2 Demographic Forms

Health Resources and Services Administration

Maternal and Child Health Bureau

Discretionary Grant Performance Measures

OMB No. 0915-0298

Expires:_________

Attachment C

Part 2-

Financial and Demographic Data Elements

OMB Clearance Package

.

FORM 1

MCHB PROJECT BUDGET DETAILS FOR FY _______

1.	MCHB GRANT AWARD AMOUNT					$
2.	UNOBLIGATED BALANCE					$
3.	MATCHING FUNDS (Required: Yes [ ] No [ ] If yes, amount)					$
	A. Local funds				$
	B. State funds				$
	C. Program Income				$
	D. Applicant/Grantee Funds				$
	E. Other funds:				$
4.	OTHER PROJECT FUNDS (Not included in 3 above)					$
	A. Local funds				$
	B. State funds				$
	C. Program Income (Clinical or Other)				$
	D. Applicant/Grantee Funds (includes in-kind)				$
	E. Other funds (including private sector, e.g., Foundations)				$
5.	TOTAL PROJECT FUNDS (Total lines 1 through 4)					$
6.	FEDERAL COLLABORATIVE FUNDS (Source(s) of additional Federal funds contributing to the project)					$
	A. Other MCHB Funds (Do not repeat grant funds from Line 1)
		1) Special Projects of Regional and National Significance (SPRANS)			$
		2) Community Integrated Service Systems (CISS)			$
		3) State Systems Development Initiative (SSDI)			$
		4) Healthy Start			$
		5) Emergency Medical Services for Children (EMSC)			$
		6) Traumatic Brain Injury			$
		7) State Title V Block Grant			$
		8) Other:			$
		9) Other:			$
		10) Other:			$
	B. Other HRSA Funds
		1) HIV/AIDS			$
		2) Primary Care			$
		3) Health Professions			$
		4) Other:			$
		5) Other:			$
		6) Other:			$
	C. Other Federal Funds
		1) Center for Medicare and Medicaid Services (CMS)			$
		2) Supplemental Security Income (SSI)			$
		3) Agriculture (WIC/other)			$
		4) Administration for Children and Families (ACF)			$
		5) Centers for Disease Control and Prevention (CDC)			$
		6) Substance Abuse and Mental Health Services Administration (SAMHSA)			$
		7) National Institutes of Health (NIH)			$
		8) Education			$
		9) Bioterrorism
		10) Other:			$
		11) Other:			$
		12) Other			$
7.	TOTAL COLLABORATIVE FEDERAL FUNDS				$

INSTRUCTIONS FOR COMPLETION OF FORM 1

MCH BUDGET DETAILS FOR FY ____

Line 1. Enter the amount of the Federal MCHB grant award for this project.

Line 2. Enter the amount of carryover (e.g, unobligated balance) from the previous year’s award, if any. New awards do not enter data in this field, since new awards will not have a carryover balance.

Line 3. If matching funds are required for this grant program list the amounts by source on lines 3A through 3E as appropriate. Where appropriate, include the dollar value of in-kind contributions.

Line 4. Enter the amount of other funds received for the project, by source on Lines 4A through 4E, specifying amounts from each source. Also include the dollar value of in-kind contributions.

Line 5. Displays the sum of lines 1 through 4.

Line 6. Enter the amount of other Federal funds received on the appropriate lines (A.1 through C.12) other than the MCHB grant award for the project. Such funds would include those from other Departments, other components of the Department of Health and Human Services, or other MCHB grants or contracts.

Line 6C.1. Enter only project funds from the Center for Medicare and Medicaid Services. Exclude Medicaid reimbursement, which is considered Program Income and should be included on Line 3C or 4C.

If lines 6A.8-10, 6B .4-6, or 6C.10-12 are utilized, specify the source(s) of the funds in the order of the amount provided, starting with the source of the most funds. .

Line 7. Displays the sum of lines in 6A.1 through 6C.12.

