Download:
pdf |
pdfOMB No.:
Expires:
0990-0221
04/30/10
TITLE X
FAMILY PLANNING
ANNUAL REPORT
•••••••••••••••••••••••••
FORMS AND INSTRUCTIONS
U.S. Department of Health and Human Services
Office of Public Health and Science
Office of Population Affairs
Office of Family Planning
EFFECTIVE JANUARY 2007
OMB No.:
Expires:
Title X Family Planning Annual Report
– ii –
0990-0221
04/30/10
OMB No.:
Expires:
0990-0221
04/30/10
TABLE OF CONTENTS
INTRODUCTION............................................................................................................. 1
GENERAL INSTRUCTIONS........................................................................................... 3
Who Submits an FPAR ________________________________________________________________3
Scope of Activities Reported in the FPAR _________________________________________________3
Submitting the FPAR__________________________________________________________________3
Submitting Revised FPAR Tables________________________________________________________3
FPAR Consistency ____________________________________________________________________4
FPAR Identification ___________________________________________________________________4
TERMS AND DEFINITIONS ........................................................................................... 5
Family Planning User__________________________________________________________________5
Family Planning Provider ______________________________________________________________5
Family Planning Encounter_____________________________________________________________6
Family Planning Service Site____________________________________________________________6
Client Records _______________________________________________________________________6
Questions about FPAR Terms and Definitions _____________________________________________7
GRANTEE PROFILE COVER SHEET............................................................................ 9
Instructions __________________________________________________________________________9
Questions about the Grantee Profile______________________________________________________9
Grantee Profile Cover Sheet ___________________________________________________________11
FAMILY PLANNING USER DEMOGRAPHIC PROFILE.............................................. 13
Instructions _________________________________________________________________________13
Terms and Definitions ________________________________________________________________13
Questions about Tables 1 to 3 __________________________________________________________14
Table 1 Unduplicated Number of Family Planning Users by Age and Gender ____________________15
Table 2 Unduplicated Number of Female Family Planning Users by Ethnicity and Race ____________16
Title X Family Planning Annual Report
– iii –
OMB No.:
Expires:
0990-0221
04/30/10
Table 3 Unduplicated Number of Male Family Planning Users by Ethnicity and Race______________17
FAMILY PLANNING USER ECONOMIC AND SOCIAL PROFILE .............................. 19
Instructions _________________________________________________________________________19
Terms and Definitions ________________________________________________________________19
Questions about Tables 4 to 6 __________________________________________________________21
Table 4 Unduplicated Number of Family Planning Users by Income Level ______________________24
Table 5 Unduplicated Number of Family Planning Users by Principal Health Insurance Coverage
Status ______________________________________________________________________25
Table 6 Unduplicated Number of Family Planning Users with Limited English Proficiency (LEP) ____26
FAMILY PLANNING METHOD USE ............................................................................ 27
Instructions _________________________________________________________________________27
Terms and Definitions ________________________________________________________________27
Questions about Tables 7 and 8_________________________________________________________29
Table 7 Unduplicated Number of Female Family Planning Users by Primary Method and Age_______30
Table 8 Unduplicated Number of Male Family Planning Users by Primary Method and Age ________31
CERVICAL AND BREAST CANCER SCREENING ..................................................... 33
Instructions _________________________________________________________________________33
Terms and Definitions ________________________________________________________________33
Questions about Tables 9 and 10________________________________________________________34
Table 9 Cervical Cancer Screening Activities _____________________________________________37
Table 10 Clinical Breast Exams and Referrals _____________________________________________38
SEXUALLY TRANSMITTED DISEASE (STD) SCREENING ....................................... 39
Instructions _________________________________________________________________________39
Terms and Definitions ________________________________________________________________39
Questions about Tables 11 and 12_______________________________________________________39
Table 11 Unduplicated Number of Family Planning Users Tested for Chlamydia by Age and Gender _41
Table 12 Number of Gonorrhea, Syphilis, and HIV Tests ____________________________________42
Title X Family Planning Annual Report
– iv –
OMB No.:
Expires:
0990-0221
04/30/10
FAMILY PLANNING ENCOUNTERS AND UTILIZATION OF CLINICAL SERVICES
PROVIDERS ................................................................................................................. 43
Instructions _________________________________________________________________________43
Terms and Definitions ________________________________________________________________43
Questions about Table 13______________________________________________________________44
Table 13 Number of Family Planning Encounters by Type of Provider _________________________46
REVENUE REPORT ..................................................................................................... 47
Instructions _________________________________________________________________________47
Terms and Definitions ________________________________________________________________47
Questions about Table 14______________________________________________________________49
Table 14 Revenue Report _____________________________________________________________50
NOTES.......................................................................................................................... 51
ABBREVIATIONS AND ACRONYMS .......................................................................... 53
APPENDIX A: COLLECTING AND TABULATING MULTI-RACE RESPONSES...... A-1
PAPERWORK REDUCTION ACT (PRA) PUBLIC BURDEN STATEMENT
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0990-0221. The time required to complete this
information collection is estimated to average 33 hours per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to:
U.S. Department of Health & Human Services
OS/OIRM/PRA
200 Independence Ave., S.W., Suite 531-H
Washington D.C. 20201
Attention: PRA Reports Clearance Officer
Title X Family Planning Annual Report
–v–
OMB No.:
Expires:
Title X Family Planning Annual Report
– vi –
0990-0221
04/30/10
OMB No.:
Expires:
0990-0221
04/30/10
INTRODUCTION
This annual reporting requirement is for family planning services delivery projects authorized and funded
under the Population Research and Voluntary Family Planning Programs (Section 1001 of Title X of the
Public Health Service Act, 42 United States Code [USC] 300). 1 The Office of Family Planning (OFP)
within the Office of Population Affairs (OPA) administers the Title X Family Planning Program.
Annual submission of the Family Planning Annual Report (FPAR) is required of all Title X family
planning services grantees for purposes of monitoring and reporting program performance (45 Code of
Federal Regulations [CFR] Part 74 2 and 45 CFR Part 92 3). FPAR data are presented in summary form,
which protects the confidentiality of individuals who receive Title X-funded services (42 CFR Part 59). 4
The FPAR is the only source of annual, uniform reporting by all Title X family planning services
grantees. It provides consistent, national-level data on the Title X Family Planning Program and its users.
Information from the FPAR is important to OPA for several reasons. First, FPAR data are used to monitor
compliance with statutory requirements, regulations, and operational guidance set forth in the Program
Guidelines for Project Grants for Family Planning Services (“Program Guidelines”), 5 which include:
Monitoring compliance with legislative mandates, such as giving priority in the provision of
services to low-income persons [Section 1006(c) of Title X of the Public Health Service Act,
42 USC 300], and
Ensuring that Title X grantees and their subcontractors provide a broad range of family
planning methods and services [Section 1001(a) of Title X of the Public Health Service Act,
42 USC 300].
Second, OPA uses FPAR data to comply with accountability and federal performance requirements for
Title X family planning funds as required by the 1993 Government Performance and Results Act
(GPRA). Current GPRA performance goals for the Title X Family Planning Program include priority in
the provision of family planning services to low-income individuals, access to and utilization of cervical
and breast cancer screening, and access to on-site human immunodeficiency virus (HIV) testing at
Title X-funded clinics.
Finally, OPA relies on FPAR data to guide strategic and financial planning, to monitor performance, and
to respond to inquiries from policymakers and Congress about the program. The FPAR allows OPA to
assemble comparable and relevant program data to answer questions about the characteristics of the
population served by Title X projects, utilization of services offered, composition of revenues, and
program impact. FPAR data are the basis for objective grant reviews, program evaluation, and assessment
of program technical needs.
1
Retrieved November 18, 2003, from http://opa.osophs.dhhs.gov/titlex/xstatut.pdf.
2
Retrieved November 18, 2003, from http://opa.osophs.dhhs.gov/cfr/45cfr74.pdf.
3
Retrieved November 18, 2003, from http://opa.osophs.dhhs.gov/cfr/45cfr92.pdf.
4
Retrieved November 18, 2003, from http://opa.osophs.dhhs.gov/titlex/ofp_regs_42cfr59_10-1-2000.pdf.
5
Program Guidelines for Project Grants for Family Planning Services, January 2001, Bethesda, MD: U.S.
Department of Health and Human Services, Office of Public Health and Science/Office of Population Affairs/Office
of Family Planning, 30 p. Retrieved November 18, 2003, from
http://opa.osophs.dhhs.gov/titlex/2001guidelines/2001_ofp_guidelines.pdf.
Title X Family Planning Annual Report
–1–
OMB No.:
Expires:
0990-0221
04/30/10
This version of the FPAR consists of a Grantee Profile Cover Sheet and 14 tables. The data collected
include demographic, social, and economic user characteristics; utilization of family planning and related
preventive health services; utilization of health personnel; and project revenues. New FPAR data elements
include information on such user characteristics as health insurance coverage and limited English
proficiency (LEP); utilization of contraception and related preventive health services by male family
planning users; summary Pap (abnormal) and confidential HIV (positive) test results; and disease-specific
information on sexually transmitted disease (STD) screening.
Title X Family Planning Annual Report
–2–
OMB No.:
Expires:
0990-0221
04/30/10
GENERAL INSTRUCTIONS
This section provides general instructions for completing the FPAR. They should be used in conjunction
with the table-specific instructions, and are cross-referenced as appropriate.
WHO SUBMITS AN FPAR
Grantees funded under Section 1001 of the Title X Public Health Service Act (42 USC 300) should
prepare and submit the FPAR. The family planning services grantee is the direct recipient of the Title X
grant. Delegates or subcontractors to the grantee receive Title X funds via the grantee. Delegate or
subcontractor agencies should not submit an FPAR report; rather, they should follow the instructions
provided to them by the grantee.
SCOPE OF ACTIVITIES REPORTED IN THE FPAR
The purpose of the FPAR is to provide a comprehensive view of the family planning activities within the
scope of the grantee’s Title X-funded project. Family planning services grantees should report the total,
unduplicated number of users, encounters, and other outputs from activities that are within the scope of a
grantee’s approved grant application. If you have questions about whether to include certain data in
this report, contact your Regional Program Consultant (RPC). An updated list of RPCs can be found
on the OPA/OFP website at http://opa.osophs.dhhs.gov/titlex/ofp-rpc.html.
SUBMITTING THE FPAR
The FPAR should be prepared and submitted no later than February 15 after the end of the reporting
period. If February 15 falls on a weekend, the FPAR is due on the following Monday.
The FPAR can be submitted electronically or in hardcopy. The two options for electronic submission
include the OPA eGrants System (encouraged) or as an electronic file attached to an e-mail message.
Grantees should select one of the following methods.
PAPER SUBMISSION – Submit three (3) paper copies of the complete FPAR to the RPC for your
region.
E-MAIL SUBMISSION – Attach one (1) electronic file to an e-mail message and mail one (1) paper
copy of the complete FPAR to the RPC for your region.
– Follow the instructions in the eGrants Applicant Manual for preparing
and submitting the FPAR.
EGRANTS SUBMISSION
Current RPC postal and e-mail addresses are available on the OPA/OFP website at http://
opa.osophs.dhhs.gov/titlex/ofp-rpc.html.
SUBMITTING REVISED FPAR TABLES
Grantees should consult with their RPC regarding any region-specific requirements and/or deadlines for
submitting revised FPAR tables. To ensure that data from revised tables are included in the national
Family Planning Annual Report, grantees should submit revised tables by April 1.
Title X Family Planning Annual Report
–3–
OMB No.:
Expires:
0990-0221
04/30/10
Grantees submitting revised FPAR tables may submit the revised table(s) using any of the following
methods, regardless of the method used to submit the initial tables.
PAPER SUBMISSION – Submit three (3) paper copies of the revised table(s) to your RPC. Indicate
that the table is a revised submission by checking the appropriate box in the table header (top of
the page). Include a completed Grantee Profile Cover Sheet with each set of revised tables.
