Form A Attachment A - Form 1 Demographic Performance Measures C

OMB No: 0906-0017
Expiration Date: 03/31/2019

THE MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING
PROGRAM

FORM 1

DEMOGRAPHIC, SERVICE UTILIZATION, AND SELECT CLINICAL
INDICATORS

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 0906-0017. Public reporting burden for this collection of information is estimated to average 560 hours per response,
including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-29,
Rockville, Maryland, 20857.
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SECTION A: PARTICIPANT DEMOGRAPHICS
Table 1: Unduplicated Count of New and Continuing Program Participants Served by MIECHV
Participants
Pregnant Women
Female Caregivers
Male Caregivers
All Adults (Auto Calculate)
Female Index Children
Male Index Children
All Index Children (Auto Calculate)

Number Newly Enrolled

Number Continuing During Reporting Period

Total

Notes:
Table 2: Unduplicated Count of Households Served by MIECHV
Households
Number of Households

Number Newly Enrolled

Number Continuing During Reporting Period

Total

Notes:
Table 3: Unduplicated Count of Participants and Households Served by State Home Visiting Programs (non-MIECHV)
Participants and Households
Pregnant Women
Female Caregivers
Male Caregivers
All Adults (Auto Calculate)
Female Index Children
Male Index Children
All Index Children (Auto Calculate)
Number of Households

Total Number Served during Reporting Period

Notes:

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Table 4: Adult Participants by Age
Adult Participants
≤17 18-19 20-21 22-24 25-29 30-34 35-44 45-54 55-64 ≥65 Unknown/Did not Report* Total
Pregnant Women
Female Caregivers
Male Caregivers
All Adults (Auto Calculate)
* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if
possible, plans to reduce the amount of missing data in future reporting.
Notes:
Table 5: Index Children by Age
Index Children
<1 year 1-2 years 3-4 years 5-6 years Unknown/Did not Report* Total
Female Index Children
Male Index Children
All Index Children (Auto Calculate)
* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if
possible, plans to reduce the amount of missing data in future reporting.
Notes:
Table 6: Participants by Ethnicity
Participants
Hispanic or Latino Not Hispanic or Latino Unknown/Did not Report* Total
Pregnant Women
Female Caregivers
Male Caregivers
All Adults (Auto Calculate)
Female Index Children
Male Index Children
All Index Children (Auto Calculate)
* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if
possible, plans to reduce the amount of missing data in future reporting.
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Notes:
Table 7: Participants by Race
Participants

American Indian
or Alaska Native

Asian

Black or African
American

Native Hawaiian or
Other Pacific Islander

White

More than
one race

Unknown/Did not
Report*

Total

Pregnant Women
Female Caregivers
Male Caregivers
All Adults (Auto
Calculate)
Female Index Children
Male Index Children
All Index Children
(Auto Calculate)
* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if
possible, plans to reduce the amount of missing data in future reporting.
Notes:
Table 8: Adult Participants by Marital Status
Adult
Participants

Never Married (Excluding Not
Married but Living Together
with Partner)

Married

Not Married but
Living Together with
Partner

Separated/Divorced/Widowed

Unknown/Did not
Report*

Total

Pregnant Women
Female
Caregivers
Male Caregivers
All Adults (Auto
Calculate)
* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if
possible, plans to reduce the amount of missing data in future reporting.
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Notes:
Table 9: Adult Participants by Educational Attainment
Adult
Participants

Less than
HS
diploma

HS
Diploma/GED

Some
college/
training

Technical
training or
certification

Associate’s
Degree

Bachelor’s
Degree or
higher

Other

Unknown/Did
not Report*

Total

Pregnant
Women
Female
Caregivers
Male Caregivers
All Adults
(Auto
Calculate)
* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if
possible, plans to reduce the amount of missing data in future reporting.
Notes:
Table 10: Adult Participants by Employment Status
Adult Participants
Employed Full Time Employed Part-Time Not employed Unknown/Did not Report* Total
Pregnant Women
Female Caregivers
Male Caregivers
All Adults (Auto Calculate)
* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if
possible, plans to reduce the amount of missing data in future reporting.
Notes:

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Table 11: Adult Participants by Housing Status
Not Homeless

