CMS-10028C.Resource Report Form - Crosswalk

Attachment C

Changes to the Resource Report Form (CMS-10028C)

Current Form	Changes to Form	Reason for Change
Top Block	Added Instructions. Complete Only One RR Form for the Entire State. Do Not Submit Sponsoring-Agency-Level or Within-State-Regional Resource Reports. All Person Counts Should Reflect Active Counselors, Coordinators, Other Staff as of the End of Each Grant Year (31 March). The Unique Count of Counselors Attending Any Update Training During the Grant Year Cannot Exceed the Grand Total Number of Counselors.	To improve quality of the entered data
Name of Grantee Agency Reporting	State Grantee Name	Reworded for clarity
State	State Code	Reworded to capture specifically the 2 character state FIPS code
6-month Report Period: _____ / _____ to ____ / ______ month / year month / year	12 Month Period for This Report From: 04 / 01 / To: 03 / 31 /	Change from two six-month reports to one 12-month report. Simplified since will always know the Month and Day, only require year entries
Person Completing Report	Person Completing Report	Same – re-positioned
Title	Title	Same – re-positioned
Telephone No.	Telephone Number	Reworded– re-positioned
Section 1
SECTION 1 - NUMBER OF ACTIVE COUNSELORS AND HOURS	Section 1 Number of Active Counselors And Hours As of 31 March	Reworded and more specific instructions
a. # Volunteer Counselors	A. Number of Volunteer Counselors	Reworded for clarity
b. # SHIP-Paid Counselors	B. Number of SHIP-Paid Counselors	Reworded for clarity
c. # In-kind Paid Counselors	C. Number of In-Kind-Paid Counselors	Reworded for clarity
TOTAL # Counselors (a+b+c)	Total Number of Counselors - A+B+C	Reworded for clarity. Will be auto-calculated, not entered
d. Volunteer Counselor Hours	D. Volunteer Counselor Hours	Reworded for clarity
e. SHIP-Paid Counselor Hours	E. SHIP-Paid Counselor Hours	Reworded for clarity
f. In-kind Paid Counselor Hours	F. In-Kind-Paid Counselor Hours	Reworded for clarity
Previously Missing	Total Counselor Hours - D+E+F	Previously missing. Will be auto-calculated, not entered
Section 2
SECTION 2 - NUMBER OF LOCAL COORDINATORS/SPONSORS AND HOURS	Section 2 Number of Local Coordinators / Sponsors and Hours As of 31 March	Reworded and more specific instructions
a. # Volunteer (unpaid) Coordinators	A. Number of Volunteer (Unpaid) Coordinators	Reworded for clarity
b. # SHIP-Paid Coordinators	B. Number of SHIP-Paid Coordinators	Reworded for clarity
c. # In-kind Paid Coordinators	C. Number of In-Kind-Paid Coordinators	Reworded for clarity
TOTAL # Coordinators (a+b+c)	Total Number of Coordinators - A+B+C	Reworded for clarity. Will be auto-calculated, not entered
d. Volunteer (unpaid) Coordinator Hours	D. Volunteer (Unpaid) Coordinator Hours	Same
e. SHIP-Paid Coordinator Hours	E. SHIP-Paid Coordinator Hours	Same
f. In-kind Paid Coordinator Hours	F. In-Kind-Paid Coordinator Hours	Same
	Total Coordinator Hours - D+E+F	Previously missing. Will be auto-calculated, not entered
Section 3
SECTION 3 - NUMBER OF OTHER PAID STAFF AND HOURS	Section 3 Number of Other Paid and Volunteer Staff And Hours As of 31 March	Reworded and more specific instructions
	A. Number of Volunteer Other Staff	Added per frequent request from State SHIPs to document volunteers other than counselors and coordinators
a. # SHIP-Paid Other Staff	B. Number of SHIP-Paid Other Staff	Reworded for clarity
b. # In-kind Paid Other Staff	C. Number of In-Kind-Paid Other Staff	Reworded for clarity
	Total Number of Other Staff - A+B+C	Previously missing. Will be auto-calculated, not entered
	D. Volunteer Other Staff Hours	Added per frequent request from State SHIPs to document volunteer hours other than counselor hours and coordinator hours
c. SHIP-Paid Other Staff Hours	E. SHIP-Paid Other Staff Hours	Same – new position
d. In-kind Paid Other Staff Hours	F. In-Kind-Paid Other Staff Hours	Same – new position
	Total Other Staff Hours - D+E+F	Previously missing. Will be auto-calculated, not entered
Section 4
SECTION 4 - COUNSELOR TRAININGS	Section 4 - Counselor Trainings	Same
	Added Instructions. Note Item E should represent the number (unduplicated) of counselors who attended at least one update training during the full 12 month period. Please do not count a counselor more than once, even if he/she attended multiple update trainings. Cannot exceed grand total number of counselors.	To improve quality of the entered data.