E-MAIL SUBMISSION – Attach one (1) electronic file to an e-mail message and mail one (1) paper
copy of the revised table(s) to your RPC. Indicate that the table is a revised submission by
checking the appropriate box in the table header (top of the page). Include a completed Grantee
Profile Cover Sheet with each set of revised tables.
– Follow the instructions in the eGrants Applicant Manual for revising and
resubmitting one or more FPAR tables.
EGRANTS SUBMISSION
FPAR CONSISTENCY
To improve FPAR consistency (1) do not leave any cells blank—if the value for the cell is zero, enter “0”;
and (2) do not report percentages—enter only whole numbers.
The numbers reported in Table 1 of the hardcopy of the FPAR will serve as a reference for consistency
checkpoints in subsequent tables in the report. The values in these tables are identified with unique,
double-letter identifiers (i.e., AA, BB, and CC). The eGrants system also has built-in consistency checks
to ensure that key cells in each table are consistent with one another.
If additional written information accompanies the table, or if one or more figures in the table are
estimated rather than actual, use the “See Notes” box or use the “Notes” option in eGrants. For each note,
please indicate the table and cell to which the note applies. For estimated figures, describe the rationale
and method for generating the estimate.
FPAR IDENTIFICATION
Key identifying information must be reported on all FPAR tables, including the Grantee Profile Cover
Sheet. This information includes:
FPAR NUMBER – Enter the four-digit number assigned to the grantee by the regional Department of
Health and Human Services (HHS) office. Do not use your HHS grant number.
DATE SUBMITTED – Specify the date that your agency (i.e., grantee) submits the report.
REPORTING PERIOD – The reporting period for the FPAR is the calendar year (i.e., January 1
through December 31). Title X grantees that begin operating after January 1 or stop operating before
December 31 should indicate which portion of the year their Title X-funded projects are active.
INITIAL SUBMISSION OR REVISION – Check the appropriate box at the top of each table, indicating
whether the table is an initial or revised submission. If you submit the FPAR using eGrants, follow
the instructions in the eGrants Applicant Manual for indicating whether a table is an initial or revised
submission.
Title X Family Planning Annual Report
–4–
OMB No.:
Expires:
0990-0221
04/30/10
TERMS AND DEFINITIONS
Definitions for key FPAR terms are provided to ensure uniform reporting among Title X grantees. The
terms describe the individuals receiving family planning and related preventive health services at Title Xfunded service sites, the range and scope of the services provided, and the family planning providers who
render care.
FAMILY PLANNING USER
A family planning user is an individual who has at least one family planning encounter at a Title X
service site during the reporting period. The same individual may be counted as a family planning user
only once during a reporting period. Grantees should follow the table-specific instructions to identify
applicable users.
FAMILY PLANNING PROVIDER
A family planning provider is the individual who assumes primary responsibility for assessing a client
and documenting services in the client record. Providers include those agency staff that exercise
independent judgment as to the services rendered to the client during an encounter. Two general types of
providers deliver Title X family planning services: clinical services providers and non-clinical services
providers.
CLINICAL SERVICES PROVIDER – Includes physicians (family and general practitioners, specialists),
physician assistants, nurse practitioners, certified nurse midwives, and other licensed health providers
(e.g., registered nurses) who are trained and permitted by state-specific regulations to perform all
aspects of the user (male and female) physical assessment, as described in Section 8.3 of the Program
Guidelines. 6 Clinical services providers are able to offer client education, 7 counseling, 8 referral, 9
follow-up,9 and/or clinical services (physical assessment, treatment, and management) relating to a
client’s proposed or adopted method of contraception, general reproductive health, or infertility
treatment.
NON-CLINICAL SERVICES PROVIDER – Includes other agency staff (e.g., nurses, health educators, social
workers, or clinic aides) that are able to offer client education,7 counseling,8 referral,9 and/or followup9 services relating to the client’s proposed or adopted method of contraception, general
reproductive health, or infertility treatment. Non-clinical services providers may also perform or
obtain samples for routine laboratory tests (e.g., urine, pregnancy, STD, and cholesterol and lipid
analysis),6 give contraceptive injections (e.g., Depo Provera), and perform routine clinical procedures
that may include some aspects of the user physical assessment (e.g., blood pressure evaluation), as
described in Section 8.3 of the Program Guidelines.6
6
Refer to “8.3 History, Physical Assessment, and Laboratory Testing” in Program Guidelines, pp. 21-23 (see
footnote 5).
7
Refer to “8.1 Client Education” in Program Guidelines, pp. 17-18 (see footnote 5).
8
Refer to “8.2 Counseling” in Program Guidelines, pp. 18-19 (see footnote 5).
9
Refer to “7.4 Referrals and Follow-up” in Program Guidelines, p. 16 (see footnote 5).
Title X Family Planning Annual Report
–5–
OMB No.:
Expires:
0990-0221
04/30/10
FAMILY PLANNING ENCOUNTER
A family planning encounter is a documented, face-to-face contact between an individual and a family
planning provider that takes place in a Title X service site. The purpose of a family planning encounter—
whether clinical or non-clinical—is to provide family planning and related preventive health services to
female and male clients who want to avoid unintended pregnancies or achieve intended pregnancies. To
be counted for purposes of the FPAR, a written record of the service(s) provided during the family
planning encounter must be documented in the client record.
There are two types of family planning encounters at Title X service sites: (1) family planning encounters
with a clinical services provider and (2) family planning encounters with a non-clinical services provider.
The type of family planning provider who renders the care, regardless of the services rendered,
determines the type of family planning encounter.
FAMILY PLANNING ENCOUNTER WITH A CLINICAL SERVICES PROVIDER – A face-to-face, documented
encounter between a family planning client and a clinical services provider that takes place in a Title
X service site.
FAMILY PLANNING ENCOUNTER WITH A NON-CLINICAL SERVICES PROVIDER – A face-to-face, documented
encounter between a family planning client and a non-clinical services provider that takes place in a
Title X service site.
Laboratory tests and related counseling and education, in and of themselves, do not constitute a family
planning encounter unless there is face-to-face contact between the client and provider, the provider
documents the encounter in the client’s record, and the test(s) is/are accompanied by family planning
counseling or education.
FAMILY PLANNING SERVICE SITE
A family planning service site refers to an established unit where grantee or delegate agency staff
provides Title X services (clinical, counseling, educational, and/or referral) that comply with the Title X
Program Guidelines, and where at least some of the encounters between the family planning provider(s)
and the individual(s) served meet the requirements of a family planning encounter. Established units
include clinics, hospital outpatient departments, homeless shelters, detention and correctional facilities,
and other locations where Title X agency staff provides these family planning services. Service sites may
also include equipped mobile vans or schools.
CLIENT RECORDS
Title X projects must establish a medical record for every client who obtains clinical services or other
screening or laboratory services (e.g., blood pressure check, urine-based pregnancy or STD test). The
medical record contains personal data; a medical history; physical exam data; laboratory test orders,
results, and follow-up; treatment and special instructions; scheduled revisits; informed consent forms;
documentation of refusal of services; and information on allergies and untoward reactions to identified
drug(s). The medical record also contains clinical findings; diagnostic and therapeutic orders; and
documentation of continuing care, referral, and follow-up. The medical record allows for entries by
counseling and social service staff. The medical record is a confidential record, accessible only to
authorized staff and secured by lock when not in use. The client medical record must contain sufficient
Title X Family Planning Annual Report
–6–
OMB No.:
Expires:
0990-0221
04/30/10
information to identify the client, indicate where and how the client can be contacted, justify the clinical
impression or diagnosis, and warrant the treatment and end results. 10
If a family planning user receives no clinical services, a record still must be established for that client.
Like a medical record, this client record must contain sufficient information to identify the client, indicate
where and how the client can be contacted, and document fully the encounter. This record is confidential,
accessible only to authorized staff, and secured by lock when not in use.
QUESTIONS ABOUT FPAR TERMS AND DEFINITIONS
1. QUESTION – Can a client have more than one family planning encounter during a single family
planning visit?
ANSWER – A client may have only one family planning encounter per visit. In the family
planning services setting, the term “encounter” is synonymous with “visit.” Although a client
may meet with both clinical and non-clinical family planning providers during an encounter, only
one provider is credited with the encounter. The provider with the highest level of training who
takes ultimate responsibility for the client’s clinical or non-clinical assessment and care during
the visit is credited with the encounter.
2. QUESTION – If an individual receives gynecological or related preventive health services (e.g.,
pelvic exam, Pap test, pregnancy test, STD screening) in a Title X-funded clinic, but does not
receive services aimed at avoiding unintended pregnancy or achieving intended pregnancy (e.g.,
contraceptive or fertility counseling), is the encounter considered a family planning encounter?
ANSWER – If a client is an ongoing family planning user who visits the clinic to obtain any type of
family planning or related preventive health services, the encounter is considered a family
planning encounter.
If a client has been sterilized, but continues to seek gynecological or related preventive health
services, the encounter is considered a family planning encounter and the agency may continue to
count the client as a family planning user.
If a client obtains gynecological or related preventive health services, but the client is neither an
ongoing family planning user nor seeks or receives services (clinical, counseling, educational,
and/or referral) to help avoid unintended pregnancy or achieve intended pregnancy, the encounter
is not a family planning encounter and the client is not a family planning user.
If a post-menopausal client obtains gynecological or related preventive health services, the
encounter is not a family planning encounter and the client is not a family planning user.
3. QUESTION – If a clinic medical aide is trained and authorized to give contraceptive injections (e.g.,
Depo Provera), should an agency report the aide as an “other” clinical services provider?
ANSWER – No. For FPAR reporting purposes, a clinic medical aide is defined as a non-clinical
services provider even though he or she may be trained and authorized to give contraceptive
injections.
10
Refer to “10.3 Medical Records” in Program Guidelines, pp. 28-29 (see footnote 5).
Title X Family Planning Annual Report
–7–
OMB No.:
Expires:
Title X Family Planning Annual Report
–8–
0990-0221
04/30/10
OMB No.:
Expires:
0990-0221
04/30/10
GRANTEE PROFILE COVER SHEET
The Grantee Profile Cover Sheet provides important contact and summary information about each grantee
and the network of service providers supported through the Title X grant. A completed Grantee Profile
Cover Sheet must accompany the initial submission of the FPAR, as well as submission of any revised
tables.
INSTRUCTIONS
GRANTEE LEGAL NAME– Provide the name of the legal recipient of the Title X family planning
services grant.
ADDRESS OF GRANTEE ADMINISTRATIVE OFFICES – Provide the grantee’s complete address, including
nine-digit zip code.
TITLE X PROJECT DIRECTOR – Provide the name, title, mailing address, phone and fax numbers, and email address for the agency representative responsible for directing the grantee’s Title X project.
GRANTEE CONTACT PERSON (PERSON COMPLETING FPAR) – Provide the name, title, mailing address,
phone and fax numbers, and e-mail address for the agency representative with primary responsibility
for preparing the FPAR.
NUMBER OF DELEGATES/SUBCONTRACTORS SUPPORTED BY THE TITLE X GRANT – Report the number of
delegate or subcontractor agencies that receive funding through the grantee’s Title X service grant.
NUMBER OF FAMILY PLANNING SERVICE SITES SUPPORTED BY THE TITLE X GRANT – Report the total
number of family planning service sites supported by the Title X grant and represented in the FPAR
data. A family planning service site refers to an established unit where grantee or delegate agency
staff provides Title X services (clinical, counseling, educational, and/or referral) that comply with the
Title X Program Guidelines, and where at least some of the encounters between the family planning
provider(s) and the individual(s) served meet the requirements of a family planning encounter.
Established units include clinics, hospital outpatient departments, homeless shelters, detention and
correctional facilities, and other locations where Title X agency staff provides these family planning
services. Service sites may also include equipped mobile vans or schools.
If the number of service sites supported by the Title X grant is different from the number provided in
the grant application, the grantee should check the box in the last row of the Cover Sheet, check the
“See Notes” box, and explain the reason for this difference in the reported number of service sites.
