Form 1 Guidance and Forms

Maternal and Child Health Services Block Grant Application/Annual Report Guidance

Guidance and Forms

MCHSB Grant Application/Annual Report Guidance

OMB: 0915-0172

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TITLE V MATERNAL AND
CHILD HEALTH SERVICES
BLOCK GRANT TO STATES
PROGRAM
GUIDANCE AND FORMS
FOR THE
TITLE V APPLICATION/ANNUAL REPORT
OMB NO: ___________
EXPIRES: ________________

U.S. Department of Health and Human Services
Health Resources and Services Administration
Maternal and Child Health Bureau
Division of State and Community Health
Room 5C-26
5600 Fishers Lane, Rockville, MD 20857
(Phone 301-443-2204 FAX 301-443-9354)

TABLE of CONTENTS

PART ONE: BACKGROUND AND ADMINISTRATIVE INFORMATION
I. Purpose of the MCH Block Grant Program

II. Background and Brief History

III. MCH Transformation and Revision of MCH Block Grant
Application/Annual Report Guidance

A. Vision and Mission

B. National Performance Measure Framework

C. Changes to the Application/Annual Report Guidance

IV. Legislative Requirements

A. Who Can Apply for Funds

B. Use of Allotment Funds

C. Application for Block Grant Funds

D. Annual Report

E. Administration of Federal and State Programs

PART TWO: APPLICATION/ANNUAL REPORT INSTRUCTIONS
I. General Requirements

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A. Letter of Transmittal

B. Face Sheet

C. Assurances and Certifications

D. Table of Contents

E. Application/Annual Report Executive Summary

II. Components of the Application/Annual Report
A. Overview of the State

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B. Five-Year Needs Assessment Summary

1. Process

2. Findings

a. MCH Population Needs

b. Title V Program Capacity

i Organizational Structure

ii Agency Capacity

iii MCH Workforce Development and Capacity

c. Partnerships, Collaboration, and Coordination

C. State Selected Priorities

D. Linkage of State Selected Priorities with National Performance
and Outcome Measures

E. Linkage of State Selected Priorities with State Performance
and Outcome Measures

F. Five-Year State Action Plan

1. State Action Plan and Strategies by MCH Population

a. Five-year State Action Plan Table

b. State Action Plan

i. Plan for the Application Year and Annual Report

ii. Other Programmatic Activities

2. MCH Workforce Development and Capacity

Family Consumer Partnership

Health Reform

Emerging Issues

Public Input

Technical Assistance

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ii

III. Budget Narrative

A. Expenditures

B. Budget

PART THREE: REPORTING FORMS

iii

PART ONE: BACKGROUND AND ADMINISTRATIVE INFORMATION

I. PURPOSE OF THE MATERNAL AND CHILD HEALTH (MCH) BLOCK GRANT
PROGRAM
As defined in section 501(a)(1) of the Title V legislation, the purpose of the MCH
Services Block Grant Program is to enable each state:
(A) To provide and to assure mothers and children (in particular those with low
income or with limited availability of health services) access to quality MCH
services;
(B) To reduce infant mortality and the incidence of preventable diseases and
handicapping conditions among children, to reduce the need for inpatient and
long-term care services, to increase the number of children (especially
preschool children) appropriately immunized against disease and the number of
low income children receiving health assessments and follow-up diagnostic and
treatment services, and otherwise to promote the health of mothers and infants
by providing prenatal, delivery, and postpartum care for low income, at-risk
pregnant women, and to promote the health of children by providing preventive
and primary care services for low income children;
(C) To provide rehabilitation services for blind and disabled individuals under the
age of 16 receiving benefits under title XVI, to the extent medical assistance for
such services is not provided under title XIX; and
(D) To provide and to promote family-centered, community-based, coordinated care
(including care coordination services, as defined in subsection (b)(3)) for
children with special health care needs (CSHCN) and to facilitate the
development of community-based systems of services for such children and
their families.

II. BACKGROUND AND BRIEF HISTORY
Since its original authorization in 1935, Title V of the Social Security Act has been
amended several times to reflect an ongoing commitment to improving the health
and well-being of our Nation's mothers, children and their families. Block-granted in
1981, with new accountability requirements added in 1989, Title V has remained a
vitally important public health program specifically targeted to the MCH population. A
more complete history of Title V can be found in Appendix A of the Supporting
Documents to the Title V MCH Block Grant Application/Annual Report Guidance.
Changes in the nation’s public health care systems, population demographics,
health care financing systems and information technology have created new
opportunities for improving access to health care and delivering quality public health
services to the nation’s MCH population (which includes women, mothers, infants,
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children, adolescents, CSHCN and their families). This Guidance document for the
state Title V MCH Block Grant programs capitalizes on the emerging opportunities
and reflects a major transformative effort within the Health Resources and Services
Administration’s (HRSA) Maternal and Child Health Bureau (MCHB), in conjunction
with its partners and stakeholders, to restructure the Application and Annual
Reporting process. The transformative changes that have been made are intended
to facilitate an increased alignment of State Title V program efforts with other MCHB
investments and to demonstrate the vital leadership role that state Title V programs
provide in assuring and advancing public health systems that continually assess and
readily respond to changing MCH population needs. Relative to the state’s
submission of a yearly Application, Annual Report and Five-year Needs
Assessment, the aims of the MCH Block Grant to States program transformation are
threefold: (1) reduce burden to states; (2) maintain state flexibility; and (3) improve
accountability.
In addition to changes that will impact the preparation and submission of the state
MCH Block Grant Application/Annual Report and Five-year Needs Assessment
report, the transformation process called for redefining the working framework for
MCH services. Figure 1 depicts the interim framework that was developed.
Relative to the changes occurring in public health systems and the delivery of health
care, the Title V MCH Services Block Grant program will continue to provide critical
support to assure the health of mothers, infants, children, including CSHCN, and
their families. The services of the Title V MCH Block Grant program serve to
complement the expanded health insurance coverage being provided through the
Patient Protection and Affordable Care Act (ACA). Specifically, the Title V program
will continue to serve as a safety-net provider for the MCH population by providing
gap-filling health care services, as well as essential public health services, to the
MCH population. These functions will lend valuable support to the successful
implementation of the ACA. Without Title V, the public health system responsible for
serving some of the nation’s most vulnerable populations would be seriously
jeopardized.
III. MCH TRANSFORMATION AND REVISION OF MCH BLOCK GRANT

APPLICATION/ANNUAL REPORT GUIDANCE
A. Vision and Mission

While the purpose and goals of the Title V MCH Block Grant program are
specified in the Title V legislation, as indicated above, clearly articulated Vision
and Mission statements serve a useful role in helping to guide priority setting
within the federal and state MCH programs. The following Vision/Mission
statements were developed as part of the MCH Block Grant transformation
process.

Figure 1

Vision of Title V
Title V envisions a nation where all mothers, children and youth, including
CSHCN, and their families are healthy and thriving.
Mission of Title V
The Mission of Title V is to improve the health and well-being of the nation’s
mothers, infants, children and youth, including children and youth with special
health care needs, and their families.
A 1988 Institute of Medicine (IOM) Report 1 defined the core functions of public
health as assessment, policy development and assurance. In operationalizing
the core public health functions and in ensuring that the unique needs of mothers
and children were adequately addressed, the MCH community worked with the
Public Health Service and the IOM to identify 10 “Essential Public Health

Institute of Medicine. (1988). The Future of Public Health. Washington, D.C.: National Academy Press.

Services” 2 in 1994. Since that time, the 10 Essential Public Health Services have
provided a framework for the delivery of MCH services, as reflected in Figure 1.
In considering potential strategies for implementing the new vision and mission
statements, the 10 Essential Public Health Services were cross walked with the
purpose of the MCH Block Grant to States Program, as defined in
Section 501(a)(1) of Title V of the Social Security Act. The strategies presented
below were developed as a result of this effort.
•

Mobilize partners, including families, at the federal, state and community
levels in promoting shared vision for leveraging resources, integrating and
improving MCH systems of care, promoting quality public health services
and developing supportive policies;

•

Integrate systems of public health, health care and related community
services to ensure access and coordination to assure maximum impact;

•

Conduct ongoing assessment of the changing health needs of the MCH
population (as impacted by cultural, linguistic, demographic
characteristics) to drive priorities for achieving equity in access and
positive health outcomes;

•

Educate the MCH workforce to build the capacity to ensure innovative,
effective programs and services and efficient use of resources;

•

Inform and educate the public and families about the unique needs of the
MCH population;

•

Promote applied research resulting in evidence-based policies and
programs;

•

Promote rapid innovation and dissemination of effective practices through
quality improvement and other emerging methods; and

•

Provide services to address unmet needs in healthcare and public health
systems for the MCH population (i.e. gap-filling services for individuals.)

B. National Performance Measurement Framework
With the MCH transformation and its emphasis on performance and
accountability at both the state and national levels, this Guidance includes a
transformed national performance measurement system that is intended to show
more clearly the contributions of Title V programs in impacting health outcomes
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Public Health in America. (1994). Washington, D.C.: U.S. Public Health Service. Essential Public Health Services
Working Group of the Core Public Health Functions Steering Committee.

while still maintaining flexibility for the states. The national performance
measurement system adopted in this Guidance is a three-tiered framework,
which includes the following measure categories: National Outcome Measures
(NOMs), National Performance Measures (NPMs) and State-initiated Evidencebased or -informed Strategy Measures (ESMs).
In the revised national performance measure framework, the focus is on the
establishment of a set of population-based measures (i.e., NPMs) which utilize
state-level data derived from national data sources and for which state Title V
programs will track prevalence rates and work towards demonstrated impact.
The NPMs are intended to drive improved outcomes relative to one or more
indicators of health status (i.e., NOMs) for the MCH population, so states will
track the NOMs to monitor impact by the NPMs. ESMs are the final tier of the
national performance measurement framework, and they are the measures by
which states will directly measure their impact on the NPMs. State-specific and
actionable, the ESMs seek to track a state Title V program’s strategies and
activities and to measure evidenced-based or evidenced-informed practices that
will impact individual population-based NPMs. The ESMs are developed by the
state, and they provide accountability for improving quality and performance
related to the NPMs and to the MCH public health issues for which they are
intended. While not part of the national performance measurement framework,
states will also develop State Performance Measures (SPMs), in addition to the
ESMs, to address the priorities they have identified based on the findings of their
Five-year Needs Assessments and to the extent that a priority need has not been
fully addressed through the selected NPMs and ESMs.
The 15 NPMs address key national MCH priority areas. Collectively, they
represent six MCH population health domains: 1) Women’s/Maternal Health; 2)
Perinatal/Infant’s Health; 3) Child Health; 4) CSHCN; 5) Adolescent Health; and
6) Cross-cutting or Life Course. The six population health domains are contained
within the three legislatively-defined MCH populations [Section 505(a)(1).] For
example, the first two domains are included under “preventive and primary care
services for pregnant women, mothers and infants up to age one,” which is the
first of the three defined MCH populations. Child health is included in the second
defined MCH population, specifically “preventive and primary care services for
children.” Services for CSHCN is the third legislatively-defined MCH population.
Cross-Cutting or Life Course refers to public health issues that impact multiple
MCH population groups.
The national MCH priority areas incorporate two significant concepts: first, Title V
is responsible for promoting the health of all mothers and children, which
includes an emphasis on CSHCN and their families; and second, the
development of life course theory has indicated that there are critical stages,
beginning before a child is born and continuing throughout life, which can
influence lifelong health and wellbeing.

States should work closely with family/consumer partnerships as they develop
the ESMs for their selected NPMs. For purposes of the Title V MCH Services
Block Grant program and this Guidance, family/consumer partnership is defined
as: “The intentional practice of working with families for the ultimate goal of
positive outcomes in all areas through the life course.” Family engagement
reflects a belief in the value of the family leadership at all levels from an
individual, community and policy level.” Relevant resources include the National
Consensus Standards for Systems of Care for Children and Youth with Special
Health Care Needs, which were released in March 2014. The report is available
on the Lucille Packard Foundation for Children’s Health website at http://lpfchcshcn.org/publications/research-reports/developing-structure-and-processstandards-for-systems-of-care-serving-children-and-youth-with-special-healthcare-needs. Examples of family/consumer partnership for Title V organizations
are highlighted on the Family Voices website at:
http://www.familyvoices.org/work/title_v?id=0012.
C. Changes to the Application/Annual Report Guidance
This Guidance is intended to enable states to tell a more cohesive and
comprehensive Title V story, while reducing the reporting burden and duplication
across sections of the Application/Annual Report. In addition, the revised
narrative will allow state Title V programs to better reflect on their leadership role
within the state and to demonstrate the program’s contributions to the state’s
public health system in building improved and expanded systems of care for the
MCH population.
Historically, the narrative reporting on state Title V activities has been organized
by performance measure rather than by population group. The organizing
framework for this guidance is based on six identified population health domains
(i.e., Women’s/Maternal Health; Perinatal/Infant’s health; Child Health; CSHCN;
Adolescent Health; and Cross-cutting or Life Course.) More specifically,
throughout the course of the Application/Annual Report/Needs Assessment
Summary, states will organize the discussion of their Title V program activities for
each of the three legislatively-defined MCH populations (i.e., preventive and
primary care services for pregnant women, mothers and infants up to age one;
preventive and primary care services for children; and services for CSHCN) in
the context of these six identified MCH population health domains.
In reporting on their Five-year Needs Assessments, a Needs Assessment
Summary will replace the more comprehensive, standalone document previously
submitted by states. The Needs Assessment Summary will be integrated into the
yearly MCH Block Grant Applications/Annual Reports. This integration will serve
to reduce the duplication in reporting that has traditionally occurred between the
Five-year Needs Assessment document and the first year Application/Annual
Report. In the first year Application/Annual Report, states will now provide a
summary report of their Five-year Needs Assessment process and findings.
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Based on their ongoing needs assessment efforts, states will provide an update
to the Needs Assessment Summary in each of the four interim year
Applications/Annual Reports.
For the first time, states will be required to include an Executive Summary for
each Application/Annual Report that they submit during the five-year reporting
cycle. The Executive Summary shall briefly describe the key points presented in
the state’s Application/Annual Report and include, at a minimum, a brief
summary of the following discussion points:
•

Emergent needs based on the Five-year/ongoing Needs Assessment
efforts and linked with the Title V program priorities and development of a
five-year State Action Plan;

•

Highest ranked priority needs for the state Title V program, including a
discussion of key SPMs and ESMs which the state developed to address,
respectively, the identified priority needs and selected NPMs; and

•

Accomplishments relative to addressing the identified needs and a plan for
the coming year that assures continued progress in achieving the desired
health status and performance outcomes.

In addition to providing a summary overview of the state Title V program and the
gains that have been realized relative to the state priority needs, the Executive
Summary can serve as a standalone document for the state in marketing its
Title V program’s achievements to other state, community and family agencies
and in soliciting programmatic input from families and other MCH stakeholders.
Revisions to the organizational framework of the state Applications/Annual
Reports are intended to position the state and national MCH priorities, and the
related Title V program activities, as the centerpiece of the narrative reporting.
The revised instructions for the state Title V MCH Block Grant Application and
reporting process are built on the premise that state priority needs and national
MCH priority areas will serve as the “drivers” for state reporting on the Five-year
(and ongoing) Needs Assessment findings, the selection of NPMs to address
state-identified priorities, the development of evidence-based or –informed
strategies with ESMs to address state and national priority areas (as reflected in
the NPMs selected for programmatic focus) and the establishment of SPMs to
address the state’s unique needs.
As part of their first-year Application/Annual Report and in follow-up to the
Five-year Needs Assessment, states will be required to develop an interim Fiveyear Action Plan Table. A sample table is provided, for the state’s consideration,
in Part Two, Section IIF.1.a of this Application/Annual Report Guidance and in
Appendix B of the Supporting Documents. This Table is intended to serve as a
planning tool and organizational framework for states in developing a five-year
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Action Plan that aligns their planned Title V program strategies and activities with
the identified priority needs and selected NPMs/SPMs. In the Year 02
Application/Annual Report (i.e., FY 2017/FY 2015), States will refine the
objectives and strategies they identified in their interim Five-year Action Plan
Table. The identified strategies should guide states in developing ESMs that
address their selected NPMs. In addition to refining their program objectives and
strategies, States will insert the ESMs and the SPMs they develop in the Fiveyear State Action Plan Table that will be included in the second year (i.e.,
FY 2017/FY 2015) Application/Annual Report.
As described above, the Five-year Action Plan Table is a tool for states to use in
developing the five-year Action Plan. States will report on their five-year Action
Plan in the narrative Applications/Annual Reports. In addition to providing
updates to the five-year Action Plan for the Application year, States will report
annually on their progress towards the implementation and achievement of the
strategies/activities outlined in the State Action Plan and their success in meeting
the established performance objectives for each of the NPMs, ESMs and SPMs.
Specifically, states will provide a narrative discussion on the development of the
five-year Action Plan in the initial Application year (i.e., FY 2016). The discussion
should build on the summary information presented in the interim Five-year
Action Plan Table. For the first two Annual Report years (i.e., FY 2014 and
FY 2015), states will report out on the previous five-year cycle. In the following
three interim year Applications/Annual Reports, states will refine their Title V
program plan for the coming year (i.e., Application year) and report on the
progress that has been achieved in implementing the five-year Action Plan (i.e.,
Annual Report.)
States will report annual performance indicators for the previous reporting cycle’s
18 NPMs and 7-10 SPMs on Form 10D for FY 2014 and FY 2015. Using
Form 10A, states will begin to report on the selected 8 NPMs, ESMs and SPMs
for this five-year reporting cycle (i.e., FY 2016-FY 2020) in the FY 2016 Annual
Report. While data reporting in the FY 2014 and the FY 2015 Annual Reports
will focus on the previous reporting cycle’s national and state performance
measures, the state’s narrative reporting will be incorporated into the five-year
Action Plan. Rather than providing a description of Last Year/Current
Year/Future Year program activities for each specific measure as required in
previous Annual Reports, performance measure trends for the FY 2014 and
FY 2015 Annual Report years will be analyzed and summarized as part of the
discussion for the relevant population health domain(s).
Two additional changes to the Application/Annual Report Guidance for this
five-year reporting cycle are the elimination of the Health System Capacity
Indicators and the incorporation of some of the Health Status Indicators (HSIs)
into the NOMs. Along with the other state data (OSD) reported on Form 11, the
NOMs will serve as the monitoring tool for states in assessing their progress
towards achieving the desired health outcomes. Effective with this Guidance,
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data for the NOMs and OSD, as available, will be collected and provided to the
state by MCHB.

IV. LEGISLATIVE REQUIREMENTS
The federal MCH Block Grant to States is authorized under Title V of the Social
Security Act, which is the longest-standing public health legislation in American
history. More than 75 years later, the law continues to support efforts to improve
the health of the nation’s women and children. The law can be viewed at:
http://www.ssa.gov/OP_Home/ssact/title05/0500.htm.
A. Who Can Apply for Funds [Section 505(a)]
The Application/Annual Report shall be developed by, or in consultation with,
the state MCH agency and shall be made public within the state in such
manner as to facilitate comment from any person (including any federal or
other public agency) during its development and after its transmittal.
B. Use of Allotment Funds [Section 504]
The state may use its Title V MCH Services Block Grant funds for the
provision of health services and related activities (including planning,
administration, education, and evaluation) consistent with its Application. In
addition, the state may request supplemental funds from the Bureau to
support identified technical assistance needs. Related to technical
assistance, the state should plan for and allot funds for the MCH and CSHCN
Directors to attend the required Block Grant Application/Annual Report review
that is held at a site designated annually by the Division of State and
Community Health (DSCH) in HRSA’s MCHB. Funds may not be used for
cash payments to intended recipients of health services or for purchase of
land, buildings, or major medical equipment. Other restrictions apply, as
specified in Section 504(b).
C. Application for Block Grant Funds [Section 505]
Each state is required to conduct a statewide Needs Assessment every five
years. Beginning in 2015, the result of that Needs Assessment will be
integrated into the Application/Annual Report for that reporting year, and any
updates will be provided in the Applications/Annual Reports that states submit
in the interim years. By law, the Application/Annual Report will contain
information that is consistent with the health status goals and national health
objectives regarding the need for:
•

Preventive and primary care services for all pregnant women, mothers,
and infants up to age one;

•

Preventive and primary care services for children; and

•

Services for CSHCN [as specified in section 501(a)(1)(D) "familycentered, community-based, coordinated care (including care
coordination services) for children with special health care needs
(CSHCN) and to facilitate the development of community-based
systems of services for such children and their families"].

The state will organize its reporting on the three legislatively-defined MCH
populations in the context of six population health domains: 1)
Women’s/Maternal Health; 2) Perinatal/Infant’s Health; 3) Child Health; 4)
CSHCN; 5) Adolescent Health; and 6) Cross-cutting or Life Course. In the
Five-year Needs Assessment Application year (i.e., FY 2016), the state’s
Application shall include an interim Five-year Action Plan Table which serves
as an organizing framework for the development of the five-year Action Plan.
In addition, states shall provide an expanded narrative description on the
development of the five-year Action Plan and the identification of Title V
program strategies/activities for addressing the priority needs that were
identified by the statewide assessment in the narrative Action Plan section of
their FY 2016 Application. The eight NPMs selected by the state should be
addressed in this discussion and a clear plan presented for how the state
plans to move forward in addressing each of the measures. Updates to the
planned program strategies and activities for addressing the priority needs
and improving performance around each of the performance measures will be
discussed in the Action Plan narrative that is submitted by states in the
subsequent four interim year Applications (i.e., FY 2017 - FY 2020.)
Beginning with the second year Application (i.e., FY 2017), this discussion
should include the ESMs developed for each of the selected NPMs and the
three to five SPMs established by the state to respond to priority needs that
are not adequately addressed by the NPMs and ESMs.
Each year, at least thirty percent (30%) of federal Title V funds must be used
for preventive and primary care services for children and at least thirty
percent (30%) for services for CSHCN, as specified in Section 501(a)(1)(D).
Such services include providing and promoting family-centered, communitybased, coordinated care (including care coordination services) for CSHCN
and facilitating the development of community-based systems of services for
such children and their families. The thirty percent (30%) requirement may be
waived as specified in Section 505(b)(1-2). A request for waiver must be
included in the Application letter of transmittal. In addition, of the amount paid
to a state under Section 503 from an allotment for a fiscal year under
Section 502(c), not more than ten percent (10%) may be used for
administering the funds paid under this section.

The state must maintain the level of funds being provided solely by such
state’s MCH programs at the level provided in fiscal year 1989.
[Section 505(a)(4)].
Other requirements for allocation of funds, charging for services, maintenance
of a toll-free hotline (and other appropriate methods) and coordination of
services with other programs are found in Section 505.
D. Annual Report [Section 506]
An Annual Report must be submitted to the MCHB each year in order to
evaluate and compare the performance of different states assisted under this
Title and to assure the proper expenditure of funds. The Annual Report will
include a description of program activities, a complete record of the purposes
for which funds were spent, the extent to which the state has met the goals
and the performance objectives it set forth, as well as the national health
objectives, and the extent to which funds were expended consistent with the
state's Application. For this five-year reporting cycle, the Action Plan will
serve as the Annual Report narrative on the state’s Title V program strategies
and activities. As described in Part One, Section III.C., states will develop
and submit an interim Five-year Action Plan Table as part of the first-year
Application/Annual Report and in follow-up to the Five-year Needs
Assessment. The Action Plan will identify program goals, objectives, key
strategies and performance measures related to each of the six population
health domains. In the four interim year Application/Annual Reports, States
will utilize the Action Plan section of the Application/Annual Report to provide
narrative discussion on the progress (by population health domain) achieved
during the reporting year relative to the implementation of planned Title V
program activities and gains in meeting the established performance measure
targets. The standardized format of the Annual Report, as described, will
allow for consistency in reporting and will facilitate the preparation of a report
to Congress [Section 506(a)(3).] It should be noted that for the first two
Annual Report years (i.e., FY 2014 and FY 2015) states will report on the
national and state performance measures and Title V program activities that
were implemented in the previous five-year cycle. As described in Part One,
Section IIIC, states will report their FY 2014 and FY 2015 annual performance
indicator data for the previous reporting cycle’s NPMs and SPMs on Form
10D, while their narrative reporting will be incorporated into the State Action
Plan.
As required in Section 509(a)(5), the MCHB has made a substantial effort to
not duplicate other federal data collection efforts. This edition of the
Application/Annual Report Guidance goes beyond previous editions in
reducing duplication of federal and state data collection, maintenance and
reporting efforts relating to the health status and health service needs of
mothers and children in the United States. Effective with this five-year
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reporting cycle, the MCHB will collect and provide national outcome and
performance measure data, as well as available OSD, for the individual
states. Data are not available from the National Center for Health Statistics
(NCHS) or other Federal sources for Puerto Rico, Guam and the Marshall
Islands, Federated States of Micronesia, Republic of Palau, Commonwealth
of the Northern Mariana Islands, American Samoa and Virgin Islands. These
jurisdictions must report their own vital statistics and health data.
E. Administration of Federal and State Programs [Section 509]
The MCHB in HRSA is the organizational unit responsible for the
administration of Title V. Within the Bureau, DSCH has responsibility for the
day-to-day operation of the Title V MCH Services Block Grant to States
Program. Applicants may obtain additional information regarding
administrative, technical and program issues concerning the Block Grant
Application/Annual Report by contacting:
Division of State and Community Health
Maternal and Child Health Bureau
Health Resources and Services Administration
5600 Fishers Lane, Room 5C-26
Rockville, Maryland 20857
Telephone: (301) 443-2204
Fax: (301) 443-9354
Within each state, the state health agency is responsible for the
administration (or supervision of the administration) of programs carried out
with Title V allotments.

PART TWO: APPLICATION/ANNUAL REPORT INSTRUCTIONS
I. GENERAL REQUIREMENTS
A. Letter of Transmittal

An electronic letter of transmittal from the responsible state health agency official
must be the first page of the Title V MCH Block Grant Application/Annual Report.
The letter must also contain the documentation for waiver of a 30 percent
allotment, if the state is so requesting. The letter of transmittal is attached to
Section I.A. of the Application/Annual Report.
B. Face Sheet
Each section of the Application Face Sheet (Standard Form 424) must be
completed and submitted electronically along with the rest of the
Application/Annual Report.
C. Assurances and Certifications
The appropriate Assurances and Certifications for the state MCH Block Grant
programs, which include Application Form Standard Form (SF)-424B,
Assurances for Non-Construction Programs and Certifications for debarment and
suspension, drug free work place, lobbying, program fraud and tobacco smoke
are included in Appendix C. States do not have to submit these forms as part of
the Application/Annual Report, but they must be maintained on file in the state’s
MCH program’s central office. The assurance and certification forms may be
attached to this section, but such an attachment is not required. Instead, the
state can provide either the URL to access the assurances/certifications, or they
can provide information on how the Assurances and Certifications can be made
available.
D. Table of Contents
The Table of Contents is automatically generated by the system, and conforms to
the headings in the different Parts/Sections of this Guidance.
E. Application/Annual Report Executive Summary
As discussed in Part One, Section III.C., states will submit an Executive
Summary with each Application/Annual Report. For each of the six identified
population health domains, the Executive Summary shall present a brief
description of the Title V program’s major accomplishments and significant
challenges relative to the cited priority and other emergent needs and the state’s
annual performance on the NOMs, NPMs, SPMs and ESMs that are specific to
13

that population health domain. In addition to the three required discussion points
listed in Part One, Section III.C, the state should provide a statement for each
population health domain which summarizes its progress on “moving the needle”
around key MCH priority areas and national and state performance measures.
The Executive Summary can be up to five pages in length, or 15,000 characters,
including charts and graphs. This Summary should reflect only the key points
that are presented in the state’s Application/Annual Report.
II. COMPONENTS OF THE APPLICATION/ANNUAL REPORT
On July 15 of each year, states and jurisdictions are required to submit an
Application/Annual Report for the federal funds they receive through the Title V MCH
Services to States Program. In addition, states are required to conduct and report
on a comprehensive, statewide Needs Assessment every five years. The findings of
this Need Assessment and the priority needs identified as a result of this process
provide the basis for the development of a five-year Action Plan for the state Title V
program. As new findings become available through ongoing needs assessment
efforts and the analyses of annual performance data, a state may refine its Action
Plan in interim years to achieve targeted progress (i.e., performance objectives)
related to the state and national MCH priority areas. These changes may include
the substitution of new or revision of existing program strategies, ESMs linked to the
selected NPMs and/or SPMs. States are encouraged not to change the selected
NPMs during the five-year reporting cycle. If a state determines that a NPM needs
to be changed, clear justification must be provided.
The state’s narrative Application/Annual Report shall include the following sections:
•

Descriptive overview of the state;

•

Summary of the Five-year (and ongoing) Needs Assessment process and
findings that speaks to the strengths/needs of the state’s MCH population (as
discussed by each of the six identified population health domains), Title V
program capacity and established partnerships/collaborations, which should
include a discussion on ongoing opportunities provided by the state for
engaging families and other stakeholders in programming efforts (e.g.,
advisory councils, family/consumer partnerships, etc.)

•

Listing of seven to ten priority needs for the state Title V program and
rationale that links the identified priorities to the five-year Needs Assessment
findings;

•

Discussion on how the selected NPMs link with the identified state MCH
priorities and rationale to demonstrate how the ESMs developed by the state
will impact the selected NPMs.

•

Discussion on how the SPMs (and state outcome measures (SOMs), if
applicable) developed by a state address the identified state priority needs
and/or the national MCH priority areas.

•

Development and annual reporting on a Five-year State Action Plan.

States shall structure the narrative discussion in this segment of the Application to
include the six sections cited above. A detailed explanation of the specific
discussion points that the state should address is provided in Sections A-F of this
Guidance.
For the first year’s Application (i.e., FY 2016) of the five-year reporting cycle, states
shall summarize the process that was used in conducting the Five-year Needs
Assessments and their overall findings relative to the specific strengths/needs that
were identified for the state’s MCH population, Title V program capacity and
partnerships/collaborations. States shall present their Needs Assessment findings
by each of the six population health domains. In addition, states should address
how their identified MCH strengths/needs link with the national MCH priority areas,
as reflected in the federal Title V program’s NHS/OMs and NPMs.
In the four subsequent interim years of the five-year reporting cycle (i.e., FY 2017FY 2020 Applications/FY 2015-FY 2018 Annual Reports), states shall update the
needs assessment information presented in the FY 2016 Application/FY 2014
Annual Report, as appropriate, to reflect improvements and/or changes in such
areas as:
•

State’s health care delivery environment (e.g., implementation of the ACA);

•

Identified strengths/needs of the state’s MCH population and its Title V and
other MCH program capacity;

•

Level of commitment to consistently engaging family/consumer partnerships
in Title V MCH and CSHCN programmatic and decision-making efforts; and

•

Approaches to building and/or expanding the reach and effectiveness of the
state’s Title V partnerships and its collaborations with other federal, tribal,
state and local entities that serve the MCH population.

A. Overview of the State
The introductory section of the Application narrative shall put into context the
Title V program within the state’s health care delivery environment. Applicants
should discuss the principal characteristics that are important to understanding
the health status and needs of the entire state’s MCH population. The state
health agency’s current priorities or initiatives and the resulting Title V program’s
roles and responsibilities should also be described. States should address how
15

health care reform efforts and ACA implementation are impacting the health
status of its MCH and CSHCN populations and the delivery of Title V-supported
services.
Included in the state overview should be a description of the process used by the
Title V administrator to determine the importance, magnitude, value, and priority
of competing factors which impact health services delivery in the state. Current
and emerging issues should be identified and discussed in terms of the other
identified MCH issues.
This overview should also address the extent to which poverty, racial and ethnic
disparities in health status, geography, urbanization, and the private sector
create unique challenges for the delivery of Title V services in the state. Specific
state statutes and other regulations that have relevance to Title V program
authority should be discussed and examined in terms of their impact on the
state’s Title V MCH and CSHCN programs.
B. Five-Year Needs Assessment Summary
The Title V legislation (Section 505(a)(1)) requires the state, as part of the
Application, to prepare and transmit a statewide Needs Assessment every five
years that identifies (consistent with the health status goals and national health
objectives) the need for:
(1) Preventive and primary care services for pregnant women, mothers and
infants up to age one;
(2) Preventive and primary care services for children; and
(3) Services for children with special health care needs.
The conceptual framework presented in Figure 2 depicts how the findings of the
State Five-year Needs Assessment are expected to serve as the “drivers” in
determining state Title V program priority needs and in developing a five-year
Action Plan to address them.
Findings from the Five-year Needs Assessment serve as a cornerstone for the
development of a five-year Action Plan for the state Title V program. The Needs
Assessment findings should inform the selection of the state’s seven to ten
highest priority needs for its MCH and CSHCN populations. Selected priority
needs should reflect the work of the state’s Title V program and address areas in
which the supported services can have direct impact on the state and federal
MCH priorities. Based on its priority needs, as identified in the Five-year Needs
Assessment, the State will select eight of 15 possible NPMs for programmatic
emphasis over the five-year reporting period.

Figure 2. TITLE V MCH BLOCK GRANT NEEDS ASSESSMENT FRAMEWORK
LOGIC MODEL

5-Year
Needs
Assessment

Assess and
Summarize MCH
Population
Needs, Program
Capacity, and
Partnerships/
Collaborations

Develop State
Performance
Measures and
Establish
Performance
Objectives

Identify State
Title V Program
Priority Needs
and Consider
National MCH
Priority Areas

Refine Five-Year
Action Plan for
Achieving
Progress on
National and
State Measures

Select National
Performance
Measures; Develop
Interim Strategies
to Address Priority
Needs and Selected
National Measures

Develop/Update
Performance
Objectives; Report
Annual State
Performance
Indicator Data

Develop Interim
Develop/Refine
Five-Year Action
Strategies for
Plan for MCH Block
Addressing Priority
Grant Program;
Needs and Selected
Establish National
National and State
Performance
Measures
Measure Objectives

Analyze
Performance
Trends

Develop Evidence
Based or Informed
Strategy Measures for
National Performance
Measure and Establish
Performance
Objectives

Reassess

Interim Year
Applications/
Annual
Reports

The five-year Action Plan to be developed by the state in the first
Application/Annual Report year (i.e., FY 2016/FY 2014) of the five-year reporting
cycle will speak to the state’s priority needs, the identified national MCH priority
areas and the state-selected NPMs. Preliminary goals, objectives and strategies
for achieving targeted progress in the specified priority areas should be clearly
outlined in the state’s Action Plan. In the second Application/Annual Report year
(i.e., FY 2017/FY 2015), the State shall refine its goals, objectives and strategies
in addition to developing ESMs for implementing the identified strategies to
address the eight selected NPMs. The purpose of the ESMs is to identify state
Title V program efforts which can contribute to improved performance relative to
the selected NPMs. Most issues in MCH are multifactorial; therefore, while
states are strongly encouraged to develop multiple strategies with a related ESM
for each strategy to impact a selected NPM, states are required to submit at least
one ESM for each of the NPMs selected. In addition, states will develop between
three and five SPMs to address its unique needs to the extent that they are not
addressed by the selected NPMs and ESMs. States will report annually on the
progress that has been achieved relative to the ESMs and the SPMs. This
framework is intended to more clearly reflect the work of the state Title V
programs in addressing state and national MCH priority areas.
A more detailed overview of the MCH Five-year Needs Assessment process and
its relationship to the planning and monitoring functions in Title V programs is
presented in Appendix D.
In this section of the Application narrative, states shall present a concise
summary of the Five-year Needs Assessment process and findings, as described
below, with annual updates provided in the four interim year Applications/Annual
Reports. The Needs Assessment Summary that is to be included in the
Application/Annual Report is intended to emphasize only the key findings of the
state’s Five-year Needs Assessment as they relate to the state MCH priority
needs and link with the national MCH priority areas. It is recognized that states
engage in a thorough and comprehensive Five-year Needs Assessment process,
with rich findings that go beyond the required content for the first year
Application/Annual Report. In addition to the required Needs Assessment
Summary, states may choose to develop a more detailed and complete Five-year
Needs Assessment document that is tailored to meet their individual program
needs, and they are encouraged to include links to state websites where such
documents are posted in the Application/Annual Report. States may also choose
to submit more detailed documentation on their Five-year Needs Assessment
findings as an attachment to this section. The total length of the Needs
Assessment Summary that is to be included in the first year Application/Annual
Report (i.e., FY 2016/FY 2014) shall not exceed 60,000 characters (or 20 pages).

