Attachment C - QuarterlyReport

PNDP Data Elements – Program Quarterly Report

OMB #0915-XXXX

Program Quarterly Report Template
[Name of Grantee]
[Period of Performance]
During the period of performance covered by this report, please describe the program activities
that took place in each of the following areas:
Program and Infrastructure Development
What planning goals were completed this quarter?
[e.g., training manuals completed, intake forms designed, community organization training
developed, internal experts scheduled to speak].

Training/Orientation/Continuing Education Session(s)
What patient navigation training activities were completed this quarter?
[Please include continuing education and ongoing quality improvement for navigators].
Date

Length of Activity

Objective

Number
PNs
Attended

Comments on Training:

Patient Navigator (PN) Staffing
How was the PN program staffed this quarter?
PN Category
Total number PN FTEs
Number PNs working less than 30 hours/week on PN
PNs providing services
PNs hired
PNs resigned or fired

Number

Comments on Staffing:

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-xxxx. Public
reporting burden for this collection of information is estimated to average xx hours per response, including the time for reviewing
instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA
Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

Number
Other
Program
Staff
Attended

PNDP Data Elements – Program Quarterly Report

OMB #0915-XXXX

PN Implementation
Please describe the number of patients assisted through each PN program. If there are multiple
PN programs at your site, each having a different disease focus, please report the number
assisted in each program. For example, please differentiate patients navigated for diabetes
versus those navigated for cancer.

Number of Patients
Receiving Navigation
Services
This Quarter

Chronic Disease Focus of
Patient Navigation

Outreach Activities
What types of outreach activities were conducted this quarter (e.g., presentations, health fairs,
brochure/flyer distribution, group screening, screening calls)? When was the outreach
conducted? What was the disease focus of the outreach (e.g., breast cancer, diabetes,
asthma)? If outreach was a presentation, where did it occur (e.g., church, community center,
senior center, clinic)?
What is the targeted health disparity population/purpose of the outreach?
Date

Type

Disease
Focus

Location

Targeted Health
Disparity Pop

# Attended

Lessons Learned
What challenges were encountered, if any, and were there any lessons learned that might be
useful for the future or for other sites? Please indicate what action your program took in
response to the challenge. If no action taken, please specify this.
Challenge

Lesson Learned/Solutions Found

Technical Assistance

Are there any specific areas where technical assistance is needed?

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-xxxx. Public
reporting burden for this collection of information is estimated to average xx hours per response, including the time for reviewing
instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA
Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.