003 MCHB Additional Data Elements Form

Health Resources and Services Administration
Maternal and Child Health Bureau
Discretionary Grant Performance Measures

OMB No. 0915-0298
Expires:

Attachment C
Part 3- Additional Data Elements

OMB Clearance Package

Draft

DIVISION OF HEALTHY START AND PERINATAL SERVICES HEALTH DATA SHEET
REVISED- Section A. Characteristics of Program Participants
ETHNICITY
Characteristics of
Program Participants

a. Number of Pregnant
Women
Under age 15
Aged 15-17
Aged 18-19
Aged 20-24
Aged 25-34
Aged 35-44
45+
Age Unknown
Total Number of
Pregnant Women
b. Number of Pregnant
Women with Incomes:
Below 100 Percent of the
FPL
Between 100-185
Percent of the FPL
Income Unknown
Total Number of
Pregnant Women with
Incomes

Hispanic
or Latino

Not Hispanic
or Latino

Unrecorded

RACE
TOTAL

America
Indian or
Alaska
Native

Asian

Black or
African
American

Native
Hawaiian or
Other
Pacific
Islander

White

More
Than One
Race

Unrecorded

Total

DIVISION OF HEALTHY START AND PERINATAL SERVICES HEALTH DATA SHEET
REVISED- Section A. Characteristics of Program Participants
ETHNICITY
Characteristics of
Program Participants

c. Number of Pregnant
Participants by Entry
into Prenatal Care:
During First Trimester
During Second Trimester
During Third Trimester
Receiving No Prenatal
Care
Total Number of
Pregnant Participants
by Entry into Prenatal
Care
Trimester Unknown
Total Number of
Pregnant Participants
by Entry into Prenatal
Care including
Trimester Unknown
d. Adequate Prenatal
Care
Total Number of
Pregnant Participants
Receiving Adequate
Prenatal Care
(Kotelchuck1,or similar
index)

Hispanic
or Latino

Not Hispanic
or Latino

Unrecorded

RACE
TOTAL

America
Indian or
Alaska
Native

Asian

Black or
African
American

Native
Hawaiian or
Other
Pacific
Islander

White

More
Than One
Race

Unrecorded

Total

DIVISION OF HEALTHY START AND PERINATAL SERVICES HEALTH DATA SHEET
REVISED- Section A. Characteristics of Program Participants
ETHNICITY
Characteristics of
Program Participants

Level of Adequate
Prenatal Care Unknown
Total number of
pregnant participants
Receiving Adequate
Prenatal Care
including unknown
Adequacy of Care
e. Live Singleton
Births to Participants
Number of live singleton
births greater than or
equal to 2500 grams to
participants
Number of live singleton
births between 2499
grams and 1500 grams to
participants
Number of live singleton
births less than 1499
grams to participants
Number of live singleton
births
weight unknown

Hispanic
or Latino

Not Hispanic
or Latino

Unrecorded

RACE
TOTAL

America
Indian or
Alaska
Native

Asian

Black or
African
American

Native
Hawaiian or
Other
Pacific
Islander

White

More
Than One
Race

Unrecorded

Total

DIVISION OF HEALTHY START AND PERINATAL SERVICES HEALTH DATA SHEET
REVISED- Section A. Characteristics of Program Participants
ETHNICITY
Characteristics of
Program Participants

Total Number of Live
Singleton Births to
Participants
Total Number of Live
Births to Participants
including Multiple
Births
Total Number of deaths
of program
participants attributed
to maternal conditions
and complications of
pregnancy and
childbirth during
pregnancy, childbirth
and up to 42 days after
delivery.
Total Number of deaths
of program
participants attributed
to maternal conditions
and complications of
pregnancy and from 43
days to one year after
delivery.
f. Number of Female
Participants in
Interconceptional
Care/Women's Health
Activities
Under age 15

Hispanic
or Latino

Not Hispanic
or Latino

Unrecorded

RACE
TOTAL

America
Indian or
Alaska
Native

Asian

Black or
African
American

Native
Hawaiian or
Other
Pacific
Islander

White

More
Than One
Race

Unrecorded

Total

DIVISION OF HEALTHY START AND PERINATAL SERVICES HEALTH DATA SHEET
REVISED- Section A. Characteristics of Program Participants
ETHNICITY
Characteristics of
Program Participants

Aged 15-17
Aged 18-19
Aged 20-23
Aged 24-34
Aged 35-44
Aged 45 +
Age Unknown
Total Number of
Female Participants in
Interconceptional
Care/Women's Health
Activities

g. Infant/Child Health
Participants
Number of Infant
Participants Aged 0 to 11
months
Number of Child
Participants aged 12 to
23 months

