Form 1 Rural Health Network Development Performance Improvement

Updated: 10/06/14

Office of Rural Health Policy: Rural Health

Community-Based Grant Programs

Performance Improvement and Measurement System (PIMS) Database

SECTION I: NETWORK

Table 1: Network Infrastructure

Table Instructions: Please provide information about the network members and network operations. Network members are defined as members who have signed a Memorandum of Understanding or Memorandum of Agreement or have a letter of commitment to participate in the network.

1.	Identify the types and number of organizations in the consortium or network for your project:
		Type of Member Organizations in the Consortium/Network	Number
	Non-Profit Organization	Area Health Education Center
		Behavioral/Mental Health Organization
		Community College
		Community Health Center
		Critical Access Hospital
		Faith-based organization
		Free Clinic
		Health Department
		Hospice
		Hospital
		Migrant Health Center
		Private Practice
		Rural Health Clinic
		School District
		Social Services Organization
		University
		Other – Specify type
		TOTAL for non-profit organization	(Automatically calculated by system)
	For-Profit Organization	Critical Access Hospital
		Hospice
		Private Practice
		Rural Health Clinic
		Other – Specify Type
		TOTAL for-profit organization	(Automatically calculated by system)
2	Indicate the total number of full-member (all members that signed MOU, MOA, or letters of commitment) network meetings conducted during the reported budget year by meeting type:
	Meeting Type		Number
	Meetings conducted face-to-face
	Meetings conducted via teleconference
	Meetings conducted via webinar
	Meetings conducted in a manner not listed above (please specify type)
3	Total number of meetings conducted in any manner (face-to-face, teleconference, etc.)?
4	Number of meetings conduced in any manner (face-to-face, teleconference, etc.) that were attended by at least 75% of board members

Table 2: Network Benefits

Table Instructions: Please provide information about the overall Network benefits that have occurred during the current budget year..

Please refer to the detailed definitions and examples in answering the following measures.

Financial Cost Saving: a reduction in historical or projected cost. Examples may include: reduced operational costs, cost sharing, and reduced cost of services.

Educational Opportunities: educational experience where new knowledge is acquired. Examples may include: webinars, conferences, workshops.

Access to Equipment: newly acquired ability to utilize equipment. Examples may include: access to shared software, in kind use of equipment,

Access to Subject Matter Experts: newly acquired ability to utilize the skills or knowledge of a person who is an authority in a particular area. Examples may include: access to a program evaluator, Health Information Technology specialist.

5	During the current budget year, assess the following overall Network benefits (check one answer for each type of network change):
	Type of Network Change	Increased	No Change	Reduced
	Financial Cost Savings
	Access to Educational Opportunities
	Access to Equipment
	Access to Subject Matter Experts
	Understanding of community health needs
	Other (Please Specify):

Table 3: Network Collaboration

Table Instructions: Please provide information about collaboration and/or integration among the network members. Refer to the activities listed in the project workplan for this project period.

6	How many activities from the project workplan were initiated by at least two or more network members?	Number
7	How many activities from the project workplan were completed by at least two or more network members?	Number

Table 4: Sustainability

Table Instructions: Please provide information about the contribution by network members and the network’s sustainability efforts.

8	How many of the network members have provided the following in-kind services during this budget period:
	Goods (Ex: equipment, food)	Number
	Services (ex: meeting space)	Number
	Staff support	Number
	Expertise (ex: legal, business, website/marketing development)	Number
	Other (please specify)
9	How many network policies or procedures were created during this budget period:	Number
10	How many network policies or procedures were amended during this budget period:	Number
11	How many network policies or procedures were implemented during this budget period:	Number
12	As a result of being part of the network, how many network member organizations were able to integrate joint policies/procedures within their respective organizations during this budget period?	Number
13	Will the activities of the Network/Consortium continue to operate after the Federal grant funding period?	All/Some/None
14	Does the network have a written long-range strategy (3-5 years) for obtaining future network revenue and economic self-sufficiency	Y/N

Table 5: Network Assessment

Table Instructions: Please provide information regarding the network’s assessment during this project period.