1. Process
In this section, states shall summarize the overall process that was used to
conduct the Title V comprehensive Needs Assessment. States should
describe the (1) goals, framework and methodology which guided the Needs
Assessment process; (2) the level and extent of stakeholder involvement;
(3) quantitative and qualitative methods that were used to assess the
strengths and needs of each of the six identified population health domains,
MCH program capacity and partnerships/collaborations; (4) data sources that
were utilized to inform the Needs Assessment process; and (5) interface
between the collection of Needs Assessment data, the finalization of the
state’s Title V priority needs and the development of the state’s Action Plan.
In interim year Applications/Annual Reports, states should describe what
actions are being taken to ensure that Needs Assessment is an ongoing
process. These updates should include a brief description of ongoing needs
assessment activities, such as data collection and analysis, program
evaluations, focus groups, surveys and other selected approaches that
enable the State to continue to monitor and assess, on an ongoing basis, the
successes and continuing needs that have resulted from the implementation
of the state’s five-year Action Plan to address the national and state MCH
priority needs.
2. Findings
In the first year Application/Annual Report (i.e., FY 2016/FY 2014), states
shall present a focused Summary of the findings of its Five-year Needs
Assessment. Highlighted in this Summary should be the health status of the
MCH population relative to the state’s noted MCH strengths/needs and the
identified national MCH priority areas, with the discussion organized and
presented by each of the six population health domains. In addition, the state
shall summarize the adequacy and limitations of its Title V program capacity
and partnership building efforts relative to addressing the identified MCH
population groups and program needs. Specific partnership and collaborative
efforts may include, but are not limited to, promotion of family/consumer
engagement and leadership, coordination with other MCHB and federal, state
and local MCH investments and established relationships with Tribes, Tribal
Organizations and Urban Indian Organizations who reside within the state’s
geographic boundaries.
In the interim year Applications/Annual Reports (i.e., FY 2017-FY 2020/
FY 2015-FY 2018), States shall provide annual updates to the findings they
presented in the Needs Assessment Application year (FY 2016 Application/
FY 2014 Annual Report.) These updates should clearly reflect ongoing needs
assessment efforts and address changes in the state’s MCH population,
Title V program capacity and level of partnerships/collaborations. Such
19

updates may include, but are not limited to, a discussion of the following
items.
•

Changes in the strengths and needs of the MCH population, Title V
program capacity and established program collaborations/partnerships
since the last MCH Block Grant Application/Annual Report was
submitted.

•

Activities undertaken to operationalize the findings of the Five-year
Needs Assessment, such as the establishment of an advisory group to
monitor state progress in addressing a targeted priority need.

a. MCH Population Needs
Using both quantitative and qualitative methods, states shall present:
i.

An overview of the health status of the state’s MCH population for
each of the six identified population health domains (i.e., Women’s/
Maternal Health, Perinatal/Infant’s Health, Child Health, CSHCN,
Adolescent Health and Cross-cutting or Life Course) within the
three legislatively-defined state MCH population groups (i.e.,
(a) pregnant women, mothers, and infants up to age 1; (b) children;
and (c) children with special health care needs.)

ii.

A summary of population-specific strengths/needs as well as
strengths/needs that cross all three of the legislatively-defined
population groups.

iii.

A concise description of the state’s successes, challenges, gaps
and areas of disparity related to major morbidity, mortality, risk
reduction or maintenance of health/wellness for each of the six
population health domains. At a minimum, the discussion should
include major health issues addressed in the state’s priority needs
and the national MCH priority areas within the MCH population as a
whole and for significant sub-populations (e.g., racial, ethnic, age,
income, geographic, frontier/rural/urban, or other relevant
characteristics.)

iv.

An analysis of Title V-specific programmatic approaches to
determine areas where current efforts work well and should be
continued and areas in which new or enhanced strategies/program
efforts are needed.

The discussion in this section should be organized by the six population
health domains and address the state-identified priority needs and
national MCH priority areas. For each population health domain, the state
20

should clearly discuss its strengths/needs relative to the state-specific
MCH priority needs (identified through the Five-year Needs Assessment
process) and the pertinent OSD, NOMs and NPMs. In the narrative
discussion, states may include other identified strengths and needs for its
MCH population (based on the findings of the Five-year Needs
Assessment,) which are unique to the state and go beyond the national
MCH priority areas. Detailed information on the performance measure
framework is presented in Appendix E. Detail sheets for the NOMs and
NPMs are included in Appendix F.
In the four interim year Applications/Annual Reports, states shall report by
population health domain on any changes in the health status of its MCH
populations, the identified strengths/needs and noted Title V program
successes/issues/ gaps/disparities that have impacted MCH morbidity,
mortality, risk reduction and/or health maintenance/wellness, based on the
findings of its ongoing needs assessment efforts.
b. Title V Program Capacity
Based on the Five-year Needs Assessment findings, states shall structure
the discussion of their Title V program capacity to include the sections
outlined below. The findings presented in the Five-year Needs
Assessment Application/Annual Report year should be updated annually
in the state’s four interim year Applications/Annual Reports, based on the
findings of their ongoing needs assessment efforts and noted changes in
the state’s organizational structure and program capacity.
i

Organizational Structure
In reporting on the organizational structure of the Title V program,
the state should:
(a) Describe the organizational structure and placement of the
Governor, state health agency and the Title V MCH and
CSHCN programs in the state government.
(b) Clarify how the state health agency is "responsible for the
administration (or supervision of the administration) of
programs carried out with allotments under Title V"
[Section 509(b)]. This description should include all of the
programs funded by the federal-state Title V MCH Block
Grant.
(c) Include an organizational chart as an attachment to this
section.
21

ii.

Agency Capacity
In reporting on Title V program capacity, the state should:
(a) Describe the state Title V agency's capacity to promote and
protect the health of all mothers and children, including
CSHCN. Included in this description should be a discussion of
the state’s capacity for providing Title V services by each of
the six population health domains. In describing the state’s
capacity for providing services to CSHCN, the state should
address its ability to provide rehabilitation services for blind
and disabled individuals under the age of 16 receiving benefits
under Title XVI (the Supplemental Security Income Program),
to the extent medical assistance for such services is not
provided under Title XIX (Medicaid).
(b) Describe the steps that state MCH and CSHCN programs
have taken to ensure a statewide system of services, which
reflect the principles of comprehensive, community-based,
coordinated, family-centered care. Highlighted in this
description is the extent to which the state effectively uses its
Title V funds to support:
(1) State program collaboration with other state agencies
and private organizations;
(2) State support for communities;
(3) Coordination with health components of communitybased systems; and
(4) Coordination of health services with other services at the
community level.

iii.

MCH Workforce Development and Capacity
(a) Describe the strengths and needs of the state MCH and
CSHCN workforce, including the number, location and fulltime equivalents of state and local staff who work on behalf of
the state Title V programs. Included in this description should
be the names and qualifications (briefly described) of senior
level management employees who serve in lead MCH-related
positions and program staff who contribute to the state’s
planning, evaluation, and data analysis capabilities. States
should also report on the number of parent and family
members, including CSHCN and their families, who are on the
22

state Title V program staff and their roles (e.g., paid consultant
or volunteer.) In addition, states are encouraged to provide
additional MCH workforce information which may be available,
such as the tenure of the state MCH workforce and projected
shifts in the MCH and CSHCN workforce over the five-year
reporting period.
(b) Provide examples of the mechanisms that the state has
developed and utilized to promote and provide culturally
competent approaches in its services delivery. Examples of
such activities may include:
(1) Collect and analyze data according to different cultural
groups (e.g. race, ethnicity, language) and use the data
to inform program development and service delivery.
(2) Ensure the provision of training, both in orientation and
ongoing professional development, for staff, family
leaders, volunteers, contractors and subcontractors in the
area of cultural and linguistic competence.
(3) Collaborate with informal community leaders/groups (e.g.
natural networks, informal leaders, spiritual leaders,
ethnic media and family advocacy groups) and families of
culturally diverse groups in needs/assets assessments,
program planning, service delivery and evaluation/
monitoring/quality improvement activities.
(4) Secure allocation of resources to adequately meet the
unique access, informational and service needs of
culturally diverse groups.
(5) Develop and implement performance standards for staff
and contractors that incorporate cultural competence
practices and policies.
(6) Provide policies and guidelines that support the above
identified items and approaches.
c. Partnerships, Collaboration, and Coordination
Based on the Five-year Needs Assessment findings, states shall describe
relevant organizational relationships which serve the legislatively-defined
MCH populations and contribute to, or expand, the capacity and reach of
the state Title V MCH and CSHCN programs. Specifically, the discussion
in this section should focus on partnerships, collaborations, and
23

cross-program coordination established by the state Title V program with
public and private sector entities; federal, state and local government
programs; Tribes, Tribal Organizations and Urban Indian Organizations;
families/consumers; primary care associations; tertiary care facilities;
academia; and other primary and public health organizations across the
state that address the priority needs of the MCH population but are not
funded by the state Title V program.
The findings presented in the Five-year Needs Assessment
Application/Annual Report year should be updated annually in the state’s
subsequent four interim year Applications/Annual Reports, based on the
findings of ongoing needs assessment efforts and noted changes in the
state’s partnership, collaboration, and coordination efforts.
In reporting on the Title V program’s ongoing commitment and efforts to
build, sustain and expand partnerships, to work collaboratively and to
coordinate with other MCH-serving organizations, the state should
describe its relationships with such programs as:
i.

Other MCHB investments (e.g., State System Development
Initiative (SSDI) Grants, CSHCN State Implementation Grants,
Maternal, Infant, and Early Childhood Home Visiting (MIECHV)
Grants, Healthy Start Grants, Early Childhood Systems of Care
(ECCS) Grants, MCH Training programs and other MCHB efforts
relating to injury prevention, autism, developmental disabilities,
adolescent health, workforce development, oral health, bullying and
emergency medical services for children);

ii.

Other Federal investments (e.g., ACF, CDC and USDA-funded
programs, such as the Personal Responsibility Education Program
(PREP) teen pregnancy grants, family planning, immunizations,
infant and child death reviews and WIC);

iii.

Other HRSA programs (e.g., federally qualified health centers and
HIV/AIDS);

iv.

State and local MCH programs (e.g., local health departments and
urban MCH programs);

Other programs within the State Department of Health (e.g., chronic
disease, prevention and health promotion, immunization, vital
records and health statistics, injury prevention, behavioral and
mental health and substance abuse);

vi.

Other governmental agencies (e.g., Medicaid, CHIP, Education,
Social Services/Child Welfare, Corrections and Rehabilitation
Services);

vii.

Tribes, Tribal Organizations and Urban Indian Organizations;

viii.

Public health and health professional educational programs and
universities;

ix.

Family/consumer partnership and leadership programs; and

Other State and local public and private organizations that serve
the state’s MCH population.

States must include, as an attachment to this section, a current copy of
the Inter-Agency Agreement (IAA) that was developed between the state’s
Medicaid agency and the Title V agency, as cited in Section 509(a)(2) of
Title V and referenced in Section 1902(a)(11)(b) of Title XIX of the Social
Security Act.
In their Five-year Needs Assessment Summary, states should
include qualitative and quantitative information on their established
family/consumer partnerships. This description should include, but is
not limited to, the following discussion points:
i.

Nature and substance of the established family/consumer
partnership;

ii.

Diversity of members engaged in the family/consumer partnership;

iii.

Number of families/consumers engaged in the family/consumer
partnership, the degree of their engagement, the compensation that
is provided to them and the number of families/consumers that
were trained on MCH core competencies;

iv.

Evidence and range of issues being addressed through the
family/consumer partnership;

Impact of family/consumer partnership on programs and policies,
including the development of promising practices; and

vi.

Description of the state’s efforts to build and strengthen family
consumer partnerships for all MCH populations, including
CYSHCN.

C. State Selected Priorities
In this section, states shall list the seven to ten highest priority needs they
identified based on the findings of the Five-Year Needs Assessment. The priority
needs selected by a state for its Title V program during the five-year reporting
period should be determined by a thorough examination of the findings from the
state’s Five-year Needs Assessment, as highlighted in the Needs Assessment
Summary of the first year Application/Annual Report. States must assure that
the selected priorities address the defined MCH population groups that were
discussed in the Needs Assessment Summary.
In addition to listing the seven to ten selected priority needs on Form 9, states
should provide a rationale for how these priority needs were determined. This
rationale should include pertinent discussions on other priority needs that were
strongly considered by the state and its stakeholders and why these needs were
not included among the final priority list. In addition, states should describe the
methodologies that were used for ranking the broad set of identified needs and
the process for selecting its final seven to ten priorities. States should also
discuss factors that have contributed to changes in the priority needs since the
previous five-year reporting cycle and note if: (1) Priorities were continued;
(2) Priorities were replaced; or (3) Priorities were added. For each priority need,
the state should discuss why a priority need was continued, replaced, or added.
Updates relative to the selected priority needs should be provided by the state in
the subsequent four interim year narrative Applications/Annual Reports.
D. Linkage of State Selected Priorities with National Performance and
Outcome Measures
The priority needs identified by the state based on the findings of its Five-year
Needs Assessment shall inform the state’s selection of the national performance
and outcome measures for programmatic focus by its Title V program. In
partnership with the state Title V program leadership and other MCH
stakeholders, the MCHB identified 15 national priority areas for the Title V MCH
program. Detail sheets for each of the 15 national performance measures are
provided in Appendix F. Based on the identified state priority needs, states shall
select eight of the 15 national measures to be addressed over the five-year
period in their Title V program.
In this section of the Five-year Needs Assessment Application/Annual Report
year (i.e., FY 2016/FY 2014), states should list the selected eight national
performance measures with a rationale for why these measures were selected.
The discussion should clearly link the selected national measures with the state’s
identified priorities. In the second year Application/Annual Report year (i.e.,
FY 2017/FY 2015), states will develop and submit ESMs to address each of the
selected national measures. States can replace or revise one or more of the
26

ESMs developed in the subsequent interim year Applications/Annual Reports
(i.e., FY 2018-FY 2020/FY 2016-FY 2018) based on its effectiveness in achieving
the targeted progress for the corresponding national measure(s). With
justification, the state can change the NPM that it selected based on the Fiveyear Needs Assessment findings during the five-year reporting cycle.
In addition to developing their structural measures, states will establish a
performance objective for each ESM as part of the second year
Application/Annual Report (i.e., FY 2017/FY 2015). States will begin reporting on
the structural measure in the Year 03 through 05 interim Applications/Annual
Reports (i.e., FY 2018-FY 2020/FY 2016-FY 2018). Annual performance data for
the NPMs, the NOMs, and the OSD will be pre-populated, as available, for the
state in the Title V information System (TVIS.)
E. Linkage of State Selected Priorities with State Performance and Outcome
Measures
In addition to the NPMs selected by the state, the state shall develop between
three and five SPMs to address its unique MCH needs to the extent that these
needs are not addressed by the national measures and ESMs. Determination of
the SPMs should be based on the findings of the Five-year Needs Assessment.
States should develop a detail sheet on Form 10b, similar to the detail sheets
provided for the national measures, for each SPM.
States will identify the established three to five SPMs on Form 10B as part of the
second year Application/Annual Report (i.e., FY 2017/2015.) In addition, they will
establish performance objectives for each of the SPMs. Annual reporting of
performance data for the SPMs will begin with the submission of the FY 2016
Annual Report. While not encouraged for reporting purposes, states may change
or revise a SPM during one of the interim reporting years in the five-year cycle.
A state may also develop (but is not required to develop) one or more SOMs
based on the MCH priorities determined as a result of the Five-year Needs
Assessment, provided that none of the NOMs address the same priority area for
the state. A SOM should be linked with a performance measure to show the
impact of performance on the intended outcome. For any SOMs developed by
the state, five-year performance objectives should be established for each of the
reporting years.
States will develop a detail sheet for any identified SOMs. On the detail sheets,
States shall define the measures; goal; the indicator, numerator, and
denominators; data source; and significance. The SOM detail sheets will be
submitted by the state as part of the second year Application/Annual Report (i.e.,
FY 2017/FY 2015.) A state will track a SOM during the five-year reporting cycle,
and the state can retire an SOM if it chooses. Data for the SOMs
(indicator/numerator/denominator) will be entered annually by the state.
27

A timeline and the required components of the three Applications/Annual Reports
(i.e., FY 2016/FY 2014 through FY 2018/FY 2016) that are due to be submitted
under this Guidance instruction are presented in Appendix G.
F. Five-Year State Action Plan
States shall develop a five-year State Action Plan in follow-up to the Five-year
Needs Assessment. This Action Plan will serve as the Application/Annual Report
narrative discussion for the state on their planned activities for the Application
year and the activities that were implemented in the Annual Report year.
Activities should be discussed in terms of the state’s targeted performance and
its achievements around the NOMs, NPMs, ESMs and SPMs. The State Action
Plan shall include a robust discussion of the health status/outcome and
performance measures for each of the six population health domains.
In developing the Action Plan, the state shall complete an interim Five-year State
Action Plan Table (see sample on page 32 (Figure 4) of this Guidance and in
Appendix B) as part of the first year Application/ Annual Report (i.e., FY 2016/
FY 2014). This Table is a tool to assist states in aligning their program
strategies, NPMs, ESMs and SPMs with the priority needs that were identified in
the Five-year Needs Assessment. States will refine the objectives and
strategies, insert the ESMs for the selected NPMs and add the SPMs to the Fiveyear Action Plan Table in the second year Application/Annual Report (i.e.,
FY 2017/FY 2015). Updates to the strategies and activities will be provided by
the state, as needed, in subsequent interim year Applications/Annual Reports.
Figure 3 depicts the steps involved in the development of and the annual
reporting on the implementation of the five-year State Action Plan.
1. State Action Plan and Strategies by MCH Population
This section will serve as the state’s narrative plan for the Application
year and as the Annual Report for the reporting year. States should
describe their planned activities for the Application year and summarize the
programmatic efforts that have been undertaken for the Annual Report year,
with primary emphasis placed on the performance impacts that have been
achieved. The discussion should be specific to how priorities identified in the
Needs Assessment Summary are being addressed through the strategies and
activities that were described in the Five-year Action Plan Table. The
narrative discussion shall be organized in the following order and grouped by
the listed population health domains:
•

Women’s/Maternal Health

•

Perinatal/Infant’s Health
28

Figure 3. Development and Implementation of Five-Year State Action Plan

Prepare Interim Five-Year
State Action Plan Table;
Summarize Needs Assessment
Findings and Analyze FY 2014
National and State
Performance Measure Data in
State Action Plan Narrative

Refine Five-Year State Action
Update Five-Year State Action
Plan Table and Insert ESMs and Update 5-Year
Plan
Table
as needed. Present
State
Action
Update 5-Year State Action
SPMs.
Present
narrative
description,
Plan
Table.
Present
narrative
narrative
description,
by
Plan Table and Insert S&PMs.
by
performance
measure
and
by
description,
by
performance
performance measure and by
Present narrative description,
domain,
ofand
planned measure andpopulation
by population
bypopulation
performance
measure
domain, of planned
domain,
of
planned
activities
activities
for
the
coming
year
by population domain, of
activities
for the coming year and
year and
planned
activities
for the achieved for the coming
(FY 2017)
and progress
progress
achieved in reporting.
progress
achieved
in reporting
coming
year
and
progress
in reporting year (FY 2015).
year.
achieved in reporting year.

Application Year 01

Application Year 02

year.

Application Year 03
through
Application Year 05

•

Child Health

•

CSHCN

•

Adolescent Health

•

Cross-cutting or Life Course

Within the description of each population domain, states shall include the
following sections:
a. Five-year State Action Plan Table
In accordance with the relevant priorities identified through the Five-year
Needs Assessment process for each of the six population health domains,
the state shall complete a State Action Plan Table. This Table should be
considered a planning tool for states to use in developing a five-year
Action Plan that aligns the identified priority needs with the program
strategies and performance measures. It is recognized that the Five-year
Action Plan Table submitted by the state in the first Application/Annual
Report year (i.e., FY 2016/FY 2014) should be considered as an interim
plan, which will be further refined and completed in the second
Application/Annual Report year (i.e., FY 2017/FY 2015.)
The Five-year Action Plan Table should include priority needs as the
starting point with objectives, key strategies and relevant performance
measures selected for each of the six population health domains to
address the identified needs. While states are not required to use the
sample format that is presented in Figure 4 on page 32 and also in
Appendix B for their State Action Plan Table, similar information must be
provided in tabular form. A description or definition of each of the
categories to be included in the State Action Plan Table is provided below.
i

Priority Needs – Title V legislation directs states to conduct a
state-wide MCH Needs Assessment every 5 years to identify the
need for preventive and primary care services for pregnant women,
mothers, infants, children, and CSHCN. From this assessment,
states select seven to ten priorities for focused programmatic
efforts over the five-year reporting cycle.

Objectives – A statement of intention with which actual
achievement and results can be measured and compared. SMART
objectives are specific, measurable, achievable, relevant and timephased.

iii Key Strategies – Strategies are the general approaches taken to
achieve the objectives; activities are specific actions to implement
the strategies. Strategies are defined as part of the interim Fiveyear State Action Plan Table and further refined in the second
Application/Annual Report year. Program activities for
implementing the identified program strategies will be discussed
and updated annually as part of the State Action Plan narrative.
iv Performance Measures – List the NPMs, ESMs and SPMs
(beginning in interim year 02) that align to the identified strategies,
and to the NOMs.
States should update the Five-year State Action Plan Table as needed in
the interim year Applications/Annual Reports.

Figure 4. Five-Year State Action Plan Table – SAMPLE
Domains

State
Priority
Needs

Objectives

Strategies

National
Outcome
Measures*

National
Performance
Measures*

Evidence-Based
or –Informed
Strategy Measures

State
Performance
Measures

Maternal/
Women’s
Health
Perinatal/
Infant’s
Health
Child
Health
CSHCN

Adolescent/
Health
CrossCutting or
Life Course
Other

* Data to be provided by MCHB

b. State Action Plan
The State Action Plan will serve as the narrative reporting for each year’s
Application/Annual Report. For each population health domain, states will
complete each of the sections outlined below.
31

Plan for the Application Year and Annual Report
In the State Action Plan narrative, states should include a Plan for
the coming year (i.e., Application year) and an Annual Report that
provides greater detail on the information that is presented in the
Five-year State Action Plan Table. For each population domain,
states should provide necessary narrative about the previous year’s
activities, accomplishments, challenges and revisions as well as a
plan for the coming year. States should primarily describe activities
for which the Title V program provides primary leadership in
administering the activity. Activities for which the state Title V
program has a partnership role, but does not have the primary
responsibility for implementing the activity, should be discussed in
Section 2.2.
The State Action Plan narrative should include an analysis of
factors contributing to progress made, challenges that have
impeded progress, and a description of the plan for the coming year
in response to both the successes and the challenges. The
narrative discussion should focus on the six identified population
domains and be organized around the planned activities for the
Application year, interpretation of the performance data provided on
Form 10D for reporting years FY 2014 and FY 2015 and on Form
10A for reporting years FY 2016-FY 2020, analyses of the
effectiveness of the current program activities and strategies and
initiation of new efforts if adequate progress has not been achieved.
In years that states are reporting on ESMs, the Action Plan should
address how the established ESMs have contributed to progress in
achieving the performance targets that were set for the NPMs.
For each population health domain, states will discuss how they are
addressing the related legislative requirements outlined in Sections
501(a)(1) and 505. States should describe critical partnerships with
other MCHB-supported programs, such as the MIECHV, Training
Programs and Healthy Start programs.

ii Other Programmatic Activities
If there are investments of federal MCH Block Grant funds for a
population health domain that do not directly align with the State
priorities that were identified through the Five-year Needs
Assessment, these investments should be described in this section.
The state should provide a rationale for these investments,
including an explanation of their role in supporting the state’s
overall system of care for the MCH population. For example, if the
state uses MCH Block Grant funds to support newborn screening,
32

but newborn screening does not fit within the state priorities for
perinatal/infant health that were identified through the Five-year
Needs Assessment, the newborn screening investment should be
described in this section. The state should provide an explanation
for the role and importance of this work to the system of care
provided by Title V in supporting perinatal/infant health.
If applicable, states should describe in this section Title V program
activities that are included in the State Plan but do not fall directly
within any of the population domains (e.g., development and/or
enhancement of MCH data infrastructure; and priorities related to
underserved areas/workforce shortages.) States should also
describe critical partnerships to advance maternal and child health,
including partnerships with other MCHB-supported programs (e.g.,
MIECHV, MCH Training Programs, Healthy Start programs and
MCHB-supported Collaborative for Innovation and Improvement
Networks (CoIINs) in which the State has been involved.)
2. MCH Workforce Development and Capacity
States should use this section to describe actions taken to improve the
capacity of the MCH workforce in the state, including changes in noted
strengths and needs. The state’s description of the MCH workforce should
identify any changes to the workforce funded by Title V, as well as the current
capacity of the workforce within the state to address the needs of the MCH
population. States should also describe critical workforce development and
training needs of state Title V staff.
3. Family/Consumer Partnership
Building the capacity of women, children and youth, including those with
special health care needs, and families to partner in decision making with
Title V programs at the federal, state and community levels is a critical
strategy in helping states to achieve national outcomes. States should
include a description of the state’s efforts and initiatives to build and
strengthen family/consumer partnerships for all MCH populations, to assure
cultural and linguistic competence and to promote health equity in the work of
the state Title V program. For purposes of the Title V MCH Services Block
Grant program and this guidance, as previously noted, family/consumer
partnership is defined as: “The intentional practice of working with families for
the ultimate goal of positive outcomes in all areas through the life
course. Family engagement reflects a belief in the value of the family
leadership at all levels from an individual, community and policy level.” States
will describe efforts to support Family/Consumer Partnerships, including
family/consumer engagement in the following strategies and activities:
33

•

Advisory Committees;

•

Strategic and Program Planning;

•

Quality Improvement;

•

Workforce Development;

•

Block Grant Development and Review;

•

Materials Development; and

•

Advocacy.

4. Health Reform
States should describe the actions taken and the evolving role that state
Title V agencies have in supporting health reform efforts. In addition, states
should describe ways in which the Title V MCH Services Block Grant
Program is providing services that help to advance the implementation of the
ACA, as appropriate. For example, states may discuss roles in supporting
the health insurance marketplace and consumer assistance, collaboration
with accountable care organizations (ACOs) or similar entities, or any roles in
working with hospital organizations on community health needs assessments.
If relevant, states should also describe ways in which the Title V MCH Block
Grant Program is providing gap-filling health care services to MCH
populations, as noted on Form 3b. Efforts to assure cultural and linguistic
competence and to promote health equity through the state’s health care
reform efforts should also be discussed, if relevant.
5. Emerging Issues
States should describe any emerging issues that were not addressed as part
of the State Action Plan narrative, but they are significant for understanding
current or projected strengths and needs of the MCH population.
6. Public Input [Section 505a]
In its Application/Annual Report, the state shall describe its process for
making the Application/Annual Report available to the public for comment
during its development and after its transmittal. This discussion should
include efforts by the state to solicit public comments during the development
of the Application/Annual Report. The number and nature of the comments
received and how they were addressed in the final Application/Annual Report
should be noted for each year.
34

The state should clearly identify specific activities for engaging families and
other stakeholders prior to, during and after the Application process. Such
activities may include:
•

Public Hearings

•

Advisory Council Review

•

Web Posting

•

Social Media

•

Public Notices

•

Other Use of Media

•

Outreach to Specific Stakeholders (e.g., MCH Training Grantees)

Further information regarding public input can be found by opening the
section titled “Technical Assistance to States” on the MCHB website,
http://www.mchb.hrsa.gov. See the resource document entitled “Facilitating
Public Comment on the Title V MCH Block Grant.”
7. Technical Assistance
States should give consideration to potential areas of needed technical
assistance as they complete their five-year Action Plan. In accordance with
the responsibilities prescribed in Section 509 of the Title V legislation, the
MCHB works with the states and jurisdictions to identify the types of technical
support and resources that are needed. To receive MCHB-supported
technical assistance, the state must complete and submit a Technical
Assistance Request Form. This form is available upon request from the
MCHB Project Officer.

III.

BUDGET NARRATIVE
A. Expenditures
The state should maintain budget documentation for Block Grant funding/
expenditures for reporting, consistent with Section 505(a), and consistent with
Section 506(a)(1) for audit. Significant variations (i.e., greater than 10%) in the
expenditure data that are reported by the state on Forms 2 and 3, as compared
to previous years’ reporting, should be discussed. In this five-year reporting
cycle, states will report federal and non-federal MCH Block Grant expenditures
separately. Expenditures for Direct Services, as defined in the Glossary in
Appendix H, should be broken out by each of the three legislatively-defined MCH
35

populations on Form 3b. Such Direct Service expenditures should be further
clarified by listing the amount expended for each specific service type that is
listed in Section 4 on Form3b. It should be noted that Title V is the payer of last
resort, by legislation, and the services listed by the state reflect services that
were not covered or reimbursed through another provider.
B. Budget
The budget narrative is intended to reflect how federal support complements the
State’s total effort and what amounts will be spent in compliance with the 30% 30% requirements. It should further describe how other spending categories
(administration and maintenance of effort) of Title V funds, as shown on Form 2,
are maintained. The state should describe how satisfaction of the required
match is achieved. Adequate discussion should be provided for significant
year-to-year variations in budget or expenditures. In this five-year reporting
cycle, the state will submit separate budget estimates for federal and non-federal
MCH Block Grant funds.
In this section, the state shall also briefly describe the maintenance of effort
from 1989 [Section 505(a)(4)]; any continuation funding for special projects
[Section 505(a)(5)(C)(i)]; or special consolidated projects noted in
Section 501(b)(1) [Section 505(a)(5)(B)].
The budget justification should further describe sources of other federal MCH
dollars, state matching funds, including non-federal dollars that meet at least the
legislatively-required minimum match for Title V, and other state funds used by
the agency in its Title V program. Significant variations in the budgeted amounts
reported by the state on Forms 2 and 3, as compared to previous years’
reporting, should be discussed.
States are reminded that any amount payable to a state under this title from
allotments for a fiscal year, which remains unobligated at the end of such year,
shall remain available to such state for obligation during the next fiscal year. No
payment may be made to a state under this title from allotments for a fiscal year
for expenditures made after the following fiscal year [Section 503(b)].

PART THREE: REPORTING FORMS
Form 1

Application for Federal Assistance (Standard Form - 424)

Form 2

MCH Budget/Expenditure Details (Federal and State) for FY_

Form 3a

Federal and State Budget and Expenditure Details by Types of Individuals
Served

Form 3b

Federal and State Budget and Expenditure Details by Types of Services

Form 4

Number and Percentage of Newborns and Others Screened, Cases
Confirmed and Treated

Form 5a

Unduplicated Count of Individuals Served under Title V

Form 5b

Total Recipient Count of Individuals Served by Title V

Form 6

Deliveries and Infants Served by Title V and Entitled to Benefits Under
Title XIX

Form 7

State MCH Toll-Free Telephone Line and Other Appropriate Methods Data

Form 8

State MCH and CSHCN Directors Contact Information

Form 9

List of MCH Priority Needs

Form 10A Tracking Measures for NOMs, NPMs, SPMs and ESMs
Form 10B

State Performance/Outcome Measure Detail Sheet

Form 10C

Evidence-Based or –Informed Strategy Measure (ESM) Detail Sheet

Form 10D

Tracking Performance Measures (FY 2011 - FY 2015)

Form 11

Other State Data #01 - #03

Instructions for Application for Federal Assistance (SF-424)
This is a standard form required for use as a cover sheet for submission of pre-applications and applications and related
information under discretionary programs. Some of the items are required and some are optional at the discretion of
the applicant or the federal agency (agency). Required fields on the form are identified with an asterisk (*) and are also
specified as "Required" in the instructions below. In addition to these instructions, applicants must consult agency
instructions to determine other specific requirements.
Item
Field Name
Type of Submission:
1.

Information
(Required) Select one type of submission in accordance with agency
instructions.
Pre-application
Application
Changed/Corrected Application - Check if this submission is to change
or correct a previously submitted application. Unless requested by the
agency, applicants may not use this form to submit changes after the
closing date.
(Required) Select one type of application in accordance with agency
instructions.
•
•
•

Type of Application:

New - An application that is being submitted to an agency for the first
time.
• Continuation - An extension for an additional funding/budget period
for a project with a projected completion date. This can include
renewals.
• Revision - Any change in the federal government's financial obligation
or contingent liability from an existing obligation. If a revision, enter
the appropriate letter(s). More than one may be selected. If "Other" is
selected, please specify in text box provided.
A. Increase Award
B. Decrease Award
C. Increase Duration
D. Decrease Duration
E. Other (specify)
Leave this field blank. This date will be assigned by the Federal agency.
Enter the entity identifier assigned buy the Federal agency, if any, or the
applicant's control number if applicable.
Enter the number assigned to your organization by the federal agency, if any.
For new applications leave blank. For a continuation or revision to an existing
award, enter the previously assigned federal award identifier number. If a
changed/corrected application, enter the federal identifier in accordance with
agency instructions.
Leave this field blank. This date will be assigned by the state, if applicable.
Leave this field blank. This identifier will be assigned by the state, if applicable.
Enter the following in accordance with agency instructions:
(Required) Enter the legal name of applicant that will undertake the
assistance activity. This is the organization that has registered with the Central
Contractor Registry (CCR). Information on registering with CCR may be
obtained by visiting www.Grants.gov.
•

3.
4.

Date Received:
Applicant Identifier:

5a.
5b.

Federal Entity Identifier:
Federal Award Identifier:

6.
7.
8.

Date Received by State:
State Application Identifier:
Applicant Information:
a. Legal Name:

b. Employer/Taxpayer Number
(EIN/TIN):
c. Organizational DUNS:
d. Address:
e. Organizational Unit:

f. Name and contact
information of person to be
contacted on matters involving
this application:
Type of Applicant: (Required)
Select up to three applicant
type(s) in accordance with
agency instructions.

10.

Name Of Federal Agency:

11.

Catalog Of Federal Domestic
Assistance Number/Title:

12.

Funding Opportunity
Number/Title:

13.

Competition Identification
Number/Title:
Areas Affected By Project:

14.