QUESTIONS ABOUT THE GRANTEE PROFILE
1. QUESTION – If agency staff provides Title X services at a clinic and two non-clinic sites, should
the agency report a total of one or three service sites on the Grantee Profile Cover Sheet?
ANSWER – For purposes of the FPAR, the agency should count and report any established unit,
clinic or non-clinic, where its staff provides Title X services and where at least some of the
encounters between the family planning provider(s) and the individual(s) served meet the
requirements of a family planning encounter. OPA assumes that each of the sites reported in the
Title X Family Planning Annual Report
–9–
OMB No.:
Expires:
0990-0221
04/30/10
Grantee Profile contributes data to the FPAR. If all three sites in this example contribute data to
the FPAR, the agency should report three service sites on the Grantee Profile Cover Sheet.
Title X Family Planning Annual Report
– 10 –
OMB No.:
Expires:
FPAR Number:
0990-0221
04/30/10
Date Submitted:
Reporting Period:
January 1, 200______ through December 31, 200______
__________________ through _____________________
(Month/day/year)
(Month/day/year)
Check One:
Initial Submission
Revision
See Notes
GRANTEE PROFILE COVER SHEET
GRANTEE LEGAL NAME
Street
ADDRESS OF GRANTEE
ADMINISTRATIVE OFFICES
City
State
Zip code
–
Zip code
–
Name
TITLE X PROJECT DIRECTOR
Title
Street
City
State
Phone
Fax
E-Mail
Name
GRANTEE CONTACT PERSON
(PERSON COMPLETING FPAR)
Title
Street
City
State
Zip code
–
Phone
Fax
E-Mail
NUMBER OF DELEGATES/SUBCONTRACTORS
SUPPORTED BY THE TITLE X GRANT
NUMBER OF FAMILY PLANNING SERVICE
SITES SUPPORTED
BY THE TITLE X GRANT
_________________
Check if total number of sites is
different from application
Title X Family Planning Annual Report
– 11 –
OMB No.:
Expires:
Title X Family Planning Annual Report
– 12 –
0990-0221
04/30/10
OMB No.:
Expires:
0990-0221
04/30/10
FAMILY PLANNING USER DEMOGRAPHIC PROFILE
Data reported in Tables 1 through 3 allow program administrators to monitor access to and use of Title X
services among the diverse population these projects aim to serve. Tables 1, 2, and 3 describe the
demographic characteristics of family planning users, including the distribution of users by age, gender,
ethnicity, and race.
The numbers reported in Table 1 serve as a reference for consistency checkpoints in subsequent tables in
the report. The values in these tables are identified with unique, double-letter identifiers (i.e., AA, BB,
and CC).
INSTRUCTIONS
TABLE 1 –
Report the unduplicated number of family planning users by age group and gender.
TABLE 2 –
Report the unduplicated number of female family planning users by race and
ethnicity.
TABLE 3 –
Report the unduplicated number of male family planning users by race and ethnicity.
TERMS AND DEFINITIONS
AGE GROUP – Categorize family planning users based on their age as of June 30th of the reporting period.
ETHNICITY AND RACE– The categories for reporting ethnicity and race in the FPAR conform to the Office
of Management and Budget (OMB) 1997 Revisions to the Standards for the Classification of Federal
Data on Race and Ethnicity, 11 and are used by other HHS programs and compilers of such national data
sets as the National Survey of Family Growth. If an agency wants to collect data for ethnic or race
subcategories, the agency must be able to aggregate the data reported into the OMB minimum standard
set of ethnicity and race categories.
OMB encourages self-identification of race. When respondents are allowed to self-identify or self-report
their race, agencies should adopt a method that allows respondents to mark or select more than one of the
five minimum race categories. Appendix A to this form provides general guidance and a list of resources
regarding collection of multi-race responses.
The two minimum OMB categories for reporting ethnicity are:
HISPANIC OR LATINO (ALL RACES) – A person of Cuban, Mexican, Puerto Rican, South or Central
American, or other Spanish culture or origin, regardless of race.
NOT HISPANIC OR LATINO (ALL RACES) – A person not of Cuban, Mexican, Puerto Rican, South or
Central American, or other Spanish culture or origin, regardless of race.
11
Office of Management and Budget, October 30, 1997, Revisions to the Standards for the Classification of Federal
Data on Race and Ethnicity, Federal Register Notice. Retrieved November 18, 2003, from http://
www.whitehouse.gov/omb/fedreg/ombdir15.html.
Title X Family Planning Annual Report
– 13 –
OMB No.:
Expires:
0990-0221
04/30/10
The five minimum categories for reporting race are:
AMERICAN INDIAN OR ALASKA NATIVE – A person having origins in any of the original peoples of North
and South America (including Central America), and who maintains tribal affiliation or community
attachment.
ASIAN – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands, Thailand, and Vietnam.
BLACK OR AFRICAN AMERICAN – A person having origins in any of the black racial groups of Africa.
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – A person having origins in any of the original peoples
of Hawaii, Guam, Samoa, or other Pacific Islands.
WHITE – A person having origins in any of the original peoples of Europe, the Middle East, or North
Africa.
QUESTIONS ABOUT TABLES 1 TO 3
1. QUESTION – How are these tables different from the previous FPAR?
ANSWER – In the revised FPAR, the age, ethnicity, and racial characteristics of family planning
users are reported using three tables instead of two as in the previous FPAR.
2. QUESTION – What if a client does not self-identify with any of the OMB minimum standard race
categories?
ANSWER – According to the 1997 OMB guidance, all races are represented in Tables 2 and 3, and
technically every client should be included in one of these categories. Nevertheless, agency staff
must respect the client’s right to not report his or her race. Agencies should report the number of
users with missing or unknown race information in the “unknown/not reported” race category.
Agency staff should be familiar with the OMB definitions for each race category so that they can
assist clients who may have questions. Further, agencies should consider providing the definition
of each race category in their data collection forms if space and formatting permit.
Hispanic or Latino clients account for a high proportion of family planning users for whom race
data are unknown (i.e., not reported). The structure of Tables 2 and 3 will allow OPA to identify
the number of female and male Hispanic or Latino clients who do not report race data.
3. QUESTION – What if a client self-identifies with more than one of the OMB minimum race
categories?
ANSWER – According to the 1997 OMB guidance, when self-identification is used agencies
should adopt a data collection method that allows respondents to self-report more than one race.
Appendix A to this form provides general guidelines and a sample question for collecting multirace responses. Please note that the information in Appendix A is not comprehensive, and serves
only to highlight important considerations and ideas for handling multi-race response. Agencies
interested in issues surrounding collection of race data should consult the resource list in
Appendix A.
Title X Family Planning Annual Report
– 14 –
OMB No.:
Expires:
FPAR Number:
0990-0221
04/30/10
Date Submitted:
Reporting Period:
January 1, 200______ through December 31, 200______
__________________ through _____________________
(Month/day/year)
(Month/day/year)
Check One:
Initial Submission
Revision
See Notes
TABLE 1
UNDUPLICATED NUMBER OF FAMILY PLANNING USERS BY AGE AND GENDER
AGE GROUP
(YEARS)
1
Under 15
2
15–17
3
18–19
4
20–24
5
25–29
6
30–34
7
35–39
8
40–44
9
Over 44
10
FEMALE USERS
(A)
MALE USERS
(B)
TOTAL USERS
(SUM COLS A + B)
(C)
TOTAL USERS
(SUM ROWS 1 TO 9)
Ð
Ð
Ð
CHECKPOINT
CHECKPOINT
CHECKPOINT
REFERENCE
REFERENCE
REFERENCE
AA
BB
CC
Title X Family Planning Annual Report
– 15 –
OMB No.:
Expires:
FPAR Number:
0990-0221
04/30/10
Date Submitted:
Reporting Period:
January 1, 200______ through December 31, 200______
__________________ through _____________________
(Month/day/year)
(Month/day/year)
Check One:
Initial Submission
Revision
See Notes
TABLE 2
UNDUPLICATED NUMBER OF FEMALE FAMILY PLANNING USERS BY ETHNICITY AND RACE
HISPANIC
OR LATINO
(A)
RACE
1
American Indian or Alaska Native
2
Asian
3
Black or African American
4
Native Hawaiian or other Pacific
Islander
5
White
6
More than one race
7
Unknown/not reported
8
NOT
HISPANIC
OR LATINO
(B)
UNKNOWN/
NOT
REPORTED
(C)
TOTAL
FEMALE USERS
(SUM COLS A + B + C)
(D)
TOTAL FEMALE USERS (SUM ROWS 1 TO 7)
Ð
SEE
CHECKPOINT
REFERENCE
AA
Title X Family Planning Annual Report
– 16 –
OMB No.:
Expires:
FPAR Number:
0990-0221
04/30/10
Date Submitted:
Reporting Period:
January 1, 200______ through December 31, 200______
__________________ through _____________________
(Month/day/year)
(Month/day/year)
Check One:
Initial Submission
Revision
See Notes
TABLE 3
UNDUPLICATED NUMBER OF MALE FAMILY PLANNING USERS BY ETHNICITY AND RACE
NOT
HISPANIC
OR LATINO
(A)
RACE
1
American Indian or Alaska Native
2
Asian
3
Black or African American
4
Native Hawaiian or other Pacific
Islander
5
White
6
More than one race
7
Unknown/not reported
8
HISPANIC
OR LATINO
(B)
UNKNOWN/
NOT
REPORTED
(C)
TOTAL
MALE
USERS
(SUM COLS A + B + C)
(D)
TOTAL MALE USERS (SUM ROWS 1 TO 7)
Ð
SEE
CHECKPOINT
REFERENCE
BB
Title X Family Planning Annual Report
– 17 –
OMB No.:
Expires:
Title X Family Planning Annual Report
– 18 –
0990-0221
04/30/10
OMB No.:
Expires:
0990-0221
04/30/10
FAMILY PLANNING USER ECONOMIC AND SOCIAL PROFILE
The data reported in Tables 4, 5, and 6 provide OPA with information on key social and economic
characteristics of individuals who receive family planning and related preventive health care in Title Xfunded clinics. OPA uses these data to monitor the program’s role as a social safety net health provider
for individuals who confront financial or sociocultural barriers to care due to low income, lack of health
insurance, or limited English proficiency (LEP). In addition, OPA uses these data to assess the program’s
compliance with legislative or regulatory mandates, including priority care to individuals who are lowincome, and ensuring meaningful access to clients with LEP. 12
INSTRUCTIONS
TABLE 4 –
Report the unduplicated number of family planning users by income level.
TABLE 5 –
Report the unduplicated number of family planning users by their principal health
insurance coverage status.
TABLE 6 –
Report the unduplicated number of family planning users with LEP.
TERMS AND DEFINITIONS
INCOME LEVEL AS A PERCENTAGE OF THE HHS POVERTY GUIDELINES – Grantees are required to collect
income data on all users at least annually. In determining user income, agencies should use the poverty
guidelines updated periodically in the Federal Register by HHS under the authority of 42 USC 9902(2). 13
Report the unduplicated number of users by income level, using the most current income information
available.
PRINCIPAL HEALTH INSURANCE COVERING PRIMARY MEDICAL CARE – Refers to public and private health
insurance plans that provide a broad set of primary medical care benefits to enrolled individuals.
Report the most current health insurance coverage information available for the client even though he or
she may not have used this health insurance to pay for family planning services received during his or her
last encounter. For individuals who have coverage under more than one health plan, principal insurance
is defined as the insurance plan that the agency would bill first (i.e., primary) if a claim were to be filed.
Categories of health insurance covering primary medical care include public and private sources of
coverage.
PUBLIC HEALTH INSURANCE COVERING PRIMARY MEDICAL CARE – Refers to federal, state, or local
government health insurance programs that provide a broad set of primary medical care benefits
for eligible individuals. Examples of such programs include Medicaid (both regular and managed
care), Medicare, state Children’s Health Insurance Programs (CHIPs), and health plans for military
personnel and their dependents (e.g., TRICARE or CHAMPVA).
