Form 1 HV Form 1

Revised August 1, 2012 by Data Work Group

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 ______ hours 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.

MIECHV

HOME VISITING FORM 1

DEMOGRAPHIC AND SERVICE UTILIZATION DATA FOR ENROLLEES AND CHILDREN

Reporting Period ___________

Service Areas: ­­­­­­­­­­­­­­­­­

Section A: Unduplicated Count of Enrollees by Type and by Primary Insurance Coverage

Table A.1

1. Total Numbers Newly Enrolled and Served during Reporting Period	Numbers Newly Enrolled	Numbers Served during Reporting Period
Enrollees
Index Children
Households

Table A.2

	No Insurance Coverage	Title XIX (Medicaid)/ Title XXI (State Children’s Insurance Program)	Tri-Care	Private or Other	Unknown/ Did not report	Total
2. Enrollees: Insurance Status
Pregnant Women
Female Caregivers
Male Caregivers
Total
3. Index Children: Insurance Status
Index children (0-5 years)

Section B: Enrollees and Children: Selected Characteristics by Ethnicity and Race

Table B

Ethnicity

Race

Hispanic or Latino

Not Hispanic or Latino

Unrecorded

Total

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

More than one race

Unrecorded

Total

4. Enrollees

Pregnant Women

Female Caregivers

Male Caregivers

Total

5. Enrollees: Marital Status

Never married

Married

Separated

Divorced

Widowed

Unknown/did not report

Total

6. Female Enrollees: Educational Attainment

Currently enrolled in high school

Of high school age, not enrolled

Less than HS diploma

GED

HS diploma

Some college/ training

Technical Training Certification, Associate’s Degree

Bachelor’s Degree, or higher

Other

Unknown/did not report

Total

7. Male Enrollees: Educational Attainment

Currently enrolled in high school

Of high school age, not enrolled

Less than HS diploma

GED

HS diploma

Some college/ training

Technical Training Certification, Associates Degree

Bachelor’s Degree, or higher

Other

Unknown/did not report

Total

8. Female Enrollees: Age (in years)

10-14

15-17

18-19

20-21

22-24

25-29

30-34

35-44

45-54

55-64

65+

Unknown/did not report

Total

9. Male Enrollees: Age (in years)

10-14

15-17

18-19

20-21

22-24

25-29

30-34

35-44

45-54

55-64

65+

Unknown/did not report

Total

10. Female Index Children: Age (in years)

Under 1 year

1-2 years

3-5 years

Unknown

Total

11. Male Index Children: Age (in years)

Under 1 year

1-2 years

3-5 years

Unknown

Total

Section C: Socioeconomic Data

Table C.1.

12. Household Income in Relation to Federal Poverty Guidelines	Number of Households
50% and under
51-100%
101-133%
134-250%
251-300%
>300
Unknown/did not report
Total

Table C.2

13. Enrollees: Employment Status	Number
Employed Full Time
Employed Part-Time
Not employed
Unknown/did not report
Total

14. Enrollees: Education/Training Status	Number
Student/trainee
Not a student/trainee
Unknown/did not report
Total

Section D: Other demographics

Table D.1

	15. Enrollees: Age
	Pregnant Women	Female Caregivers	Male Caregivers
10-14
15-17
18-19
20-21
22-24
25-29
30-34
35-44
45-54
55-64
65+
Age Unknown/did not report
Total

Table D.2

16. Primary Language Exposure of Index Children	Number of index children
English
Spanish
Arabic
Chinese
French
Italian
Japanese
Korean
Polish
Russian
Tagalog
Vietnamese
Tribal languages
Other
Unknown/Did Not Report
Total

Section E: Priority Populations—Actual Numbers Enrolled During Reporting Period

Table E

Legislatively Identified Priority Populations	Number of newly enrolled individuals
17. Have low incomes
18. Are pregnant women who have not attained age 21
19. Have a history of child abuse or neglect or have had interactions with child welfare services
20. Have a history of substance abuse or need substance abuse treatment
21. Are users of tobacco products in the home
22. Have or have a child/children with low student achievement
23. Have a child/children with developmental delays or disabilities
24. Are in families that include individuals who are serving or formerly served in the Armed forces, including such families that have members of the armed Forces who have had multiple deployments outside of the United States.

Section F: Service Utilization Across all Models

Table F.1

25. Family Retention Across All Models	Number of families
Currently receiving services
Completed program
Stopped services before completion
Other
Total

Table F.2

26. Total Number of Home Visits

Section G: Missing data

INSTRUCTIONS FOR COMPLETION OF HOME VISITING FORM 1

DEMOGRAPHIC AND SERVICE UTILIZATION DATA

Enter data into all required data cells. If sampling of the program population was utilized, please explain the sampling methodology and any estimates used.

Note: Ages are expressed as “x – y” (e.g., 3-5 years, meaning age 3 years through 5 years, i.e., up to but not including 6 years of age). Also, symbols are used to indicate directions. 45+ means age 45 years and over.

