Form 0920-1046 NBCCEDP Clinic-Level Data Collection Instruments

Attachment 6: NBCCEDP Clinic-Level Data Collection Instruments

NBCCEDP NOFO DP22-2202

OMB # 0920-1046

Expiration Date: XX/XX/XXXX

National Breast and Cervical Cancer Early Detection Program (NBCCEDP)

Breast Clinic Data Dictionary

Public reporting burden of this collection of information is estimated to average 45 minutes 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 NE, MS D‐74, Atlanta, Georgia 30333; ATTN: PRA (0920-1046)

NBCCEDP-Breast Clinic Data Dictionary (NOFO DP22-2202)

Contents

Part I: Partner and Record Identifiers

NBCCEDP DP22-2202

Program Years (PY)

	Start Date	end date
PY 1	July 1, 2022	June 30, 2023
PY 2	July 1, 2023	June 30, 2024
PY 3	July 1, 2024	June 30, 2025
PY 4	July 1, 2025	June 30, 2026
PY 5	July 1, 2026	June 30, 2027

Part II: Baseline and Annual Record Data Items

Section 1. Baseline and Annual Clinic NBCCEDP Activity and Status

Section 2. Baseline and Annual Health System and Clinic Characteristics and Clinic Patient Population

Section 3. Baseline and Annual Breast Cancer Screening Rates

• Screening Rate Status

• Chart Review (CR) Screening Rates

• Electronic Health Record (EHR) Screening Rates

Section 4. Baseline and Annual Monitoring and Quality Improvement Activities

Section 5. Baseline and Annual Evidence-based Interventions (EBIs) and Other Clinic Activities

• 5-1: EBI-Patient Reminder System

• 5-2: EBI-Provider Reminder System

• 5-3: EBI-Provider Assessment and Feedback

• 5-4: EBI-Reducing Structural Barriers

• 5-5: EBI-Small Media

• 5-6: Patient Education for Clinic Patients

• 5-7: EBI- Reducing out-of-pocket costs

• 5-8: Professional Development and Provider Education

• 5-9: EBI -Community Outreach, Education, and Support

• 5-10: EBI- Patient Navigation

Section 6. Other Baseline and Annual Breast Cancer Activities and Comments

Data Collection Notes:

• Baseline data are required for all clinics participating in NBCCEDP- NOFO DP22-2202.

• For clinics enrolled during the previous NBCCEDP funding period (NOFO DP17-1701) for breast activities and still active, awardees must re-submit baseline data using the clinics’ DP17-1701 program year 5 reported screening rates as the current baseline screening rates.

• For new clinics, baseline data are reported when new clinics are enrolled to participate in NBCCEDP-breast activities and reflect activities prior to NBCCEDP-breast activity implementation (Item B1-2: Clinic NBCCEDP-Breast Activities Start Date).

Part I. Partner and Record Identifiers

Identifying information for the partner clinic and health system.

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
P1	R	B	Recipient code	Baseline Record: Two-character Recipient Code (assigned by CDC) Annual Record: N/A	List	TBD- 2-character code
P2	R	B	NBCCEDP Partner Entity	Baseline Record: Indicates the organizational level of the partner entity working with the grantee to implement breast cancer screening EBIs and the associated population used for calculating screening rates. Clinic partnerships are the preferred action. When reporting clinic-level data, the clinic/grantee must report clinic-specific screening rates and population counts (not health system rates and counts). To report Health System-level data, you must have approval from CDC's Evaluation Team before enrolling the Health System. In addition, four criteria must be met: All Clinics within the health system must be participating in NBCCEDP. The same EBIs must be implemented uniformly across ALL clinics within the health system The reported screening rate and population counts must be Health System-wide for ALL eligible patients at all clinics within the health system. Data for any individual clinic within the health system must not be reported separately. Thus, you will have only one record reported for the entire health system in B&C-BARS. Within the record, information at the health system level will be reported for both the Health System and the individual Clinic fields. Contact CDC’s evaluation team for help with reporting these data. Annual Record: N/A	List	Clinic Health System Other _______________
P3	R	B, A	Partner Agreement	Baseline Record: The initial type of formal agreement the grantee made with the partner health system and/or clinic for NBCCEDP activities. Annual Record: The type of formal agreement the grantee had in place with the partner health system and/or clinic for NBCCEDP activities at the end of the program year (July 1- June 30).	List	MOU/MOA Contract Other None
P4	R	B	Date of Partner Agreement	Baseline Record: The original date the formal agreement was finalized between the grantee and partner clinic or health system for NBCCEDP DP22-2202 activities. Annual Record: N/A	Date	MM/DD/YYYY
HS1	R	B	Health system name	Baseline Record: Name of the partner health system under which the clinic (intervention/partner site) operates. Annual Record: N/A	Char	Free text 100 Char limit
HS2	R	B	Health system ID	Baseline Record: Unique three-digit identification code for the partner health system assigned by the grantee. Start with “001” and continue assigning numbers sequentially as health system partnerships are established. If this health system was recruited during NOFO DP17-1701, continue to use the existing three-digit health system ID that was assigned during NOFO DP17-1701. If this is a clinic where CDC’s CRCCP activities are also being implemented, we encourage using the same three-digit health system identification code assigned by the CRCCP staff. Contact the CRCCP staff in your state for a list of clinics participating in the CRCCP. Annual Record: N/A	Num	001-999
HS3	R	B	Health System Address	Baseline Record: Street address for the partner health system. If the street address is more than two lines, use a comma for separation. Annual Record: N/A	Char	Street, City, State, Zip, County
CL1	R	B	Clinic name	Baseline Record: Name of the partner health clinic (intervention site). If the partner is a health system (item P2 is “Health System”) then re-enter the Health System information as the clinic name Annual Record: N/A	Char	Free text 100 Char limit
CL2	R	B	Clinic ID	Baseline Record: Unique three-digit identification code for the partner clinic assigned by the grantee. Start with “001” and continue assigning numbers sequentially as health system partnerships are established. If this clinic was recruited during NOFO DP17-1701, continue to use the existing 3-digit clinic ID that was assigned during NOFO DP17-1701. If this is a clinic where CDC’s CRCCP activities are also being implemented, we encourage using the same three-digit clinic identification code assigned by the CRCCP staff. Contact the CRCCP staff in your state for a list of clinics participating in the CRCCP. Annual Record: N/A	Num	001-999
CL3	R	B	Clinic Address	Baseline Record: Street address for the partner clinic. If the street address is more than two lines, use a comma for separation. If the partner is a health system (item P2 is “Health System”) then re-enter the Health System information as the clinic street Annual Record: N/A	Char	Street, City, State, Zip, county
P5	O	B	Part 1 Comments	Optional comments for Part 1.	Char	Free text 200 Char limit