Adult
Participan
ts

Owns or
shares own
home,
condominiu
m, or
apartment

Total
Not
Homele
ss
Rents or
shares
own
home or
apartme
nt

Lives
in
public
housin
g

Lives
with
parent
or
family
membe
r

Some
other
arrangeme
nt

Homeless

Homele
ss and
sharing
housing

Total
Homele
ss
Homeless
and living
in an
emergenc
y or
transition
al shelter

Unknown/D
id not
Report*

Tota
l

Some
other
arrangeme
nt

Pregnant
Women
Female
Caregivers
Male
Caregivers
All Adults
(Auto
Calculate)
* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if
possible, plans to reduce the amount of missing data in future reporting.
Notes:
Table 12: Primary Language Spoken at Home
Index Children
Number Percent
English
Spanish
Other
Unknown/Did Not Report*
All Index Children (Auto Calculate)
100
* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if
possible, plans to reduce the amount of missing data in future reporting.

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Notes:
Table 13: Household Income in Relation to Federal Poverty Guidelines
Households
Number of Households Percent
50% and under
51-100%
101-133%
134-200%
201-300%
>300%
Unknown/Did not Report*
All Households (Auto Calculate)
100
* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if
possible, plans to reduce the amount of missing data in future reporting.
Notes:
Table 14: For Each Household Indicate the Priority Population Characteristics
Households
Yes
1.
2.
3.
4.
5.
6.

No

Unknown/Did not
Report*

Total

Low income household
Household contains an enrollee who is pregnant and under age 21
Household has a history of child abuse or neglect or has had interactions with child welfare services
Household has a history of substance abuse or needs substance abuse treatment
Someone in the household uses tobacco products in the home
Someone in the household has attained low student achievement or has a child with low student
achievement
7. Household has a child with developmental delays or disabilities
8. Household includes individuals who are serving or formerly served in the US armed forces
* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if
possible, plans to reduce the amount of missing data in future reporting.
Notes:

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Expiration Date: 03/31/2019

SECTION B: SERVICE UTILIZATION
Table 15: Service Utilization
Home Visits
Total Number of Home Visits completed

Number

Notes:
Table 16: Family Engagement by Household
Households
Number of Households
Percent
Currently receiving services
Completed program
Stopped services before completion
Enrolled but not currently receiving services/Other
Unknown/Did not Report*
All Categories (Auto Calculate)
* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if
possible, plans to reduce the amount of missing data in future reporting.
Notes:
Table 17: Unduplicated Count of Households by Evidence-Based Home Visiting Model or Promising Approach
Home Visiting Model (Select One per Row – Add Rows for Additional
Models)

Number Newly
Enrolled

Number Continuing During Reporting
Period

Notes:

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Total

OMB No: 0906-0017
Expiration Date: 03/31/2019

SECTION C: INSURANCE AND CLINICAL INDICATORS
Table 18: Participants by Type of Health Insurance Coverage
Participants

No Insurance
Coverage

Medicaid or
CHIP

TriCare

Private or
Other

Unknown/Did not
Report*

Total

Pregnant Women
Female Caregivers
Male Caregivers
All Adults (Auto Calculate)
Female Index Children
Male Index Children
All Index Children (Auto
Calculate)
* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if
possible, plans to reduce the amount of missing data in future reporting.
Notes:
Table 19: Index Children by Usual Source of Medical Care
Index Children

Doctor’s/Nurse
Practitioner’s
Office

Hospital
Emergency
Room

Hospital
Outpatient

Federally
Qualified
Health Center

Retail Store
or Minute
Clinic

Other

None

Unknown/Did
not Report*

Total

Female Index
Children
Male Index
Children
All Index
Children (Auto
Calculate)
* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if
possible, plans to reduce the amount of missing data in future reporting.
Notes:

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Table 20: Index Children (≥ 12 months of age) by Usual Source of Dental Care
Index Children

Have a Usual Source of Dental
Care

Do not have a Usual Source of Dental
Care

Unknown/Did not
Report*

Total

Female Index Children
Male Index Children
All Index Children (Auto
Calculate)
* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if
possible, plans to reduce the amount of missing data in future reporting.
Notes:

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DEFINITIONS OF KEY TERMS

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Table
Number
All
Tables

Field

Key Terms Requiring Definitions
MIECHV Household: For the purposes of reporting to HRSA on Form 1, a “MIECHV household” is defined as a
family served during the reporting period by a trained home visitor implementing services with fidelity to the model
and that is identified as a MIECHV household at enrollment. HRSA has identified two different methods that can be
used to identify MIECHV households that are described below:

1.

2.

