Health
Career
Promotion Forms

Practice
Entry and
Support Forms 

These are East Texas AHEC’s Data Reporting Forms.  These forms, formatted for Word and Excel, may be viewed, copied and used for your reporting purposes.  The acknowledgement statement should read as follows:  Created by East Texas Area Health Education Center, funded in part by USDHHS/HRSA/BHP Grant # 1 U77HP01066.

• Table P1: Health Careers Promotion Events with Age Break tab
  This table should include any "One-touch" events, which focus on health careers promotion. "One-touch" is defined as health career activities where any select group or individual benefits from AHEC services one time, i.e. career fairs.

• Table P2; Part 1 : Health Careers Enrichment Projects with Age Break tab

  This table should include the "Longitudinal" programs which focus on health careers enrichment.  "Longitudinal" is defined as health career activities where any select group or individual benefits from AHEC services beyond a one-time visit.
• Table P2: Part 2 : Enrichment Projects Summaries (Word Document)
  Summaries of projects listed on Table P2: Part 1
• Table P3: Promotions Activities by Independent School District, Schools and Counties
  This table should include any schools with activities reported on Tables P1 and P2.
• Table P4: Health Career Activities with Teachers and Counselors
  Programs/activities which focus on enhancing teachers and counselors ability to provide information about and/or prepare people for health careers.
• Table P5: Matriculant Tracking – Outcomes
  Reports the number of participants in enrichment activities that matriculate into health science programs and their underrepresented/disadvantaged populations status.
• Table P6: Student Loan/Scholarship Linking Services
  This table is to report any loan/scholarship linking services that you may have made referrals to.

  PRACTICE ENTRY AND SUPPORT

• Table D5: Continuing Education/ Distance Learning Programs  (one file - 2 Worksheets)
  Part 1: Continuing Education Reports continuing education activities. 

  Part 2: Other Activities Delivered by Distance Learning Technology

  Reports distance learning activities.

• Table D6: Continuing Education by Disadvantaged/Underrepresented Minority Trainees

  Reports ethnicity of continuing education trainees.

• Table D7: Continuing Education from Underserved Sites

  Number of trainees from medically underserved sites (employment location for participants)

• Table D7b: Continuing Education by Participants Profession and Hours

COMMUNITY-BASED EDUCATION

• Table E8: Community Based Education by Disadvantaged/Underrepresented Minority Trainees

  This table reports the estimated number of disadvantaged/underrepresented minority trainees.

• Table E9: Community Based Education (one file - 2 Worksheets)

  Part 1: Trainees by Sites

  This table reports the number of trainees at medically underserved training sites.

  Part 2: Underserved and Other Sites

  This table reports medically underserved training sites.

• Table E10: AHEC Training Sites and Community Faculty

  This table reports the number of Sites & Community Faculty by discipline.

• Table E11: Primary Care Trainees

  This table is to report student experiences that have an AHEC touch.  The table is generally for primary care students only.

• Table E12: Non-Primary Care Trainees   (one file - 2 Worksheets)

  Part 1: Totals

  This table is to report student experiences that have an AHEC touch. This table is for non-primary care students.

  Part 2: Details for ‘Other’ types of students

  This table is for any student reported as “Other” in Part 1

• Table E13: Student Housing Utilization

  This table lists usage of all student-housing facilities.

• Table E14: Student Housing Expenses and Funding

  This table lists expenditures of all student-housing facilities.

• Table E15: Community Faculty

  This table lists all community faculty.

COMMUNITY HEALTH SYSTEMS

• Table CHS20: Health Systems (2 Worksheets)

  Part 1: Projects

  Reports on the project/program/activity.

  Part 2: Participants

  Reports on the participants in each project.

• Table CHS20-1b – Community Health Systems Narratives         

  A brief paragraph describing the program.

GENERAL INFORMATION

• Table G14: Marketing / Public Relations
  This table should include all marketing and public relations efforts

• Table G15: Outcomes - Increase of HC Professionals in Our Region

  A cumulative record of health care professionals in our region that have received an AHEC Touch.

• Table G16:  Programs New/Enhanced/Established
  Focus on this year’s initiatives to develop a new program or enhance an existing program

• Table G17: Partnerships

  This table will help us to update the lists of our partnerships and also give us a brief description of our activities with these partners.

• Table G18:  Center Funding
  This table should include all funding sources.

• Table G19: Employees
  This table should include both past and present full-time employees.  This is a cumulative record.

• Table G20:  Center Conference Presentations
  This table is to report any presentations made at conferences that are NOT included in Continuing Education, such as professional presentations made at national and state meetings.  You can also include publication of articles and papers.

• General instructions, explanations and checklist