(Required) Enter the employer or taxpayer identification number (EIN or TIN)
as assigned by the Internal Revenue Service. If your organization is not in the
US, enter 44-4444444.
(Required) Enter the organization's DUNS or DUNS+4 number received from
Dun and Bradstreet. Information on obtaining a DUNS number may be
obtained by visiting www.Grants.gov.
Enter address: Street 1 (Required); city (Required); County/Parish, State
(Required if country is US), Province, Country (Required), 9-digit zip/postal
code (Required if country US).
Enter the name of the primary organizational unit, department or division
that will undertake the assistance activity.
Enter the first and last name (Required); prefix, middle name, suffix, title.
Enter organizational affiliation if affiliated with an organization other than
that in 7.a. Telephone number and email (Required); fax number.
A. State Government
B. County Government
C. City or Township Government
D. Special District Government
E. Regional Organization
F. U.S. Territory or Possession
G. Independent School District
H. Public/State Controlled Institution of Higher Education
I. Indian/Native American Tribal Government (Federally Recognized)
J. Indian/Native American Tribal Government (Other than Federally
Recognized)
K. Indian/Native American Tribally Designated Organization
L. Public/Indian Housing
M. Nonprofit
N. Private Institution of Higher Education
O. Individual
P. For-Profit Organization (Other than Small Business)
Q. Small Business
R. Hispanic-serving Institution
S. Historically Black Colleges and Universities (HBCUs)
T. Tribally Controlled Colleges and Universities (TCCUs)
U. Alaska Native and Native Hawaiian Serving Institutions
V. Non-US Entity
W. Other (specify)
(Required) Enter the name of the federal agency from which assistance is
being requested with this application.
Enter the Catalog of Federal Domestic Assistance number and title of the
program under which assistance is requested, as found in the program
announcement, if applicable.
(Required) Enter the Funding Opportunity Number and title of the
opportunity under which assistance is requested, as found in the program
announcement.
Enter the competition identification number and title of the competition
under which assistance is requested, if applicable.
This data element is intended for use only by programs for which the area(s)
42

15.

Descriptive Title of Applicant's
Project:

16.

Congressional Districts Of:

17.

Proposed Project Start and End
Dates:
Estimated Funding:

18.

19.

Is Application Subject to Review
by State Under Executive Order
12372 Process?

20.

Is the Applicant Delinquent on
any Federal Debt?

21.

Authorized Representative:

affected are likely to be different than the place(s) of performance reported
on the SF-424 Project/Performance Site Location(s) Form. Add attachment to
enter additional areas, if needed.
(Required) Enter a brief descriptive title of the project. If appropriate, attach a
map showing project location (e.g., construction or real property projects).
For pre-applications, attach a summary description of the project.
15a. (Required) Enter the applicant's congressional district. 15b. Enter all
district(s) affected by the program or project. Enter in the format: 2 characters
state abbreviation - 3 characters district number, e.g., CA-005 for California
5th district, CA-012 for California 12 district, NC-103 for North Carolina's 103
district. If all congressional districts in a state are affected, enter "all" for the
district number, e.g., MD-all for all congressional districts in Maryland. If
nationwide, i.e. all districts within all states are affected, enter US-all. If the
program/project is outside the US, enter 00-000. This optional data element is
intended for use only by programs for which the area(s) affected are likely to
be different than place(s) of performance reported on the SF-424
Project/Performance Site Location(s) Form. Attach an additional list of
program/project congressional districts, if needed.
(Required) Enter the proposed start date and end date of the project.
(Required) Enter the amount requested, or to be contributed during the first
funding/budget period by each contributor. Value of in-kind contributions
should be included on appropriate lines, as applicable. If the action will result
in a dollar change to an existing award, indicate only the amount of the
change. For decreases, enclose the amounts in parentheses.
(Required) Applicants should contact the State Single Point of Contact (SPOC)
for Federal Executive Order 12372 to determine whether the application is
subject to the State intergovernmental review process. Select the appropriate
box. If "a." is selected, enter the date the application was submitted to the
State.
(Required) Select the appropriate box. This question applies to the applicant
organization, not the person who signs as the authorized representative.
Categories of federal debt include; but, may not be limited to: delinquent
audit disallowances, loans and taxes. If yes, include an explanation in an
attachment.
To be signed and dated by the authorized representative of the applicant
organization. Enter the first and last name (Required); prefix, middle name,
suffix. Enter title, telephone number, email (Required); and fax number. A
copy of the governing body's authorization for you to sign this application as
the official representative must be on file in the applicant's office. (Certain
federal agencies may require that this authorization be submitted as part of
the application.)

FORM 2
MCH BUDGET/EXPENDITURE DETAILS
[SECTIONS 504(d) AND 505(a)(3),(4)]
FY__ Application
Budgeted

FY__ Annual Report
Expended

$___________

A. Preventive and Primary Care for Children:

$___________ (__%)

B. Children with Special Health Care Needs:

$___________ (__%)

C. Title V Administrative Costs:

$___________ (__%)

2. UNOBLIGATED BALANCE (Item 18b of SF- 424)

$___________

3. STATE MCH FUNDS (Item 18c of SF-424)

$___________

4. LOCAL MCH FUNDS (Item 18d of SF-424)

$___________

5. OTHER FUNDS (Item 18e of the SF-424)

$___________

6. PROGRAM INCOME (Item 18f of SF-424)

$___________

7. TOTAL STATE MATCH (Lines 3 through 6)
$___________
A. Enter your State's FY 1989
Maintenance of Effort Amount $____________________

$___________

1. FEDERAL ALLOCATION
(Referenced items on the Application Face
Sheet [SF-424] apply only to the Application Year)
Of the Federal Allocation, the amount earmarked for:

8. FEDERAL-STATE TITLE V BLOCK GRANT PARTNERSHIP SUBTOTAL
(Total lines 1 through 6. Same as line 18g of SF-424)

$___________

9. OTHER FEDERAL FUNDS [Select Appropriate Funding Sources from the Drop-Down Box]
(Report only funds under the control of the Title V Program Administrator)
Select the Appropriate Federal Department
Select the Appropriate Federal Agency.

$___________

Select the Appropriate Federal Grant Program.

$___________

10. OTHER FEDERAL FUNDS (SUBTOTAL of all funds under item 9)

$___________

11. STATE MCH BUDGET/EXPENDITURE GRAND TOTAL
(Partnership Subtotal + Other Federal MCH Funds Subtotal)

$__________

$___________

INSTRUCTIONS FOR COMPLETION OF FORM 2
MCH BUDGET/EXPENDITURE DETAILS FOR FY ____
Title V Citation: Section 504(d) states: “Of the amounts paid to a State...not more than 10 percent may be
used for administering the funds paid....” In order to be entitled to payments for allotments under Title V,
Section 505(a)(3) provides that the State will use: “(A) at least 30 percent of such payment amounts for
preventive and primary care services for children, and (B) at least 30 percent of such payment amounts for
services to children with special health care needs.” Section 505(a)(4) provides that a State receiving funds for
maternal and child health services “...shall maintain the level of funds being provided solely by such State for
maternal and child health programs at a level at least equal to the level that such State provided for such
programs in fiscal year 1989....”
Instructions: This form provides details of the State’s MCH budget and the fulfillment of certain spending
requirements under Title V for a given year. A Glossary that contains terms applicable to this form is provided
in Appendix H of the Supporting Documents, which accompany the Application/Annual Report Guidance.
LINE NUMBER
1

INSTRUCTIONS
Enter the amount of the Federal Title V allocation for both the budget (Application) and
expenditure (Annual Report) years.

Enter the amount of the Federal allotment for preventive and primary care for children. The
percentage of the total (Line 1) that this amount represents will be calculated by the Title V
Information System (TVIS).

Enter the amount of the Federal allotment for children with special health care needs. The
percentage of the total (Line 1) that this amount represents will be calculated by the Title V
Information System (TVIS).

Enter the amount of the Federal allotment for the administration of the allotment. The
percentage of the total (Line 1) that this amount represents will be calculated by the Title V
Information System (TVIS).

Enter the amount of carryover from the previous fiscal year’s MCH Block Grant Allocation (the
unobligated balance). Any unspent funds for the expenditure year should also be noted.

Enter the amount of your State total funds for the Title V allocation (match).

Enter the amount of total MCH dedicated matching funds garnered from local jurisdictions
within your State.

Enter the total of MCH funds available from other sources such as foundations.

Enter the amount of MCH program income funds collected by your State’s MCH agencies
from insurance payments, MEDICAID, HMO’s, etc.

The TVIS will calculate the sum total of Lines 3, 4, 5, and 6 for the total of your State match
and overmatch.

Enter your State’s FY 1989 Maintenance of Effort amount.

The TVIS will calculate the total for Lines 1, 2, and 7. This amount is the “Federal-State Title V
Block Grant “Partnership.”

Enter Federal funds other than the Title V Block Grant that are directly under the control of
the Title V Program Administrator.

The TVIS will calculate the sum of all lines in item 9.

The TVIS will calculate the sum of Lines 8 and 10. This amount is the total of all MCH funds
administered by your State’s MCH program.
45

FORM 3a
BUDGET AND EXPENDITURE DETAILS BY TYPES OF INDIVIDUALS SERVED (IA and IB)
[Section 506(a)(2)(A)(iv), Section 505(a)(2)(A-B) and Section 506(a)(1)(A-D)]
I. TYPES OF INDIVIDUALS SERVED

FY ____ Application

IA. Federal MCH
Block Grant

FY ____ Annual Report

Budgeted

Expended

Pregnant Women

$_______

Infants < 1 year

$_______

Children 1-22 years

$_______

CSHCN

$_______

All Others

$_______

Federal TOTAL

$_______

FY ____ Application
IB. Non-Federal MCH
Block Grant

FY ____ Annual Report

Budgeted

Expended

Pregnant Women

$_______

Infants < 1 year

$_______

Children 1-22 years

$_______

CSHCN

$_______

All Others

$_______

Non-Federal TOTAL

$_______

FY ____ Application
Budgeted
FEDERAL-STATE MCH BLOCK GRANT
PARTNERSHIP TOTAL

$_______

FY ____ Annual Report
Expended
$_______

INSTRUCTIONS FOR COMPLETION OF FORM 3a
BUDGET/EXPENDITURE DETAILS BY TYPES OF INDIVIDUALS SERVED
Title V Citation: Section 506(a)(2)(A)(iv) requires that each State submit an annual report of its activities under
its Title V program. Among the items required to be reported are, “...the amount spent under this title...by
class of individuals served.”
Instructions: Complete all required data cells. If an actual number is not available, the State should provide an
estimate. All estimates should be explained in a footnote. A Glossary that contains terms applicable to this
form is provided in Appendix H of the Supporting Documents, which accompany the Application/Annual
Report Guidance.
LINE NUMBER
I.A.1 – I.A.5

INSTRUCTIONS
Enter the budgeted (Application year) and expended (Annual Report year) amounts for the
Federal MCH allocation.

I.A.1
Federal TOTAL

The TVIS will calculate the sum of the amounts entered for Lines I.A.1 through I.A.5.

I.B.1 - I.B.5

Enter the budgeted (Application year) and expended (Annual Report year) amounts for the
non-Federal Title V program funds.

I.B.1
Non-Federal
TOTAL

The TVIS will calculate the sum of the amounts entered for Lines I.B.1 through I.B.5.

Federal-State
MCH Block
Grant
Partnership
TOTAL

The TVIS will calculate the sum of the amounts entered for the I.A.1 TOTAL and I.B.1 TOTAL.

FORM 3b
BUDGET AND EXPENDITURE DETAILS BY TYPES OF SERVICES (IIA and IIB)
[Section 506(a)(2)(A)(iv), Section 505(a)(2)(A-B) and Section 506(a)(1)(A-D)]
II. TYPES OF INDIVIDUALS SERVICES
FY ____ Application
IIA. Federal MCH Block Grant

FY ____ Annual Report

Budgeted

Expended

Direct Services

$_______

a. Preventive and primary care
services for all pregnant
women, mothers, and infants
up to age one

$_______

b. Preventive and primary care
services for children

$_______

c. Services for CSHCN

$_______

Enabling Services

$_______

Public Health Services and
Systems

$_______

4. Check below the specific types of Federally-supported “Direct Services”, as reported in II.A.1. Provide the
total amount of Federal MCH Block Grant funds expended for each type of reported service.
1.
2.
3.
4.
5.
6.
7.

Pharmacy
Physician/Office Charges
Hospital Charges (Includes Inpatient and Outpatient Services)
Dental Care (Does Not Include Orthodontic Services)
Durable Medical Equipment and Supplies
Select Service Type
Laboratory Services
Other _____________________

FY ____ Application
Budgeted
FEDERAL TOTAL

$_______

_____(Yes)
_____(Yes)
_____(Yes)
_____(Yes)
_____(Yes)
_____(Yes)
_____(Yes)

($)_____
($)_____
($) _____
($)_____
($)_____
($)_____
($)_____

FY ____ Annual Report
Expended
$_______

FY ____ Annual Report

Budgeted

Expended

Direct Services

$_______

a. Preventive and primary care
services for all pregnant
women, mothers, and infants
up to age one

$_______

b. Preventive and primary care
services for children

$_______

c. Services for CSHCN

$_______

Enabling Services

$_______

Public Health Services and
Systems

$_______

Pharmacy
Physician Office Services
Hospital Charges (Includes Inpatient and Outpatient Services)
Dental Care (Does Not Include Orthodontic Services)
Durable Medical Equipment and Supplies
Select Service Type
Laboratory Services
Other _____________________

FY ____ Application
Budgeted
NON-FEDERAL TOTAL

$_______

_____(Yes)
_____(Yes)
_____(Yes)
_____(Yes)
_____(Yes)
_____(Yes)
_____(Yes)

($) _____
($) _____
($) _____
($) _____
($) _____
($) _____
($) _____

FY ____ Annual Report
Expended
$_______

INSTRUCTIONS FOR THE COMPLETION OF FORM 3b
STATE TITLE V PROGRAM BUDGET AND EXPENDITURES BY TYPES OF SERVICES
Title V Citation: Section 505(a)(2) states, in part, “In order to be entitled to payments for allotments...a State
must prepare and transmit to the Secretary an application...that includes for each fiscal year (A) a plan for
meeting the needs identified by the state-wide needs assessment...and (B) a description of how funds allotted
to the State...will be used for the provision and coordination of services to carry out such a plan that shall
include - [(B)(iii)] an identification of the types of services to be provided....”
Section 506(a)(1) states, “Each State shall prepare and submit to the Secretary annual reports on its activities
under this title. Among the items required to be reported (Section 506(a)(2)(A)(i-iv)) are, “...the number of
individuals served by the State under this title (by class of individuals), the proportion of each class of such
individuals which has health coverage, the types (as defined by the Secretary) of services provided under this
title to individuals within each such class and the amounts spent under this title on each type of services, by
class of individuals served.”
Instructions: Complete all required data cells. If an actual number is not available, the State should make an
estimate. All estimates should be explained in a footnote. A Glossary that contains terms applicable to this
form is provided in Appendix H of the Supporting Documents, which accompany the Application/Annual
Report Guidance.
LINE NUMBER
II.A.1

INSTRUCTIONS
Of the Federal MCH allocation, enter the Total budgeted (Application year) and expended
(Annual Report year) amounts for Direct Services.

II.A.1.a –
II.A.1c

Of the Federal MCH allocation, enter the Total budgeted (Application year) and expended
(Annual Report year) amounts for Direct Services by types of services and MCH population
group.

II.A.2

Of the Federal MCH allocation, enter the Total budgeted (Application year) and expended
(Annual Report year) amounts for Enabling Services.

II.A.3

Of the Federal MCH allocation, enter the Total budgeted (Application year) and expended
(Annual Report year) amounts for Public Health Services and Systems.

II.A.4

Using the list of services provided in the drop down box, select any direct service that the
State supports through its Federal Title V funds. Check “Yes” and enter the amount of
Federal funds expended for this service. Additional services may be included by checking
“Other” and entering the type of service that is supported.

Federal
TOTAL

The TVIS will calculate the sum of the Federal amounts entered for Line II.A.1, Line II.A.2 and
Line II.A.3.

INSTRUCTIONS FOR THE COMPLETION OF FORM 3b (Continued)
STATE TITLE V PROGRAM BUDGET AND EXPENDITURES BY TYPES OF SERVICES
LINE NUMBER
II.B.1
II.B.1.a –
II.B.1c

INSTRUCTIONS
Of the non-Federal MCH allocation, enter the Total budgeted (Application year) and
expended (Annual Report year) amounts for Direct Services.
Of the non-Federal MCH allocation, enter the Total budgeted (Application year) and
expended (Annual Report year) amounts for Direct Services by types of services and MCH
population group.

II.B.2

Of the non-Federal MCH allocation, enter the Total budgeted (Application year) and
expended (Annual Report year) amounts for Enabling Services.

II.B.3

Of the non-Federal MCH allocation, enter the Total budgeted (Application year) and
expended (Annual Report year) amounts for Public Health Services and Systems.

II.B.4

Using the list of services provided in the drop down box, select any direct service that the
State supports through its non-Federal Title V funds. Check “Yes” and enter the amount of
non-Federal funds expended for this service. Additional services may be included by
checking “Other” and entering the type of service that is supported.

Non-Federal
TOTAL

The TVIS will calculate the sum of the non-Federal amounts entered for Line II.B.1, Line II.B.2
and Line II.B.3.

FORM 4
NUMBER AND PERCENTAGE OF NEWBORNS AND OTHERS SCREENED,
CASES CONFIRMED AND TREATED
[SECTION 506(a)(2)(B)(iii)]
Total Births by Occurrence: _____________________
Type of Screening Tests

(A)
Number
Receiving at
Least One
Screen( 1)
No.

Reporting Year: _____________________

(B)
Number
Presumptive
Positive
Screens

(D)
Number
Referred for
Treatment ( 3)
No.

1. Newborn Screening
Program
Select all applicable
screening tests from the
core and secondary
conditions in the
Recommended Uniform
Screening Panel (RUSP)
using the drop down list.

2. Other Newborn Screening
Tests (Specify by Name)
1. Newborn Hearing
2. ______ ______
3. ____ ________
3. Screening Programs for
Older Children & Women
1) ______ ______
2) ____ ________
3) ______ ______
4. Long-term follow-up (follow-up beyond referring an infant for treatment) varies based on State policy and
practice. Please describe your State’s practice for monitoring infants with confirmed diagnoses, including what
information is obtained and for how long infants are monitored.

Use occurrent births as denominator.
Report only those from resident births.
3
Use number of confirmed cases as denominator.
2

INSTRUCTIONS FOR THE COMPLETION OF FORM 4
NUMBER AND PERCENTAGE OF NEWBORNS AND OTHERS SCREENED,
CASES CONFIRMED, AND TREATED
Title V Citation: Section 506(a)(1) requires each State to submit an annual report on its activities under Title
V. Included in this requirement is the following: (2)(B)(iii) “... information on such other indicators of maternal,
infant, and child health care status as the Secretary may specify.”
Instructions: Complete all required data cells. If an actual number is not available, make an estimate. All
estimates should be explained in a footnote. A Glossary that contains terms applicable to this Form is provided
in Appendix H of the Supporting Documents, which accompany the Application/Annual Report Guidance.
LINE NUMBER
Lines: “Total
Births by
Occurrence”
and “Reporting
Year”

INSTRUCTIONS
Enter the total number of occurrent births for the State and the year for which the data
apply. Total births by occurrence are to be defined as “all births that occur in the State
regardless of residency.” States should use the number submitted by the Vital Records
program to the National Center for Health Statistics. The reporting year is to be defined as
calendar year, January 1 – December 31. Please note that the “Total Births...” figure is
related to the “Total infants < 1 year of age” row in Form 5a and 5b, and the “TOTAL
INFANTS IN STATE” row in section I of Form 6. While these figures are not expected to
match, there should be a fairly close relationship between them.

1. Newborn
Screening
Program

All States now require screening for at least 29 out of the 31 conditions on the
Recommended Uniform Screening Panel (RUSP). All tests done during the reporting year
should be listed along with the number of infants screened and followed.
Using the drop down box, States should select the names of any screening tests specific to
its newborn population and complete Columns A through D for each of the selected
conditions.
a. In column A, for all screening tests listed, enter the number and percentage of occurrent
births that received one of the tests indicated. Percentage is to be based on occurrent
births receiving one test out of the total listed at the top of the form.
b. In column B, enter the number of presumptive positive screens.
c. In column C, enter the number of confirmed cases discovered. Use only those from
resident births.
d. In column D, enter the number and percent of those confirmed cases that were referred
for treatment. Use confirmed cases as the denominator.

2. Other
Newborn
Screening
Tests

States should enter additional screening tests specific to its newborn population, such as
newborn hearing screening or screenings for other conditions that are not listed in the RUSP.
Complete Columns A through D for each of the listed screenings.

3. Screening
Programs
for Older
Children
and
Women

Using the drop down box, States should list any screening tests that are specific to older
children and women. Complete Columns A through D for each of the listed screenings. Note
that the % (percentage) portion of Column A is not to be completed since the denominator
of Total Births by Occurrence does not apply. Enter the specific names of any other screens
that are not listed and complete Columns A through D.

FORM 5a
UNDUPLICATED COUNT OF INDIVIDUALS SERVED UNDER TITLE V
(By Class of Individuals and Percent of Health Coverage)
[Section 506(a)(2)(A)(i-ii)]

Reporting Year__________
Type of Individuals Served
1.

Pregnant Women

Infants < 1 year of age

Children 1 to 22 years of age

Children with Special Health
Care Needs

Others

(A)
TITLE V
Total
Served

(B)

(C)

Title XIX
%

(D)

TOTAL
FORM 5b
TOTAL RECIPIENT COUNT OF INDIVIDUALS SERVED BY TITLE V
(By Class of Individuals)
[Section 506(a)(2)(A)(i-ii)]

Reporting Year ________
Type of Individuals Served by Title V

Total Served

1. Pregnant Women

_______

2. Infants < 1 year of age

_______

3. Children 1 to 22 years of age

_______

4. Children with Special Health Care Needs

_______

5. Others

_______

TOTAL

_______

(E)

(F)

PRIMARY SOURCE OF COVERAGE
Title XXI
Private/Other
None
Unknown
%
%
%
%

INSTRUCTIONS FOR THE COMPLETION OF FORM 5a and Form 5b
UNDUPLICATED COUNT OF INDIVIDUALS SERVED UNDER TITLE V
AND
TOTAL RECIPIENT COUNT OF INDIVIDUALS SERVED BY TITLE V
[Section 506(a)(2)(A)(i-ii)]
Title V Citation: Section 506(a)(1) requires each State to submit an annual report on its activities under Title V.
Included in this requirement is the following: “(2) Each annual report...shall include the following information:
(A)(i) The number of individuals served by the State under the title (by class of individuals)…(ii) The proportion
of each class of such individuals which has health coverage.”
Instructions: Complete all required data cells. If an actual number is not available, the State should make an
estimate. All estimates should be explained in a footnote. A Glossary that contains terms applicable to this
form is provided in Appendix H of the Supporting Documents, which accompany the Application/Annual
Report Guidance.
The purpose of Form 5a and Form 5b is two-fold.
Form 5a, Unduplicated Count of Individuals Served Under Title V, enables the State to track and report on the
number of individuals who were served by the Title V program within the top level of the MCH Pyramid.
Form 5b, Total Recipient Count of Individuals Served by Title V, enables the State to track and report on the
number of individuals who received a Title V service within the top two service levels of the MCH Pyramid.
Since States began to report Title V program participant data in the 1990’s, MCH programs have seen a shift in
the delivery of services from direct primary care MCH services to public health and preventive services within
well-coordinated and comprehensive systems of care that are designed for the MCH population. This shift has
resulted in a need for more complete reporting of individuals served by Title V, which goes beyond an
unduplicated count of individuals served (often derived from reimbursement data for MCH direct services).
It is recognized that precisely quantifying the number of individuals reached through population-based services
(e.g., preventive health screenings, outreach, immunizations and health education) is difficult, and informed
estimates are often required. Relying only on reimbursement data for the individual services supported by
Title V, however, can lead to serious underestimates of the number of individuals in a State who actually
received and benefitted from a Title V-supported service. For this reason, Form 5b was developed to better
capture the full “reach” of the State’s Title V program in serving its MCH population.

1 -5,
Columns B - F
Form 5b

INSTRUCTIONS

States should report an unduplicated number of the individuals served by Title V in each of
the listed MCH population groups.
Enter the reporting year for which the data apply at the top of Form 5a on the designated
line.
Enter the best possible estimate for an unduplicated count of individuals served by the
Title V program across the top level (i.e., Direct Services) of the MCH Pyramid, regardless of
the primary source of coverage. These services would include all individuals served by total
dollars reported on line 8 of Form 2. Please note that the figure in the “Title V Total Served”
column of the “Infants < 1 year of age” row is related to the “Total Births by Occurrence” line
in Form 4.
Report the percentages of individuals who were served by Title V within the listed classes
and their primary source of coverage. These counts may be estimates. If individuals are
covered by more than one source, the primary source of coverage should be reported.
States should report an estimate for the total number of individuals who received a Title V
service in each of the listed MCH population groups. This estimate should include the public
health services that are described in the top two levels (i.e., Direct Services and Enabling
Services) of the MCH Pyramid and include individuals who receive services supported by
other Federal programs (e.g., Title X) which are under the control of the Title V
Administrator, as reported on Line 9 of Form 2.
It is recognized that some individuals will receive services under multiple Title V-supported
programs (e.g., local clinics and school-based screenings) and, thus, may be counted more
than once. The purpose of this form is to better capture the breadth of the State’s Title V
program and its reach in serving the MCH population. Derivation of estimates should be
properly explained in a data note, as needed. For example, if a State is implementing a
media campaign under Title V that targets adolescents, estimates of the number of
adolescents reached may be derived from sample data or market surveys.

Reporting Year
1-5

Enter the reporting year for which the data apply at the top of Form 5b on the designated
line.
Enter the best possible estimate for a total count of individuals served by the Title V program
across the top two levels of the MCH Pyramid. These services would include all individuals
served by the total dollars reported on line 8 of Form 2. Please note that the figure in the
“Title V Total Served” column of the “Infants < 1 year of age” row is related to the “Total
Births by Occurrence” line in Form 4.

FORM 6
DELIVERIES AND INFANTS SERVED BY TITLE V
AND ENTITLED TO BENEFITS UNDER TITLE XIX
(By Race and Ethnicity)

[Section 506(a)(2)(C-D)]
I. UNDUPLICATED COUNT BY RACE

(A)
TOTAL
ALL
RACES

(B)
White

(B)
TOTAL
HISPANIC
OR LATINO

(D)
American
Indian or
Native
Alaskan

1. TOTAL DELIVERIES
IN STATE
TITLE V SERVED
ELIGIBLE FOR
TITLE XIX
2. TOTAL INFANTS
IN STATE
TITLE V SERVED
ELIGIBLE FOR
TITLE XIX
II. UNDUPLICATED COUNT BY ETHNICITY
(A)
TOTAL
NOT
HISPANIC
OR LATINO
1. TOTAL DELIVERIES
IN STATE
TITLE V SERVED
ELIGIBLE FOR
TITLE XIX
2. TOTAL INFANTS
IN STATE
TITLE V SERVED
ELIGIBLE FOR
TITLE XIX

(E)
Asian

Reporting Year: ________
(F)
(G)
(H)
Native
More
Other &
Hawaiian Than One Unknown
or Other
Race
Pacific
Reported
Islander

INSTRUCTIONS FOR THE COMPLETION OF FORM 6
DELIVERIES AND INFANTS SERVED BY TITLE V
AND ENTITLED TO BENEFITS UNDER TITLE XIX
Title V Citation: Section 506 (a)(1) requires each State to submit an Annual Report on its activities under
Title V. Included in this requirement is the following:
(2)(C) “Information (by racial and ethnic group) on-(i) the number of deliveries in the State in the year, and
(ii) the number of such deliveries to pregnant women who were provided prenatal, delivery, or
postpartum care under this title or were entitled to benefits with respect to such deliveries under
the State plan under title XIX in the year.
(2)(D) Information (by racial and ethnic group) on-(i) the number of infants under one year of age who were in the State in the year, and
(ii) the number of such infants who were provided services under this title or were entitled to
benefits under the State plan under title XIX at any time during the year.”
Instructions: Complete all required data cells. If an actual number is not available, the State should
make an estimate. All estimates should be explained in a footnote. A Glossary that contains terms
applicable to this form is provided in Appendix H of the Supporting Documents, which accompany the
Application/Annual Report Guidance. It is recognized that there will be overlap between the reported
totals for “Title V Served” and “Eligible for Title XIX”, due to an individual’s changing insurance eligibility
status during the course of a year (i.e., “churning”.) Form 6 asks for all individuals who are served by
Title V and an estimate of the individuals in the State who are eligible for Title XIX. The form does not
ask for a report on those individuals served by Title V who are also eligible for Title XIX.
LINE NUMBER
INSTRUCTIONS
Section I: Unduplicated Count by Race
Total Deliveries In Column A, enter the number for the population-based total of all deliveries in the State
in State
for the reporting year eligible for Title XIX who were provided delivery of services in the
reporting year. For Columns B-H, enter the number of individuals who were eligible by race.
Total Infants in
State

In column A, for “Total Infants in State,” enter the number of infants who were eligible for
Title XIX during the reporting year. (Please note that this figure is related to the “Total Births
by Occurrence” line in Form 4, and the “Total infants < 1 year of age” row in Form 5. While
these figures are not expected to match, they should show a fairly close relationship to each
other). For columns B-H, the State should enter the number of infants who were eligible by
race.
Section II: Unduplicated Count by Ethnicity
Total Deliveries Enter the total number of deliveries in the State by ethnicity, specifically Hispanic or Latino in
in State
Column A, Not Hispanic or Latino in Column B or Ethnicity Not Reported in Column C.
Total Infants in
State

Enter the total number of infants in the State by ethnicity, specifically Hispanic or Latino in
Column A, Not Hispanic or Latino in Column B or Ethnicity Not Reported in Column C.

FORM 7
STATE TITLE V MCH SERVICES BLOCK GRANT
STATE PROFILE FOR FY____
A. State MCH Toll-Free Telephone Line [Sections 505(a)(5)(E) and 509(a)(8)]:
STATE: _______
FY__
1. State MCH Toll-Free
“Hotline” Telephone
Number

________________________________________

2. State MCH Toll-Free
“Hotline” Name

________________________________________

3. Name of Contact Person for
State MCH “Hotline”

________________________________________

4. Contact Person’s Telephone
Number

________________________________________

5. Number of Calls Received
on the State MCH “Hotline”
in this Reporting Period

________________________________________

B. Other Appropriate Methods [Sections 505(a)(5)(E) and 509(a)(8)]:
FY__
1. Other Toll-Free “Hotline”
Names (e.g., 2-1-1 Infoline)

________________________________________

2. Number of Calls on the
State 2-1-1 Infoline or Other
Relevant Hotlines in this
Reporting Period

________________________________________

3. State Title V Program
Website Address

________________________________________

4. Number of Hits to Title V
Program Website

________________________________________

5. State Title V Social Media
Websites

________________________________________

6. Number of Hits to Title V
Program Social Media
Websites

________________________________________

INSTRUCTIONS FOR THE COMPLETION OF FORM 7
STATE MCH TOLL-FREE TELEPHONE LINE AND OTHER APPROPRIATE METHODS DATA FORM
Title V Citation: Section 505(a)(5)(E) states, in part, “the State agency (or agencies) administering the
State’s program under this title will provide for a toll-free telephone number (and other appropriate
methods) for the use of parents to access information about health care providers and practitioners who
provide health care services under this title and title XIX and about other relevant health and
health-related providers and practitioners...”
The Maternal and Child Health Bureau is the designee of the Secretary of the Department of Health and
Human Services to carry out the mandate of Section 509(a)(8) of Title V, which requires that a national
directory of toll-free numbers be made available to State agencies that administer the State’s Title V
programs.
Instructions: Complete all required data cells. If an actual number of calls received or hits to the
website is not available, the State should make an estimate. All estimates should be explained in a
footnote.
LINE NUMBER
State

Fiscal Year (FY)

INSTRUCTIONS

Enter the name of the State.

Enter the reporting year at the top of the column.

A.1

Enter the State’s primary toll-free MCH information line telephone number.

A.2

Enter the name of the State’s primary toll-free MCH information line.

A.3

Enter the name of the person who should be contacted with any concerns about the State’s
primary toll-free MCH information line.

A.4

Enter the telephone number of the contact person that is listed on Line A.3.

A.5

For the reporting year, enter the number of calls received on the State’s primary toll-free
MCH information line.

LINE NUMBER
B.1
B.2

INSTRUCTIONS
Enter the names of other toll-free information lines that are administered by the State.
For the reporting year, enter the number of calls received by the other toll-free MCH
information lines administered by the State.

B.3

Enter the URL for the State Title V Program website.

B.4

For the reporting year, enter the number of hits to the State Title V Program website address
listed on Line B.3.

B.5

Enter the URLs for the State Title V Social Media Websites

B.6

For the reporting year, enter the number of hits to the State Title V Program social media
website addresses listed on Line B.5.

FORM 8
STATE TITLE V MCH SERVICES BLOCK GRANT
STATE PROFILE FOR FY____
STATE: __________________________
1. Title V Maternal and Child Health (MCH) Director
Name:
__________________________________
Title
__________________________________
Street Address:
__________________________________
Room Number:
__________________________________
City/State/Zip:
__________________________________
Telephone:
__________________________________
Email:
__________________________________

2. Title V Children with Special Health Care Needs (CSHCN) Director
Name:
__________________________________
Title
__________________________________
Street Address:
__________________________________
Room Number:
__________________________________
City/State/Zip:
__________________________________
Telephone:
__________________________________
Email:
__________________________________

3. State Family or Youth Leader (Optional):
Name:
__________________________________
Title
__________________________________
Street Address:
__________________________________
Room Number:
__________________________________
City/State/Zip:
__________________________________
Telephone:
__________________________________
Email:
__________________________________
Instructions: Enter the name of the Title V MCH Director, CSHCN Director and, at the option of the
State, the Family and/or Youth Leader. For each of the listed contacts, provide the title, address,
telephone number and e-mail address.

FORM 9
LIST OF MCH PRIORITY NEEDS
[Section 505(a)(1)]
Your state’s Five-Year Statewide Needs Assessment should identify the need for preventive and
primary care services for pregnant women, mothers, and infants; preventive and primary care services
for children; and services for Children with Special Health Care Needs. The established priorities
should guide the activities that are included in the State's Five-year Action Plan. In order to evaluate
success in meeting the goals of the priority needs, the State should determine, at the time of priority
setting, its plan for assessing if priority needs have been addressed. This assessment should include
the development of State Performance Measures (SPMs), which are specifically tailored to a priority
need to the extent that such need is not fully addressed by the National Performance Measures
(NPMs) or the State Evidence-based or –informed Strategy Measures (ESMs).
With each year’s Block Grant Application, the State should provide a list, (whether or not the priority
needs change) of its top maternal and child health needs and crosslink the identified priorities with the
existing National Outcome Measures (NOMs), NPMs, SPMs and ESMs. Use a simple sentence or
phrase to list your State’s needs below. Examples of such statements are: “To reduce the barriers to
the delivery of care for pregnant women,” and “The infant mortality rate for minorities should be
reduced.” For each priority, indicate if it a new priority need for this five-year reporting cycle or if it is
being continued from the previous five-year cycle. A rationale should be provided for any identified
priority that is not linked to a specific performance/outcome measure.
MCHB will capture annually every State’s top 7 to 10 priority needs in an information system for
comparison, tracking, and reporting purposes. The State must list at least 7 priority needs, and the
form will only accept up to 10. If desired, the State may list and describe additional priority needs in a
form note. Note that the numerical listing below is for computer tracking only and is not meant to
indicate a priority order.
STATE__________________________________

PRIORITY NEEDS

FY_________

NEW (N), REPLACED (R) OR CONTINUED
(C) PRIORITY NEED FOR THIS FIVE-YEAR
REPORTING PERIOD
N
R
C

1
2
3
4
5
6
7
8
9
10

RATIONALE IF PRIORITY NEED
DOES NOT HAVE A
CORRESPONDING STATE OR
NATIONAL PERFORMANCE/
OUTCOME MEASURE

FORM 10A
TRACKING MEASURES
(for National Outcome, National Performance, State Performance, and Evidence-based or –Informed Strategy Measures)
[Sections 505(a)(2)(B)(i),(iii) and 506(a)(2)(A)(iii)]
Annual Reporting Year: Objective and Performance Data
MEASURE #__
(Measure Title)

FY__
(Reporting Year)

Annual Objective
Annual Indicator

FY__

______

Numerator

______

Denominator

______

Data Source (Reporting Year):
___________________________
Note (Reporting Year):
____________________________

Description: As the standard form to be used by States in tracking all measurement types [National Outcome Measures (NOMs), National Performance
Measures (NPMs), State Performance Measures (SPMs) and Evidence-based or –informed Strategy Measures (ESMs)] specified in this Guidance, this
form serves a dual purpose: 1) Displays 5-year planned objectives (targets) for each NPM, SPM and ESM as part of the Application, and 2) Reports
Annual Indicators, values actually achieved during a reporting year, for each NOM, NPM, SPM and ESM as part of the Annual Report. States are not
required to establish performance targets for the NOMs. A Glossary that contains terms applicable to this form is provided in Appendix H of the
Supporting Documents, which accompany the Application/Annual Report Guidance.