Part II. Baseline and Annual Record Data Items

Section 1. Baseline and Annual Clinic NBCCEDP Activity and Status

If the partner is a health system (P2= “Health System”) then clinic data reported must represent the entire Health System

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
B1-1	R	B	Clinic Enrollment NOFO, Breast Activities	Baseline Record: Indicates the NOFO during which the clinic was first enrolled into NBCCEDP. Identifies the clinic as new to NBCCEDP and newly enrolled during NOFO DP22-2202 or if the clinic was recruited prior to this funding cycle and is continuing from DP17-1701 and if so, its status at the end of DP17-1701. DP22-2202: Clinic is new to NBCCEDP (did not participate in NOFO DP17-1701) DP17-1701 never terminated: Clinic is continuing on from NOFO DP17-1701 for breast cancer screening activities (never terminated) DP17-1701 previously terminated: Clinic enrolled during NOFO DP17-1701 for breast cancer screening activities but ended NBCCEDP participation during that NOFO and is being re-enrolled into NBCCEDP as part of DP22-2202. If unknown, select DP22-2202. Annual Record: N/A	List	DP22-2202 DP17-1701 never terminated DP17-1701 previously terminated
B1-2	R	B	Clinic NBCCEDP-Breast Activities Start Date	Baseline Record: Indicates the date the clinic (or health system if reporting health system-level data) began actively implementing NBCCEDP [NOFO DP22-2202] breast activities. Enter the date that the clinic started implementing NBCCEDP [NOFO DP22-2202] breast program activities to increase clinic-level breast cancer screening rates. Activities can include: Enhancing existing EBIs for breast cancer screening Implementing new NBCCEDP-breast EBI activities Conducting quality improvement activities to increase breast cancer screening rates such as: Improving the quality of EHR screening data to produce an accurate breast cancer screening rate, integrate patient and provider reminder systems, or produce feedback reports; Process mapping to identify areas where breast cancer screening can best be promoted or implemented; Other activities that improve service delivery in ways to increase breast cancer screening. Note: For clinics enrolled during the previous NBCCEDP funding period (NOFO DP17-1701,), grantees must re-submit baseline data using the clinic's NOFO DP17-1701, PY5 screening rates for NOFO DP20-2022 baseline screening rates. In such cases, the same 12-month screening rate measurement period and the same screening rate measure (e.g., UDS) must be used for reporting under DP20-2022. For active clinics continuing from NOFO DP17-1701, (item B1-1, Clinic Enrollment NOFO is “DP17-1701 not terminated”) the clinic NBCCEDP activities start date will be automatically entered by B&C-BARS as 07/01/2022. Annual Record: N/A	Date	MM/DD/YYYY
B1-3	Comp	B	Baseline PY	Baseline Record: Baseline PY (based on activities start date) - auto-calculated based on NBCCEDP-Breast Activities Start Date (item, B1-2) Annual Record: N/A	List	NBCCEDP 2022-2202-py1 NBCCEDP 2022-2202-py2 NBCCEDP 2022-2202-py3 NBCCEDP 2022-2202-py4 NBCCEDP 2022-2202-py5
B1-4	R	B	Partner Type	Baseline Record: Organizational classification of partner clinic/health system. Community Health Center/Federally Qualified Heath Center (CHC/FQHC) includes “FQHC look-alikes” that meet program requirements but do not receive funding from the HRSA Health Center Program. Tribal health clinic includes IHS, Tribal or Urban Indian clinics (I/T/U) that serve AI/AN. Annual Record: N/A	List	CHC/FQHC Health system/Hospital owned Private/Physician owned Health department Tribal health Primary Care Facility (non-CHC/FQHC) Other
A1-1	Comp	A	Annual Report Period	Baseline Record: N/A Annual Record: Indicates the reporting period represented in the data submission Annual data are reported at the end of each NBCCEDP program year (PY) and reflect activities conducted during that completed program year. Select the PY that matches the data that are being reported. Screening rates reported at baseline and annually use a consistent 12-month measurement period that may be different from the NBCCEDP PY.	List	NBCCEDP 2022-2202-py1 NBCCEDP 2022-2202-py2 NBCCEDP 2022-2202-py3 NBCCEDP 2022-2202-py4 NBCCEDP 2022-2202-py5
A1-2	R	A	Annual Partner Status	Baseline Record: N/A Annual Record: Indicates the status of NBCCEDP supported breast cancer EBI implementation and screening rate monitoring activities at this clinic or health system during the program year. Select only one response. Active: Grantee actively worked with the clinic or health system to 1) plan and/or implement NBCCEDP breast cancer EBI activities and 2) monitor the breast cancer screening rate. If any NBCCEDP activities were planned or conducted at any point during the PY with support from the grantee, enter “Active”. Monitoring: Grantee did not provide NBCCEDP breast cancer EBI planning or implementation support (no active technical assistance provided) to the clinic during the PY but continued to monitor its screening rate and EBI implementation. Suspended: Partnership with the clinic was temporarily stopped for the PY with no NBCCEDP EBI breast cancer planning or implementation or screening rate monitoring activities conducted during any time of this PY, but the clinic intends to resume NBCCEDP EBI activities at some time before the end of the current cooperative agreement. Note: If any NBCCEDP activities were conducted during the PY, enter “Active” and submit a full annual record for this PY. Only use the response “Suspended” if NBCCEDP implementation was halted for the full year. Terminated: Partnership with the clinic or health system has ended with no NBCCEDP breast cancer EBI implementation or screening rate monitoring activities conducted during the PY or planned through the end of the cooperative agreement. Note: If any NBCCEDP activities were conducted during the PY, enter “Active” and submit a full annual record for this PY. Only use the response “Terminated” if NBCCEDP implementation was terminated for the full year. If active or monitoring, skip to COV-1 If suspended or terminated, indicate date and reason in A1-2a through A1-2i *Full annual record required for active or monitoring	List	Active Monitoring Suspended Terminated
A1-2a	R	A	Suspension/Termination date	Baseline Record: N/A Annual Record: Indicates the date when the clinic partnership for NBCCEDP breast cancer EBI activities and screening rate monitoring activities were suspended or terminated. If the day is unknown use “15”	Date	MM/DD/YYYY
A1-2b	R	A	Reason for Suspension	Baseline Record: N/A Annual Record: Reason that NBCCEDP breast cancer EBI planning or implementation and screening rate monitoring activities have been suspended or terminated at this clinic.	Check all that apply	Clinic implementation completed-no longer monitoring screening rates Clinic non-performance Clinic does not have resources/capacity to participate Clinic EHR problems or unable to collect clinic data Clinic merged with another clinic Clinic closed Other ______________