15	Did the network meet its program objectives?	All (100%) Most (50-99%) Some (less than 50%) None (0%)
16	Does the network include a process or tool to assess effectiveness of network performance?	Y/N
17	If yes, how is network performance assessed?	open-ended response
18	Are network performance measures and outcomes disseminated in writing to members at least annually?	Y/N
19	Does the network include a process or tool to assess effectiveness of network director?	Y/N
20	If yes, how is the network director assessed?	open-ended response

Table 6: Impact

Table Instructions: Information collected in this table provides an aggregate count of the number of people targeted within the service area, which may or may not be the total population residing within the service area. Please indicate a numerical figure or DK for do not know, if applicable

Number of people in target population

• Denotes the number of people your program is trying to serve (not necessarily the number of people who availed themselves of your services). For example, if the network focuses its mission on serving a particular population such as migrant and seasonal farm workers, then the migrant and seasonal farm workers may be a subset of the total population within the service area.

21	Number of people in target population	Number/ DK
22	Number of people in the target population with access to new or expanded programs/services this year as a result of network activities funded by the Rural Health Network Development Program	Number
23	Number of new programs/services implemented by the network this year - as a result of grant funding from the Rural Health Network Development Program

24	Type(s) of new and/or expanded services provided by the network as a result of the Rural Health Network Development grant funding	Please check  Please check any boxes below that apply to any new and/or expanded services provided as a result of Network Development grant funding. NOTE: Please check at least one box.
	Cardiovascular Disease
	Case Management
	Diabetes / Obesity Management
	Elderly / Geriatric Care
	Emergency Medical Services (EMS)
	Health Education
	Health Literacy / Translation Services
	Health Promotion / Disease Prevention
	Maternal and Child Health/Women's Health School Board
	Mental / Behavioral Health
	Nutrition
	Oral Health
	Pharmacy
	Primary Care
	Substance Abuse Treatment
	Telehealth / Telemedicine
	Transportation
	Workforce
	Other, please specify.
	None- Explain	open-ended response

25	Are discounted services currently available as a result of the activities conducted by your network?	None/Limited/Moderate/Significant
26	What is your ratio for Economic Impact vs. HRSA Program Funding? Use the HRSA’s Economic Impact Analysis Tool (http://www.raconline.org/econtool/) to identify your ratio.	Ratio

Section II: Demographics – All program activities

Table 7: Demographics- Number of People Served by the Program

Table Instructions: Please provide the total number of people who were served by the activities of your program over the past budget year. This number represents the total number of people served by all of the activities outlined in your work plan (Attachment 1 of your application) and includes all direct clinical (if applicable) and non-clinical people served by the program. Please provide information on race, ethnicity, and age. Where possible, please obtain and report on patient reported race. If the total number that is Hispanic or Latino is zero (0), please put zero in the appropriate section. Do not leave any sections blank. There should not be a N/A (not applicable) response since all measures are applicable. The totals for each section (number of people served by the program, number served by ethnicity, number served by race, number served by age group) should be the same.

Number of people served through program by ethnicity (Hispanic or Latino/Not Hispanic or Latino) is defined as:

• Hispanic or Latino origin includes Mexican, Mexican American, Chicano, Puerto Rican, Cuban and other Hispanic, Latino or Spanish origin (i.e. Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard etc.)

27	Number of people served by the program	Number
28	Number of people served by ethnicity:	Number
	Hispanic or Latino
	Not Hispanic or Latino
	Unknown
29	Number of people served by race:	Number
	American Indian or Alaska Native
	Asian
	Black or African American
	Native Hawaiian or Other Pacific Islander
	White
	More than one race
	Unknown
30	Number of people served, by age group:	Number
	Children (0-12)
	Adolescents (13-17)
	Adults (18-64)
	Elderly (65 and over)
	Unknown

SECTION III: DEMOGRAPHICS- DIRECT Clinical SERVICES (IF APPLICABLE)

Table 8: Demographics of People Receiving Direct Clinical Services (If applicable)

Table Instructions: If your program provides direct clinical services, please fill out the following table Numbers provided here are based only on the number of people receiving direct clinical services funded through this grant program. Information collected in this table provides an aggregate count of the number of people receiving clinical services through your program. .Please provide information on race, ethnicity, and age. Where possible, please obtain and report on patient reported race. If the total number that is Hispanic or Latino is zero (0), please put zero in the appropriate section. Do not leave any sections blank. There should not be a N/A (not applicable) response since all measures are applicable. The totals for each section (number of people served by the program, number served by ethnicity, number served by race, number served by age group) should be the same.

Number of people served through program by ethnicity (Hispanic or Latino/Not Hispanic or Latino) is defined as:

Hispanic or Latino origin includes Mexican, Mexican American, Chicano, Puerto Rican, Cuban and other Hispanic, Latino or Spanish origin (i.e. Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard etc.)

