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Maternal and Child Health Bureau Performance Measures for Discretionary Grants

Attach D - ADE

Maternal and Child Health Bureau Performance Measures for Discretionary Grants

OMB: 0915-0298

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0915-0298 can be found here:

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OMB # 0915-0298

EXPIRATION DATE:___________

Health Resources and Services Administration

Maternal and Child Health Bureau

Discretionary Grant Program Performance Measures

OMB No. 0915-0298

Expires: __________

Attachment D

Part 3

Additional Data Elements

OMB Clearance Package

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


	ETHNICITY				RACE
Characteristics of Program Participants	Hispanic or Latino	Not Hispanic or Latino	Unrecorded	TOTAL	America Indian or Alaska Native	Asian	Black or African American	Native Hawaiian or Other Pacific Islander	White	More Than One Race	Unrecorded	Total
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
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)
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 less than 1499 grams to participants, including multiple births
Number of live singleton births weight unknown
Total Number of Live Singleton Births to Participants
Total Number of Live Births to Participants including Multiple Births
Total Number of program participant maternal deaths defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes
Total Number of program participant late maternal deaths defined as the death of a woman from direct or indirect obstetric causes more than 42 days but less than one year after termination of pregnancy
f. Number of Female Participants in Interconceptional Care/Women's Health Activities
Under age 15
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
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

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

			B. RISK REDUCTION/PREVENTION SERVICES
			(For Program Participants)
RISK FACTORS	Number Screened	Number Screened Positive		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
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
Fecal Occult Blood Test
Asthma
Peridontal Infection

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

C. HEALTHY START MAJOR SERVICE TABLE
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

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.

a. 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.

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.

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:	Number of participants with reported first prenatal visit:
During First Trimester	before 13 weeks gestation.
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

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.

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..

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.
Enter the total number of program participant maternal deaths defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.
Enter the total number of program participant late maternal deaths defined as the death of a woman from direct or indirect obstetric causes more than 42 days but less than one year after termination of pregnancy.

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.

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

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.

h. 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.

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.

b. 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.

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.

b. Enabling Services

Enter data for the enabling services listed.

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.

c. 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.

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	Ethnicity (Hispanic or Latino, Not Hispanic or Latino, Unrecorded)	Race (American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, White, More than One Race, Unrecorded)	Gender (Male or Female)	Discipline	Year Hired in MCH Leadership Training Program	Former MCHB Trainee? (Yes/No)
Faculty

Staff

Other

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 non-supported trainees).

Total Number of long-term trainees participating in the training program* __________

Name

Ethnicity

Race

Gender

Address (For supported trainees ONLY)

City

State

Country

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: [ ] Undergraduate [ ] Pre-doctoral [ ] Post-doctoral

[ ] Part-time student [ ] Full-time student

Epidemiology training grants ONLY

Length of time receiving support: ____________

Research Topic or Title________________________________________________________

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

Former Trainee Information (Long-term trainees and former trainees of the Pipeline and Certificate Programs)

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

Project does not have any trainees who have completed the Training Program 5 years prior to current reporting year.

Name	Year Graduated	Degree(s) Earned with MCH support (if applicable)	Was University able to contact the trainee?	City of Residence	State of Residence	Country of Residence	Current Employment Setting (see pick list below)*	Working in Public Health organization or agency (including Title V)? (Yes/No)	Working in MCH? (Yes/No)	Working with underserved populations or vulnerable groups**? (Yes/No)	Met criteria for Leadership in PM 08? (Yes/No)

* 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, heath centers and clinics)
Private sector
Other (specify)

** 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.

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

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)

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 or Latino

__ Not Hispanic or Latino

__ Unrecorded

Race: (choose one)

__ 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).

__ Black or African American refers to people having origins in any of the Black racial groups of Africa.

__ 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.

__ White refers to people having origins in any of the original peoples of Europe, the Middle East, or North Africa.

__ More than One Race includes individuals who identify with more than one racial designation.

__ Unrecorded is included for individuals who do not indicate their racial category.

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)
__	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.

Medium Term Trainees

DEFINITION: Medium term trainees are trainees with 40 - 299 contact hours in the current reporting year.