Hispanic
or Latino

Not Hispanic
or Latino

Unrecorded

RACE
TOTAL

America
Indian or
Alaska
Native

Asian

Black or
African
American

Native
Hawaiian or
Other
Pacific
Islander

White

More
Than One
Race

Unrecorded

Total

DIVISION OF HEALTHY START AND PERINATAL SERVICES HEALTH DATA SHEET
REVISED- Section A. Characteristics of Program Participants
ETHNICITY
Characteristics of
Program Participants

Number of Infant/Child
Participants Age
Unknown
Total Number of
Infant/Child Health
Participants
h. Male Support
Services Participants
Number of Male
Participants 17 years and
under
Number of Male
Participants 18 years and
older
Number of Male
Participants
Age Unknown
Total Number of Male
Support Services
Participants

Hispanic
or Latino

Not Hispanic
or Latino

Unrecorded

RACE
TOTAL

America
Indian or
Alaska
Native

Asian

Black or
African
American

Native
Hawaiian or
Other
Pacific
Islander

White

More
Than One
Race

Unrecorded

Total

B. RISK REDUCTION/PREVENTION SERVICES
(For Program Participants)
RISK FACTORS

a. PRENATAL
PROGRAM
PARTICIPANTS
Group B Strep or
Bacterial Vaginosis
HIV/AIDS
Other STDs
Smoking
Alcohol
Illicit Drugs
Depression
Other Mental Health
Problem
Domestic Violence
Homelessness
Overweight & Obesity
Underweight
Hypertension
Gestational Diabetes
Family History of Breast
Cancer
Asthma
Peridontal Infection

Number
Screened

Number Receiving
Risk Prevention
Counseling and/or
Risk Reduction
Counseling

Number
whose
Treatment is
Supported by
Grant

Number
Referred for
Further
Assessment
and/or
Treatment

RISK FACTORS

b.
INTERCONCEPTIONAL
WOMEN PARTICIPANTS
Group B Strep or Bacterial
Vaginosis
HIV/AIDS
Other STDs
Smoking
Alcohol
Illicit Drugs
Depression
Other Mental Health
Problem
Domestic Violence
Homelessness
Overweight & Obesity
Underweight
Lack of Physical Activity
Hypertension
Cholesterol
Diabetes
Family History of Breast
Cancer

B. RISK REDUCTION/PREVENTION SERVICES
(For Program Participants)
Numb
Number
Number
Number
er
Receiving Risk
whose
Referred
Screen
Prevention
Treatment for Further
ed
Counseling
is
Assessment
and/or Risk
Supported
and/or
Reduction
by Grant
Treatment
Counseling

Fecal Occult Blood Test
Asthma

Peridontal Infection

RISK FACTORS

c. INFANT CHILD (0-23
months)
Prenatal Drug Exposure
Prenatal Alcohol Exposure
Mental Health Problems
Family Violence/Intentional
Injury
Homelessness
Not Attaining Appropriate
Height or Length for Age
Developmental Delays
Asthma
HIV/AIDS
Other Special Health Care
Needs
Failure to Thrive

B. RISK REDUCTION/PREVENTION SERVICES
(For Program Participants)
Number
Number
Number
Number
Screened
Receiving
whose
Referred
Risk
Treatment for Further
Prevention
is
Assessment
Counseling Supported
and/or
and/or Risk
by Grant
Treatment
Reduction
Counseling

C. HEALTHY START MAJOR SERVICE TABLE
a. DIRECT HEALTH CARE SERVICES
Prenatal Clinic Visits:
Number of Medical Visits
by All Prenatal Participants
Postpartum Clinic Visits
Number of Medical Visits
by All Postpartum Participants
Well Baby/ Pediatric Clinic Visits
Number of Any Provider Visits
by All Infant/Child Participants
Adolescent Health Services
Number of any Provider Visits
by Participants age 17 and under
Family Planning
Number of Participants Receiving
Family Planning Services
Women’s Health
Number of Participants Receiving
Women’s Health Services
b. ENABLING SERVICES

Total Number of Families Served
Number of Families in the Prenatal Period
Assisted by Case Management
Number of Families in the Interconceptional Period Assisted by Case
Management
Number of Families in the Prenatal Period
Assisted by Outreach
Number of Families in the Interconceptional

Period Assisted by Outreach
Number of Families in the Prenatal Period
Receiving Home Visiting
Number of Families in the Interconceptional
Period Receiving Home Visiting

Number of Participants Age 17 and Under who participated in Adolescent
Pregnancy Prevention Activities
Number of Families who participated in
Pregnancy/Childbirth Education Activities
Number of Families who participated in
Parenting Skill Building/Education
Number of Participants in
Youth Empowerment/Peer Education/
Self-Esteem/Mentor Programs
Number of Families Who Received
Transportation Services
Includes Tokens, Taxis and Vans
Number of Families Who Receive
Translation Services
Number of Families Receiving
Child Care Services
Number of Participants Who Received
Breastfeeding Education , Counseling and Support