INSTRUCTIONS FOR THE COMPLETION OF FORM 10A
TRACKING MEASURES
(for National Outcome, National Performance, State Performance
and Evidence-Based or –Informed Strategy Measures)
Title V Citation: Section 505(a)(2)(B)(i),(iii) requires the States to submit an Application that includes, ...a
statement of the goals and objectives consistent with the health status goals and national health
objectives...for meeting the needs specified in the State plan...[and]...an identification of the types of
services to be provided... “Section 506(a)(2)(A)(iii) requires the States to report annually on the ...type (as
defined by the Secretary) of services provided under this title...”
Instructions: For the Application Year, States will establish five-year performance targets for each
selected NPM, SPM and ESM. Within the five-year period, performance targets that were established by
the State in previous years’ Applications will be pre-populated on the form.
For the Annual Reporting year, States will complete the required data cells (i.e., Annual Indicator,
Numerator, Denominator, Data Source and Reporting Note) for the SPMs and ESMs. If the final data are
not available, the State should provide provisional or estimated data. All provisional or estimated data
should be explained in a footnote. If neither the actual data nor an estimate can be provided, the State
must provide a footnote that describes a time-framed plan for providing the required data. In such
cases the “Annual Objective” and “Annual Indicator,” lines should be left blank. SPMs are automatically
assigned when a State creates the detail sheet (Form 10B) for each of its established SPMs. ESMs are
automatically assigned when a State creates the detail sheet (Form 10C) for each of the measures that
are developed to address a selected NPM.
While not responsible for entering an Annual Indicator, States will be responsible for tracking their
annual progress on the NPMs and their related NOMs. For the NPMs and the NOMs, the Annual
Indicator data will be populated annually by the Maternal and Child Health Bureau, as available, using
the referenced national data source identified on the detail sheet for each specific NPM and NOM.
LINE NUMBER
Measure
Number

INSTRUCTIONS
The measure number will be populated from the number that is defined on the
Measure Detail Sheet.

Fiscal Year (FY)

Enter the reporting year at the top of the appropriate column.

Annual
Objective

For the Application year, complete five-year Annual Objectives for each of the
selected NPMs, SPMs and ESMs.

Annual
Indicator

For the Annual Reporting year, enter the Annual Indicator, including the Numerator
and Denominator, for each SPM and ESM.

Data Source
Note

For the Annual Reporting year, enter the data source for the reported Annual
Indicator for each SPM and ESM.
For the Annual Reporting year, enter a data note to clarify any estimated or
provisional data and to describe other limitations which impact the reporting of an
Annual Indicator for each of the SPMs and the ESMs.

FORM 10B
STATE PERFORMANCE/OUTCOME MEASURE DETAIL SHEET
SPM ☐

SOM ☐

SPM/SOM # ___________
PERFORMANCE MEASURE TITLE:

CHOOSE THE POPULATION DOMAIN TO WHICH THIS
MEASURE LINKS (Choose one):

Women’s/Maternal Health
Perinatal/Infant Health
Child Health
Adolescent Health
Children with Special Health Needs
Cross-cutting or Life Course

GOAL

DEFINITION

Numerator:
Denominator:
Units:

HEALTHY PEOPLE 2020
OBJECTIVE

DATA SOURCES and DATA ISSUES

SIGNIFICANCE

________
(Number)

_________
(Text)

INSTRUCTIONS FOR THE COMPLETION OF FORM 10B
STATE PERFORMANCE/OUTCOME MEASURE DETAIL SHEET
Title V Citation: Section 505(a)(2)(B)(i),(iii) requires the States to submit an application that includes:
“...a statement of the goals and objectives consistent with the health status goals and national health
objectives...for meeting the needs specified in the State plan...[and]...an identification of the types of
services to be provided...” Section 506(a)(2)(A)(iii) requires the States to report annually on the “...type
(as defined by the Secretary) of services provided under this title...”
Instructions: This form is to be used for creating both a State Performance Measure (SPM) and a State
Outcome Measure (SOM), if the State chooses to add one. Complete each section as appropriate for the
measure being described. Note that the Performance or Outcome Measure’s title and numerator and
denominator data will be displayed on Form 10A as they are defined on this form. A Glossary that
contains terms applicable to this form is provided in Appendix H of the Supporting Documents, which
accompany the Application/Annual Report Guidance.
LINE NUMBER

SPM/SOM Checkboxes
SPM or SOM #
Performance Measure
Choose the Population
Domain to which to which this
measure links
Goal
Definition

Healthy People 2020
Objective
Data Source & Data Issues

Significance

INSTRUCTIONS

Please check the appropriate box for the type of measure being created.
The measure number will be automatically generated by TVIS when the State creates
this detail sheet.
Enter the narrative description of the performance or outcome measure.
Select the related population domain from the displayed pick list.

Enter a short statement indicating what the State hopes to accomplish by tracking
this measure.
Numerator: If the measure is a percentage, rate, or ratio, provide a clear description
of the numerator.
Denominator: If the measure is a percentage, rate, or ratio, provide a clear
description of the denominator.
Units: If the measure is a percentage, rate, ratio, or scale, indicate the units in which
the measure is to be expressed (e.g., 10,000; 1,000; 100) by selecting a choice in pick
list for the "Number" field. Select the type of measure from the pick list (e.g.,
percentage, rate, ratio, scale, yes/no) on "Text" field.
If the measure is related to a Healthy People 2020 objective describe the objective
and corresponding number.
Enter the source(s) of the data used in determining the value of the measure and any
issues concerning the methods of data collection or limitations of the data used.
Briefly describe why this measure is significant, especially as it relates to the Goal.
Describe also how the value of the measure is determined from the data. If the value
of the measure is a scale or a “yes/no,” a clear description of what those values mean
and how they are determined should be provided.

FORM 10C
EVIDENCE-BASED OR –INFORMED STRATEGY MEASURE (ESM) DETAIL SHEET
ESM # ___________
PERFORMANCE MEASURE TITLE:
CHOOSE THE NATIONAL PERFORMANCE
MEASURE TO WHICH THIS ESM IS
LINKED: (Choose one)

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

GOAL
DEFINITION

Percent of women with a past year preventive visit
Percent of cesarean deliveries among low-risk first births
Percent of very low birth weight (VLBW) infants born in a hospital
with a Level III+ Neonatal Intensive Care Unit (NICU)
A) Percent of infants who are ever breastfed and B) Percent of
infants breastfed exclusively through 6 months
Percent of infants placed to sleep on their backs
Percent of children, ages 9 through 71 months, receiving a
developmental screening using a parent-completed screening
tool
Rate of injury-related hospital admissions per population ages 0
through 19 years
Percent of children ages 6 through 11 years and adolescents ages
12 through 17 years who are physically active at least 60 minutes
per day
Percent of adolescents, ages 12 through 17 years, who are bullied
Percent of adolescents with a preventive services visit in the last
year
Percent of children with and without special health care needs
having a medical home
Percent of children with and without special health care needs
who received services necessary to make transitions to adult
health care
A) Percent of women who had a dental visit during pregnancy and
B) Percent of infants and children, ages 1 through 17 years, who
had a preventive dental visit in the last year
A) Percent of women who smoke during pregnancy and B) Percent
of children who live in households where someone smokes
Percent of children 0 through 17 years who are adequately
insured

Numerator:
Denominator:
Units: ________
(Number)

DATA SOURCES and DATA ISSUES
SIGNIFICANCE

_________
(Text)

INSTRUCTIONS FOR THE COMPLETION OF FORM 10C
EVIDENCE-BASED OR –INFORMED STRATEGY MEASURE (ESM) DETAIL SHEET
Title V Citation: Section 505(a)(2)(B)(i),(iii) requires the States to submit an application that includes:
“...a statement of the goals and objectives consistent with the health status goals and national health
objectives...for meeting the needs specified in the State plan...[and]...an identification of the types of
services to be provided...” Section 506(a)(2)(A)(iii) requires the States to report annually on the “...type
(as defined by the Secretary) of services provided under this title...”
Instructions: This form is to be used for creating an Evidence-based or –informed Strategy Measure
(ESM). Complete each section as appropriate for the measure being described. Note that the ESM title
and numerator and denominator data will be displayed on Form 10A as they are defined on this form. A
Glossary that contains terms applicable to this form is provided in Appendix H of the Supporting
Documents, which accompany the Application/Annual Report Guidance.
LINE NUMBER
ESM #

Strategy Measure

INSTRUCTIONS

The measure number will be automatically generated by TVIS when the State creates
this detail sheet.
Enter the narrative description of the strategy measure.

Choose the National
Performance Measure to
which this ESM is linked

Select the related national performance measure from the displayed pick list.

Goal

Enter a short statement indicating what the State hopes to accomplish by tracking
this measure.

Definition

Healthy People 2020
Objective

Numerator: If the measure is a percentage, rate, or ratio, provide a clear description
of the numerator.
Denominator: If the measure is a percentage, rate, or ratio, provide a clear
description of the denominator.
Units: If the measure is a percentage, rate, ratio, or scale, indicate the units in which
the measure is to be expressed (e.g., 10,000; 1,000; 100) by selecting a choice in pick
list for the "Number" field. Select the type of measure from the pick list (e.g.,
percentage, rate, ratio, scale, yes/no) on "Text" field.
If the measure is related to a Healthy People 2020 objective describe the objective
and corresponding number.

Data Source & Data Issues

Enter the source(s) of the data used in determining the value of the measure and any
issues concerning the methods of data collection or limitations of the data used.

Significance

Briefly describe why this measure is significant, especially as it relates to the Goal.
Describe also how the value of the measure is determined from the data. If the value
of the measure is a scale or a “yes/no,” a clear description of what those values mean
and how they are determined should be provided.

FORM 10D
TRACKING PERFORMANCE MEASURES
(FY 2011 – 2015)
[Sections 505(a)(2)(B)(i),(iii) and 506(a)(2)(A)(iii)]
Annual Reporting Year:
Objective and Performance Data

STATE: __________________________

FY 2015

NATIONAL PERFORMANCE MEASURE #__
(Select from Table Below)
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________

FY 2014

Annual Objective

______

Annual Indicator

______

Numerator

______

Denominator

______

Data Source

______

Data Note

______

FY 2015

STATE PERFORMANCE MEASURE #__
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________

FY 2014

Annual Objective

______

Annual Indicator

______

Numerator

______

Denominator

______

Data Source

______

Data Note

______

FORM 10D
TRACKING PERFORMANCE MEASURES
(FY 2011 – 2015)
[Sections 505(a)(2)(B)(i),(iii) and 506(a)(2)(A)(iii)]
FY 2011 – FY 2015
NUMBER
NATIONAL PERFORMANCE MEASURES
The percent of screen positive newborns who received timely follow up to definitive
diagnosis and clinical management for condition(s) mandated by their State-sponsored
1
newborn screening programs.
The percent of children with special health care needs age 0 to 18 years whose
families partner in decision making at all levels and are satisfied with the services they
2
receive. (CSHCN survey)
The percent of children with special health care needs age 0 to 18 who receive
3
coordinated, ongoing, comprehensive care within a medical home. (CSHCN Survey)
The percent of children with special health care needs age 0 to 18 whose families have
adequate private and/or public insurance to pay for the services they need. (CSHCN
4
Survey)
Percent of children with special health care needs age 0 to 18 whose families report
the community-based service systems are organized so they can use them easily.
5
(CSHCN Survey)
The percentage of youth with special health care needs who received the services
necessary to make transitions to all aspects of adult life, including adult health care,
6
work, and independence.
Percent of 19 to 35 month olds who have received full schedule of age appropriate
immunizations against Measles, Mumps, Rubella, Polio, Diphtheria, Tetanus, Pertussis,
7
Haemophilus Influenza, and Hepatitis B.
8
The rate of birth (per 1,000) for teenagers aged 15 through 17 years.
Percent of third grade children who have received protective sealants on at least one
9
permanent molar tooth.
The rate of deaths to children aged 14 years and younger caused by motor vehicle
10
crashes per 100,000 children.
11
The percent of mothers who breastfeed their infants at 6 months of age.
Percentage of newborns who have been screened for hearing before hospital
12
discharge.
13
Percent of children without health insurance.
Percentage of children, ages 2 to 5 years, receiving WIC services with a Body Mass
14
Index (BMI) at or above the 85th percentile.
15
Percentage of women who smoke in the last three months of pregnancy.
16
The rate (per 100,000) of suicide deaths among youths aged 15 through 19.
Percent of very low birth weight infants delivered at facilities for high-risk deliveries
17
and neonates.
Percent of infants born to pregnant women receiving prenatal care beginning in the
18
first trimester.

INSTRUCTIONS FOR THE COMPLETION OF FORM 10D
TRACKING PERFORMANCE MEASURES
(FY 2011-2015)
Title V Citation: Section 505(a)(2)(B)(i),(iii) requires the States to submit an Application that includes, ...a
statement of the goals and objectives consistent with the health status goals and national health
objectives...for meeting the needs specified in the State plan...[and]...an identification of the types of
services to be provided... “Section 506(a)(2)(A)(iii) requires the States to report annually on the ...type (as
defined by the Secretary) of services provided under this title...”
Instructions: For the appropriate Annual Reporting year (i.e., fiscal year (FY) 2014 or FY 2015), complete
the data cells for the Annual Indicator (including the Numerator and Denominator), Data Source and
Data Note for each of the previous reporting cycle’s 18 National Performance Measures (NPMs) and the
7-10 State Performance Measures (SPMs) that were developed by the State. If final data are not
available, the State should provide provisional or estimated data. All provisional or estimated data
should be explained in a footnote. The Annual Objectives for FY 2014 and for FY 2015 that were
established by the State in previous Application years will be pre-populated on the reporting form. In
addition, the previously reported Annual Indicators will also be pre-populated on this form. This
reporting form addresses the legislative requirement in Section 506(a)(1) for States to submit an Annual
Report on their Title V program expenditures and activities.
LINE NUMBER
State
Annual
Objective

INSTRUCTIONS
Enter the name of the State/jurisdiction.

Performance targets previously established by the State for FY 2014 and FY 2015 will be
pre-populated for the State on the reporting form.

Annual
Indicator

For the appropriate Annual Reporting year (i.e., FY 2014 or FY 2015), enter the Annual
Indicator, including the Numerator and Denominator, for each of the National Performance
Measures and the State Performance Measures.

Data Source

Enter the data source for the reported Annual Indicators for each of the National and State
Performance Measure.

Note

Enter a data note to clarify estimated or provisional data and to describe other limitations
which impact the reporting of an Annual Indicator for each of the National and State
Performance Measures.

FORM 11
OTHER STATE DATA (OSD) - #01- #03
OSD #01A – Infant mortality rate and rate of low birth weight by race and ethnicity
Reporting Year _________
Are these data from a State Projection?
CATEGORY
RATE BY RACE

STATE RACE

WHITE

BLACK
OR AFRICAN
AMERICAN

AMERICAN
INDIAN
OR
NATIVE
ALASKAN

[SECTION 506 [42 U.S.C. 705] (a)(2)(B)(i)]
⃝ YES
⃝ NO (Parts A and B)

ASIAN

NATIVE
HAWAIIAN
OR OTHER
PACIFIC
ISLANDER

MORE THAN
ONE RACE
REPORTED

OTHER
AND
UNKNOWN

Infant Mortality
Rate
Rate of Low
Birth Weight

OSD #01B – Infant mortality rate and rate of low birth weight by race and ethnicity
CATEGORY
RATE BY HISPANIC ETHNICITY
Infant Mortality Rate
Rate of Low Birth Weight

TOTAL
NOT HISPANIC OR LATINO

[Section 506 [42 U.S.C. 705] (a)(2)(B)(i)]

TOTAL
HISPANIC OR LATINO

ETHNICITY NOT REPORTED

OSD #02 – Infant mortality rate and rate of low birth weight by county
[SECTION 506 [42 U.S.C. 705] (a)(2)(B)(i)]
Reporting Year _________
Are these data from a State Projection? ⃝ YES ⃝ NO (Parts A and B)
COUNTY
(List each
County)

INFANT
MORTALITY

RATE OF LOW
BIRTH WEIGHT

FORM 11
OTHER STATE DATA (OSD) - #01- #03
(Continuation Page)
OSD #03 –State MCH Workforce [SECTION 506 [42 U.S.C. 705] (a)(2)(E)(i-vi)]
Reporting Year _________ Are these data from a State Projection? ⃝ YES ⃝ NO
WORKFORCE CATEGORY
OBSTETRICIANS
FAMILY PRACTITIONERS
CERTIFIED FAMILY NURSE PRACTITIONERS
CERTIFIED NURSE MIDWIVES
PEDIATRICIANS
CERTIFIED PEDIATRIC NURSE PRACTITIONERS

TOTAL NUMBER

INSTRUCTIONS FOR THE COMPLETION OF FORM 11
OTHER STATE DATA (OSD) - #01- #03
Title V Citation: See OSD reporting tables above.
Instructions: A glossary of terms applicable to this form is presented in Appendix H of the Supporting
Documents, which accompany the Application/Annual Report Guidance.
States are not required to collect or report on any of the OSD elements. The purpose of this form is to
make available, annually, other State data required by the Title V legislation. Required data elements on
this form will be pre-populated by the Maternal and Child Health Bureau (MCHB), as available, for the
States. States should review and monitor the annual data.
The OSD #01 data form has two parts (A and B), and the OSD #02 and #03 data forms each have one
part. The racial and ethnic population categories included in these tables are based on the Office of
Management and Budget guidelines. More specific instructions are provided below.
At the top of each table, enter the year for which the data are being reported and check the appropriate
box to indicate if the data are from a State projection. For OSD 1, the reporting year will be the same for
parts A and B of each form
FORM NUMBER

INSTRUCTIONS

OSD #01A:

In the column labeled “STATE RATE,” the rate for the State is entered in the category specified. In the
next seven columns the rate of the State in the racial categories indicated at the head of each column
and in the categories specified is entered. In the column headed “OTHER AND UNKNOWN” the rate
for other racial categories not shown and/or population figures where the racial category is not
known is entered. Since these data are reported by rates, these data are not totaled.

OSD #01B

In the column headed “TOTAL NOT HISPANIC OR LATINO,” the rate for the category specified, that are
not of Hispanic or Latino ethnicity is entered. In the column headed “TOTAL HISPANIC OR LATINO”
the rate for those that are of Hispanic or Latino ethnicity is entered. In the column headed
“EHTNICITY NOT REPORTED” the rate whose ethnicity is not reported is entered. Since these data are
reported by rates, these data are not totaled.

OSD #02

Data are collected in this table for the infant mortality rate and rate of low birth weight by each
county in the State. In the first column of the first row, the name of the county is entered. In the
second cell of the first row, the rate of infant mortality for that county is entered. In the third cell of
the first row, the rate of low birth weight for that county is entered. In subsequent rows, the names
of each county and the rates requested are entered. Depending on the size of the population being
reported for each county, rates may need to use a three-year moving average. Since these data are
reported by rates, these data are not totaled.

OSD #03

Data are collected in this table for the numbers of MCH workforce professionals noted that are
licensed in the State in the reporting year identified. In the second cell of the first row, the number of
obstetricians is entered. In the second cell of the each remaining rows, the number of family
practitioners, certified family nurse practitioners, certified nurse midwives, pediatricians, and certified
pediatric nurse practitioners are entered, as noted.

TITLE V MATERNAL AND
CHILD HEALTH SERVICES
BLOCK GRANT TO STATES
PROGRAM
GUIDANCE AND FORMS
FOR THE
TITLE V APPLICATION/ANNUAL REPORT

APPENDIX OF SUPPORTING DOCUMENTS
U.S. Department of Health and Human Services
Health Resources and Services Administration
Maternal and Child Health Bureau
Division of State and Community Health
Room 5C-26
5600 Fishers Lane, Rockville, MD 20857
(Phone 301-443-2204 FAX 301-443-9354)

TABLE of CONTENTS
APPENDIX A: HISTORY AND ADMINISTRATIVE BACKGROUND

APPENDIX B: SAMPLE OF FIVE-YEAR STATE ACTION PLAN TABLE

APPENDIX C: ASSURARANCES AND CERTIFICATIONS

APPENDIX D: NEEDS ASSESSMENT − BACKGROUND AND
CONCEPTUAL FRAMEWORK

APPENDIX E: PERFORMANCE MEASURE FRAMEWORK

APPENDIX F: DETAIL SHEETS FOR THE NATIONAL OUTCOME
MEASURES AND NATIONAL PERFORMANCE MEASURES

APPENDIX G: REQUIRED APPLICATION/ANNUAL REPORT COMPONENTS
AND TIMELINE

APPENDIX H: GLOSSARY

APPENDIX A: HISTORY AND ADMINISTRATIVE BACKGROUND

As one of the largest Federal block grant programs, Title V is a key source of support
for promoting and improving the health of all the nation’s mothers and children. When
Congress passed the Social Security Act in 1935, it contained the initial key landmark
legislation which established Title V. This legislation is the origin of the federal
government’s pledge of support to states and their efforts to extend and improve health
and welfare services for mothers and children throughout the nation. To date, the
Title V federal-state partnership continues to provide a dynamic program to improve the
health of all mothers and children, including children with special health care needs
(CSHCN.)
A. The Maternal and Child Health Bureau
The Maternal and Child Health Bureau (MCHB) is the principal focus within Health
Resources and Services Administration (HRSA) for all Maternal and Child Health
(MCH) activities within the Department of Health and Human Services (HHS).
MCHB’s mission is to provide national leadership through working in partnership with
states, communities, public/private partners, tribal entities and families to strengthen
the MCH infrastructure, and to build knowledge and human resources. Its mission
also includes ensuring continued improvement in the health, safety, and well-being
of the MCH population. To achieve its mission, MCHB directs resources towards a
combination of integrated public health services and coordinated systems of care for
the MCH population.
Within the MCHB, the Division of State and Community Health (DSCH) has the
administrative responsibility for the Title V MCH Block Grant to States Program.
DSCH is committed to being the Bureau’s main line of communication with states
and communities, in order to consult and work closely with both of these groups and
others who have an interest in and contribute to the provision of a wide range of
MCH programs and community-based service systems.
B. Maternal and Child Health Services Block Grant (Title V)
Under Title V, MCHB administers a Block Grant and competitive Discretionary
Grants. The purpose of the Title V MCH Services Block Grant Program is to create
federal/state partnerships in all 59 states for developing service systems that
address MCH challenges, such as:
•

Significantly reducing infant mortality;

•

Providing comprehensive care for all women before, during, and after pregnancy
and childbirth;

•

Providing preventive and primary care services for infants, children, and
adolescents;

•

Providing comprehensive care for children and adolescents with special health
care needs;

•

Immunizing all children;

•

Reducing adolescent pregnancy;

•

Preventing injury and violence;

•

Putting into community practice national standards and guidelines for prenatal
care, for healthy and safe child care, and for the health supervision of infants,
children, and adolescents;

•

Assuring access to care for all mothers and children; and

•

Meeting the nutritional and developmental needs of mothers, children and
families.

Under Title V, MCHB also administers two types of Federal Discretionary Grants,
Special Projects of Regional and National Significance (SPRANS) and Community
Integrated Service Systems (CISS) grants. SPRANS funds projects (through grants,
contracts, and other mechanisms) in research, training, genetic services and
newborn screening/follow-up, sickle cell disease, hemophilia, and MCH
improvement. CISS projects (through grants, contracts, and other mechanisms)
seek to increase the capacity for service delivery at the local level and to foster
formation of comprehensive, integrated, community level service systems for
mothers and children.
In addition to SPRANS and CISS grants, the MCHB also administers the following
categorical programs:
•

Emergency Medical Services for Children;

•

Traumatic Brain Injury;

•

Healthy Start Initiative;

•

Universal Newborn Hearing Screening;

•

Autism; and

•

Home Visiting Program

In recent years, some state Title V programs have begun to utilize the life course
model as an organizing framework for addressing identified MCH needs. The life
course approach points to broad social, economic, and environmental factors as
underlying contributors to health and social outcomes. This approach also focuses
on persistent inequalities in the health and well-being of individuals and how the
interplay of risk and protective factors at critical points of time can influence an
individual’s health across his/her lifespan and potentially across generations.
C. Maternal and Child Health Block Grant to States Program
Since its original authorization in 1935, Title V of the Social Security Act has been
amended several times to reflect the increasing national interest in maternal and
child health and well-being. One of the first changes occurred when Title V was
converted to a block grant program as part of the Omnibus Budget Reconciliation
Act (OBRA) of 1981. This change resulted in the consolidation of seven categorical
programs into a single block grant. These programs included:
•

Maternal and Child Health and Services for Children with Special Health Care
Needs (Title V of the Social Security Act);

•

Supplemental Security Income for children with disabilities (Section 1651(c) of
the Social Security Act);

•

Lead-based paint poisoning prevention programs (Section 316 of the Public
Health Service (PHS) Act);

•

Genetic disease programs (Section 101 of the PHS Act);

•

Sudden infant death syndrome programs (Section 1121 of the PHS Act);

•

Hemophilia treatment centers (Section 1131 of the PHS Act); and

•

Adolescent pregnancy grants (Public Law PL 95-626).

Another significant change in the Title V MCH Block Grant came as a result of the
Omnibus Budget Reconciliation Act (OBRA) of 1989, which specified new
requirements for accountability. The amendments enacted under OBRA introduced
stricter requirements for the use of federal funds and for state planning and
reporting. Congress sought to balance the flexibility of the block grant with greater
accountability, by requiring State Title V programs to report their progress on key
MCH indicators and other program information. Thus, the block grant legislation
emphasizes accountability while providing states with appropriate flexibility to
respond to state-specific MCH needs and to develop targeted interventions and
solutions for addressing them. This theme of assisting states in the design and
implementation of MCH programs to meet state and local needs, while at the same
time asking them to account for the use of federal/state Title V funds, was embodied
4

in the requirements contained in the Guidance documents for the state MCH Block
Grant Applications/Annual Reports.
In 1993 the Government Performance and Results Act (GPRA), Public Law 103-62,
required federal agencies to establish measurable goals that could be reported as
part of the budgetary process. For the first time, funding decisions were linked
directly with performance. Among its purposes, GPRA is intended to “...improve
federal program effectiveness and public accountability by promoting a new focus on
results, service quality, and customer satisfaction.” GPRA requires each federal
agency to develop comprehensive strategic plans, annual performance plans with
measurable goals and objectives, and annual reports on actual performance
compared to performance goals. The MCHB effort to respond to GPRA
requirements coincided with other planned improvements to the MCH Block Grant
Guidance. As a result, the MCH Block Grant Application/Annual Report and forms
contained in the 1997 edition of the Maternal and Child Health Services Title V Block
Grant Program - Guidance and Forms for the Title V Application/Annual Report
served to ensure that the states and jurisdictions could clearly, concisely, and
accurately tell their MCH “stories.” This Application/Annual Report became the basis
by which MCHB met its GPRA reporting requirements for the MCH Block Grant to
States Program.
In 1996, the MCHB began a process of programmatic assessments and planning
activities aimed at improving the Title V MCH Block Grant Application/Annual Report
Guidance document for states. Since that time, the Maternal and Child Health
Services Title V Block Grant Program - Guidance and Forms for the Title V
Application/Annual Report (Guidance) has been revised, submitted to and approved
by the Office of Management and Budget (OMB) six times. Revisions to each
subsequent edition were based on changes in MCH priorities, availability of new
national data sources and continuing efforts to refine and streamline the
Application/Annual Report preparation and submission process for states. The
reduced burden that resulted from this latter commitment was largely achieved
through efficiencies that were created by the electronic reporting vehicle for the state
MCH Block Grant Applications/Annual Reports, specifically the Title V Information
System (TVIS.)
D. Title V Information System
The development of an electronic reporting package in 1996 was a significant milestone
for the Title V MCH Block Grant to States Program. Advances in technology allowed for
the development of an electronic information system (TVIS) within the next several
years. The TVIS is designed to capture the performance data and other program and
financial information contained in the state Applications/Annual Reports. While
descriptive information is available on state Title V-supported efforts, state MCH
partnership efforts and other program-specific initiatives of the state in meeting its MCH
needs, TVIS primarily serves as an online, Web-accessible interface for the submission
of the 59 state and jurisdictional Title V MCH Block Grant Applications/Annual Reports
5

each year on July 15th. Developed in conjunction with the program requirements
outlined in the Title V MCH Block Grant Application/Annual Report Guidance, the TVIS
is available to the public on the World Wide Web at:
https://mchdata.hrsa.gov/TVISReports/. Over the years, the TVIS has increasingly
become recognized as a powerful and useful tool for a number of audiences. The
transformational changes to the Title V MCH Block Grant to States Program outlined in
this revised Application/Annual Report Guidance mandate the development of a new
data collection and web report system for the TVIS. HRSA is providing funding support
for a contract to develop, implement and operate this new information system.
Integrated with HRSA’s grants management system (i.e., the HRSA Electronic
Handbooks (EHB),) the TVIS makes available to the public through its web reports the
key financial, program, performance, and health indicator data reported by states in
their yearly MCH Block Grant Applications/Annual Reports. Examples of the data that
are collected include information on populations served; budget and expenditure
breakdowns by source of funding, service and program; program data, such as
individuals served and breakdowns of MCH populations by race/ethnicity, other state
data (OSD), and performance and outcome measure data for the national and state
measures. Reporting on performance relative to the national measures is used to
assess national progress in key MCH priority areas and to facilitate the Bureau’s annual
GPRA reporting.

APPENDIX B: SAMPLE OF FIVE-YEAR STATE ACTION PLAN TABLE

States will prepare a Five-year State Action Plan Table in follow-up to the Five-Year
Needs Assessment and submit an interim State Action Plan Table as part of the first
year Title V MCH Block Grant Application/Annual Report. (Note: States will refine the
interim State Action Plan Table in the second year Application/Annual Report by further
clarifying the identified objectives and strategies and by adding the Evidence-based or
–informed Strategy Measures (ESMs) and the State Performance Measures (SPMs).)
The following sample is provided to help guide states in understanding the types of
information that they should include in their Five-year Action Plan Table. States can
use a different tabular form for presenting similar information in the Five-year State
Action Plan Table that they prepare.
The Five-year State Action Plan Table is intended to serve as a working tool for states
in developing an Action Plan that addresses the state and national MCH priorities
identified through the Five-year Needs Assessment process. While there is no required
format for the Five-year State Action Plan Table, the information contained must be
clearly presented, organized by population health domain, link the state priority needs to
the defined priority needs/strategies and serve to inform the selection/development of
the NOMs, NPMs, SPMs and ESMs.
As the organizational framework, states will utilize the Five-year State Action Plan Table
in developing a five-year State Action Plan. States should review the Table annually
and provide updates, as needed, in preparing each year’s Application/Annual Report.
In the narrative State Action Plan (i.e., Application/Annual Report), states will report
annually on their planned activities for the coming year and on the activities they
implemented in the reporting year; their planned efforts for improving performance and
analyses of current performance trends relative to the NOMs, NPMs, SPMs and ESMs;
and their progress/achievements in addressing their identified priority needs through the
implementation of strategies defined in their Five-year State Action Plan Table.

Five-Year State Action Plan Table – SAMPLE
Domains

State
Priority
Needs

Objectives

Strategies

National
Outcome
Measures*

Women’s/
Maternal
Health
Perinatal/
Infant’s
Health
Child
Health
CSHCN

Adolescent
Health
CrossCutting or
Life Course
Other

* Data to be provided by MCHB

National
Performance
Measures*

Evidence-Based
or –Informed
Strategy
Measures

State
Performance
Measures

APPENDIX C: ASSURARANCES AND CERTIFICATIONS
View Burden Statement

OMB Number: 4040-0007
Expiration Date: 06130/2014

ASSURANCES - NON-CONSTRUCTION PROGRAMS

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0040), Washington, DC 20503.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND
IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
NOTE:

Certain of these assurances may not be applicable to your project or program. If you have questions, please contact the
awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional assurances.
If such is the case, you will be notified.

As the duly authorized representative of the applicant, I certify that the applicant:
1.

Has the legal authority to apply for Federal assistance
and the institutional, managerial and financial capability
(including funds sufficient to pay the non-Federal share
of project cost) to ensure proper planning, management
and completion of the project described in this
application.

Will give the awarding agency, the Comptroller General
of the United States and, if appropriate, the State,
through any authorized representative, access to and
the right to examine all records, books, papers, or
documents related to the award; and will establish a
proper accounting system in accordance with generally
accepted accounting standards or agency directives.

Will establish safeguards to prohibit employees from
using their positions for a purpose that constitutes or
presents the appearance of personal or organizational
conflict of interest, or personal gain.

Will initiate and complete the work within the applicable
time frame after receipt of approval of the awarding
agency.

Will comply with the Intergovernmental Personnel Act of
1970 (42 U.S.C. §§4728-4763) relating to prescribed
standards for merit systems for programs funded under
one of the 19 statutes or regulations specified in
Appendix A of OPM's Standards for a Merit System of
Personnel Administration (5 C.F.R. 900, Subpart F).

Will comply with all Federal statutes relating to
nondiscrimination. These include but are not limited to:
(a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352)
which prohibits discrimination on the basis of race, color
or national origin; (b) Title IX of the Education
Amendments of 1972, as amended (20 U.S.C.§§16811683, and 1685-1686), which prohibits discrimination on
the basis of sex; (c) Section 504 of the Rehabilitation

Act of 1973, as amended (29 U.S.C. §794), which
prohibits discrimination on the basis of handicaps; (d)
the Age Discrimination Act of 1975, as amended (42 U.
S.C. §§6101-6107), which prohibits discrimination on
the basis of age; (e) the Drug Abuse Office and
Treatment Act of 1972 (P.L. 92-255), as amended,
relating to nondiscrimination on the basis of drug
abuse; (f) the Comprehensive Alcohol Abuse and
Alcoholism Prevention, Treatment and Rehabilitation
Act of 1970 (P.L. 91-616), as amended, relating to
nondiscrimination on the basis of alcohol abuse or
alcoholism; (g) §§523 and 527 of the Public Health
Service Act of 1912 (42 U.S.C. §§290 dd-3 and 290
ee- 3), as amended, relating to confidentiality of alcohol
and drug abuse patient records; (h) Title VIII of the Civil
Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as
amended, relating to nondiscrimination in the sale,
rental or financing of housing; (i) any other
nondiscrimination provisions in the specific statute(s)
under which application for Federal assistance is being
made; and, U) the requirements of any other
nondiscrimination statute(s) which may apply to the
application.
7.

Will comply, or has already complied, with the
requirements of Titles II and Ill of the Uniform
Relocation Assistance and Real Property Acquisition
Policies Act of 1970 (P.L. 91-646) which provide for
fair and equitable treatment of persons displaced or
whose property is acquired as a result of Federal or
federally-assisted programs. These requirements
apply to all interests in real property acquired for
project purposes regardless of Federal participation in
purchases.