FORM 2

PROJECT FUNDING PROFILE

		FY_____				FY_____				FY_____				FY_____				FY_____
		Budgeted		Expended		Budgeted		Expended		Budgeted		Expended		Budgeted		Expended		Budgeted		Expended
1	MCHB Grant Award Amount Line 1, Form 2	$		$		$		$		$		$		$		$		$		$
2	Unobligated Balance Line 2, Form 2	$		$		$		$		$		$		$		$		$		$
3	Matching Funds (If required) Line 3, Form 2	$		$		$		$		$		$		$		$		$		$
4	Other Project Funds Line 4, Form 2	$		$		$		$		$		$		$		$		$		$
5	Total Project Funds Line 5, Form 2	$		$		$		$		$		$		$		$		$		$
6	Total Federal Collaborative Funds Line 7, Form 2	$		$		$		$		$		$		$		$		$		$

INSTRUCTIONS FOR THE COMPLETION OF FORM 2

PROJECT FUNDING PROFILE

Instructions:

Complete all required data cells. If an actual number is not available, use an estimate. Explain all estimates in a note.

The form is intended to provide funding data at a glance on the estimated budgeted amounts and actual expended amounts of an MCH project.

For each fiscal year, the data in the columns labeled Budgeted on this form are to contain the same figures that appear on the Application Face Sheet (for a non-competing continuation) or the Notice of Grant Award (for a performance report). The lines under the columns labeled Expended are to contain the actual amounts expended for each grant year that has been completed.

FORM 3

BUDGET DETAILS BY TYPES OF INDIVIDUALS SERVED

For Projects Providing Direct Health Care, Enabling, or Population-based Services

	FY________		FY________
Target Population(s)	$ Budgeted	$ Expended	$ Budgeted	$ Expended
Pregnant Women (All Ages)
Infants (Age 0 to 1 year)
Children and Youth (Age 1 year to 25 years)
CSHCN Infants (Age 0 to 1 year )
CSHCN Children and Youth (Age 1 year to 25 years)
Non-pregnant Women (Age 25 and over)
Other
TOTAL

INSTRUCTIONS FOR COMPLETION OF FORM 3

BUDGET DETAILS BY TYPES OF INDIVIDUALS SERVED

For Projects Providing Direct Health Care, Enabling, or Population-based Services

If the project provides direct health care services, complete all required data cells for all years of the grant. If an actual number is not available make an estimate. Please explain all estimates in a note.

All ages are to be read from x to y, not including y. For example, infants are those from birth to 1, and

children and youth are from age 1 to 25.

Enter the budgeted amounts for the appropriate fiscal year, for each targeted population group. Note that the Total for each budgeted column is to be the same as that appearing in the corresponding budgeted column in Form 2, Line 5.

Enter the expended amounts for the appropriate fiscal year that has been completed for each target

population group. Note that the Total for the expended column is to be the same as that appearing in the corresponding expended column in Form 2, Line 5.

.

FORM 4

PROJECT BUDGET AND EXPENDITURES

By Types of Services

		FY _____				FY _____
	TYPES OF SERVICES	Budgeted		Expended		Budgeted		Expended
I.	Direct Health Care Services (Basic Health Services and Health Services for CSHCN.)	$		$		$		$
II.	Enabling Services (Transportation, Translation, Outreach, Respite Care, Health Education, Family Support Services, Purchase of Health Insurance, Case Management, and Coordination with Medicaid, WIC and Education.)	$		$		$		$
III.	Population-Based Services (Newborn Screening, Lead Screening, Immunization, Sudden Infant Death Syndrome Counseling, Oral Health, Injury Prevention, Nutrition, and Outreach/Public Education.)	$		$		$		$
IV.	Infrastructure Building Services (Needs Assessment, Evaluation, Planning, Policy Development, Coordination, Quality Assurance, Standards Development, Monitoring, Training, Applied Research, Systems of Care, and Information Systems.)	$		$		$		$
V.	TOTAL	$		$		$		$

INSTRUCTIONS FOR THE COMPLETION OF FORM 4

PROJECT BUDGET AND EXPENDITURES BY TYPES OF SERVICES

Complete all required data cells for all years of the g rant. If an actual number is not available, make an estimate. Please explain all estimates in a note. Administrative dollars should be allocated to the appropriate level(s) of the pyramid on lines I, II, II or IV. If an estimate of administrative funds use is necessary, one method would be to allocate those dollars to Lines I, II, III and IV at the same percentage as program dollars are allocated to Lines I through IV.

