State and Community Awardee Tool

Form Approved

OMB No. 0920-0952

Exp. 12/31/2015

State and Community Awardee Performance Measure Reporting Tool

Public reporting burden of this collection of information is estimated to average 4 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-xxxx).

Grantee: _________________________

Please complete these performance measures to CDC once per year as part of your Annual Progress Report due December 31 of each year (reporting period October 1-September 30). Under the evidence based program performance measures, please report letters d through h separately for each implementation partner and program (you may combine information for different facilitators). Under the clinical performance measures, please report letters a through f separately for each clinical partner.

Table of Contents

I. Evidence-Based Program Performance Measures 3

a. Implementation Partners 3

b. Facilitators 3

c. Program youth served and retained in all evidence-based interventions during this reporting period 3

d. Evidence-based intervention sessions 5

e. Evidence based intervention adaptations 5

f. Program youth targeted 5

g. Youth served and retained 5

h. Youth Outcomes for Evidence-Based Interventions 6

i. Other Clients Served by Evidence-Based Programs 7

II. Clinical Component Performance Measures 8

a. Linkages and Referrals 8

b. Billable Source by Revenue for adolescent patients between the ages of 12-19 years 9

c. Training on Adolescent Development 9

d. Continuous Quality Improvement (CQI) efforts and processes 9

e. Clinical Best Practices 10

f. Use of health care services by adolescents 11

III. Community Mobilization and Sustainability Performance Measures 17

a. Core Partner Leadership Team 17

b. Community Action Team Participation 17

c. Youth Leadership Team 17

IV. Stakeholder Education Performance Measures 18

V. Working with Diverse Communities Performance Measures 19

VI. Dissemination 20

a. Manuscripts 20

b. Presentations 20

1. Evidence-Based Program Performance Measures

1. Implementation Partners

# of implementation partners to date		# of new implementation partners obtained during this reporting period
# of implementation partners retained during this reporting period

2. Facilitators

# of facilitators/teachers newly trained on any program during this reporting period

# of facilitators/teachers with follow up training on any program during this reporting period

3. Program youth served¹ and retained² in all evidence-based interventions during this reporting period

Characteristics of Program Youth3	Males		Females		Youth who did not report Gender
	# served	# retained	# served	# retained
Age (one response per participant)
10 years or younger
11-12 years
13-14 years
15-16 years
17-18 years
19 years or older
Grade (one response per participant)
6th grade or lower
7-8th grade
9-10th grade
11-12th grade
GED program
Technical/vocational training
College (any year)
Not currently in school
Ethnicity (one response per participant)
Hispanic or Latino
Not Hispanic or Latino
Unknown/unreported
Race (one response per participant)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
More than one race
Unknown/unreported
Primary language spoken at home (one response per participant)
English
Spanish
Chinese
Other
Special populations (one response per participant)
None
Pregnant or parenting teens
Youth in foster care
Homeless youth
Youth in the juvenile justice system
Other (describe____________________)
Total

TOTAL NUMBER OF YOUTH SERVED⁴ _________________________

TOTAL NUMBER OF YOUTH RETAINED⁵ _______________________

Method of collection and reporting for youth served: _________________________________

Method of collection and reporting for youth retained: ________________________________

*Please report sections d through h separately for each implementation partner and program (you may combine information for different facilitators)* Indicate whether this partner is a formal TA partner or informal TA partner

Implementation Partner 1:_______________________________________ ID:___________________

Program 1:_____________________________________________

Please indicate the nature of the partnership: (Check all that apply)

• We provide funding to this partner

• We provide ongoing Technical Assistance and Training to this partner

• We have provided only Training to this partner

• This partner participates fully in the collection of Performance Measures

4. Evidence-based intervention sessions⁶

Setting(s)7		# of cycles8 implemented this reporting period
Fidelity: mean % of activities implemented as planned		Mean % of activities implemented as planned for sessions observed
Mean overall quality rating of observed sessions

5. Evidence based intervention adaptations

Adaptations this reporting period9	Planned10	Unplanned11

6. Program youth targeted

Total number of targeted youth in this setting¹², during this reporting period:_____________________

Total number of targeted males in this setting, during this reporting period:_____________________

Total number of targeted females in this setting, during this reporting period:____________________

7. Youth served and retained

Total number of youth served during this reporting period:___________________

Total number of youth retained during this reporting period:_________________

Percent of youth retained during this reporting period:______________________

8. Youth Outcomes for Evidence-Based Interventions

# of pre-tests completed		# post-tests completed
# of youth who completed both a pre- and post-test		% of youth who completed both a pre- and post-test
Youth satisfaction post- test score (mean %)		% of participants with 75% or better attendance
Mean attendance rate (%) among youth who completed both pre- and post-tests13		Median attendance rate (%) among youth who completed both pre- and post-tests