Home Visitor Personnel Cost Method (preferred method): Households are designated as MIECHV at
enrollment based on the designation of the home visitor they are assigned. Using this methodology, recipients
designate all households as MIECHV that are served by home visitors for whom at least 25 percent of his/her
personnel costs (salary/wages including benefits) are paid for with MIECHV funding.
Enrollment Slot Method (temporary option): Households are designated as MIECHV households based on the
slot they are assigned to at enrollment. Using this methodology, recipients identify certain slots as MIECHVfunded and assign households to these slots at enrollment in accordance with the terms of the contractual
agreement between the MIECHV state recipient and the LIA regardless of the percentage of the slot funded by
MIECHV.

Once designated as a MIECHV household, the household is tracked for the purposes of data collection through the
tenure of household participation in the program.
1

Unduplicated Count of New
and Continuing Program
Participants Served by
MIECHV

New Participant: A participant, including a pregnant woman, female caregiver, or male caregiver, who signs up to
participate in the home visiting program at any time during the reporting period who was identified as being part of
a MIECHV household at enrollment (see definition of a MIECHV Household included at the beginning of the
Definition of Key Terms).
Continuing Participant: A participant, including a pregnant woman, female caregiver, or male caregiver, who was
signed up and actively enrolled in the home visiting program prior to the beginning of the reporting period who was
identified as being part of a MIECHV household at enrollment (see definition of a MIECHV Household included at
the beginning of the Definition of Key Terms).
Pregnant women are participants who were either pregnant at enrollment or pregnant at the annual update of
information in a subsequent reporting period.
Female caregivers are those female household members who are enrolled in the program during the reporting
period, are considered a caregiver of the index child, and were not pregnant at the time of enrollment or the annual
update of this information (e.g., biological mothers, adoptive mothers, foster mothers, grandmothers).

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Male caregivers include those male household members (e.g. expectant fathers, biological fathers, step-fathers, and
partners) who also meet the definition of an enrollee.

2

3

Unduplicated Count of
Household Served by
MIECHV

4

Unduplicated Count of
Participants and
Households Served by State
Home Visiting Programs
(non-MIECHV)
Adult Participants by Age

5

Index Children by Age

6

Participants by Ethnicity

7

Participants by Race

8

Adult Participants by
Marital Status

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Index Child (Birth – Kindergarten Entry): the child (or children) in an individual household who is under the
care of the enrollee(s) and who is enrolled in the program and was identified as being part of a MIECHV household
at enrollment (see definition of a MIECHV Household included at the beginning of the Definition of Key Terms).
More than one index child per household can be identified.
New Household: A household, including a pregnant woman, female caregiver, and/or male caregiver who signs up
to participate in the home visiting program at any time during the reporting period. The household may include
multiple caregivers depending on model-specific definitions.
Continuing Household: A household, including a pregnant woman, female caregiver, and/or male caregiver who
were signed up and actively enrolled in the home visiting program prior to the beginning of the reporting period.
The household may include multiple caregivers depending on model-specific definitions.
Participant Served by a State Home Visiting Program (non-MIECHV): A participant, including a pregnant
woman, female caregiver, or male caregiver, who signs up to participate in the home visiting program at any time
during the reporting period who was identified as being part of a non-MIECHV household at enrollment (see
definition of a MIECHV Household included at the beginning of the Definition of Key Terms).
Adult Participants: includes the person or persons in the household who signed up to participate in the home
visiting program (e.g., a teenage parent would be counted as an adult participant but not an index child). The
category can include more than one member of the household if more than one individual are enrolled in the
program (e.g., a father and a mother have both signed up to participate). It should include at a minimum for every
household the primary caregiver of the index child.
Index Child (Birth – Kindergarten Entry): the child (or children) in an individual household who is under the
care of the enrollee(s) and who is enrolled in the program and who was identified as being part of a MIECHV
household at enrollment (see definition of a MIECHV Household included at the beginning of the Definition of Key
Terms). More than one index child per household can be identified.
The responses regarding ethnicity should reflect what the person considers herself/himself to be and are not based
on percentages of ancestry. If ethnicity is unknown or not reported for some participants, enter that count in the
respective “Unknown/Did not report” column.
The responses regarding race should reflect what the person considers herself/himself to be and are not based on
percentages of ancestry. Participants who select more than one race should be reported in the “More than one race”
category. If ethnicity and race are unknown or not reported for some participants, enter that count in the respective
“Unknown/Did not Report” columns.
Adult Participants: includes the person or persons in the household who signed up to participate in the home
visiting program (e.g., a teenage parent would be counted as an adult participant but not an index child). The
category can include more than one member of the household if more than one individual are enrolled in the
program (e.g., a father and a mother have both signed up to participate). It should include at a minimum for every
household the primary caregiver of the index child.
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Adult Participants by
Educational Attainment