COV-1	R	B, A	COVID-19 clinic closure or hours/days reduced	Baseline Record: Indicates whether the clinic closed for an extended period of time (a full week or more) or reduced hours/days because of COVID-19 at any time during the year prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). Response option notes: Closed= the clinic was completely closed to patients for an extended period of time (at least a full week or more) because of COVID-19. Hours reduced= the clinic was partially closed to patients for a set number of days per week or a set number of hours per day because of COVID-19. If closed, specify # of weeks in item COV-2 If reduced hours/days, specify amount in item COV-3 through COV-6 If both closed and reduced hours/days, specify amount in COV-2 through COV-6 If no, skip to COV-7 Annual Record: Indicates whether the clinic closed for an extended period of time (a full week or more) or reduced hours/days because of COVID-19 at any time during the program year (July 1- June 30). Response option notes: Closed= the clinic was completely closed to patients for an extended period of time (at least a full week or more) because of COVID-19. Hours reduced= the clinic was partially closed to patients for a set number of days per week or a set number of hours per day because of COVID-19. If closed, specify # of weeks in item COV-2 If reduced hours/days, specify amount in item COV-3 through COV-6 If both closed and reduced hours/days, specify amount in COV-2 through COV-6 If no, skip to COV-7	List	Yes, closed Yes, reduced hours/days Yes, both closed and reduced hours/days No, clinic did not close or reduce hours/days
COV-2	R	B, A	COVID-19 closure amount	Baseline Record: Indicates the amount of weeks, in total, the clinic was closed because of COVID-19 at any time during the year prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). Annual Record: Indicates the amount of weeks, in total, the clinic was closed because of COVID-19 at any time during the program year (July 1- June 30).	Num	_# of weeks
COV-3	R	B, A	Clinic Hours – pre COVID-19	Baseline Record: Indicates the typical number of hours a week the clinic was open before closing and/or reducing hours due to COVID-19 during the year prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). Example: For a clinic that was normally open eight hours each day, five days a week prior to COVID-19, you would enter ‘40 hours’ to indicate the normal clinic hours. Annual Record: Indicates the typical number of hours a week the clinic was open before closing and/or reducing hours due to COVID-19. Example: For a clinic that was normally open eight hours each day, five days a week prior to COVID-19, you would enter ‘40 hours’ to indicate the normal clinic hours.	Num	_#__ hours each week
COV-4	R	B, A	COVID-19 Hours reduced	Baseline Record: Indicates the number of hours, in total, the clinic reduced hours/days because of COVID-19 at any time during a given week during the year prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). Note: You will be entering number of hours reduced and the number of weeks for these reduced hours. If the reduction in hours changed over time, you can enter an average for the number of hours per week. If the clinic reduced hours for a set amount of hours per day, provide the number of hours reduced for the entire week during the year prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). Example: For a clinic that is normally open eight hours each day, five days a week and it closed for one day a week because of COVID-19, you would enter ‘8 hours’ to indicate the reduction in hours each week. If this clinic was closed for one day a week and open for two less hours each remaining day, you would enter ’16 hours’. Annual Record: Indicates the number of hours, in total, the clinic reduced hours/days because of COVID-19 at any time during a given week during the program year (July 1- June 30). Note: You will be entering number of hours reduced and the number of weeks for these reduced hours. If the reduction in hours changed over time, you can enter an average for the number of hours per week. If the clinic reduced hours for a set amount of hours per day, provide the number of hours reduced for the entire week during the program year. Example: For a clinic that is normally open eight hours each day, five days a week and it closed for one day a week because of COVID-19, you would enter ‘8 hours’ to indicate the reduction in hours each week. If this clinic was closed for one day a week and open for two less hours each remaining day, you would enter ’16 hours’.	Num	_#__ hours each week for __#__weeks
COV-5	R	B, A	COVID-19 screening/diagnostic impact	Baseline: Indicates whether COVID-19 negatively impacted the clinic’s delivery of breast cancer screening and diagnostic services during the year prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). If yes, indicate how the clinic was impacted in items COV-5a If no, skip to COV-6 Annual: Indicates whether COVID-19 negatively impacted the clinic’s delivery of breast cancer screening and diagnostic services during the program year (July 1- June 30). If yes, indicate how the clinic was impacted in items COV-5a If no, skip to COV-6	List	Yes No
COV-5a	R	B, A	Clinic activities impacted	Baseline: Indicates the ways COVID-19 negatively impacted the clinic’s delivery of breast cancer screening and diagnostic services during the year prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). Check all that apply Annual: Indicates the ways COVID-19 negatively impacted the clinic’s delivery of breast cancer screening and diagnostic services during the program year (July 1- June 30). Check all that apply	Check all that apply	Clinic visits were restricted to sick patients, with limited or no preventive care available Clinic visits were limited to patients at high risk or with symptoms for breast cancer Clinic visits were restricted to telehealth/telemedicine only Clinic could not refer average risk patients for mammography due to limited availability of mammography services Clinic could not refer patients with abnormal mammography for follow-up testing due to limited availability of diagnostic services Patients cancelled or did not schedule appointments due to COVID concerns Patients fearful of getting COVID-19. If patients were not fearful of getting COVID-19 or If the clinic was unable to capture/collect/note this information, select ‘No’. Clinic breast cancer screening activities were limited due to the clinic’s prioritization of COVID-19 vaccination of patients COVID-19 negatively impacted the clinic’s delivery of breast cancer screening and diagnostic services that cannot be categorized in the above options. Specify: _________________
COV-6	R	B, A	COVID-19 EBI impact	Baseline: Indicates whether COVID-19 negatively impacted the clinic’s implementation of evidence-based interventions (EBIs) or Patient Navigation activities for breast cancer screening during the year prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). (e.g., implementation of some or all EBIs were suspended) If yes, indicate all activities negatively impacted by COVID-19 in COV-6a If no, skip to COV-7 Annual: Indicates whether COVID-19 negatively impacted the clinic’s implementation of evidence-based interventions (EBIs) or Patient Navigation activities for breast cancer screening during the program year (July 1-June 30). (e.g., implementation of some or all EBIs were suspended) If yes, indicate all activities negatively impacted by COVID-19 in COV-6a If no, skip to COV-7	List	Yes No
COV-6a	R	B, A	EBIs impacted	Baseline: Indicates which of the clinic’s evidence-based interventions (EBIs) for breast cancer screening were impacted by COVID-19 during the year prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). (e.g., implementation of some or all EBIs were suspended) Check all that apply Annual: Indicates which of the clinic’s evidence-based interventions (EBIs) for breast cancer screening were impacted by COVID-19 during the program year (July 1-June 30). (e.g., implementation of some or all EBIs were suspended) Check all that apply		Patient Reminders Provider Reminders Provider Assessment and Feedback Reducing Structural Barriers Small Media impact Patient Education impact Reducing Out-of-Pocket Costs impact Professional Development/Provider Education Patient Navigation
COV-7	O	B, A	COVID-19 Comments	Optional comments for COVID-19 Section	Char	Free text 200 char limit