Note: Lines I, II and II are for projects providing services. If grant funds are used to build the infrastructure for direct care delivery, enabling or population-based services, these amounts should be reported in Line IV (i.e., building data collection capacity for newborn hearing screening).

Line I Direct Health Care Services - enter the budgeted and expended amounts for the appropriate fiscal year completed and budget estimates only for all other years.

Direct Health Care Services are those services generally delivered one-on-one between a health professional and a patient in an office, clinic or emergency room which may include primary care physicians, registered dietitians, public health or visiting nurses, nurses certified for obstetric and pediatric primary care, medical social workers, nutritionists, dentists, sub-specialty physicians who serve children with special health care needs, audiologists, occupational therapists, physical therapists, speech and language therapists, specialty registered dietitians. Basic services include what most consider ordinary medical care, inpatient and outpatient medical services, allied health services, drugs, laboratory testing, x-ray services, dental care, and pharmaceutical products and services. State Title V programs support - by directly operating programs or by funding local providers - services such as prenatal care, child health including immunizations and treatment or referrals, school health and family planning. For CSHCN, these services include specialty and sub-specialty care for those with HIV/AIDS, hemophilia, birth defects, chronic illness, and other conditions requiring sophisticated technology, access to highly trained specialists, or an array of services not generally available in most communities.

Line II Enabling Services - enter the budgeted and expended amounts for the appropriate fiscal year completed and budget estimates only for all other years.

Enabling Services allow or provide for access to and the derivation of benefits from, the array of basic health care services and include such things as transportation, translation services, outreach, respite care, health education, family support services, purchase of health insurance, case management, coordination of with Medicaid, WIC and educations. These services are especially required for the low income, disadvantaged, geographically or culturally isolated, and those with special and complicated health needs. For many of these individuals, the enabling services are essential - for without them access is not possible. Enabling services most commonly provided by agencies for CSHCN include transportation, care coordination, translation services, home visiting, and family outreach. Family support activities include parent support groups, family training workshops, advocacy, nutrition and social work.

Line III Population-Based Services - enter the budgeted and expended amounts for the appropriate fiscal year completed and budget estimates only for all other years.

Population Based Services are preventive interventions and personal health services, developed and available for the entire MCH population of the State rather than for individuals in a one-on-one situation. Disease prevention, health promotion, and statewide outreach are major components. Common among these services are newborn screening, lead screening, immunization, Sudden Infant Death Syndrome counseling, oral health, injury prevention, nutrition and outreach/public education. These services are generally available whether the mother or child receives care in the private or public system, in a rural clinic or an HMO, and whether insured or not.

Line IV Infrastructure Building Services - enter the budgeted and expended amounts for the appropriate fiscal year completed and budget estimates only for all other years.

Infrastructure Building Services are the base of the MCH pyramid of health services and form its foundation. They are activities directed at improving and maintaining the health status of all women and children by providing support for development and maintenance of comprehensive health services systems and resources including development and maintenance of health services standards/guidelines, training, data and planning systems. Examples include needs assessment, evaluation, planning, policy development, coordination, quality assurance, standards development, monitoring, training, applied research, information systems and systems of care. In the development of systems of care it should be assured that the systems are family centered, community based and culturally competent.

Line V Total – Displays the total amounts for each column, budgeted for each year and expended for each year completed.

FORM 5

NUMBER OF INDIVIDUALS SERVED (UNDUPLICATED)

By Type of Individual and Source of Primary Insurance Coverage

For Projects Providing Direct Health Care, Enabling or Population-based Services

Reporting Year________

Table 1

Pregnant Women Served	(a) Number Served	(b) Total Served	(c) Title XIX %	(d) Title XXI %	(e) Private/ Other %	(f) None %	(g) Unknown %
Pregnant Women (All Ages)
10-14
15-19
20-24
25-34
35-44
45 +

Table 2

Infants, Children and Youth Served	(a) Number Served	(b) Total Served	(c) Title XIX %	(d) Title XXI %	(e) Private/ Other %	(f) None %	(g) Unknown %
Infants <1
Children and Youth 1 to 25 years
12-24 months
25 months- 4 years
5-9
10-14
15-19
20-24