12
See U.S. Department of Health and Human Services, Guidance to Federal Financial Assistance Recipients
Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient
Persons (“Revised HHS LEP Guidance”), August 8, 2003, Federal Register, 68(153), 47311-47323. Retrieved
November 18, 2003, from http://www.hhs.gov/ocr/lep/lep_guidance080403.pdf.
13
See U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and
Evaluation, Poverty Guidelines, Research, and Measurement. Retrieved November 18, 2003, from
http://aspe.hhs.gov/poverty/poverty.shtml.
Title X Family Planning Annual Report
– 19 –
OMB No.:
Expires:
0990-0221
04/30/10
PRIVATE HEALTH INSURANCE COVERING PRIMARY MEDICAL CARE – Refers to health insurance coverage
through an employer, union, or direct purchase that provides a broad set of primary medical care
benefits for the enrolled individual (beneficiary or dependent).
(OPTIONAL) PRIVATE HEALTH INSURANCE COVERAGE FOR FAMILY PLANNING SERVICES – Title X grantees
have the option of reporting additional information on the level of private health insurance coverage
for family planning services. Family planning services are defined broadly as any services – physical
exam, lab tests, counseling and education, contraceptive supplies, and/or prescription medication –
that a client receives during a family planning encounter with a clinical or non-clinical services
provider. Levels of family planning coverage are defined as follows:
PRIVATE INSURANCE/ALL OR SOME FAMILY PLANNING SERVICES COVERAGE – The user reports that
his or her private health insurance plan covers all or some family planning services.
PRIVATE INSURANCE/NO FAMILY PLANNING SERVICES COVERAGE – The user reports that his or her
private health insurance plan covers no family planning services.
PRIVATE INSURANCE/UNKNOWN FAMILY PLANNING SERVICES COVERAGE – The user reports that he or
she does not know about family planning service coverage under his or her private health
insurance plan.
UNINSURED – Refers to clients who do not have a public or private health insurance plan that covers
broad, primary medical care benefits. Clients whose services are subsidized through state or local
indigent care programs, or clients insured through the Indian Health Service who obtain care in a nonparticipating facility, are considered uninsured.
LIMITED ENGLISH PROFICIENCY (LEP) – Refers to clients whose native or dominant language is not English
and whose skills in listening to, speaking, reading, or writing English are such that they derive little
benefit from family planning and related preventive health services provided in English. 14 In Table 6,
report the unduplicated number of family planning users who required oral language assistance services to
optimize their use of Title X services. Include those users who received family planning and related
preventive health services from bilingual staff or who were assisted by a competent agency or contracted
interpreter. Also include users who opted to use a family member or friend as interpreter after refusing an
agency’s offer to provide a qualified interpreter at no cost to the user. Agencies should consult the
Revised HHS LEP Guidance, referenced in footnote 12, for further information about identifying LEP
individuals who need language assistance.
ENGLISH PROFICIENCY – Refers to an individual’s adeptness at English, as indicated by reading skills (the
ability to comprehend and interpret text); listening skills (the ability to understand verbal expressions of
the language); writing skills (the ability to produce written text with content and format); and speaking
skills (the ability to use oral language appropriately and effectively). 15
14
Adapted from the U.S. Department of Education, Survey of Classes that Serve Children Prior to Kindergarten in
Public Schools, p.1. Retrieved November 18, 2003, from http://nces.ed.gov/surveys/frss/publications/2003019/pdf/
questionnaire.pdf.
15
Adapted from the U.S. Department of Education National Center for Education Statistics (NCES) Nonfiscal Data
Handbook for Early Childhood, Elementary, and Secondary Education, p.10. Retrieved November 18, 2003, from
http://nces.ed.gov/pubs2003/2003419f.pdf.
Title X Family Planning Annual Report
– 20 –
OMB No.:
Expires:
0990-0221
04/30/10
NATIVE LANGUAGE – Refers to the language or dialect first learned by an individual or first used by the
parent/guardian with a child. The terms “native” and “primary” language are used interchangeably. 16
DOMINANT LANGUAGE – Refers to the language or dialect an individual best understands and with which he
or she is most comfortable. A person may be dominant in one language in some situations and dominant
in another language in other situations. 17
INTERPRETER COMPETENCE – Competency to interpret does not necessarily mean formal certification as an
interpreter, although certification is helpful. To be considered competent, interpreters must:
Demonstrate proficiency in and ability to communicate information accurately in both English and in
the other language, and identify and employ the appropriate mode of interpreting;
Have knowledge in both languages of any specialized family planning or reproductive health terms or
concepts, and of any particularized vocabulary and phraseology used in the LEP person’s country of
origin;
Understand and follow confidentiality and impartiality rules to the same extent as the recipient
employee for whom they are interpreting and/or to the extent their position requires; and
Understand and adhere to their role as interpreter without deviating into other roles—such as
counselor or legal advisor—where such deviation would be inappropriate. 18
QUESTIONS ABOUT TABLES 4 TO 6
1. QUESTION – How are these tables different from the previous FPAR?
ANSWER – The table on distribution of users by income level (Table 4) extends from 100% and
below the HHS poverty guidelines to more than 250% of the guidelines. The income range in the
previous FPAR extended to only 200% of the guidelines. Further, the revised FPAR includes two
additional tables on the health insurance coverage status and English language proficiency of
family planning users. Together, this set of tables provides information on the extent to which
individuals with financial and other social barriers to preventive health services, including family
planning, utilize Title X-funded services.
2. QUESTION –If a client has private health insurance that covers a broad set of primary medical care
benefits, including some or all family planning services, but he or she chooses not to use his or
her health insurance plan to pay for some or all of the cost of services, how should an agency
classify this client for purposes of Table 5 reporting?
ANSWER – Although an insured client may elect not to use his or her health insurance to pay for
services, he or she is considered insured and should be reported in either Row 1 or Row 2 of the
table according to type of health coverage (public or private).
16
See footnote 15.
17
See footnote 15.
18
Adapted from Revised HHS LEP Guidance, p.47316 (see footnote 12).
Title X Family Planning Annual Report
– 21 –
OMB No.:
Expires:
0990-0221
04/30/10
3. QUESTION – Are Title X agencies required to verify client health insurance status and, if insured,
the level of family planning service coverage under the health plan?
ANSWER – No. The information required to complete Table 5 is based on clients’ self-reported
insurance coverage. Other than asking clients and recording their response, the agency should
make no additional effort to verify coverage and levels of family planning service coverage
unless clients intend to use their health insurance to pay for services rendered.
4. QUESTION – How do I classify a client who has coverage for a specific type of care or health
condition – for example, dental services or expanded Medicaid coverage under the Breast and
Cervical Cancer Prevention and Treatment Act of 2000 – but has no health insurance that
provides a broad set of primary medical care benefits?
ANSWER – Users who do not have a health insurance plan that provides a broad set of primary
medical care benefits, even though they may have coverage for a specific condition, are
considered uninsured.
5. QUESTION – If a client has coverage for family planning services under a Medicaid family
planning expansion program (i.e., 1115 waiver demonstration project), is he or she considered
insured for purposes of FPAR reporting?
ANSWER – A client is insured if (1) he or she is enrolled in a Medicaid family planning expansion
program that covers a broad set of primary medical care benefits, in addition to family
planning, or (2) he or she is enrolled in a Medicaid expansion program that covers only family
planning services and he or she has coverage under another plan that covers a broad set of
primary medical care benefits.
A client is uninsured if he or she is enrolled in a Medicaid family planning expansion program
that covers only family planning services and he or she has no coverage under another plan that
covers a broad set of primary medical care benefits.
Title X grantees operating in states where the family planning expansion program is limited to
family planning services may check the “See Notes” box for Table 5 if they wish to provide
clarifying remarks.
6. QUESTION – In Table 6 should an agency report clients who received care from a bilingual
provider in their preferred, non-English language?
ANSWER – In Table 6 report the number of users who are best served in a language other than
English, including clients who received care from bilingual providers in their preferred, nonEnglish language; clients for whom competent agency or contracted interpreters were required;
and clients for whom friends or family members served as interpreters.
QUESTION – Is it permissible to allow friends, family, or minor children to serve as interpreters?
ANSWER – According to the August 2003 HHS guidance, “…when a recipient encounters an LEP
person attempting to access its services, the recipient should make the LEP person aware that he
or she has the option of having the recipient provide an interpreter for him or her without charge,
or of using his or her own interpreter. Although recipients should not plan to rely on an LEP
person’s family members, friends, or other informal interpreters to provide meaningful access to
important programs and activities, the recipient should, except as noted below, respect an LEP
person’s desire to use an interpreter of his or her own choosing (whether a professional
interpreter, family member, or friend) in place of the free language services expressly offered by
Title X Family Planning Annual Report
– 22 –
OMB No.:
Expires:
0990-0221
04/30/10
the recipient. However, a recipient may not require an LEP person to use a family member or
friend as an interpreter.” 19
Confidentiality, privacy, conflicts of interest, and competence as a medical services interpreter
are several limitations of using family members or friends as interpreters in the Title X clinic
setting. While in some cases an individual with LEP may feel more comfortable when a trusted
family member or friend acts as an interpreter, the family member or friend may not be
competent to provide quality and accurate interpretations, particularly if the service provided is
complex and/or not of a routine nature. If a client opts to provide his or her own interpreter, and
the service provider determines at any point during the service that the client’s interpreter is not
competent in this role, the service provider should obtain the services of a competent interpreter.
19
Revised HHS LEP Guidance, p.47317 (see footnote 12).
Title X Family Planning Annual Report
– 23 –
OMB No.:
Expires:
FPAR Number:
0990-0221
04/30/10
Date Submitted:
Reporting Period:
January 1, 200______ through December 31, 200______
__________________ through _____________________
(Month/day/year)
(Month/day/year)
Check One:
Initial Submission
Revision
See Notes
TABLE 4
UNDUPLICATED NUMBER OF FAMILY PLANNING USERS BY INCOME LEVEL
INCOME AS PERCENT OF THE HHS POVERTY GUIDELINES
1
100% and below
2
101%–150%
3
151%–200%
4
201%–250%
5
Over 250%
6
Unknown/not reported
7
NUMBER OF USERS
(A)
TOTAL USERS (SUM ROWS 1 TO 6)
Ð
SEE
CHECKPOINT
REFERENCE
CC
Title X Family Planning Annual Report
– 24 –
OMB No.:
Expires:
FPAR Number:
0990-0221
04/30/10
Date Submitted:
Reporting Period:
January 1, 200______ through December 31, 200______
__________________ through _____________________
(Month/day/year)
(Month/day/year)
Check One:
Initial Submission
Revision
See Notes
TABLE 5
UNDUPLICATED NUMBER OF FAMILY PLANNING USERS BY PRINCIPAL HEALTH INSURANCE COVERAGE STATUS
PRINCIPAL HEALTH INSURANCE COVERING PRIMARY MEDICAL CARE
1
Public health insurance covering primary medical care
2
Private health insurance covering primary medical care (SUM ROWS 2a TO 2c)
2a
(Optional) Coverage for all or some family planning services
2b
(Optional) Coverage for no family planning services
2c
(Optional) Coverage unknown for family planning services
3
Uninsured (no public or private health insurance)
4
Unknown/not reported
5
NUMBER OF
USERS
(A)
TOTAL USERS (SUM ROWS 1 TO 4)
Ð
SEE
CHECKPOINT
REFERENCE
CC
Title X Family Planning Annual Report
– 25 –
OMB No.:
Expires:
FPAR Number:
0990-0221
04/30/10
Date Submitted:
Reporting Period:
January 1, 200______ through December 31, 200______
__________________ through _____________________
(Month/day/year)
(Month/day/year)
Check One:
Initial Submission
Revision
See Notes
TABLE 6
UNDUPLICATED NUMBER OF FAMILY PLANNING USERS WITH LIMITED ENGLISH PROFICIENCY (LEP)
NUMBER OF
USERS
(A)
1
Number of users with limited English proficiency (LEP)
Title X Family Planning Annual Report
– 26 –
OMB No.:
Expires:
0990-0221
04/30/10
FAMILY PLANNING METHOD USE
Title X projects are required to provide a broad range of acceptable and effective family planning
methods and services. 20 Tables 7 and 8 provide gender- and age-specific information on the types of
family planning methods that clients use to prevent unintended pregnancy. The method, age, and gender
data allow OPA to compare the data from Title X clinics with other sources of information, including the
National Survey of Family Growth. These data also permit OPA to track patterns in method use over time
at the state, regional, and national levels; to examine the extent to which Title X providers contribute to
increased access to and use of newer family planning technologies; and to assess the program’s
contribution to Healthy People 2010 objectives.
