Grantees, Subrecipients, and Service Sites

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

Title X Family Planning Annual Report (FPAR) 2.0 Data Element Survey

Draft August 11, 2014

Introduction and Instructions

John Snow Inc. (JSI) has been hired by the Office of Population Affairs (OPA) to administer this survey within the Title X Family Planning Network to help Title X prepare for FPAR 2.0. Your feedback is important! Please fill out this voluntary survey to give OPA your opinions on the proposed revised data set and data collection procedures for FPAR 2.0. The survey is designed to assess the clarity of definitions for new data elements, ease of data collection, potential modification of data system(s), and encounter-level data reporting for the FPAR 2.0 data elements.

This survey consists of four sections: (1) Section A: Current Data Elements, (2) Section B: Modified Data Elements, (3) Section C: New Data Elements, and (4) Section D: Organization Information. Questions on the data elements ask about:

• Encounter-level reporting (Sections A, B, and C)

• Data collection (Sections A and B)

• Modification of data system(s) (Sections A and B)

• Data element definitions (Section C)

The survey should be completed online by a staff member who is knowledgeable about your agency’s data collection, data system(s), and FPAR reporting procedures.

Please complete this survey by XXX.

For your convenience, we have included a PDF to help you and others review the questions before completing the survey online and to use as a reference. The PDF version will not be accepted via fax or email – only surveys completed using the online survey system will be accepted. If you need additional assistance completing the survey, please contact XXX at XXX@jsi.com or XXX-XXX-XXXX.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-xxxx . The time required to complete this information collection is estimated to average ___hours/ minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Section A. Current Data Elements

Section A below will review current FPAR data elements with no changes for FPAR 2.0. Subsequent sections B and C will review proposed modified data elements and proposed new data elements.

This section asks about data elements that are currently collected for FPAR with no proposed modifications for FPAR 2.0.

• Subrecipient Site ID

• Service Site ID

• Client ID Number

• Visit date

• Date of Birth

• Sex

• Chlamydia Test Performed

• Gonorrhea Test Performed

• HIV Test Performed

• Pap Test Performed

For each of the data elements listed below, please rate your agency’s level of difficulty for extracting and reporting encounter-level data for this data element. Please keep in mind the development or modifications of exports or reports in your data system(s) that would be needed in order for your agency to extract and report this encounter-level data.

A1a: For each of the data elements listed in the table below, reporting encounter-level data for this data element would be…

Data Element	Very Difficult	Difficult	Neither Difficult nor Easy	Easy	Very Easy	[If “very difficult” or “difficult”] Please describe your agency’s challenges with reporting this data element at the encounter-level.
Subrecipient Site ID					
Service Site ID					
Client ID Number					
Visit date					
Date of Birth					
Sex					
Chlamydia Test Performed					
Gonorrhea Test Performed					
HIV Test Performed					
Pap Test Performed					

A2b: Please provide any additional feedback or comments on the reporting of any of these data elements at the encounter-level.

Section B. Modified Data Elements

This second section of four sections asks about data elements that are currently captured for FPAR, but with proposed modifications for FPAR 2.0.

• Family Planning Provider

• Race

• Ethnicity

• Household Income

• Household size

• Limited English Proficiency Status

• Principal Health Insurance Status/Coverage

• Contraceptive Method at Exit

• Reason for no method at exit

For each of the data elements listed below, please rate your agency’s level of difficulty for collecting the modified version of this data element at the point of care for FPAR 2.0. Please keep in mind any changes to workflow, paper forms, or other documentation procedures that would be needed in order for your agency to collect this data at the point of care. For more information on the response options, data types, and formats for these fields, please see the FPAR 2.0 Draft Data Dictionary.

B1a: For each of the data elements listed in the table below, collecting this data element would be…

