Form 1 RESEP Performance Meaures_2015

OMB Number: 0915-XXXX

Expiration date: XX/XX/201X

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 24 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.

Radiation Exposure Screening and Education Program (RESEP)

Measures:

Table 1: DEMOGRAPHICS (applicable to all RESEP grantees)

Instructions:

Please provide the number of RESEP medical users in your service population by age, gender, race and ethnicity. The number individuals recorded within each category of this measure is reflective of the total population who have sought services from your organization’s RESEP facility and/or facilities.

If the number of people is zero (0), please put zero (0) 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.

For the number of total medical users by race, reports >0, please describe in comments section.

Number of people served through program by ethnicity (Hispanic or Latino/Not Hispanic or Latino). 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.)

Demographics		Number
1	Age Group – Number of Medical Users
	Under 40
	40-44
	45-49
	50-54
	55-59
	60-64
	65-69
	70-74
	75-79
	80-84
	85+
2	Gender – Number of Total Users
	Male
	Female
3	Race-Number of Total Users
	Black or African American
	Asian
	Native Hawaiian/Other Pacific Islander
	American Indian/Alaska Native
	White
	Other (if >0, please describe in comments section)
4	Ethnicity – Number of Total Users
	Hispanic/Latino
	Not Hispanic/Latino

Table 2: ANNUAL PROGRAM DATA SCREENING AND OUTREACH (applicable to all RESEP grantees)

Instructions:

Please refer to each category description for completing reporting for this measure.

Program Activities by Type

Screening: Please provide the number of initial medical encounters of eligible individuals who receive an employment history and physical examination by a health care provider.

Re-Screening: Please provide the number of medical encounters that occur at least one year after the initial physical examination of an eligible individual by a health care provider.

Screening Follow-Up Contacts: Please provide all medical related inquiries (face-to-face, calls and letters) with patients, and primary care providers and specialists regarding issues related to follow up after a screening. This also includes case management, general screening follow-up contacts, contacts regarding patients’ questions about their screening exam or results, contacts as a result of a screening exam or test that were done, referral for additional diagnostic testing or treatment, and any other activities related to a RESEP screening.

Medical Referrals: Please provide the number of all referrals for diagnosis and/or treatment made as a result of a RESEP screening exam.

Follow-Up/Diagnosis: Please provide the total number of referrals made, this is the number of patients referred for additional diagnostic testing of a RECA eligible disease or cancer.

Follow-Up/Treatment: Please provide the total number of referrals made, this is the number of patients referred for treatment of a RECA eligible disease or cancer.

Depression Screening: Positive Test and Referral: Please provide the total number of RESEP patients that test positive for depression (according to the two question instrument in the RESEP guidance under Depression Screening) and were referred for treatment of, either to their primary care, behavioral health or mental health provider.

RECA Eligibility Assistance Encounters: Please provide the total number of all RECA related encounters including: one-on-one counseling or assistance provided to individuals about eligibility for the RECA program, including information about patient claims, required documentation (e.g., medical, residency, and work history), application instructions, filing and approval processes, possible compensation, and referral for legal services. RECA eligibility assistance can be provided to individuals screened through the RESEP clinic, individuals who contact clinics for information about RECA eligibility without being screened at that clinic, family members of RECA-eligible individuals (living or deceased), and individuals with legal representation. This also includes repeat counseling sessions for RECA eligibility. This assistance can be provided through face to- face interactions, telephone encounters, or individual RECA claims assistance.

Sessions or Distributed Items

Presentations: Please provide the number of formal or informal sessions held (e.g., Community meetings, forums, events, health fairs, education classes) that include information about RESEP (may also include information about RECA).

Pamphlets/Brochures/Letters Distributed: Please provide the number of items distributed that included information about RESEP (may also include information about RECA). This category can include materials distributed at: community meetings, forums, health fairs or education classes. Letters counted in this category should only be those related to outreach and education, not letters related to screening results or referrals.

