Attachment D: Web-based Data Collection Form for Grantee Selected Indicators
Web-based data collection form for grantee selected Indicators
Evaluation of the Early Childhood Comprehensive Systems (ECCS) Grant Program
INTRODUCTION:
Welcome to the Web-based Data Collection Form for Grantee Selected Indicators being administered by the Altarum Institute on behalf of the Maternal and Child Health Bureau in the U.S. Department of Health and Human Services. This form is designed to collect information on a small number of early childhood and family outcome indicators used by your State ECCS Team. The data you enter will be part of a national evaluation of the implementation and effectiveness of the ECCS Grant Program.
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-XXXX . The time required to complete this information collection is estimated to average 90 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Completing this form is expected to take approximately 45 minutes. 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/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Your agency’s name and location, and your general job title (e.g. State ECCS Coordinator) will be identified in reports prepared for this study and in data files provided to HRSA. None of your responses will be released in a form that identifies you or any other staff member by name.
REspondent Information:
The first set of questions is designed to find out a little about your State/Jurisdiction.
Please select the name of your State/Jurisdiction from the list below:
DROPDOWN LIST OF ALL STATES/JURISDICTIONS
Who should we contact if we have questions about the information that you report on this form?
Name: __________________________________________________
Title: ___________________________________________________
Organization: ____________________________________________
Address: ________________________________________________
City: ____________________________ State: ___ Zip Code: ______
Phone: ___________ E-mail: ________________________________
SAMPLE OF OUTCOME INDICATORS:
This next set of questions is designed to gather information about the outcome indicators that you believe could be affected by your State’s ECCS systems-building strategies. We would like to know your understanding of how specific ECCS strategies will lead to positive changes for young children and families.
Instructions
Select the three statewide indicators for early childhood and family outcomes that you believe could be affected by your State’s ECCS strategies. These indicators should come from the set of indicators your State Team has identified for monitoring child and family well-being. Choose outcome indicators that are likely to show a measurable change within a 5- to 10-year time frame upon implementing a given ECCS strategy or set of strategies.
Enter statewide data on each of your selected indicators for the most current year available and the previous 5 years, if available.
For each selected indicator, provide a brief description of the:
Overall trend in data for the outcome indicator to date,
Specific ECCS strategy or set of ECCS strategies to which the outcome indicator is related,
Rationale for the proposed link between the ECCS strategy/strategies and the outcome indicator, and
Key ECCS State Team members and other partners who are most involved in positively changing the outcome indicator.
Outcome Indicator 1
Please list Outcome Indicator 1 in the space below:
SPACE for INDICATOR 1
Examples of statewide childhood and family outcome indicators would include the following:
Infant mortality rate
Teen birth rate
Percent of children with dental sealants
Percent of children up-to-date on immunizations
Percent of uninsured children
Percent of overweight children in WIC
Percent of infants born to pregnant women receiving early prenatal care
What is the unit of measurement for Outcome Indicator 1? Please be as specific as possible.
SPACE for UNIT OF MEASURE 1
Examples of units of measure would include the following:
Number of deaths of infants (1 year of age or younger) per 1,000 live births
Number of live births to 15- to 17-year-olds per 1,000 population
Percent of third grade children who have received protective sealants on at least one permanent molar tooth
Percent of 19- to 35-month-olds who have received the full schedule of age appropriate immunizations against Measles, Mumps, Rubella, Polio, Diphtheria, Tetanus, Pertussis, Haemophilus Influenza, and Hepatitis B
Number of children without health insurance
Percent of children, ages 2-5), receiving WIC services with a Body Mass Index (BMI) at or above the 85th percentile
Percent of infants born to pregnant women receiving prenatal care beginning in the first trimester
Enter statewide data for Outcome Indicator 1 for the most current year available and up to the previous 5 years below.
Year [dropdown] Type of Indicator[dropdown] Space for data points
2009 Rate
2008 Percent
2007 Number
2006 Other
2005
2004
2003
2002
2001
2000
What trend have you seen in Outcome Indicator 1 to date?
SPACE FOR TREND DESCRIPTION
What factors do you think have driven this trend?
SPACE FOR TREND FACTORS
Which ECCS strategy or set of related strategies is believed to produce a change in Outcome Indicator 1? Please be as specific as possible.