Medium-term Trainees with 40-149 contact hours during the past 12-month grant period

Total Number ______

Disciplines (check all that apply):

Audiology

Dentistry-Pediatric

Dentistry – Other

Education/Special Education

Family/Parent/Youth Advocacy

Genetics/Genetic Counseling

Health Administration

Medicine-General

Medicine-Adolescent Medicine

Medicine-Developmental-Behavioral Pediatrics

Medicine-Neurodevelopmental Disabilities

Medicine-Pediatrics

Medicine-Pediatric Pulmonology

Medicine – Other

Nursing-General

Nursing-Family/Pediatric Nurse Practitioner

Nursing-Midwife

Nursing – Other

Nutrition

Occupational Therapy

Parent

Physical Therapy

Psychiatry

Psychology

Public Health

Respiratory Therapy

Social Work

Speech-Language Pathology

Other (Specify)

Medium Term Trainees with 150-299 contact hours

The totals for gender, ethnicity, race and discipline must equal the total number of medium term trainees with 150-299 contact hours

Total Number ________

Gender

(number not percent)

Male _____

Female _____

Ethnicity

(number not percent)

Hispanic or Latino _____

Not Hispanic or Latino ______

Unrecorded _______

Race

(number not percent)

American Indian or Alaska Native: _____

Asian: _____

Black or African American: _____

Native Hawaiian or Other Pacific Islander: ______

White: ______

More than One Race: ______

Unrecorded:______

Discipline

Number Discipline

____ Audiology

____ Dentistry-Pediatric

____ Dentistry – Other

____ Education/Special Education

____ Family/Parent/Youth Advocacy

____ Genetics/Genetic Counseling

____ Health Administration

____ Medicine-General

____ Medicine-Adolescent Medicine

____ Medicine-Developmental-Behavioral Pediatrics

____ Medicine-Neurodevelopmental Disabilities

____ Medicine-Pediatrics

____ Medicine-Pediatric Pulmonology

____ Medicine – Other

____ Nursing-General

____ Nursing-Family/Pediatric Nurse Practitioner

____ Nursing-Midwife

____ Nursing – Other

____ Nutrition

____ Occupational Therapy

____ Parent

____ Physical Therapy

____ Psychiatry

____ Psychology

____ Public Health

____ Respiratory Therapy

____ Social Work

____ Speech-Language Pathology

____ Other (Specify)_________

TOTAL Number of Medium term Trainees: _________

Short Term Trainees

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)

Total number of short term trainees during the past 12-month grant period________

Indicate disciplines (check all that apply)

Audiology

Dentistry-Pediatric

Dentistry – Other

Education/Special Education

Family/Parent/Youth Advocacy

Genetics/Genetic Counseling

Health Administration

Medicine-General

Medicine-Adolescent Medicine

Medicine-Developmental-Behavioral Pediatrics

Medicine-Neurodevelopmental Disabilities

Medicine-Pediatrics

Medicine-Pediatric Pulmonology

Medicine – Other

Nursing-General

Nursing-Family/Pediatric Nurse Practitioner

Nursing-Midwife

Nursing – Other

Nutrition

Occupational Therapy

Parent

Physical Therapy

Psychiatry

Psychology

Public Health

Respiratory Therapy

Social Work

Speech-Language Pathology

Other (Specify)

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.

Provide the following summary information on ALL TA provided

Total Number of Technical Assistance/Collaboration Activities

TA Activities by Type of Recipient

Number of TA Activities by

Target Audience

_________

Other Divisions/ Departments in a University

Title V (MCH Programs)

State Health Dept.

Health Insurance/ Organization

Education

Medicaid agency

Social Service Agency

Mental Health Agency

Juvenile Justice or other Legal Entity

State Adolescent Health

Developmental Disability Agency

Early Intervention

Other Govt. Agencies

Mixed Agencies

Professional Organizations/Associations

Family and/or Consumer Group

Foundations

Clinical Programs/ Hospitals

Other Please Specify

Local

Within State

Another State

Regional

National

International

_____

B. Provide information below on the 5-10 most significant technical assistance/collaborative activities in the past year. In the notes, briefly state why these were the most significant TA events.

Title

Topic of Technical Assistance/Collaboration

Select one from list A and all that apply from List B.