Table 3

CSHCN Infants, Children and Youth Served	(a) Number Served	(b) Total Served	(c) Title XIX %	(d) Title XXI %	(e) Private/ Other %	(f) None %	(g) Unknown %
Infants <1 yr
Children and Youth 1 to 25 years
12-24 months
25 months- 4 years
5-9
10-14
15-19
20-24

Table 4

Women Served	(a) Number Served	(b) Total Served	(c) Title XIX %	(d) Title XXI %	(e) Private/ Other %	(f) None %	Unknown % (g)
Women 25+
25-29
30-34
35-44
45-54
55-64
65+

Table 5

Other	(a) Number Served	(b) Total Served	(c) Title XIX %	(d) Title XXI %	(e) Private/ Other %	(f) None %	Unknown % (g)
Men 25+

TOTAL SERVED: ________________

INSTRUCTIONS FOR THE COMPLETION OF FORM 5

NUMBER OF INDIVIDUALS SERVED (UNDUPLICATED)

By Type of Individual and Source of Primary Insurance Coverage

For Projects Providing Direct Health Care, Enabling or Population-based Services

Enter data into all required (unshaded) data cells. If an actual number is not available, make an estimate. Please explain all estimates, in a note.

Note that ages are expressed as either x to y, (i.e., 1 to 25, meaning from age 1 up to age 25, but not including 25) or x – y (i.e., 1 – 4 meaning age 1 through age 4). Also, symbols are used to indicate directions. For example, <1 means less than 1, or from birth up to, but not including age 1. On the other hand, 45+ means age 45 and over.

1. At the top of the Form, the Line Reporting Year displays the year for which the data applies.

2. In Column (a), enter the unduplicated count of individuals who received a direct service from the project regardless of the primary source of insurance coverage. These services would generally be included in the top three levels of the MCH pyramid (the fourth, or base level, would generally not contain direct services) and would include individuals served by total dollars reported on Form 3, Line 5.

3. In Column (b), the total number of the individuals served is summed from Column (a).

4. In the remaining columns, report the percentage of those individuals receiving direct health care, enabling or population-based services, who have as their primary source of coverage:

Column (c): Title XIX (includes Medicaid expansion under Title XXI)

Column (d): Title XXI

Column (e): Private or other coverage

Column (f): None

Column (g): Unknown

These may be estimates. If individuals are covered by more than one source of insurance, they should be listed under the column of their primary source.

REVISED FORM 6

MATERNAL & CHILD HEALTH DISCRETIONARY GRANT

PROJECT ABSTRACT

FOR FY____

PROJECT:__________________________________________________________________________________

I. PROJECT IDENTIFIER INFORMATION

1. Project Title:

2. Project Number:

3. E-mail address:

II. BUDGET

1. MCHB Grant Award $_____________

(Line 1, Form 2)

2. Unobligated Balance $_____________

(Line 2, Form 2)

3. Matching Funds (if applicable) $_____________

(Line 3, Form 2)

4. Other Project Funds $_____________

(Line 4, Form 2)

5. Total Project Funds $_____________

(Line 5, Form 2)

III. TYPE(S) OF SERVICE PROVIDED (Choose all that apply)

[ ] Direct Health Care Services

[ ] Enabling Services

[ ] Population-Based Services

[ ] Infrastructure Building Services

4. PROJECT DESCRIPTION OR EXPERIENCE TO DATE

A. Project Description

1. Problem (in 50 words, maximum):

2. Goals and Objectives: (List up to 5 major goals and time-framed objectives per goal for the project)

Goal 1:

Objective 1:

Objective 2:

Goal 2:

Objective 1:

Objective 2:

Goal 3:

Objective 1:

Objective 2:

Goal 4:

Objective 1:

Objective 2:

Goal 5:

Objective 1:

Objective 2:

3. Activities planned to meet project goals

4. Specify the primary Healthy People 2010 objectives(s) (up to three) which this project addresses:

a.

b.

c.

