Sustainability Assessment Grantees

Sustainability Assessment - Grantees (DRAFT 3)
Grantee Sustainabilty Assessment

Dear Title X Grantee: 

This form is a pilot tool that OPA is developing to assist sites and grantees in understanding their readiness to respond 
to health system changes. This survey should be completed by the Title X grantee who receives funding directly from the 
Office of Population Affairs (OPA). OPA will use the information collected by this tool to identify technical assistance and 
training needs. Please note that OPA will not use the information to make funding decisions. 

Also note that this tool is part of a larger effort to collect information on sustainability and supplements a data collection 
form that will be completed at the service site level. 

Thank you for your time.  

Sincerely,  
Office of Population Affairs 

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Sustainability Assessment - Grantees (DRAFT 3)
Grantee Information

*1. Please provide your contact information in case we have questions about this tool
Name:
Address:
Address 2:
City/Town:
State:

6

ZIP:
Email Address:
Phone Number:

*2. What is your grantee name?

*3. In what state is your grantee organization primarily located? If your organization is

located in more than one state, please respond based on the state in which your Title X
program has its highest client volume.
State:

6

*4. Please select the option that best describes your organization type.
j Community health center/Federally Qualified Health Center
k
l
m
n
j Correctional facility­based
k
l
m
n
j Faith­based
k
l
m
n

j Free­standing Family Planning Organization
k
l
m
n

j Health Department (e.g., state, county, local)
k
l
m
n
j Hospital­based
k
l
m
n

j Other Private Nonprofit
k
l
m
n
j Planned Parenthood
k
l
m
n
j School­based
k
l
m
n

j Tribal health center
k
l
m
n
j University­based
k
l
m
n

*5. How many Title X sites are currently in your service delivery network?
Number of Sites

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Sustainability Assessment - Grantees (DRAFT 3)
Policy

For these questions, if the grantee is located in more than one state, please respond based on the state in which the 
grantee’s Title X program has its highest client volume. 

*6. For family planning services, does your state have:
j Medicaid Waiver
k
l
m
n

j Family Planning State Plan Amendment
k
l
m
n

j Both a Medicaid Waiver and a Family Planning State Plan Amendment
k
l
m
n
j None of the above
k
l
m
n

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Sustainability Assessment - Grantees (DRAFT 3)

*7. What is the highest income range level under your state's Medicaid waiver or Family

Planning State Plan Amendment for family planning services?
j <100% of the Federal Poverty Level (FPL)
k
l
m
n
j 100% of the Federal Poverty Level (FPL)
k
l
m
n
j 133% to less than 185% FPL
k
l
m
n
j 185% to less than 200% FPL
k
l
m
n
j 200% to less than 250% FPL
k
l
m
n
j 250% FPL
k
l
m
n

j >250% FPL
k
l
m
n

Please describe any eligibility special conditions (e.g. age, gender) other than income. 

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Sustainability Assessment - Grantees (DRAFT 3)

*8. Are you aware of any efforts underway in the state to obtain either an 1115 Medicaid

waiver or a State Plan Amendment?

j Yes
k
l
m
n
j No
k
l
m
n

*9. Do you have a mechanism to provide input to Medicaid or Health Insurance

Marketplace decisions in its state?

j Yes
k
l
m
n
j No
k
l
m
n

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Sustainability Assessment - Grantees (DRAFT 3)

*10. Please describe the mechanism(s) for policy input and the grantee’s level of

involvement (e.g. Medicaid policy committee, member):
5
6  

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Sustainability Assessment - Grantees (DRAFT 3)
Enrollment and Quality Monitoring

*11. What resources have you provided to your sites to conduct enrollment activities?

Please select all that apply:
c Training
d
e
f
g

c Technical assistance
d
e
f
g

c Materials to distribute to clients
d
e
f
g

c Funding for onsite enrollment staff
d
e
f
g

c Equipment (e.g. mobile devices or computers to assist people with enrollment)
d
e
f
g
c None of the above
d
e
f
g

Other (please specify) 

*12. Please select the answer that best describes your current efforts to measure quality

in your service delivery network. Our program:

c has established performance measures to monitor quality and have processes for spreading program improvements among sites.
d
e
f
g
c has established performance measures to monitor quality.
d
e
f
g

c is in the process of establishing performance measures to monitor quality.
d
e
f
g
c does not intend to establish performance measures to monitor quality.
d
e
f
g

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Sustainability Assessment - Grantees (DRAFT 3)
THANK YOU!

Thank you for completing this assessment. Please remember to ask every service site to complete the site assessment. 

For the pilot, please let us know how many minutes it took to complete this assessment.  
THANK YOU FOR COMPLETING THIS PILOT ASSESSMENT. 

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