Recipient of TA/Collaborator

Intensity of TA

Primary Target Audience

List A (select one)

Clinical care related (including medical home)
Cultural Competence Related
Data, Research, Evaluation Methods (Knowledge Translation)
Family Involvement
Interdisciplinary Teaming
Healthcare Workforce Leadership
Policy
Prevention
Systems Development/ Improvement

List B (select all that apply)

Women’s/Reproductive/ Perinatal Health
Early Childhood Health/ Development (birth to school age)
School Age Children
Adolescent
CSHCN/Developmental Disabilities
Autism
Emergency Preparedness
Health Information Technology
Mental Health
Nutrition
Oral Health
Patient Safety
Respiratory Disease
Vulnerable Populations*
Racial and Ethnic Diversity or Disparities
Other

Other Divisions/ Departments in a University
Title V (MCH Programs)
State Health Dept.
Health Insurance/ Organization
Education
Medicaid agency
Social Service Agency
Mental Health Agency
Juvenile Justice or other Legal Entity
State Adolescent Health
Developmental Disability Agency
Early Intervention
Other Govt. Agencies
Mixed Agencies
Professional Organizations/Associations
Family and/or Consumer Group
Foundations
Clinical Programs/ Hospitals
Other (specify)

One time brief (single contact)
One time extended (multi-day contact provided one time)
On-going infrequent (3 or less contacts per year)
On-going frequent (more than 3 contacts per year)

Local
Within State
Another State
Regional
National
International

Example

G- Policy

11- Oral Health

E - Education

"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.

If yes, specify the topic(s):_____________________________________________________________________

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 Within 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	_____

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: List A select one	Topic: List B: select all that apply	Primary Target Audience Local Within State Another state Regional National International	Method* In-person Distance Mixed	Number of Participants	Continuing Education Credits Provided? (Yes/No)
	Clinical Care-Related (including medical home) Cultural Competence-Related Data, Research, Evaluation Methods (Knowledge Translation) Family Involvement Interdisciplinary Teaming Healthcare Workforce Leadership Policy Prevention Systems Development/ Improvement	Women’s Reproductive/ Perinatal Health Early Childhood Health/ Development (birth to school age) School Age Children Adolescent CSHCN/Developmental Disabilities Autism Emergency Preparedness Health Information Technology Mental Health Nutrition Oral Health Patient Safety Respiratory Disease Vulnerable Populations* Racial and Ethnic Diversity or Disparities Other (specify)
1.
2.
3.

* "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):_____________________________________________________________________

REVISED

Products, Publications and Submissions Data Collection Form

Part 1

Instructions: Please list the number of products, publications and submissions addressing maternal and child health that have been published or produced by your staff during the reporting period (counting the original completed product or publication developed, not each time it is disseminated or presented). Products and Publications include the following types:

Type	Number
Peer-reviewed publications in scholarly journals – published (including peer-reviewed journal commentaries or supplements)
Peer-reviewed publications in scholarly journals – submitted
Books
Book chapters
Reports and monographs (including policy briefs and best practices reports)
Conference presentations and posters presented
Web-based products (Blogs, podcasts, Web-based video clips, wikis, RSS feeds, news aggregators, social networking sites)
Electronic products (CD-ROMs, DVDs, audio or videotapes)
Press communications (TV/Radio interviews, newspaper interviews, public service announcements, and editorial articles)
Newsletters (electronic or print)
Pamphlets, brochures, or fact sheets
Academic course development
Distance learning modules
Doctoral dissertations/Master’s theses
Other

Part 2

Instructions: For each product, publication and submission listed in Part 1, complete all elements marked with an “*.”

Data collection form for: primary author in peer-reviewed publications in scholarly journals – published

*Title: ________________________________________________________________________

*Author(s): ____________________________________________________________________

*Publication: __________________________________________________________________

*Volume: ______ *Number: _______ Supplement: _____ *Year: _______ *Page(s):________

*Target Audience: Consumers/Families ___ Professionals ___ Policymakers ___ Students ____

*To obtain copies (URL): ________________________________________________________

Key Words (No more than 5): _____________________________________________________

Notes: ________________________________________________________________________

Data collection form for: contributing author in peer-reviewed publications in scholarly journals – published