HRSA Grant Budget Request Form | UAMS Regional Campuses

Before filling out this form, please obtain all appropriate approvals, signatures and documentation needed for final processing. Attach all supporting documentation, such as signed official function forms, event request forms, quotes, signed contracts, list of students and MPY numbers, etc. in the file upload at the bottom of the form.

Date(Required)

MM slash DD slash YYYY

Recipient's Name(Required)

First Last

Recipient's Email(Required)

Amount Requested from HRSA Budget(Required)

Type of request

Please provide a detailed description of the request and how it enhances medical student education:

Select the HRSA Grant these funds are being requested from:(Required)

Possible Grant Objectives

Objective 1: Enhance pre-medical recruitment and retention strategies to increase the number of students from Arkansas’ rural and/or MUCs enrolling in the UAMS COM, and who ultimately return to practice in rural and/or MUC primary care settings in Arkansas.
Objective 2: Standardize performance improvement activities, communications and evaluation processes to effectively document, track, measure, and disseminate findings and outcomes for this project and all community- based primary care initiatives.
Objective 3: Expand UAMS COM curricular offerings that include clinical, didactic, and community-based training activities, with an emphasis on the care of vulnerable populations in rural communities and/or medically underserved communities, to increase selection of residency programs in family medicine, general internal medicine, general pediatrics, or combination of internal medicine and general pediatrics.
Objective 4: Increase community-based clinical/experiential opportunities in rural and/or MUC primary care clinical training sites by leveraging strategic partnerships across the state.
Objective 5: Develop and implement a Faculty/Staff Development series designed specifically for new preceptors/teaching clinicians.
None of the above

NOTE: The goal of the MSE program is to increase the number of primary care physicians practicing in the top quintile of states with a projected primary care provider shortage in 2025.

Which grant objective is satisfied by your request?(Required)

Objective 1

Objective 2

Objective 3

Objective 4

Objective 5

None of the above

NOTE: The goal of the MSE program is to increase the number of primary care physicians practicing in the top quintile of states with a projected primary care provider shortage in 2025.

Possible Grant Objectives

Objective 1: Recruit, retain and graduate medical students from tribal, rural, and/or medically underserved communities who are interested in practicing in these areas following residency training.
Objective 2: Increase the number of medical school graduates who select residency programs in family medicine, general internal medicine, general pediatrics, or combination of internal medicine and general pediatrics to increase the primary care physician workforce in tribal, rural and medically underserved communities.
Objective 3: Develop or enhance strategic partnerships, including one or more rotations in primary care such as at a teaching health center or community-based setting to collaborate on educational and training activities for the medical students.

Which grant objective is satisfied by your request?(Required)

Objective 1

Objective 2

Objective 3

Possible Grant Objectives

Objective 1: Improve the quality of training by standardizing curricular didactic topics, rotational goals and objectives; strengthening faculty teaching skills and incorporating clinical rotations in rural and MUC areas
Objective 2: Increase the number of UAMSRP Family Medicine residents with experience in rural and/or underserved clinical settings.
Objective 3: Establish new Family Medicine Rural Residency Programs and/or Rural Training Programs.
Objective 4: Assist rural communities in recruiting graduates to practice in rural and/or underserved areas.

Which grant objective is satisfied by your request?(Required)

Objective 1

Objective 2

Objective 3

Objective 4

If you selected “None of the above” please explain:

Is this request supported within the narrative of the budget?(Required)

Yes

If yes, please select a category for your request.(Required)

If requesting an AHEC Scholars Award (Student), select assisting recruiter/advisor:(Required)

If 'Other', please provide the name of the recruiter/advisor assisting with this submission:(Required)

Recruiter/Advisor's Email(Required)

Name of person completing this form(Required)

First Last

If the person submitting this form is different from the fund recipient.

Email address for person completing this form(Required)

If the person submitting this form is different from the fund recipient.

Purpose of Request (provide a detailed description of the request)

Please attach vendor number and any other supporting documentation needed for this fund request. *Please do not attach W9 or Vendor forms, or any documents that list protected information. For AHEC Scholars awards, W9 forms are to be emailed directly to Sheila Williams. Vendor Setup is now a Workday Process.

Drop files here or

Max. file size: 15 MB.

Additional Information (Optional)