*Reminder: Include only pre-test information on youth behaviors*

Youth Behaviors14 among all youth who completed a pre-test	Males		Females
	Pre-Test Response		Pre-Test Response
	N	%	N	%
Youth who have ever had sex
Youth who had sex in the past 3 months (sexually active)
Sexually active youth who used hormonal contraception, an IUD, or a condom at last sex

Knowledge, attitudes, and intentions of targeted outcomes for youth with matched pre- and post-tests15	Participant			Comparison or control group16			T-test17 score comparing participants and control groups
	Mean pre-test response score	Mean post-test response score	Mean difference between pre- and post-test scores	Mean pre-test response score	Mean post-test response score	Mean difference between pre- and post-test scores

9. Other Clients Served by Evidence-Based Programs

Program Name
Mean # of Program Services Received by Parents/Guardians
Median # of Program Services Received by Parents/Guardians
Mean # of Program Services Received by Other Clients Served (Siblings, other Family Members, Etc.)
Median # of Program Services Received by Other Clients Served (Siblings, other Family Members, Etc.)
Client Type	# served	# retained18
Parents/Guardians
Other Clients Served (Siblings, other Family Members, Etc.)
Total

2. Clinical Component Performance Measures

Total Number of clinical partners:________________________________

Clinical Partner 1: ________________________________________

1. Linkages and Referrals

Please indicate the total number of formal and informal linkages¹⁹,²⁰ to date that your health center has developed with organizations, providers, programs, and/or institutions for the purposes of increasing access to and utilization of contraceptive or reproductive health services among adolescents, the number of new formal and informal linkages obtained during this reporting period, and the percent of formal and informal linkages that were obtained during this reporting period (Denominator = total number of formal or informal linkages to date). By “formal linkages” we mean written agreements to work with these providers or organizations to enhance access to contraceptive or reproductive health services that your health center provides; by “informal linkages” we mean no written agreement exists.

# of Formal Linkages to date	# of New Formal Linkages obtained this reporting period

# of Informal Linkages to date	# of New Informal Linkages obtained this reporting period

Please indicate the total number of youth referred by organizations/providers with whom you have formal or informal linkages and the total number of youth referrals that resulted in the receipt of care.

Total number of youth referred (optional, depending on data availability): __________________________

Total number of youth referrals that resulted in the receipt of care: _______________________

2. Billable Source by Revenue for adolescent patients between the ages of 12-19 years

Please indicate both the percentage of revenue by source that the health center receives for adolescent visits at which contraceptive or reproductive health services²¹ are provided (Denominator = total number of unduplicated adolescent visits), and the number of visits at which contraceptive or reproductive health services are provided, per revenue source.

Data reporting period __________________ indicate the date range for the data provided below.

%	# of Visits	Source of Revenue
		Medicaid Fee for Service
		Medicaid Family Planning Waiver
		Medicaid Managed Care
		Commercial Insurance
		Sliding Fee Scale (Patient pays for a portion of the charges out-of-pocket)
		Full Pay (Patient pays for the full cost of service out-of-pocket)
		No pay (services are covered by grants, e.g., Title X, Title V, 330, Private Foundation, etc)
		Uninsured (health center absorbs costs of services)
		Other (Please describe):

3. Training on Adolescent Development

Please indicate the number and percentage of ALL health center staff (e.g., all clinical and non-clinical staff who have direct contact with adolescent clients) who have received training in Stages of Adolescent Development during the past two years: ____________________

4. Continuous Quality Improvement (CQI) efforts and processes

Does the health center	Yes	No
Have a set of performance measures that are collected on a regular basis (e.g., quarterly, monthly) for monitoring the use of health care services for adolescents?
Have a set of performance measures that are collected on a regular basis (e.g., quarterly, monthly) for monitoring the delivery of contraceptive, reproductive, or sexual health care services for adolescents?

5. Clinical Best Practices²²

Promoting “Teen Friendly” Services: Health Care Delivery System, Contraceptive and Reproductive Health Best Practices	Total number of best practices implemented to date	Number of new best practices implemented during the past reporting cycle
Subset 1: Contraceptive Access (7)
Subset 2: Quick Start Method for Initiation of Hormonal Contraception and IUD (4)
Subset 3: Emergency Contraception (3)
Subset 4: Cervical Cancer Screening (1)
Subset 5: STD and HIV Testing (6)
Subset 6: Cost, Confidentiality and Consent (2)
Subset 7: Infrastructure (3)
Subset 8: Environment (5)
Total (31)

6. Use of health care services by adolescents

The following data may be collected via billing records, EMRs, and other methods. It is recommended that you collect these data for each month.