INSTRUCTIONS
TABLE 7 –
Report the unduplicated number of female family planning users by primary method
and age.
TABLE 8 –
Report the unduplicated number of male family planning users by primary method
and age.
TERMS AND DEFINITIONS
AGE – Use the client’s age as of June 30th of the reporting period.
PRIMARY METHOD OF FAMILY PLANNING – The primary method of family planning is the user’s method—
adopted or continued—at the time of exit from his or her last encounter in the reporting period. If the user
reports that he or she is using more than one family planning method, report the most effective one as the
primary method. Family planning methods include:
FEMALE STERILIZATION – Refers to surgical (tubal ligation) or non-surgical (Essure™ implants)
sterilization procedures performed on a female user in the current or any previous reporting period. In
Table 7, report the number of female users who rely on female sterilization as their primary family
planning method.
INTRAUTERINE DEVICE (IUD) – In Table 7, report the number of female users who use a long-term
hormonal or other type of intrauterine device (IUD) or system as their primary family planning
method.
HORMONAL IMPLANT – In Table 7, report the number of female users who use a long-term, subdermal
hormonal implant as their primary family planning method.
1- MONTH HORMONAL INJECTION – In Table 7, report the number of female users who use 1-month
injectable hormonal contraception as their primary family planning method.
3- MONTH HORMONAL INJECTION – In Table 7, report the number of female users who use 3-month
injectable hormonal contraception as their primary family planning method.
20
See 42 CFR Part 59.5(a)(1) (see footnote 4).
Title X Family Planning Annual Report
– 27 –
OMB No.:
Expires:
0990-0221
04/30/10
ORAL CONTRACEPTIVE – In Table 7, report the number of female users who use any oral contraceptive,
including combination and progestin-only (“mini-pills”) formulations, as their primary family
planning method.
HORMONAL/CONTRACEPTIVE PATCH – In Table 7, report the number of female users who use a
transdermal hormonal contraceptive patch as their primary family planning method.
VAGINAL RING – In Table 7, report the number of female users who use a hormonal vaginal ring as
their primary family planning method.
CERVICAL CAP/DIAPHRAGM – In Table 7, report the number of female users who use a cervical cap or
diaphragm (with or without spermicidal jelly or cream) as their primary family planning method.
CONTRACEPTIVE SPONGE – In Table 7, report the number of female users who use a contraceptive
sponge as their primary family planning method.
FEMALE CONDOM – In Table 7, report the number of female users who use female condoms (with or
without spermicidal foam or film) as their primary family planning method.
SPERMICIDE (USED ALONE) – In Table 7, report the number of female users who use only spermicidal
jelly, cream, foam, or film (i.e., not in conjunction with another method of contraception) as their
primary family planning method.
FERTILITY AWARENESS METHOD (FAM) – Refers to family planning methods that rely on identifying
potentially fertile days in each menstrual cycle when intercourse is most likely to result in a
pregnancy. Fertility awareness methods include rhythm/calendar, Standard Days™, Basal Body
Temperature, Cervical Mucus, and Sympto-Thermal methods. In Tables 7 and 8, report the number of
users who use one or a combination of the FAMs listed above as their primary family planning
method. Post-partum women who are practicing the lactational amenorrhea method (LAM) should
also be reported with users of fertility awareness methods in Tables 7 and 8.
ABSTINENCE – For purposes of FPAR reporting, abstinence is defined as refraining from oral, vaginal,
and anal intercourse. In Table 7, report the number of female users who rely on abstinence as their
primary family planning method or who are not currently sexually active and therefore not using
contraception. In Table 8, report the number of male users who rely on abstinence as their primary
family planning method or who are not currently sexually active.
OTHER METHOD – In Tables 7 and 8, report the number of female and male users, respectively, who
use withdrawal or other methods not listed in the tables as their primary family planning method.
METHOD UNKNOWN – In Tables 7 and 8, report the number of users for whom documentation exists
that the users adopted or continued use of a family planning method, but information about the
specific method(s) used is unavailable.
NO METHOD–[PARTNER] PREGNANT OR SEEKING PREGNANCY – In Tables 7 and 8, report the number of
users who are not using any family planning method because they (Table 7) or their partners (Table 8)
are pregnant or seeking pregnancy.
NO METHOD–OTHER REASON – In Tables 7 and 8, report the number of users who are not using any
family planning method to avoid pregnancy due to reasons other than pregnancy or seeking
pregnancy, including if either partner is sterile without having been sterilized surgically.
VASECTOMY – Refers to conventional incisional or no-scalpel vasectomy performed on a male user, or
the male partner of a female user, in the current or any previous reporting period. In Table 7, report
the number of female users who rely on vasectomy as their (partner’s) primary family planning
method. In Table 8, report the number of male users on whom a vasectomy was performed in the
current or any previous reporting period.
Title X Family Planning Annual Report
– 28 –
OMB No.:
Expires:
0990-0221
04/30/10
MALE CONDOM – In Table 7, report the number of female users who rely on their sexual partner to use
male condoms (with or without spermicidal foam or film) as their primary family planning method. In
Table 8, report the number of male users who use male condoms (with or without spermicidal foam
or film) as their primary family planning method.
RELY ON FEMALE METHOD(S) – In Table 8, report the number of male family planning users who rely
on their female partner’s family planning method(s) as their primary method. “Female” contraceptive
methods include female sterilization, IUDs, hormonal implants, 1- and 3-month hormonal injections,
oral contraceptives, hormonal/contraceptive patches, vaginal rings, cervical caps/diaphragms,
contraceptive sponges, female condoms, and spermicides.
QUESTIONS ABOUT TABLES 7 AND 8
1. QUESTION – How are these tables different from the previous FPAR?
ANSWER – Changes to the collection of primary family planning method data in the FPAR include
the addition of a new table (Table 8) for reporting primary family planning method use among
male users, the addition of new, FDA-approved family planning methods to the list for female
users (Table 7), and collection of data on primary method use by age group.
2. QUESTION – If family planning users, male or female, rely on their partners’ family planning method
for pregnancy prevention, how should the grantee report this information in Tables 7 or 8?
ANSWER – If a female family planning user relies on a “male” family planning method (e.g.,
vasectomy or male condoms) for pregnancy prevention, report this user on Row 19 or 20 of Table 7,
respectively. If the female user relies on withdrawal, report this user on Row 15 of Table 7 (other
method).
If a male client relies on a “female” family planning method for pregnancy prevention, report this
client on Row 9 of Table 8 if his partner’s method is female sterilization, IUD, hormonal implant, 1or 3-month hormonal injection, oral contraceptives, hormonal/contraceptive patch, vaginal ring,
cervical cap or diaphragm, contraceptive sponge, female condoms, or spermicide.
If a male client and his female sexual partner rely on pills (for pregnancy prevention) and condoms
(for STD or pregnancy prevention), record the method that is most effective in terms of pregnancy
prevention (i.e., pills). In this example, the male user’s family planning method would be “rely on
female method” (Table 8, Row 9).
If this same male client were to report that he relies on condoms for pregnancy prevention because of
his partner’s inconsistent pill use, report male condoms (Table 8, Row 2) as the client’s primary
contraceptive method.
Title X Family Planning Annual Report
– 29 –
OMB No.:
Expires:
FPAR Number:
0990-0221
04/30/10
Date Submitted:
Reporting Period:
January 1, 200______ through December 31, 200______
__________________ through _____________________
(Month/day/year)
(Month/day/year)
Check One:
Initial Submission
Revision
See Notes
TABLE 7
UNDUPLICATED NUMBER OF FEMALE FAMILY PLANNING USERS BY PRIMARY METHOD AND AGE
UNDUPLICATED NUMBER OF FEMALE USERS BY AGE
< 15
(A)
PRIMARY METHOD
1
Female sterilization
2
Intrauterine device (IUD)
3
Hormonal implant
4
1-Month hormonal injection
5
3-Month hormonal injection
6
Oral contraceptive
7
Hormonal/contraceptive patch
8
Vaginal ring
9
Cervical cap/diaphragm
10
Contraceptive sponge
11
Female condom
12
Spermicide (used alone)
13
Fertility awareness method (FAM)
14
Abstinence
15
Other method
16
Method unknown
15–17
(B)
18–19
(C)
20–24
(D)
25–29
(E)
30–34
(F)
35–39
(G )
40–44
(H)
> 44
(I )
TOTAL FEMALE
USERS
(SUM COLS A TO I)
(J)
NO METHOD
17
Pregnant or seeking pregnancy
18
Other reason
RELY ON MALE METHOD
19
Vasectomy
20
Male condom
21
TOTAL FEMALE USERS
(SUM ROWS 1 TO 20)
Ð
SEE CHECKPOINT
REFERENCE
AA
Title X Family Planning Annual Report
– 30 –
OMB No.:
Expires:
FPAR Number:
0990-0221
04/30/10
Date Submitted:
Reporting Period:
January 1, 200______ through December 31, 200______
__________________ through _____________________
(Month/day/year)
(Month/day/year)
Check One:
Initial Submission
Revision
See Notes
TABLE 8
UNDUPLICATED NUMBER OF MALE FAMILY PLANNING USERS BY PRIMARY METHOD AND AGE
UNDUPLICATED NUMBER OF MALE USERS BY AGE
< 15
(A)
PRIMARY METHOD
1
Vasectomy
2
Male condom
3
Fertility awareness method (FAM)
4
Abstinence
5
Other method
6
Method unknown
15–17
(B)
18–19
(C)
20–24
(D)
25–29
(E)
30–34
(F)
35–39
(G )
40–44
(H)
> 44
(I )
TOTAL MALE
USERS
(SUM COLS A TO I)
(J)
NO METHOD
7
Partner pregnant or seeking
pregnancy
8
Other reason
9
RELY ON FEMALE METHOD(S)
10
TOTAL MALE USERS
(SUM ROWS 1 TO 9)
Ð
SEE
CHECKPOINT
REFERENCE
BB
Title X Family Planning Annual Report
– 31 –
OMB No.:
Expires:
Title X Family Planning Annual Report
– 32 –
0990-0221
04/30/10
OMB No.:
Expires:
0990-0221
04/30/10
CERVICAL AND BREAST CANCER SCREENING
Tables 9 and 10 provide information on the cervical and breast cancer screening activities that are
performed in Title X-funded clinics. Data from these tables permit OPA to monitor compliance with
legislative mandates, measure achievement of program performance objectives, and assess the program’s
contribution to national health objectives (i.e., Healthy People 2010) related to early cancer detection and
health promotion. Data from these tables are also used to monitor the number of abnormal results that
require further follow-up by Title X providers.
INSTRUCTIONS
TABLE 9 –
Report the following information on cervical cancer screening activities. Refer to the
chart in Exhibit 1 for reporting information on Pap test results.
Unduplicated number of users who obtained a Pap test.
Number of Pap tests performed.
Number of Pap tests with an ASC or higher result, including ASC-US, ASC-H,
LSIL, HSIL, AGC, adenocarcinoma, and presence of endometrial cells in a woman
≥ 40 years of age (see Exhibit 1).
Number of Pap tests with an HSIL or higher result (i.e., HSIL, AGC,
adenocarcinoma, and presence of endometrial cells in a woman ≥ 40 years of age)
(see Exhibit 1).
TABLE 10 – Report the following information on breast health screening and referral activities.
Unduplicated number of users receiving a clinical breast exam (CBE).
Unduplicated number of users referred for further evaluation based on CBE results.