Please refer to the detailed definitions and guidelines in answering the following measures.

Direct Clinical Services are defined as a documented interaction between a patient/client and a clinical or non-clinical health professional that has been funded with ORHP grant dollars. Examples of direct services include (but are not limited to) patient visits, counseling, and education.

Number of people served through program by ethnicity (Hispanic or Latino/Not Hispanic or Latino) is defined as:

• Hispanic or Latino origin includes Mexican, Mexican American, Chicano, Puerto Rican, Cuban and other Hispanic, Latino or Spanish origin (i.e. Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard etc.)

31	Number of people served by ethnicity:	Number
	Hispanic or Latino
	Not Hispanic or Latino
	Unknown
32	Number of people served by race:	Number
	American Indian or Alaska Native
	Asian
	Black or African American
	Native Hawaiian or Other Pacific Islander
	White
	More than one race
	Unknown
33	Number of people served, by age group:	Number
	Children (0-12)
	Adolescents (13-17)
	Adults (18-64)
	Elderly (65 and over)
	Unknown

section Iv: INSURANCE STATUS/COVERAGE –DIRECT CLINICAL SERVICES (IF APPLICABLE)

Table 9: Insurance Status/Coverage of People Receiving Direct Clinical Services (If applicable)

Table Instructions: If your program provides direct clinical services, please fill out the following table. Individuals should only be counted once.

Please respond to the following questions based on these guidelines:

• Uninsured is defined as those without health insurance.

• Medicare is defined as Federal insurance for the aged, blind, and disabled (Title XVIII of the Social Security Act).

• Medicaid is defined as State-run programs operating under the guidelines of Titles XIX (and XXI as appropriate) of the Social Security Act.

• The Children’s Health Insurance Program (CHIP) provides primary health care coverage for children.

• Other state-sponsored or public assistance program includes State and/or local government programs.

• Private insurance is health insurance provided by commercial and not for profit companies. Individuals may obtain insurance through employers or on their own.

34	Number of uninsured people	Number
35	Number of people covered through only Medicare	Number
36	Number of people covered through only Medicaid	Number
37	Number of people covered by both Medicare and Medicaid (Dual Eligible)	Number
38	Number of people covered through only the Children’s Health Insurance Program (CHIP)	Number
39	Number of people covered through only other state-sponsored insurance or public assistance program	Number
40	Number of people covered by only private insurance	Number
41	Unknown	Number

section v: Staffing

Table 10: Staffing

Table Instructions: Please provide the number of clinical and non-clinical positions funded by this grant. Please indicate a numerical figure. There should not be a N/A (not applicable) response since all questions are applicable.

Please refer to the detailed definitions and guidelines in answering the following measures

Clinical Staff is defined as a provider or non-provider that has direct contact with the patient (doctor, nurse, technician) or is a staff member whose job supports the clinical service provided (billing, check-in receptionist)

Non-Clinical Staff is defined as anyone who does not have contact with a patient and does not support a clinic visit (ex: program administrator, secretary, IT support person)

42	Number of positions funded by grant dollars	Part-Time (<1.0 FTE)	Full-Time (1.0 FTE)
	Clinical Staff
	Non-Clinical Staff

SECTION VI: HEALTH INFORMATION TECHNOLOGY

Table 11: Health Information Technology

Table Instructions: Please select all types of technology implemented, expanded or strengthened through this program.

43	Type(s) of technology implemented, expanded or strengthened through this program: (Please check all that apply)	Selection list
	Computerized provider order entry (CPOE)
	Electronic entry of prescriptions/e-prescribing
	Electronic medical records/electronic health records
	Health information exchange (HIE)
	Patient/disease registry
	Telehealth/telemedicine
	None
	Other – please specify
44	Have your organization and/or any of your organization’s providers attested to Meaningful Use? If yes, please select all that apply.	Y/N
	Stage 1
	Stage 2
	Stage 3
	If no, is your organization and/or providers planning to attest in the next 12 months?
	If yes, have your organization and/or providers received incentive payments?

SECTION VII: QUALITY IMPROVEMENT

Table 12: Quality Improvement

Table Instructions: Please report on quality improvement activities and initiatives implemented, expanded or strengthened through this program.

Please refer to the detailed definitions and guidelines in answering the following

• An Accountable Care Organization (ACO) is a group of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to Medicare patients.