Data Element	Brief Description of Modification	Very Difficult	Difficult	Neither Difficult nor Easy	Easy	Very Easy	[If “very difficult” or “difficult”] Please describe your agency’s challenges with collecting the modified version of this data element for FPAR 2.0.
Family Planning Provider	Revised response options: RN with expanded scope of practice (new) Educator/Counselor/ Case Manager/All Others (revised from Other Services provider)					
Race	Revised response options: Declined to state (new) Not Reported (revised from Unknown/Not reported)					
Ethnicity	Revised response options: Declined to state (new) Not Reported (revised from Unknown/Not reported)					
Household Income	Collection of numeric data replacing poverty status					
Household Size	Collection of numeric data replacing poverty status					
Limited English Proficiency Status	Revised response options: Not Reported (revised from Unknown/Not reported)					
Principal Health Insurance Status/Coverage	Revised response options: Medicaid (new) Medicare (new) Other public insurance - non-CHIP (new) Other public insurance – CHIP (new) Uninsured –self pay (revised from Uninsured) Not Reported (revised from Unknown/not reported)					
Contraceptive Method at Exit	Revised Response Options: Withdrawal (new) Removed Abstinence Collapsed 1 month/3 month injections LAM/FAM separated into 2 responses					
Reason for no method at exit	Revised Response Options: Abstinence (new) Not at risk of unintended pregnancy (sterile, same sex partner only?) (new) Client declined all methods offered (new) Other – at risk of unintended pregnancy (revised from other reasons)					

B1b: Please provide any additional feedback or comments on the collection of the modified version of any of the data elements for FPAR 2.0.

For each of the data elements listed below, please rate your agency’s level of difficulty for modifying data system(s) to accommodate this data element. Please keep in mind any data system modification costs and/or any additional data entry time needed in order for your agency to store this data. For more information on the response options, data types, and formats for these fields, please see the FPAR 2.0 Draft Data Dictionary.

B2a: For each of the data elements listed in the table below, modifying my agency’s data system(s) for this data element would be…

Data Element	Brief Description of Modification	Very Difficult	Difficult	Neither Difficult nor Easy	Easy	Very Easy	[If “very difficult” or “difficult”] Please describe your agency’s challenges with modifying data system(s) to accommodate the modified version of this data element for FPAR 2.0.
Family Planning Provider	Revised response options: RN with expanded scope of practice (new) Educator/Counselor/ Case Manager/All Others (revised from Other Services provider)					
Race	Revised response options: Declined to state (new) Not Reported (revised from Unknown/Not reported)					
Ethnicity	Revised response options: Declined to state (new) Not Reported (revised from Unknown/Not reported)					
Household Income	Collection of numeric data replacing poverty status					
Household Size	Collection of numeric data replacing poverty status					
Limited English Proficiency Status	Revised response options: Not Reported (revised from Unknown/Not reported)					
Principal Health Insurance Status/Coverage	Revised response options: Medicaid (new) Medicare (new) Other public insurance - non-CHIP (new) Other public insurance – CHIP (new) Uninsured –self pay (revised from Uninsured) Not Reported (revised from Unknown/not reported)					
Contraceptive Method at Exit	Revised Response Options: Withdrawal (new) Removed Abstinence Collapsed 1 month/3 month injections LAM/FAM separated into 2 responses					
Reason for no method at exit	Revised Response Options: Abstinence (new) Not at risk of unintended pregnancy (sterile, same sex partner only?) (new) Client declined all methods offered (new) Other – at risk of unintended pregnancy (revised from other reasons)					

B2b: Please provide any additional feedback or comments on the modification of data system(s) to accommodate the modified version of any of the data elements for FPAR 2.0.

For each of the data elements listed below, please rate your agency’s level of difficulty for extracting and reporting encounter-level data for the modified version of these data elements for FPAR 2.0. Please keep in mind the development or modifications of exports or reports in your data system(s) that would be needed in order for your agency to extract and report this encounter-level data.

B3a: For each of the data elements listed in the table below, reporting encounter-level data for this data element would be…

Data Element	Brief Description of Modification	Very Difficult	Difficult	Neither Difficult nor Easy	Easy	Very Easy	[If “very difficult” or “difficult”] Please describe your agency’s challenges with reporting the modified version of this data element for FPAR 2.0 at the encounter-level.
Family Planning Provider	Revised response options: RN with expanded scope of practice (new) Educator/Counselor/ Case Manager/All Others (revised from Other Services provider)					
Race	Revised response options: Declined to state (new) Not Reported (revised from Unknown/Not reported)					
Ethnicity	Revised response options: Declined to state (new) Not Reported (revised from Unknown/Not reported)					
Household Income	Collection of numeric data replacing poverty status					
Household Size	Collection of numeric data replacing poverty status					
Limited English Proficiency Status	Revised response options: Not Reported (revised from Unknown/Not reported)					
Principal Health Insurance Status/Coverage	Revised response options: Medicaid (new) Medicare (new) Other public insurance - non-CHIP (new) Other public insurance – CHIP (new) Uninsured –self pay (revised from Uninsured) Not Reported (revised from Unknown/not reported)					
Contraceptive Method at Exit	Revised Response Options: Withdrawal (new) Removed Abstinence Collapsed 1 month/3 month injections LAM/FAM separated into 2 responses					
Reason for no method at exit	Revised Response Options: Abstinence (new) Not at risk of unintended pregnancy (sterile, same sex partner only?) (new) Client declined all methods offered (new) Other – at risk of unintended pregnancy (revised from other reasons)					

B3b: Please provide any additional feedback or comments on the reporting of the modified version of any of the data elements for FPAR 2.0 at the encounter-level.