Number of Participants Who Received Nutrition Education and
Counseling Services including WIC Services

Number of Participants in
Male Support Services:
Number of Participants Referred for
Housing Assistance
Total Participants assisted with
Jobs/Jobs Training
Total Participants served in
Prison/Jail Initiatives
c. POPULATION
Number Of Immunizations
Provided
Public Information/Education:
Number of Individuals Reached
d. INFRASTRUCTURE BUILDING
Consortia Training
Number of Individual Members Trained
Provider Training
Number of Individual Providers Trained

Instructions for Additional Data Elements
Division of Healthy Start and Perinatal Services Health Data Sheet
Description:
The Division of Healthy Start and Perinatal Services has an additional data element form. This form is
divided into three sections:
Section A. Characteristics of Participants;
Section B. Risk Reduction/Prevention Services; and
Section C. Healthy Start Major Service Table.
The following contains information on how to complete each section of the form.
Section A. Characteristics of Program Participants
•
•
•

a.

The three pages contains columns noting ethnicity and race.
Ethnicity is broken down into three columns: Hispanic or Latino, Not Hispanic or Latino, and
unrecorded.
Race is broken down into seven columns: American Indian or Alaska Native, Asian, Black or
African American, Native Hawaiian or Other Pacific Islander, White, and more than one, and
unrecorded.
Number of Pregnant Women

•

Enter the unduplicated count of all pregnant program participants by age group and ethnicity/race.
The response should reflect what the person considers herself to be and is not based on
percentages of ancestry.

•

Enter the count of all pregnant program participants during whose age is umknown by
ethnicity/race. Participant’s age and appropriate age groups should be determined at time of
enrollment into any Healthy Start activity

NOTE: The number pre-populated in the total columns for Hispanic or Latino or not Hispanic
or Latino should be identical to the race total column. If the numbers in both total columns are
not identical, please explain the discrepancy in the note section.
b.

Income Level of Program Participants

Income level of the program participant refers to the annual income for the client’s family, compared to the
Federal Poverty Level, recorded at enrollment as percentage of level for a family of the same size. Annual
income data can be estimated from monthly data, if necessary (Monthly income x 12). Grantees may wish
to record information on income and family size and calculate poverty levels separately, or enter only the
computed poverty level for the client. The Federal poverty level is updated annually in February and
published in the Federal Register.
•

Enter the unduplicated count of all pregnant program participants with incomes below 100% of the
FPL by race/ethnicity served by your grant.

•

Enter the unduplicated count of all pregnant program participants with incomes between 100-185
% of the FPL by race/ethnicity served by your grant.

•

Enter the unduplicated count of all pregnant program participants with income level unknown by
race/ethnicity served by your grant.

NOTE: The number pre-populated in the total columns for Hispanic or Latino or not Hispanic or Latino
should be identical to the race total column. If the numbers in both total columns are not identical, please
explain the discrepancy in the note section.
c.

Number of Pregnant Participants who Enter Prenatal Care

Healthy Start Prenatal Care Definition
A visit made for the medical supervision of a pregnancy by a physician or other health care provider during
the pregnancy, and/or other ancillary services occurring during the antenatal period (e.g., nutrition, health
assessments and education, lab test, and psychosocial services).
Trimester of entry into prenatal care is defined as:
Number of Pregnant Women who Enter
Prenatal Care:
During First Trimester

Number of participants with reported first prenatal visit:

During Second Trimester

between 13 week and 25 week

During Third Trimester

between 26 and delivery

Receiving No Prenatal Care

Participants who report no prenatal care

before 13 weeks gestation.

•

Enter the number of pregnant participants who enter prenatal care by ethnicity/race during First
Trimester.

•

Enter the number of pregnant participants who enter prenatal care by ethnicity/race during second
Trimester.

•

Enter the number of pregnant participants who enter prenatal care by ethnicity/race during third
Trimester.

•

Enter the number of pregnant participants who enter prenatal care by ethnicity/race receiving no
prenatal care.

•

Enter the number of pregnant participants whose entry into prenatal care is unknown.

The total number of pregnant participants who enter prenatal care by ethnicity and race is the sum of the
following four rows of data for each respective column: During First Trimester, During Second Trimester,
During Third Trimester, and Receiving No Prenatal Care. The number entered in the total columns for
Hispanic or Latino or not Hispanic or Latino should be identical to the race total column. The number
entered in the total columns should be identical to the number entered for the denominator on form 9,
performance measure number 36.
NOTE: The number pre-populated in the total columns for Hispanic or Latino or not Hispanic or Latino
should be identical to the race total column. If the numbers in both total columns are not identical, please
explain the discrepancy in the note section.

d.