5. Coordination (List the State, local health agencies or other organizations involved in the project and their roles)

6. Evaluation (briefly describe the methods which will be used to determine whether process and outcome objectives are met)

2. Continuing Grants ONLY

1. Experience to Date (For continuing projects ONLY):

2. Website URL and annual number of hits

a. ________ Number of web hits

b. _________ Number of unique visitors

V. KEY WORDS

VI. ANNOTATION

REVISED INSTRUCTIONS FOR THE COMPLETION OF FORM 6

PROJECT ABSTRACT

NOTE: All information provided should fit into the space provided in the form. The completed form should be no more than 3 pages in length. Where information has previously been entered in forms 1 through 5, the information will automatically be transferred electronically to the appropriate place on this form.

Section I – Project Identifier Information

Project Title: Displays the title for the project.

Project Number: Displays the number assigned to the project (e.g., the grant number)

E-mail address: Displays the electronic mail address of the project director

Section II – Budget - These figures will be transferred from Form 1, Lines 1 through 5.

Section III - Types of Services

Indicate which type(s) of services your project provides, checking all that apply.

Section IV – Program Description OR Current Status (DO NOT EXCEED THE SPACE PROVIDED)

A. New Projects only are to complete the following items:

1. A brief description of the project and the problem it addresses, such as preventive and primary care services for pregnant women, mothers, and infants; preventive and primary care services for children; and services for Children with Special Health Care Needs.

2. Provide up to 5 goals of the project, in priority order. Examples are: To reduce the barriers to the delivery of care for pregnant women, to reduce the infant mortality rate for minorities and “services or system development for children with special healthcare needs.” MCHB will capture annually every project’s top goals in an information system for comparison, tracking, and reporting purposes; you must list at least 1 and no more than 5 goals. For each goal, list the two most important objectives. The objective must be specific (i.e., decrease incidence by 10%) and time limited (by 2005).

3. Displays the primary Healthy people 2010 goal(s) that the project addresses.

4. Describe the programs and activities used to attain the goals and objectives, and comment on innovation, cost, and other characteristics of the methodology, proposed or are being implemented. Lists with numbered items can be used in this section.

5. Describe the coordination planned and carried out, in the space provided, if applicable, with appropriate State and/or local health and other agencies in areas(s) served by the project.

6. Briefly describe the evaluation methods that will be used to assess the success of the project in attaining its goals and objectives.

2. For continuing projects ONLY:

1. Provide a brief description of the major activities and accomplishments over the past year (not to exceed 200 words).

2. If applicable, provide the number of hits by unique visitors to the website (or section of website) funded by MCHB for the past year.

Section V – Key Words

Provide up to 10 key words to describe the project, including populations served. Choose key words from the included list.

Section VI – Annotation

Provide a three- to five-sentence description of your project that identifies the project’s purpose, the needs and problems, which are addressed, the goals and objectives of the project, the activities, which will be used to attain the goals, and the materials, which will be developed.

REVISED FORM 7

DISCRETIONARY GRANT PROJECT

SUMMARY DATA

1. Project Service Focus

[ ] Urban/Central City [ ] Suburban [ ] Metropolitan Area (city & suburbs)

[ ] Rural [ ] Frontier [ ] Border (US-Mexico)

2. Project Scope

[ ] Local [ ] Multi-county [ ] State-wide

[ ] Regional [ ] National

3. Grantee Organization Type

[ ] State Agency

[ ] Community Government Agency

[ ] School District

[ ] University/Institution Of Higher Learning (Non-Hospital Based)

[ ] Academic Medical Center

[ ] Community-Based Non-Governmental Organization (Health Care)

[ ] Community-Based Non-Governmental Organization (Non-Health Care)

[ ] Professional Membership Organization (Individuals Constitute Its Membership)

[ ] National Organization (Other Organizations Constitute Its Membership)

[ ] National Organization (Non-Membership Based)

[ ] Independent Research/Planning/Policy Organization

[ ] Other _________________________________________________________

4. Project Infrastructure Focus (from MCH Pyramid) if applicable

[ ] Guidelines/Standards Development And Maintenance

[ ] Policies And Programs Study And Analysis

[ ] Synthesis Of Data And Information

[ ] Translation Of Data And Information For Different Audiences

[ ] Dissemination Of Information And Resources

[ ] Quality Assurance

[ ] Technical Assistance

[ ] Training

[ ] Systems Development

[ ] Other

5. Demographic Characteristics of Project Participants

Indicate the service level:

D irect Health Care Services	Population-Based Services
Enabling Services	Infrastructure Building Services

RACE (Indicate all that apply)

ETHNICITY

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

More than One Race

Unrecorded

Total

Hispanic or Latino

Not Hispanic or Latino

Unrecorded

Total

Pregnant Women (All Ages)

Infants <1 year

Children and Youth 1 to 25 years

CSHCN Infants <1 year

CSHCN Children and Youth 1 to 25 years

Women 25+ years

Men 25+

TOTALS

6. Clients’ Primary Language(s)

__________________________________

__________________________________

__________________________________

7. Population Served

[ ] Homeless

[ ] Incarcerated

[ ] Severely Depressed

[ ] Migrant Worker/Population

[ ] Uninsured

[ ] Adolescent Pregnancy

[ ] Food Stamp Eligible

[ ] Other

7.8. Resource/TA and Training Centers ONLY

Answer all that apply.

1. Characteristics of Primary Intended Audience(s)

[ ] Policy Makers/Public Servants

[ ] Consumers

[ ] Providers/Professionals

b. Number of Requests Received/Answered: ___/____

3. Number of Continuing Education credits provided: _______

4. Number of Individuals/Participants Reached: _______

5. Number of Organizations Assisted: _______

6. Major Type of TA or Training Provided:

[ ] continuing education courses,

[ ] workshops,

[ ] on-site assistance,

[ ] distance learning classes

[ ] other

INSTRUCTIONS FOR THE COMPLETION OF FORM 7

PROJECT SUMMARY

Section 1 – Project Service Focus

Select all that apply

Section 2 – Project Scope

Choose the one that best applies to your project.

Section 3 – Grantee Organization Type

Choose the one that best applies to your organization.

Section 4 – Project Infrastructure Focus

If applicable, choose all that apply.

Section 5 – Demographic Characteristics of Project Participants

Indicate the service level for the grant program. Multiple selections may be made. Infrastructure cannot be selected by itself; it must be selected with another service level. Please fill in each of the cells as appropriate.

Direct Health Care Services are those services generally delivered one-on-one between a health professional and a patient in an office, clinic or emergency room which may include primary care physicians, registered dietitians, public health or visiting nurses, nurses certified for obstetric and pediatric primary care, medical social workers, nutritionists, dentists, sub-specialty physicians who serve children with special health care needs, audiologists, occupational therapists, physical therapists, speech and language therapists, specialty registered dietitians. Basic services include what most consider ordinary medical care, inpatient and outpatient medical services, allied health services, drugs, laboratory testing, x-ray services, dental care, and pharmaceutical products and services. State Title V programs support - by directly operating programs or by funding local providers - services such as prenatal care, child health including immunizations and treatment or referrals, school health and family planning. For CSHCN, these services include specialty and sub-specialty care for those with HIV/AIDS, hemophilia, birth defects, chronic illness, and other conditions requiring sophisticated technology, access to highly trained specialists, or an array of services not generally available in most communities.

Enabling Services allow or provide for access to and the derivation of benefits from, the array of basic health care services and include such things as transportation, translation services, outreach, respite care, health education, family support services, purchase of health insurance, case management, coordination of with Medicaid, WIC and educations. These services are especially required for the low income, disadvantaged, geographically or culturally isolated, and those with special and complicated health needs. For many of these individuals, the enabling services are essential - for without them access is not possible. Enabling services most commonly provided by agencies for CSHCN include transportation, care coordination, translation services, home visiting, and family outreach. Family support activities include parent support groups, family training workshops, advocacy, nutrition and social work.

Population Based Services are preventive interventions and personal health services, developed and available for the entire MCH population of the State rather than for individuals in a one-on-one situation. Disease prevention, health promotion, and statewide outreach are major components. Common among these services are newborn screening, lead screening, immunization, Sudden Infant Death Syndrome counseling, oral health, injury prevention, nutrition and outreach/public education. These services are generally available whether the mother or child receives care in the private or public system, in a rural clinic or an HMO, and whether insured or not.