Section 2. Baseline and Annual Health System and Clinic Characteristics and Clinic Patient Population

If the partner is a health system (P2=” Health System”) then clinic data reported must represent the entire Health System

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
B2-1 A2-1	R	B, A	Total # of primary care clinics in health system	Baseline Record: The total number of primary health care clinics that operate under the partner health system, including those serving specific populations such as pediatric clinics, prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). A clinic is defined as a location where primary care services are delivered. Clinics may also be referred to as "sites" or “practices”. Annual Record: The total number of primary health care clinics that operated under the partner health system, including those serving specific populations such as pediatric clinics during the program year (July 1-June 30). A clinic is defined as a location where primary care services are delivered. Clinics may also be referred to as "sites" or “practices”.	Num	1-9999999
B2-2 A2-2	R	B, A	Total # of primary care providers in health system	Baseline Record: Total number of primary care providers who are delivering services for the parent health system prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). Primary care providers include physicians (e.g., internists, family practice, OB/GYN, attending physicians, fellows and residents), nurses, nurse practitioners, and physician assistants. Do not include specialty providers in this number. Report on individuals, not full-time equivalents (FTEs). Annual Record: Total number of primary care providers who were delivering services for the parent health system during the program year (July 1-June 30). Primary care providers include physicians (e.g., internists, family practice, OB/GYN, attending physicians, fellows and residents) nurses, nurse practitioners, and physician assistants. Do not include specialty providers in this number. Report on individuals, not full-time equivalents (FTEs).	Num	1-99999
B2-3 A2-3	R	B, A	# of primary care providers at clinic	Baseline Record: Indicates the total number of primary care providers who were delivering primary care services at the clinic prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). Primary care providers include physicians (e.g., internists, family practice, OB/GYN attending physicians, fellows and residents), nurses, nurse practitioners, and physician assistants. Do not include specialty providers in this number. Report on individuals, not full-time equivalents (FTEs). If the partner is a health system (P2=” Health System”) then re-enter the number of primary care providers at the Health System Annual Record: Indicates the total number of primary care providers who were delivering primary care services at the clinic during the program year (July 1-June 30). Primary care providers include physicians (e.g., internists, family practice, OB/GYN attending physicians, fellows and residents), nurses, nurse practitioners, and physician assistants. Do not include specialty providers in this number. Report on individuals, not full-time equivalents (FTEs). If the partner is a health system (P2=” Health System”) then re-enter the number of primary care providers at the Health System	Num	1-99999
B2-4 A2-4	R	B, A	Total # of clinic patients	Baseline Record: The total number of clinic patients who had at least one medical visit to the clinic in the last complete calendar year prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). If the partner is a health system (P2= “Health System”) then enter the number of clinic patients at the Health System Annual Record: The total number of clinic patients who had at least one medical visit to the clinic in the last complete program year (July 1-June 30). If the partner is a health system (P2= “Health System”) then enter the number of clinic patients at the Health System.	Num	1-9999999
B2-5 A2-5	R	B, A	Total # of clinic patients, women age 50-74	Baseline Record: The total number of clinic patients who had at least one medical visit to the clinic in the last complete calendar year (January-December) prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date) AND were women age 50-74. If unavailable, it is acceptable to report on a similar age range used by the clinic for measuring screening rates (e.g., 52-74 used for calculating a HEDIS screening rate). Annual Record: The total number of clinic patients who had at least one medical visit to the clinic during the program year (July 1- June 30) AND were women age 50-74. If unavailable, it is acceptable to report on a similar age range used by the clinic for measuring screening rates (e.g., 52-74 used for calculating a HEDIS screening rate).	Num	1-9999999
B2-5a A2-5a	R	B, A	% of women patients age 50-74, uninsured	Baseline Record: Indicates the percent of the total # of clinic patients, women age 50-74, who had at least one medical visit to the clinic in the year prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date) who did not have any form of public or private health insurance. Report as a whole number percent. For example, enter 67 for 67%, not 0.67. It is acceptable to report the percent based on the total clinic population if unknown for those age 50-74. Annual Record: Indicates the percent of the total # of clinic patients, women age 50-74, who had at least one medical visit to the clinic during the program year (July 1- June 30) (item A2-5) who did not have any form of public or private health insurance. Report as a whole number percent. For example, enter 67 for 67%, not 0.67. Leave blank if unknown. It is acceptable to report the percent based on the total clinic population if unknown for those age 50-74.	Num	00-100
B2-5b	O	B	% of women patients age 50-74, Hispanic	Baseline Record: Indicates the percent of the total number of clinic patients, women age 50-74 who had at least one medical visit to the clinic in the year prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date) who are of Hispanic or Latino ethnicity (i.e., persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race). Report as a whole number percent. For example, enter 67 for 67%, not 0.67. Leave blank if unknown. It is acceptable to report the percent based on the total clinic population if unknown for those age 50-74. Annual Record: N/A	Num	00-100
