Form 1 TRC Grant Program Performance Indicator Report

OMB # 0915-XXXX

Expiration XX/XX/201X

TRC Performance Indicator Data Collection Tool

The Telehealth Resource Center (TRC) Performance Indicator Data Collection Tool is intended to collect data elements that are required for reporting to the Office for the Advancement of Telehealth (OAT) on TRC performance measures. The performance measures and associated data elements are designed to assess how the TRC program is meeting its goals to:

1. Expand the availability of telehealth services in underserved communities

2. Improve the quality, efficiency, and effectiveness of telehealth services

3. Promote knowledge exchange and dissemination about efficient and effective telehealth practices and technology

4. Establish sustainable technical assistance (TA) centers providing quality, unbiased TA for the development and expansion of effective and efficient telehealth services in underserved communities

OAT will require all TRC grantees to complete this tool every six months based on TRC activity for the preceding six-month reporting period. The TRC Performance Indicator Data Collection Tool collects telehealth service data at the telehealth program/network level, the originating site level, and also collects data on TRC activities, client service assessments and the impact of TRC activities. Please respond to all questions based on the current reporting period.

COMPLETE QUESTIONS 1-5

1. Service Utilization by Type of Organization Requesting Service and Outcomes for Reporting Period

Total number of individual clients/departments requesting TRC services and hours of client contact service provided, including preparation time.

Total number of new/first time _____________

Total number of repeat clients ((those who received service in the past – prior to the current reporting period – who are returning for more/other services) ______________

Total number of hours of technical assistance provided including preparation time __________

2. Method of Query for Reporting Period

Conference/Meeting or other In-Person Contact

Email

Referral from another TRC

Social Media (Twitter, Facebook, LinkedIN, etc.)

TRC Initiated

Website

Other

3. Topic of Query for Reporting Period

General Information

Clinical Service Program Development/Operations

Equipment and Technology Assessment Selection

Financial (Reimbursement, Business Models, Grants)

Policy

Other

4. Types of Services Provided by TRC during Reporting Period

Training/Education and Outreach

Events

Organize/Host Conference or Training Event

# of Events ________ Total Direct Service Hours _________ Total # of Participants_______

Presentation at Conferences/Meetings/Webinars

# of Presentations _________ Total Direct Service Hours ________ Total # of Participants ________

Other _________________

Communications/Promotional Activities

Exhibits

# of Hours _____________ # of contacts ____________

Newsletter

# of newsletters _______________ # of subscribers ______________

Website

# of unique visitors __________ # of pages viewed by visitors _____________

Research Publications

# of publications ___________

General Media

# of interviews/articles __________

Social Media

Facebook # of pages likes, ________ # of posts__________

Twitter # of followers __________ # of tweets ________

LinkedIn # of followers _________ # of posts _________

Technical Assistance/Consultation

Method Used to Respond to Queries

Email (# of responses) _____________

Phone (# responses) _____________

Videoconference (# of responses) ____________

In Person Visit (# of responses) _____________

Group Collaboration/Planning (# of responses) ____________

Client Satisfaction Survey Results

The following 4 questions come from the standardized Client Satisfaction Questionnaire – CSQ-8 and ratings are on a 4 point scale)

How would you rate the quality of service you received – Excellent, Good, Fair, Poor

# respondents ____________ average rating __________________

If a colleague were in need of similar help, would you recommend our program to him or her – No, definitely not, No, I don’t think so, Yes, I think so, Yes definitely

# respondents ________________ average rating __________________

In an overall, general sense, how satisfied are you with the services you have received – Very satisfied, Mostly satisfied, Indifferent or mildly dissatisfied, Quite dissatisfied

# respondents _______________ average rating _____________

If you were to seek help again, would you come back to our program – No, definitely not, No, I don’t think so, Yes, I think so, Yes, definitely

# respondents ______________ average rating ___________________

Tools/Materials/Resources

# developed __________________ # distributed ________________

5. New telehealth sites or services developed

Number of new telehealth sites established as a result of TRC TA __________________

Number of new telehealth services initiated as a result of TRC TA __________________