• A Medical Home is defined as comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. To become a medical home an organization generally gains a level of certification from an accrediting body.

• Care coordination is defined as the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services.

• The Partnership for Patients is a public/private partnership focused on making hospital care safer, more reliable, and less costly through two goals: reducing preventable hospital-acquired conditions and improving care transitions. (http://partnershipforpatients.cms.gov/)

• Million Hearts is a national initiative to prevent 1 million heart attacks and strokes by 2017. (http://millionhearts.hhs.gov/index.html)

• The Medicare Beneficiary Quality Improvement Project (MBQIP) is a Flex Grant Program activity within the core area of quality improvement for Critical Access Hospitals (CAH). (http://www.hrsa.gov/ruralhealth/about/hospitalstate/medicareflexibility_.html)

45	Participation in Accountable Care Organization (ACO) Is your organization participating in an ACO? (If yes, please check all that apply)	Yes/No (Selection List)
	Medicare Shared Savings Program
	Advanced Payment ACO Model
	Pioneer ACO Model
	Non-Medicare ACO
46	Participation in Medical Home Is your organization participating in a Medical Home or Patient Centered Medical Home (PCMH) initiative?	Yes/No
47	If yes, have you achieved or are you pursuing certification or recognition? (If yes, please check all that apply)	Yes/No (Selection List)
	National Committee for Quality Assurance (NCQA)
	Accreditation Association for Ambulatory Health Care (AAAHC)
	The Joint Commission
	State/Medicaid Program
	Other – specify
48	Care Coordination Activities	Yes/No (Selection List)
	Referral tracking system
	Patient support and engagement
	Integrated care delivery system (agreements with specialists, hospitals, community organizations, etc. to coordinate care)
	Case management
	Care plans
	Medication management
	Other – specify
49	Participation in Partnership for Patients	Yes/No
50	Participation in Million Hearts	Yes/No
51	Critical Access Hospitals: Participation in Medicare Beneficiary Quality Improvement Project (MBQIP)	Yes/No
52	Other – please specify

SECTION VIII: Clinical Measures

Table 13: Clinical Measures

Table Instructions:

Table 9: CLINICAL MEASURES

Table Instructions:

Please use your health information technology system to extract the clinical data requested. Please refer to the specific definitions for each measure.

Measure 1: Percentage of patients aged 18 years and older who were screened for tobacco use at least once during the two-year measurement period AND who received cessation counseling intervention if identified as a tobacco user

Numerator: Patients who were screened for tobacco use* at least once during the two-year measurement period AND who received tobacco cessation counseling intervention** if identified as a tobacco user
*Includes use of any type of tobacco
** Cessation counseling intervention includes brief counseling (3 minutes or less), and/or pharmacotherapy.Numerator Details: ${NumeratorDetails}

Denominator: All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period

Measure 2: Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool AND follow-up plan documented

Numerator: Patient’s screening for clinical depression using an age appropriate standardized tool AND follow-up plan is documented

Denominator: All patients aged 12 years and older

Measure 3: The percentage of patients 18 to 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year.

Numerator: The number of patients in the denominator whose most recent BP is adequately controlled during the measurement year. For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified.

Denominator: Patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.

Measure 4: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who have a LDL-C result <100 mg/dL OR patients who have a LDL-C result >=100 mg/dL and have a documented plan of care to achieve LDL-C <100mg/dL, including at a minimum the prescription of a statin

Numerator: The number of patients who have a LDL-C result <100 mg/dL

OR

Patients who have a LDL-C result >=100 mg/dL and have a documented plan of care1 to achieve LDL-C <100 mg/dL, including at a minimum the prescription of a statin within a 12 month period

Numerator Details:

${NumeratorDetails}

Denominator: All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period

Measure 5: The percentage of patients 18 - 75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level is <8.0% during the measurement year.

Numerator: Patients whose HbA1c level is <8.0% during the measurement year.

Denominator: Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.  

Measure 6: The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent LDL-C test is <100 mg/dL during the measurement year.

Numerator: Patients whose most recent LDL-C test is <100 mg/dL during the measurement year.

Denominator: Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.

Measure 7: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents

Numerator: Body mass index (BMI) percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year.

Denominator: Patients 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or OB-GYN.

