Form 8 Grantee Data Collection Form

Frontier Community Healthcare Network Coordination Grant

GranteeDataCollection_OMBClearancePackage_10032013

Grantee Data Collection Form

OMB: 0915-0383

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Grantee Data Collection Form

Frontier Community Health Care Network Coordination Grant


Data Collection Strategy

Community Health Workers or other staff from the grantee organization will complete an Excel® Spreadsheet including the following fields on a monthly basis about program activities at the implementation site and about all clients/patients who have participated in the program.

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Public Burden Statement: 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. The OMB control number for this project is 0915-XXXX. Public reporting burden for this collection of information is estimated to average 4 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-29, Rockville, Maryland, 20857.

















Data Element

Response Options

Information about Clients Active during the month
Data will be collected using one row per participant.

Client (Medicare) Identification Number


Qualifying Chronic Condition

Mark all that are applicable:

  • Diabetes Mellitus Type II (DM)

  • Cardiovascular Disease (CVD) including hypertension

  • Congestive Heart Failure (CHF)

  • Coronary Artery Disease (CAD)

  • Chronic Obstructive Pulmonary Disease (COPD)

Payer

Mark all that are applicable:

  • Medicare

  • Medicaid

  • Private/commercial insurer

  • Other (open text)

  • None

Intervention Start Date


Intervention Goal


Intervention Activities/ Design


Update on achievement of goal


Partners involved in intervention


Did the intervention involve any resources beyond that supplied by the grant?

Mark all that apply

  • None

  • Financial – source (open text)

  • Equipment – describe and source (open text)

  • Volunteer work – explain (open text)

Intervention Completion Date

Date

Reason for Completion

  • Achieved intervention goal

  • Loss of interest by client

  • Moved

  • Death

  • Other (open text)


Grant Design and Implementation during Month
These data will be collected using one row per program site

Client recruitment attempts


Source of attempts


Method of recruitment


Number of new enrollments


Understood reason(s) for unsuccessful attempts


Total hours spent by CHWs on program


Did the overall program (not including specific interventions) require any resources beyond that supplied by the grant?

Mark all that apply

  • None

  • Financial – source (open text)

  • Equipment – describe and source (open text)

  • Volunteer work – explain (open text)







OMB Control Number 0915-XXXX Expiration Date XX/XX/201X

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorBrad Smith
File Modified0000-00-00
File Created2021-01-28

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