Form 1 Attachment A - Demographic Performance Measures

OMB No: 0906-XXXX

Expiration Date: XX/XX/20XX

THE MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING PROGRAM

FORM 1

DEMOGRAPHIC, SERVICE UTILIZATION, AND SELECT CLINICAL INDICATORS

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 425 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.

SECTION A: PARTICIPANT DEMOGRAPHICS

Table 1: Unduplicated Count of New and Continuing Program Participants Served by MIECHV Home Visitors

Participants	Number Newly Enrolled	Number Continuing During Reporting Period	Total
Pregnant Women
Female Caregivers
Male Caregivers
All Adults (Auto Calculate)
Female Index Children
Male Index Children
All Index Children (Auto Calculate)

Table 2: Unduplicated Count of Household Served by MIECHV Home Visitors

Households	Number Newly Enrolled	Number Continuing During Reporting Period	Total
Number of Households

Table 3: Unduplicated Count of Participants and Households Served by State Home Visiting Programs (not MIECHV)

Participants and Households	Total Number Served during Reporting Period
Pregnant Women
Female Caregivers
Male Caregivers
All Adults (Auto Calculate)
Female Index Children
Male Index Children
All Index Children (Auto Calculate)
Number of Households

Table 4: Adult Participants by Age

Adult Participants	≤17	18-19	20-21	22-24	25-29	30-34	35-44	45-54	55-64	≥65	Unknown/Did not Report	Total
Pregnant Women
Female Caregivers
Male Caregivers
All Adults (Auto Calculate)

Table 5: Index Children by Age

Index Children	<1 year	1-2 years	3-5 years	5-6 years	Unknown/Did not Report	Total
Female Index Children
Male Index Children
All Index Children (Auto Calculate)

Table 6: Participants by Ethnicity

Participants	Hispanic or Latino	Not Hispanic or Latino	Unknown/Did not Report	Total
Pregnant Women
Female Caregivers
Male Caregivers
All Adults (Auto Calculate)
Female Index Children
Male Index Children
All Index Children (Auto Calculate)

Table 7: Participants by Race

Participants	American Indian or Alaska Native	Asian	Black or African American	Native Hawaiian or Other Pacific Islander	White	More than one race	Unknown/Did not Report	Total
Pregnant Women
Female Caregivers
Male Caregivers
All Adults (Auto Calculate)
Female Index Children
Male Index Children
All Index Children (Auto Calculate)

Table 8: Adult Participants by Marital Status

Adult Participants	Never married	Married	Not married but living together with partner	Separated/Divorced/Widowed	Unknown/Did not Report	Total
Pregnant Women
Female Caregivers
Male Caregivers
All Adults (Auto Calculate)

Table 9: Adult Participants by Educational Attainment

Adult Participants	Less than HS diploma	HS Diploma/GED	Some college/ training	Technical training or certification	Associate’s Degree	Bachelor’s Degree or higher	Other	Unknown/Did not Report	Total
Pregnant Women
Female Caregivers
Male Caregivers
All Adults (Auto Calculate)

Table 10: Adult Participants by Educational Status

Adult Participants	Student/trainee	Not a student/trainee	Unknown/Did not Report	Total
Pregnant Women
Female Caregivers
Male Caregivers
All Adults (Auto Calculate)

Table 11: Adult Participants by Employment Status

Adult Participants	Employed Full Time	Employed Part-Time	Not employed	Unknown/Did not Report	Total
Pregnant Women
Female Caregivers
Male Caregivers
All Adults (Auto Calculate)

Table 12: Adult Participants by Housing Status

Not Homeless

Total Not Homeless

Homeless

Total Homeless

Unknown/Did not Report

Total

Adult Participants

Owns or shares own home, condominium, or apartment

Rents or shares own home or apartment

Lives in public housing

Lives with parent or family member

Some other arrangement

Homeless and sharing housing

Homeless and living in an emergency or transitional shelter

Some other arrangement

Pregnant Women

Female Caregivers

Male Caregivers

All Adults (Auto Calculate)

Table 13: Primary Language Spoken at Home

Index Children	Number	Percent
English
Spanish
Other
Unknown/Did Not Report
All Index Children (Auto Calculate)		100

Table 14: Household Income in Relation to Federal Poverty Guidelines

Households	Number of Households	Percent
50% and under
51-100%
101-133%
134-200%
201-300%
>300%
Unknown/Did not Report
All Households (Auto Calculate)		100