B2-5d	O	B	% of women patients age 50-74, White	Baseline Record: Indicates the percent of the total number of clinic patients, women age 50-74 who had at least one medical visit to the clinic in the year prior to starting NBCCECP (item B1-2: Clinic NBCCEDP-Breast Activities Start Date) who are White/Caucasian (i.e., persons having origins in any of the original peoples of Europe, the Middle East, or North Africa.) Report as a whole number percent. For example, enter 67 for 67%, not 0.67. Leave blank if unknown. It is acceptable to report the percent based on the total clinic population if unknown for those age 50-74. Annual Record: N/A	Num	00-100
B2-5e	O	B	% of women patients age 50-74, Black or African American	Baseline Record: Indicates the percent of the total number of clinic patients, women age 50-74 who had at least one medical visit to the clinic in the year prior to starting NBCCECP (item B1-2: Clinic NBCCEDP-Breast Activities Start Date) who are Black or African American (i.e., persons having origins in any of the black racial groups of Africa). Report as a whole number percent. For example, enter 67 for 67%, not 0.67. Leave blank if unknown. It is acceptable to report the percent based on the total clinic population if unknown for those age 50-74. Annual Record: N/A	Num	00-100
B2-5f	O	B	% of women patients age 50-74, Asian	Baseline Record: Indicates the percent of the total number of clinic patients, women age 50-74 who had at least one medical visit to the clinic in the year prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date) who are Asian (i.e., 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, Thailand, and Vietnam). Report as a whole number percent. For example, enter 67 for 67%, not 0.67. Leave blank if unknown. It is acceptable to report the percent based on the total clinic population if unknown for those age 50-74. Annual Record: N/A	Num	00-100
B2-5g	O	B	% of women patients age 50-74, Native Hawaiian or other Pacific Islander	Baseline Record: Indicates the percent of the total number of clinic patients, women age 50-74 who had at least one medical visit to the clinic in the year prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date) who are Native Hawaiian or other Pacific Islander (i.e., persons having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands). Report as a whole number percent. For example, enter 67 for 67%, not 0.67. Leave blank if unknown. It is acceptable to report the percent based on the total clinic population if unknown for those age 50-74. Annual Record: N/A	Num	00-100
B2-5h	O	B	% of women patients age 50-74, American Indian or Alaskan Native	Baseline Record: Indicates the percent of the total number of clinic patients, women age 50-74 who had at least one medical visit to the clinic in the year prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date) who are American Indian or Alaskan Native (i.e., persons having origins in any of the original peoples of North and South America, including Central America, and who maintain tribal affiliation or community attachment). Report as a whole number percent. For example, enter 67 for 67%, not 0.67. Leave blank if unknown. It is acceptable to report the percent based on the total clinic population if unknown for those age 50-74. Annual Record: N/A	Num	00-100
B2-5i	O	B	% of women patients age 50-74, more than one race	Baseline Record: Indicates the percent of the total number of clinic patients, women age 50-74 who had at least one medical visit to the clinic in the year prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date) who are of more than one race (i.e., persons having origins in two or more of the federally designated racial categories). Report as a whole number percent. For example, enter 67 for 67%, not 0.67. Leave blank if unknown. It is acceptable to report the percent based on the total clinic population if unknown for those age 50-74. Annual Record: N/A	Num	00-100
B2-6 A2-6	R	B, A	Name of primary EHR vendor at clinic	Baseline Record: Indicates the primary EHR that was in use at the clinic prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). Annual Record: Indicates the primary EHR that was in use at the clinic during the program year (July 1-June 30).	List	Allscripts Athenahealth Cerner eClinicalWorks Epic GE Healthcare Greenway Health Kareo McKesson Meditech NextGen (Quality Systems, Inc.) Practice Fusion Other_________________ None
B2-7 A2-7	R	B, A	Primary EHR home	Level of EHR implementation and functionality: EHR system unique to the clinic versus health-system wide EHR system shared by all clinics. Baseline Record: Indicates the breadth and functionality of the clinic EHR system that was in use prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). Annual Record: Indicates the breadth and functionality of the primary EHR system that was in use at the clinic during the program year (July 1-June 30).	List	EHR specific to the clinic Health system wide EHR Other: _____________
B2-8	R	B	Newly screening or opened	Baseline Record: Identifies clinics that have recently started providing breast cancer screening services and/or are newly opened prior to time of NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). Recently started providing breast cancer screening services: clinic has started providing breast cancer screening within 1 year of the Clinic NBCCEDP-Breast Activities Start Date (item B1-2). Newly opened clinic: clinic has been in operation for less than 1 year at the time of Clinic NBCCEDP-Breast Activities Start Date (itemB1-2). If yes (<1 year), do not report baseline screening rates or baseline screening practices and outcomes (Section 3) Annual Record: N/A	List	Yes (< 1 year) No (1 or more years)
B2-9 A2-9	O	B, A	Section 2 Comments	Optional comments for section 2	Char	Free text 200 char limit

Section 3. Baseline and Annual Breast Cancer Screening Rates

If the partner is a health system (P2=” Health System”) then clinic data reported must represent the entire Health System

