Data Collection Form - Help

Data Field Explanations
Data Field	Data field Description	Data - description
Client Data
Location	Program Site/ Facility Site	open response- location by name or by site number
Client number	Internal patient identifier (if applicable)	sequential numbers
Qualifying Chronic Condition	This data field provides a list of chronic conditions which the patient may have. There may be more than one positive response.
Diabetes Mellitus Type II (DM)	Type of chronic condition	"Yes" or "No"
Cardiovascular Disease (CVD) including hypertension	Type of chronic condition	"Yes" or "No"
Congestive Heart Failure (CHF)	Type of chronic condition	"Yes" or "No"
Coronary Artery Disease (CAD)	Type of chronic condition	"Yes" or "No"
Chronic Obstructive Pulmonary Disease (COPD)	Type of chronic condition	"Yes" or "No"
Other Influential Conditions	Other conditions that influence a client’s participation and intervention design	Free text
Payer	This data field describes the type and number of payers that a patient may be using. There may be more than one positive response.
Medicare	Type of payer of medical insurance	"Yes" or "No"
Medicaid	Type of payer of medical insurance	"Yes" or "No"
Private/commercial insurer	Type of payer of medical insurance	"Yes" or "No"
Other (free text)	Type of payer of medical insurance	Free text
None	Type of payer of medical insurance	"Yes" or "No"
Intervention Start Date	Date which the patient started the intervention	mm/dd/yyyy
Intervention Goal	This data field describes the patient's goal in participating in the program.	Free text
Intervention Activities/ Design	This data field describes the patient's intervention activities and/ or design of the patient's intervention	Free text
Update on achievement of goal	This data field is a description of the improvement or achievement of intervention goal's	Free text
Partners involved in intervention	This data field is a list of partners involved in the intervention including [ list examples]	Free text
Were any additional resources used?	This data field answers whether any resources beyond the grant that were used in the client’s intervention.	"Yes" or "No"
Financial	This data field describes any additional financial resources used to provide client interventions. List sources, amounts, and use of financial resources.	Free text, any response indicates "Yes"
Equipment	This data field describes any additional equipment resources used to provide client interventions. List type, volume, and value (if possible) of equipment.	Free text, any response indicates "Yes"
Volunteer work	This data field describes any volunteer/labor used to provide client interventions. List type (e.g. position and/or task performed), volume (e.g., number of hours), and value (if possible) of volunteer/unpaid labor	Free text, any response indicates "Yes"
Other (explain)	This data field describes any resources used to provide client intervention but that cannot be described as financial, equipment, or volunteer work.	Free text, any response indicates "Yes"
Intervention Completion Date	This is the date at which the intervention was complete	mm/dd/yyyy
Intervention Completion Status	This set of data fields refer to why the intervention was ended.
Achieved intervention goal	This data field is filled in if the patient achieved their goal	"Yes" or "No"
Loss of interest by client	Indicate "Yes" if the patient did not complete due to loss of interest	"Yes" or "No"
Moved	Indicate "Yes" if the patient did not complete due to moving away	"Yes" or "No"
Death	Indicate "Yes" if the patient did not complete due to death	"Yes" or "No"
Other	Indicate "Yes" if the patient did not complete due to other reasons	Free text
Design and Implementation Data
Client recruitment attempts	Number of patients that the CHW attempted to recruit during the observation quarter	Number
Source of attempts	The source from which the CHW identified the patients that s/he attempted to recruit.	Free text
Method(s) of recruitment	This data field describes how the patient was recruited	Free text
Number of new enrollments	The number of new clients recruited to the observation quarter	Number
Understood reason(s) for unsuccessful attempts	This data field records the reasons provided by recruited patients to CHWs for declining to participate in the program	Free text
Total hours spent by CHWs on program?	This data field is the total number of hours that the CHW spent working on the program	Number
Were any additional resources used?	This data field answers whether any resources beyond the grant were used to conduct non-intervention aspects of program.	"Yes" or "No"
Financial - source (open text)	This data field describes any additional financial resources provided to conduct the program. List sources, amounts, and uses of additional financial resources.	free text, any response indicates "Yes"
Equipment - describe and source (open text)	This data field describes any additional equipment (not purchased with grant funds) that was used by program and its staff to conduct the program. List type, volume, and value (if possible) of equipment	free text, any response indicates "Yes"
Volunteer work - explain (open text)	This data field describes any additional volunteer/unpaid labor that was used to conduct the program. List type (e.g. position and/or task performed), volume (e.g., number of hours), and value (if possible) of volunteer/unpaid labor	free text, any response indicates "Yes"
Other (explain)	This data field describes any resources used to to conduct the program but that cannot be described as financial, equipment, or volunteer work.	Free text, any response indicates "Yes"