Adequate Prenatal Care

Adequate prenatal care is defined as the number of participants who receive adequate prenatal care as

measured by the Kotelchuck Scale, Kessner Index or similar index.

Kotelchuck Scale: percent of women whose ratio of observed to expected prenatal visits is greater
than or equal to 80% defined in the Adequacy of Prenatal Care Units (APNCU) as the lower
boundary of “adequate care” (expected visits are adjusted for gestational age and month prenatal
care began).
Kessner Index: This index takes into account three factors: month in which prenatal care began
number of prenatal care visits, and length of gestation. “Not adequate” prenatal care includes
intermediate, inadequate, and unknown adequacy of care.
•
•

Enter the number of pregnant participants receiving adequate prenatal care by
ethnicity/race (Kotelchuck, Kessner or similar index). Specify the index when you enter
data for this item.
Enter the number of pregnant participants whose adequacy of prenatal care is unknown
by ethnicity/race.

NOTE: The number pre-populated in the total columns for Hispanic or Latino or not Hispanic or
Latino should be identical to the race total column. If the numbers in both total columns are not
identical, please explain the discrepancy in the note section.

e.

Live Singleton Births to Participants

Report the birth outcomes on all live singleton births to program participants.
• Enter the number of live singleton births to program participants 2500 grams or greater by
ethnicity/race. The number entered in the total column should be identical to the number entered
for the numerator on form 9, performance measures numbers 50-54.
• Enter the number of live singleton births between 1500 and 2499 (Low Birth Weight or LBW)
grams to participants by ethnicity/race served. The number entered in the total column should be
identical to the number entered for the denominator on form 9, performance measure number 51.
• Enter the number of live singleton births less than 1499 grams (Very Low Birth Weight or
VLBW) to program participants by ethnicity/race served by your grant.The number entered in the
total column should be identical to the number entered for the denominator on form 9,
performance measure number 50.
• Enter the number of live singleton births to program participants whose weight is unknown by
ethnicity/race served.
• Enter the total number of live singleton births including multiple births to program participants by
ethnicity/race.
NOTE: The number pre-populated in the total columns for Hispanic or Latino or not Hispanic or Latino
should be identical to the race total column. If the numbers in both total columns are not identical, please
explain the discrepancy in the note section.
f.

Interconceptional Care Services

Interconceptional care services are defined as services to participants who both enrolled and received
services in the period from the delivery to two year’s following delivery. Participant’s age and appropriate
age groups should be determined at time of enrollment into any Healthy Start activity or in the case of
women enrolled prenatally, the initiation of inter-conceptional services.

•

Enter the number of program participants receiving interconceptional care/women’s health care
during the reporting period to program participants by ethnicity/race.

•

Enter the number of program participants receiving interconceptional care/women’s health care
during the reporting period whose age is unknown to program participants by ethnicity/race.

g.

Infanct/Child Health Participants
•
•
•

h.

Enter the number of infant participants aged 0 to 11 months by race/ethnicity.
Enter the number of child participants aged 12 to 23 months by race/ethnicity.
Enter the number of child participants whose age is unknown by race/ethnicity.
Male Support Services Participants

Male participants are defined as the parenting male who has received a Healthy Start service, directly or
indirectly, such as involvement in the HS supported fatherhood or male support group or case
management/case coordination services.
•
•
•

Enter the number of male participants 17 years and under by race/ethnicity.
Enter the number of male participants 18 years and over by race/ethnicity
Enter the number of male participants whose age is unknown by race/ethnicity.

Section B. Risk Reduction/Prevention Services
•

This three page document contains tables with the first column noting prenatal participants,
interconceptional women participants, and infant/child (0-23 months) and their respective risk
factors.

•

The prevention services for this table are broken down into five columns: Risk Factors, Number
Screened, Number Receiving Risk Prevention Counseling and/or Risk Reduction Counseling,
Number whose Treatment is Supported by Grant, Number Referred for Further Assessment and/or
Treatment.

•

All entry fields in this table are numeric; no commas or text are permitted.

a.

Prenatal Program Participants

Enter numbers of prenatal program participants that have received prevention services for the risk factors
listed.
•

b.

The risk factors for prenatal participants are: Group B Strep or Bacterial Vaginosis, HIV/AIDS,
Other STDs, Smoking, Alcohol, Illicit Drugs, Depression, Other Mental Health Problems,
Domestic Violence, Homelessness, Overweight & Obesity, Underweight, Hypertension,
Gestational Diabetes, Family History of Breast Cancer, Periodontal Infection, and Asthma.
Interconceptional Women Participants

Enter numbers of interconceptional women participants that have received prevention services for the risk
factors listed.
•

The risk factors for interconceptional women participants are: Group B Strep or Bacterial
Vaginosis, HIV/AIDS, Other STDs, Smoking, Alcohol, Illicit Drugs, Depression, Other Mental
Health Problems, Domestic Violence, Homelessness, Overweight & Obesity, Underweight, Lack

of Physical Activity, Hypertension, Cholesterol, Diabetes, Family History of Breast Cancer, Fecal
Occult Blood Test, Periodontal Infection, and Asthma.
c.