Infrastructure Building Services are the base of the MCH pyramid of health services and form its foundation. They are activities directed at improving and maintaining the health status of all women and children by providing support for development and maintenance of comprehensive health services systems and resources including development and maintenance of health services standards/guidelines, training, data and planning systems. Examples include needs assessment, evaluation, planning, policy development, coordination, quality assurance, standards development, monitoring, training, applied research, information systems and systems of care. In the development of systems of care it should be assured that the systems are family centered, community based and culturally competent.

Section 6 – Clients Primary Language(s)

Indicate which languages your clients speak as their primary language, other than English, for the data provided in Section 6. List up to three languages.

Section 7 – Check all population served

Section 8 – Resource/TA and Training Centers (Only)

Answer all that apply.

FORM 8

(For Research Projects ONLY)

MATERNAL & CHILD HEALTH DISCRETIONARY GRANT

PROJECT ABSTRACT

FOR FY____

I. PROJECT IDENTIFIER INFORMATION

1. Project Title:

2. Project Number:

3. Project Director:

4. Principle Investigator(s), Discipline

II. BUDGET

1. MCHB Grant Award $_____________

(Line 1, Form 2)

2. Unobligated Balance $_____________

(Line 2, Form 2)

3. Matching Funds (if applicable) $_____________

(Line 3, Form 2)

3. Other Project Funds $_____________

(Line 4, Form 2)

3. Total Project Funds $_____________

(Line 5, Form 2)

III. CARE EMPHASIS

[ ] Interventional

[ ] Non-interventional

IV. POPULATION FOCUS

[ ] Neonates [ ] Pregnant Women

[ ] Infants [ ] Postpartum Women

[ ] Toddlers [ ] Parents/Mothers/Fathers

[ ] Preschool Children [ ] Adolescent Parents

[ ] School-Aged Children [ ] Grandparents

[ ] Adolescents [ ] Physicians

[ ] Adolescents (Pregnancy Related) [ ] Others

[ ] Young Adults (>20)

V. STUDY DESIGN

[ ] Experimental

[ ] Quasi-Experimental

[ ] Observational

VI. TIME DESIGN

[ ] Cross-sectional

[ ] Longitudinal

[ ] Mixed

VII. PRIORITY RESEARCH ISSUES AND QUESTIONS OF FOCUS

From the Maternal and Child Health Bureau (MCHB) Strategic Research Issues: Fiscal Years (FYs) 2004 – 2009.

Primary area addressed by research:

Secondary area addressed by research:

VIII. ABSTRACT

IX. KEY WORDS

X. ANNOTATION

INSTRUCTIONS FOR THE COMPLETION OF FORM 8

MATERNAL & CHILD HEALTH

RESEARCH PROJECT ABSTRACT

NOTE: All information provided should fit into the space provided in the form. Do not exceed the space provided.

Where information has previously been entered in forms 1 through 5, the information will automatically be transferred electronically to the appropriate place on this form.

Section I – Project Identifier Information

Project Title: Displays the title for the project.

Project Number: Displays the number assigned to the project (e.g., the grant number).

Project Director: Displays the name and degree(s) of the project director as listed on the grant application.

Principal Investigator: Enter the name(s) and discipline(s) of the principal investigator(s).

Section II – Budget

The amounts for Lines 1 through 5 will be transferred from Form 1, Lines 1 through 5.

Section III – Care Emphasis

Indicate whether the study is interventional or non-interventional.

Section IV – Population Focus

Indicate which population(s) are the focus of the study. Check all that apply.

Section V – Study Design

Indicate which type of design the study uses.

Section VI – Time Design

Indicate which type of design the study uses.

Section VII – Priority Research Issues and Questions of Focus (DO NOT EXCEED THE SPACE PROVIDED)

Provide a brief statement of the primary and secondary (if applicable) areas to be addressed by the research. The topic(s) should be from those listed in the Maternal and Child Health Bureau (MCHB) Strategic Research Issues: Fiscal Years (FYs) 2004 – 2009).

Section VIII – Abstract

Section IX - -Key Words

Provide up to 10 key words to describe the project, including populations served. A list of key words used to classify active projects is included. Choose keywords from this list when describing your project.

Section X – Annotation

Provide a three- to five-sentence description of your project that identifies the project’s purpose, the needs and problems, which are addressed, the goals and objectives of the project, the activities, which will be used to attain the goals, and the materials, which will be developed.