Table 15: For Each Household Indicate the Priority Population Characteristics

Households	Yes	No	Unknown/Did not Report	Total
Low income household
Household contains an enrollee who is pregnant and under age 21
Household has a history of child abuse or neglect or has had interactions with child welfare services
Household has a history of substance abuse or needs substance abuse treatment
Someone in the household uses tobacco products in the home
Someone in the household has attained low student achievement or has a child with low student achievement
Household has a child with developmental delays or disabilities
Household includes individuals who are serving or formerly served in the US armed forces

SECTION B: SERVICE UTILIZATION

Table 16: Service Utilization

Home Visits	Number
Total Number of Home Visits completed

Table 17: Family Engagement by Household

Households	Number of Households	Percent
Currently receiving services
Completed program
Stopped services before completion
Enrolled but not currently receiving services/Other
Unknown/Did not Report
All Categories (Auto Calculate)

Table 18: Unduplicated Count of Home Visitor Full Time Equivalents

Home Visitors	Number
Number of FTE Home Visitors

Table 19: Unduplicated Count of Households by Evidence-Based Home Visiting Model or Promising Approach

Home Visiting Model (Select One per Row – Add Rows for Additional Models)	Number Newly Enrolled	Number Continuing During Reporting Period	Total

SECTION C: INSURANCE AND CLINICAL INDICATORS

Table 20: Participants by Type of Health Insurance Coverage

Participants	No Insurance Coverage	Medicaid or CHIP	Tri-Care	Private or Other	Unknown/Did not Report	Total
Pregnant Women
Female Caregivers
Male Caregivers
All Adults (Auto Calculate)
Female Index Children
Male Index Children
All Index Children (Auto Calculate)

Table 21: Index Children by Usual Source of Medical Care

Index Children	Doctor’s/Nurse Practitioner’s Office	Hospital Emergency Room	Hospital Outpatient	Federally Qualified Health Center	Retail Store or Minute Clinic	Other	None	Unknown/Did not Report	Total
Female Index Children
Male Index Children
All Index Children (Auto Calculate)

Table 22: Index Children by Usual Source of Dental Care

Index Children	Have a Usual Source of Dental Care	Do not have a Usual Source of Dental Care	Unknown/Did not Report	Total
Female Index Children
Male Index Children
All Index Children (Auto Calculate)

NOTES:

DEFINITIONS OF KEY TERMS

Table Number	Field	Key Terms Requiring Definitions
1	Unduplicated Count of New and Continuing Program Participants Served by MIECHV Home Visitors	New Participant: A participant, including a pregnant woman, female caregiver, or male caregiver, who signs up to participate in the home visiting program at any time during the reporting period and continues enrollment during the reporting period who was served by a trained home visitor implementing services with fidelity to the model for whom at least 25% of his/her personnel costs (salary/wages including benefits) is paid for with MIECHV funding. Continuing Participant: A participant, including a pregnant woman, female caregiver, or male caregiver, who was signed up and actively enrolled in the home visiting program prior to the beginning of the reporting period and continues enrollment during the reporting period who was served by a trained home visitor implementing services with fidelity to the model for whom at least 25% of his/her personnel costs (salary/wages including benefits) is paid for with MIECHV funding.. 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. Index Child (Birth – 5 years): 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.
2	Unduplicated Count of Household Served by MIECHV Home Visitors	New Household: A household, including a pregnant woman, female caregiver, and/or male caregiver who signs up to participate in the home visiting program at any time during the reporting period and continues enrollment during the reporting period. The household may include multiple caregivers depending on model-specific definitions. Continuing Household: A household, including a pregnant woman, female caregiver, and/or male caregiver who were signed up and actively enrolled in the home visiting program prior to the beginning of the reporting period and continues enrollment during the reporting period. The household may include multiple caregivers depending on model-specific definitions.
3	Unduplicated Count of Participants and Households Served by a State Home Visiting Program (not MIECHV)	Participant Served by a State Home Visiting Program (not MIECHV): A participant, including a pregnant woman, female caregiver, or male caregiver, who signs up to participate in the home visiting program at any time during the reporting period and continues enrollment during the reporting period who was served by a trained home visitor implementing services with fidelity to the model for whom less than 25% of his/her personnel costs (salary/wages including benefits) is paid for with MIECHV funding
4	Adult Participants by Age	Adult Participants: 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 adult participant 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.
5	Index Children by Age	Index Child (Birth – 5 years): 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.
6	Participants by Ethnicity	The responses regarding ethnicity should reflect what the person considers herself/himself to be and are not based on percentages of ancestry. If ethnicity is unknown or not reported for some participants, enter that count in the respective “Unknown/Did not report” column.
7	Participants by Race	The responses regarding race should reflect what the person considers herself/himself to be and are not based on percentages of ancestry. 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 “Unknown/Did not Report” columns.
8	Adult Participants by Marital Status	Adult Participants: 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 adult participant 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. 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.
9	Adult Participants by Educational Attainment	Adult Participants: 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 adult participant 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. Less than high school diploma includes individuals who are older than 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 Technical training or certification category includes those who received technical training or certification in the past. The Associate’s Degree category includes those who obtained an Associate’s Degree. The Bachelor’s Degree category includes those who obtained ana Bachelor’s Degree. The Other category includes those individuals who did not fall into the specified categories.
10	Adult Participants by Educational 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.
11	Adult Participants by Employment Status	Employed: refers to whether the person is currently working for pay. Employed Full Time: an employee who works an average of at least 30 hours per week Employed Part Time: an employee who works an average of less than 30 hours per week1 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)
12	Adult Participants by Housing Status	Homeless: individuals who lack a fixed, regular, and adequate nighttime residence (within the meaning of section 103(a)(1) of the McKinney-Vento Homeless Assistance Act); and Homeless and sharing housing: individuals who are sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason Homeless and living in an emergency or transitional shelter: individuals who are living in emergency or transitional shelters; are abandoned in hospitals; or are awaiting foster care placement Some other arrangement: individuals who are living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations; individuals who have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings (within the meaning of section 103(a)(2)(C)); individuals who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings2
13	Primary Language Spoken at Home	Primary language: the language used in the home the majority of the time. Index Child (Birth – 5 years): 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.
14	Household Income in Relation to Federal Poverty Guidelines	The appropriate category for a given family will depend both on household income and on the number of household members counted in the household (both home visiting enrollees and non-enrollees). Household income refers to the annual gross income for the household as defined in programmatic guidance, recorded at enrollment and annually thereafter. Federal Poverty Guidelines: 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 https://aspe.hhs.gov/2015-poverty-guidelines for the 2015 guidelines.
15	For Each Household Indicate the Priority Population Characteristics	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. Tobacco use is defined as combustibles (cigarettes, cigars, pipes, hookahs, bidis), non-combustibles (chew, dip, snuff, snus, and dissolvables), and electronic nicotine delivery systems (ENDS). 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.
16	Service Utilization	Home visit refers to the definition of a completed home visit enacted by the various evidence-based home visiting models approved for implementation through the MIECHV program or a Promising Approach. Please refer to model-specific guidance for specific definitions.
17	Family Engagement by Household	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. Enrolled but not currently receiving services/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.)
18	Unduplicated Count of Home Visitor Full Time Equivalents	Full Time Equivalent: A full time equivalent home visitor(s)/supervisor(s)/other staff who begins employment with a contracted local implementing agency during the quarterly reporting period. Grantees should only report the proportion of the FTE that is supported by MIECHV grant funds.
19	Unduplicated Count of Households by Evidence-Based Home Visiting Model or Promising Approach	A household, including a pregnant woman, female caregiver, and/or male caregiver who were signed up and actively enrolled in the home visiting program prior to the beginning of or during the reporting period and continues enrollment during the reporting period. The household may include multiple caregivers depending on model-specific definitions.
20	Participants by Type of Health Insurance Coverage	Index Child (Birth – 5 years): 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, etcetc.). Thus, there may be more than one female or male index child in a given household. 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.
21	Index Children by Usual Source of Medical Care	Index Child (Birth – 5 years): 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. Usual source of care: the particular medical professional, doctor's office, clinic, health center, or other place where a person would usually go if sick or in need of advice about his or her health.
22	Index Children by Usual Source of Dental Care	Usual source of dental care: a usual source of dental care, or dental home, means that a child's oral health care is delivered in a comprehensive, continuously accessible, coordinated and family-centered way by a licensed dentist. The concept of the Dental Home reflects the AAPD's clinical guidelines and best principles for the proper delivery of oral health care to all children, with a concentration on infant/age one patients. 3

1 Healthcare.gov Glossary. https://www.healthcare.gov/glossary/full-time-employee/

2 Administration for Children and Families. Early Childhood Learning and Knowledge Center, 2014. http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/family/family/Homelessness/hmls/definition/definition-legal.html

3 American Academy of Pediatric Dentistry. Dental Home Resource Center. http://www.aapd.org/advocacy/dentalhome/

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