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
B3-1 A3-1	R	B, A	Breast Cancer Screening Rate Status	Baseline Record: Indicates the availability of baseline breast cancer screening rate data and associated information on data sources/approach for calculating the screening rates. If “Chart review rate only” skip to B3-2 and skip EHR section. If “EHR rate only” skip to B3-2, then skip to B3-5a (skip CR section). If “Both Chart Review rate and EHR rate”, skip to B3-2 and complete both the CR section (B3-4a to B3-4l) and the EHR rate section (B3-5a to B3-5l). If “No, not yet available” go to B3-1a and enter date available and then skip to Section 4: Baseline and Annual Monitoring and Quality Improvement Activities If “No, cannot obtain” skip to Section 4: Baseline and Annual Monitoring and Quality Improvement Activities Annual Record: Indicates the availability of annual breast cancer screening rate data and associated information on data sources/approach for calculating the screening rates. If “Yes, chart review rate only” skip to A3-2 and skip EHR section. If “Yes, EHR rate only” skip to A3-2, then skip to A3-5a (skip CR section). If “Yes, both Chart Review rate and EHR rate”, skip to A3-2 and complete both the CR section (A3-4a to A3-4l) and the EHR rate section (A3-5a to A3-5l). If “No. not yet available” go to A3-1a and enter date available and then skip to Section 4: Baseline and Annual Monitoring and Quality Improvement Activities If “No, cannot obtain” skip to Section 4: Baseline and Annual Monitoring and Quality Improvement Activities.	List	Chart Review rate only EHR rate only Both Chart Review and EHR Rate No, not yet available No, cannot obtain
B3-1a A3-1a	R	B, A	Breast cancer screening rate date available	Baseline Record: If a baseline screening rate is not yet available, provide the approximate date that the screening rate will be available. skip to Section 4: Baseline and Annual Monitoring and Quality Improvement Activities Annual Record: If an annual screening rate cannot be obtained or is not yet available when submitting the annual clinic data, provide the approximate date that the screening rate will be available. skip to Section 4: Baseline and Annual Monitoring and Quality Improvement Activities	Date	MM/DD/YYYY
B3-2 A3-2	R	B, A	Start date of 12-month breast cancer SR measurement period	Baseline Record: The start date of the 12-month screening rate measurement period used to calculate the clinic’s baseline breast cancer screening rate. The 12-month measurement period does not need to coincide with the program year. Any 12-month period may be used as the measurement period. The measurement period for the baseline screening rate should be the most recent 12-month measurement period prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). Note that the date that implementation activities started (Item B1-2: Clinic NBCCEDP-Breast Activities Start Date) must be after the end of the baseline 12-month measurement period. This same 12-month measurement period must be used for reporting subsequent annual breast cancer screening rates for this clinic. Annual Record: The start date of the annual breast cancer screening rate 12-month measurement period. The 12-month measurement period for all annual records for this clinic should be consistent over time and match that used for the baseline screening rate. Measurement periods, starting with the baseline measurement period, should represent consecutive years. For example, if the baseline measurement period was 01/01/2021- 12/31/2021, then the first annual screening rate measurement period should be 01/01/2022 - 12/31/2022. The first annual measurement period (year 1 for the clinic) should include the date that implementation activities started (Item B1-2: Clinic NBCCEDP-Breast Activities Start Date).	Date	MM/DD/YYYY
B3-3 A3-3	comp	B, A	End date of 12-month breast cancer SR measurement period	Baseline Record: This date will be automatically calculated from the 12-month start date. Indicates the end date of the 12-month measurement period used to calculate the clinic’s baseline breast cancer screening rate. The measurement period for the baseline screening rate should be the most recent 12-month measurement period available prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). This same 12-month measurement period must be used for reporting subsequent annual Breast cancer screening rates for this clinic. Annual Record: Indicates the end date of the annual breast cancer screening rate 12-month measurement period. The 12-month measurement period for all annual records for this clinic should be consistent over time and match that used for the baseline screening rate. Measurement periods, starting with the baseline measurement period, should represent consecutive years. For example, if the baseline measurement period was 01/01/2021 - 12/31/2021, then the first annual screening rate measurement period should be 01/01/2022 - 12/31/2022.	Date	MM/DD/YYYY
Chart Review Screening Rates ***This section should be skipped at baseline for clinics that are newly screening or newly opened***
B3-4a A3-4a	R	B, A	CR- Breast Cancer screening rate (%)	Breast Cancer Screening Rate via Chart Review Baseline Record: Numerator and Denominator are dependent on the measure used (e.g., UDS, HEDIS). Please see Appendix 3 in CDC Guidance for Measuring Breast, Cervical, and Colorectal Cancer Screening Rates in Health System Clinics. Annual Record: Numerator and Denominator are dependent on the measure used (e.g., UDS, HEDIS). Please see Appendix 3 in CDC Guidance for Measuring Breast, Cervical, and Colorectal Cancer Screening Rates in Health System Clinics.	Num	Rate:__computed___ Numerator: _____ Denominator: _____
B3-4d A3-4d	R	B, A	CR- Breast Cancer Screening Quality Measure	Quality Measure followed to calculate the Breast Cancer Screening Rate via Chart Review Baseline Record: Indicates the measure that was used to calculate the numerator and denominator for the clinic’s breast cancer screening rate. If an existing quality measure (e.g., UDS, HEDIS, GPRA) was not used, the CDC Guidance for Measuring Breast, Cervical, and Colorectal Cancer Screening Rates in Health System Clinics provides information on calculating an NQF-endorsed measure. If this is used, "NQF" should be selected. The same measure reported at baseline must be used for reporting subsequent annual breast cancer screening rates for this clinic. Annual Record: If an existing quality measure (e.g. UDS, HEDIS, GPRA) was not used, the CDC Guidance for Measuring Breast, Cervical, and Colorectal Cancer Screening Rates in Health System Clinics provides information on calculating an NQF-endorsed measure. If this is used, "NQF" should be selected. The same measure reported at baseline must be used for reporting subsequent annual breast cancer screening rates for this clinic.	List	GPRA HEDIS NQF UDS Other