If more than one individual is enrolled in the program, enter the status for all enrollees. For example, if a pregnant
woman is enrolled with her spouse in the program, both participants would be counted under the married category.
Adult Participants: includes the person or persons in the household who signed up to participate in the home
visiting program (e.g., a teenage parent would be counted as an adult participant but not an index child). The
category can include more than one member of the household if more than one individual are enrolled in the
program (e.g., a father and a mother have both signed up to participate). It should include at a minimum for every
household the primary caregiver of the index child.
Less than high school diploma includes individuals who have not completed their high school education.
The Some college/training category includes those who are currently enrolled and those who attended in the past.
The Technical training or certification category includes those who received technical training or certification in
the past.
The Associate’s Degree category includes those who obtained an Associate’s Degree.
The Bachelor’s Degree category includes those who obtained a Bachelor’s Degree.

10

Adult Participants by
Employment Status

The Other category includes those individuals who did not fall into the specified categories.
Employed: refers to whether the person is currently working for pay.
Employed Full Time: an employee who works an average of at least 30 hours per week
Employed Part Time: an employee who works an average of less than 30 hours per week1

11

Adult Participants by
Housing Status

Not Employed: indicates that the person is not working for pay (this category may include, for example, students,
homemakers and those enrollees actively seeking work but currently not employed)
Not homeless: individuals who have a fixed, regular, and adequate nighttime residence (within the meaning of
section 103(a)(1) of the McKinney-Vento Homeless Assistance Act); and
Not homeless and lives in public housing: individuals who live in a public housing unit that is
administered by a public housing agency (excludes individuals who utilize housing voucher programs)
Homeless: individuals who lack a fixed, regular, and adequate nighttime residence (within the meaning of section
103(a)(1) of the McKinney-Vento Homeless Assistance Act); and

1

Healthcare.gov Glossary. https://www.healthcare.gov/glossary/full-time-employee/

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Homeless and sharing housing: individuals who are sharing the housing of other persons due to loss of
housing, economic hardship, or a similar reason
Homeless and living in an emergency or transitional shelter: individuals who are living in emergency
or transitional shelters; are abandoned in hospitals; or are awaiting foster care placement

12

13

14

Primary Language Spoken
at Home

Household Income in
Relation to Federal Poverty
Guidelines

For Each Household
Indicate the Priority
Population Characteristics

Homeless and some other arrangement: individuals who are living in motels, hotels, trailer parks, or
camping grounds due to the lack of alternative adequate accommodations; individuals who have a primary
nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping
accommodation for human beings (within the meaning of section 103(a)(2)(C)); individuals who are living
in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar
settings2
Primary language: the language used in the home the majority of the time.
Index Child (Birth – Kindergarten Entry): the child (or children) in an individual household who is under the
care of the enrollee(s) and who is enrolled in the program and was served by a trained home visitor implementing
services with fidelity to the model who was identified as being part of a MIECHV household at enrollment (see
definition of a MIECHV Household included at the beginning of the Definition of Key Terms). More than one
index child per household can be identified.
The appropriate category for a given family will depend both on household income and on the number of household
members counted in the household (both home visiting enrollees and non-enrollees). Household income refers to
the annual gross income for the household as defined in programmatic guidance, recorded at enrollment and
annually thereafter.
Federal Poverty Guidelines: Annual income data can be estimated from monthly data (monthly income x 12). The
HHS Poverty Guidelines are updated annually in February and published in the Federal Register. See
https://aspe.hhs.gov/poverty-guidelines .
Low-Income: An individual or family with an income determined to be below the Federal Poverty Guidelines. The
HHS Poverty Guidelines are updated annually in February and published in the Federal Register. See
https://aspe.hhs.gov/poverty-guidelines.
Pregnant women under 21: Households with expectant mothers who enroll in the program and are under 21 years
old during the reporting period.
Have a history of child abuse or neglect or have had interactions with child welfare services: Based on selfreport, a household with members who have a history of abuse or neglect and have had involvement with child
welfare services either as a child or as an adult.