Measure 8 : Percentage of patients aged 18 years and older with a documented BMI during the current encounter or during the previous six months AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the encounter. (Normal Parameters: Age 65 years and older BMI > or = 23 and < 30; Age 18 – 64 years BMI > or = 18.5 and < 25)

Numerator: Patients with a documented BMI during the encounter or during the previous six months, AND when the BMI is outside of normal parameters, follow-up is documented during the encounter or during the previous six months of the encounter with the BMI outside of normal parameters

Denominator: All patients aged 18 years and older

Measure 9: NQF 0038: Childhood Immunization Status (CIS): Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DtaP); three polio (IPV); one measles, mumps and rubella (MMR); three H influenza type B(HiB); three hepatitis B (HepB); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and nine separate combination rates.

Numerator: Children who have evidence showing they received recommended vaccines by their second birthday.

Denominator: Children who turn 2 years of age during the measurement year are eligible for inclusion.

Measure 10: Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization

Numerator: Patients who received an influenza immunization OR who reported previous receipt* of an influenza immunization

*Previous receipt can include: previous receipt of the current season’s influenza immunization from another provider OR from same provider prior to the visit to which the measures is applied (typically, prior vaccination would include influenza vaccine given since August 1st).

Denominator: All patients aged 6 months and older seen for a visit during this PIMS reporting year.

Measure 11: Children Who Received Preventive Dental Care: Assesses how many preventive dental visits during the previous 12 months

Numerator: Percentage of children who had one or more preventive dental visits in the past 12 months.

Denominator: Children age 1-17 years

Measure 12: Children Who Have Dental Decay or Cavities: Assesses if children age 1-17 years have had a toothache, tooth decay or cavities in the past 6 months

Numerator: Whether child had toothache, cavities or decayed teeth in past 6 months.

Denominator: Children and adolescents age 1-17 years

		Numerator	Denominator	Percent
	Behavioral Health
1	NQF 0028: Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention: Percentage of patients aged 18 years and older who were screened for tobacco use at least once during the two-year measurement period AND who received cessation counseling intervention if identified as a tobacco user
2	NQF 0418: Screening for clinical depression: Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool AND follow-up plan documented
	Cardiovascular
3	NQF 0018: Controlling High Blood Pressure: The percentage of patients 18 to 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year.
4	NQF 0074: Chronic Stable Coronary Artery Disease: Lipid Control: The percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who have a LDL-C result <100 mg/dL OR patients who have a LDL-C result >=100 mg/dL and have a documented plan of care to achieve LDL-C <100mg/dL, including at a minimum the prescription of a statin
	Diabetes
5	NQF 0575: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%): The percentage of patients 18 - 75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level is <8.0% during the measurement year.
6	NQF 0064: Comprehensive Diabetes Care: LDL-C Control <100 mg/dL: Percent of adult patients, 18- 75 years of age with diabetes (type 1 or type 2) who had LDL-C less than 100 mg/dL
	Environment and Public/Population Health
7	NQF 0024: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents: Percentage of patients 3-17 years of age who had an outpatient visit with a primary care physician (PCP) or an OB/GYN and who had evidence of the following during the measurement year: - Body mass index (BMI) percentile documentation - Counseling for nutrition - Counseling for physical activity
8	NQF 0421: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up: Percentage of patients aged 18 years and older with a documented BMI during the current encounter or during the previous six months AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the encounter.
	Immunization
9	NQF 0038: Childhood Immunization Status (CIS): Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DtaP); three polio (IPV); one measles, mumps and rubella (MMR); three H influenza type B(HiB); three hepatitis B (HepB); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and nine separate combination rates.
10	NQF 0041: Influenza immunization: Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization
	Oral Health
11	NQF 1334: Children Who Received Preventive Dental Care: Assesses how many preventive dental visits during the previous 12 months
12	NQF 1335: Children Who Have Dental Decay or Cavities: Assesses if children age 1-17 years have had a toothache, tooth decay or cavities in the past 6 months

Is your program addressing an NQF not provided in the table above

Yes

No

If your program IS addressing an NQF measure NOT provided in the table above, please provide the NQF number(s), numerator, denominator and percent in the table below.

		Numerator	Denominator	Percent
	NQF:
	NQF:

SECTION IV: PROGRAM INITIATIVE

Table 14: Program Initiative

Table Instructions: Please fill out the following table regarding your program’s initiative.

53	Does your program focus on an initiative not covered by these measures?	Yes/No
54	If yes, what is your program’s initiative?	Open ended response

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 0906-XXXX.  Public reporting burden for this collection of information is estimated to average 6.7 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 10C-03I, Rockville, Maryland, 20857.

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