SPACE FOR strategies ECCS DOMAIN THE strategy ADDRESSES [Check all that apply for each activity]
Early Care and Education
Social-Emotional Development/Mental Health
Family Support Services
Parenting Education
Medical Homes/Health Care
Examples of specific types of ECCS strategies would include the following:
Research, identify, and implement presumptive eligibility within private and public systems to enroll eligible families into public insurance programs
Develop and implement a systematic, statewide process of universal screening of children at birth, at 2 years old, and at school entry
Develop statewide standards for conducting developmental screenings and provide monitoring to ensure appropriate use of screening standards among providers
Require that all State or community funding for family support programs go only to programs that can meet evidence-based or promising practices
Develop a set of core competencies in early childhood mental health and social-emotional development and incentives for encouraging more providers to achieve these competencies
a. Why do you believe the systems-building strategy or set of strategies reported in Question 7 will produce a measurable change in Outcome Indicator 1 within the next 5–10 years?
SPACE FOR LINK BTW ACTIVITY AND INDICATOR
b. How much do you think the future trend in Outcome Indicator 1 will be related to external forces over the next 5–10 years, such as the political climate, local economy, or other types of initiatives that may be underway in your State?
SPACE FOR IMPACT OF EXTERNAL FORCES
Which ECCS State Team members or other key partners are most directly involved in positively changing Outcome Indicator 1?
NAME TITLE AGENCY/ORGANIZATION
SPACE FOR NAME 1 SPACE FOR TITLE 1 SPACE FOR AGENCY/ORG 1
SPACE FOR NAME 2 SPACE FOR TITLE 2 SPACE FOR AGENCY/ORG 2
SPACE FOR NAME 3 SPACE FOR TITLE 3 SPACE FOR AGENCY/ORG 3
SPACE FOR NAME 4 SPACE FOR TITLE 4 SPACE FOR AGENCY/ORG 4
SPACE FOR NAME 5 SPACE FOR TITLE 5 SPACE FOR AGENCY/ORG 5
outcome INDICator 2
Please list Outcome Indicator 2 in the space below:
SPACE FOR INDICATOR 2
Examples of statewide childhood and family outcome indicators would include the following:
Infant mortality rate
Teen birth rate
Percent of children with dental sealants
Percent of children up-to-date on immunizations
Percent of uninsured children
Percent of overweight children in WIC
Percent of infants born to pregnant women receiving early prenatal care
What is the unit of measurement for Outcome Indicator 2? Please be as specific as possible.
SPACE FOR UNIT OF MEASURE 2
Examples of units of measure would include the following:
Number of deaths of infants (1 year of age or younger) per 1,000 live births
Number of live births to 15- to 17-year-olds per 1,000 population
Percent of third grade children who have received protective sealants on at least one permanent molar tooth
Percent of 19- to 35-month-olds who have received the full schedule of age appropriate immunizations against Measles, Mumps, Rubella, Polio, Diphtheria, Tetanus, Pertussis, Haemophilus Influenza, and Hepatitis B
Number of children without health insurance
Percent of children, ages 2-5), receiving WIC services with a Body Mass Index (BMI) at or above the 85th percentile
Percent of infants born to pregnant women receiving prenatal care beginning in the first trimester
Enter statewide data for outcome indicator 2 for the most current year available and up to the previous 5 years below.
Year [dropdown] Type of Indicator [dropdown] Space for data points
2009 Rate
2008 Percent
2007 Number
2006 Other
2005
2004
2003
2002
2001
2000
a. What trend have you seen in Outcome Indicator 2 to date?
SPACE FOR TREND DESCRIPTION
b. What factors do you think have driven this trend?
SPACE FOR TREND FACTORS
Which ECCS strategy or set of related strategies is believed to produce a change in Outcome Indicator 2? Please be as specific as possible.
SPACE FOR ACTIVITIES ECCS DOMAIN THE ACTIVITY ADDRESSES [Check all the apply for each activity]
Early Care and Education
Social-Emotional Development/Mental Health
Family Support Services
Parenting Education
Medical Homes/Health Care
Examples of specific types of ECCS strategies would include the following:
Research, identify, and implement presumptive eligibility within private and public systems to enroll eligible families into public insurance programs
Develop and implement a systematic, statewide process of universal screening of children at birth, at 2 years old, and at school entry
Develop statewide standards for conducting developmental screenings and provide monitoring to ensure appropriate use of screening standards among providers
Require that all State or community funding for family support programs go only to programs that can meet evidence-based or promising practices
Develop a set of core competencies in early childhood mental health and social-emotional development and incentives for encouraging more providers to achieve these competencies
a. Why do you believe the system-building strategy or set of strategies reported in Question 14 will produce a measurable change in Outcome Indicator 2 within the next 5–10 years?
SPACE FOR SPACE FOR LINK BTW ACTIVITY AND INDICATOR
b. How much do you think the future trend in Outcome Indicator 2 will be related to external forces over the next 5–10 years, such as the political climate, local economy, or other types of initiatives that may be underway in your State?
