Form 1 PIMS Measures

OMB Number (0906-0012)

Expiration date:

Public Burden Statement:  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0906-0012.  Public reporting burden for this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857.

HRSA-17-025

Radiation Exposure Screening and Education Program

Performance Measures

Goal:

Funded eligible entities to carry out programs to develop educational programs; disseminate information on radiogenic diseases and the importance of early detection; screen eligible individuals for cancer and other radiogenic diseases; provide appropriate referrals for medical treatment; and facilitate documentation of Radiation Exposure Compensation Act (RECA) claims.

Tables/Categories:

1. Demographics

2. Annual Program Data Screening

3. Annual Program Date Outreach

Measures:

DEMOGRAPHICS

Instructions:

Please provide the number of RESEP program users in your service population by age, gender, race and ethnicity. The number of individuals recorded within each category of this measure is reflective of the total population who have sought services from your organization’s RESEP facility and/or facilities.

If the number of people is zero (0), please put zero (0) in the appropriate section; do not leave any sections blank. There should not be a N/A (not applicable) response since all measures are applicable.

For the number of total users by race.

Hispanic or Latino Ethnicity

• Column A (Hispanic/Latino): Report the number of persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, broken down by their racial identification and including those Hispanics/Latinos born in the United States. Do not count persons from Portugal, Brazil, or Haiti whose ethnicity is not tied to the Spanish language.

• Column B (Non-Hispanic/Latino): Report the number of all other people except those for whom there are neither racial nor Hispanic/Latino ethnicity data. If a person has chosen a race (described below) but has not made a selection for the Hispanic /non-Hispanic question, the patient is presumed to be non-Hispanic/Latino.

• Column C (Unreported/Refused to Report): Only one cell is available in this column. Report on Line 7, Column C only those patients who left the entire race and Hispanic/Latino ethnicity part of the intake form blank.

People who self-report as Hispanic/Latino but do not separately select a race must be reported on Line 7, Column A as Hispanic/Latino whose race is unreported or refused to report. Health centers may not default these people to “White,” “Native American,” “more than one race,” or any other category.

Race

All people must be classified in one of the racial categories (including a category for persons who are “Unreported/Refused to Report”). This includes individuals who also consider themselves to be Hispanic or Latino. People who self-report race, but do not separately indicate if they are Hispanic or Latino, are presumed to be non-Hispanic/Latino and are to be reported on the appropriate race line in Column B.

People sometimes categorized as “Asian/Other Pacific Islander” in other systems are divided into three separate categories:

• Line 1, Asian: Persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Indonesia, Thailand, or Vietnam

• Line 2a, Native Hawaiian: Persons having origins in any of the original peoples of Hawaii

• Line 2b, Other Pacific Islander: Persons having origins in any of the original peoples of Guam, Samoa, Tonga, Palau, Truk, Yap, Saipan, Kosrae, Ebeye, Pohnpei or other Pacific Islands in Micronesia, Melanesia, or Polynesia

• Line 2, Total Native Hawaiian/Other Pacific Islander: Must equal lines 2a+2b

American Indian/Alaska Native (Line 4): Persons who trace their origins to any of the original peoples of North and South America (including Central America) and who maintain Tribal affiliation or community attachment.

More than one race (Line 6): “More than one race” should not appear as a selection option on your intake form. Use this line only if your system captures multiple races (but not a race and an ethnicity) and the person has chosen two or more races. This is usually done with an intake form that lists the races and tells the person to “check one or more” or “check all that apply.” “More than one race” must not be used as a default for Hispanics/Latinos who do not check a separate race. They are to be reported on Line 7 (Unreported/Refused to Report), as noted above.

Demographics					Number
1	Age Group – Number of Medical Users
	Under 40
	40-44
	45-49
	50-54
	55-59
	60-64
	65-69
	70-74
	75-79
	80-84
	85+
2	Gender – Number of Total Users
	Male
	Female
3	Number of users by Race	Hispanic/Latino (a)	Non-Hispanic/Latino (b)	Unreported/ Refused to Report Ethnicity (c)		Total (d)
	Asian
	Native Hawaiian/Other Pacific Islander
	Black/African American
	American Indian/ Alaska Native
	White
	More than one race
	Unreported/Refused to report race
	Total of individuals served (automatically calculated)					Equal to the total of the number of individuals in the target population

ANNUAL PROGRAM DATA SCREENING

Instructions:

Please refer to each category description for completing reporting for this measure.

Screening by Type

4a Screening: Please provide the number of initial medical encounters of eligible individuals who receive an employment history and physical examination by a health care provider.

4b Re-Screening: Please provide the number of medical encounters that occur at least one year after the initial physical examination of an eligible individual by a health care provider.