TERMS AND DEFINITIONS
TESTS – Report Pap tests and CBEs that are documented in the client medical record and provided within
the scope of the agency’s Title X project during the reporting period.
ATYPICAL SQUAMOUS CELLS (ASC) – ASC refers to cytological changes that are suggestive of a squamous
intraepithelial lesion. The 2001 Bethesda System (see Exhibit 1) subdivides atypical squamous cells into
two categories: 21
Atypical squamous cells of undetermined significance (ASC-US) – Cytological changes that are
suggestive of a squamous intraepithelial lesion, but lack criteria for a definitive interpretation.
Atypical squamous cells, cannot exclude HSIL (ASC-H) – Cytological changes that are suggestive
of a high-grade squamous intraepithelial lesion, but lack criteria for a definitive interpretation.
21
T.C. Wright, Jr., J.T. Cox, L.S. Massad, L.B. Twiggs, E.J. Wilkinson, “2001 Consensus Guidelines for the
Management of Women with Cervical Cytological Abnormalities,” Journal of the American Medical Association
Vol. 287, No. 16 (2002): 2122.
Title X Family Planning Annual Report
– 33 –
OMB No.:
Expires:
0990-0221
04/30/10
LOW-GRADE SQUAMOUS INTRAEPITHELIAL LESIONS (LSIL) – LSIL refers to low-grade squamous
intraepithelial lesions encompassing human papillomavirus, mild dysplasia, and cervical intraepithelial
neoplasia (CIN) 1 (see Exhibit 1). 22
HIGH-GRADE SQUAMOUS INTRAEPITHELIAL LESIONS (HSIL) – HSIL refers to high-grade squamous
intraepithelial lesions encompassing moderate and severe dysplasia, carcinoma in situ, CIN 2, and CIN 3
(see Exhibit 1). 23
ATYPICAL GLANDULAR CELLS (AGC) – AGC refers to glandular cell abnormalities, including
adenocarcinoma. The 2001 Bethesda System (see Exhibit 1) classifies AGC less severe than
adenocarcinoma into three categories. 24
Atypical glandular cells, either endocervical, endometrial, or “glandular cells” not otherwise
specified (AGC NOS).
Atypical glandular cells, either endocervical or “glandular cells” favor neoplasia (AGC “favor
neoplasia”).
Endocervical adenocarcinoma in situ (AIS).
QUESTIONS ABOUT TABLES 9 AND 10
1. QUESTION – Are there any changes to these tables?
ANSWER – Yes. OPA is requesting additional information about the utilization and outcome of
cervical and breast cancer screening activities that are performed within the scope of the agency’s
Title X project. This additional information includes information on the unduplicated number of
female users that obtain a Pap test, the number of Pap tests with an ASC or higher result, the
number of Pap tests with an HSIL or higher result, and the unduplicated number of clients who
are referred for further evaluation based on their CBE. Pap test result reporting is based on the
2001 Bethesda System that is summarized in Exhibit 1.
2. QUESTION – What if the CBE appears on the clinic encounter form or “super bill” as part of a
“bundled” billing or service code (e.g., as part of a comprehensive exam)?
ANSWER – If an agency does not have a separate count of the number of CBEs performed due to
the structure of the “bundled” billing/service code, report the estimated number of CBEs
performed in Row 1 of Table 10, mark the “See Notes” box in the header of the table, and
provide a brief explanation about the reported figure.
3. QUESTION – In Table 9, does the total number of Pap tests reported in Row 3 include tests
reported in Row 4?
ANSWER – Yes. In Table 9, Row 3 will include the tests reported in Row 4 because tests with a
result of HSIL and higher are also tests with a result of ASC and higher.
22
D. Solomon, D. Davey, R. Kurman, A. Moriarty, D. O’Connor, M. Prey, S. Raab, M. Sherman, D. Wilbur, T.
Wright, Jr., and N. Young, “The 2001 Bethesda System: Terminology for Reporting Results of Cervical Cytology,”
Journal of the American Medical Association Vol. 287, No. 16 (2002): 2116.
23
See footnote 22.
24
Wright et al., p. 2124 (see footnote 21).
Title X Family Planning Annual Report
– 34 –
OMB No.:
Expires:
0990-0221
04/30/10
4. QUESTION – How should a grantee complete Table 9 if it does not receive the results of Pap tests
performed at the end of the reporting period in time to be included in the FPAR?
ANSWER – Agencies have two options for dealing with delayed Pap test results. Under the first
option, the agency can report the Pap testing (Table 9, Rows 1 and 2) and results (Table 9, Rows
3 and 4) figures that are available at the time it prepares the FPAR. If results data for Pap tests
performed at the end of the reporting period are delayed, check the “See Notes” box, and explain
that the figures reported in Rows 3 and 4 are estimated rather than actual due to delayed
laboratory reporting.
Under the second option, the agency can report testing and results data for a 12-month period that
has complete results data and is close in time to the reporting period. For example, if Pap testing
and results data are complete for the 12-month period from December to November, but not for
January to December, report the figures for December to November, check the “See Notes” box,
and explain that Table 9 data are for a different 12-month period than the reporting period.
Consult your RPC if you have any questions about reporting Table 9 data when Pap testing
results are delayed.
Title X Family Planning Annual Report
– 35 –
OMB No.:
Expires:
0990-0221
04/30/10
EXHIBIT 1. THE 2001 BETHESDA SYSTEM (Abridged)
SPECIMEN ADEQUACY
Satisfactory for evaluation (note presence/absence of endocervical/
transformation zone component)
Unsatisfactory for evaluation … (specify reason)
Specimen rejected/not processed (specify reason)
Specimen processed and examined, but unsatisfactory for evaluation of
epithelial abnormality because of (specify reason)
GENERAL CATEGORIZATION (Optional)
Negative for intraepithelial lesion or malignancy
Epithelial cell abnormality
Other
INTERPRETATION/RESULT
Negative for Intraepithelial Lesion or Malignancy
Organisms
Trichomonas vaginalis
Fungal organisms morphologically consistent with Candida species
Shift in flora suggestive of bacteria vaginosis
Bacteria morphologically consistent with Actinomyces species
Cellular changes consistent with herpes simplex virus
Other non-neoplastic findings (Optional to report; list not comprehensive)
Reactive cellular changes associated with
inflammation (includes typical repair)
radiation
intrauterine contraceptive device
Glandular cells status posthysterectomy
Atrophy
Epithelial Cell Abnormalities
Squamous cell
Atypical squamous cells (ASC)
of undetermined significance (ASC-US)
cannot exclude HSIL (ASC-H)
Low-grade squamous intraepithelial lesion (LSIL)
encompassing: human papillomavirus/mild dysplasia/cervical
intraepithelial neoplasia (CIN) 1
High-grade squamous intraepithelial lesion (HSIL)
encompassing: moderate and severe dysplasia, carcinoma in situ;
CIN 2 and CIN 3
Squamous cell carcinoma
Glandular cell
Atypical glandular cells (AGC) (specify endocervical, endometrial, or not
otherwise specified)
Atypical glandular cells, favor neoplastic (specify endocervical
or not otherwise specified)
Endocervical adenocarcinoma in situ (AIS)
Adenocarcinoma
Report in
Table 9
Row 3
Report in
Table 9
Row 4
Other (List not comprehensive)
Endometrial cells in a woman ≥ 40 years of age
AUTOMATED REVIEW and ANCILLARY TESTING (Include as appropriate)
EDUCATIONAL NOTES and SUGGESTIONS (Optional)
Note: From “The 2001 Bethesda System: Terminology for Reporting Results of Cervical Cytology,” by D. Solomon, D. Davey,
R. Kurman, A. Moriarty, D. O’Connor, M. Prey, S. Raab, M. Sherman, D. Wilbur, T. Wright, Jr., and N. Young, 2002, Journal
of the American Medical Association Vol. 287, No. 16 (2002): 2116. Copyright © (2002), American Medical Association. All
rights reserved. Reprinted with permission.
Title X Family Planning Annual Report
– 36 –
OMB No.:
Expires:
FPAR Number:
0990-0221
04/30/10
Date Submitted:
Reporting Period:
January 1, 200______ through December 31, 200______
__________________ through _____________________
(Month/day/year)
(Month/day/year)
Check One:
Initial Submission
Revision
See Notes
TABLE 9
CERVICAL CANCER SCREENING ACTIVITIES
SCREENING ACTIVITY
1
Unduplicated number of users who obtained a Pap test
2
Number of Pap tests performed
3
Number of Pap tests with an ASC or higher result
4
Number of Pap tests with an HSIL or higher result
Title X Family Planning Annual Report
– 37 –
NUMBER OF USERS OR
NUMBER OF TESTS
(A)
OMB No.:
Expires:
FPAR Number:
0990-0221
04/30/10
Date Submitted:
Reporting Period:
January 1, 200______ through December 31, 200______
__________________ through _____________________
(Month/day/year)
(Month/day/year)
Check One:
Initial Submission
Revision
See Notes
TABLE 10
CLINICAL BREAST EXAMS AND REFERRALS
SCREENING ACTIVITY
1
Unduplicated number of users who received a clinical breast exam (CBE)
2
Unduplicated number of users referred for further evaluation based on their CBE
Title X Family Planning Annual Report
– 38 –
NUMBER OF
USERS
(A)
OMB No.:
Expires:
0990-0221
04/30/10
SEXUALLY TRANSMITTED DISEASE (STD) SCREENING
Tables 11 and 12 provide information on the utilization of STD testing services provided in Title X
clinics. Data from these tables permit OPA to monitor compliance with legislative mandates, measure
achievement of program performance objectives, and assess the program’s contribution to national health
objectives for disease prevention (e.g., STDs and HIV) and health promotion.
INSTRUCTIONS
TABLE 11 – Report the unduplicated number of family planning users tested for chlamydia by age
group (< 15, 15-17, 18-19, 20-24, and 25 and over) and gender.
TABLE 12 – Report the number of gonorrhea, syphilis, and HIV tests performed by gender.
Report the number of positive, confidential HIV tests and the number of anonymous
HIV tests performed.
TERMS AND DEFINITIONS
AGE – Use the client’s age as of June 30th of the reporting period.
TESTS – Report STD (chlamydia, gonorrhea, and syphilis) and HIV (confidential and anonymous) tests that an
agency performs within the scope of its Title X project. Do not report tests performed in an STD clinic
operated by the Title X-funded agency, unless the activities of the STD clinic are within the defined scope of
the agency’s Title X project.
QUESTIONS ABOUT TABLES 11 AND 12
1. QUESTION – Are there any changes to these tables?
ANSWER – The revised FPAR requires that agencies report additional information about STD and
HIV tests performed within the scope of their Title X projects, including gender- and age-specific
information on users tested for chlamydia; gender-specific information on the number of
gonorrhea, syphilis, and confidential HIV tests performed; information on the total number of
confidential HIV tests that are positive; and information on the number of anonymous HIV tests
performed. The revised FPAR table excludes STD test information for herpes simplex virus
(HSV), hepatitis B virus (HBV), and trichomoniasis.
2. QUESTION – How should an agency complete Table 12 if the results for HIV tests performed at the
end of the reporting period are not received in time to be included in the FPAR?
ANSWER – An agency has two options for dealing with delayed HIV test results. Under the first
option, the agency can report the HIV testing (Table 12, Row 3) and results (Table 12, Row 4)
figures that are available at the time it prepares the FPAR. If results data for HIV tests performed
at the end of the reporting period are delayed, check the “See Notes” box, and explain that the
figure reported in Row 4 is estimated rather than actual due to delayed laboratory reporting.
Under the second option, the agency can report testing and results data for a 12-month period that
has complete results data and is close in time to the reporting period. For example, if HIV testing
and results data are complete for the period December to November, but not for January to
December, report the figures for December to November, check the “See Notes” box, and explain
that Table 12 data are for a different 12-month period than the reporting period. Consult your
Title X Family Planning Annual Report
– 39 –
OMB No.:
Expires:
0990-0221
04/30/10
RPC if you have any questions about reporting Table 12 data when HIV testing results are
delayed.
