In this section, the grantee may expand the accordion menu to view the following details:

• Ethnicity Definitions
• Race Definitions
• Other Definitions
• Leadership activities Definitions
• Instructions

In this section, the grantee indicates if the training program has trainees that completed the training program at least 2 and/or 5 years ago and must answer to the following question:

A note will display under the blue header Training Program Options as follows:

• Provide one entry for each long-term trainee that completed the MCH Training Program 2 years ago and 5 years ago. If you include former trainee data from 5 years ago, you must also enter former trainee data from 2 years ago. If you have received MCHB funding for less than two years, you are not required to provide former trainee information on this form.

Does your program have any long-term trainees who have completed the Training Program at least 2 and/or 5 years prior to the reporting period?

• This is a required question, and the following validation will display on the radio buttons: Please provide a response for this field. The grantee must select a Yes or No response from the radio buttons.

If the grantee selects Yes, they are required to enter the data in the grid under Former Trainees Training Program Information section. The following validation will display on top of the grid if no data is entered: You are required to provide information for at least one former trainee.

In this section, the grantee provides information for each long-term trainee who completed the MCHB-funded training program 2 or 5 years ago.

Total Number of Trainees

• The Total Number of Trainees field available above the grid to the right of the screen will be auto calculated as the grantee enters information in the grid below, which has the following column names:
  • Name
  • Email address
  • When did the trainee complete the MCHB-funded Training Program?
  • Year Graduated
  • Primary discipline of study
  • Do you have follow-up data to report on the trainee?
  • Status
  • Action: The grantee may click on the X Delete link to delete the entire row or the Edit link to edit previously added information.

+ Add New

• This button will be available below the grid and the grantee can add a new row by clicking on this button. An overlay window will open with the header Former Trainee when the grantee clicks on Add New.

Former Trainee: On the overlay window, the grantee answers the following questions:

NOTE: The screenshot of the full modal window is at the bottom of the section.

Name

• This is a required field, and the following validation will display on the text box: Provide a response for this field.

Email address

• This is a required field, and the following validation will display on the text box: Provide a response for this field.

When did the trainee complete their MCHB Training Program?

• This is a required field, and the following validation will display on the checkboxes: Provide a response for this field. The grantee must select one of the responses from the following checkbox options:
  • 2 years ago
  • 5 years ago

Primary discipline of study (during MCH Training Program):

• This is a required field, and the following validation will display on the dropdown box: Provide a response for this field. The grantee must select one or more responses from the following that reflect the Primary Discipline of Study:
  • Applied Behavior Analysis
  • Audiology
  • Community Health Worker
  • Community Member/Person with Lived Experience
  • Dentistry-Pediatric
  • Dentistry-Other
  • Dietetics
  • Disability Studies
  • Doula
  • Education/Special Education
  • Family Member
  • Genetics/Genetic Counseling
  • Health Administration
  • Law
  • Medicine-General
  • Medicine-Adolescent Medicine
  • Medicine-Adult Providers
  • Medicine-Developmental-Behavioral Pediatrics
  • Medicine-Neurodevelopmental Disabilities
  • Medicine-Pediatrics
  • Medicine-Pediatric Pulmonology
  • Medicine-Sleep
  • Medicine-Other
  • Nursing-General
  • Nursing-Family/Pediatric Nurse Practitioner
  • Nursing-Midwife
  • Nursing-Other
  • Nutrition
  • Occupational Therapy
  • Pharmacy
  • Physician Assistant
  • Physical Therapy
  • Psychiatry
  • Psychology
  • Public Health
  • Respiratory Therapy
  • School Psychology/School Counseling
  • Self-Advocate/Person with a Disability or Special Health Care Need
  • Social Work
  • Speech-Language Pathology
  • Other (Specify)

NOTE: If the grantee selects Other (specify) from the dropdown, a description is required in the Other Discipline Description field and the following validation will display on the field: Provide a description for ‘Other’. The Other Discipline Description field accepts text, numbers, and special characters (not to exceed 100 characters).

Year Graduated

• This is a required field, and the following validation will display on the text box: Provide an appropriate four digit year.

Ethnicity (Refer to Detail Sheet for Definitions)

• This is a required field, and the following validation will display on the dropdown box: Provide a response for this field. The grantee must select one of the responses from the following drop-down values:
  • Hispanic or Latino
  • Not Hispanic or Latino
  • Unrecorded

Race (Refer to Detail Sheet for Definitions)

• This is a required field, and the following validation will display on the dropdown box: Provide a response for this field. The grantee must select one of the responses from the following drop-down values:
  • American Indian or Alaska Native
  • Asian
  • Black or African American
  • Native Hawaiian or Other Pacific Islander
  • White
  • More than One Race
  • Unrecorded

First-generation college student?