At the top of the Form, “Reporting Period” should reflect the federal fiscal year for which the data applies. Under the “Service Areas” tab, enter the zip codes in which MIECHV services are being provided.

For purposes of this data collection form, families and households are considered synonymous. For each household, the demographic and service utilization data should be based at a minimum on information collected from the enrolled primary caregiver and the index child cared for by the enrollee.

This form consists of seven sections:

Section A: Unduplicated Count of Enrollees by Type and by Primary Insurance Coverage

Section B: Enrollees and Children: Selected Characteristics by Ethnicity and Race

Section C: Socioeconomic Data

Section D: Other Demographics

Section E: Priority Populations—Actual Numbers Enrolled During Reporting Period

Section F: Service Utilization Across all Models

Section G: Missing Data

Section A, B, C, and D data are collected at the time of enrollment and annually thereafter. Section E data are collected on those individuals who are newly enrolled in the program during the reporting period. These data are collected at the time of enrollment and reflect familial or individual risk factors. Utilization data for Section F for all families reported on in Sections A-D should be assessed at the end of the reporting period.

Section A: Unduplicated Count of Enrollees by Type and by Primary Insurance Coverage

In table A1, item 1, enter the unduplicated count respectively of enrollees, index children, and families newly enrolled during the reporting period in the first column. Enter in the second column the total number of all enrollees, index children and families served (i.e., who received at least one home visit) during the reporting period. This column includes both families enrolled during the reporting period and families previously enrolled who continue to receive services during the reporting period. (For the first reporting year, the numbers in the two columns may be the same.) The term “Unduplicated” only applies to the count of families and individuals served during the reporting period (i.e., the count of families and enrollees continuously enrolled in the program from one year to another restarts for each reporting period). Totals in subsequent tables for enrollees, index children, and families should equal the numbers served from Table A.1 (except for table E where numbers newly enrolled apply). The category “Enrollees” includes the person or persons in the household who signed up to participate in the home visiting program (e.g., a teenage parent could be counted as an enrollee but not an index child). The category can include more than one member of the household if more than one individual are enrolled in the program (e.g., a father and a mother have both signed up to participate). It should include at a minimum for every household the primary caregiver of the index child.

The index child (Birth – 5 years) is the target child in an individual household who is under the care of the enrollee(s). More than one index child can be identified (e.g., in the case of twins, triplets, etc). Thus, there may be more than one female or male index child in a given household.

In table A2, (items 2 and 3), enter the unduplicated count of enrollees served by insurance status. Pregnant women are participants who have been enrolled in the program while pregnant at any time during the reporting period. Female caregivers are those female household members who are enrolled in the program during the reporting period, are considered a caregiver of the index child, and have not delivered the child during the reporting period (e.g., biological mothers, adoptive mothers, foster mothers, grandmothers). Male caregivers include those male household members (e.g. expectant fathers, biological fathers, step-fathers, and partners) who also meet the definition of an enrollee. Information about all newly enrolled caregivers should be collected at intake or shortly thereafter. The insurance coverage categories are mutually exclusive. No insurance coverage indicates that the individual is currently not covered by any source of insurance. This table is intended to capture insurance status, not health care access: receipt of care provided for instance by the Indian Health Service or another safety net health care provider such as a Federally Qualified Health Center does not constitute insurance coverage.

Section B: Enrollees and Children: Selected Characteristics by Ethnicity and Race

The responses regarding ethnicity and race in table B should reflect what the person considers herself/himself to be and are not based on percentages of ancestry. Data should be collected on ethnicity and race. Participants who select more than one race, should be reported in the More than one race category. If ethnicity and race are unknown or not reported for some participants, enter that count in the respective “Unrecorded” columns.

In table B, item 4, enter the unduplicated count for each category of enrollees by ethnicity and race.

In table B, item 5, enter the marital status of the enrollees by ethnicity and race. If more than one individual is enrolled in the program, enter the status for all enrollees. For example, if a pregnant woman is enrolled with her spouse in the program, both participants would be counted under the married category.

In table B, item 6 enter the unduplicated count of female enrollees by level of educational attainment and ethnicity and race. The female enrollee population includes the unduplicated count of pregnant women and female caregivers. Of high school age, not enrolled includes those individuals who are of high school age, and are not currently enrolled. For example, a teenage mother who is 16 years of age and could be enrolled in high school but is not. Less than high school diploma includes individuals who are not of high school age and who did not complete their high school education. For example, a 23 year old mother who did not finish high school would be included in this category because she is not of high school age and did not finish her high school education. The Some college/training category includes those who are currently enrolled and those who attended in the past. The Other category includes those individuals who did not fall into the specified categories.

In table B, item 7 enter the unduplicated count of male enrollees by level of educational attainment and by ethnicity and race.

In table B, item 8 enter the unduplicated count of female enrollees by age group and ethnicity and race.

In table B, item 9 enter the unduplicated count of male enrollees by age group and ethnicity and race.