3. QUESTION – In Table 12 should an agency count and report confirmatory HIV tests separately from
the initial HIV test (i.e., one versus two tests)?
ANSWER – To the extent possible, an agency should report all HIV tests – initial and confirmatory –
performed within the scope of its Title X project, including HIV tests performed onsite and tests for
which a specimen is collected onsite and analyzed offsite (e.g., laboratory). If an offsite laboratory
performs a confirmatory test using the same specimen obtained for the initial test, the agency should
not count the confirmatory test unless (1) it has billing or other transaction records to document that
the laboratory performed a second/confirmatory test and (2) compiling and reporting confirmatory test
counts do not pose an undue burden. Agencies should check the “See Notes” box and explain if HIV
test counts include or exclude confirmatory tests.
Title X Family Planning Annual Report
– 40 –
OMB No.:
Expires:
FPAR Number:
0990-0221
04/30/10
Date Submitted:
Reporting Period:
January 1, 200______ through December 31, 200______
__________________ through _____________________
(Month/day/year)
(Month/day/year)
Check One:
Initial Submission
Revision
See Notes
TABLE 11
UNDUPLICATED NUMBER OF FAMILY PLANNING USERS TESTED FOR CHLAMYDIA BY AGE AND GENDER
NUMBER OF USERS
AGE GROUP
(YEARS)
1
Under 15
2
15–17
3
18–19
4
20–24
5
25 and over
6
FEMALE USERS
(A)
TOTAL USERS
(SUM ROWS 1 TO 5)
Title X Family Planning Annual Report
– 41 –
MALE USERS
(B)
OMB No.:
Expires:
FPAR Number:
0990-0221
04/30/10
Date Submitted:
Reporting Period:
January 1, 200______ through December 31, 200______
__________________ through _____________________
(Month/day/year)
(Month/day/year)
Check One:
Initial Submission
Revision
See Notes
TABLE 12
NUMBER OF GONORRHEA, SYPHILIS, AND HIV TESTS
NUMBER OF TESTS
FEMALE
(A)
TEST TYPE
1
Gonorrhea
2
Syphilis
3
HIV – All confidential tests
4
HIV – Positive confidential tests
5
HIV – Anonymous tests
MALE
(B)
Title X Family Planning Annual Report
– 42 –
TOTAL TESTS
(SUM COLS A + B)
(C)
OMB No.:
Expires:
0990-0221
04/30/10
FAMILY PLANNING ENCOUNTERS AND UTILIZATION OF
CLINICAL SERVICES PROVIDERS
Table 13 provides information on the number and type of family planning encounters, as well as the
utilization of clinical services providers in the delivery of Title X-funded family planning and related
preventive health services.
INSTRUCTIONS
TABLE 13 – Report the following provider utilization and encounter data:
Number of full-time equivalent (FTE) family planning clinical services providers
by type of provider (Column A).
Number of family planning encounters with clinical services providers (Column
B, Row 1).
Number of family planning encounters with non-clinical services providers
(Column B, Row 2).
TERMS AND DEFINITIONS
FAMILY PLANNING PROVIDER – A family planning provider is the individual who assumes primary
responsibility for assessing a client and documenting services in the client record. Providers include those
agency staff that exercise independent judgment as to the services rendered to the client during an
encounter. Two general types of providers deliver Title X family planning services: clinical services
providers and non-clinical services providers.
CLINICAL SERVICES PROVIDER – Includes physicians (family and general practitioners, specialists),
physician assistants, nurse practitioners, certified nurse midwives, and other licensed health providers
(e.g., registered nurses) who are trained and permitted by state-specific regulations to perform all
aspects of the user (male and female) physical assessment, as described in Section 8.3 of the Program
Guidelines. 25 Clinical services providers are able to offer client education, 26 counseling, 27 referral, 28
follow-up,28 and/or clinical services (physical assessment, treatment, and management) relating to a
client’s proposed or adopted method of contraception, general reproductive health, or infertility
treatment.
NON-CLINICAL SERVICES PROVIDER – Includes other agency staff (e.g., nurses, health educators, social
workers, or clinic aides) that are able to offer client education,26 counseling,27 referral,28 and/or
follow-up28 services relating to the client’s proposed or adopted method of contraception, general
reproductive health, or infertility treatment. Non-clinical services providers may also perform or
obtain samples for routine laboratory tests (e.g., urine, pregnancy, STD, and cholesterol and lipid
analysis),25 give contraceptive injections (e.g., Depo Provera), and perform routine clinical procedures
25
Refer to “8.3 History, Physical Assessment, and Laboratory Testing” in Program Guidelines, pp. 21-23 (see
footnote 5).
26
Refer to “8.1 Client Education” in Program Guidelines, pp. 17-18 (see footnote 5).
27
Refer to “8.2 Counseling” in Program Guidelines, pp. 18-19 (see footnote 5).
28
Refer to “7.4 Referrals and Follow-up” in Program Guidelines, p. 16 (see footnote 5).
Title X Family Planning Annual Report
– 43 –
OMB No.:
Expires:
0990-0221
04/30/10
that may include some aspects of the user physical assessment (e.g., blood pressure evaluation), as
described in Section 8.3 of the Program Guidelines.25
FAMILY PLANNING ENCOUNTER – A family planning encounter is a documented, face-to-face contact
between an individual and a family planning provider that takes place in a Title X service site. The
purpose of a family planning encounter—whether clinical or non-clinical—is to provide family planning
and related preventive health services to female and male clients who want to avoid unintended
pregnancies or achieve intended pregnancies. To be counted for purposes of the FPAR, a written record of
the service(s) provided during the family planning encounter must be documented in the client record.
There are two types of family planning encounters at Title X service sites: (1) family planning encounters
with a clinical services provider and (2) family planning encounters with a non-clinical services provider.
The type of family planning provider who renders the care, regardless of the services rendered,
determines the type of family planning encounter.
FAMILY PLANNING ENCOUNTER WITH A CLINICAL SERVICES PROVIDER – A face-to-face, documented
encounter between a family planning client and a clinical services provider that takes place in a
Title X service site.
FAMILY PLANNING ENCOUNTER WITH A NON-CLINICAL SERVICES PROVIDER – A face-to-face, documented
encounter between a family planning client and a non-clinical services provider that takes place in a
Title X service site.
Laboratory tests and related counseling and education, in and of themselves, do not constitute a
family planning encounter unless there is face-to-face contact between the client and provider, the
provider documents the encounter in the client’s record, and the test(s) is/are accompanied by family
planning counseling or education.
FULL-TIME EQUIVALENT (FTE) – For each type of clinical services provider, report the time in FTEs that
these providers are involved in the direct provision of Title X services (i.e., engaged in a family planning
encounter).
QUESTIONS ABOUT TABLE 13
1. QUESTION – How is this table different from the previous FPAR?
ANSWER – The revised table includes data for family planning encounters with both clinical and
non-clinical services providers, and has expanded the types of clinical services providers to
include other licensed health providers (e.g., registered nurses) who are trained and permitted by
state-specific regulations to perform all aspects of the user (male and female) physical
assessment, as described in Section 8.3 of the Program Guidelines. Further, agencies will no
longer be required to report the number of encounters by type of clinical services provider.
Instead, agencies will report the total number of family planning encounters with clinical services
providers and the total number of family planning encounters with non-clinical services
providers.
2. QUESTION – Can a client have more than one family planning encounter during a single family
planning visit?
ANSWER – As noted in the “Terms and Definitions” section of the report, a client may have only
one family planning encounter per visit. In the family planning services setting, the term
“encounter” is synonymous with “visit.” Although a client may meet with both clinical and nonclinical family planning providers during an encounter, only one provider is credited with the
encounter. The provider with the highest level of training who takes ultimate responsibility for
Title X Family Planning Annual Report
– 44 –
OMB No.:
Expires:
0990-0221
04/30/10
the client’s clinical or non-clinical assessment and care during the visit is credited with the
encounter.
3. QUESTION – If an individual receives gynecological or related preventive health services (e.g.,
pelvic exam, Pap test, pregnancy test, STD screening) in a Title X-funded clinic, but does not
receive services aimed at avoiding unintended pregnancy or achieving intended pregnancy (e.g.,
contraceptive or fertility counseling), is the encounter considered a family planning encounter?
ANSWER – If a client is an ongoing family planning user who visits the clinic to obtain any type of
family planning or related preventive health services, the encounter is considered a family
planning encounter.
If a client has been sterilized, but continues to seek gynecological or related preventive health
services, the encounter is considered a family planning encounter and the agency may continue to
count the client as a family planning user.
If a client obtains gynecological or related preventive health services, but the client is neither an
ongoing family planning user nor seeks or receives services (clinical, counseling, educational,
and/or referral) to help avoid unintended pregnancy or achieve intended pregnancy, the encounter
is not a family planning encounter and the client is not a family planning user.
If a post-menopausal client obtains gynecological or related preventive health services, the
encounter is not a family planning encounter and the client is not a family planning user.
Title X Family Planning Annual Report
– 45 –
OMB No.:
Expires:
FPAR Number:
0990-0221
04/30/10
Date Submitted:
Reporting Period:
January 1, 200______ through December 31, 200______
__________________ through _____________________
(Month/day/year)
(Month/day/year)
Check One:
Initial Submission
Revision
See Notes
TABLE 13
NUMBER OF FAMILY PLANNING ENCOUNTERS BY TYPE OF PROVIDER
NUMBER OF
FTES
(A)
PROVIDER TYPE
1
CLINICAL SERVICES PROVIDERS
1a
Physicians
1b
Physician assistants/nurse practitioners/
certified nurse midwives
1c
Other clinical services providers (e.g.,
registered nurses)
2
3
NON-CLINICAL SERVICES PROVIDERS
TOTAL FAMILY PLANNING ENCOUNTERS (SUM ROWS 1 + 2)
Title X Family Planning Annual Report
– 46 –
NUMBER OF
FAMILY PLANNING
ENCOUNTERS
(B)
OMB No.:
Expires:
0990-0221
04/30/10
REVENUE REPORT
Title X grantees are required to maintain a financial management system that meets the standards for
grant administration, and to document and keep records of all income and expenditures. 29 Table 14
identifies the source and amount of funds received during the reporting period that support activities
within the scope of the grantee’s Title X family planning services grant.
INSTRUCTIONS
TABLE 14 – Report the revenues (i.e., actual cash receipts) received during the reporting period, by
funding source, even if the funds were not expended during the reporting period. Include
(1) all receipts from federal grants; (2) collections from patients and third parties for
services rendered; and (3) receipts from other sources such as state and local funds. If the
value for a cell is zero, enter “0.” The agency must retain for audit purposes all
worksheets that document how the agency derived the reported amounts. 30
TERMS AND DEFINITIONS
FEDERAL GRANTS (Rows 1–5) – Refers to funds the grantee received directly from the federal
government. Do not include federal funds that were first received by a state government, local
government, or other agency and then passed on to the grantee.
TITLE X GRANT (Row 1) – Enter the amount received during the reporting period from the Title X
grant. Do not enter the amount of grant funds awarded unless this figure is the same as the actual cash
receipts.
BUREAU OF PRIMARY HEALTH CARE (BPHC) (Row 2) – Specify the amount of revenue received from
BPHC grants (e.g., Section 330) during the reporting period that supported services within the scope
of the grantee’s Title X project.
OTHER FEDERAL GRANT (Rows 3–4) – Specify the amount and source of any other federal grant
revenue received during the reporting period that supported services within the scope of the grantee’s
Title X project.
PAYMENT FOR SERVICES (Rows 6–9) – Refers to revenues from public and private third parties (capitated
or fee-for-service) and funds collected directly from clients.
TOTAL CLIENT COLLECTIONS/SELF-PAY (Row 6) – Report the amount collected directly from clients
during the reporting period for services rendered within the scope of the grantee’s Title X project.
