Attachment A _MIECHV Form 4 TRACKED

OMB No: 0906-0016

Expiration date: 02/28/2022

THE MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING PROGRAM

FORM 4

QUARTERLY PERFORMANCE REPORT

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 0906-0016. Public reporting burden for this collection of information is estimated to average 24 hours per response for Section A and 200 hours per response for Section B, 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857.

Maternal, Infant, and Early Childhood Home Visiting (MIECHV) grantees are required to submit the information outlined below on a quarterly basis.

Quarterly reporting periods are defined as follows. Reports are due 45 days after the end of each reporting period:

• Q1 - October 1-December 31;

• Q2 - January 1-March 31;

• Q3 – April 1-June 30;

• Q4 – July 1-September 30

Definitions for key terms are included in Appendix A. Please carefully consult key term definitions before completing this form.

Grant Number(s):

Section A:

Table A.1: Program Capacity

Column A	Column B	Column C	Column D	Column E
Number of New Households Enrolled	Number of Continuing Households	Current Caseload (A+B) (Auto-Calculate)	Maximum Service Capacity	Capacity Percentage (C÷D) (Auto-Calculate)

Table A.2: Place-Based Services

Add a row for each Local Implementing Agency (LIA) providing services during the reporting period. For each LIA, add the address of the LIA, the counties served by that LIA, the zip codes of families served by that LIA, and the evidence based home visiting model(s) or promising approaches implemented by the LIA.

Column A	Column B	Column C**	Column D**	Column E**
Local Implementing Agency (LIA) Organization Name	LIA Address	Counties*	Zip Codes	Evidence Based Home Visiting Models or Promising Approaches

*Note that the same county can be served by multiple LIAs.

**Additional rows can be added if needed. Table A.3: Family Engagement

Column A1	Column B	Column C	Column D	Column E
Number of Households Currently Receiving Services	Number of Households who Completed Program	Number of Households who Stopped Services Before Completion	Other	Total (A+B+C+D) (Auto- Calculate)

¹ Validation: Column A should equal Table A.1. columns A and B

Table A.4: Staff Recruitment and Retention

Column A	Column B	Column C
Number of FTE MIECHV Home Visitors	Number of FTE MIECHV Supervisors	Number of FTE MIECHV Other Staff

Section B:

Section B is only applicable to awardees that are currently on a corrective action plan related to a formal assessment of improvement. See reporting requirements for Form 2: Performance and Systems Outcome Measures.

DEFINITIONS OF KEY TERMS

Table Number	Field	Key Terms Requiring Definitions
A.1	Program Capacity	New Household: A household, including a pregnant participant and/or caregiver, who signs up to participate in the home visiting program at any time during the reporting period and continues enrollment during the reporting period. The household may include multiple caregivers depending on model-specific definitions. Continuing Household: A household, including a pregnant participant and/or caregiver who were signed up and actively enrolled in the home visiting program prior to the beginning of the reporting period and continues enrollment during the reporting period. The household may include multiple caregivers depending on model-specific definitions. Current Caseload: The number of households actively enrolled at the end of the quarterly reporting period. All members of one household represent a single caseload slot. Maximum Service Capacity: The highest number of households that could potentially be enrolled at the end of the quarterly reporting period if the program were operating with a full complement of hired and trained home visitors Note: The maximum service capacity is equivalent to the caseload of family slots approved by HRSA Caseload of Family Slots: The highest number of families (or households) that could potentially be enrolled at any given time if the program were operating with a full complement of hired and trained home visitors. Family slots are those enrollment slots identified as MIECHV in accordance with the identified enrollment method of the awardee. For more information on the definition of a MIECHV family slot see the FY 2108 MIECHV Notice of Funding Opportunity Announcement. All members of one family or household represent a single caseload slot. The count of slots should be distinguished from the cumulative number of enrolled families during the grant period. It is known that the caseload of family slots may vary by federal fiscal year pending variation in available funding in each fiscal year. Applicants should remember that inability to meet proposed caseloads may results in deobligated funds, which may impact future funding. Capacity Percentage: Capacity percentage is a calculated indicator that results from dividing the current caseload by the maximum service capacity and multiplying by 100.
A.2	Place-Based Services	LIA Organization Name: Each LIA organization name should reflect a unique and distinct local implementing agency. There should not be duplicate LIA submissions. If an LIA has multiple locations or sites, the LIA organization name should represent service delivery across all locations. LIAAddress: Only one address should be entered per LIA. If an LIA has multiple locations or addresses, the LIA address should reflect the address that most accurately reflects where services are delivered. Counties and Zip Codes: Counties and zip codes should reflect geographic distribution of households served by the LIA during the quarterly reporting period. Evidence BasedPromising Models or Home Visiting Approaches: Information submitted should reflect evidence-based home visiting model(s) implemented by the LIA. For LIAs implementing multiple models during the quarterly reporting period, all models implemented should be recorded for that LIA.
A.3	Family Engagement	Currently Receiving Services: The number of households currently receiving services refers to households that are participating in services at the end of the reporting period. Completed Program: The number of households who completed the program refers to households who have completed the program or transitioned to another program according to home visiting model-specific definitions and criteria during the reporting period. Stopped Services Before Completion: The number of households who stopped services before completion refers to households who left the program for any reason prior to completion. Other: Other refers to those households

Table Number	Field	Key Terms Requiring Definitions
		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.4	Staffing	Full Time Equivalent Home Visitor/Supervisor/Other Staff: A full time equivalent home visitor(s)/supervisor(s)/other staff who is employed with a contracted local implementing agency at the end of the quarterly reporting period. Awardees should only report the proportion of the FTE that is supported by MIECHV grant funds. For example, a 1.0 FTE staff member who is supported at 30% through MIECHV funds and 70% through other funds would be reported as 0.3 FTE for the purposes of this table.

DRAFT July 7, 2021September 17, 2021

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