Infant/Child Health Participants

Enter numbers of infant or child participants (0-23 months) that have received prevention services for the
risk factors listed.
•

The risk factors for infant or child participants are: Prenatal Drug Exposure, Prenatal Alcohol
Exposure, Mental Health Problems, Family Violence/Intentional Injury, Homelessness, Not
Attaining Height or Length for Age, Developmental Delays, Asthma, HIV/AIDS, and Other
Special Health Care Needs and Failure to thrive.

Perinatal Data Form Section C. Major Services Data Table
This document consists of four sub-sections:
a. Direct Health Care Services,
b. Enabling Services,
c. Population, and
d. Infrastructure Building.
•

Healthy Start major services for each of these subsection are listed.

•

All entry fields in this table are numeric; no commas or text are permitted. Enter data for those
services provided either direclty or indirectly, by the Healthy Start grant.

•

Unless otherwise noted data entered is for program participants only. Data for Community
Participants that receive Direct Health Care Services and/or Enabling Services should be detailed
in the notes section.

a.

Direct Health Care Services

Enter data for the direct health care services listed.
•
•

b.

The direct health care services listed are: Prenatal Clinic Visits, Postpartum Clinic Visits, Well
Baby/Pediatric Clinic Visits, Adolescent Health Services, Family Planning, and Women’s Health.
Data is entered for only those services that your grant provided or that is a documented completed
referral.
Enabling Services

Enter data for the enabling services listed.
•

•

c.

The enabling services listed are: Families Served, Case Management, Outreach, Home Visiting,
Adolescent Pregnancy Prevention Activities, Pregnancy/Childbirth Education Activities,
Parenting Skill Building/Education, Youth Empowerment/Peer Education/Self-Esteem/Mentor
Programs, Transportation Services, Translation Services, Child Care Services, Breastfeeding
Education, Counseling and Support, Nutrition Education and Counseling Services, Male Support
Services, Housing Assistance, Jobs/Job Training, and Prison/Jail Initiatives.
Data is entered for only those services that your grant provided or that is a documented completed
referral.
Population Based Services

Enter data for the population-based services listed, if applicable.

•

The population-based services listed are: Immunizations and Public Information/Education.

Note: Data entered for Public Information/Education are for community participants only.
d.

Infrastructure Building Services

Note: Data entered here are for community participants only.
Enter data for the infrastructure building services listed, if necessary.
•
•

The infrastructure building services listed are: Consortia Training and Provider Training.
Data is entered for only those services that your grant provided.

REVISED- MCH TRAINING AND EDUCATION PROGRAMS DATA FORM
Faculty and Staff Information

List all personnel (faculty, staff, and others) contributing1 to your training project, including those listed in the budget
form and budget narrative and others that your program considers to have a central and ongoing role in the leadership
training program whether they are supported or not supported by the grant.
Personnel (Do not list trainees)
Name

Race
(choose one: e.g.,
American Indian or Alaska
Native, Asian, Black or
African American, Native
Hawaiian or Other Pacific
Islander, White, other)

Ethnicity
(Hispanic or
NonHispanic)

Gender
(male or
female)

Discipline

Year Hired in
MCH
Leadership
Training
Program

Former
MCHB
Trainee?
Y/N

Faculty

Staff

Other

1

A ‘central’ role refers to those that regularly participate in on-going training activities such as acting as a preceptors;
teaching core courses; and participating in other core leadership training activities that would be documented in the
progress reports.

REVISED-

Former Trainee Information (For Long-term Trainees ONLY)

The following information is to be provided for each long-term trainee who
completed the Training Program 5 years prior to the current reporting year.
Definition of Former Trainee = Grant supported trainees who completed the program 5
years ago
Name

Year

Degree(s)

City of

State of

Current

Working in

Working

Working with

Met criteria

Graduated

Earned with

Residence

Residence

Employment

Public Health

in MCH?

underserved

for

MCH support

Setting (see

organization or

(Y/N)

populations or

Leadership in

(if applicable)

pick list

agency

vulnerable

PM 08?

below*)

(including Title

groups**?