Section C. New Data Elements

This section asks about proposed new data elements for FPAR 2.0 that are not currently collected for FPAR:

• Systolic Blood Pressure

• Diastolic Blood Pressure

• Height

• Weight

• Chlamydia Test Result

• Gonorrhea Test Result

• HIV Supplemental Test- Positive

• HIV Supplemental Test - Positive Result Communicated

• HIV Supplemental Test - Positive Result - Linked to HIV Medical Care

• HPV Test Performed

• Date of Last Pap Test

• Date of Last HPV Test

• Current Pregnancy Status

• Pregnancy intention

• Pregnancy history

• Contraceptive method at entry

• Reason for no method at entry

• Smoking status

For each of the data element definitions listed below, please rate how clear you think the definition is, on a scale from “very unclear” to “very clear.”

C1a: For each of the data elements listed in the table below, the definition of the data element is…

Data Element	Definition	Very Unclear	Unclear	Neither Unclear nor Clear	Clear	Very Clear	[If “very unclear” or “clear”] How would you modify this definition to make it clearer?
Systolic Blood Pressure	Refers to the client's systolic blood pressure measurement documented during a family planning encounter.					
Diastolic Blood Pressure	Refers to the client's diastolic blood pressure measurement documented during a family planning encounter.					
Height	Refers to the client's height as documented during a family planning encounter.					
Weight	Refers to the client's weight as documented during a family planning encounter.					
Chlamydia Test Result	Confirmed chlamydia test results from an accredited lab.					
Gonorrhea Test Result	Confirmed gonorrhea test results from an accredited lab.					
HIV Supplemental Test- Positive	A reactive initial HIV test confirmed by a positive supplemental HIV test was received by the healthcare provider.					
HIV Supplemental Test - Positive Result Communicated	A client with a positive confirmatory test was provided his/her test results.					
HIV Supplemental Test - Positive Result - Linked to HIV Medical Care	The client has a positive HIV confirmatory test result and has been linked to care (seen by a physician, nurse practitioner, or physician assistant within 3 months of positive test).					
HPV Test Performed	An HPV Test was performed for the client during a family planning encounter.					
Date of Last Pap Test	The date, at minimum the month and year, of the client's last pap test (may be the date of current visit if pap performed; pap test does not have to be performed at the Title X service site).					
Date of Last HPV Test	The date, at minimum the month and year, of the client's last HPV test (may be the date of current visit if HPV performed; HPV test does not have to be performed at the Title X service site).					
Current Pregnancy Status	Client’s current pregnancy status.					
Pregnancy intention	Client’s intention (or client’s partner) to get pregnant either for the first time or have an additional pregnancy within the next year.					
Pregnancy history	The number of times a female client has been pregnant, often called gravidity, regardless of outcome (including live births, stillbirths, miscarriages, abortions, and tubal and other ectopic pregnancies).					
Contraceptive method at entry	The contraceptive method of family planning is the user’s method—adopted or continued — at the last sexual encounter. If the user reports that he or she is using more than one family planning method, report the most effective one as the initial method.					
Reason for no method at entry	For those clients that are not using a contraceptive method at the last sexual encounter, the reason the client is not using a contraceptive method including if either partner is sterile without having been sterilized surgically, if either partner has had a non-contraceptive surgical procedure that has rendered him or her unable to conceive or impregnate, or if the client has a same-sex sexual partner.					
Smoking status	The client's smoking status as reported by the client during a family planning encounter.					

C1b: Please provide any additional feedback or comments on the definitions of any of the data elements.

For each of the data elements listed below, please rate your agency’s level of difficulty for collecting this data element at the point of care. Please keep in mind any changes to workflow, paper forms, or other documentation procedures that would be needed in order for your agency to collect this data at the point of care. For more information on the response options, data types, and formats for these fields, please see the FPAR 2.0 Draft Data Dictionary.