Data reporting period____________ indicate the date range for the data in all tables below.

FEMALE Adolescent Clients (Unduplicated) and Visits by Race/Ethnicity, Age Group, and Reporting Period

FEMALES	# Adolescent Clients (Unduplicated)	# Adolescent Visits23	# Adolescent Visits in which Contraceptive, Reproductive, or Sexual Health Services are Provided24
Hispanic/Latino(a) – All Races25
12-14 years
15-17 years
18-19 years
Total
Black or African American (Non-Hispanic)
12-14 years
15-17 years
18-19 years
Total
White (Non-Hispanic)
12-14 years
15-17 years
18-19 years
Total
Other (Non-Hispanic)
12-14 years
15-17 years
18-19 years
Total
Unknown Race and Ethnicity
12-14 years
15-17 years
18-19 years
Total
All Races and Ethnicities
12-14 years
15-17 years
18-19 years
Total

Table 2. MALE Adolescent Clients (Unduplicated) and Visits by Race/Ethnicity, Age Group, for each Reporting Period²⁶

MALES	# Adolescent Clients (Unduplicated)	# Adolescent Visits27	# Adolescent Visits in which Contraceptive, Reproductive or Sexual Health Services are Provided28
Hispanic/Latino(a) – All Races29
12-14 years
15-17 years
18-19 years
Total
Black or African American (Non-Hispanic)
12-14 years
15-17 years
18-19 years
Total
White (Non-Hispanic)
12-14 years
15-17 years
18-19 years
Total
Other (Non-Hispanic)
12-14 years
15-17 years
18-19 years
Total
Unknown Race and Ethnicity
12-14 years
15-17 years
18-19 years
Total
All Races and Ethnicities
12-14 years
15-17 years
18-19 years
Total

Table 3. FEMALE Adolescent Clients (Unduplicated) and Number Provided (i.e., dispensed on-site or by prescription) Contraception by Age Group, for each Reporting Period³⁰

FEMALES	# Adolescent Clients (Unduplicated)
All Unduplicated Clients (Total)
12-14 years
15-17 years
18-19 years
Total
Provided Hormonal Contraception31 (not including IUDs or Implants)
12-14 years
15-17 years
18-19 years
Total
Provided the Pill
12-14 years
15-17 years
18-19 years
Total
Provided Injectable Contraception (e.g., Depo Provera)
12-14 years
15-17 years
18-19 years
Total
Provided IUD
12-14 years
15-17 years
18-19 years
Total
Provided Contraceptive Implants (e.g., Implanon)
12-14 years
15-17 years
18-19 years
Total
Provided Emergency Contraception (EC)32
12-14 years
15-17 years
18-19 years
Total
% Contraceptive Coverage33
12-14 years
15-17 years
18-19 years
Total
% LARC Coverage34
12-14 years
15-17 years
18-19 years
Total

Table 4. FEMALE Adolescent Clients (Unduplicated) and Number Provided (i.e., dispensed on-site or by prescription) Contraception by Race/Ethnicity Group, for each Reporting Period³⁵

FEMALES	# Adolescent Clients (Unduplicated)
All Unduplicated Clients (Total)
Hispanic/Latina (all races)
Black or African American (non-Hispanic)
White (non-Hispanic)
Other (non-Hispanic)
Unknown/unreported
Total
Provided Hormonal Contraception36 (not including IUDs or Implants)
Hispanic/Latina (all races)
Black or African American (non-Hispanic)
White (non-Hispanic)
Other (non-Hispanic)
Unknown/unreported
Total
Provided the Pill
Hispanic/Latina (all races)
Black or African American (non-Hispanic)
White (non-Hispanic)
Other (non-Hispanic)
Unknown/unreported
Total
Provided Injectable Contraception (e.g., Depo Provera)
Hispanic/Latina (all races)
Black or African American (non-Hispanic)
White (non-Hispanic)
Other (non-Hispanic)
Unknown/unreported
Total
Provided IUD
Hispanic/Latina (all races)
Black or African American (non-Hispanic)
White (non-Hispanic)
Other (non-Hispanic)
Unknown/unreported
Total
Provided Contraceptive Implants (e.g., Implanon)
Hispanic/Latina (all races)
Black or African American (non-Hispanic)
White (non-Hispanic)
Other (non-Hispanic)
Unknown/unreported
Total
Provided Emergency Contraception (EC)37
Hispanic/Latina (all races)
Black or African American (non-Hispanic)
White (non-Hispanic)
Other (non-Hispanic)
Unknown/unreported
Total
% Contraceptive Coverage38
Hispanic/Latina (all races)
Black or African American (non-Hispanic)
White (non-Hispanic)
Other (non-Hispanic)
Unknown/unreported
Total
% LARC Coverage39
Hispanic/Latina (all races)
Black or African American (non-Hispanic)
White (non-Hispanic)
Other (non-Hispanic)
Unknown/unreported
Total

