Form 1 NAMRS Agency Component Instrument

OMB Control Number 0970-XXXX

Expiration Date: XX/XX/XXXX

ATTACHMENT A

AGENCY COMPONENT DATA

Updated June 9, 2016

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)

Public reporting burden for this collection of information is estimated to average 13 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.

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 Agency Component data will be entered directly onto an online form on the NAMRS website. Once entered, the state can update information annually. The reporting period is the federal fiscal year (October–September).

Table 1–General Information

Element No.	Element Name	Element Description	Required	Field Entry Format
Agency 1.1	Agency Name 1	Department or agency name	Yes	Text - 100 characters
Agency 1.2	Agency Name 2	Branch or unit name	No	Text - 100 characters
Agency 2.1	Street 1	First line street address of agency physical address	Yes	Text - 100 characters
Agency 2.2	Street 2	Second line street address of agency physical address	No	Text - 100 characters
Agency 2.3	City	City of agency physical address	Yes	Text - 100 characters
Agency 2.4	State	State of agency physical address	Yes	Select from list of states/territories
Agency 2.5	ZIP	ZIP of agency physical address	Yes	##### or #####-####
Agency 3.1	Street 1	First line street address of agency mailing address	Yes	Text - 100 characters
Agency 3.2	Street 2	Second line street address of agency physical address	No	Text - 100 characters
Agency 3.3	City	City of agency physical address	Yes	Text - 100 characters
Agency 3.4	State	State of agency physical address	Yes	Select from list of states/territories
Agency 3.5	ZIP	ZIP of agency physical address	Yes	##### or #####-####
Multiple contact names and associated information can be entered.
Agency4.1	Name	Contact name	Yes	Text - 100 characters
Agency 4.2	Title	Contact title	Yes	Text - 100 characters
Agency 4.3	E-mail	Contact e-mail	Yes	E-mail address format
Agency 4.4	Phone	Contact telephone	Yes	Text - 50 characters
Agency 4.5	Contact’s role in agency	Contact’s role in agency Selection List: Case manager Data coordinator/manager Field coordinator Intake manager/supervisor Investigator IT/data specialist Manager/director/supervisor Policy specialist Regional supervisor Social worker Training coordinator/specialist	No	Select one from list

Table 2–Agency Profile

Element No.	Element Name	Element Description	Required	Field Entry Format
Agency 5	Data Sources	The sources of information used to submit data this year to NAMRS. Selection List: APS agency only APS and other agencies	No	Select one from list
Agency 5.1	Comment	Provide names of other agencies that provided data.	No	Text – 5,000 characters
Agency 6	Population Served	Provide the citation in state statute or regulation, or agency policy, regarding the population your APS agency is mandated to serve.	No	Text – 5,000 characters
Agency 6.1	Population served: setting	If your agency investigates allegations in residential care communities and/or nursing homes, please indicate whether or not your agency would conduct an investigation if the allegation does not pertain to a specific resident, but rather to the residents in general.	No	Text – 5,000 characters
Agency 7	Investigator FTEs filled	Number of filled APS FTEs responsible for the hotline and/or conducting investigations.	No	Numeric – 10 integers
Agency 7.1	Supervisor FTEs filled	Number of filled APS FTEs responsible for supervision.	No	Numeric – 10 integers
Agency 7.2	Comment	Provide additional information as to whether the numbers in 7 and 7.1 were the annual total or total for a given day.	No	Text – 5,000 characters
Agency 8	Intake	Centralized or localized intake of APS reports. Selection List: Centralized at a statewide hotline or call in number Combination of both statewide and local hotlines or call in numbers Local at county or regional hotlines or call in numbers Other	No	Select one from list
Agency 8.1	Comment	Provide additional information on your state’s definition of intake.	No	Text – 5,000 characters
Agency 9	Reports Accepted for Investigation	Number of reports accepted for investigation during the reporting period.	No	Numeric – 10 integers
Agency 9.1	Reports Not Accepted, or Resolved Through I&R/I&RA	Number of reports that were either not accepted by APS for investigation, or were resolved through Information & Referral (I&R)/Information & Referral Assistance (I&RA).	No	Numeric – 10 integers
Agency 9.2	Comment	Please confirm that the sum of 9 and 9.1 is the total number of investigations received during the reporting period. Please provide additional information regarding policy for accepting reports and not accepting reports, or resolving through I&R/I&RA.	No	Text – 5,000 characters
Agency 10	Response Time	The length of time (hours) from receipt of call or notice of alleged maltreatment to face-to-face contact with the client by the APS worker, based on the standard set by policy or practice.	No	Numeric – 3 integers

Element No.	Element Name	Element Description	Required	Field Entry Format
Agency 10.1	Comment	Provide additional information on the definition of response time to allegations of maltreatment. If different types of allegations are given different priorities in terms of response time, please provide additional information.	No	Text – 5,000 characters
Agency 11	Investigation Completion Time	The length of time (days) from investigation start to investigation completion, based on the standard set by policy or practice.	No	Numeric – 3 integers
Agency 11.1	Comment	Provide additional information on the definition of start of investigation and completion of an investigation.	No	Text – 5,000 characters
Agency 12	Types of Maltreatment	Indicate which types of maltreatment are investigated by APS. Selection List: Abandonment Emotional abuse Exploitation (non-specific) Financial exploitation Other exploitation Neglect Physical abuse Sexual abuse Suspicious death Self-neglect Other	No	Select one or more from list
Agency 12.1	Comment	Provide citation or URL in state law, regulations, or program guidance for maltreatment types investigated by APS.	No	Text – 5,000 characters
Agency 13	Standard of Evidence	Standard used for substantiating an allegation of maltreatment. Selection List: Clear and convincing Credible, reasonable, or probable cause Different standards based on type of perpetrator No state standard Preponderance Other	No	Select one from list
Agency 13.1	Comment	Provide citation or URL of state law, regulations, or program guidance. Include discussion of definitions of perpetrator if relevant.	No	Text – 5,000 characters
Agency14	Assessment Tools	Indicate whether APS personnel use standard assessment tools throughout the state, such as client safety, at risk factors, or behavioral conditions. Selection List: No, assessment instruments are determined by each county or left to the worker’s discretion Yes, use common instrument or tool throughout the state	No	Select one from list
Agency 14.1	Comment	Provide the name and reference (i.e., URL) for each standardized tool that is used.	No	Text – 5,000 characters

Element No.	Element Name	Element Description	Required	Field Entry Format
Agency 15	Service Gaps	Indicate which services are not available or accessible in the state. Selection List: Care/Case Management Services Caregiver Support Services Community Day Services Education, Employment, and Training Services Emergency Assistance and Material Aid Services Financial Planning Services Housing and Relocation Services In-home Assistance Services Legal Services Medical and Dental Services Medical Rehabilitation Services Mental Health Services Nutrition Public Assistance Benefits Substance Use Services Transportation Victim Services Other Services	No	Select one or more from list
Agency 15.1	Comment	Provide additional information on how gaps in services were identified, if possible.	No	Text – 5,000 characters
Agency 16	Perpetrators	Does APS collect person-specific data on persons found to be perpetrators of substantiated maltreatment? Does your information system collect unique IDs and demographic characteristics of such persons? If there is specific state statute or regulation, or agency policy on such data, please provide the citation.	No	Text – 5,000 characters