SPACE FOR IMPACT OF EXTERNAL FORCES
Which ECCS State Team members or other key partners are most directly involved in positively changing Outcome Indicator 2?
NAME TITLE AGENCY/ORGANIZATION
SPACE FOR NAME 1 SPACE FOR TITLE 1 SPACE FOR AGENCY/ORG 1
SPACE FOR NAME 2 SPACE FOR TITLE 2 SPACE FOR AGENCY/ORG 2
SPACE FOR NAME 3 SPACE FOR TITLE 3 SPACE FOR AGENCY/ORG 3
SPACE FOR NAME 4 SPACE FOR TITLE 4 SPACE FOR AGENCY/ORG 4
SPACE FOR NAME 5 SPACE FOR TITLE 5 SPACE FOR AGENCY/ORG 5
outcome indicator 3
Please list outcome indicator 3 in the space below:
SPACE FOR INDICATOR 3
Examples of statewide childhood and family outcome indicators would include the following:
Infant mortality rate
Teen birth rate
Percent of children with dental sealants
Percent of children up-to-date on immunizations
Percent of uninsured children
Percent of overweight children in WIC
Percent of infants born to pregnant women receiving early prenatal care
What is the unit of measurement for Outcome Indicator 3? Please be as specific as possible.
SPACE FOR UNIT OF MEASURE 3
Examples of units of measure would include the following:
Number of deaths of infants (1 year of age or younger) per 1,000 live births
Number of live births to 15- to 17-year-olds per 1,000 population
Percent of third grade children who have received protective sealants on at least one permanent molar tooth
Percent of 19- to 35-month-olds who have received the full schedule of age appropriate immunizations against Measles, Mumps, Rubella, Polio, Diphtheria, Tetanus, Pertussis, Haemophilus Influenza, and Hepatitis B
Number of children without health insurance
Percent of children, ages 2-5), receiving WIC services with a Body Mass Index (BMI) at or above the 85th percentile
Percent of infants born to pregnant women receiving prenatal care beginning in the first trimester
Enter statewide data for Outcome Indicator 3 for the most current year available and up to the previous 5 years below.
Year [dropdown] Type of Indicator [dropdown] Space for data points
2009 Rate
2008 Percent
2007 Number
2006 Other
2005
2004
2003
2002
2001
2000
a. What trend have you seen in Outcome Indicator 3 to date?
SPACE FOR TREND DESCRIPTION
b. What factors do you think have driven this trend?
SPACE FOR TREND FACTORS
Which ECCS strategy or set of related strategies is believed to produce a change in Outcome Indicator 3? Please be as specific as possible.
SPACE FOR ACTIVITIES ECCS DOMAIN THE ACTIVITY ADDRESSES [Check all that apply for each activity]
Early Care and Education
Social-Emotional Development/Mental Health
Family Support Services
Parenting Education
Medical Homes/Health Care
Examples of specific types of ECCS strategies would include the following:
Research, identify, and implement presumptive eligibility within private and public systems to enroll eligible families into public insurance programs
Develop and implement a systematic, statewide process of universal screening of children at birth, at 2 years old, and at school entry
Develop statewide standards for conducting developmental screenings and provide monitoring to ensure appropriate use of screening standards among providers
Require that all State or community funding for family support programs go only to programs that can meet evidence-based or promising practices
Develop a set of core competencies in early childhood mental health and social-emotional development and incentives for encouraging more providers to achieve these competencies
a. Why do you believe the systems-building strategy or set of strategies reported in Question 21 will produce a measurable change in Outcome Indicator 3 within the next 5–10 years?
SPACE FOR SPACE FOR LINK BTW ACTIVITY AND INDICATOR
b. How much do you think the future trend in Outcome Indicator 3 will be related to external forces over the next 5–10 years, such as the political climate, local economy, or other types of initiatives that may be underway in your State?
SPACE FOR IMPACT OF EXTERNAL FORCES
Which ECCS State Team members or other key partners are most directly involved in positively changing Outcome Indicator 3?
NAME TITLE AGENCY/ORGANIZATION
SPACE FOR NAME 1 SPACE FOR TITLE 1 SPACE FOR AGENCY/ORG 1
SPACE FOR NAME 2 SPACE FOR TITLE 2 SPACE FOR AGENCY/ORG 2
SPACE FOR NAME 3 SPACE FOR TITLE 3 SPACE FOR AGENCY/ORG 3
SPACE FOR NAME 4 SPACE FOR TITLE 4 SPACE FOR AGENCY/ORG 4
SPACE FOR NAME 5 SPACE FOR TITLE 5 SPACE FOR AGENCY/ORG 5
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Amy Brown |
| File Modified | 0000-00-00 |
| File Created | 2021-02-02 |