____ Other (Specify)_________ TOTAL Number of Medium term Trainees: _________ Short Term Trainees DEFINITION: Short-term trainees are trainees with less than 40 contact hours in the current reporting year. (Continuing Education participants are not counted in this category) Total number of short term trainees during the past 12-month grant period________ Indicate disciplines (check all that apply) Audiology Dentistry-Pediatric Dentistry Other – Education/Special Education Family/Parent/Youth Advocacy Genetics/Genetic Counseling Health Administration Medicine-General Medicine-Adolescent Medicine Medicine-Developmental-Behavioral Pediatrics Medicine-Neurodevelopmental Disabilities Medicine-Pediatrics Medicine-Pediatric Pulmonology Medicine Other – Nursing-General Nursing-Family/Pediatric Nurse Practitioner Nursing-Midwife Nursing Other – Nutrition Occupational Therapy Parent Physical Therapy Psychiatry Psychology Public Health Respiratory Therapy Social Work Speech-Language Pathology Other (Specify) Technical Assistance/Collaboration Form DEFINITION: Technical Assistance/Collaboration refers to mutual problem solving and collaboration on a range of issues, which may include program development, clinical services, collaboration, program evaluation, needs assessment, and policy & guidelines formulation. It may include administrative services, site visitation and review/advisory functions. Collaborative partners might include State or local health agencies, and education or social service agencies. Faculty may serve on advisory boards to develop &/or review policies at the local, State,
____ Other (Specify)_________ TOTAL Number of Medium term Trainees: _________ Short Term Trainees DEFINITION: Short-term trainees are trainees with less than 40 contact hours in the current reporting year. (Continuing Education participants are not counted in this category) Total number of short term trainees during the past 12-month grant period________ Indicate disciplines (check all that apply) Audiology Dentistry-Pediatric Dentistry – Other Education/Special Education Family/Parent/Youth Advocacy Genetics/Genetic Counseling Health Administration Medicine-General Medicine-Adolescent Medicine Medicine-Developmental-Behavioral Pediatrics Medicine-Neurodevelopmental Disabilities Medicine-Pediatrics Medicine-Pediatric Pulmonology Medicine – Other Nursing-General Nursing-Family/Pediatric Nurse Practitioner Nursing-Midwife Nursing – Other Nutrition Occupational Therapy Parent Physical Therapy Psychiatry Psychology Public Health Respiratory Therapy Social Work Speech-Language Pathology Other (Specify) Technical Assistance/Collaboration Form DEFINITION: Technical Assistance/Collaboration refers to mutual problem solving and collaboration on a range of issues, which may include program development, clinical services, collaboration, program evaluation, needs assessment, and policy & guidelines formulation. It may include administrative services, site visitation and review/advisory functions. Collaborative partners might include State or local health agencies, and education or social service agencies. Faculty may serve on advisory boards to develop &/or review policies at the local, State,
T72.2%20-%20DGIS%20Forms%20and%20PMs.docx