Quarterly Health Center Performance Measure Reporting Tool

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Form Approved
OMB No.0920-1156 
Exp.01/31/2020 








Quarterly Health Center Performance Measure Reporting Tool





















Public reporting burden of this collection of information is estimated to average 4 hours per response including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing 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.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-1156). 

Health Center Information 
Health Center Name: _________________________	Date Completed:________________
Practice Setting Description (e.g., pediatrics, family planning): ____________________
Health Center/Practice Setting ID:____________	

Reporting Period:  Fiscal Year__________ (October to September)
Quarter 1 (October to December)	Quarter 2 (January to March)	
Quarter 3 (April to June)		

Please complete the following questions for each participating practice settings within your health center.  Most items request information for the past quarter that has most recently ended and for the year to date.  See the appendix titled ‘Additional Guidance’ at the end of this document for more information on completing Tables 2 and 3.

Operational Changes and Project Activities

Health Care Service Use by 15 to 19 year olds
Table 1. Adolescent Clients Ages 15-19 (Unduplicated) Receiving Any Service within the Identified Practice Setting
# Female Clients Ages 15-19 (Unduplicated)

# Male Clients Ages 15-19 (Unduplicated)

Last Quarter
Fiscal Year to Date
Last Quarter
Fiscal Year to Date





Table 2. Receipt of Reproductive or Sexual Health Services by Clients, Ages 15-19 (Unduplicated)      See appendix at the end of this document for additional guidance on completing this table.

Number of Female Clients Ages 15 to 19 Years who Received the Specified Service
Number of Male Clients Ages 15 to 19 Years who Received the Specified Service

Last Quarter
Fiscal Year to Date
Last Quarter
Fiscal Year to Date
Received any reproductive or sexual health service




Received STD screening/ counseling/treatment and/or HIV  testing/counseling




Screened to determine if sexually active




Sexual health assessment conducted





Table 3. Female Clients, Ages 15-19 Years Old, (Unduplicated) Adopting or Continuing Use of Moderately or Highly Effective Contraception                                                                                                    See appendix at the end of this document for additional guidance on completing this table.

Number of 15-19 Year Old Clients who Adopted or Continued Use (Unduplicated)

Last Quarter
Fiscal Year to Date
Pill, Patch, Ring, or Injectable Contraception (e.g., Depo Provera) 



IUD (e.g., Mirena or ParaGard)



Contraceptive Implants (e.g.,  Nexplanon) 



Table 4. Confidence in Data Reported
After reviewing the data collected in Tables 1 through 3, please indicate your level of confidence in the accuracy of each type of data retrieved from your health center's electronic medical record. Please reflect on how confident your team is that the data reported for each of the items listed below accurately represents the extent of sexual and reproductive health services being provided in your practice setting.

No Confidence
Low Confidence
Moderate Confidence
High Confidence
Number of clients, ages 15-19




Received any reproductive or sexual health service




Received STD screening/ counseling/treatment and/or HIV  testing/counseling




Screened to determine if sexually active




Sexual health assessment conducted




Adopted or continued pill, patch, ring, or injectable contraception (e.g., Depo Provera)




Adopted or continued IUD (e.g., Mirena or Paragard)




Adopted or continued contraceptive implants (e.g.,  Nexplanon)






Appendix: Additional Guidance

Table 2 Variables
Received any reproductive or sexual health service
Include the following services:
Provision/Surveillance/Maintenance of contraceptive methods (same codes as for Table 3, see below)
STD screening/STD treatment/STD counseling/HIV testing /HIV counseling 
Pregnancy Testing
Gynecological Exam/Pap Smear
HIV Counseling
Counseling on Sexual Attitude, Behavior and Orientation
STD Prevention Education/Counseling
Provided Emergency Contraception
Provided Condoms-Male and Female

Screened to determine if sexually active and sexual health assessment conducted
Accurately collecting this information will require that additional fields are added to health center partners’ EMRs.  Standard, existing codes do not adequately assess for these activities.  We recognize that not all health centers are able to modify their EMR.  They will not be expected to report this data.  

Table 3 Variables
Please de-duplicate data, so that you only report on one form of contraception per patient.  If a patient is provided a service related to more than one form of contraception during a reporting period, please only consider the most recent. The one exception is that patients provided a contraceptive implant who later receive oral contraception for management of side effects associated with the implant should be counted as an implant user.
Pill, Patch, Ring, or Injectable Contraception (e.g., Depo Provera)
Number of 15-19 year old female clients who adopted or continued use of pill should be determined using codes for 1) initial prescription and 2) surveillance/prescription refill/management.  Adopted or continued use of patch should be determined using codes for prescription.  Adopted or continued use of ring should be determined using codes for 1) prescription and 2) surveillance/maintenance.  Adopted or continued use of injectable contraception should be determined using codes for 1) initial dose and 2) surveillance/subsequent dose/management.
IUD (e.g., Mirena or ParaGard)
Number of 15-19 year old female clients who adopted or continued use of an IUD should be determined by examining codes for 1) insertion of  the IUD, 2) surveillance/management of the IUD, 3) removal and reinsertion of the IUD, and 4) IUD present.
Contraceptive Implants (e.g.,  Nexplanon)
Number of 15-19 year old female clients who adopted or continued use of a contraceptive implant should be determined by examining codes for 1) insertion/reinsertion of the implant, 2) surveillance/management of the implant, and 3) implant present.