8. Will comply, as applicable, with provisions of the
Hatch Act (5 U.S.C. §§1501-1508 and 7324-7328)
which limit the political activities of employees whose
principal employment activities are funded in whole
or in part with Federal funds.

Previous Edition Usable

Authorized for Local Reproduction

Standard Form 4248 (Rev. 7-97)
Prescribed by OMB Circular A-102

9. Will comply, as applicable, with the provisions of the Davis
Bacon Act (40 U.S.C. §§276a to 276a-7), the Copeland Act
(40 U.S.C. §276c and 18 U.S.C. §874), and the Contract
Work Hours and Safety Standards Act (40 U.S.C. §§327333), regarding labor standards for federally-assisted
construction subagreements.
10. Will comply, if applicable, with flood insurance purchase
requirements of Section 102(a) of the Flood Disaster
Protection Act of 1973 (P.L. 93-234) which requires
recipients in a special flood hazard area to participate in the
program and to purchase flood insurance if the total cost of
insurable construction and acquisition is $10,000 or more.
11. Will comply with environmental standards which may be
prescribed pursuant to the following: (a) institution of
environmental quality control measures under the National
Environmental Policy Act of 1969 (P.L. 91-190) and
Executive Order (EO) 11514; (b) notification of violating
facilities pursuant to EO 11738; (c) protection of wetlands
pursuant to EO 11990; (d) evaluation of flood hazards in
floodplains in accordance with EO 11988; (e) assurance of
project consistency with the approved State management
program developed under the Coastal Zone Management
Act of 1972 (16 U.S.C. §§1451 et seq.); (f) conformity of
Federal actions to State (Clean Air) Implementation Plans
under Section 176(c) of the Clean Air Act of 1955, as
amended (42 U.S.C. §§7401 etseq.); (g) protection of
underground sources of drinking water under the Safe
Drinking Water Act of 1974, as amended (P.L. 93-523);
and, (h) protection of endangered species under the
Endangered Species Act of 1973, as amended (P.L. 93205).
12. Will comply with the Wild and Scenic Rivers Act of
1968 (16 U.S.C. §§1271 et seq.) related to protecting
components or potential components of the national
wild and scenic rivers system.

13. Will assist the awarding agency in assuring compliance
with Section 106 of the National Historic Preservation
Actof1966, as amended (16 U.S.C. §470), EO 11593
(identification and protection of historic properties), and
the Archaeological and Historic Preservation Act of
1974 (16 U.S.C. §§469a-1 et seq.).
14. Will comply with P.L. 93-348 regarding the protection of
human subjects involved in research, development, and
related activities supported by this award of assistance.
15. Will comply with the Laboratory Animal Welfare Act of
1966 (P.L. 89-544, as amended, 7 U.S.C. §§2131 et
seq.) pertaining to the care, handling, and treatment of
warm blooded animals held for research, teaching, or
other activities supported by this award of assistance.
16. Will comply with the Lead-Based Paint Poisoning
Prevention Act (42 U.S.C. §§4801 et seq.) which
prohibits the use of lead-based paint in construction or
rehabilitation of residence structures.
17. Will cause to be performed the required financial and
compliance audits in accordance with the Single Audit
Act Amendments of 1996 and OMB Circular No. A-133,
"Audits of States, Local Governments, and Non-Profit
Organizations."
18. Will comply with all applicable requirements of all other
Federal laws, executive orders, regulations, and policies
governing this program.
19. Will comply with the requirements of Section 106(g) of
the Trafficking Victims Protection Act (TVPA) of 2000, as
amended (22 U.S.C. 7104) which prohibits grant award
recipients or a sub-recipient from (1) Engaging in severe
forms of trafficking in persons during the period of time
that the award is in effect (2) Procuring a commercial
sex act during the period of time that the award is in
effect or (3) Using forced labor in the performance of the
award or subawards under the award.

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

TITLE

APPLICANT ORGANIZATION

DATE SUBMITTED
Standard Fonn 4248 (Rev. 7-97) Back

HHS-5161-1 (08/2007)

CERTIFICATIONS

1. CERTIF1CATION REGARDING LOBBYING

OMB Approval No. 0990-0317

3. CERTIF1CATION REGARDING
ENVIRONMENTAL TOBACCO SMOKE

Title 31, United States Code, Section 1352, entitled
"Limitation on use of appropriated funds to influence
certain Federal contracting and financial transactions,"
generally prohibits recipients of Federal grants and
cooperative agreements from using Federal (appropriated)
funds for lobbying the Executive or Legislative Branches
of the Federal Government in connection with a
SPECIFIC grant or cooperative agreement. Section 1352
also requires that each person who requests or receives a
Federal grant or cooperative agreement must disclose
lobbying undertaken with non-Federal (non-appropriated)
funds. These requirements apply to grants and cooperative
agreements EXCEEDING $100,000 in total costs (45
CFR Part 93). By signing and submitting this application,
the applicant is providing certification set out in Appendix
A to 45 CFR Part 93.

2. CERTIF1CATION REGARDING PROGRAM FRAUD
CIVIL REMEDIES ACT (PFCRA)

The authorized official signing for the applicant
organization certifies that the statements herein are true,
complete, and accurate to the best of his or her
knowledge, and that he or she is aware that any false,
fictitious, or fraudulent statements or claims may subject
him or her to criminal, civil, or administrative penalties.
The official signing agrees that the applicant organization
will comply with the HHS terms and conditions of award
if a grant is awarded as a result of this application.

Public Law 103-227, also known as the Pro-Children
Act of 1994 (Act), requires that smoking not be
permitted in any portion of any indoor facility owned
or leased or contracted for by an entity and used
routinely or regularly for the provision of health, day
care, early childhood development services, education
or library services to children under the age of 18, if the
services are funded by Federal programs either directly
or through State or local governments, by Federal
grant, contract, loan, or loan guarantee. The law also
applies to children's services that are provided in
indoor facilities that are constructed, operated, or
maintained with such Federal funds. The law does not
apply to children's services provided in private
residence, portions of facilities used for inpatient drug
or alcohol treatment, service providers whose sole
source of applicable Federal funds is Medicare or
Medicaid, or facilities where WIC coupons are
redeemed.
Failure to comply with the provisions of the law may
result in the imposition of a civil monetary penalty of
up to $1,000 for each violation and/or the imposition of
an administrative compliance order on the responsible
entity.
The authorized official signing for the applicant
organization certifies that the applicant organization
will comply with the requirements of the Act and will
not allow smoking within any portion of any indoor
facility used for the provision of services for children
as defmed by the Act. The applicant organization
agrees that it will require that the language of this
certification be included in any sub-awards which
contain provisions for children's services and that all
sub-recipients shall certify accordingly.
HHS strongly encourages all grant recipients to provide
a smoke-free workplace and promote the non-use of
tobacco products. This is consistent with the HHS
mission to protect and advance the physical and mental
health of the American people.

HHS Certifications (08-2007)

APPENDIX D:

NEEDS ASSESSMENT − BACKGROUND AND
CONCEPTUAL FRAMEWORK

Needs Assessment is a systematic process to acquire an accurate, thorough picture of
the strengths and weaknesses of a state’s public health system that can be used in
response to the preventive and primary care services needs for ALL pregnant women,
mothers, infants (up to age one), children including children with special health care
needs [Section 505 (a)(1)]. The Needs Assessment process includes the collection and
examination of information about the state’s capacity and infrastructure, needs and
desired outcomes for the MCH population, and legislative mandates, etc. This
information is utilized to determine priority goals, develop a plan of action, and to
allocate funds and resources. The Needs Assessment is a collaborative process that
should include the HRSA/MCHB, the state Department of Health, families, practitioners,
the community, and other agencies and organizations within each state and jurisdiction
that have an interest in the wellbeing of the MCH population.
Title V of the Social Security Act requires states to conduct a statewide Needs
Assessment every five years. States will report on the next Five-year Needs
Assessment in calendar year 2015 as part of the FY 2016 MCH Block Grant
Application process. Rather than submitting a comprehensive “stand-alone
document, as in previous years, states will submit a Five-year Needs Assessment
Summary that concisely describes the process and findings. As the Needs
Assessment document may serve multiple purposes, a state may wish to develop a
more comprehensive document to meets its broader needs. This document cannot
be submitted in place of the required Five-year Needs Assessment Summary, but
states may include a URL, if the document is posted online, in the Five-year Needs
Assessment Summary or they may submit the document as an attachment to the
Application/Annual Report in the electronic application system. Over the five-year
reporting period, states are encouraged to continuously revisit the Five-Year Needs
Assessment Summary and to provide updates, as needed, in the interim year
Applications/Annual Reports. Furthermore, it is expected that states will have
ongoing communication with stakeholders and partners throughout the Needs
Assessment process and continue to engage with such partners during the interim
reporting years.
The following figure illustrates the continuity of the Needs Assessment process and its
relationship to the planning and monitoring functions of Title V and the population that it
serves. The primary goal of the statewide Needs Assessment is to improve MCH
outcomes and to strengthen its state, local and community partnerships for addressing
the needs of its MCH population. A brief description of the steps involved in the Needs
Assessment process is presented in the following sections.
1.

Engage Stakeholders
As depicted, the starting point for the Needs Assessment process is to
engage stakeholders. Engaging stakeholders and strengthening
12

partnerships is a continuous and on-going activity. The state needs strong
partnerships with its stakeholders throughout the Needs Assessment
process. Effective coalitions can help the state to realistically assess
needs and identify desired outcomes and mandates, assess strengths and
examine capacity, select priorities, seek resources, set performance
objectives, develop an action plan, allocate resources, and monitor
progress for impact on targeted outcomes.

State Title V MCH Program Needs Assessment, Planning,
Implementation and Monitoring Process

Assess Needs and Identify Desired Outcomes and Mandates
The second stage in the process is to assess needs of the MCH
population groups using the Title V National Outcome Measures (NOMs),
national, state and structural/process performance measures and other
available state-level quantitative and qualitative data. States should
13

assess MCH population needs based on the following six population
health domains: 1) Women’s/Maternal Health; 2) Perinatal/Infant’s Health;
3) Child Health; 4) Adolescent Health; 5) Children with Special Health
Care Needs (CSHCN); and 6) Cross-cutting or Life Course. These
population health domains fall with the three MCH population groups that
are defined in Section 505(a)(1) of the Title V legislation. The anticipated
outcome of this assessment is to identify community/system needs and
desired outcomes by specific MCH population groups. In addition, the
state will need to identify legislative, political, community-driven, financial,
and/or other internal and external mandates which may go beyond the
findings identified through the Needs Assessment process but are
priorities for implementation within the state.
3.

Examine Strengths and Capacity
The third stage in the Needs Assessment process is examining
strengths and capacity. This stage involves examining the State’s
capacity to engage in various activities, including conducting the statewide
Five-year Needs Assessment and collecting/reporting annual performance
data based on the six identified MCH population health domains and the
types of MCH services provided. The working framework for MCH
services is presented in Figure 1 of Part One, Section II of the Title V MCH
Block Grant to States Application/Annual Report Guidance.
This stage involves describing and assessing the state’s current
resources, activities, and services as well as the state’s ability to continue
to provide quality services by each of the three MCH service levels.
These levels include 1) Direct Services; 2) Enabling Services; and
3) Public Health Services and Systems. The anticipated outcome is a
better understanding of the relationship of the state’s existing
program/system capacity to its identified strengths and needs. This
examination may reveal strengths and weaknesses in capacity not
previously identified.

Select Priorities
In the select priorities stage, each state examines the identified needs
and matches them to the desired outcomes, required mandates and level
of existing capacity. As a result, states will select seven to ten priority
areas for targeted focus in promoting continued improvement and
progress. Examples of inputs include: the Needs Assessment process,
the opinions of stakeholders, the examination of program capacity and the
political priorities within the State. The anticipated outcome is the
development of a set of priority needs (between seven and ten), which are
unique to the individual state based on its Needs Assessment findings.
Priorities identified should address areas in which the state believes there
14

is reasonable opportunity for a focused programmatic effort (e.g., new or
enhanced interventions, initiatives, or systems of care) to lead to an
improved outcome.
5.

Set Performance Objectives
Setting performance objectives consists of two phases. In the first
phase, each state will develop action strategies to address their identified
priority needs. Based on the priority needs and program strategies
developed, the state will select eight National Performance Measures
(NPMs) as part of its interim Five-year Action Plan. States will also give
consideration to the potential Evidence-based or –informed Strategy
Measures (ESMs) for addressing the selected NPMs and the three to five
State Performance Measures (SPMs) that will be developed in Application
Year 02. The SPMs should be based on the state’s identified MCH
priorities and target those priority needs that are not fully addressed by the
selected NPMs and their related ESMs.
Secondly, the state will set five-year targets (i.e., performance objectives)
for the eight selected NPMs in Application Year 01. In Application Year
02, the state will develop five-year performance targets for the ESMs and
the SPMs. The anticipated results of this stage are the identification of
NOMs, NPMs, SPMs and, ultimately, ESMs that directly relate to the State
priorities and establish a level of accountability for achieving measureable
progress.

Develop an Action Plan
The next stage is to develop an action plan, which involves the planning
and identification of specific activities for implementing the program
strategies which were developed in Stage 5 to address the identified
priority needs and selected national/state measures. In developing an
Action Plan, states will create the Five-year State Action Plan Table
described in Appendix B. As a planning tool, states will have flexibility in
how they format the Table provided that the information is organized
around the six identified population health domains. At a minimum, the
Five-year State Action Plan Table should include the relevant priority
needs, key strategies and measures (i.e., NOMs, NPMs, SPMs and
ESMs) for each of the population health domains. Based on the identified
priorities, measures and strategies, the state will develop a five-year
program plan that includes specific activities for achieving the targeted
outcomes and performance specific to each population health domain.
In developing the Action Plan, the state shall complete an interim Fiveyear State Action Plan Table (see sample in Appendix B) as part of the
first year Application/ Annual Report (i.e., FY 2016/FY 2014). This Table
15

is a tool to assist states in aligning their program strategies, NPMs, SPMs
and ESMs with the priority needs that were identified in the Five-year
Needs Assessment. States will refine the objectives and strategies and
add the ESMs for the selected NPMs and the SPMs to the Five-year
Action Plan Table in the second year Application/Annual Report (i.e.,
FY 2017/FY 2015). Updates to the strategies and activities will be
provided by the state, as needed, in subsequent interim year
Applications/Annual Reports. Figure 3 in Part Two, Section II.F of the
Application/Annual Report Guidance depicts the steps involved in the
development of, and the annual reporting on, the implementation of the
Five-year State Action Plan.
7.

Seek and Allocate Resources
Following the identification of program activities is the allocation of
resources stage. In this stage, the focus is on the funding of planned
activities to address state priorities. Inputs include the five-year State
Action Plan, current budgets, political priorities, and partnerships. The
anticipated outcome is the development of a program budget and plan that
directs available resources towards the activities identified in Stage Six as
the most important for addressing the state's priorities.

Monitor Progress for Impact on Outcomes
In monitoring progress for impact on outcomes, the states examine
the results of their efforts to see if there has been improvement. Inputs
include NOMs, NPMs, SPMs and ESMs, performance objectives and
other quantitative and qualitative information. Potential outcomes may
include altered activities and shifting of resource allocations to address
current levels of performance and availability of resources. Feedback
loops between various stages of the process allow for continuous input
and re-evaluation of the outputs.

Report Back to Stakeholders
This final step assures accountability to the stakeholders and partners
who have worked with the MCH staff throughout the Needs Assessment
process. It also assures the continued involvement of all stakeholders and
partners in the ongoing Needs Assessment processes.

APPENDIX E: PERFORMANCE MEASURE FRAMEWORK

Overview of the Framework

The performance measure framework is based on a three-tiered performance measure
system: National Outcome Measures (NOMs), National Performance Measures
(NPMs), and Evidence-based or -informed Strategy Measures (ESMs).
Measures were considered as NOMs, which are reflective of population health status, if
they met one or more of the following criteria: it was mandated by the Title V legislation
that the data be collected; it was considered a sentinel health marker for women,
infants, or children; it was a major focus of either the Title V legislation or Title V
activities; it was considered an important health condition to monitor because the
prevalence was increasing, but the reasons for the increase were unclear; or there was
a recognized need to move the MCH field forward in this area, even if there was not yet
a consensus on how to measure the construct. The latter were considered
developmental outcome measures.
Measures were considered as NPMs if they met one or more of the following criteria:
there was a large investment of resources as determined by the State narratives; it was
considered modifiable through Title V activities; a state could delineate measurable
activities to address the performance measures; significant disparities existed among
population groups; research had indicated that the condition or activity had large
societal costs; or research had indicated that the promotion of certain behaviors,
practices or policies had improved outcomes. There also had to be evidence that an
NPM was associated with at least one of the NOMs (see Table 1). Fifteen NPMs were
identified for the Title V MCH Services Block Grant. Data for NOMs and NPMs will be
populated by MCHB from national data sources, as available. NPMs will be stratified by
different risk factors, when available. See Table 2 for planned stratifiers.
The ESMs are the key to understanding how a State Title V program tracks
programmatic investments designed to impact the NPMs. In the framework, States
create ESMs designed to impact the NPMs. These measures would assess the impact
of State Title V strategies and activities contained in the State Action Plan. The
development of ESMs is guided through an examination of the evidenced-based or
evidence-informed practices on what strategies and activities are both practical and
measurable. The main criteria for ESMs would be that the activities had to measurable,
and there had to be evidence that the activity was related to the NPM chosen. States
Can determine the number of ESMs that they will use for addressing the selected NPMs
but there is a required minimum of one ESM for each NPM. States may also retire an
ESM during the five-year reporting cycle, if it has successfully achieved its objective
toward the NPM or new ESMs are introduced measuring new, promising practices.
Fifteen NPMs were identified for the Title V MCH Services Block Grant, covering six
population domains: Women’s/Maternal Health, Perinatal/Infant’s Health, Child Health,
Adolescent Health, Children with Special Health Care Needs, and Cross-cutting or Life
17

Course. In the table below are the 15 national priority areas addressed by the NPMs
and the corresponding MCH Population domain(s).
Table 3. NPMs and MCH Population Domains
NPM #

National Performance Priority
Areas

MCH Population Domains

1
2
3
4
5
6
7

Well woman care
Low risk cesarean deliveries
Perinatal regionalization
Breastfeeding
Safe sleep
Developmental screening
Injury

Women/Maternal Health
Women/Maternal Health
Perinatal/Infant Health
Perinatal/Infant Health
Perinatal/Infant Health
Child Health
Child Health and/or Adolescent Health

8
9
10
11
12
13
14
15

Physical activity
Bullying
Adolescent well-visit
Medical home
Transition
Oral health
Smoking
Adequate insurance coverage

Child Health and/or Adolescent Health
Adolescent Health
Adolescent Health
Children with Special Health Care Needs
Children with Special Health Care Needs
Cross-cutting/Life course
Cross-cutting/Life course
Cross-cutting/Life course

In implementing this framework, states will choose eight (8) out of 15 NPMS for its
Title V program to address during the five-year needs assessment cycle. States shall
ensure that at least one NPM from each of the six MCH Population domains is selected
and that the selected NPMs are based on the findings of the Five-Year Needs
Assessment process. There are no mandatory NPMs. For the NPMs on injury and
physical activity, they can be selected for either the children’s or the adolescent
domains or both because the age ranges span both domains, but the interventions to
either reduce injuries or increase physical activity are different, depending on the
children’s ages.
Implementation of Measurement
National Outcome Measures
NOMs are for population health assessment which is an important core function of
public health. They should be tracked to understand the MCH population’s health, and
are important for the development of the needs assessment. Changes in NOM
indicators can be discussed in the appropriate population domain section of the
narrative but there is not a reporting requirement for this discussion. Data for NOMs will
be prepopulated, where possible. States do not provide performance objectives for
NOMs.

National Performance Measures
Once NPMs are selected, a state will track the eight NPMs throughout the five-year
reporting cycle. States are encouraged not to change the selected NPMs during the
five-year reporting cycle. If a state determines that a NPM needs to be changed, clear
justification must be provided. In an effort to reduce state burden, annual performance
data (indicator/numerator/denominator) for the NOMs and the NPMs will be prepopulated by MCHB from national data sources, as available, and provided to the states
for their use in preparing the yearly Title V MCH Block Grant Applications/Annual
Reports. If a state selects a NPM for which it is not part of the national data source, the
state can develop its own detail sheet and report its data for the measure. However, the
definition and data that are collected must match the definition and measure of the
national data source.
In the first reporting year of this guidance, a State selects its NPMs and determines
performance objectives for FY 2016-2020 for the NPMs. Performance objectives for
future years can be changed for individual NPMs based on ongoing needs assessment
efforts and performance monitoring.
Other Guidelines for NPMs
Use of Provisional Data: States may, but are not required to, include more timely
provisional data if they choose. This will not replace the prepopulated final data
provided for the measures.
Lacking a National Data Source: States can choose a measure if they do not have the
data source noted on the detail sheet, as long as they provide the indicator, numerator
and denominator data as defined on the detail sheet. As for PRAMS, States will be able
to submit their PRAMS or PRAMS-like data to TVIS following the same definition for a
given measure if CDC cannot furnish it. The same situation may apply to other data
sources; for example, all states with hospital discharge data provided to AHRQ. If a
state provides its own data from a different source, this should be annotated in a field
note.
Integrated Measures: For integrated measures, states can choose a NPM even if they
do not have the data from both data sources. Both measures will be reported for these
types of measures. Where there are data for both sources, data will be displayed and
would need to be discussed for both populations. If only one data source is available,
that population will need to be addressed. States will develop an ESM to address each
of the strategies developed for the measure.
Evidence-based or -informed Strategy Measures
Developed by the State, Evidence-based or -informed Strategy Measures would assess
the impact of State Title V strategies and activities contained in the State Action Plan. It
is envisioned that the development of the ESMs will be guided through an examination
19

of the evidenced-based or evidence-informed practices on what strategies and activities
are both practical and measurable. The main criteria for the state ESMs would be that
the strategies and activities have to be measurable, and there has to be evidence that
the activity is related to the performance measure chosen. Most issues in MCH are
multifactorial, therefore, while states are strongly encouraged to develop multiple
strategies with a related ESM for each strategy to impact a selected NPM, states are
required to submit at least one ESM for each of the NPMs selected.
In the second reporting year (FY 2017 Application/FY 2015 Annual Report), states will
develop a detail sheet for each ESM, which they will submit as part of the FY 2017
Application/FY 2015 Annual Report. On the detail sheet, states will define the:
(1) measures; (2) goal; (3) indicator, numerator, and denominator; (4) data source; and
(5) significance. Beginning with the third reporting year (FY 2018 Application/FY 2016
Annual Report), states will track performance for the ESMs that were established for
this five-year needs assessment cycle. States will determine performance objectives for
each of the ESMs for application years FY 2018-FY 2020. These objectives can be
revised, as needed, for future reporting years. Data for the ESMs (i.e.,
numerator/denominator) will be entered annually by the state. During the five-year
reporting cycle, the ESMs may be modified, replaced, or retired, based on analysis of
the effectiveness of the strategy or the validity of the measure.
State Performance and Outcome Measures
To address state priorities not addressed by the National Performance Measures, the
State Performance Measures (SPMs) will be developed as part of the second reporting
year Application/Annual Report (i.e., FY 2017 Application/FY 2015 Annual Report), and
states will establish performance objectives for five years FY 2018-FY 2022) for each of
the measures. States may revise their SPM objectives in future years’
Applications/Annual Reports. The development of the SPMs coincides with the
development of the state ESMs.
States will also develop detail sheets on these measures, which will define the:
(1) measure; (2) goal; (3) indicator, numerator, and denominator; (4) data source; and
(5) significance. States will track their three to five SPMs throughout the five-year
reporting cycle. Data for the SPMs (i.e., indicator/numerator/denominator) will be
entered annually by the state. A state can retire a SPM during the five-year reporting
cycle and replace it with another SPM based on its MCH priority needs. States are not
required to develop ESMs for SPMs.
A state may also develop (but is not required to develop) one or more State Outcome
Measures (SOMs) based on its MCH priorities, as determined by the findings of the
Five-Year Needs Assessment, provided that none of the NOMs address the same
priority area for the state. A SOM should be linked with a performance measure to
show the impact of performance on the intended outcome. States will track the SOMs
during the five-year reporting cycle and the SOM can be retired if the state chooses.

Data for the SOMs (i.e., indicator/numerator/ denominator) will be entered annually by
the state.
Table 1. National Outcome Measures - National Performance Measures Linkage
NPM
#

National Performance Measure (NPM)

National Outcome Measures
Associated with National Performance Measure

Well woman care (Percent of women with a past
year preventive visit)

Severe maternal morbidity per 10,000 delivery
hospitalizations
Low birth weight rate (%)
Preterm birth rate (%)
Infant mortality per 1,000 live births
Perinatal mortality per 1,000 live births plus fetal deaths
Neonatal mortality per 1,000 live births
Preterm-related mortality per 1,000 live births

Low risk cesarean deliveries (Percent of cesarean
deliveries among low-risk first births)

Severe maternal morbidity per 10,000 delivery
hospitalizations
Maternal death rate per 100,000 live births

Perinatal regionalization (Percent of very low birth
weight (VLBW) infants born in a hospital with a
Level III+ Neonatal Intensive Care Unit (NICU))

Infant mortality per 1,000 live births
Perinatal mortality per 1,000 live births plus fetal deaths
Neonatal mortality per 1,000 live births
Preterm-related mortality per 1,000 live births

Breastfeeding (A. Percent of infants who are ever
breastfed and B. Percent of infants breastfed
exclusively through 6 months)

Sleep-related SUID mortality per 1,000 live births

Safe sleep (Percent of infants placed to sleep on
their backs)

Infant mortality per 1,000 live births
Post neonatal mortality per 1,000 live births
Sleep-related SUID mortality per 1,000 live births

Developmental screening (Percent of children, ages
9 through 71 months, receiving a developmental
screening using a parent-completed screening tool)

Percent of children in excellent or very good health
Percent of children meeting the criteria developed for
school readiness

NPM
#

National Performance Measure (NPM)

National Outcome Measures
Associated with National Performance Measure

Child Injury (Rate of injury-related hospital
admissions per population aged 0 through 19 years

The child death rate per 100,000 children aged 1
through 9
Rate of death in adolescents age 10-19 per 100,000

Physical activity (Percent of children ages 6 through
11 and adolescents ages 12 through 17 who are
physically active at least 60 minutes per day)

Percent of children and adolescents who are
overweight or obese (BMI at or above the 85th
percentile)

Bullying (Percent of adolescents, 12 through 17,
who are bullied)

Rate of death in adolescents age 10-19 per 100,000
Rate of suicide deaths among youths aged 15 through
19 per 100

Adolescent well-visit (Percent of adolescents with a
preventive services visit in the last year)

Percent of children and adolescents in very good health
Immunization (Percent of children and adolescents who
have completed recommended vaccines)
Rate of death in adolescents 12-20 per 100,000
Rate of suicide deaths among youths aged 15 through
19 per 100,000
Percent of adolescents in grades 9-12 who used
tobacco products in the past month
Percent of adolescents with mental health problems
who receive treatment

Medical home (Percent of children with and without
special health care needs having a medical home)

Systems of care for children with special health care
needs (Percent of children and youth with special health
care needs (CYSHCN) receiving care in a wellfunctioning system)

Transition (Percent of children with and without
special health care needs who received services
necessary to make transitions to adult health care)

Systems of care for children with special health care
needs (Percent of children and youth with special health
care needs (CYSHCN) receiving care in a wellfunctioning system)

Oral health (A. Percent of women who had a dental
visit during pregnancy and B. Percent of infants and
children, ages 1 to 17 years, who had a preventive
dental visit in the last year)

Percent of children and adolescents in very good health

Percent of children ages 1-6 who have decayed teeth or
cavities in the past 12 months

NPM
#

National Performance Measure (NPM)

National Outcome Measures
Associated with National Performance Measure

Smoking during Pregnancy and Household Smoking
(A. Percent of women who smoke during pregnancy
and B. Percent of children who live in households
where someone smokes)

Low birth weight rate (%)
Preterm birth rate (%)
Infant mortality per 1,000 live births
Perinatal mortality per 1,000 live births plus fetal deaths
Neonatal mortality per 1,000 live births
Preterm-related mortality per 1,000 live births
Post neonatal mortality per 1,000 live births
Sleep-related SUID mortality per 1,000 live births
Severe maternal morbidity per 10,000 delivery
hospitalizations
Percent of children in excellent or very good health

Adequate insurance coverage (Percent of children 0
through 17 who are adequately insured)

Percent of children without health insurance
Systems of care for children with special health care
needs (Percent of children and youth with special health
care needs (CYSHCN) receiving care in a wellfunctioning system)

Table 2. Stratifiers for National Performance Measures
No.

Title

Planned Stratifiers

Percent of women with a past year preventive visit

Percent of cesarean deliveries among low-risk first births

Percent of very low birth weight (VLBW) infants born in a
hospital with a Level III+ Neonatal Intensive Care Unit (NICU)

A) Percent of infants who are ever breastfed and B) Percent of
infants breastfed exclusively through 6 months

Sex
Birth order
Maternal race/ethnicity
Maternal age
Maternal education Poverty
Marital status
WIC
Metro status

Percent of infants placed to sleep on their backs

Percent of children, ages 9 through 71 months, receiving a
developmental screening using a parent-completed screening
tool

Age
Race/ethnicity
Education
Insurance
Marital status
Age
Sex
Race/ethnicity
Nativity
Language
CSHCN status
Household structure
Parental education Poverty
Insurance
Metro/non-metro

Rate of injury-related hospital admissions per population ages
0 through 19 years

Age
Race/ethnicity
Nativity
Education
Income
Insurance
Metro/non-metro
Age
Race/ethnicity
Nativity
Education
Insurance
Marital status
Quarter of the year
Metro/non-metro
Age
Race/ethnicity
Nativity
Education
Insurance
Marital status
Metro/non-metro

Age
Sex
Race/ethnicity
Insurance
Metro/non-metro

No.
8

Title

Planned Stratifiers

Percent of children ages 6 through 11 years and adolescents
ages 12 through 17 years who are physically active at least 60
minutes per day

YRBSS:
Sex
Grade
Race/ethnicity
NSCH:
Age
Sex
Race/ethnicity
Nativity
Language
CSHCN status
Household structure
Parental education Poverty
Insurance
Metro/non-metro

Percent of adolescents, ages 12 through 17 years, who are
bullied

YRBSS:
Sex
Grade
Race/ethnicity
NSCH:
Age
Sex
Race/ethnicity
Nativity
Language
CSHCN status
Household structure
Parental education Poverty
Insurance
Metro/non-metro

Percent of adolescents with a preventive services visit in the
last year

Age
Sex
Race/ethnicity
Nativity
Language
CSHCN status
Household structure
Parental education Poverty
Insurance
Metro/non-metro

Percent of children with and without special health care needs
having a medical home

Age
Sex
Race/ethnicity
Nativity
Language
CSHCN status
Household structure
Parental education Poverty
Insurance
Metro/non-metro

No.

Title

Planned Stratifiers

Percent of children with and without special health care needs
who received services necessary to make transitions to adult
health care

Age
Sex
Race/ethnicity
Nativity
Language
CSHCN status
Household structure
Parental education Poverty
Insurance
Metro/non-metro

A) Percent of women who had a dental visit during pregnancy
and B) Percent of infants and children, ages 1 through 17
years, who had a preventive dental visit in the last year

PRAMS:
Age
Race/ethnicity
Education
Insurance
Marital status

NSCH:
Age
Sex
Race/ethnicity
Nativity
Language
CSHCN status
Household structure
Parental education Poverty
Insurance
Metro/non-metro
14

A) Percent of women who smoke during pregnancy and B)
Percent of children who live in households where someone
smokes

Vitals:
Age
Race/ethnicity
Nativity
Education
Insurance
Marital status
Quarter of the year
Metro/non-metro
NSCH:
Age
Sex
Race/ethnicity
Nativity
Language
CSHCN status
Household structure
Parental education Poverty
Insurance
Metro/non-metro

No.
15

Title

Planned Stratifiers

Percent of children 0 through 17 years who are adequately
insured

Age
Sex
Race/ethnicity
Nativity
Language
CSHCN status
Household structure
Parental education Poverty
Insurance
Metro/non-metro

APPENDIX F:

DETAIL SHEETS FOR THE NATIONAL OUTCOME
MEASURES AND NATIONAL PERFORMANCE
MEASURES

A. National Outcome Measures

B. National Performance Measures

A.
NOM #
1
2

National Outcome Measure
Percent of infants born to pregnant women receiving prenatal care beginning in the first
trimester
Percent of delivery or postpartum hospitalizations with an indication of severe maternal
morbidity

3
4.1
4.2
4.3
5.1
5.2
5.3
6
7

Maternal mortality rate per 100,000 live births
Percent of low birth weight deliveries (<2,500 grams)
Percent of very low birth weight deliveries (<1,500 grams)
Percent of moderately low birth weight deliveries (1,500-2,499 grams)
Percent of preterm births (<37 weeks gestation)
Percent of early preterm births (<34 weeks gestation)
Percent of late preterm births (34-36 weeks gestation)
Percent of early term births (37,38 weeks gestation
Percent of non-medically indicated delivery at 37, 38 weeks' gestation among singleton
deliveries without pre-existing conditions

8
9.1
9.2
9.3
9.4
9.5
10
11

Perinatal mortality rate per 1,000 live births plus fetal deaths
Infant mortality rate per 1,000 live births
Neonatal mortality rate per 1,000 live births
Postneonatal mortality rate per 1,000 live births
Preterm-related mortality rate per 1,000 live births
Sudden Unexpected Infant Deaths (SUID) mortality rate per 1,000 live births
The rate of infants born with fetal alcohol syndrome per 10,000 delivery hospitalizations
The rate of infants born with neonatal abstinence syndrome per 10,000 delivery
hospitalizations
Percent of eligible newborns screened for heritable disorders with on time physician
notification for out of range screens who are followed up in a timely manner.
(DEVELOPMENTAL)

Percent of children meeting the criteria developed for school readiness
(DEVELOPMENTAL)

Percent of children ages 1-6 who have decayed teeth or cavities in the past 12 months

15
16.1
16.2

Rate of death in children aged 1 through 9 per 100,000
Rate of death in adolescents age 10-19 per 100,000
Rate of deaths to children aged 15-19 years caused by motor vehicle crashes per
100,000

16.3
17.1
17.2

Rate of suicide deaths among youths aged 15 through 19 per 100,000
Percent of children with special health care needs
Percent of children with special health care needs (CSHCN) receiving care in a wellfunctioning system

17.3
17.4

Percent of children diagnosed with an autism spectrum disorder
Percent of children diagnosed with Attention Deficit Disorder/Attention Deficit
Hyperactivity Disorder (ADD/ADHD)

18
19
20

Percent of children with a mental/behavioral condition who receive treatment
Percent of children in excellent or very good health
Percent of children and adolescents who are overweight or obese (BMI at or above the
85th percentile)

21
22.1

Percent of children without health insurance
Percent of children ages 19-35 months, with the 4:3:1:3(4):3:1 :4 combined series of
vaccines

22.2

Percent of children 6 months to 17 years who are vaccinated annually against seasonal
influenza

NOM #
22.3

National Outcome Measure
Percent of adolescents, ages 13-17, who have received at least one dose of the HPV
vaccine

22.4

Percent of adolescents, ages 13-17, who have received at least one dose of the Tdap
vaccine

22.5

Percent of adolescents, ages 13-17, who have received at least one dose of the
meningococcal conjugate vaccine

OUTCOME MEASURE 1

Percent of infants born to pregnant women
receiving prenatal care beginning in the first
trimester

GOAL

To ensure early entrance into prenatal care to enhance
pregnancy outcomes.

