Youth Serving Organization Performance Measure Reporting

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Youth Serving Organization (YSO) Performance Measure Reporting Tool

Public reporting burden of this collection of information is estimated to average 1 hour per response including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (XXXX-XXXX).

Youth Serving Organization Performance Measure Reporting Tool

YSO Name: _____________________________________

YSO ID:__________________

Date Completed:__________

Reporting Period: Fiscal Year__________

Quarter 1 (October to December) Quarter 2 (January to March)

Quarter 3 (April to June) Quarter 4 (July to September)

Instructions:

Youth Served in the Previous Quarter

1. How many youth, ages 15 to 19 years old, did your agency serve in the previous quarter (i.e., were provided services of any kind even if unrelated to this project)? ___________________

2. During the previous quarter, which youth were targeted for screening and referral to reproductive health services? This might be all youth at your agency or it might be all youth who received a particular type of service (e.g., case management). _______________________________________________________________________

3. How many youth, ages 15 to 19 years old, did your agency serve in the previous quarter of the last fiscal year that were in the target group for screening and referral to reproductive health services? For example, if the target group was all youth receiving case management and 148 youth received case management services in the last 3 months, then the correct response is 148). ____________

Please indicate the number of youth, ages 15 to 19 years old, who received each of the following materials or services in the previous quarter:
	Male	Female	Unknown	Total
Referral guide on sexual and reproductive health services
Screening to determine if youth is in need of sexual and reproductive health services
Passive referral to a health center for sexual and reproductive health services
Active referral to a health center for sexual and reproductive health services
Contacted the referral source to find out if the youth was seen
Followed-up with youth to ask if he/she has made and kept appointment based on the staff members’ referral

Please indicate the number of youth, ages 15 to 19 years old, who received each of the following services in the previous quarter:
	Male	Female	Unknown	Total
Evidence based teen pregnancy prevention intervention (See http://tppevidencereview.aspe.hhs.gov/EvidencePrograms.aspx for a complete list)
Health center visits to familiarize youth with the health center and its services
Other services provided as part of this project (Please specify: _______________________ _______________________)

End of measure for Quarters 1, 2 and 3. Remaining items will only be asked when YSO partner reports on the 4^th quarter of the fiscal year.

Youth Served in the Last Fiscal Year

5. How many youth, ages 15 to 19 years old, did your agency serve last fiscal year (i.e., were provided services of any kind even if unrelated to this project)? __________________

6. Last fiscal year, which youth were targeted for screening and referral to reproductive health services? This might be all youth at your agency or it might be all youth who received a particular type of service (e.g., case management). ________________________________________________________________________

7. How many youth, ages 15 to 19 years old, did your agency serve in the last fiscal year that were in the target group for screening and referral to reproductive health services? ____________

9. Please briefly describe any increases or decreases in funding or other resources (e.g., staffing) for teen programming in the past fiscal year and indicate how this effected your agency’s ability to serve teens.

Special instructions for Tables 10 and 11: If your record keeping system allows you to calculate the number of unduplicated youth receiving each service, please fill out tables 10 and 11. Being able to calculate the number of unduplicated youth would mean that you are able to determine that a specific youth was, for example, screened 2 or more times and then count them only once when calculating the number of youth screened.

Check here if you are not able to report on unduplicated numbers of youth served in the past fiscal year and go to item 12.

Please indicate the number of unduplicated youth, ages 15 to 19 years old, who received each of the following materials or services in the past fiscal year:
	Male	Female	Unknown	Total
Referral guide on sexual and reproductive health services
Screening to determine if youth is in need of sexual and reproductive health services
Passive referral to a health center for sexual and reproductive health services
Active referral to a health center for sexual and reproductive health services
Contacted the referral source to find out if the youth was seen
Followed-up with youth to ask if he/she has made and kept appointment based on the staff members’ referral

Please indicate the number of youth, ages 15 to 19 years old, who received each of the following services in the past fiscal year:
	Male	Female	Unknown	Total
Evidence based teen pregnancy prevention intervention (See http://tppevidencereview.aspe.hhs.gov/EvidencePrograms.aspx for a complete list)
Health center visits to familiarize youth with the health center and its services
Other services provided as part of this project (Please specify: _______________________ _______________________)

Staff and Staff Training

10. Please describe which staff members were selected to screen youth and provide referrals for sexual and reproductive health services. This might be all staff members, all case managers, all counselors, etc. ________________________________________________________________________________________________________________________________________________

10. How many staff members are currently part of the group of staff selected to screen youth and provide referrals? If all staff were selected to participate, you would indicate the current number of staff at your agency. If all case managers were selected to participate, you would indicate the number of case managers at your agency. _____________________________

10. How many of you staff members in the group selected to provide referrals having been working at your organization for less than 12 months? __________

10. How many of your current staff members from the identified group (e.g., all staff, all case managers) have received training in “Providing Effective and Confidential Referrals” including organizational referral policy, steps in making a referral, tracking referrals, use of a referral guide and what youth should expect in a clinic visit? __________________________________

10. How many of your current staff members from the identified group (e.g., all staff, all case managers) have received training in “Adolescent Sexual and Reproductive Health” including state and local rates of teen pregnancy, STD’s and HIV, sexual and reproductive health 101, state laws and regulations on minors rights to and confidentiality regarding sexual and reproductive health services, reporting requirements, and trauma informed care?_____________________________

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