(Y/N)

V)? Y/N

Y/N

*Employment pick list:
-student
-schools or school system (includes EI programs, elementary and secondary)
-post-secondary setting
-government agency
-clinical health care setting (includes hospitals, health centers and clinics)
-private sector
-other (specify in notes field)

**Vulnerable Groups refers to social groups with increased relative risk (i.e. exposure to risk
factors) or susceptibility to health-related problems. This vulnerability is evidenced in higher
comparative mortality rates, lower life expectancy, reduced access to care, and diminished
quality of life. (i.e, Immigrant Populations Tribal Populations, Migrant Populations, Uninsured
Populations, Individuals Who Have Experienced Family Violence, Homeless, Foster Care,
HIV/AIDS, etc) Source: Center for Vulnerable Populations Research. UCLA.
http://www.nursing.ucla.edu/orgs/cvpr/who-are-vulnerable.html

NEW FORM
MCH TRAINING PROGRAM GRADUATE FOLLOW-UP QUESTIONS

Contact / Background Information
*Name (first, middle, last):
Previous Name (if used while
enrolled in the training
program):

*Address:
City

State

Zip

Phone:
Primary Email:
Permanent Contact Information (someone at a different address who will know how to contact you in the
future, e.g., parents)
*Name of Contact:
Relationship:
*Address:
City

State

Zip

Phone:
What year did you graduate/complete the MCH Training Program? _________
Degree(s) earned while participating in the MCH Training Program _____________(a pick list will be
provided- same as the one provided in the EHB faculty information form)
Race: (choose one)
__ White refers to people having origins in any of the original peoples of Europe, the Middle East, or
North Africa.
__ Black or African American refers to people having origins in any of the Black racial groups of
Africa.
__ American Indian and Alaskan Native refer to people having origins in any of the original peoples
of North and South America (including Central America), and who maintain tribal affiliation or
community attachment. Tribe: __________
__ Asian refers to people having origins in any of the original peoples of the Far East, Southeast Asia,
or the Indian subcontinent (e.g. Asian Indian).
__ Native Hawaiian and Other Pacific Islander refers to people having origins in any of the original
peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
__ Two or more races includes individuals who identify with two or more racial designations.
__ Other is included for individuals who are unable to identify with the categories.
Ethnicity: (choose one)
Hispanic is an ethnic category for people whose origins are in the Spanish-speaking countries of Latin
America or who identify with a Spanish-speaking culture. Individuals who are Hispanic may be of any
race.
__ Hispanic

__ Non-Hispanic

Survey
Please answer all of the following questions as thoroughly as possible. When you have filled out the entire
survey, return it to your Center/Program.

1. What best describes your current employment setting:
__ student
__ schools or school system (includes EI programs, elementary and secondary)
__ post-secondary setting
__ government agency
__ clinical health care setting (includes hospitals, health centers and clinics)
__ private sector
__ other: please specify: ____________________________________
2. Do you currently work in a public health organization or agency (including Title V)? Y/N
3. Does your current work relate to Maternal and Child Health (MCH) populations ((i.e.

women, infants and children, adolescents, and their families including fathers and children
and youth with special health care needs,)?
__ yes
__ no
4. Does your current work relate to underserved or vulnerable2 populations (i.e, Immigrant
Populations Tribal Populations, Migrant Populations, Uninsured Populations, Individuals Who Have
Experienced Family Violence, Homeless, Foster Care, HIV/AIDS, health disparities, etc)
__ yes
__ no
5. Have you done any of the following activities since completing your training program?
__

a. Participated on any of the following as a group leader, initiator, key contributor or in a
position of influence/authority: committees of state, national or local organizations; task
forces; community boards; advocacy groups; research societies; professional societies; etc.

__

b. Served in a clinical position of influence (e.g. director, senior therapist, team leader, etc.)

__

c. Provided consultation or technical assistance in MCH areas

__

d. Taught/mentored in my discipline or other MCH related field

__

e. Conducted research or quality improvement on MCH issues

__

f. Disseminated information on MCH Issues (e.g., Peer reviewed publications, key
presentations, training manuals, issue briefs, best practices documents, standards of care)

2

The term “underserved” refers to “Medically Underserved Areas and Medically Underserved
Populations with shortages of primary medical care, dental or mental health providers.
Populations may be defined by geographic (a county or service area) or demographic (low
income, Medicaid-eligible populations, cultural and/or linguistic access barriers to primary medical
care services) factors. The term "vulnerable groups," refers to social groups with increased relative risk
(i.e. exposure to risk factors) or susceptibility to health-related problems. This vulnerability is evidenced in
higher comparative mortality rates, lower life expectancy, reduced access to care, and diminished quality of
life.

__

g. Served as a reviewer (e.g., for a journal, conference abstracts, grant, quality assurance
process) (ac, c)

__

h. Procured grant and other funding in MCH areas

__

i. Conducted strategic planning or program evaluation

__

j. Participated in public policy development activities (e.g., Participated in community
engagement or coalition building efforts, written policy or guidelines, influenced MCH
related legislation (provided testimony, educated legislators, etc))

__

k. None

6. If you checked any of the activities above, in which of the following settings or capacities
would you say these activities occurred? (check all that apply)
__ a. Academic
__ b. Clinical
__ c. Public Health
__ d. Public Policy & Advocacy
(end of survey)

Confidentiality Statement
Thank you for agreeing to provide information that will enable your training program to track your training
experience and follow up with you after the completion of your training. Your input is critical to our own
improvement efforts and our compliance with Federal reporting requirements. Please know that your
participation in providing information is entirely voluntary. The information you provide will only be used
for monitoring and improvement of the training program. Please also be assured that we take the
confidentiality of your personal information very seriously. We very much appreciate your time and
assistance in helping to document outcomes of the Training Program. We look forward to learning about
your academic and professional development.