Individuals Attending Presentations: Please provide the number of individuals who attended the presentations as described above

Other: Please provide the number of other media types (e.g. e-mails, posters or flyers) disseminated to inform a target audience about RESEP. The number of items goes in the box. Also, please enter the description of which items and the quantity of each "Other" category item disseminated.

Individual Encounters

Face to Face: Please provide the number of one-on-one encounters with individuals regarding general, nonmedical questions about RESEP. These face-to-face encounters can include interactions focused on facilitating access and/or informing clients of available RESEP services. These face-to-face encounters can be the result of a range of education and outreach efforts, including RESEP presentations, media activity, publications, or word of mouth.

Telephone/General: Please provide the number of telephone encounters with individuals regarding general, nonmedical questions about RESEP. These telephone encounters can include interactions focused on facilitating access and/or informing clients of available RESEP services. These telephone encounters can be the result of a range of education and outreach efforts, including RESEP presentations, media activity, publications, or word of mouth.

Sessions or Distributed Items by Media Type

Radio: Please provide the number of advertisements, feature stories, or other radio announcements that inform the target audience about RESEP.

TV Spots: Please provide the number of advertisements, feature stories, or other television announcements that inform the target audience about RESEP.

Newspaper: Please provide the number of advertisements or articles that run in printed publications with the aim of reaching the target audience.

Other: Please provide the number of other media types (e.g. e-mails, posters, or flyers) disseminated to inform a target audience about RESEP. The number of items goes in the box. Also, please enter the description of which items and the quantity of each "Other" category item disseminated.

Annual Program Data and Screening Outreach		Number
5	Program Activities by Type
	Screening
	Re-Screening
	Screening Follow-Up Contacts
	Medical Referrals
	Follow-Up/Diagnosis
	Follow-Up/Treatment
	Depression Screening: Positive Test and Referral
	RECA Eligibility Assistance Encounters
6	Sessions or Distributed Items
	Presentations
	Pamphlets/Brochures/Letters Distributed
	Individuals Attending Presentations
	Other
7	Individual Encounters
	Face to Face
	Telephone/General
8	Sessions or Distributed Items by Media Type
	Radio
	TV Spots
	Newspaper
	Letters
	Other
9	Geographic Regions Reached via Media Efforts (up to 500 characters)

Table 4: RECA-ELIGIBLE DISEASES BY EXPOSURE CATEGORY (applicable to all RESEP grantees)

Instructions:

Please refer to each category description for completing reporting for this measure.

Exposure Activities for Malignant Diseases: Please provide the total number of RECA-eligible malignant diseases by exposure activity discovered during the reporting period.

Exposure Activities for Non-Malignant Diseases: Please provide the total number of RECA-eligible non-malignant disease by exposure activity discovered during the reporting period.

10 Exposure Activities for Malignant Diseases	Uranium Mining	Uranium Milling	Ore Transporting	Downwinder	Onsite Participant	Multiple Activities
Multiple Myeloma
Non-Hodgkin’s Lymphomas
Leukemia
Lung Cancer
Renal Cancer
Thyroid Cancer
Breast Cancer
Esophagus Cancer
Stomach Cancer
Pharynx Cancer
Bile Duct Cancer
Gall Bladder Cancer
Salivary Gland Cancer
Urinary Bladder Cancer
Brain Cancer Colon Cancer
Ovarian Cancer
Liver Cancer
Kidney Cancer

11 Exposure Activities for Non-Malignant Diseases	Uranium Mining	Uranium Milling	Ore Transporting	Downwinder	Onsite Participant	Multiple Activities
Respiratory Diseases
Chronic Renal Disease
Lung Disease Pulmonary Fibrosis
Fibrosis Cor Pulmonale
Renal Cancer
Silicosis
Pneumoconiosis

Table 5: OTHER DISEASES (NOT-ELIGIBLE FOR RECA) (applicable to all RESEP grantees)

Instructions:

Please refer to each category description for completing reporting for this measure.

Malignant Diseases Number: Please specify the type of malignant diseases (Not-Eligible for RECA) and the total number discovered.