3. Community Mobilization and Sustainability Performance Measures

1. Core Partner Leadership Team

Total # of Core Partner Leadership Team Meetings Convened
# of Core Partner Leadership Team Members
# of Core Partner Leadership Team Members who Attend at least 75% of Team Meetings
Significant Action Items40	Completed
1
2
3
4
5

2. Community Action Team Participation

Total # of Community Action Team Meetings Convened
# of Community Action Team members
# of Community Action Team Members who Attend at least 75% of Team Meetings
Significant Action Items41	Completed
1
2
3
4
5

3. Youth Leadership Team

Total # of Youth Leadership Team Meetings Convened
# of Youth Leadership Team Members
# of Youth Leadership Team Members who Attend at least 75% of Team Meetings
Significant Action Items42	Completed
1
2
3
4
5

4. Stakeholder Education Performance Measures

Total number of stakeholder education strategies guided by best practices implemented to date: ______________

Number of new stakeholder education strategies guided by best practices implemented during the past reporting cycle:_____________

5. Working with Diverse Communities Performance Measures

Working with Diverse Communities strategies guided by best practice43	Total number of strategies guided by best practices implemented to date	Number of new strategies guided by best practices implemented during the past reporting cycle
Subset 1: Engage diverse youth (7)
Subset 2: Utilize participatory approaches for community mobilization to include diverse youth (8)
Subset 3: Engage a diverse group of community partners to participate in teen pregnancy prevention efforts (3)
Subset 4: Support implementation partners’ programmatic practices (8)
Subset 5: Support clinical partners to develop culturally competent clinical services (7)
Subset 6: Support community outreach practices (4)
Total (37)

6. Dissemination

1. Manuscripts

How many manuscripts related to this project have been accepted for publication or published during the past reporting cycle? _________________

How many manuscripts related to this project have been published to date? ______________

Please list the references for any published manuscripts.

2. Presentations

How many presentations have you made at each of the following levels during the past reporting cycle:

National or regional? ___

Please list titles of all presentations and venue (e.g., conference or organization to which the presentation was made).

State? ____

Please list titles of all presentations and venue (e.g., conference or organization to which the presentation was made).

1 Number of youth who attended at least one session

2 Number of youth who attended at least 75% of sessions

3 Characteristics may be obtained from attendance records or pre-/post-tests

4 The total number of youth served including those who did not report gender or other demographic information should equal the total number of youth served by all programs as reported in section 1.g.

5 The total number of youth retained including those who did not report gender or other demographic information should equal the total number of youth retained by all programs as reported in section 1.g.

6 Session refers to one meeting for an evidence based intervention. We are interested in the number of sessions as opposed to modules or lessons because many partners have made adaptations so that one lesson may be split across two different sessions/meetings.

7 Settings could include a school, church, youth development program, recreation center, clinic, etc. If a partner is implementing the same program in different settings, consider reporting information for sections c through h separately for each setting.

8 Cycle refers to a complete offering of an evidence based intervention

9 Adaptations could include add-on lessons/modules, etc.

10 Planned adaptations received prior CDC approval before the start of implementation.

11 Unplanned adaptations did not receive CDC approval before the start of implementation.

12 For example, if implementing a program among 9^th graders in a particular school, the targeted number of youth in the setting would be all 9^th graders in the school.

13 If it is not possible to match attendance rates to pre-/post-test data, a question on attendance may be added to the post test

14 Include behavioral data for as many youth served as possible; time periods (e.g., past 3 months) may not be exact

15 May be reported as individual items or as a composite score. If composite scores are reported, please provide the individual survey questions and the scale.

16 Include scores for comparison group(s) when available. Comparisons could be made with separate youth or youth could serve as their own comparison.