2

Administration for Children and Families. Early Childhood Learning and Knowledge Center, 2014. http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/family/family/Homelessness/hmls/definition/definitionlegal.html

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Have a history of substance abuse or need substance abuse treatment: Based on self-report, a household with
members who have a history of substance abuse or who have been identified as needing substance abuse services
through a substance abuse screening administered upon enrollment.
Are users of tobacco products in the home: Based on self-report, a household with members who use tobacco
products in the home or who have been identified as using tobacco through a substance abuse screening
administered during intake. Tobacco use is defined as combustibles (cigarettes, cigars, pipes, hookahs, bidis), noncombustibles (chew, dip, snuff, snus, and dissolvables), and electronic nicotine delivery systems (ENDS).
Have, or have children with, low student achievement: Based on self-report, a household with members who
have perceived themselves or their child(ren) as having low student achievement.
Have a child or children with developmental delays or disabilities: Based on self-report or home visitor/staff
observation, a household with members who have a child or children suspected of having a developmental delay or
disability.

15

Service Utilization

16

Family Engagement by
Household

Are in families that are or have served in the armed forces: Based on self-report, households that include
individuals who are serving or formerly served in the Armed Forces, including such households that have members
of the Armed Forces who have had multiple deployments outside of the United States. For this criterion, definition
includes a military member’s dependent acquired through marriage, adoption, or other action during the course of a
member’s current tour of assigned duty.
Home visit refers to the definition of a completed home visit enacted by the various evidence-based home visiting
models approved for implementation through the MIECHV program or a Promising Approach. Please refer to
model-specific guidance for specific definitions.
Currently receiving services refers to families that are participating in services at the end of the reporting period.
Completed program refers to families who have completed the program according to model-specific definitions
and criteria during the reporting period.
Stopped services before completion refers to families who left the program for any reason prior to completion.

17

Unduplicated Count of
Households by EvidenceBased Home Visiting Model
or Promising Approach

July 19, 2018

Enrolled but not currently receiving services/Other refers to those families who do not fall into the previous
categories and may include unreachable participants (i.e. the family is not regularly participating but did not
actively sever ties, etc.)
A Household, including a pregnant woman, female caregiver, and/or male caregiver who were signed up and
actively enrolled in the home visiting program prior to the beginning of or during the reporting period and continues
enrollment during the reporting period. The household may include multiple caregivers depending on modelspecific definitions.

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19

20

Participants by Type of
Health Insurance Coverage

Index Children by Usual
Source of Medical Care

Index Children (≥ 12
months of age) by Usual
Source of Dental Care

Index Child (Birth – Kindergarten Entry): the child (or children) in an individual household who is under the
care of the enrollee(s) and who is enrolled in the program and who was identified as being part of a MIECHV
household at enrollment (see definition of a MIECHV Household included at the beginning of the Definition of Key
Terms). More than one index child per household can be identified.
The insurance coverage categories are mutually exclusive. No insurance coverage indicates that the individual is
currently not covered by any source of insurance. This table is intended to capture insurance status, not health care
access: receipt of care provided for instance by the Indian Health Service or another safety net health care provider
such as a Federally Qualified Health Center does not constitute insurance coverage.
Index Child (Birth – Kindergarten Entry): the child (or children) in an individual household who is under the
care of the enrollee(s) and who is enrolled in the program and who was identified as being part of a MIECHV
household at enrollment (see definition of a MIECHV Household included at the beginning of the Definition of Key
Terms). More than one index child per household can be identified.
Usual source of care: the particular medical professional, doctor's office, clinic, health center, or other place where
a person would usually go if sick or in need of advice about his or her health.
Index Child (Birth – Kindergarten Entry): the child (or children) in an individual household who is under the
care of the enrollee(s) and who is enrolled in the program and who was identified as being part of a MIECHV
household at enrollment (see definition of a MIECHV Household included at the beginning of the Definition of Key
Terms). More than one index child per household can be identified.
Usual source of dental care: a usual source of dental care, or dental home, is a place where a child can receive
consistent, comprehensive, compassionate dental care. The concept of the Dental Home reflects the AAPD's clinical
guidelines and best principles for the proper delivery of oral health care to all children, with a concentration on
infant/age one patients and should be established no later than 12 months of age. 3

3

American Academy of Pediatric Dentistry. Dental Home Resource Center. http://www.aapd.org/advocacy/dentalhome/

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