BHPr Performance Measures Forms

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 0915-0061. Public reporting burden for this collection of information is estimated to average .25 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.

PERFORMANCE REPORT FOR GRANTS AND COOPERATIVE AGREEMENTS

FORM NAME: State Primary Care Offices (PCOs)

SECTION A. Number of NHSC Site Application State Recommendation Forms Submitted.

Block 1. Indicate the Total Number of complete forms submitted by state PCO to NHSC within 21 calendar days (15 business days) from site submission date

Block 2. Total Number of complete forms submitted by state PCO to NHSC

SECTION B. Number of federal and state obligated health care providers addressing identified shortages in HPSAs.

Indicate the following for each obligated health care provider serving in a HPSA:

Block 3. Indicate primary care HPSA Name

Block 4. Indicate primary care HPSA ID#

Block 5. Indicate primary care provider discipline

Block 6. Indicate full-time equivalent hours for obligated providers per week.

Block 7. Indicate name of federal or state recruitment program supporting primary care FTE

Block 8. Indicate dental care HPSA Name

Block 9. Indicate dental care HPSA ID#

Block 10. Indicate dental care provider discipline

Block 11. Indicate full-time equivalent hours for obligated providers per week.

Block 12. Indicate name of federal or state recruitment program supporting dental care FTE

Block 13. Indicate mental health care HPSA Name

Block 14. Indicate mental health care HPSA ID#

Block 15. Indicate mental health care provider discipline

Block 16. Indicate full-time equivalent hours for obligated providers per week.

Block 17. Indicate name of federal or state recruitment program supporting mental health care FTE

(To Be Collected in Chart Format)

Primary Care HPSA Name	HPSA ID#	Provider Discipline	Provider FTE/week	Federal or state program supporting FTE
Dental HPSA Name	HPSA ID#	Provider Discipline	Provider FTE/week	Federal or state program supporting FTE
Mental HPSA Name	HPSA ID#	Provider Discipline	Provider FTE/week	Federal or state program supporting FTE

SECTION C. Number of individuals and communities who received technical assistance by requestor type and topic.

Block 18. Indicate the type of clients who received technical assistance by requestor type and topic:

Types of Requestor:

Community

Provider

J-1 Waiver

CHC

Health Dept

State Agency

DRO

Medicaid

PCA

SLRP

RHC

NHSC

Other

Total

Topics of Technical Assistance:

NHSC
Expansion
Data Share
Designation
Needs Assessment
Other TA Types (Specify)

(To Be Collected in Chart Format)

	TA Topic
TA Requestor	NHSC	Expansion	Data Share	Designation	Needs Assessment	Other TA Types	Specify Other Types
Community
Provider
J-1 Waiver
CHC
Health Dept
State Agency
DRO
Medicaid
PCA
SLRP
RHC
NHSC
Other
Total

SECTION D: Number of groups who received technical assistance by setting and type.
Block 19: Technical Assistance Numbers by Setting:
High school students
Students in health professions training programs (undergraduate)
Students in health professions training programs (graduate)
Residency program participants
Professional Meeting
Community Meeting
State sponsored Meeting
Other Outreach (specify)

Numbers Reached by Technical Assistance Outreach:

Indicate number of group sessions conducted annually

Indicate number of individuals reached in all group sessions

Indicate brief description of setting

(To Be Collected In Chart Format)

Setting	# of sessions annually	Total #’s reached annually	Describe outreach setting*
High school students
Students in health professions training programs (undergraduate)
Students in health professions training programs (graduate)
Residency program participants
Professional Meeting
Community Meeting
State sponsored Meeting
Other Outreach (specify)
Total

INSTRUCTIONS

Purpose: The State Primary Care Offices form captures information about activities conducted through BHW-funded grant programs. The State Primary Care Offices form is divided into four sections: Section A measures number of NHSC Site Application State Recommendation Forms Submitted within 21 days; Section B measures the impact of federal and state obligated health care providers on addressing identified shortages in HPSAs;

Section C captures information about number of individuals and communities who received technical assistance; Section D captures information about number of groups reached by technical assistance. Please complete the applicable sections and blocks using the instructions below.

SECTION A

Number of Site Application Recommendation State Recommendation Forms Submitted

Block 1. Indicate the total number of National Health Service Corps' (NHSC) Site application state recommendation forms submitted by the state Primary Care Office to the NHSC within 14 days (10 business days).

Block 2. Indicate the number of National Health Service Corps' (NHSC) Site application state recommendation forms submitted by the State Primary Care Office to the NHSC.

SECTION B

Number of federal and state obligated health care providers addressing identified shortages in HPSAs.

Block 3. Indicate primary care HPSA Name

Block 4. Indicate primary care HPSA ID#

Block 5. Indicate primary care provider discipline

Block 6. Indicate full-time equivalent hours for obligated providers per week.

Block 7. Indicate name of federal or state recruitment program supporting primary care FTE

Block 8. Indicate dental care HPSA Name

Block 9. Indicate dental care HPSA ID#

Block 10. Indicate dental care provider discipline

Block 11. Indicate full-time equivalent hours for obligated providers per week.

Block 12. Indicate name of federal or state recruitment program supporting dental care FTE

Block 13. Indicate mental health care HPSA Name

Block 14. Indicate mental health care HPSA ID#

Block 15. Indicate mental health care provider discipline

Block 16. Indicate full-time equivalent hours for obligated providers per week.

Block 17. Indicate name of federal or state recruitment program supporting mental health care FTE

Disciplines include:

Non-psychiatric Physician (MD or DO)

Dentist (DDS/DMD)

Nurse Practitioner (NP)

Nurse Midwife

(NM)

Physician Assistant (PA)

Dental Hygienist (DH)

Psychiatrist (MD&DO)

Clinical Psychologist (CP)

Licensed Clinical Social Worker (LCSW)

Psychiatric Nurse Specialist (PNS)

Other Mental Health Clinician (specify)

Licensed Professional Counselor (LPC)

Marriage and Family Therapist (MFT)

Other (specify)

Only count providers that were obligated as of September 30^th each reporting year. This measure does not have a start and end data collection date. This measure ONLY has an end date.

SECTION C

Number of individuals and communities who received technical assistance reported by requestor type and topic

Block 18. Select the type of clients who received technical assistance from the type and requestor options below:

Types of Requestor:

Community

Provider

J-1 Waiver

CHC

Health Dept

State Agency

DRO

Medicaid

PCA

SLRP

RHC

NHSC

Other

Total

Topics of Technical Assistance:

NHSC
Expansion
Data Share
Designation
Needs Assessment
Other TA Types (Specify)

SECTION D

Number of Groups who received technical assistance reported by setting and type.

Block 19. Indicate the number of clients who received technical assistance by setting and type from the options below:

Technical Assistance Numbers by Setting:

High school students

Students in health professions training programs (undergraduate)

Students in health professions training programs (graduate)

Residency program participants

Professional Meeting

Community Meeting

State sponsored Meeting

Other Outreach (specify)

Total

Numbers Reached by Technical Assistance Outreach:

Indicate number of group sessions conducted annually

Indicate number of individuals reached in each group session

Indicate brief description of group session setting

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