Outcomes Education Maternal Child Health

Form Approved

OMB No. 0990-0460

Exp. Date XX/XX/20XX

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0460. The time required to complete this information collection is estimated to average 5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Pregnancy Assistance Fund Program Outcomes Forms

Educational Outcomes (New to this ICR)

1. For expectant and parenting teens enrolled in high school and served by the PAF program during the federal grant year, how many dropped out of school during the federal grant year? (dropout defined as participant dropping out of school and not returning)

_________

2. For expectant and parenting teens enrolled in high school and served by the PAF program, how many graduated from high school during the federal grant year? _________

3. For expectant and parenting teens served by the PAF program and not enrolled in high school, how many obtained a GED (or other high school equivalency credential) during the federal grant year? _________

Maternal and Child Measures (New to this ICR)

For Parenting Female Teens served by the PAF program during the federal grant year:

1. How many parenting female teens (­< 19) served by the program reported a new pregnancy during the grant year? _______

For Expectant Female Participant served by the PAF program during the federal grant year:

Collect following items to all expectant or parenting females who had a live birth at any point during the federal grant year. Grantees would aggregate responses to report to OAH. These items were adapted from the Pregnancy Risk Assessment Monitoring System (PRAMS) Core Questionnaire [questions 17, 18, 19, 25, 27] from the Centers for Disease Control and Prevention.

1. How many expectant female participants who were served by the PAF program during the grant year reported a live birth at any point during the federal grant year? _________

2. How many female participants who were expectant at the time of intake report the birth of an infant that is low birth weight (less than 5 lbs., 8 oz.) while participating in the program during the grant year? __________

3. How many female participants who were expectant at the time of intake report a premature birth (less than 37 weeks gestation) while participating in the program during the grant year? _____________