop pro

5. Attach the validated and saved D&D- BHW Program Specific Data form in the Other Attachments section.

6. Click on the Save button.

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disciplineOther:

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g4d_Subtotal_c2: 0

g4d_Subtotal_c3: 0

sectionGHispanicLatinoYNQuestion: Off

facultyFundingYNQuestion: Off

sectionBHispanicLatinoYNQuestion: Off

validateSaveBtn:

b3_Subtotal_c3: 0

b3a_c1:

b3b_c1:

b3c_c1:

b3d_c1:

b3e_c1:

b3f_c1:

b3g_c1:

b3a_c2:

b3b_c2:

b3c_c2:

b3d_c2:

b3e_c2:

b3f_c2:

b3g_c2:

b3a_c3:

b3b_c3:

b3c_c3:

b3d_c3:

b3e_c3:

b3f_c3:

b3g_c3:

b3_Subtotal_c1: 0

b3_Subtotal_c2: 0

instructionsButton:

File details come from the government source that posted it. Updated Mar 8, 2024.