REVISED-

MCH TRAINING AND EDUCATION PROGRAMS DATA FORM

Medium Term Trainees
DEFINITION: Medium term trainees are trainees with 40 - 299 contact hours in
the current reporting year.
TOTAL Number of Medium term Trainees: _________

Medium-term Trainees with 40-149 contact hours during the
past 12-month grant period
Number ______
Disciplines (list):

(For gender, ethnicity and race enter total number not percent.)
Medium Term Trainees with 150-299 contact hours
Number
________

Gender

Male _____

Female _____

Ethnicity

Hispanic: _____

Non Hispanic ______

Race

American Indian/Alaska Native: _____
Asian: _____
Black: _____
Native Hawaiian /Other Pacific Island: ______
White: ______
Other:______

Discipline
Number
____
e.g.
5
13
2

Discipline (select from pick list)
_________
Nursing
Pediatrics
Social Work

REVISED-

Short Term Trainees

MCH TRAINING AND EDUCATION PROGRAMS DATA FORM

DEFINITION: Short-term Trainees are trainees with less than 40 contact hours in
the current reporting year. (Continuing Education participants are not counted in
this category)

Number of Short term Trainees during the past 12-month grant period________
List types/disciplines (i.e., pediatricians, nutritionists, etc)__________________

Trainee Information (Long –term Trainees Only)
Definition: Long-term trainees (those with greater than or equal to 300 contact hours
within the training program) benefiting from the training grant (both supported and nonsupported trainees).
Total Number of long term trainees participating in the training program __________*
Name
Ethnicity
Race (indicate one or more of above categories)
Gender
Permanent Address (For supported trainees ONLY)
Discipline(s) upon Entrance to the Program
Degree(s)
Position at Admission (position title and setting)
Degree Program in which enrolled
Received financial MCH support? [ ] Yes [ ] No
Amount: $_________________
Type: [ ] Pre-doctoral
[ ] Post-doctoral
[ ] Part-time student
[ ] Full-time student
Epidemiology training grants ONLY
Length of time receiving support: ____________
Research Topic or
Title________________________________________________________
Products completed through the project
[ ] manuscripts
[ ] Presentations
[ ] monographs
[ ]
Other

________________________________________________________________________
___
*All trainees participating in the program, whether receiving MCH stipend support or not.

REVISED-

MCH Training and Education Program Data Forms
Technical Assistance/Collaboration Form

DEFINITION: Technical Assistance/Collaboration refers to mutual problem solving and collaboration on a
range of issues, which may include program development, clinical services, collaboration, program
evaluation, needs assessment, and policy & guidelines formulation. It may include administrative services,
site visitation and review/advisory functions. Collaborative partners might include State or local health
agencies, and education or social service agencies. Faculty may serve on advisory boards to develop &/or
review policies at the local, State, regional, national or international levels. The technical assistance (TA)
effort may be a one-time or on-going activity of brief or extended frequency. The intent of the measure is to
illustrate the reach of the training program beyond trainees.

A. Provide the following summary information on the ALL TA provided (DGIS will calculate
percentages on recipients and audience)

Total Number of
Technical Assistance/
Collaboration Activities

Number of TA Activities by Type
of Recipient
Type of Recipient Number of TA
Activities

(use Recipient pick
list from table below)

Ex: Medicaid

___3____
_________ _______
_________ _______
_________ _______

Number of TA Activities by
Target Audience
Local
With-in-State
Another State
Regional
National
International

_____
_____
_____
_____
_____
_____

B. Provide information below on the 8-10 most significant technical
assistance/collaborative activities in the past year. In the field notes briefly state why
these were the most significant TA events.
Topic of Technical
Assistance/Collaboration.
Select one from list A and all that apply from
List B.
List A (select one)
List B (select all that
apply)
A. Clinical care related
(including medical
1. Women’s/Reproduchome)
tive/Perinatal Health
B. Cultural Competence 2. Early Childhood
Related
Health/ Development
C. Data, Research,
(birth to school age)
Evaluation Methods
3. School Age Children
(Knowledge
4. Adolescent
Translation)
5. CSHCN/Development
D. Family Involvement
al Disabilities
E. Interdisciplinary
6. Autism
Teaming
7. Emergency
F. Healthcare
Preparedness
Workforce
8. Health Information
Leadership
Technology
G. Policy
9. Mental Health
H. Prevention
10.Nutrition
I. Systems
11.Oral Health
Development/
12.Patient Safety
Improvement
13.Respiratory Disease
J. Racial and Ethnic
14. Vulnerable
Diversity or
Populations*
Disparities
15: Other