Non-Malignant Diseases Number: Please specify the type of non-malignant diseases (i.e., those diseases not eligible for RECA) and the number discovered.

12	Malignant Diseases:	Number
	pituitary adenoma
	uterine cancer
	endometrial cancer
	prostate cancer
	cervical cancer
13	Non-Malignant Diseases:	Number
	depression
	kidney mass
	pneumonia
	irregular heart beat
	hematuria
	dysphagia
	hypertension
	hypothyroid
	BPH
	dementia
	pernicious anemia
	liver nodules
14	Annual Program Data Screening and Outreach Form Comments

Table 5: OUTREACH AND EDCUATION SESSIONS (applicable to all RESEP grantees)

Energy Employment Occupational Illness Compensation Program Act (EEOICPA)

Instructions:

Please refer to each category description for completing reporting for this measure.

Number of Encounters (face-to-face): Enter the total staff hours and hourly wage spent with individuals in face to face encounters. (Enter whole numbers only) "Total Cost" will automatically be calculated. Enter dollar amount spent on supplies including pens, note pads, posters, brochures/handout materials, mileage local travel. (Enter whole numbers only)

Number of Telephone Inquiries Number: Enter the total staff hours and hourly wage spent with individuals in telephone encounters. (Enter whole numbers only) "Total Cost" will automatically be calculated. Enter dollar amount spent on supplies including pens, note pads and telephones (Enter whole numbers only)

*Note: Total Cost = Total Staff Hours * Hourly Wage

Outreach and Education Sessions		Number
15	Number of Encounters (face-to-face)
	Total Staff Hours
	Hourly Wage
	*Total Cost
	Dollar Amount for Supplies (to include pens, note pads, posters, brochures/handout materials, mileage local travel)
16	Number of Telephone Inquiries:
	Total Staff Hours
	Hourly Wage
	*Total Cost
	Dollar Amount for Supplies (to include pens, note pads, telephone)

Table 6: ELIGIBILITY COUNSELING AND REFERRAL SESSIONS (applicable to all RESEP grantees)

Energy Employment Occupational Illness Compensation Program Act (EEOICPA)

Instructions:

Please refer to each category description for completing reporting for this measure.

Number of Encounters (face-to-face): Enter the total staff hours and hourly wage spent with individuals in face to face encounters. (Enter whole numbers only) "Total Cost" will automatically be calculated. Enter dollar amount spent on supplies including pens, note pads, posters, brochures/handout materials, mileage local travel. (Enter whole numbers only)

*Note: Total Cost = Total Staff Hours * Hourly Wage

Eligibility Counseling and Referral Sessions		Number
15	Number of Encounters (face-to-face)
	Total Staff Hours
	Hourly Wage
	*Total Cost
	Dollar Amount for Supplies (to include pens, note pads, telephone)

Table 7: IMPAIRMENT EXAMS

Energy Employment Occupational Illness Compensation Program Act (EEOICPA)

Instructions:

Please refer to each category description for completing reporting for this measure.

Number of Medical Exams: Enter the total staff hours and hourly wage spent with individuals performing medical exams. (Enter whole numbers only) "Total Cost" will automatically be calculated. Enter dollar amount spent on medical equipment used to perform actions such as pulmonary functions, arterial blood gases, lab result, x-rays etc. (Enter whole numbers only)

*Note: Total Cost = Total Staff Hours * Hourly Wage

*Note: Grand Total = Total Cost + Supplies

Impairment Exams		Number
15	Number of Medical Exams
	Total Staff Hours
	Hourly Wage
	*Total Cost
	Dollar Amount for Supplies (to include pens, note pads, posters, brochures/handout materials, mileage local travel)
	*Grand Total
	Total Staff Hours
	Hourly Wage
	*Total Cost
	Dollar Amount for Supplies (to include pens, note pads, telephone)
16	Energy Employment Occupational Illness Compensation Program Act (EEOICPA) Form Comments

16