4c Screening Follow-Up Contacts:

Please provide the number of users who have received a follow-up contact (face-to-face, calls and letters) with patients, and primary care providers and specialists regarding issues related to follow up after a screening. This also includes case management, general screening follow-up contacts, contacts regarding patients’ questions about their screening exam or results, contacts as a result of a screening exam or test that were done, referral for additional diagnostic testing or treatment, and any other activities related to a RESEP screening.

4	Screening by Type	Number
4a	Screening
4b	Re-Screening
4c	Screening Follow-Up Contacts

Referral by Type

5a Medical Referrals: Please provide the number of all referrals (inclusive and exclusive of RECA eligibility) for diagnosis and/or treatment made as a result of a RESEP screening exam.

5b Medical Referrals for RECA Diagnostic: Please provide the total number of referrals made, this is the number of patients referred for additional diagnostic testing of a RECA eligible disease or cancer.

5c Medical Referrals for RECA Treatment: Please provide the total number of referrals made, this is the number of patients referred for treatment of a RECA eligible disease or cancer.

5	Referrals by Type	Number
5a	All Medical Referrals
5b	Medical Referrals for RECA Diagnostic
5c	Medical Referrals for RECA Treatment

Other Type of Program Services

6a Depression Screening: Positive Test and Referral: Please provide the total number of RESEP patients that test positive for depression (according to the two question instrument in the RESEP guidance under Depression Screening) and were referred for treatment of, either to their primary care, behavioral health or mental health provider.

6b RECA Eligibility Assistance Encounters: Please provide the total number of all RECA related encounters including: one-on-one counseling or assistance provided to individuals about eligibility for the RECA program, including information about patient claims, required documentation (e.g., medical, residency, and work history), application instructions, filing and approval processes, possible compensation, and referral for legal services. RECA eligibility assistance can be provided to individuals screened through the RESEP clinic, individuals who contact clinics for information about RECA eligibility without being screened at that clinic, family members of RECA-eligible individuals (living or deceased), and individuals with legal representation. This also includes repeat counseling sessions for RECA eligibility. This assistance can be provided through face to- face interactions, telephone encounters, or individual RECA claims assistance.

6	Other Type of Program Services	Number
6a	Depression Screening: Positive Test and Referral
6b	RECA Eligibility Assistance Encounters

ANNUAL PROGRAM DATA OUTREACH

Sessions or Distributed Items

7a Presentations: Please provide the number of formal or informal sessions held (e.g. Community meetings, forums, events, health fairs, education classes) that include information about RESEP (may also include information about RECA).

7b Individuals Attending Presentations: Please provide the number of individuals who attended the presentations as described above

7c Pamphlets/Brochures/Letters Distributed: Please provide the number of items distributed that included information about RESEP (may also include information about RECA). This category can include materials distributed at: community meetings, forums, health fairs or education classes. Letters counted in this category should only be those related to outreach and education, not letters related to screening results or referrals.

7d Other: Please provide the number of other media types (e.g. e-mails, posters or flyers) disseminated to inform a target audience about RESEP. The number of items goes in the box. Also, please enter the description of which items and the quantity of each "Other" category item disseminated.

7	Sessions or Distributed Items	Number
7a	Presentations
7b	Individuals Attending Presentations
7c	Pamphlets/Brochures/Letters Distributed
7d	Other

Individual Encounters

8a Face to Face: Please provide the number of one-on-one encounters with individuals regarding general, nonmedical questions about RESEP. These face-to-face encounters can include interactions focused on facilitating access and/or informing clients of available RESEP services. These face-to-face encounters can be the result of a range of education and outreach efforts, including RESEP presentations, media activity, publications, or word of mouth.

8b Telephone/General: Please provide the number of telephone encounters with individuals regarding general, nonmedical questions about RESEP. These telephone encounters can include interactions focused on facilitating access and/or informing clients of available RESEP services. These telephone encounters can be the result of a range of education and outreach efforts, including RESEP presentations, media activity, publications, or word of mouth.

8	Individual Encounters	Number
8a	Face to Face
8b	Telephone/General

Sessions or Distributed Items by Media Type

9a Radio: Please provide the number of advertisements, feature stories, or other radio announcements that inform the target audience about RESEP.

9b TV Spots: Please provide the number of advertisements, feature stories, or other television announcements that inform the target audience about RESEP.

9c Newspaper: Please provide the number of advertisements or articles that run in printed publications with the aim of reaching the target audience.

9d Letter: Please provide the number of letter distributed that included information about RESEP or RECA related to outreach and education, not letters related to screening results or referrals.

9e Social Media: Please provide the number of advertisements or articles that run on Social Media with the aim of reaching the target audience.

9f Other: Please provide the number of other media types (e.g. e-mails, posters or flyers) disseminated to inform a target audience about RESEP. The number of items goes in the box. Also, please enter the description of which items and the quantity of each "Other" category item disseminated.