B3-4e A3-4e	comp	B, A	% of charts reviewed	Baseline and Annual Records: Indicates the percent of medical charts that were reviewed for the breast cancer screening rate. A minimum of 10% or 100 charts should be reviewed. THIS % WILL BE AUTOMATICALLY CALCULATED USING THE DENOMINATOR AND TOTAL # OF CLINIC PATIENTS, WOMEN AGE 50-74 (ITEM B2-5 & A2-5).	Num	auto-calculated
B3-4f A3-4f	R	B, A	Sampling Method	Baseline and Annual Records: Indicates if records were selected through either a random or systematic sampling method to generate a representative sample of the entire population of patients who meet the inclusion/selection criteria for the measure used. See CDC Guidance for Measuring Breast, Cervical, and Colorectal Cancer Screening Rates in Health System Clinics. A random sample takes a randomly assigned subset of the population identified in the sampling frame. This is typically accomplished through generating a random number that will be assigned to each patient in the sampling frame. This can be accomplished in many ways (e.g., random number table, web-based software, computer software). A systematic sample orders every patient (e.g., alphabetically, by ID) in the sampling frame and then selects every nth patient.	List	Yes No Unknown
B3-4g A3-4g	R	B, A	CR- Breast cancer SR confidence,	Baseline and Annual Records: Indicates the grantee's confidence in the accuracy of the CR-calculated breast cancer screening rate. Accuracy of CR-calculated screening rates can vary depending on how charts are sampled and the information available in the charts.	List	Not confident Somewhat confident Very confident
B3-4h A3-4h	R	B, A	CR- Breast Cancer screening rate problem	Baseline and Annual Records: Indicates if there are known unresolved problems with the CR reported breast cancer screening rate or screening data quality.	List	Yes No Unknown Other:_____________
B3-4k A3-4k	O	B, A	Comments for CR rates	Optional Comments for CR rates.	Char	Free text 200 char limit
EHR Screening Rates ***This section should be skipped at baseline for clinics that are newly screening or newly opened***
B3-5a A3-5a	comp	B, A	EHR- breast cancer SR (%)	Breast Cancer Screening Rate via EHR Baseline Record: Numerator and Denominator are dependent on the measure used (e.g., UDS, HEDIS). Please see Appendix 3 in CDC Guidance for Measuring Breast, Cervical, and Colorectal Cancer Screening Rates in Health System Clinics. Annual Record: Numerator and Denominator are dependent on the measure used (e.g., UDS, HEDIS). Please see Appendix 3 in CDC Guidance for Measuring Breast, Cervical, and Colorectal Cancer Screening Rates in Health System Clinics.	Num	Rate:__computed___ Numerator: _____ Denominator: _____
B3-5d A3-5d	R	B, A	EHR- breast cancer SR quality measure	Baseline and Annual Records: Indicates the measure that was used to calculate the numerator and denominator for the clinic’s breast cancer screening rate. If an existing quality measure (e.g. UDS, HEDIS, GPRA) was not used, the CDC Guidance for Measuring Breast, Cervical, and Colorectal Cancer Screening Rates in Health System Clinics (Appendix 3) provides information on calculating a NQF-endorsed measure. If this is used, "NQF" should be selected. The same measure reported at baseline must be used for reporting subsequent annual breast cancer screening rates for this clinic.	List	GPRA HEDIS NQF UDS Other
B3-5e A3-5e	N/A	N/A	N/A for EHR	N/A for EHR	N/A for EHR	N/A for EHR
B3-5f A3-5f	N/A	N/A	N/A for EHR	N/A for EHR	N/A for EHR	N/A for EHR
B3-5g A3-5g	R	B, A	EHR- breast cancer SR confidence	Baseline and Annual Records: Indicates the grantee's confidence in the accuracy of the EHR-calculated breast cancer screening rate. Accuracy of EHR-calculated screening rates can vary depending on how data are documented and entered into the EHR. For additional information, see the National Colorectal Cancer Roundtable’s summary report, “Use of Electronic Medical Records to Facilitate Colorectal Cancer Screening in Community Health Centers" and "CDC Guidance for Measuring Breast, Cervical, and Colorectal Cancer Screening Rates in Health System Clinics."	List	Not confident Somewhat confident Very confident
B3-5h A3-5h	R	B, A	EHR- breast cancer SR problem	Baseline and Annual Records: Indicates if there are known unresolved problems with the EHR reported breast cancer screening rate or screening data quality.	List	Yes No Unknown Other
B3-5i A3-5i	R	B, A	EHR- breast cancer SR reporting source	Baseline and Annual Records: Indicates the source of the denominator and numerator data reported for the EHR breast cancer screening rate	List	HCCN data warehouse Clinic EHR Health system EHR EHR Vendor Other
B3-5j A3-5j	O	B, A	Comments for EHR rates	Optional comments for EHR rates	Char	Free text 200 char limit
B3-6 A3-6	R	B, A	Clinic breast cancer SR target for next year	Baseline Record: Indicates the clinic-level breast cancer screening rate target established by the clinic for its first NBCCEDP annual clinic record. Considering the Chart Review and/or EHR-reported baseline breast cancer screening rate, specify a targeted clinic-level breast cancer screening rate (i.e., the screening rate you want to achieve) for the clinic’s first annual record, i.e. the breast cancer screening rate for the next 12-month measurement period after the baseline screening rate measurement period. Do not enter the expected additional % increase. Targets should be: Clinic-level targets. Do no report targets for the health system unless the partner is the health system (item P2= Health System). Unique to each clinic. Ambitious but realistic and achievable Annual Record: Indicates the clinic-level breast cancer screening rate target established by the clinic for its next subsequent NBCCEDP annual clinic record. Considering the Chart Review and/or EHR-reported annual breast cancer screening rate, specify a targeted clinic-level breast cancer screening rate (i.e., the screening rate you want to achieve) for the next annual record, i.e. the breast cancer screening rate for the next 12-month measurement period. Do not enter the expected additional % increase. Targets should be: Clinic-level targets. Do no report targets for the health system unless the partner is the health system (item P2= Health System). Unique to each clinic. Ambitious but realistic and achievable	Num	1-100 999 (no target set)
B3-7 A3-7	O	B, A	Section 3 Comments	Optional Comments for Section 3.	Char	Free text 200 char limit