In table B, item 10 enter the unduplicated count of the female index children by age group and ethnicity and race. Index children are the population of children birth -5 years who are enrolled in the home visiting program and identified as the index child in an individual household. More than one index child can be identified (e.g., in the case of twins, triplets, etc.) Therefore, there may be more than one female or male child in a given household.

In table B, item 11 enter the unduplicated count of the male index children by age group and ethnicity and race.

Section C: Socioeconomic Data

In table C1, item 12 enter the unduplicated count of families by income category according to the annual update of the HHS Poverty Guidelines. The appropriate category for a given family will depend both on household income and on the number of enrollees and index children counted in the household. Household income refers to the annual gross income for the household as defined in programmatic guidance, recorded at enrollment and annually thereafter. Annual income data can be estimated from monthly data (monthly income x 12). The HHS Poverty Guidelines are updated annually in February and published in the Federal Register. See http://aspe.hhs.gov/poverty/12poverty.shtml for the 2012 guidelines.

In table C2, item 13 enter the unduplicated count of enrollees served by employment status. Employed refers to whether the person is currently working for pay. Grantees have discretion to define “employed full-time” and “employed part-time” for purposes of this data collection. Not employed indicates that the person is not working for pay (this category may include, for example, students, homemakers and those enrollees actively seeking work but currently not employed)

In table C2, item 14 enter the unduplicated count of enrollees by their education status. Student/trainee indicates that the individual is considered a full- or part-time student by the institution he/she is attending. Not a student/trainee refers to individuals who are not currently enrolled in any type of educational or training programs.

Section D: Other Demographics

In table D1, item 15, enter the unduplicated count of enrollees served by age.

In table D2, item 16, enter the unduplicated count of index children by the primary language to which the child is exposed in the household. Primary language is the one used in the home the majority of the time.

Section E: Priority Populations: Actual Numbers Newly Enrolled during the Reporting Period

The purpose of the data collection in this section is to determine if the MIECHV program is enrolling the priority populations specified in H.R. 3590-220. In table E, items 17-24 enter the count of enrollees who were newly enrolled during the reporting period and meet criteria for each eligibility priority category (as identified in the grantee’s determination for eligibility, through the intake process, or through ongoing contact). These categories are: low-income; pregnant women under 21; history of child abuse or neglect or interactions with child welfare; history of substance abuse or need substance abuse treatment; users of tobacco products in the home; have or have children with low student achievement; have children with developmental delays; and families with members who are serving or have served in the armed forces. An enrollee meeting more than one category can be counted more than once. The legislation identified but did not provide definitions for the priority populations. Grantees therefore have discretion in applying the criteria below in identifying priority populations for reporting purposes.

Below are criteria for eligible participants:

• Low-Income: An individual or family with an income determined to be below the official poverty line defined by the Office of Management and Budget and revised annually in accordance with section 673(2) of the Omnibus Budget Reconciliation Act of 1981 [Title V, Sec. 501(b)(2)]. See http://www.federalregister.gov/articles/2011/01/20/2011-1237/annual-update-of-the-hhs-poverty-guidelines
  
  

• Pregnant women under 21: Expectant mothers who enroll in the program and are under 21 years old during the reporting period.

• Have a history of child abuse or neglect or have had interactions with child welfare services: Based on self-report, an enrollee who has a history of abuse or neglect and has had involvement with child welfare services either as a child or as an adult.

• Have a history of substance abuse or need substance abuse treatment: Based on self-report, an enrollee who has a history of substance abuse or who has been identified as needing substance abuse services through a substance abuse screening administered upon enrollment.

• Are users of tobacco products in the home: Based on self-report, enrollees who use tobacco products in the home or who have been identified as using tobacco through a substance abuse screening administered during intake.

• Have, or have children with low student achievement: Based on self-report, enrollees who have perceived themselves or their child(ren) as having low student achievement.

• Have a child or children with developmental delays or disabilities: Based on self-report or home visitor/staff observation, enrollees who have a child or children suspected of having a developmental delay or disability.

• Are in families that are or have served in the armed forces:  Based on self-report, families that include individuals who are serving or formerly served in the Armed Forces, including such families that have members of the Armed Forces who have had multiple deployments outside of the United States.  For this criterion, definition includes a military member’s dependent acquired through marriage, adoption, or other action during the course of a member’s current tour of assigned duty.

Section F: Service Utilization Across all Models

In table F.1, item 25, enter the unduplicated count of all enrolled families by retention status in relation to the home visiting program at the end of the reporting period. Currently receiving services refers to families that are participating in services at the end of the reporting period. Completed program refers to families who have completed the program according to model-specific definitions and criteria during the reporting period. Stopped services before completion refers to families who left the program for any reason prior to completion. Other refers to those families who do not fall into the previous categories and may include unreachable participants (i.e. the family is not regularly participating but did not actively sever ties, etc.)

In table F.2, item 26, enter the total count of home visits delivered to families participating in the program by all implementing sites during the reporting period.

Section G: Missing data

Utilize box G to provide an explanation for unknown or unreported data. This box may also be used to explain any sampling methodology and estimates used.

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