9g Geographic Regions Reached via Media Efforts: Please provide the geographic regions reached via your media efforts (ie counties, communities, neighborhoods)

9	Sessions or Distributed Items by Media Type	Number
9a	Radio
9b	TV Spots
9c	Newspaper
9d	Letters
9e	Social Media
9f	Other
9g	Geographic Regions Reached via Media Efforts (up to 500 characters)

RECA-ELIGIBLE DISEASES BY EXPOSURE CATEGORY

Instructions:

Please refer to each category description for completing reporting for this measure.

10 Exposure Activities for Malignant Diseases: Please provide the total number of RECA-eligible malignant diseases by exposure activity discovered during the reporting period.

11 Exposure Activities for Non-Malignant Diseases: Please provide the total number of RECA-eligible non-malignant disease by exposure activity discovered during the reporting period.

10 Exposure Activities for Malignant Diseases	Uranium Mining	Uranium Milling	Ore Transporting	Downwinder	Onsite Participant	Multiple Activities	Total
Multiple Myeloma
Non-Hodgkin’s Lymphomas
Leukemia
Lung Cancer
Renal Cancer
Thyroid Cancer
Breast Cancer
Esophagus Cancer
Stomach Cancer
Pharynx Cancer
Bile Duct Cancer
Gall Bladder Cancer
Salivary Gland Cancer
Urinary Bladder Cancer
Brain Cancer Colon Cancer
Ovarian Cancer
Liver Cancer
Kidney Cancer

11 Exposure Activities for Non-Malignant Diseases	Uranium Mining	Uranium Milling	Ore Transporting	Downwinder	Onsite Participant	Multiple Activities	Total
Respiratory Diseases
Chronic Renal Disease
Lung Disease Pulmonary Fibrosis
Fibrosis Cor Pulmonale
Renal Cancer
Silicosis
Pneumoconiosis

OTHER DISEASES (NOT-ELIGIBLE FOR RECA)

Instructions:

Please refer to each category description for completing reporting for this measure.

12 Malignant Diseases Number: Please specify the type of malignant diseases (Not-Eligible for RECA) and the total number discovered.

13 Non-Malignant Diseases Number: Please specify the type of non-malignant diseases (i.e., those diseases not eligible for RECA) and the number discovered.

14 Please provide comments on the Annual Program Data Screening and Outreach Form (500 word limit).

12	Malignant Diseases:	Number
	Pituitary Adenoma
	Uterine Cancer
	Endometrial Cancer
	Prostate Cancer
	Cervical Cancer
13	Non-Malignant Diseases:	Number
	Depression
	Kidney Mass
	Pneumonia
	Irregular Heart Beat
	Hematuria
	Dysphagia
	Hypertension
	Hypothyroid
	BPH
	Dementia
	Pernicious Anemia
	Liver Nodules
14	Annual Program Data Screening and Outreach Form Comments

TELEHEALTH (This section is only applicable to projects utilizing telehealth services)

Table Instructions: Telehealth is the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance. If your RESEP grant program utilizes telehealth please fill out the following table.

In the table, enter the names of each consultant site (hub site) in column 1 and each originating site (patient data site) in column 2. For many programs, the telehealth provider site will be serving all your remote sites. We ask that you still list the telehealth provider (hub) site in column 1.

Estimate the distance between the two (in miles) and enter this number into column 3. This information can be obtained by using Google maps (https://www.google.com/maps) or other mapping resources.

Enter the number of patient care sessions between the two locations in column 5. For group sessions/clinics, each patient should be counted separately, as each would have had to travel for these sessions. For simplicity reasons (and to avoid collecting information from each patient) the distance a patient travels from their home to the remote site is intentionally omitted. Home patients should be excluded from this entire reporting sheet. Patients being stabilized prior to transport should be excluded as well, as their travel is not averted, only delayed.

Columns 4 and 6 will fill in automatically. You do not need to enter anything into these cells.

Definitions:

Consultant or Hub site: Site at which the physician or other licensed practitioner delivering the service is located at the time the service is provided via telecommunications system.

Originating Site/Patient Data Site: Site at which the patient is located or where patient data is collected at the time the service is provided via telecommunications system.

Patient-Care Sessions: Include therapy and counseling (including nutritional, group, etc.) but NOT didactic education, community meetings or administrative sessions.

Question 15
1	2	3	4	5	6
Consultant Site	Patient/Patient-data Site	Distance Between (miles)	Miles Roundtrip ('column 3' X 2)	# Patient Care Sessions	Miles Saved ('column 4' X 'column 5')
			0		0
			0		0
			0		0
			0		0
			0		0
		Total:	0	0	0

26