• This is a required question, and the following validation will display on the dropdown box: Provide a response for this field. The grantee must select one of the responses from the drop-down values:
  • Yes
  • No
  • Choose not to disclose/Unrecorded

Do you have follow-up data to report on the trainee (e.g. former trainee survey)?

• This is a required question, and the following validation will display on the dropdown box: Provide a response for this field. The grantee must select a Yes or No response from the dropdown menu.
• All the questions under this question will remain disabled and will only be enabled for the data entry if Yes is selected.

What is the trainee's current employment setting? (Select one)

• This is a required question if the grantee answers Yes to the question Do you have follow-up data to report on the trainee (e.g. former trainee survey)?. The grantee must select one of the responses from the following drop-down values:
  • Clinical health care setting (includes hospitals, health centers and clinics)
  • Community-based organization or non-profit
  • Elementary or secondary school or school system
  • Not currently working or retired
  • Other government agency (e.g. Federal, state or local)
  • Other private sector organization
  • State health department, including Title V
  • Student
  • Undergraduate or graduate-level institution
  • Other (specify)

NOTE: If the grantee selects Other (specify) from the dropdown, a description is required in the Other Employment Description field and the following validation will display on the field: Provide a description for ‘Other’. The Other Employment Description field accepts text, numbers, and special characters (not to exceed 100 characters).

Zip code of employment setting selected (For locations without a US postal code, please enter 99999 in this field.)

• This is a required field, and the following validation will display on the integer box: Enter a 5 digit Zip Code.

Does the trainee's current work support or serve any of the following MCH populations? (select all that apply)

• This is a required field, and the following validation will display on the dropdown box: Provide a response for this field. The grantee must select one or more of the responses from the following that reflect the trainee’s current work support:
  • Adolescents and young adults
  • Children
  • Children and youth with special health care needs, including children with autism spectrum disorder or other developmental disabilities
  • Fathers or other caregivers
  • Infants
  • Women who have given birth
  • None or unknown
•  If None or unknown is selected, the grantee select any other option.

Does the trainee's current work support or serve populations that have been historically underserved or marginalized? (select all that apply)

• This is a required field, and the following validation will display on the dropdown box: Provide a response for this field. The grantee must select one or more of the responses from the following drop-down values:
  • Children and youth with special healthcare needs
  • Indigenous populations
  • Military veterans
  • People experiencing homelessness
  • People living in poverty
  • People with disabilities
  • Racially/ethnically diverse populations
  • Rural populations
  • None or unknown
• If None or unknown is selected, the grantee to select any other option.

Has the trainee done any of the following leadership activities since completing their training program? (select all that apply)

• This is a required field, and the following validation will display on the dropdown box: Provide a response for this field. The grantee must select the one or more of the responses from the following that reflect the leadership activities:
  • Academic leadership activities
  • Clinical leadership activities
  • Public health leadership activities
  • Public policy leadership activities
  • None or unknown
• If None or unknown is selected, the grantee should not be able to select any other option.

Has the trainee participated in or led any of the following interdisciplinary/interprofessional activities since completing your training program? (select all that apply)

• This is a required field, and the following validation will display on the dropdown box: Provide a response for this field. The grantee must select one or more of the responses from the following that reflect the level of training:
  • Sought input or information from other professions, disciplines, people with lived experience, or self-advocates to address a need in their work
  • Provided input or information to other professions or disciplines
  • Developed a shared vision, roles and responsibilities across disciplines
  • Utilized shared vision, roles or responsibilities to develop a coordinated, prioritized plan across disciplines to address a need in their work
  • Established decision-making procedures in an interdisciplinary group
  • Collaborated with various disciplines across agencies/entities
  • Advanced policies & programs that promote collaboration with other disciplines or professions
  • Engaged in clinical practice working in collaboration across disciplines and with the patient
  • None or unknown
• If None or unknown is selected, the grantee should not be able to select any other option.

In this section, the grantee can enter additional information (not to exceed 5,000 characters). The Comments field accepts text, numbers, and special characters.

The grantee must click on Save or Save and Continue buttons before navigating away from this form to ensure all data entered is saved successfully.

• The Save button will save the validated information captured in the form and grantee will remain on the same form.
• The Save and Continue button will save the validated information and grantee will navigate to the next form.
• The Go to Previous Form button will navigate to the previous form without saving any previously unsaved information.