DEFINITION

Numerator:
Number of live births with reported first prenatal visit during the
first trimester (before 13 weeks’ gestation) in the calendar year
Denominator:
Number of live births in the State in the calendar year
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) 10.1.
Increase the proportion of pregnant women who receive
prenatal care beginning in the first trimester. (Baseline: 70.8 %
of females delivering a live birth received prenatal care
beginning in the first trimester in 2007, Target: 77.9%)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

Early identification of maternal disease and risks for
complications of pregnancy or birth are the primary reason for
first trimester entry into prenatal care. This can help ensure that
women with complex problems and women with chronic illness
or other risks are seen by specialists. Early high-quality prenatal
care is critical to improving pregnancy outcomes.

OUTCOME MEASURE 2

Percent of deliveries or postpartum
hospitalizations with an indication of severe
maternal morbidity

GOAL

To reduce life-threatening maternal illness and complications.

DEFINITION

Numerator:
Deliveries or postpartum hospitalizations with an indication of
severe morbidity from ICD-10 diagnosis or procedure codes
(e.g. heart or kidney failure, stroke, embolism, hemorrhage).
Exact codes TBD
Denominator:
Delivery hospitalizations
Units: 10,000

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Rate

Related to Maternal, Infant, and Child Health (MICH) 5. Reduce
the rate of maternal mortality. (Baseline:12.7 maternal deaths
per 100,000 live births in 2007, Target: 11.4 maternal deaths per
100,000 live births)
Related to Maternal, Infant, and Child Health (MICH) 6. Reduce
maternal illness and complications due to pregnancy
(complications during hospitalized labor and delivery) .
(Baseline: 31.1%, Target: 28%)

DATA SOURCES and DATA
ISSUES

HCUP – State inpatient database

SIGNIFICANCE

Severe maternal morbidity is more than 100 times as common
as pregnancy-related mortality—translating to about 52,000
women affected annually—and it is estimated to have increased
by 75 percent over the past decade. Rises in chronic conditions,
including obesity, diabetes, hypertension, and cardiovascular
disease, are likely to have contributed to this increase
(Callaghan et al, 2012).
Minority women and particularly non-Hispanic black women
have higher rates of severe maternal morbidity. Non-Hispanic
Black, Hispanic, Asian/Pacific Islander, and American
Indian/Alaska Native women had 2.1, 1.3, 1.2, and 1.7 times,
respectively, higher rates of severe morbidity compared with
non-Hispanic white women (Creanga et al, 2014).

OUTCOME MEASURE 3

The maternal death rate per 100,000 live births

GOAL

To reduce the maternal death rate.

DEFINITION

Numerator:
Deaths related to or aggravated by pregnancy and occurring
within 42 days of the end of a pregnancy
Denominator:
Number of resident live births
Units: 100,000

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Rate

Identical to Maternal, Infant, and Child Health (MICH) 5.
Reduce the rate of maternal mortality. (Baseline:12.7 maternal
deaths per 100,000 live births in 2007, Target: 11.4 maternal
deaths per 100,000 live births)
Related to Maternal, Infant, and Child Health (MICH) 6. Reduce
maternal illness and complications due to pregnancy
(complications during hospitalized labor and delivery) .
(Baseline: 31.1%, Target: 28%)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System-Mortality (NVSS-M),
CDC/NCHS; National Vital Statistics System-Natality (NVSS-N),
CDC/NCHS

SIGNIFICANCE

Maternal deaths related to childbirth in the U.S. are nearly at the
highest rate in a quarter century, and the U.S. has seen a rise in
maternal mortality over the past decade. The rate of death for
mothers for every 100,000 live births was18.5 in the U.S. in
2013, a total of almost 800 deaths, showing a rise in
pregnancy-related deaths in the U.S. since at least 1987, when
the mortality rate was 7.2 per 100,000 births.
There are also significant racial disparities with Black women
being three times as likely White women to experience maternal
death.

OUTCOME MEASURE 4.1

Percent of low birth weight deliveries (<2,500
grams)

GOAL

To reduce the proportion of low birth weight deliveries

DEFINITION

Numerator:
Number of resident live births weighing less than 2,500 grams
Denominator:
Number of live resident births
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Identical to Maternal, Infant, and Child Health (MICH) Objective
8.1: Reduce low birth weight (LBW). (Baseline: 8.2% in 2007,
Target 7.8%)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

The general category of low birth weight infants includes preterm infants and infants with intrauterine growth retardation.
Many risk factors have been identified for low birth weight
babies including: both young and old maternal age, poverty,
late prenatal care, smoking, substance abuse, and multiple
births. Advanced maternal age and in vitro fertilization has
increased the number of multiple births. Multiple births often
result in shortened gestation and low or very low birth weight
infants. In 2010, 68% of all infant deaths occurred to the 8.2% of
low birth weight infants and over half (53%) of all infant deaths
occurred to the 1.5% of very low birth weight infants.
Infants born to non-Hispanic Black women have the highest
rates of low birth weight, particularly very low birth weight. In
2012, 13.2 percent of non-Hispanic Black infants were born low
birthweight and 2.9 percent were born at very low birth weight-these rates are 1.9 and 2.6 times the rates for infants born to
non-Hispanic Whites women (7.0 and 1.1 percent, respectively).
Infants born to Puerto Rican women also have elevated rates of
low and very low birth weight (9.4 and 1.8, respectively).

OUTCOME MEASURE 4.2

Percent of very low birth weight deliveries
(<1,500 grams)

GOAL

To reduce the proportion of low birth weight deliveries

DEFINITION

Numerator:
Number of resident live births weighing less than 1,500 grams
Denominator:
Number of live resident births
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Identical to MICH Objective 8.2: Reduce very low birth weight
(VLBW). (Baseline: 1.5% in 2007, Target 1.4%)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

OUTCOME MEASURE 4.3

Percent of moderately low birth weight deliveries
(1,500-2,499 grams)

GOAL

To reduce the proportion of low birth weight deliveries

DEFINITION

Numerator:
Number of resident live births weighing between 1,500-2,499
grams
Denominator:
Number of live resident births
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective
8.1: Reduce low birth weight (LBW). (Baseline: 8.2% in 2007,
Target 7.8%)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

The general category of low birth weight infants includes preterm infants and infants with intrauterine growth retardation.
Many risk factors have been identified for low birth weight
babies including: both young and old maternal age, poverty,
late prenatal care, smoking, substance abuse, and multiple
births. Advanced maternal age and in vitro fertilization has
increased the number of multiple births. Multiple births often
result in shortened gestation and low or very low birth weight
infants. In 2010, 68% of all infant deaths occurred to the 8.2%
of low birth weight infants and over half (53%) of all infant
deaths occurred to the 1.5% of very low birth weight infants.
Infants born to non-Hispanic Black women have the highest
rates of low birth weight, particularly very low birth weight. In
2012, 13.2 percent of non-Hispanic Black infants were born low
birthweight and 2.9 percent were born at very low birth weight-these rates are 1.9 and 2.6 times the rates for infants born to
non-Hispanic Whites women (7.0 and 1.1 percent, respectively).
Infants born to Puerto Rican women also have elevated rates of
low and very low birth weight (9.4 and 1.8, respectively).

OUTCOME MEASURE 5.1

Percent of preterm births (<37 weeks)

GOAL

To reduce the proportion of all preterm, early term, and early
elective deliveries.

DEFINITION

Numerator:
Number of resident live births before 37 weeks of complete
gestation
Denominator:
Number of live resident births
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Identical to Maternal, Infant, and Child Health (MICH) Objective
9.1: Reduce total preterm births (PTB). (Baseline:12.7% in
2007, Target 11.4%)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

Babies born preterm, before 37 completed weeks of gestation,
are at increased risk of immediate life-threatening health
problems, as well as long-term complications and
developmental delays. Among preterm infants, complications
that can occur during the newborn period include respiratory
distress, jaundice, anemia, and infection, while long-term
complications can include learning and behavioral problems,
cerebral palsy, lung problems, and vision and hearing loss. As a
result of these risks, preterm birth is a leading cause of infant
death and childhood disability. Although the risk of complications
is greatest among those babies who are born the earliest, even
those babies born “late preterm” (34 to 36 weeks’ gestation) and
"early term" (37, 38 weeks' gestation) are more likely than fullterm babies to experience morbidity and mortality.
Infants born to non-Hispanic Black women have the highest
rates of preterm birth, particularly early preterm birth. In 2012,
16.5 percent of non-Hispanic Black infants were born preterm
and 5.9 percent were born early preterm--these rates are 1.6
and 2.0 times the rates for infants born to non-Hispanic Whites
women (10.3 and 2.9 percent, respectively). Infants born to
Puerto Rican, Cuban, and American Indian/Alaska Native
mothers also had elevated rates of preterm and early preterm
birth.
Non-medically indicated early term births (37,38 weeks) present
avoidable risks of neonatal morbidity and costly NICU admission
(Clark et al, 2009; Tita et al, 2009). Early elective delivery prior
to 39 weeks is an endorsed perinatal quality measure by the
Joint Commission, National Quality Forum, ACOG/NCQA,
Leapfrog Group, and CMS/CHIPRA.

OUTCOME MEASURE 5.2

Percent of early preterm births (<34 weeks)

GOAL

To reduce the proportion of all preterm, early term, and early
elective deliveries.

DEFINITION

Numerator:
Number of resident live births before 34 weeks of completed
gestation.
Denominator:
Number of live resident births
Units: 100

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Percent

Related to Maternal, Infant, and Child Health (MICH) Objective
9.3: Reduce live births at 32-33 weeks. (Baseline: 1.6% in 2007,
Target 1.4%)
Related to MICH Objective 9.4: Reduce early preterm or births
at less than 32 weeks' gestation. (Baseline: 2.0% in 2007,
Target 1.8%)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

Joint Commission, National Quality Forum, ACOG/NCQA,
Leapfrog Group, and CMS/CHIPRA.

OUTCOME MEASURE 5.3

Percent of late preterm births (34-36 weeks)

GOAL

To reduce the proportion of all preterm, early term, and early
elective deliveries.

DEFINITION

Numerator:
Number of resident live births between 34 and 36 weeks of
completed gestation
Denominator:
Number of live resident births
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Identical to MICH Objective 9.2: Reduce late preterm or births at
34-36 weeks' gestation. (Baseline: 9.0% in 2007, Target 8.1%)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

OUTCOME MEASURE 6

Percent of early term births (37,38 weeks)

GOAL

To reduce the proportion of all preterm, early term, and early
elective deliveries.

DEFINITION

Numerator:
Number of live resident births born at 37,38 weeks of completed
gestation
Denominator:
Number of live resident births
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE
DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

OUTCOME MEASURE 7

Percent of non-medically indicated early term
deliveries (37,38 weeks) among singleton term
deliveries

GOAL

To reduce the proportion of all preterm, early term, and early
elective deliveries.

DEFINITION

Numerator:
Inductions or cesareans without trial of labor and without
indication (fetal distress, prolonged labor, PROMS) at 37, 38
weeks' gestation among singleton deliveries without pre-existing
conditions, following The Joint Commission list of conditions
possibly justifying delivery <39 weeks
Denominator:
Number of singleton live births at 37-41 weeks' gestation without
pre-existing conditions, following the Joint Commission list of
conditions possibly justifying delivery <39 weeks
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE
DATA SOURCES and DATA
ISSUES

CMS HospitalCompare data

SIGNIFICANCE

(Clark et al, 2009; Tita et al, 2009). Early elective delivery prior
to 39 weeks is an endorsed perinatal quality measure by the
Joint Commission, National Quality Forum, ACOG/NCQA,
Leapfrog Group, and CMS/CHIPRA.

OUTCOME MEASURE 8

Perinatal mortality rate per 1,000 live births plus
fetal deaths

GOAL

To reduce the rate of perinatal deaths.

DEFINITION

Numerator:
Number of fetal deaths 28 weeks or more gestation plus early
neonatal deaths occurring under 7 days
Denominator:
The number of live resident births plus fetal deaths
Units: 1,000

Text: Rate

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective
1.2: Reduce the rate of fetal and infant deaths during the
perinatal period (28 weeks of gestation to 7 days after birth).
(Baseline: 6.6 fetal and infant deaths per 1,000 live births and
fetal deaths occurred during the perinatal period, 28 weeks
gestation to 7 days after birth, in 2005; Target: 5.9 perinatal
deaths per 1,000 live births and fetal deaths)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

Perinatal mortality is a reflection of the health of the pregnant
woman and newborn and reflects the pregnancy environment
and early newborn care.
Perinatal mortality is particularly high for non-Hispanic Black
women. In 2006, the rate for non-Hispanic black women (11.76)
was the highest among the racial and ethnic groups, and was
more than twice the rate for non-Hispanic white women.

OUTCOME MEASURE 9.1

Infant mortality rate per 1,000 live births

GOAL

To reduce the rate of infant death.

DEFINITION

Numerator:
Number of deaths to infants from birth through 364 days of age
Denominator:
Number of live resident births
Units: 1,000

Text: Rate

HEALTHY PEOPLE 2020
OBJECTIVE

Identical to Maternal, Infant, and Child Health (MICH) Objective
1.3: Reduce the rate of all infant deaths (within 1 year).
(Baseline: 6.7 infant deaths per 1,000 live births within the first
year of life in 2006, Target: 6.0 infant deaths per 1,000 live
births)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

The U.S. infant mortality rate has substantially declined over the
last century. Based on preliminary data for 2011, 23,910 infants
died before age one year, representing an infant mortality rate of
6.05 deaths per 1,000 live births, which is the lowest infant
mortality rate recorded in the U.S. However, significant
disparities continue to persist in U.S. infant deaths between
racial groups, especially for Blacks and American Indians and
Alaskan Natives. The non-Hispanic Black infant mortality rate
(12.2 deaths per 1,000 live births in 2010) is nearly two and half
times the rate among non-Hispanic Whites and Hispanics.
(Child Health USA 2013: Department of Health and Human
Services, HRSA). The infant mortality rate in American Indians
and Alaskan Natives is more than one and a half times the rate
of non-Hispanic Whites. Infant mortality continues to be an
extremely complex health issue with many medical, social, and
economic determinants, including race/ethnicity, maternal age,
education, smoking and health status.

OUTCOME MEASURE 9.2

Neonatal mortality rate per 1,000 live births

GOAL

To reduce the rate of neonatal deaths.

DEFINITION

Numerator:
Number of deaths to infants under 28 days
Denominator:
Number of live resident births
Units: 1,000

Text: Rate

HEALTHY PEOPLE 2020
OBJECTIVE

Identical to Maternal, Infant, and Child Health (MICH) Objective
1.4: Reduce the rate of neonatal deaths (within the first 28 days
of life). (Baseline: 4.5 neonatal deaths per 1,000 live births
occurred within the first 28 days of life in 2006, Target: 4.1
neonatal deaths per 1,000 live births)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

The preliminary U.S. neonatal infant mortality rate was 4.06
deaths per 1,000 live births in 2011, accounting for two-thirds of
all infant deaths. Neonatal mortality is related to gestational
age, low birth weight, congenital malformations and health
problems originating in the perinatal period, such as infections or
birth trauma.
A significant disparity exists in neonatal deaths between racial
groups, especially for infants born to Black women. NonHispanic black women had the highest neonatal mortality rate in
2010 at 7.45, 2.2 times that for non-Hispanic white women
(3.35). Neonatal mortality rates were also higher for Puerto
Rican (4.82), AIAN (4.28), and Mexican women (3.53) than for
non-Hispanic white women.

OUTCOME MEASURE 9.3

Post neonatal mortality rate per 1,000 live births

GOAL

To reduce the rate of post-neonatal deaths.

DEFINITION

Numerator:
Number of deaths to infants 28 through 364 days of age
Denominator:
Number of live births
Units: 1,000

Text: Rate

HEALTHY PEOPLE 2020
OBJECTIVE

Identical to Maternal, Infant, and Child Health (MICH) Objective
1.5: Reduce the rate of post-neonatal deaths (between 28 days
and 1 year). (Baseline: 2.2 post-neonatal deaths per 1,000 live
births occurred between 28 days and 1 year of life in 2006,
Target: 2.0 post-neonatal deaths per 1,000 live births)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

Postneonatal mortality is generally related to Sudden
Unexpected Infant Death (SUID)/Sudden Infant Death
Syndrome (SIDS), unintentional injuries and congenital
malformations. In 2011, the preliminary U.S. postneonatal
mortality rate was 2.01 deaths per 1,000 live births.
Similar to overall infant mortality, infants of non-Hispanic black
(4.01) and AIAN (4.00) women had the highest postneonatal
mortality rates of any group—more than twice those for nonHispanic white women (1.82) in 2010. The postneonatal
mortality rate was also higher for Puerto Rican women (2.28)
than for non-Hispanic white women.

OUTCOME MEASURE 9.4

Rate of deaths due to preterm-related causes

GOAL

To reduce the number of preterm-related deaths.

DEFINITION

Numerator:
Number of deaths due to preterm-related causes. Causes are
defined as preterm-related if 75% or more of infants whose
deaths were attributed to that cause were born at at less than 37
weeks of gestation, and the cause of death was a direct
consequence of preterm birth based on a clinical evaluation and
review of the literature. This includes low birth weight, several
maternal complications, respiratory distress, bacterial sepsis,
etc. To be included as a preterm-related death, the infant must
have been born preterm (<37 completed weeks of gestation)
with the underlying cause of death assigned to one of the
following ICD-10 categories: K550, P000, P010, P011, P015,
P020, P021, P027, P070–P073, P102, P220–229, P250–279,
P280, P281, P360–369, P520–523, and P77.
Denominator:
Number of live resident births
Units: 1,000

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Rate

Related to Maternal, Infant, and Child Health (MICH) Objective
1.4: Reduce the rate of neonatal deaths (within the first 28 days
of life). (Baseline: 4.5 neonatal deaths per 1,000 live births
occurred within the first 28 days of life in 2006, Target: 4.1
neonatal deaths per 1,000 live births)
Related to Maternal, Infant, and Child Health (MICH) Objective
1.3: Reduce the rate of all infant deaths (within 1 year).
(Baseline: 6.7 infant deaths per 1,000 live births within the first
year of life in 2006, Target: 6.0 infant deaths per 1,000 live
births)
Related to Maternal, Infant, and Child Health (MICH) Objective
9.1: Reduce total preterm births (PTB). (Baseline:12.7% in
2007, Target 11.4%)
Related to Maternal, Infant, and Child Health (MICH) 33:
Increase the proportion of very low birth weight (VLBW) infants
born at Level III hospitals or subspecialty perinatal centers
(Baseline: 75% in 2003-2006, Target: 83.7)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

Preterm birth is a leading cause of infant mortality. In 2010,
35% of infant deaths were preterm-related or considered to be a
direct consequence of prematurity. There are significant
racial/ethnic disparities in preterm-related deaths. The pretermrelated infant mortality rate for non-Hispanic black women (4.87
per 1,000) is three times that for non-Hispanic white women.
The preterm-related infant mortality rate is 86% higher for

Puerto Rican women (2.95 per 1,000), and 10% higher for
Mexican women (1.74 per 100,000), than for non-Hispanic white
women.

OUTCOME MEASURE 9.5

Rate of sleep-related Sudden Unexpected Infant
Deaths (SUID) deaths to infants

GOAL

To reduce the number of sleep-related SUID deaths.

DEFINITION

Numerator:
Number of sleep-related SUID deaths to infants
Denominator:
Number of live resident births
Units: 1,000

Text: Rate

HEALTHY PEOPLE 2020
OBJECTIVE

Identical to Maternal, Infant, and Child Health (MICH) Objective
1.9: Reduce the rate of infant deaths from sudden unexpected
infant deaths (includes SIDS, Unknown Cause, Accidental
Suffocation, and Strangulation in Bed). (Baseline: .93 per 1,000
live births in 2006, Target: .84 infant deaths per 1,000 live births)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

Sleep-related SUIDs are the leading cause of death in infants
from one month up to one year (postneonatal deaths) and the
third leading cause of all infant deaths. In 2010, there were a
total of 3,610 or 0.9 sudden unexpected infant deaths (SUID)
per 1,000 live births, accounting for 43 percent of postneonatal
deaths and 15 percent of all infant deaths.
SUID rates vary greatly by race and ethnicity. In 2010, SUID
rates were highest for infants born to American Indian/Alaska
Native and non-Hispanic Black mothers (1.82 and 1.77 per
1,000, respectively); these rates were more than twice the rate
among infants born to non-Hispanic Whites (0.87 per 1,000).

OUTCOME MEASURE 10

The rate of infants born with fetal alcohol
syndrome per 10,000 delivery
hospitalizations

GOAL

To reduce the number of infants born with fetal alcohol
syndrome (FAS)

DEFINITION

Numerator:
Number of infants born with fetal alcohol syndrome (FAS)
Denominator:
Number of delivery hospitalizations
Units: 10,000

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Rate

Related to Maternal, Infant, and Child Health (MICH) 2.11.
Increase abstinence from alcohol among pregnant women.
(Baseline: 89.4 percent of pregnant females aged 15 to 44 years
reported abstaining from alcohol in the past 30 days in 2007–08,
Target: 98.3%)
Related to Maternal, Infant, and Child Health (MICH) 25.
Reduce the occurrence of fetal alcohol syndrome. (Baseline: 3.6
cases of fetal alcohol syndrome per 10,000 live births in 2006
were suspected or confirmed among children born in 2001–04,
Target: Not Applicable)

DATA SOURCES and DATA
ISSUES

HCUP – State Inpatient Database

SIGNIFICANCE

Fetal alcohol syndrome (FAS) represents the severe end of fetal
alcohol spectrum disorders, and is characterized by abnormal
facial features (e.g., smooth ridge between nose and upper lip),
lower than average height or weight, and central nervous
system problems that create deficits in learning, memory,
attention, communication, vision, and/or hearing. FAS is
completely preventable through abstinence from alcohol among
pregnant women. Early diagnosis and intervention programs are
critical to improve developmental outcomes for children with
FAS.

OUTCOME MEASURE 11

The rate of infants born with neonatal
abstinence syndrome per 10,000 delivery
hospitalizations

GOAL

To reduce the number of infants born with drug dependency.

DEFINITION

Numerator:
Number of infants born with neonatal abstinence syndrome
Denominator:
Number of delivery hospitalizations
Units: 10,000

Text: Rate

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Maternal, Infant, and Child Health Objective 11.4.
Increase abstinence from illicit drugs among pregnant women.
(Baseline: 94.8 percent of pregnant females aged 15 to 44 years
reported abstaining from illicit drugs in the past 30 days in 2007–
08; Target 100%)

DATA SOURCES and DATA
ISSUES
SIGNIFICANCE

HCUP – State Inpatient Database
Neonatal drug dependency or withdrawal symptoms, known as
neonatal abstinence syndrome (NAS), occur from maternal use
of opiates such as heroin, methadone, and prescription pain
medications. Symptoms of NAS include fever, diarrhea,
irritability, trembling, and increased muscle tone. Along with a
rise in prescription drug abuse, the incidence of NAS nearly
tripled over the past decade with substantial increases in health
care costs (Patrick et al, 2012). Prevention strategies exist
along the continuum from preconception, prenatal, postpartum,
and infant/childhood stages to help avert substance-exposed
pregnancies and improve outcomes for infants born with NAS
(ASTHO, 2014; SAMHSA, 2009).

OUTCOME MEASURE 12

Percent of eligible newborns screened for
heritable disorders with on time physician
notification for out of range screens who are
followed up in a timely manner.
(DEVELOPMENTAL)

GOAL

To increase the percent of eligible newborns screened for
heritable disorders with on-time physician notification for out of
range screens and timely follow up.

DEFINITION

Numerator:
Number of eligible newborns screened for heritable disorders
with on time physician notification for out of range screens who
are followed up in a timely manner. UNDER DEVELOPMENT.
Denominator:
Number of live eligible resident births
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Identical to Maternal, Infant, and Child Health (MICH) Objective
32: Increase appropriate newborn blood-spot screening and
follow-up testing (Baseline: 98.3% of screen-positive children
received follow-up testing within the recommended time period
in 2003–06, Target: 100%).

DATA SOURCES and DATA
ISSUES

The American Public Health Laboratories data set

SIGNIFICANCE

Newborn screening detects thousands of babies each year with
potentially devastating, but treatable disorders. The benefits of
newborn screening depend upon timely collection of the
newborn blood-spots or administration of a point-of-care test
(pulse oximeter for critical congenital heart disease), receipt of
the newborn blood spot at the laboratory, testing of the newborn
blood spot, and reporting out of all results. Timely detection
prevents death, mental retardation, and other significant health
complications.
1) The number of eligible infants for screening differs by state so
the denominator should reflect the individual state protocol. This
will typically be the number of live births minus those who die
before screening can occur, or transferred and screened
elsewhere, or or whom screening may not be appropriate. 2)
The American Public Health Laboratories is a voluntary
database so not all states will be represented. 3) The Health
People Objective was written before point-of-care testing for
CCHD was added to the Recommended Uniform Screening
Panel.

OUTCOME MEASURE 13

Percent of children meeting the criteria
developed for school readiness
(DEVELOPMENTAL)

GOAL

To increase the number of children ready for school.

DEFINITION

Numerator:
Under development
Denominator:
Under development
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Early and Middle Childhood (EMC) 1.
(Developmental) Increase the proportion of children who are
ready for school in all five domains of healthy development:
physical development, social-emotional development,
approaches to learning, language, and cognitive development.

DATA SOURCES and DATA
ISSUES

National Survey of Children's Health (NSCH)

SIGNIFICANCE

The early years are a critical period where the pathways to a
child’s lifetime social, emotional and educational outcomes
begin. Although early experiences do not determine children’s
ongoing development, the patterns laid down early tend to be
very persistent and some have lifelong consequences. Studies
have shown that children’s literacy and numeracy skills at age
4–5 are a good predictor of academic achievement in primary
school. Social gradients in language and literacy,
communication and socioemotional functioning emerge early for
children across socioeconomic backgrounds, and these
differences persist into the school years. There are also
disparities in the US as to who participates in an early childhood
program. Further, it is known that children at risk of poor
developmental and educational outcomes benefit from attending
high-quality education and care programs in the years before
school.

OUTCOME MEASURE 14

Percent of children ages 1-6 who have decayed
teeth or cavities in the past 12 months

GOAL

To reduce the proportion of children and adolescents who have
dental caries or decayed teeth.

DEFINITION

Numerator:
Number of children ages 1-6 who have decayed teeth or cavities
in the past 12 months
Denominator:
All children, ages 1-6
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Oral Health of Children and Adolescents (OH)
Objectives 1.1 : Reduce the proportion of children aged 3-5 who
have dental caries experience in their primary or permanent
teeth, (Baseline: 33.3%, Target: 30.0%) and 1.2: Reduce the
proportion of children aged 6-9 who have dental caries
experience in their primary or permanent teeth (Baseline:
54.4%, Target: 49.0%)

DATA SOURCES and DATA
ISSUES

National Survey of Children's Health (NSCH)

SIGNIFICANCE

Early childhood caries (ECC), despite being preventable,
remains extremely consequential and prevalent (NHANES
reports 11% of 2 year olds and 21% of 3 year olds, 34% of 4
year olds, and 44% of 5 year olds are affected). Early childhood
is the only life period for which CDC reports increasing
prevalence and ECC is the best predictor of future caries risk.
ECC is marked by profound income and racial disparities as
evidenced by federal NHANES, NHIS, and NSCH data.

OUTCOME MEASURE 15

The child death rate per 100,000 children aged 1
through 9

GOAL

To reduce the death rate of children aged 1 through 9.

DEFINITION

Numerator:
Number of deaths among children aged 1 through 9 years
Denominator:
Number of children aged 1 through 9
Units: 100,000

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Rate

Related to Maternal, Infant, and Child Health (MICH) Objective
3.1: Reduce the rate of child deaths aged 1 to 4 years.
(Baseline: 28.6 deaths among children aged 1 to 4 years per
100,000 population occurred in 2007, Target: 25.7 deaths per
100,000 population)
Related to Objective Maternal, Infant, and Child Health (MICH)
3.2: Reduce the rate of child deaths aged 5 to 9 years.
(Baseline: 13.7 deaths among children aged 5 to 9 years per
100,000 population occurred in 2007, Target: 12.3 deaths per
100,000 population)

DATA SOURCES and DATA
ISSUES

Child death certificates are collected by State vital
records/NVSS. Data on total number of children comes from the
U.S. Census Bureau.

SIGNIFICANCE

The overall mortality rate for children 1 to 4 years was 26.5 per
100,000 children in 2010 and 12.9 per 100,000 for children aged
5 to 14 years. Unintentional injury continues to be the leading
cause of death in children 1 to 14 years. Mortality rates were
higher among males than females in each age group. Also,
child death rates reflect racial/ethnic disparities, with nonHispanic Black children having considerably higher rates of
mortality than children of other racial/ethnic groups. (Child
Health USA 2012, Department of Health and Human Services,
HRSA)

OUTCOME MEASURE 16.1

Rate of death in adolescents age 10-19 per
100,000

GOAL

To reduce the death rate of adolescents age 10-19.

DEFINITION

Numerator:
Number of deaths among adolescents aged 10 through 19 years
Denominator:
Number of adolescents aged 10 through 19
Units: 100,000

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Rate

Related to Objective Maternal, Infant, and Child Health (MICH)
4.1: Reduce the rate of adolescent deaths aged 10 to 14 years.
(Baseline: 16.9 deaths among adolescents aged 10 to 14 years
per 100,000 population occurred in 2007, Target: 15.2 deaths
per 100,000)
Related to Objective Maternal, Infant, and Child Health (MICH)
4.2: Reduce the rate of adolescent deaths aged 15 to 19 years.
(Baseline: 60.3 deaths among adolescents aged 15 to 19 years
per 100,000 population occurred in 2007, Target: 54.3 deaths
per 100,000)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

The leading causes of illness and death among adolescents and
young adults are largely preventable. Health outcomes for
adolescents and young adults are grounded in their social
environments and are frequently mediated by their behaviors.
Behaviors of young people are influenced at the individual, peer,
family, school, community, and societal levels.

OUTCOME MEASURE 16.2

The rate of deaths to children aged 15-19 years
caused by motor vehicle crashes per 100,000
children

GOAL

To reduce the death rate of adolescents age 15-19 from motor
vehicle crashes

DEFINITION

Numerator:
Number of deaths to children aged 15-19 years caused by motor
vehicle crashes. This includes all occupant, pedestrian,
motorcycle, bicycle, etc. deaths caused by motor vehicles
Denominator:
All children in the State aged 15-19 years
Units: 100,000

Text: Rate

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Objective IVP-13: Reduce motor vehicle crashrelated deaths. (Baseline: 13.8 motor vehicle traffic-related
deaths per 100,000 population occurred in 2007 , Target: 12.4
deaths per 100,000 population)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

Unintentional injuries are the leading cause of mortality among
adolescents, with motor vehicle crashes accounting for 64% of
those deaths.

OUTCOME MEASURE 16.3

Rate of suicide deaths among youths aged 15
through 19 per 100,000

GOAL

To eliminate self-induced, preventable morbidity and mortality.

DEFINITION

Numerator:
Number of deaths attributed to suicide among youths aged 15
through 19
Denominator:
Number of youths aged 15 through 19
Units: 100,000

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Rate

Related to Mental Health and Mental Disorders (MHMD)
Objective 1: Reduce the suicide rate. (Baseline: 11.3 suicides
per 100,000 in 2007, Target: 10.2 suicides per 100,000)
Related to Mental Health and Mental Disorders (MHMD)
Objective 2: Reduce suicide attempts by adolescents.
(Baseline: 1.9 suicide attempts per 100 occurred in 2009,
Target: 1.7 suicide attempts per 100)

DATA SOURCES and DATA
ISSUES

National Vital Statistics System (NVSS)

SIGNIFICANCE

Suicide is the second leading cause of death for ages 10-24,
and the third leading cause of death for college age youths and
ages 12-18. In the U.S. each day, there are an average of more
than 5,400 suicide attempts by young people grades 7-12.

OUTCOME MEASURE 17.1

Percent of children with special health care
needs

GOAL

To track the percent of children and youth with special health
care needs, autism spectrum disorder (ASD), and attention
deficit disorder/attent deficit hyperactivity disorder (ADD/ADHD).

DEFINITION

Numerator:
Parent report on number of children, ages 0-17, who met the
criteria for having a special health care need based on the
CSHCN screener
Denominator:
All children, ages 0-17
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE
DATA SOURCES and DATA
ISSUES

The revised National Survey of Children's Health (NSCH).
States can use the 2009-2010 National Survey of Children with
Special Health Care Needs as a baseline.

SIGNIFICANCE

The percent of children with special health care needs has been
increasing since 2001. About 12-18% of all US children are
considered to have special health care needs. However, they
account for almost half of all health care expenditures for
children.

OUTCOME MEASURE 17.2

Percent of children with special health care
needs (CSHCN) receiving care in a wellfunctioning system

GOAL

To ensure access to needed and continuous systems of care for
children and youth with special health care needs.

DEFINITION

Numerator:
Parent report on number of CSHCN that received all
components of a well-functioning system (family partnership,
medical home, early screening, adequate insurance, easy
access to services, and preparation for adult transition)
Denominator:
All CSHCN
Units: 100

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Percent

Related to Maternal, Infant, and Child Health (MICH) Objectives
30.1 : Increase the proportion of children who have access to a
medical home, (Baseline: 57.5%, Target: 63.3%) and 30.2:
Increase the proportion of children with special health care
needs who have access to a medical home. (Baseline: 49.8%,
Target: 54.8%)
Related to Objective Maternal, Infant, and Child Health (MICH)
31: Increase the proportion of children with special health care
needs who receive their care in family-centered, comprehensive,
coordinated systems. (Baseline: 20.4% for children aged 0-11
Target: 22.4% Baseline: 13.8%, for children aged 12 through
17, Target: 15.2%)

DATA SOURCES and DATA
ISSUES

The revised National Survey of Children's Health (NSCH).
States can use the 2009-2010 National Survey of Children with
Special Health Care Needs as a baseline.

SIGNIFICANCE

According to the 2009-10 NS-CSHCN, only 17.6% of CSHCN
receive services in a well-functioning system of services. The
Omnibus Budget Reconciliation Act of 1989 requires Title V to
provide and promote family-centered, community-based,
coordinated care and facilitate the development of communitybased systems of services for children with special health care
needs and their families. To address this requirement a
minimum of 30 percent of the Title V Block Grant funding is
allocated for this purpose, and HP 2020 Objective MICH-31
establishes the goal to increase the proportion of children with
special health care needs who receive their care in familycentered, comprehensive, and coordinated systems.

OUTCOME MEASURE 17.3

Percent of children diagnosed with an autism
spectrum disorder

GOAL

To track the percent of children and youth with special health
care needs, autism spectrum disorder (ASD), and attention
deficit disorder/attent deficit hyperactivity disorder (ADD/ADHD).

DEFINITION

Numerator:
Number of children, ages 3-17, reported by their parents to have
been diagnosed by a health care provider with ASD
Denominator:
Number of children, ages 3-17
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE
DATA SOURCES and DATA
ISSUES

National Survey of Children's Health (NSCH)

SIGNIFICANCE

The prevalence of autism spectrum disorders has risen sharply
over the last two decades. However, the average age at
diagnosis for ASD is 4 years old, while the American Academy
of Pediatrics recommends screening beginning at nine months.
Interventions for ASD are more effective when they're started
earlier.

OUTCOME MEASURE 17.4

Percent of children diagnosed with Attention
Deficit Disorder/Attention Deficit Hyperactivity
Disorder (ADD/ADHD)

GOAL

To track the percent of children and youth with special health
care needs, autism spectrum disorder (ASD), and attention
deficit disorder/attent deficit hyperactivity disorder (ADD/ADHD).