THIRD-PARTY PAYERS (Rows 7a–7e) – For each third-party source listed, enter the amount of funds
received during the reporting period for services rendered within the scope of the grantee’s Title X
project. Only revenue from pre-paid (capitated) managed care arrangements (e.g., capitated Medicare,
Medicaid, and private managed care contracts) should be reported as “pre-paid.” Revenues received
after the service was rendered, even under managed care arrangements, should be reported as “not
pre-paid.”
29
As specified in 45 CFR Part 74 and 45 CFR Part 92 (see footnotes 2 and 3).
30
See footnote 29.
Title X Family Planning Annual Report
– 47 –
OMB No.:
Expires:
0990-0221
04/30/10
MEDICAID (Row 7a) – Grantees should report as “Medicaid” all services paid for by Medicaid
(Title XIX) regardless of whether they were paid directly by Medicaid or through a fiscal
intermediary or a health maintenance organization (HMO). For example, in states with a capitated
Medicaid program (i.e., the grantee has a contract with a private plan like Blue Cross), the payer
is Medicaid, even though the actual payment may come from Blue Cross. Report revenue from
state-only Medicaid programs in accordance with the services covered by the state plan.
MEDICARE (Row 7b) – Grantees should report as “Medicare” all services paid for by Medicare
(Title XVIII) regardless of whether they were paid directly by Medicare or through a fiscal
intermediary or an HMO. For clients enrolled in a capitated Medicare program (i.e., where the
grantee has a contract with a private plan like Blue Cross), the payer is Medicare, even though the
actual payment may come from Blue Cross.
STATE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) (Row 7c) – Enter the amount of funds
received in the reporting period from the non-Medicaid, state CHIPs for services rendered within
the scope of the grantee’s Title X project.
OTHER PUBLIC HEALTH INSURANCE (Row 7d) – Enter the amount of funds received in the reporting
period from other federal, state, and/or local government health insurance programs for services
rendered within the scope of the grantee’s Title X project. Examples of other public third-party
insurance programs include health insurance plans for military personnel and their dependents
(e.g., TRICARE, CHAMPVA).
PRIVATE HEALTH INSURANCE (Row 7e) – Refers to health insurance provided by commercial and
non-profit companies. Individuals may obtain health insurance through employers, unions, or on
their own.
OTHER REVENUE (Rows 10–18) – Enter the amount of funds from contracts, state and local indigent
care programs, and other public or private revenues that were received during the reporting period
and that supported services within the scope of the grantee’s Title X project.
TITLE V (MATERNAL AND CHILD HEALTH [MCH] BLOCK GRANT) (Row 10) – Enter the amount of
Title V funds received during the reporting period that supported services within the scope of the
grantee’s Title X project.
TITLE XX (SOCIAL SERVICES BLOCK GRANT) (Row 11) – Enter the amount of Title XX funds
received during the reporting period that supported services within the scope of the grantee’s
Title X project.
TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) (Row 12) – Enter the amount of TANF
funds received during the reporting period that supported services within the scope of the
grantee’s Title X project.
LOCAL GOVERNMENT GRANTS AND CONTRACTS (Row 13) – Enter the amount of funds from local
government grants or contracts that were received during the reporting period and that supported
services within the scope of the grantee’s Title X project.
OTHER REVENUE (Rows 14–17) – Enter the amount and specify the source of funds received
during the reporting period from other sources that supported services within the scope of the
grantee’s Title X project. This may include revenue from private grants and donations,
fundraising, interest income, or other sources.
Title X Family Planning Annual Report
– 48 –
OMB No.:
Expires:
0990-0221
04/30/10
QUESTION ABOUT TABLE 14
1. QUESTION – How is this table different from the revenue table in the previous FPAR?
ANSWER – In the revised FPAR, only federal funds that are distributed directly to the grantee are
included under the heading of “Federal Grants,” while federal funds that are distributed by the
state under such programs as Title V, Title XX, and TANF are reported under the heading of
“Other Revenue.”
Title X Family Planning Annual Report
– 49 –
OMB No.:
Expires:
FPAR Number:
0990-0221
04/30/10
Date Submitted:
Reporting Period:
January 1, 200______ through December 31, 200______
__________________ through _____________________
(Month/day/year)
(Month/day/year)
Check One:
Initial Submission
Revision
See Notes
TABLE 14
REVENUE REPORT
FEDERAL GRANTS
AMOUNT
1
Title X (family planning services)
$
2
Bureau of Primary Health Care (BPHC)
$
3
Other federal grant (Specify: ________________________)
$
4
Other federal grant (Specify: ________________________)
$
TOTAL– FEDERAL GRANTS
(SUM ROWS 1 TO 4)
5
$
PAYMENT FOR SERVICES
6
Total client collections/self-pay
7
Third-party payers
$
PREPAID
(A)
NOT PRE-PAID
(B)
7a
Medicaid (Title XIX)
$
$
7b
Medicare (Title XVIII)
$
$
7c
State Children’s Health Insurance Program (state CHIP)
$
$
7d
Other public health insurance
$
$
7e
Private health insurance
$
$
$
$
TOTAL – THIRD-PARTY PAYERS
(SUM ROWS 7a TO 7e)
TOTAL – PAYMENT FOR SERVICES
(SUM ROW 6 + CELL 8A + CELL 8B)
8
9
$
OTHER REVENUE
10
Title V (MCH Block Grant)
$
11
Title XX (Social Services Block Grant)
$
12
Temporary Assistance for Needy Families (TANF)
$
13
Local government
$
14
State government
$
15
Other (Specify:____________________________________)
$
16
Other (Specify:____________________________________)
$
17
Other (Specify:____________________________________)
$
18
TOTAL– OTHER REVENUE
(SUM ROWS 10 TO 17)
$
19
TOTAL REVENUE
(SUM ROWS 5 + 9 + 18)
$
Title X Family Planning Annual Report
– 50 –
OMB No.:
Expires:
NOTES
Title X Family Planning Annual Report
– 51 –
0990-0221
04/30/10
OMB No.:
Expires:
NOTES (CONTINUED)
Title X Family Planning Annual Report
– 52 –
0990-0221
04/30/10
OMB No.:
Expires:
ABBREVIATIONS AND ACRONYMS
AGC
atypical glandular cells
AGC NOS
atypical glandular cells, not otherwise specified
AIS
adenocarcinoma in situ
ASC
atypical squamous cells
ASC-H
atypical squamous cells, cannot exclude HSIL
ASC-US
atypical squamous cells of undetermined significance
BPHC
Bureau of Primary Health Care
CBE
clinical breast exam
CFR
Code of Federal Regulations
CHIP
Children’s Health Insurance Program
CIN
cervical intraepithelial neoplasia
FAM
fertility awareness method
FPAR
Family Planning Annual Report
FTE
full-time equivalent
GPRA
Government Performance and Results Act
HBV
hepatitis B virus
HHS
Department of Health and Human Services
HIV
human immunodeficiency virus
HMO
health maintenance organization
HSIL
high-grade squamous intraepithelial lesion
HSV
herpes simplex virus
IUD
intrauterine device
LEP
limited English proficiency, limited English proficient
LSIL
low-grade squamous intraepithelial lesion
MCH
maternal and child health
OFP
Office of Family Planning
OMB
Office of Management and Budget
OPA
Office of Population Affairs
RPC
regional program consultant
STD
sexually transmitted disease
TANF
Temporary Assistance for Needy Families
USC
United States Code
Title X Family Planning Annual Report
– 53 –
0990-0221
04/30/10
OMB No.:
Expires:
Title X Family Planning Annual Report
– 54 –
0990-0221
04/30/10
OMB No.:
Expires:
0990-0221
04/30/10
APPENDIX A:
COLLECTING AND TABULATING MULTI-RACE RESPONSES
Background. On October 24, 1997, the Department of Health and Human Services (HHS) issued a Policy
Statement on Inclusion of Race and Ethnicity in DHHS Data Collection Activities. 31 This policy requires
the inclusion of racial and ethnic categories in HHS-funded and -sponsored data collection and reporting
systems. Implementation of this policy is intended to help to identify major health conditions of minority
populations, monitor progress in meeting their needs, and ensure nondiscrimination in access to and
provision of appropriate HHS services for various racial and ethnic groups. Though programs that are
directed to minority racial or ethnic populations have exemptions, they are encouraged to collect and
report data on subgroups within their target populations.
The HHS inclusion policy refers to the Office of Management and Budget (OMB) 1997 Revisions to the
Standards for the Classification of Federal Data on Race and Ethnicity, 32 and any subsequent revisions,
as the standard for racial and ethnic reporting categories in HHS-funded programs. The FPAR race and
ethnicity categories comply with the 1997 OMB revised minimum standards.
Reporting more than one race. According to the 1997 OMB revised standards, when respondents are
allowed to self-identify with or self-report more than one race:
Agencies should adopt a method that allows respondents to mark or select more than one of
the five minimum race categories.
The method for respondents to report more than one race should take the form of multiple
responses to a single question and not a single “multiracial” category.
When a list of races is provided to respondents, the list should not contain a “multiracial”
category.
Based on research conducted so far, two recommended forms for the instruction
accompanying the multiple-response question are “Mark one or more…” and “Select one or
more…”
If the criteria for data quality and confidentiality are met, provision should be made to report,
at a minimum, the number of individuals identifying with more than one race. Data producers
are encouraged to provide greater detail about the distribution of multiple responses.
Agencies are encouraged to consult with their Regional Program Consultant (RPC) if they have further
questions about collecting multi-race responses. On the following page is a sample question, designed to
be self-administered, for collecting race data. A list of references on this topic is also included.
31
U.S. Department of Health and Human Services, October 24, 1997, Policy Statement on Inclusion of Race and
Ethnicity in DHHS Data Collection Activities. Retrieved November 18, 2003, from http://www.hhs.gov/oirm/
infocollect/nclusion.html.
32
Office of Management and Budget, October 30, 1997, Revisions to the Standards for the Classification of Federal
Data on Race and Ethnicity, Federal Register Notice. Retrieved November 18, 2003, from http://
www.whitehouse.gov/omb/fedreg/ombdir15.html.
Title X Family Planning Annual Report
– A -1 –
OMB No.:
Expires:
0990-0221
04/30/10
What is your race? Select one or more.
American Indian or Alaskan Native: A person having origins in any of the original peoples of
North and South America (including Central America), and who maintains tribal affiliation or
community attachment.
Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or
the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands, Thailand, and Vietnam.
Black or African American: A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Pacific Islander: A person having origins in any of the original peoples of
Hawaii, Guam, Samoa, or other Pacific Islands.
White: A person having origins in any of the original peoples of Europe, the Middle East, or North
Africa.
References
Office of Management and Budget, March 9, 2000, “Guidance on Aggregation and Allocation of Data on
Race for Use in Civil Rights Monitoring and Enforcement,” OMB Bulletin No. 00-02. Retrieved
November 18, 2003, from http://www.whitehouse.gov/omb/bulletins/b00-02.html.
Office of Management and Budget, 2000, Provisional Guidance on the Implementation of the 1997
Standards for Federal Data on Race and Ethnicity. Retrieved November 18, 2003, from
http://www.whitehouse.gov/omb/inforeg/re_guidance2000update.pdf.
Office of Management and Budget, October 30, 1997, Revisions to the Standards for the Classification of
Federal Data on Race and Ethnicity, Federal Register Notice. Retrieved November 18, 2003, from
http://www.whitehouse.gov/omb/fedreg/ombdir15.html.
U.S. Census Bureau, 2001, “The Two or More Races Population: 2000,” Census 2000 Brief,
No. C2KBR/01-6. Retrieved November 18, 2003, from http://www.census.gov/prod/2001pubs/
c2kbr01-6.pdf.
U.S. Department of Health and Human Services, October 24, 1997, Policy Statement on Inclusion of Race
and Ethnicity in DHHS Data Collection Activities. Retrieved November 18, 2003, from
http://www.hhs.gov/oirm/infocollect/nclusion.html.
Title X Family Planning Annual Report
– A -2 –
| File Type | application/pdf |
| Author | Connie Winkle |
| File Modified | 2007-05-21 |
| File Created | 2007-05-21 |