17 Matched pairs t-test

18 If there are multiple sessions

19 Linkage: A formal partnership between community organizations, agencies, or other institutions (which may include but are not limited to health centers, schools, and churches). The partnership is formalized through a written agreement (e.g., a MOU) that clearly defines how partners will share resources and services related to teen pregnancy prevention.

Referral: An informal mechanism or medium that directs clients to care. Referral sources can include friends, family members, Internet sources, schools, as well as linkage partner organizations/agencies/institutions.

20 Please include linkages created during this project as well as linkages created before the start of this project.

21 Includes adolescent visits at which contraceptive or reproductive health services are provided, regardless of the primary reason for the visit.

22 Best practice refers to strategies and activities that have been evaluated and demonstrate effectiveness at promoting sexual health for adolescents. The clinical best practices focus on systems related to access, processes for the delivery of care, utilization of evidence-based clinical recommendations, cost, confidentiality, supportive infrastructure, and the health care delivery environment. Where gaps exist, as identified through assessment activities, improvement efforts should focus on strategies to ensure that the set of “best practices” are adopted and implemented over the course of the project.

23 Any visit where an adolescent is seen by a healthcare team member – not only visits designated as reproductive/sexual health visits.

24 Includes any health center visit where contraceptive , reproductive, or sexual health services are provided to the adolescent patient, regardless of the primary reason for the visit.

25 Count data for all clients that indicated Hispanic/Latino(a) ethnicity, regardless of race

26 Data should be pulled for unduplicated adolescents by hormonal contraception or IUD adopted or continued, at the time of exit from their last encounter (visit) to the health center in the given reporting period. If the client reports using more than one method of birth control, report the most effective one as the primary method (e.g., if a client is given the patch and emergency contraception as a backup method, only include information on the patch).

27 Any visit during which an adolescent is seen by a healthcare team member – not only visits designated as reproductive/sexual health visits.

28 Includes any health center visit at which contraceptive, reproductive, or sexual health services are provided to the adolescent patient, regardless of the primary reason for the visit.

29 Count data for all clients that indicated Hispanic/Latino(a) ethnicity, regardless of race

30 Data should be pulled for unduplicated adolescents by hormonal contraception or IUD adopted or continued, at the time of exit from their last encounter (visit) to the health center in the given reporting period. If the client reports using more than one method of birth control, report the most effective one as the primary method (e.g., if a client is given the patch and emergency contraception as a backup method, only include information on the patch).

31 Hormonal contraception here includes the pill, patch, ring, and injectable contraception

32 Including the provision of EC as a backup method along with another contraceptive method

33 Calculated as the proportion of all unduplicated adolescent female clients provided hormonal contraception, contraceptive implants, or IUD.

34 Calculated as the proportion of all unduplicated adolescent female clients provided contraceptive implants, or IUD.

35 Data should be pulled for unduplicated adolescents by hormonal contraception or IUD adopted or continued, at the time of exit from their last encounter (visit) to the health center in the given reporting period. If the client reports using more than one method of birth control, report the most effective one as the primary method (e.g., if a client is given the patch and emergency contraception as a backup method, only include information on the patch).

36 Hormonal contraception here includes the pill, patch, ring, and injectable contraception

37 Including the provision of EC as a backup method along with another contraceptive method

38 Calculated as the proportion of all unduplicated adolescent female clients provided hormonal contraception, contraceptive implants, or IUD.

39 Calculated as the proportion of all unduplicated adolescent female clients provided contraceptive implants, or IUD.

40 Significant items include the large or key action items that the group would like to accomplish each year. We anticipate that each group would have no more than 5 significant action items per year.

41 Significant items include the large or key action items that the group would like to accomplish each year. We anticipate that each group would have no more than 5 significant action items per year.

42 Significant items include the large or key action items that the group would like to accomplish each year. We anticipate that each group would have no more than 5 significant action items per year.

43 Best practice refers to strategies and activities that have been evaluated and demonstrate effectiveness at promoting sexual health for adolescents. Strategies that do not have strong evidence of effectiveness (e.g., less rigorous evaluation) are considered strategies guided by best practices (e.g., lessons learned). The WDC strategies guided by best practice focus on identifying and developing a plan for serving diverse, hard-to-reach, marginalized, or vulnerable youth with teen pregnancy prevention programs and services (e.g., African American and Latino youth, youth in foster care, youth in the juvenile justice system, GLTBQ youth, and pregnant and parenting teens); conducting activities to educate community partners on the link between social determinants and teen pregnancy (e.g., workshops, webinars); and training clinical and program partners to provide teen-friendly, culturally competent services and programs.

50