DEFINITION

Numerator:
Number of children, ages 3-17, reported by their parents to have
been diagnosed by a health care provider with ADD/ADHD
Denominator:
Number of children, ages 3-17
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE
DATA SOURCES and DATA
ISSUES

National Survey of Children's Health (NSCH)

SIGNIFICANCE

Attention-deficit/hyperactivity disorder (ADHD) is one of the most
common neurobehavioral disorders of childhood. The
prevalence has been increasing over the last decade for
reasons that are not yet clear. It is sometimes referred to as
Attention Deficit Disorder (ADD). It is usually first diagnosed in
childhood and often lasts into adulthood. Children with ADHD
may have trouble paying attention, controlling impulsive
behaviors, or be overly active.

OUTCOME MEASURE 18

Percent of children with a mental/behavioral
condition who receive treatment

GOAL

To increase the percent of children with a mental/behavioral
condition who receive treatment.

DEFINITION

Numerator:
Number of children, ages 3-17, reported by their parents to have
been diagnosed by a health care provider with a
mental/behavioral condition (depression, anxiety problems, or
behavioral or conduct problems) who received treatment
Denominator:
Number of children, aged 3-17, reported by their parents to have
been diagnosed by a health care provider with a
mental/behavioral condition (depression, anxiety problems, or
behavioral or conduct problems
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Mental Health and Mental Disorders Objective 6:
Increase the proportion of children with mental health problems
who receive treatment (Baseline: 68.9% in 2008, Target: 75.0%)

DATA SOURCES and DATA
ISSUES

National Survey of Children's Health (NSCH)

SIGNIFICANCE

The prevalence of mental/behavioral health conditions has been
increasing among children and has been found to vary by
geographic and sociodemographic factors. However, a
significant portion of children diagnosed with a mental health
condition do not receive treatment. Further, the receipt of
treatment is generally dependent on sociodemographic and
health-related factors.

OUTCOME MEASURE 19

Percent of children in excellent or very good
health

GOAL

To improve the health status of children.

DEFINITION

Numerator:
Number of children ages 0-17 years reported by their parents to
be in excellent or very good health
Denominator:
Number of children aged 0-17
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE
DATA SOURCES and DATA
ISSUES

National Survey of Children's Health (NSCH)

SIGNIFICANCE

Overall health status for children provides a global, summary
measure of children’s health and well-being. Children reported
to be in excellent or very good health are more likely to thrive in
a variety of health dimensions, including physical and mental
health.

OUTCOME MEASURE 20

Percent of children and adolescents who are
overweight or obese (BMI at or above the 85th
percentile)

GOAL

To reduce the proportion of children and adolescents who are
considered overweight or obese.

DEFINITION

Numerator:
Number of children and adolescents aged 2-17 years were
considered overweight or obese
Denominator:
Number of children and adolescents aged 2-17
Units: 100

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Percent

Related to Nutrition and Weigh Status (NWS) 10.4. Reduce the
proportion of children and adolescents aged 2 to 19 years who
are considered obese. (Baseline: 16.1% in 2005-2008, Target:
14.5%).
Related to NWS 11. (Developmental) Prevent inappropriate
weight gain in youth and adults.

DATA SOURCES and DATA
ISSUES

WIC for children 2-5 years; NSCH for children 10-17 years
(parent-report); YRBSS for adolescents grades 9-12

SIGNIFICANCE

Childhood overweight/obesity is a serious health problem in the
United States, and the prevalence of overweight among
preschool children has doubled since the 1970s. There have
been significant increases in the prevalence of overweight in
children younger than 5 years of age across all ethnic groups.
Onset of overweight in childhood accounts for 25 percent of
adult obesity; but overweight that begins before age 8 and
persists into adulthood is associated with an even greater
degree of adult obesity. Childhood overweight is associated
with a variety of adverse consequences, including an increased
risk of cardiovascular disease, type 2 diabetes mellitus, asthma,
social stigmatization, and low self-esteem.

OUTCOME MEASURE 21

Percent of children without health insurance

GOAL

To ensure access to needed and continuous health care
services for children.

DEFINITION

Numerator:
Number of children under 18 in the State who are not covered
by any private or public health insurance (Including Medicaid or
risk pools) at some time during the reporting year
Denominator:
Number of children in the State under 18 (estimated by Census
Bureau)
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Access to Health Services Objective 1: Increase the
proportion of persons with health insurance. (Baseline: 83.2%
persons had medical insurance in 2008, Target: 100%)

DATA SOURCES and DATA
ISSUES

The U.S. Census Bureau (American Community Survey, 2009)
and the National Survey of Children’s Health provides data on
health insurance coverage for children

SIGNIFICANCE

There is a well documented benefit for children in having health
insurance. Research has shown that children who acquire
health insurance are more likely to have access to a usual
source of care, receive well child care and immunizations, to
have developmental milestones monitored, and receive
prescriptions drugs, appropriate care for asthma and basic
dental services. Serious childhood problems are more likely to
be identified early in children with insurance, and insured
children with special health care needs are more likely to have
access to specialists. Insured children not only receive more
timely diagnosis of serious health care conditions but experience
fewer avoidable hospitalizations, improved asthma outcomes
and fewer missed school days. (Institute of Medicine’s report,
America’s Uninsured Crisis: Consequences for Health and
Health Care, 2009)

OUTCOME MEASURE 22.1

Percent of children ages 19-35 months, with the
4:3:1:3(4):3:1:4 combined series of vaccines

GOAL

To increase the number of children and adolescents who have
completed recommended vaccines.

DEFINITION

Numerator:
Children, ages 19-35 months, with the 4:3:1:3(4):3:1:4 combined
series of vaccines
Denominator:
All children, ages 19-35 months

Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Identical to Immunization and Infectious Disease (IID) 8.0:
Increase the percentage of children aged 19 to 35 months who
receive the recommended doses of DTaP, polio, MMR, Hib,
hepatitis B, varicella and pneumococcal conjugate vaccine
(PCV) (Baseline in 2009 of 44.3%, Target of 80.0%)

DATA SOURCES and DATA
ISSUES

National Immunization Survey (NIS)

SIGNIFICANCE

Vaccination is one of the greatest public health achievements of
the 20th century, resulting in dramatic declines in morbidity and
mortality for many infectious diseases. Childhood vaccination in
particular is considered among the most cost-effective
preventive services available, as it averts a potential lifetime lost
to death and disability.
Currently, there are 12 different vaccines recommended by the
Centers for Disease Control and Prevention from birth through
age 18, many of which require multiple doses for effectiveness
as well as boosters to sustain immunity. (CDC National
Immunization Program; Child Health USA 2012)

OUTCOME MEASURE 22.2

Percent of children 6 months to 17 years who are
vaccinated annually against seasonal influenza

GOAL

To increase the number of children and adolescents who have
completed recommended vaccines.

DEFINITION

Numerator:
Children 6 months to 17 years who are vaccinated annually
against seasonal influenza
Denominator:
All children, ages 6 months through 17 years
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Identical to Immunization and Infectious Disease (IID) 12.11.
Increase the percentage of children aged 6 months through 17
years who are vaccinated annually against seasonal influenza
(Baseline of 46.9% in 2010-11 flu season, Target of 70%)

DATA SOURCES and DATA
ISSUES

National Health Interview Survey (NHIS)

SIGNIFICANCE

OUTCOME MEASURE 22.3

Percent of adolescents, ages 13-17, who have
received at least one dose of the HPV vaccine

GOAL

To increase the number of children and adolescents who have
completed recommended vaccines.

DEFINITION

Numerator:
Adolescents, ages 13-17, who have received at least one dose
of the HPV vaccine
Denominator:
All adolescents, ages 13-17 years
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Immunization and Infectious Disease (IID) 11.4
Increase the vaccination coverage level of 3 doses of human
papillomavirus (HPV) vaccine for females by age 13 to 15 years
(Baseline in 2008 of 16.6%, Target of 80%)

DATA SOURCES and DATA
ISSUES

National Immunization Survey (NIS)

SIGNIFICANCE

OUTCOME MEASURE 22.4

Percent of adolescents, ages 13-17, who have
received at least one dose of the Tdap vaccine

GOAL

To increase the number of children and adolescents who have
completed recommended vaccines.

DEFINITION

Numerator:
Adolescents, ages 13-17, who have received at least one dose
of the Tdap vaccine
Denominator:
All adolescents, ages 13-17 years

Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Immunization and Infectious Disease (IID) 11.1.
Increase the vaccination coverage level of 1 dose of tetanusdiphtheria-acellular pertussis (Tdap) booster vaccine for
adolescents by age 13 to 15 years (Baseline 46.7% in 2008;
Target of 80%)

DATA SOURCES and DATA
ISSUES

National Immunization Survey (NIS)

SIGNIFICANCE

OUTCOME MEASURE 22.5

Percent of adolescents, ages 13-17, who have
received at least one dose of the meningococcal
conjugate vaccine

GOAL

To increase the number of children and adolescents who have
completed recommended vaccines.

DEFINITION

Numerator:
Adolescents, ages 13-17, who have received at least one dose
of the meningococcal conjugate vaccine
Denominator:
All adolescents, ages 13-17 years
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Immunization and Infectious Disease (IID)
11.3.Increase the vaccination coverage level of 1 dose
meningococcal conjugate vaccine for adolescents by age 13 to
15 years (Baseline 43.9% in 2008; Target 80%)

DATA SOURCES and DATA
ISSUES

National Immunization Survey (NIS)

SIGNIFICANCE

Title V MCH Services Block Grant
National Performance Measures
No. National Performance Measure
1

Percent of women with a past year preventive visit

Percent of cesarean deliveries among low-risk first births

Percent of very low birth weight (VLBW) infants born in a hospital with a Level III+
Neonatal Intensive Care Unit (NICU)
A) Percent of infants who are ever breastfed and B) Percent of infants breastfed
exclusively through 6 months
Percent of infants placed to sleep on their backs

4
5
6
7
8

Percent of children, ages 9 through 71 months, receiving a developmental screening using
a parent-completed screening tool
Rate of injury-related hospital admissions per population ages 0 through 19 years

Percent of children ages 6 through 11 years and adolescents ages 12 through 17 years
who are physically active at least 60 minutes per day
Percent of adolescents, ages 12 through 17 years, who are bullied

10
11

Percent of adolescents with a preventive services visit in the last year
Percent of children with and without special health care needs having a medical home

Percent of children with and without special health care needs who received services
necessary to make transitions to adult health care
A) Percent of women who had a dental visit during pregnancy and B) Percent of infants
and children, ages 1 to 6 years, who had a preventive dental visit in the last year

13
14

A) Percent of women who smoke during pregnancy and B) Percent of children who live in
households where someone smokes

Percent of children 0 through 17 years who are adequately insured

PERFORMANCE MEASURE 1

Percent of women with a past year preventive
visit

GOAL

To increase the number of women who have a preventive visit.

DEFINITION

Numerator:
Women who reported having a routine check-up in the last year
Denominator:
Women, ages 18-44
Units: 100

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Percent

Related to Maternal, Infant, and Child Health (MICH)
Developmental Objective 16.1: Increase the percentage of
women delivering a live birth who discussed preconception
health with a health care worker prior to pregnancy
Related to Access to Health Services (AHS) Developmental
Objective 7.0: Increase the proportion of persons who receive
appropriate clinical preventive services

DATA SOURCES and DATA
ISSUES

Behavioral Risk Factor Surveillance System (BRFSS)

MCH POPULATION DOMAIN

Women/Maternal Health

SIGNIFICANCE

A well-woman or preconception visit provides a critical
opportunity to receive recommended clinical preventive
services, including screening, counseling, and immunizations,
which can lead to appropriate identification, treatment, and
prevention of disease to optimize the health of women before,
between, and beyond potential pregnancies. For example,
screening and management of chronic conditions such as
diabetes, and counseling to achieve a healthy weight and
smoking cessation, can be advanced within a well woman visit
to promote women’s health prior to and between pregnancies
and improve subsequent maternal and perinatal outcomes. The
annual well-woman visit has been endorsed by the American
College of Obstetrics and Gynecologists (ACOG) and was also
identified among the women’s preventive services required by
the Affordable Care Act (ACA) to be covered by private
insurance plans without cost-sharing.

PERFORMANCE MEASURE 2

Percent of cesarean deliveries among low-risk
first births

GOAL

To reduce the number of cesarean deliveries among low-risk
first births.

DEFINITION

Numerator:
Cesarean delivery among term (37+ weeks), singleton, vertex
births to nulliparous women
Denominator:
All term (37+ weeks), singleton, vertex births to nulliparous
women
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective
7.1. Reduce cesarean births among low-risk women with no
prior cesarean (Baseline: 26.5%, Target: 23.9%)

DATA SOURCES and DATA
ISSUES

Birth certificates

MCH POPULATION DOMAIN

Women/Maternal Health

SIGNIFICANCE

Cesarean delivery can be a life-saving procedure for certain
medical indications. However, for most low-risk pregnancies,
cesarean delivery poses avoidable maternal risks of morbidity
and mortality, including hemorrhage, infection, and blood clots—
risks that compound with subsequent cesarean deliveries.
Much of the temporal increase in cesarean delivery (over 50% in
the past decade), and wide variation across states, hospitals,
and practitioners, can be attributed to first-birth cesareans.
Moreover, cesarean delivery in low-risk first births may be most
amenable to intervention through quality improvement efforts.
This low-risk cesarean measure, also known as nulliparous term
singleton vertex (NTSV) cesarean, is endorsed by the ACOG,
The Joint Commission (PC-02), National Quality Forum (#0471),
Center for Medicaid and Medicare Services (CMS) – CHIPRA
Child Core Set of Maternity Measures, and the American
Medical Association-Physician Consortium for Patient
Improvement.

PERFORMANCE MEASURE 3

Percent of very low birth weight (VLBW) infants
born in a hospital with a Level III+ Neonatal
Intensive Care Unit (NICU)

GOAL

To ensure that higher risk mothers and newborns deliver at
appropriate level hospitals.

DEFINITION

Numerator:
VLBW infants born in a hospital with a level III or higher NICU
Denominator:
VLBW infants (< 1500 grams)
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective
33: Increase the proportion of VLBW infants born at level III
hospitals or subspecialty perinatal centers (Baseline: 75%,
Target: 83.7%)

DATA SOURCES and DATA
ISSUES

Linked birth certificate and hospital data on NICU levels from
American Academy of Pediatrics (AAP)

MCH POPULATION DOMAIN

Perinatal/Infant Health

SIGNIFICANCE

Very low birth weight infants (<1,500 grams or 3.25 pounds) are
the most fragile newborns. Although they represented less than
2% of all births in 2010, VLBW infants accounted for 53% of all
infant deaths, with a risk of death over 100 times higher than
that of normal birth weight infants (≥2,500 grams or 5.5 pounds).
VLBW infants are significantly more likely to survive and thrive
when born in a facility with a level-III Neonatal Intensive Care
Unit (NICU), a subspecialty facility equipped to handle high-risk
neonates. In 2012, the AAP provided updated guidelines on the
definitions of neonatal levels of care to include Level I (basic
care), Level II (specialty care), and Levels III and IV
(subspecialty intensive care) based on the availability of
appropriate personnel, physical space, equipment, and
organization. Given overwhelming evidence of improved
outcomes, the AAP recommends that VLBW and/or very
preterm infants (<32 weeks’ gestation) be born in only level III or
IV facilities. This measure is endorsed by the National Quality
Forum (#0477).

PERFORMANCE MEASURE 4

A) Percent of infants who are ever breastfed
and
B) Percent of infants breastfed exclusively
through 6 months

GOAL

To increase the proportion of infants who are breastfed and who
are breastfed at six months

DEFINITION

Numerator:
A) Number of infants who were ever breastfed
B) Number of infants breastfed exclusively through 6 months
Denominator:
A) All infants born in a calendar year
B) All infants born in a calendar year
Units: 100

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Percent

Related to Maternal, Infant, and Child Health (MICH) Objective
21.1: Increase the proportion of children who are ever breastfed
(Baseline: 74% in 2006, Target: 81.9%)
Related to Maternal, Infant, and Child Health (MICH) Objective
21.5: Increase the proportion of children who are breastfed
exclusively at (Baseline: 14.1% in 2006, Target: 25.5%)

DATA SOURCES and DATA
ISSUES

CDC’s National Immunization Survey (NIS)

MCH POPULATION DOMAIN

Perinatal/Infant Health

SIGNIFICANCE

Advantages of breastfeeding are indisputable. The American
Academy of Pediatrics recommends all infants (including
premature and sick newborns) exclusively breastfeed for about
six months as human milk supports optimal growth and
development by providing all required nutrients during that time.
Breastfeeding strengthens the immune system, improves normal
immune response to certain vaccines, offers possible protection
from allergies, and reduces probability of SIDS. Research
demonstrates breastfed children may be less likely to develop
juvenile diabetes; and may have a lower risk of developing
childhood obesity, and asthma; and tend to have fewer dental
cavities throughout life. The bond of a nursing mother and child
is stronger than any other human contact. A woman's ability to
meet her child’s nutritional needs improves confidence and
bonding with the baby and reduces feelings of anxiety and post
natal depression. Increased release of oxytocin while
breastfeeding, leads to a reduction in post-partum hemorrhage
and quicker return to a normal sized uterus over time, mothers
who breastfeed may be less likely to develop breast, uterine and
ovarian cancer and have a reduced risk of developing
osteoporosis.

PERFORMANCE MEASURE 5

Percent of infants placed to sleep on their backs

GOAL

To increase the number of infants placed to sleep on their backs

DEFINITION

Numerator:
Mothers reporting that they most often place their baby to sleep
on their back (Excludes multiple responses of back and
combination with side or stomach sleep positions)
Denominator:
Live births
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Identical to Maternal, Infant, and Child Health (MICH) Objective
20: Increase the proportion of infants placed to sleep on their
backs (Baseline: 69.0%, Target: 75.9%)

DATA SOURCES and DATA
ISSUES

Pregnancy Risk Assessment Monitoring System (PRAMS)

MCH POPULATION DOMAIN

Perinatal/Infant Health

SIGNIFICANCE

Sleep-related infant deaths, also called Sudden Unexpected
Infant Deaths (SUID), are the leading cause of infant death after
the first month of life and the third leading cause of infant death
overall. Sleep-related SUIDs include Sudden Infant Death
Syndrome (SIDS), unknown cause, and accidental suffocation
and strangulation in bed. Due to heightened risk of SIDS when
infants are placed to sleep in side (lateral) or stomach (prone)
sleep positions, the AAP has long recommended the back
(supine) sleep position. However, in 2011, AAP expanded its
recommendations to help reduce the risk of all sleep-related
deaths through a safe sleep environment that includes use of
the back-sleep position, on a separate firm sleep surface (roomsharing without bed sharing), and without loose bedding.
Among others, additional higher-level recommendations include
breastfeeding and avoiding smoke exposure during pregnancy
and after birth. These expanded recommendations have formed
the basis of the National Institute of Child Health and
Development (NICHD) Safe to Sleep Campaign.

PERFORMANCE MEASURE 6

Percent of children, ages 9 through 71 months,
receiving a developmental screening using a
parent-completed screening tool

GOAL

To increase the number of children who receive a
developmental screening.

DEFINITION

Numerator:
Parent reporting they have filled out a questionnaire provided by
a health care provider concerning child's development,
communication or social behaviors for a child ages 9 through 71
months
Denominator:
All children ages 9 through 71 months
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective
29-1: Increase the proportion of children (aged 10-35 months)
who have been screened for an Autism Spectrum Disorder and
other developmental delays. (Baseline: 22.6%, Target: 24.9%)

DATA SOURCES and DATA
ISSUES

The revised National Survey of Children's Health (NSCH) in
2017. States can use the 2011-2012 NSCH as a baseline until
that time.

MCH POPULATION DOMAIN

Child Health

SIGNIFICANCE

Early identification of developmental disorders is critical to the
well-being of children and their families. It is an integral function
of the primary care medical home. The percent of children with
a developmental disorder has been increasing, yet overall
screening rates have remained low. The American Academy of
Pediatrics recommends screening tests begin at the nine month
visit.

PERFORMANCE MEASURE 7

Rate of injury-related hospital admissions per
population ages 0 through 19 years

GOAL

To decrease the number of injury-related hospital admissions
among children ages 0 through 19 years.

DEFINITION

Numerator:
Number of hospital admissions among children ages 0 through
19 years with a diagnosis of unintentional or intentional injury.
(first admission for an injury event, excludes readmissions for
same event)
Denominator:
Number of children and adolescents 0 through 19 years
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Injury and Violence Prevention (IVP) Objective 1.2:
Reduce hospitalizations for nonfatal injuries. (Baseline: 617.6
per 100,000. Target: 555.8 per 100,000.)

DATA SOURCES and DATA
ISSUES

State Hospital Discharge data in the State Inpatient Databases
(SID)

MCH POPULATION DOMAIN

Child Health and/or Adolescent Health

SIGNIFICANCE

Injury is the leading cause of child mortality. For those who
suffer non-fatal severe injuries, many will become children with
special health care needs. Effective interventions to reduce
injury exist but are not fully implemented in systems of care that
serve children and their families. Reducing the burden of
nonfatal injury can greatly improve the life course trajectory of
infants, children, and adolescents resulting in improved quality
of life and cost savings.

PERFORMANCE MEASURE 8

Percent of children ages 6 through 11 years and
adolescents ages 12 through 17 years who are
physically active at least 60 minutes per day

GOAL

To increase the number of children and adolescents who are
physically active.

DEFINITION

Numerator:
Parent report of children (in NSCH), ages 6 through 11 years,
and adolescents (in NSCH), ages 12 through 17 years, who are
physically active at least 60 minutes per day. (YRBSS is also
available and provides self-report by adolescents)
Denominator:
All children ages 6 through 11 years and adolescents ages 12
through 17 years
Units: 100

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Percent

Related to Physical Activity (PA) Objective 4.1: Increase the
proportion of the Nation’s public and private elementary schools
that require daily physical education for all students. (Baseline:
3.8%, Target: 4.2%)
Related to Physical Activity (PA) Objective 3: Increase the
proportion of adolescents who meet current Federal physical
activity guidelines for aerobic physical activity and for musclestrengthening activity. (Baseline: 18.4%, Target: 20.2% for
adolescents to meet current physical activity guidelines for
aerobic physical activity)

DATA SOURCES and DATA
ISSUES

The revised National Survey of Children's Health (NSCH),
beginning in 2017 and the Youth Risk Behavior Surveillance
System.

MCH POPULATION DOMAIN

Child Health and/or Adolescent Health

SIGNIFICANCE

Regular physical activity can improve the health and quality of
life of Americans of all ages, regardless of the presence of a
chronic disease or disability. Physical activity in children and
adolescents reduces the risk of early life risk factors for
cardiovascular disease, hypertension, Type II diabetes, and
osteoporosis. In addition to aerobic and muscle-strengthening
activities, bone-strengthening activities are especially important
for children and young adolescents because the majority of peak
bone mass is obtained by the end of adolescence.

PERFORMANCE MEASURE 9

Percent of adolescents, ages 12 through 17
years, who are bullied

GOAL

To reduce the number of adolescents who are bullied.

DEFINITION

Numerator:
Parent report on adolescents (in NSCH), and adolescent report
(in YRBSS), for adolescents ages 12 through 17 years, who
were bullied
Denominator:
Number of adolescents, ages 12 through 17 years
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Injury and Violence Prevention (IVP) Objective 35:
Reduce bullying among adolescents. (Baseline: 19.9%, Target:
17.9%)

DATA SOURCES and DATA
ISSUES

Youth Risk Behavior Surveillance System (YRBSS), and the
National Survey of Children's Health (NSCH). States can use
data from the 2013 YRBSS and from the 2011-2012 NSCH as a
baseline. (The state will be able to use both data sources as the
YRBSS is reported by the adolescents and the NSCH is
reported by the parents. The YRBSS is available every other
year, and the NSCH will be available annually).

MCH POPULATION DOMAIN

Adolescent Health

SIGNIFICANCE

Bullying, particularly among school-age children, is a major
public health problem. Current estimates suggest nearly 30% of
American adolescents reported at least moderate bullying
experiences as the bully, the victim, or both. Specifically, of a
nationally representative sample of adolescents, 13% reported
being a bully, 11% reported being a victim of bullying, and 6%
reported being both a bully and a victim. Studies indicate
bullying experiences are associated with a number of
behavioral, emotional, and physical adjustment problems.
Adolescents who bully others tend to exhibit other defiant and
delinquent behaviors, have poor school performance, be more
likely to drop-out of school, and are more likely to bring weapons
to school. Victims of bullying tend to report feelings of
depression, anxiety, low self-esteem, and isolation; poor school
performance; suicidal ideation; and suicide attempts. Evidence
further suggests that people who are the victims of bullying and
who also perpetrate bullying (i.e., bully-victims) may exhibit the
poorest functioning, in comparison with either victims or bullies.
Emotional and behavioral problems experienced by victims,
bullies, and bully-victims may continue into adulthood and
produce long-term negative outcomes, including low self-esteem
and self-worth, depression, antisocial behavior, vandalism, drug
use and abuse, criminal behavior, gang membership, and
suicidal ideation.

PERFORMANCE MEASURE
10

Percent of adolescents with a preventive
services visit in the last year

GOAL

To increase the number of adolescents who have a preventive
services visit.

DEFINITION

Numerator:
Parent report of adolescents, ages 12 through 17, with a
preventive services visit in the past year from the survey
Denominator:
Number of adolescents, ages 12 through 17 years
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Adolescent Health (AH) Objective 1: Increase the
proportion of adolescents who have had a wellness checkup in
the past 12 months. (Baseline: 68.7%, Target: 75.6%)

DATA SOURCES and DATA
ISSUES

The revised National Survey of Children's Health (NSCH)
beginning in 2017. States can use data from the 2011-2012
NSCH as a baseline.

MCH POPULATION DOMAIN

Adolescent Health

SIGNIFICANCE

Adolescence is a period of major physical, psychological, and
social development. As adolescents move from childhood to
adulthood, they assume individual responsibility for health
habits, and those who have chronic health problems take on a
greater role in managing those conditions. Initiation of risky
behaviors is a critical health issue during adolescence, as
adolescents try on adult roles and behaviors. Risky behaviors
often initiated in adolescence include unsafe sexual activity,
unsafe driving, and use of substances, including tobacco,
alcohol, and illegal drugs.
Receiving health care services, including annual adolescent
preventive well visits, helps adolescents adopt or maintain
healthy habits and behaviors, avoid health‐damaging behaviors,
manage chronic conditions, and prevent disease. Receipt of
services can help prepare adolescents to manage their health
and health care as adults.
The Bright Futures guidelines recommends that adolescents
have an annual checkup starting at age 11. The visit should
cover a comprehensive set of preventive services, such as a
physical examination, discussion of health‐related behaviors,
and immunizations. It recommends that the annual checkup
include discussion of several health‐related topics, including
healthy eating, physical activity, substance use, sexual behavior,
violence, and motor vehicle safety.

PERFORMANCE MEASURE
11

Percent of children with and without special
health care needs having a medical home

GOAL

To increase the number of children with and without special
health care needs who have a medical home

DEFINITION

Numerator:
Parent report for all children with and without special health care
needs, ages 0 to 18 years, who meet the criteria for having a
medical home, with subset analyses for children with special
health care needs
Denominator:
All children and adolescents, ages 0 to 18 years
Units: 100

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Percent

Related to Maternal, Infant, and Child Health (MICH) Objectives
30.1: Increase the proportion of children who have access to a
medical home, (Baseline: 57.5%, Target: 63.3%) and 30.2:
Increase the proportion of children with special health care
needs who have access to a medical home. (Baseline: 49.8%,
Target: 54.8%)
Related to Objective Maternal, Infant, and Child Health (MICH)
Objective 31: Increase the proportion of children with special
health care needs who receive their care in family-centered,
comprehensive, coordinated systems. (Baseline: 20.4% for
children aged 0-11, Target: 22.4%; Baseline: 13.8% for children
aged 12 through 17, Target 15.2%)

DATA SOURCES and DATA
ISSUES

The revised National Survey of Children's Health (NSCH)
beginning in 2017. States can use data from the 2011-2012
NSCH as a baseline.

MCH POPULATION DOMAIN

Children with Special Health Care Needs

SIGNIFICANCE

The American Academy of Pediatrics (AAP) specifies seven
qualities essential to medical home care: accessible, familycentered, continuous, comprehensive, coordinated,
compassionate and culturally effective. Ideally, medical home
care is delivered within the context of a trusting and
collaborative relationship between the child’s family and a
competent health professional familiar with the child and family
and the child’s health history. Providing comprehensive care to
children in a medical home is the standard of pediatric practice.
Research indicates that children with a stable and continuous
source of health care are more likely to receive appropriate
preventive care and immunizations, are less likely to be
hospitalized for preventable conditions, and are more likely to be
diagnosed early for chronic or disabling conditions. The
Maternal and Child Health Bureau uses the AAP definition of
medical home.

PERFORMANCE MEASURE
12

Percent of children with and without special
health care needs who received services
necessary to make transitions to adult health
care

GOAL

To increase the percent of youth with and without special health
care needs who have received the services necessary to make
transitions to all aspects of adult life, including adult health care,
work, and independence.

DEFINITION

Numerator:
Parent report of youth with and without special health care
needs, ages 12 through 17, whose families report that they
received the services necessary to transition to adult health
care, with subset analyses for children with special health care
needs
Denominator:
All adolescents, ages 12 through 17 years
Units: 100

Text: Percent

HEALTHY PEOPLE 2020
OBJECTIVE

Related to Disability and Health (DH) Objective 5: Increase the
proportion of youth with special health care needs whose health
care provider has discussed transition planning from pediatric to
adult health care. (Baseline: 41.2%, Target: 45.3%)

DATA SOURCES and DATA
ISSUES

The revised National Survey of Children's Health (NSCH)
beginning in 2017. States can use data from the 2011-2012
NSCH as a baseline.

MCH POPULATION DOMAIN

Children with Special Health Care Needs

SIGNIFICANCE

The transition of youth to adulthood has become a priority issue
nationwide as evidenced by the clinical report and algorithm
developed jointly by the AAP, American Academy of Family
Physicians and American College of Physicians to improve
healthcare transitions for all youth and families. Over 90 percent
of children with special health care needs now live to adulthood,
but are less likely than their non-disabled peers to complete high
school, attend college or to be employed. Health and health
care are cited as two of the major barriers to making successful
transitions.

PERFORMANCE MEASURE
13

A) Percent of women who had a dental visit
during pregnancy and
B) Percent of infants and children, ages 1
through 17 years, who had a preventive dental
visit in the last year

GOAL

A) To increase the number of pregnant women who have a
dental visit and
B) To increase the number of infants and children, ages 1
through 17 years, who had a preventive dental visit in the last
year.

DEFINITION

Numerator:
A) Report of a dental visit during pregnancy
B) Parent report of infant or child, ages 1 through 17 years, who
had a preventive dental visit in the last year
Denominator:
A) All live births
B) All infants and children, ages 1 through 17 years
Units: 100

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Percent

Related to Oral Health (OH) Objective 7. Increase the
proportion of children, adolescents, and adults who used the
oral health care system in the past year. (Baseline: 44.5%,
Target: 49.0%)
Related to Oral Health (OH) Objective 8. Increase the
proportion of low-income children and adolescents who receive
any preventive dental service during the past year. (Baseline:
30.2%, Target: 33.2%)

DATA SOURCES and DATA
ISSUES

This is an integrated measure with two data sources:
A) CDC's Pregnancy Risk Assessment Monitoring System
(PRAMS);
B) the revised National Survey of Children's Health (NSCH)
beginning in 2017. States can use data from the 2011-2012
NSCH as a baseline.
If a state has access to both PRAMS and the NSCH, the state
needs to address both parts (A & B) of the measure. If a state
does not have access to PRAMS, the state will need to address
part B of the measure.

MCH POPULATION DOMAIN

Cross-cutting/Life course

SIGNIFICANCE

Oral health is a vital component of overall health. Access to oral
health care, good oral hygiene, and adequate nutrition are
essential component of oral health to help ensure that children,
adolescents, and adults achieve and maintain oral health.
People with limited access to preventive oral health services are
at greater risk for oral diseases.

Oral health care remains the greatest unmet health need for
children. Insufficient access to oral health care and effective
preventive services affects children’s health, education, and
ability to prosper. Early dental visits teach children that oral
health is important. Children who receive oral health care early
in life are more likely to have a good attitude about oral health
professionals and dental visits. Pregnant women who receive
oral health care are more likely to take their children to get oral
health care.
State Title V Maternal Child Health programs have long
recognized the importance of improving the availability and
quality of services to improve oral health for children and
pregnant women. States monitor and guide service delivery to
assure that all children have access to preventive oral health
services. Strategies for promoting oral health include providing
preventive interventions, such as dental sealants and use of
fluoride, increasing the capacity of State oral health programs to
provide preventive services, evaluating and improving methods
of monitoring oral diseases and conditions, and increasing the
number of community health centers with an oral health
component.

PERFORMANCE MEASURE
14

A) Percent of women who smoke during
pregnancy and
B) Percent of children who live in households
where someone smokes

GOAL

A) To decrease the number of women who smoke during
pregnancy and
B) To decrease the number of households where someone
smokes.

DEFINITION

Numerator:
A) Women who report smoking during pregnancy
B) Parent report of cigar, cigarette, or pipe tobacco use by
household members
Denominator:
A) All women who delivered a live birth in a calendar year
B) All children, ages 0 to 18 years
Units: 100

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Percent

Related to Tobacco Use (TU) Objective 6: Increase smoking
cessation during pregnancy (Target: 30.0%) and related to
Tobacco Use (TU) Objective 11.1: Reduce the proportion of
children aged 3 to 11 years exposed to secondhand smoke.
(Baseline: 52.2% , Target 47%)
Related to Respiratory Diseases (RD) Objective 7.5: Increase
the proportion of persons with current asthma who have been
advised by a health professional to change things in their home,
school, and work environments to reduce exposure to irritants or
allergens to which they are sensitive according to National
Asthma Education and prevention Program guidelines.
(Baseline: 50.8%, Target: 54.5%)

DATA SOURCES and DATA
ISSUES

This is an integrated measure with two data sources:
A) National Vital Statistics System (NVSS) for smoking during
pregnancy and
B) the revised National Survey of Children's Health (NSCH)
beginning in 2017. States can use data from the 2011-2012
NSCH as a baseline.
If selected, the state needs to address both parts (A & B) of the
measure.

MCH POPULATION DOMAIN

Cross-cutting/Life course

SIGNIFICANCE

Women who smoke during pregnancy are more likely to
experience a fetal death or deliver a low birth weight baby.
Further, secondhand smoke (SHS) is a mixture of mainstream
smoke (exhaled by smoker) and the more toxic side stream
smoke (from lit end of nicotine product) which is classified as a
“known human carcinogen” by the US Environmental Protection
Agency, the US National Toxicology Program, and the

International Agency for Research on Cancer. Adverse effects
of parental smoking on children have been a clinical and public
health concern for decades and were documented in the 1986
U.S. Surgeon General Report. The only way to fully protect
non-smokers from indoor exposure to SHS is to prevent all
smoking in the space; separating smokers from non-smokers,
cleaning the air, and ventilating buildings do not eliminate
exposure. Unfortunately, millions (more than 60%) of children
are exposed to SHS in their homes. These children have an
increased frequency of ear infections; acute respiratory illnesses
and related hospital admissions during infancy; severe asthma
and asthma-related problems; lower respiratory tract infections
leading to 7,500 to 15,000 hospitalizations annually in children
under 18 months; and sudden infant death syndrome (SIDS).
Higher intensity medical services are also required by children of
parents who smoke including an increased need for intensive
care unit services when admitted for flu, longer hospital stays;
and more frequent use of breathing tubes during admissions.