1
2
3
4
5
6
7
8
9
10

Ex: G- Policy

11- Oral Health

Intensity of
TA

Primary
Target
Audience

12- Early
Intervention

1: One time brief
(single contact)

13. Other Govt.
Agencies (Federal,
State, Regional,
Local)

2:One time
extended
(multi-day
Contact
provided one
time)

1. Local
2. Within
state
3. Another
state
4. Regional
5. National
6.International

Recipient of TA/Collaborator

1-Other Divisions/
Departments in a University
2-Title V (MCH Programs)
3-State Health Dept.
4-Health Insurance/
Organization
5- Education (State
Department of Education,
School District, Local
education organizations)
6-Medicaid agency
7-Social Service Agency

14-Mixed agencies
15-Professional
Organizations/
Associations
16-Family and/or
Consumer Group

8.Mental Health Agency/
9. Juvenile Justice or other
Legal Entity

17-Foundations

10. State Adolescent Health

18-Clinical
Programs/
Hospitals

11-Developmental Disability
Agency

19-Other: Please
Specify

5- Education

3: On-going
infrequent (3
or less
contacts per
year)
4: On-going
frequent (more
than 3 contacts
per year)

2

"Vulnerable groups," refers to social groups with increased relative risk (i.e. exposure to risk factors) or
susceptibility to health-related problems. This vulnerability is evidenced in higher comparative mortality
rates, lower life expectancy, reduced access to care, and diminished quality of life.

C. In the past year have you provided technical assistance on emerging issues that are not
represented in the topic list above? YES/ NO.

2

If yes, specify the
topic(s):________________________________________________________________
_____

REVISED-

MCH Training and Education Program Data Forms
Continuing Education Form

Continuing Education is defined as continuing education programs or trainings that serve
to enhance the knowledge and/or maintain the credentials and licensure of professional
providers. Training may also serve to enhance the knowledge base of community
outreach workers, families, and other members who directly serve the community.
A. Provide information related to the total number of CE activities

provided through your training program last year.
Total Number of CE Participants
Total Number of CE Sessions/Activities
Number of CE Sessions/Activities by Primary Target Audience
Number of Local CE Activities
Number of State CE Activities
Number of CE Activities in Another State
Number of Regional CE Activities
Number of National CE Activities
Number of International CE Activities

Number of CE Sessions/Activities for which Credits are Provided

_____
_____
_____
_____
_____
_____
_____
_____
_____

B.

For up to 10 of the most significant CE activities in the past project year, list the title, topics, methods, number of participants, duration and
whether CE units were provided. In the field notes, briefly state why these were the most significant CE events (e.g., most participants reached;
key topic addressed, new collaboration opportunity, emerging issues, diversity of participants (other than healthcare workers etc))

Title

Topic: Level A
select one
A. Clinical CareRelated (including
medical home)
B. Cultural
Competence-Related
C. Data, Research,
Evaluation Methods
(Knowledge
Translation)
D. Family Involvement
E. Interdisciplinary
Teaming
F. Healthcare
Workforce
Leadership
G. Policy
H. Prevention
I. Systems
Development/
Improvement

Topic: Level B: select all
that apply
1. Women’s/Reproductive/
Peri- natal Health
2. Early Childhood Health/
Development (birth to
school age)
3. School Age Children
4. Adolescent
5. CSHCN/Developmental
Disabilities
6. Autism
7. Emergency Preparedness
8. Health Information
Technology
9. Mental Health
10. Nutrition
11. Oral Health
12. Patient Safety
13. Respiratory Disease
14. Vulnerable Populations*
15. Racial and Ethnic
Diversity or Disparities
16. Other: (specify)

Primary
Target
Audience

Method*

A.
B.
C.

A. In-person
B. Distance
C. Mixed

D.
E.
F.
G.

Local
State
Another
state
Regional
National
International

Number of
Participants

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
* "Vulnerable groups" refers to social groups with increased relative risk (i.e. exposure to risk factors) or susceptibility
to health-related problems. This vulnerability is evidenced in higher comparative mortality rates, lower life expectancy,
reduced access to care, and diminished quality of life. Center for Vulnerable Populations Research. UCLA.
http://www.nursing.ucla.edu/orgs/cvpr/who-are-vulnerable.html
C. In the past year have you provided continuing education on emerging issues that are not
represented in the topic list above? YES/ NO. If yes, specify the
topic(s):_____________________________________________________________________

Continuing
Education
Credits
Provided?
Yes
No