C2a: For each of the data elements listed in the table below, collecting this data element would be…

Data Element	Very Difficult	Difficult	Neither Difficult nor Easy	Easy	Very Easy	[If “very difficult” or “difficult”] Please describe your agency’s challenges with collecting this data element.
Systolic BP					
Diastolic BP					
Height					
Weight					
Chlamydia Test Result					
Gonorrhea Test Result					
HIV Supplemental Test- Positive					
HIV Supplemental Test - Positive Result Communicated					
HIV Supplemental Test - Positive Result - Linked to HIV Medical Care					
HPV Test Performed					
Date of Last Pap Test					
Date of Last HPV Test					
Current Pregnancy Status					
Pregnancy intention					
Pregnancy history					
Contraceptive method at entry					
Reason for no method at entry					
Smoking status					

C2b: Please provide any additional feedback or comments on the collection of any of the data elements.

For each of the data elements listed below, please rate your agency’s level of difficulty for modifying data system(s) to accommodate this data element. Please keep in mind any data system modification costs and/or any additional data entry time needed in order for your agency to store this data. For more information on the response options, data types, and formats for these fields, please see the FPAR 2.0 Draft Data Dictionary.

C3a: For each of the data elements listed in the table below, modifying my agency’s data system(s) for this data element would be…

Data Element	Very Difficult	Difficult	Neither Difficult nor Easy	Easy	Very Easy	[If “very difficult” or “difficult”] Please describe your agency’s challenges with modifying data system(s) to accommodate this data element.
Systolic BP					
Diastolic BP					
Height					
Weight					
Chlamydia Test Result					
Gonorrhea Test Result					
HIV Supplemental Test- Positive					
HIV Supplemental Test - Positive Result Communicated					
HIV Supplemental Test - Positive Result - Linked to HIV Medical Care					
HPV Test Performed					
Date of Last Pap Test					
Date of Last HPV Test					
Current Pregnancy Status					
Pregnancy intention					
Pregnancy history					
Contraceptive method at entry					
Reason for no method at entry					
Smoking status					

C3b: Please provide any additional feedback or comments on the modification of data system(s) to accommodate any of the data elements.

For each of the data elements listed below, please rate your agency’s level of difficulty for extracting and reporting encounter-level data for this data element. Please keep in mind the development or modifications of exports or reports in your data system(s) that would be needed in order for your agency to extract and report this encounter-level data.

C4a: For each of the data elements listed in the table below, reporting encounter-level data for this data element would be…

Data Element	Very Difficult	Difficult	Neither Difficult nor Easy	Easy	Very Easy	[If “very difficult” or “difficult”] Please describe your agency’s challenges with reporting this data element at the encounter-level.
Systolic BP					
Diastolic BP					
Height					
Weight					
Chlamydia Test Result					
Gonorrhea Test Result					
HIV Supplemental Test- Positive					
HIV Supplemental Test - Positive Result Communicated					
HIV Supplemental Test - Positive Result - Linked to HIV Medical Care					
HPV Test Performed					
Date of Last Pap Test					
Date of Last HPV Test					
Current Pregnancy Status					
Pregnancy intention					
Pregnancy history					
Contraceptive method at entry					
Reason for no method at entry					
Smoking status					

C4b: Please provide any additional feedback or comments on the reporting of any of the data elements at the encounter-level.

Section D: Organization Information

This section asks about your workplace setting and your role.

D1: Which of the following best describes your workplace setting? (select one, *required)

• Health department (e.g., state, county, local)

• Hospital-based

• Planned Parenthood

• Free-standing Family Planning Organization

• Community health center/Federally Qualified Health Center

• Tribal health center

• University-based

• School-based

• Faith-based

• Correctional facility-based

• Other private, non-profit

• Federal government

• Other, please specify: _____________________________

D2: How long has your organization been Title X funded? (select one, *required)

• Less than 1 year

• 1-3 years

• 4-6 years

• 7-9 years

• 10 years or more

D3: What best describes your primary role at your workplace? (select one, *required)

• Health Educator/Counselor/Health Care Associate/Medical Assistant

• Community Outreach Staff

• Manager/Administrator/Center Coordinator

• Clinical Provider

• Nurse

• Front Desk/Reception

• Billing/Finance Assistant

• Other, please specify: _____________________________

END

Once you click the submit button, you will not be able to change your responses. If you are not ready to submit, click the back button below.

Thank you for taking the time to complete the Title X Family Planning Annual Report (FPAR) 2.0 Data Element Survey. OPA will use this information to refine and finalize FPAR 2.0 data elements and inform implementation efforts.

Title X Family Planning Annual Report (FPAR) 2.0 Data Element Survey

Draft August 11, 2014 2