a. # Initial Training(s) for New SHIP Counselors	A. Number of Initial Trainings for New SHIP Counselors	Reworded for clarity
b. # New SHIP Counselors Attending Initial Training(s)	B. Number of New SHIP Counselors Attending Initial Trainings	Reworded for clarity
c. Total # Counselor Hours in Initial Training(s)	C. Total Number of Counselor Hours in Initial Trainings	Reworded for clarity
d. # Update Training(s) for SHIP Counselors	D. Number of Update Trainings for SHIP Counselors	Reworded for clarity
e. # SHIP Counselors Attending Update Training(s)	E. Number of SHIP Counselors Attending Update Trainings	Reworded for clarity
f. Total # Counselor Hours in Update Training(s)	F. Total Number of Counselor Hours in Update Trainings	Reworded for clarity
Section 5
SECTION 5 - NUMBER OF ACTIVE COUNSELORS WITH THE FOLLOWING CHARACTERISTICS	Section 5 - Number of Total Active Counselors (SHIP-Paid, In-Kind-Paid, and Volunteer Counselors) with the Following Characteristics	Reworded for clarity and for increased precision of the reported data
a. Years of SHIP Service: Less than 1 year 1 year up to 3 years 3 years up to 5 years Over 5 years Not collected	Years of SHIP Service Less Than 1 Year 1 Year Up to 3 Years 3 Years Up to 5 Years More Than 5 Years Not Collected	One option slightly reworded for clarity
b. Age: Less than 65 years of age 65 years or older Not collected	Counselor Age Less Than 65 Years of Age 65 Years or Older Not Collected	Title bar reworded for clarity
c. Disability Status Disabled Not disabled Not collected	Counselor Disability Disabled Not Disabled Not Collected	Title bar reworded for clarity
d. Gender Female Male Not collected	Counselor Gender Female Male Not Collected	Title bar reworded for clarity
e. Ethnicity/Race American Indian or Alaska Native Asian Black or African-American Hispanic or Latino Native Hawaiian or other Pacific Islander White Other Not collected	Counselor Race – Ethnicity Hispanic, Latino, or Spanish Origin White, Non-Hispanic Black, African American American Indian or Alaska Native Asian Indian Chinese Filipino Japanese Korean Vietnamese Native Hawaiian Guamanian or Chamorro Samoan Other Asian Other Pacific Islander Some Other Race-Ethnicity More Than One Race-Ethnicity Not Collected	Title bar reworded for clarity Response options expanded to approximate Census 2010 categories and to allow more direct comparisons to client race-ethnicity distributions to assess diversity of counselors recruited to assist clients of various race-ethnicity backgrounds
	Counselor Speaks Another Language Language Other Than English English Speaker Only Not Collected	Added data element. To allow more direct comparisons to the client language data element to assess efforts to reach various hard-to-reach or language-isolated client groups.
Section 6
SECTION 6 - WEB-SITE VISITORS (if applicable) Total # of visits/visitors to web-site during the 6-month report period: 1st Quarter Web Site Visitors 2nd Quarter Web Site Visitors	Dropped Entire Section 6	Not deemed mission-critical. Difficulty for states to identify unique visitors vs page-views etc.
Section 7
SECTION 7 - DID YOU WORK WITH ANY PARTNERS IN PROVIDING ANY SHIP SERVICES? Yes No If yes, check the type of partner involved (check all that apply): Training Counseling Enrollment/application assistance (e.g. Medicare Prescription Drug Coverage activities) Presentations Outreach Other Please include details of your partnership involvement in narrative form. Include names of partnership organizations when possible	Dropped Entire Section 7	CMS feels that the National SHIP program adequately captures this information twice a year in the State SHIP Response to Grant Application and in the State SHIP Midterm Report
Section 8
SECTION 8 - ACTIVITIES, LESSONS LEARNED, SIGNIFICANT EVENTS (Briefly describe on separate sheets. This section should address the following four topic areas: outreach (including activities targeted at underserved populations), information access and dissemination, training, and partnerships and networking.)	Dropped Entire Section 8	CMS feels that the National SHIP program adequately captures this information twice a year in the State SHIP Response to Grant Application and in the State SHIP Midterm Report

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