PERFORMANCE MEASURE
15

Percent of children 0 through 17 years who are
adequately insured

GOAL

To increase the number of children who are adequately insured

DEFINITION

Numerator:
Parent report of children, ages 0 through 17 years, who were
reported to be adequately insured, based on 3 criteria: whether
their children’s insurance covers needed services and providers,
and reasonably covers costs. If a parent answered “always” or
“usually” to all three dimensions of adequacy, then the child was
considered to have adequate insurance coverage. (No out-ofpocket costs were considered to be “always” reasonable.)
Denominator:
All children, 0 through 17 years
Units: 100

HEALTHY PEOPLE 2020
OBJECTIVE

Text: Percent

Related to Access to Health Services (AHS) Objective 1:
Increase the proportion of persons with health insurance
Related to Access to Health Services (AHS) Objective 6:
Reduce the proportion of persons who are unable to obtain or
delay in obtaining necessary medical care, dental care, or
prescription medicines

DATA SOURCES and DATA
ISSUES

The National Survey of Children's Health (NSCH). States can
use data from the 2011-2012 NSCH as a baseline.

MCH POPULATION DOMAIN

Cross-cutting/Life course

SIGNIFICANCE

Almost one-quarter of American children with continuous
insurance coverage are not adequately insured. Inadequately
insured children are more likely to have delayed or forgone care,
lack a medical home, be less likely to receive needed referrals
and care coordination, and receive family-centered care. The
American Academy of Pediatrics highlighted the importance of
this issue with a policy statement. The major problems cited
were cost-sharing requirements that are too high, benefit
limitations, and inadequate coverage of needed services.

APPENDIX G:

Submission
Date
July 15, 2015

REQUIRED APPLICATION/ANNUAL REPORT COMPONENTS
AND TIMELINE
Application Year

Annual Report Year

Fiscal Year (FY) 2016
(First Application Year of New Five-year
Reporting Cycle.)

FY 2014
(Interim Year 04 of Previous Reporting Cycle)

 Complete Application for Federal
Assistance (Standard Form - 424)
 Develop Executive Summary for
Application
 Include Needs Assessment Summary in the
Application
 Identify 7-10 Priority Needs (Form #9)
 Select 8 National Performance Measures
(NPMs) and Enter Five-year Performance
Objectives on Form #10A
 Prepare Interim Five-Year State Action
Plan Table
 Complete Narrative Sections of
Application, including Presentation of the
State’s Five-year Action Plan by Population
Health Domain
 Enter Budgeted Data for Application Year
on Forms #2, #3a and #3b
 List Names of MCH Director, CSHSN
Director and Family/Youth Leader on
Form #8

 Enter the FY 2014 Annual Indicator Data
(specifically, the Numerator, Denominator,
Data Source and Data Note) for the 18
NPMs and State Performance Measures
(SPMs) from the Previous Reporting Cycle
on Form #10D
 Report on FY 2014 Program Activities and
Analyze Performance, by Population
Health Domain, using New Narrative
Format
 Enter Expenditure Data on Forms #2, #3a,
and #3b
 Enter Required Data (i.e., Newborn and
Others Screening, Unduplicated Count and
Total Encounters of Individuals Served,
Deliveries and Infants Served by Title V and
Entitled to Benefits Under Title XIX and
State Toll-free Hotline and Other
Appropriate Methods Data) on Forms #4,
#5a, #5b, #6 and #7 for the Reporting Year.

 Review Other State Data (OSD) on
Form #11 and Form #10A for National
Outcome Measures (NOMs)
July 15, 2016

FY 2017
(Second Year Application, or Interim Year 01,
of Five-year Reporting Cycle)
 Complete SF-424
 Update Executive Summary
 Update Needs Assessment Summary
91

FY 2015
(Last Annual Report Year, or Interim Year 05,
of Previous Five-year Reporting Cycle)
 Enter the FY 2015 Annual Indicator Data
(specifically, the Numerator, Denominator,
Data Source and Data Note) for the 18
NPMs and SPMs from the Previous
Reporting Cycle on Form #10D

Submission
Date

Application Year

Annual Report Year

FY 2017 (Continued)

FY 2015 (Continued)

 Incorporate Ongoing Needs Assessment
Activities/Findings into Annual Update on
State Priority Needs
 Add FY 2021 Performance Objective for
Each Selected NPMs on Form #10A
 Develop Evidence-based or -informed
Strategy Measures (ESMs) for Each
Selected NPM; Prepare Detail Sheet for
each ESM on Form #10C; and Enter Fiveyear Performance Objectives for Each ESM
on Form #10A
 Develop 3-5 SPMs to Address Priority
Needs Not Addressed Through the NPMs
and ESMs; Prepare Detail Sheet for Each
SPM on Form #10B; and Enter Five-year
Performance Objectives for Each SPM on
Form #10A

 Report on FY 2015 Program Activities and
Analyze Performance, by Population
Health Domain, using New Narrative
Format
 Enter Expenditure Data on Forms #2, #3a,
and #3b
 Enter Required Data (i.e., Newborn and
Others Screening, Unduplicated Count and
Total Encounters of Individuals Served,
Deliveries and Infants Served by Title V and
Entitled to Benefits Under Title XIX and
State Toll-free Hotline and Other
Appropriate Methods Data) on Forms #4,
#5a, #5b, #6 and #7 for the Reporting Year.

 Add Strategies, ESMs and SPMs to Finalize
the Five-Year State Action Plan Table
 Complete Narrative Sections of
Application, including Presentation of the
State’s Five-year Action Plan by Population
Health Domain
 Enter Budgeted Data for Application Year
on Forms #2, #3a and #3b
 Update Listed Names of MCH Director,
CSHSN Director and Family/Youth Leader
on Form #8
 Review Other State Data (OSD) on
Form #11 and Form #10A for NOMs
July 15, 2017

FY 2018
(Interim Year 03 Application)

FY 2016
(First Annual Report of New Five-year
Reporting Cycle)

 Complete SF-424
 Update Executive Summary
 Update Needs Assessment Summary
92

 Enter the FY 2016 Annual Indicator Data
(specifically, the Numerator, Denominator,
Data Source and Data Note) for the
Selected NPMs, ESMs and SPMs

Submission
Date

Application Year

Annual Report Year

FY 2018 (Continued)
 Incorporate Ongoing Needs Assessment
Activities/Findings into Annual Update on
State Priority Needs
 Add FY 2022 Performance Objective for
Each Selected NPMs, ESMs and SPMs on
Form #10A
 Update the State Action Plan, as Needed
 Complete Narrative Sections of
Application, including Presentation of the
State’s Five-year Action Plan by Population
Health Domain
 Enter Budgeted Data for Application Year
on Forms #2, #3a and #3b
 Update Listed Names of MCH Director,
CSHSN Director and Family/Youth Leader
on Form #8
 Review Other State Data (OSD) on Form 11
and Form #10A for NOMs

FY 2018 (Continued)
 Report on FY 2016 Program Activities and
Analyze Performance, by Population
Health Domain, in the State Action Plan
 Enter Expenditure Data on Forms #2, #3a,
and #3b
 Enter Required Data (i.e., Newborn and
Others Screening, Unduplicated Count and
Total Encounters of Individuals Served,
Deliveries and Infants Served by Title V and
Entitled to Benefits Under Title XIX and
State Toll-free Hotline and Other
Appropriate Methods Data) on Forms #4,
#5a, #5b, #6 and #7 for the Reporting Year

APPENDIX H:

GLOSSARY

A comprehensive glossary of terms relevant to maternal and child health (MCH)
practice, including services for children with special health care needs (CSHCN), is
available on the MCH Navigator site. To access the Glossary, click on:
http://www.mchnavigator.org. This project is administered by Georgetown University
through funding provided by the Health Resources and Services Administration’s
(HRSA) Maternal and Child Health Bureau (MCHB.) The MCH Navigator is a learning
portal for MCH professionals, students, and others working to improve the health and
well-being of women, children, adolescents, and families.
Definitions included in this Glossary are intended to supplement the broader set of
terms that are included in the MCH Navigator Glossary. The following list of terms and
their definitions have specific relevance to the State Title V MCH Block Grant programs.
MCH Working Framework: MCH Pyramid of Services

As depicted on the Revised MCH Pyramid, the working framework for the Title V MCH
Block Grant to States Program aligns with the 10 MCH Essential Services and consists
of three levels. Definitions are provided on the next page for each level of service.
In developing systems of care, States should assure that they are family centered,
community based and culturally competent.
94

Direct Services – Direct services are preventive, primary, or specialty clinical services
to pregnant women and children, including children with special health care
needs, where MCH Services Block Grant funds are used to reimburse or fund providers
for these services through a formal process similar to paying a medical billing claim or
managed care contracts. State reporting on direct services should not include the costs
of clinical services which are delivered with Title V dollars but reimbursed by Medicaid,
CHIP or other public or private payers. Examples include, but are not limited to,
preventive, primary or specialty care visits, emergency department visits, inpatient
services, outpatient and inpatient mental and behavioral health services, prescription
drugs, occupational and physical therapy, speech therapy, durable medical equipment
and medical supplies, medical foods, dental care, and vision care.
Enabling Services – Enabling services are non-clinical services (i.e., not included as
direct or public health services) that enable individuals to access health care and
improve health outcomes where MCH Services Block Grant funds are used to finance
these services. Enabling services include, but are not limited to: case management,
care coordination, referrals, translation/interpretation, transportation, eligibility
assistance, health education for individuals or families, environmental health risk
reduction, health literacy, and outreach. State reporting on enabling services should
not include the costs for enabling services that are reimbursed by Medicaid, CHIP, or
other public and private payers. This category may include salary and operational
support to a clinic or program that enable individuals to access health care or improve
health outcomes. Examples include the salary of a public health nurse who provides
prenatal care in a local clinic or compensation provided to a specialist pediatrician who
provides services for children with special health care needs.
Public Health Services and Systems – Public health services and systems are
activities and infrastructure to carry out the core public health functions of assessment,
assurance, and policy development, and the 10 essential public health services.
Examples include the development of standards and guidelines, needs assessment,
program planning, implementation, and evaluation, policy development, quality
assurance and improvement, workforce development, and population-based disease
prevention and health promotion campaigns for services such as newborn screening,
immunization, injury prevention, safe-sleep education and anti-smoking. State reporting
on public health services and systems should not include costs for direct clinical
preventive services, such as immunization, newborn screening tests, or smoking
cessation.
Title V Program Administration
Administrative Title V Funds - The amount of funds the State uses for the management
of the Title V allocation. This amount is limited by statute to 10 percent of the Federal
Title V allotment.

Capacity – Program capacity includes delivery systems, workforce, policies, and
support systems (e.g., training, research, technical assistance, and information
systems) and other infrastructure needed to maintain service delivery and policy making
activities. Program capacity results measure the strength of the human and material
resources necessary to meet public health obligations. As program capacity sets the
stage for other activities, program capacity results are closely related to the results for
process, health outcome, and risk factors. Program capacity results should answer the
question, “What does the State need to achieve the results we want?”
Children – A child from his/her first birthday through the 21st year, who is not otherwise
included in any other class of individuals (e.g., counted as a pregnant woman.)
Data Systems Development – Development of data management systems (electronic or
other) or linking of existing databases to support States’ ability to collect, tabulate,
analyze, and report data accurately. (See Systems Development.)
Early Neonatal Period – The early neonatal period begins at birth and lasts through the
6th day of life.
Federal Allocation – The funding provided to the States under the Federal Title V Block
Grant in any given fiscal year; applies specifically to the Application Face Sheet
(SF-424) and Form 2.
Government Performance and Results Act (GPRA) – Federal legislation enacted in
1993 that requires Federal agencies to develop strategic plans, prepare annual plans
setting performance goals, and report annually on actual performance.
Infants – Children less than one year of age that are not included in any other class of
individuals.
Jurisdictions – The following jurisdictions receive Title V Maternal and Child Health
Block Grant Program funding: the District of Columbia, the Republic of the Marshall
Islands, the Federated States of Micronesia, the Republic of Palau and the U.S.
territories of the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American
Samoa, and the Commonwealth of the Northern Mariana Islands.
Life Course Theory (LCT) – A conceptual framework that helps explain health and
disease patterns – particularly health disparities – across populations and over time.
Instead of focusing on differences in health patterns based on one disease or condition
at a time, LCT points to broad social, economic and environmental factors as underlying
causes of persistent inequalities in health for a wide range of diseases and conditions
across population groups. LCT is population focused, and firmly rooted in social
determinants and social equity models. Though not often explicitly state, LCT is also
community (or “place”) focused, since social, economic and environmental patterns are
closely linked to community and neighborhood settings. 1
1

http://mchb.hrsa.gov/lifecourse/rethinkingmchlifecourse.pdf

Local – Funds derived from local jurisdictions within the State, which are used for MCH
program activities and reported on the Application Face Sheet (SF 424) and Form 2.
Low Income – An individual or family with an income that is determined to be below the
income official federal poverty line, as 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)]
Needs Assessment – A process to understand the strengths and needs of the health
service system within a community or population. For maternal and child health
purposes, needs assessment efforts consider the following components: 1) health
status, 2) health service utilization, 3) health systems capacity, and 4) population/
community characteristics and contextual characteristics.
Neonatal Period – The neonatal period begins at birth and lasts through the 28th day
following birth.
Newborn – A human infant from the time of birth through the 28th day of life.
Other Federal Funds – Federal funds other than the Title V Block Grant that are under
the control of the person responsible for administration of the Title V program and
reported on the Application Face Sheet (SF 424) and Form 2. These funds may
include, but are not limited to: WIC, EMSC, Healthy Start, SPRANS, HIV/AIDs monies,
CISS funds, MCH targeted funds from CDC, MCH Education funds and Medicaid
Federal Medical Assistance Percentage (FMAP).
Others (Class of Individuals) – Women of childbearing age, over age 21, and any others
defined by the State who are not otherwise included in any of the other listed classes of
individuals. (Form 3a and Form 5a)
Perinatal – The period of gestation between 28 weeks or more to 7 days or less after
birth.
Post-neonatal Period – The period between the end of the first month to a year after
birth.
Pregnant Woman – A female from the time that she conceives to 60 days after birth,
delivery, or expulsion of fetus.
Prenatal – Occurring or existing before birth, referring to both the care of the woman
during pregnancy and the growth and development of the fetus.
Program Income – Funds collected by State MCH agencies from sources generated by
the State’s MCH program to include insurance payments, Medicaid reimbursements,
HMO payments, etc., as reported on the Application Face Sheet [SF 424] and Form 2.
97

State – Terminology used in this Guidance to reference the 50 States and the nine
jurisdictions. (See also “Jurisdictions”)
State Funds – The State’s required matching funds (including overmatch) in any given
year, as reported on the Application Face Sheet [SF 424] and Form 2.
Technical Assistance (TA) – The process of providing advice, assistance, and training
by an expert with specific technical/content knowledge to address an identified need.
Technical Assistance relationships are program-focused, and may use an interactive,
on-site/hands-on approach as well as telephone or email assistance. Technical Assistance delivery is short in duration, customized to meet the needs of the client, and offers
prescriptive solutions to a specific issue. [Concordia University, 2007www.mnsmart.org]
Title V of the Social Security Act – The authorizing legislation for the Maternal and Child
Health Services Block Grant to States Program.
Title V Reporting Form 6, Deliveries to Pregnant Women – Unduplicated number of
deliveries to pregnant women who were provided prenatal, delivery, or post-partum
services through the Title V program during the reporting period.
Title V Reporting Form 6, Infants Served by Title V – The unduplicated count of infants
provided a direct service by the State’s Title V program during the reporting period.
Title XIX of the Social Security Act – The authorizing legislation for the Medicaid
program.
Title XIX Reporting on Form 6, Pregnant Women Eligible for Title XIX – The number of
pregnant women who delivered during the reporting period and were eligible for the
State’s Title XIX (Medicaid) program.
Title XIX Reporting on Form 6, Infants Eligible for Title XIX – The number of infants
eligible for the State’s Title XIX (Medicaid) program.
Title XXI – Children’s Health Insurance Program (CHIP) financed via the Centers for
Medicare and Medicaid Services (CMS). The purpose of this title is to provide funds to
States to enable them to initiate and expand the provision of child health assistance to
uninsured, low-income children in an effective and efficient manner that is coordinated
with other sources of health benefits coverage for children.
(Sec. 2101. [42 U.S.C. 1397aa])
Total MCH Funding – All of the MCH funds administered by a State MCH program.
Included in this sum total are: 1) the Federal Title V Block grant allocation; 2) the
Applicant’s funds, which consists of the unobligated balance from the previous year’s
MCH Block Grant allocation, the State’s total matching funds for the Title V allocation
(match and overmatch); 3) the Local funds, which are the total amount of MCH
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dedicated funds from local government within the State); 4) Other Federal funds
(monies other than the Title V Block Grant that are under the control of the person
responsible for administration of the Title V program), and 5) Program Income (funds
collected by State MCH agencies from insurance payments, Medicaid, HMO’s, private
grants, etc.)
Unobligated Balance – The amount of unexpended funds from the previous year’s
Title V MCH Block Grant, as reported as Applicant funds on the Application Face Sheet
[SF 424] and as Unobligated Balance on Form 2.
Performance Measurement
Objectives – The yardsticks by which an agency can measure its efforts to accomplish a
goal. (See also Performance Objectives)
Outcome Measure – The ultimate focus and desired result of any set of public health
program activities and interventions is an improved health and well-being outcome.
Health and well-being outcomes are usually longer term and tied to the ultimate
program goal. Morbidity and mortality statistics are indicators of achievement of health
outcomes. Other outcomes reflect commonly accepted indicators of a highly
functioning system of care for children with special health care needs and their families,
positive outcomes, outcomes which are legislatively mandated or are a legislative focus,
outcomes where the prevalence is increasing, and developmental outcomes where a
fully functioning data system does not exist.
Performance Indicator – The statistical or quantitative value that expresses the result of
a performance objective.
Performance Measure – A narrative statement that describes a specific maternal and
child health need or requirement that, when successfully addressed, will lead to or will
assist in leading to a specific health outcome within a community or jurisdiction and
generally within a specified time frame. (Example: “The rate of women in [State] who
receive early prenatal care in 20__.” This performance measure will assist in leading to
[the health outcome measure of] reducing the rate of infant mortality in the State).
Performance Measurement – The collection of data on, recording of, or tabulation of
results or achievements, usually for comparison to a benchmark.
Performance Objectives – A statement of intention with which actual achievement and
results can be measured and compared. Performance objective statements clearly
describe what is to be achieved, when it is to be achieved, the extent of the
achievement, and the target populations.
Evidence-based or –Informed Strategy Measure (ESM) –Developed by the State, ESMs
would assess the impact of State Title V strategies and activities contained in the State
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Action Plan. It is envisioned that the development of the ESMs will be guided through
an examination of the evidenced-based or evidence-informed practices on what
strategies and activities are both practical and measurable. The main criteria for the
ESM would be that the activities had to be measurable, and there had to be evidence
that the activity was related to the performance measure chosen.
Evidence-based or –Informed Strategy Measure (ESM) Objectives – The objectives for
activities and interventions that drive the achievement of higher-level objectives by the
State Title V program.
Risk Factors – Public health activities and programs that focus on reduction of
scientifically established direct causes of, and contributors to, morbidity and mortality
(i.e., risk factors) are essential steps toward achieving desired health outcomes.
Changes in behavior or physiological conditions are the indicators of achievement of
risk factor results. Results focused on risk factors tend to be intermediate term. Risk
factor results should answer the question, “Why should the State address this risk factor
(i.e., what health outcome will this result support)?”
Risk Factor Objectives – Objectives that describe an improvement in risk factors
(usually behavioral or physiological) that are associated with morbidity and mortality.
Targets – An aspired outcome that is explicitly stated, e.g. achieve 90% of timeliness of
reporting, 100% completeness of reporting, etc. In this Guidance, “Targets” is often
used interchangeably with “Objectives.”
Collaborative Learning, Innovation and Quality Improvement
Aim Statement – A written measureable description of desired outcomes used in a
quality improvement initiative. A strong AIM statement outlines what is to be
accomplished, quantifies the changes that are to be achieved and sets a date by which
the goals will be reached.
Blueprint for Change – A tool to help define action steps for a team’s strategic priorities.
CoIIN versus COIN – The Collaborative Improvement and Innovation Network (CoIIN)
initiative extends the Collaboration Innovation Network (COIN) model to include the
concept of improvement in recognition of the need to strengthen existing investments in
maternal and infant health as well as to develop innovative, new approaches.
Collaborative Innovation Network (COIN) – A cyberteam of self-motivated people with a
collective vision, enabled by the Web to collaborate in achieving a common goal by
sharing ideas, information and work. 2

Gloor, Peter A. “Swarm Creativity.” Competitive Advantage through Collaborative Innovation
Networks. (2006)

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Collaborative Learning – Projects using this model enable learners of different abilities
and interests to work jointly in small groups to complete a project or solve a problem.
Collective Impact – A concept that provides a framework for bringing diverse people and
organizations together in a structured way to achieve social change. 3
Driver Diagram – A logic chart that organizes the different aspects of an improvement
project so key interventions and relationships between these interventions may be
clearly understood by all involved.
Infant Mortality CoIIN Framework – A framework that presents a theory of the
relationships between (1) key domains of influence (e.g., engaged leadership or
innovation), (2) the periods of engagement, and (3) the strategies priorities that will be
employed to reduce infant mortality rates in the U.S.
Learning Collaborative – A group of individuals or organizations that come together for a
defined period of time to work together to improve process relevant to a specific topic.
Members of a learning collaborative generally agree upon a shared set of data to
measure and meet regularly to learn from each other and project experts.
Learning Sessions – Members of learning collaboratives generally agree to a regular
schedule of multi-day meetings throughout the collaborative. These meetings may be in
person or virtual. The learning sessions allow Collaborative faculty and partners to
share latest research or important information on the topic of the collaborative, and they
allow participants to share their work and to learn from each other.
Perinatal Periods of Risk (PPOR) – Both a community approach and an analytic
framework for investigating and addressing high infant mortality rates in urban settings.
The overall intent of the PPOR approach is to develop a simple method that can be
used by communities to mobilize and prioritize prevention efforts. PPOR brings
community stakeholders together to build consensus, support and partnership around
infant mortality rates. 4
Primary Drivers – Found in the CoIIN framework and driver diagrams, drivers are
system components, factors or broad improvement areas that contribute directly to
achieving the stated outcome. For example, if the outcome is reducing infant mortality,
a strategic priority/primary driver might be to improve access to and quality of prenatal
care for women. (See Strategic Priorities)
Potential Action/Change Concept – Actionable steps for change targeted at improving
specific processes, often originating from brainstorming sessions with the team and
evidence-based best practices.

3
4

http://collectiveimpactforum.org/what-collective-impact
http://www.citymatch.org/projects/perinatal-periods-risk-ppor

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Quality Improvement in Public Health – The use of a deliberate and defined
improvement process, which is focused on activities that are responsive to community
needs and improving population health. This effort is continuous and ongoing to
achieve measureable improvements in the efficiency, effectiveness, performance,
accountability, outcomes and other indicators of quality in services or processes, which
achieve equity and improve the health of the community. 5
Strategic Priorities – Found in the CoIIN framework and driver diagrams, these priorities
are system components, factors or broad improvement areas that contribute directly to
achieving the stated outcome. For example, if the outcome is reducing infant mortality,
a strategic priority/primary driver might be to improve access to and quality of prenatal
care for women.
Family/Consumer Engagement
Cultural Competence – A set of values, behaviors, attitudes, and practices within a
system, organization, program or among individuals and which enables them to work
effectively cross culturally. Further, cultural competence refers to the ability to honor
and respect the beliefs, language, inter-personal styles and behaviors of individuals and
families receiving services, as well as staff who are providing such services. At a
systems, organizational, or program level, cultural competence requires a
comprehensive and coordinated plan that includes interventions at all the levels from
policy-making to the individual, and is a dynamic, ongoing, process that requires a longterm commitment. A component of cultural competence is linguistic competence, the
capacity of an organization and its personnel to communicate effectively, and convey
information in a manner that is easily understood by diverse audiences including
persons of limited English proficiency, those who are not literate or who have low
literacy skills and individuals with disabilities.
Regarding the principles of cultural competence, an organization should value diversity
in families, staff, providers and communities; have the capacity for cultural selfassessment; be conscious of the dynamics inherent when cultures interact, e.g. families
and providers; institutionalize cultural knowledge; and develop adaptations to service
delivery and partnership building which reflects an understanding of cultural diversity.
An individual should examine one’s own attitude and values; acquire the values,
knowledge, and skills for working in cross cultural situations; and remember that
everyone has a culture. 6
5

http://www.apha.org/NR/rdonlyres/6CC21952-4A55-4E3F-BB511BA060BF60FE/0/QI_in_PH_IT_Works.pdf

Maternal and Child Health Bureau (MCHB), Guidance and Performance Measures for
Discretionary Grants, Health Resources and Services Administration, U.S. Department of
Health and Human Services, Denboba and Goode, 1999 and 2004; Cross, Bazron, Dennis
and Isaacs, Towards a Culturally Competent System of Care, 1989; Goode and Jones,
Definition of Linguistic Competence, National Center for Cultural Competence, Revised
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Culturally Sensitive – The recognition and understanding that different cultures may
have different concepts and practices with regard to health care; the respect of those
differences and the development of approaches to health care with those differences in
mind.
Family-Centered Care – Approach that assures the health and well-being of children
and their families through a respectful family-professional partnership. It honors the
strengths, cultures, traditions and expertise that everyone brings to this relationship.
Family-centered care is the standard of practice which results in high quality services.
Family Consumer Partnership – The intentional practice of working with families for the
ultimate goal of positive outcomes in all areas through the life course. Family
engagement reflects a belief in the value of the family leadership at all levels from an
individual, community and policy level. 7 Examples of family/consumer partnership for
Title V organizations can be found on the Family Voices website at:
http://www.familyvoices.org/work/title_v?id=0012
Children with Special Health Care Needs
Care Coordination Services – Services that promote the effective and efficient
organization and utilization of resources to assure access to necessary comprehensive
services for children with special health care needs and their families.
[Title V Sec. 501(b)(3)] This category sometimes overlaps with services identified as
case management.
Case Management Services – Services that assure access to quality prenatal, delivery
and postpartum care for pregnant women; Services that assure access to quality
preventive and primary care services for infants up to age one. [Title V Sec. 501(b)(4)]
Children With Special Health Care Needs (CSHCN) – Children who have health
problems that require more than routine and basic care, which includes children with or
at risk of disabilities; chronic illnesses and conditions; and health-related education and
behavioral problems. For budgetary purposes, CSHCN are infants or children from birth
through the 21st year who have special health care needs and for whom the State has
elected to provide with services that are funded through Title V. For planning and
systems development, CSHCN are children who have or are at increased risk for a
chronic physical, developmental, behavioral, or emotional condition and who also
require health and related services of a type or amount that goes beyond that which is
required by children generally.
2004; and Denboba, “Federal Viewpoint,” Special Additions Newsletter for Children with
Special Health Care Needs, Spring/Summer 2005.
7

Definition provided by the Family and Youth Leadership Committee of AMCHP.
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Constructs of a Service System for CSHCN:
1. State Program Collaboration with Other State Agencies and Private
Organizations
States establish and maintain ongoing interagency collaborative processes for
the assessment of needs with respect to the development of community-based
systems of services for CSHCN. State programs collaborate with other agencies
and organizations in the formulation of coordinated policies, standards, data
collection and analysis, financing of services, and program monitoring to assure
comprehensive, coordinated services for CSHCN and their families.
2. State Support for Communities
State programs emphasize the development of community-based programs by
establishing and maintaining a process for facilitating community systems
building through mechanisms, such as technical assistance and consultation,
education and training, common data protocols, and financial resources for
communities engaged in systems development to assure that the unique needs
of CSHCN are met.
3. Coordination of Health Components of Community-Based Systems
A mechanism exists in communities across the State for coordination of health
services with one another. This mechanism includes coordination among
providers of primary care, habilitative and rehabilitative services, other specialty
medical treatment services, mental health services and home health care.
4.

Coordination of Health Services with Other Services at the Community
Level
A mechanism exists in communities across the State for coordination and service
integration among programs serving CSHCN, which includes early intervention
and special education, social services and family support services.

Additional MCH Terms
Acquired Brain Injury – Injury to the brain which is not hereditary, congenital,
degenerative, or induced by birth trauma. Traumatic brain injury is a type of acquired
brain injury.
Bullying – Unwanted, aggressive behavior among school aged children that involves a
real or perceived power imbalance. The behavior is repeated, or has the potential to be
repeated, over time. Additional guidance on bullying surveillance is available at:
http://www.cdc.gov/violenceprevention/pdf/bullying-definitions-final-a.pdf.

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Clinical Genetics – Clinical and laboratory services for individuals and families with, or
at risk for, health problems with a heritable component. The application of the principles
of inheritance and our knowledge of human genes to diagnose, prevent and treat
disease and improve health.
Community – A group of individuals living as a smaller social unit within the confines of
a larger one due to common geographic boundaries, cultural identity, a common work
environment, common interests and other uniting factors.
Community-based Care – Services provided within the context of a defined community
Community-based Service System – An organized network of services that are
grounded in a plan that is developed by a community and based on an assessment of
needs.
Genetic Counseling: The process of helping people to understand and adapt to the
medical, psychological, and familial implications of genetic contributions to disease. This
process integrates: interpretation of family and medical history to assess the chance of
disease occurrence or recurrence; education about inheritance, testing, management,
prevention, resources and research; counseling to promote informed choices; and
adaptation to the risk or condition.
Health Care System – The entirety of the agencies, services, and providers involved or
potentially involved in the health care of community members and the interactions
among those agencies, services and providers.
(Human) Genetics: The science of genes, heredity and variation in human organisms
Health Care Transition – The process of changing from a pediatric to an adult model of
health care. The goal of health care transition (HCT) is to optimize health and assist
youth in reaching their full potential. To reach that goal, there’s an active process over
time that addresses many aspects of a youth’s life, including medical, psychosocial,
educational, and vocational needs and ensures continuity of developmental and age
appropriate health care services. Successful transition involves the engagement and
participation of the pediatric and adult medical home team, the family and other care
givers, and the individual youth collaborating in a positive and mutually respectful
relationship.
Medical Home – An approach to providing health care that is accessible, familycentered, continuous, comprehensive, coordinated, compassionate, and culturally
effective. Care occurs in an environment of trust and mutual responsibility between the
family, patient, and primary care provider. The principle of family-centered care defines
the care to be received in a medical home while a team-based approach is central to
delivering care in the medical home. Within the medical home, care coordination
addresses interrelated medical, dental, mental and behavioral, social, educational, and
financial needs to achieve optimal health and wellness outcomes.
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Morbidity – A general term for any health condition that encompasses diseases, injuries,
and impairments in a population or group.
Mortality – A general term for the incidence of deaths in a population or group. The
number of deaths may be reported by age, sex, race/ethnicity, geographic area, and
cause of death.
Mortality Rate – The number of deaths occurring in a particular population during a
specific time period, as calculated by the number of deaths in that group (numerator)
divided by the total population (denominator) and expressed as per 1,000 live births
(infant mortality rate only) or per 100,000 population, generally at mid-year.
National Improvement Partnership Network (NIPN) – A network of States who have an
Improvement Partnership (IP), which is a durable collaborative of public and private
partners that use the science of quality improvement and a systems approach to
improve healthcare infrastructure and practice. Established in 2009, NIPN is led by the
Vermont Child Health Improvement Program (VCHIP).
National Survey of Children’s Health (NSCH) – Sponsored by the Maternal and Child
Health Bureau of the Health Resources and Services Administration, the NSCH
examines the physical and emotional health of children ages 0-17 years of age. Special
emphasis is placed on factors that may relate to well-being of children, including
medical homes, family interactions, parental health, school and after-school
experiences, and safe neighborhoods. The NSCH has been fielded three times, in
2003, 2007 and 2011-2012, yielding both State- and nationally-representative data.
The NSCH is currently being redesigned, with the first public release of data scheduled
for spring 2017.
National Survey of Children with Special Health Care Needs (NS-CSHCN) – This
survey was sponsored by the Maternal and Child Health Bureau of the Health
Resources and Services Administration. The NS-CSHCN was conducted three times,
in 2001, 2005-2006 and 2009-2010, and yielded State- and nationally-representative
data on the health care experiences of CSHCN and their families. The NS-CSHCN is
currently being combined with the NSCH to provide one unified survey.
Newborn Screening (NBS) – The process of testing newborn babies for some serious,
but treatable, conditions. NBS can include a heel stick, hearing screen, and pulse
oximetry. The conditions that newborn babies are screened for varies by state. When a
newborn screening result is positive, further diagnostic testing is usually required to
confirm or specify the results.
Newborn Screening Long-term Follow-up – Comprises the assurance and provision of
quality chronic disease management, condition-specific treatment, and age-appropriate
preventive care throughout the lifespan of individuals identified with a condition included
in newborn screening. Integral to assuring appropriate long-term follow-up are activities
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related to improving care delivery, including engagement of affected individuals and
their families as effective partners in care management, continuous quality improvement
through the medical home, research into pathophysiology and treatment options, and
active surveillance and evaluation of data related to care and outcomes.
Newborn Screening Short-term Follow-up – The process of ensuring that all newborns
are screened, that an appropriate follow-up caregiver is informed of results, that
confirmatory testing has been completed, and that the infant has received a diagnosis
and, if necessary, treatment.
Preventive Services – Activities aimed at reducing the incidence of health problems or
disease prevalence in the community, or the personal risk factors for such diseases or
conditions.
Preventive Oral Health Services – Activities that aim to improve and maintain good oral
health and function by reducing the onset and/or development of oral diseases or
deformities and the occurrence of oro-facial injuries. Examples of preventive oral health
services include, but are not limited to, oral hygiene instructions, fluoride treatment, and
Dental Sealants.
Primary Care/Primary Care Services – The provision of comprehensive personal health
services that include health maintenance and preventive services, initial assessment of
health problems, treatment of uncomplicated and diagnosed chronic health problems,
and the overall management of an individual’s or family’s health care services.
Recommended Uniform Screening Panel (RUSP) – The RUSP is a list of disorders that
are screened at birth and recommended by the Secretary of the Department of Health
and Human Services (HHS) for States to screen as part of their State universal newborn
screening (NBS) programs. Disorders on the RUSP are chosen based on evidence that
supports the potential net benefit of screening, the ability of states to screen for the
disorder, and the availability of effective treatments. It is recommended that every
newborn be screened for all disorders on the RUSP. Most States screen for the
majority of disorders on the RUSP; newer conditions are still in process of adoption.
Some states also screen for additional disorders. Although States ultimately determine
what disorders their NBS program will screen for, the RUSP establishes a standardized
list of disorders that have been supported by the Discretionary Advisory Committee on
Heritable Disorders in Newborns and Children (DACHDNC) and the Secretary of HHS.
Safe Infant Sleep Environment – Infant is placed to sleep on its back, in its own crib
without blankets or soft items or bed-sharing. Reference:
http://pediatrics.aappublications.org/content/early/2011/10/12/peds.2011-2284
Sudden Unexpected Infant Deaths (SUID) - Deaths in infants less than one year of age
that occur suddenly and unexpectedly, and in whom the cause of death is not
immediately obvious prior to investigation.

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Sudden Infant Death Syndrome (SIDS) – The sudden death of an infant less than one
year of age that cannot be explained after a thorough investigation is conducted,
including a complete autopsy, examination of the death scene, and review of the clinical
history.
Systems Development – Activities involving the creation or enhancement of
organizational infrastructures at the community level for the delivery of health services
and other needed ancillary services to individuals in the community by improving the
service capacity of health care service providers.
Traumatic Brain Injury – An alteration in brain function, or other evidence of brain
pathology caused by an external force.

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