Section 4: Baseline and Annual Monitoring and Quality Improvement Activities

Information on the clinic’s practices, policies, and support received to improve implementation of EBIs and/or monitoring of BREAST screening rates

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
B4-1 A4-1	R	B, A	Clinic breast cancer screening policy	A credible policy should include a defined set of guidelines and procedures in place and in use at the clinic or parent health system to support breast cancer screening, a team responsible for implementing the policy, and a quality assurance structure (e.g., professional screening guideline followed such as USPSTF, process to assess patient screening history/risk/preference/insurance, process for scheduling screening or referral, steps/procedures/roles to implement the office policy). Baseline Record: Indicates if the clinic had a written Breast cancer screening policy or protocol in use prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). Annual Record: Indicates if the clinic had a written breast cancer screening policy or protocol in use during the program year.	List	Yes No
B4-2 A4-2	R	B, A	Clinic breast cancer champion	Baseline Record: Indicates if there was a known champion for breast cancer screening internal to this clinic or parent health system prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date) Annual Record: Indicates if there was a known champion or champions for breast cancer screening internal to this clinic or parent health system for at least 6 months during this program year (July 1- June 30).	List	Yes No
B4-3 A4-3	R	B, A	Utilizing health IT to improve data collection and quality	Baseline Record: Indicates if the clinic was using health information technology (health IT) to improve collection, accuracy and validity of breast cancer screening data prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). Activities may include standardization of data definitions used to document a patient’s breast cancer screening, linkage of data to screening reports, EHR improvements and enhancements, provider training on proper EHR data entry and use, etc. Annual Record: Clinic used health information technology (health IT) to improve collection, accuracy, and validity of breast cancer screening data during the program year (July 1- June 30). Activities may include standardization of data definitions used to document a patient’s breast cancer screening, linkage of data to screening reports, EHR improvements and enhancements, provider training on proper EHR data entry and use, etc.	List	Yes No
B4-4 A4-4	R	B, A	Utilizing health IT tools for monitoring program performance	Baseline Record: Indicates if the clinic was using health IT to perform data analytics and reporting to monitor and improve their breast cancer screening program and rates prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). Examples include: EHR overlays, Population Health Management software, data visualization software and programs. Annual Record: Clinic used health information technology (health IT) tools to perform data analytics and reporting to monitor and improve their breast cancer screening program and rates during the program year (July 1- June 30). Examples include: EHR overlays, Population Health Management software, data visualization software and programs.	List	Yes No
B4-5 A4-5	R	B, A	QA/QI support	Baseline Record: Indicates whether the clinic had a quality assurance/quality improvement specialist or team in place that addressed breast cancer screening prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). The person or team could work at the health system level and provide QA/QI support to the clinic. Annual Record: Indicates whether the clinic had a quality assurance/quality improvement specialist or team in place that addressed breast cancer screening during the program year (July 1- June 30). The person or team could work at the health system level and provide QA/QI support to the clinic.	List	Yes No
A4-6	R	A	Process Improvements	Baseline Record: N/A Annual Record: Indicates whether process improvements were made at the clinic during the program year (July 1- June 30) to facilitate increased breast cancer screening of patients. Examples include process mapping to identify points to improve screening, daily huddles or other daily processes to identify persons due for screening and use of QI processes to improve screening.	List	Yes No
A4-7	R	A	Frequency of monitoring breast cancer screening rate	Baseline Record: N/A Annual Record: Indicates how often the clinic breast cancer screening rate was monitored and reviewed by clinic personnel during the program year (July 1- June 30). Select the response that best matches monitoring frequency during this program year.	List	Monthly Quarterly Semi-annually Annually
A4-8	R	A	Validated screening rate	Baseline Record: N/A Annual Record: Indicates if the clinic-level breast cancer screening rate data were validated using chart review or other methods during this program year (July 1- June 30). If yes, indicate all methods used to validate the screening rate in items A4-8a to A4-8d. If no, skip to A4-9.	List	Yes, indicate method Manual Chart Review Validation of the EHR system and/or its query algorithm Other:____________ No
A4-9	R	A	Health Center Controlled Network	Baseline Record: N/A Annual Record: For Community Health Centers/FQHCs only, indicates whether the clinic received technical assistance from a Health Center Controlled Network to implement EBIs or improve use of the clinic’s EHR to better measure and monitor breast cancer screening rates during the program year (July 1- June 30).	List	Yes No
A4-10	R	A	Frequency of implementation support to clinic	Baseline Record: N/A Annual Record: Indicates the frequency of on-site or direct contacts (e.g., telephone) with the clinic to support and improve implementation activities for EBIs/SAs and breast cancer screening data quality during this program year (PY). Support could be provided by a grantee or contracted agent. Examples of support activities include conducting a clinic workflow assessment, providing technical assistance to improve HIT, providing technical assistance on implementing an EBI/SA, training staff to support an EBI/SA, providing technical assistance to develop a breast cancer screening policy, providing support to a champion, or providing feedback to staff from monitoring or evaluating an EBI/SA implementation. Select the response that best matches delivery of implementation support during this program year (July 1- June 30).	List	Weekly Monthly Quarterly Semi-annually Annually
B4-11 A4-11	R	B, A	BCCEDP clinical services	Baseline: Indicates if the grantee reimbursed for breast cancer screening, diagnostics, and/or patient navigation services at this clinic in the year prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date. Funding could come from CDC, your state, or other sources. Annual: Indicates if the grantee reimbursed for breast cancer screening, diagnostics, and/or patient navigation services at this clinic during the program year. Funding could come from CDC, your state, or other sources.	List	Yes No
A4-12	R	A	BCCEDP financial resources	Baseline Record: N/A Annual Record: Indicates whether the grantee or a subcontractor of the grantee provided financial resources to this clinic and/or its parent health system during the program year (July 1- June 30) to support NBCCEDP health system change activities. Funding could come from CDC, your state, or other sources. Funds for screening and clinical services should not be included here. If yes, answer items A4-12a and A4-12b If no, skip to A4-13	List	Yes, to the clinic Yes, to the parent health system No
A4-12a	R	A	Use of BCCEDP financial resources	If BCCEDP financial resources were provided (item A4-11 is Yes), indicates whether the funds were for Breast Cancer activities only or for both Breast and Cervical Cancer activities.	List	Breast Cancer only Breast and Cervical Cancer
A4-12b	R	A	Amount of BCCEDP financial resources	Baseline Record: N/A Annual Record: If BCCEDP financial resources were provided (item A4-11 is Yes), indicate the total amount of financial resources provided to the clinic during this program year (PY). Pro-rate funding, if needed, to associate with the PY. Do NOT include in-kind resources. If financial resources were provided to the parent health system (item A4-11 is “Yes, to the parent health system”) rather than directly to the clinic, and you do not know how much of those funds were used for this specific clinic, please divide the amount given to the health system by the number of clinics in that health system that were enrolled in the NBCCEDP program during the program year (July 1- June 30). If resources were given for both breast and cervical (item A4-11a= “Breast and Cervical Cancer”), then enter the total amount given to the clinic.	Num	Dollar amount 1-900000 999999 (UNK)
B4-13 A4-13	O	B, A	Section 4 Comments	Optional comments for section 4.	Char	Free text 200 char limit

Section 5: Baseline and Annual Evidence-based Interventions (EBIs) and Other Clinic Activities

Information on implementation status and sustainability of activities, put in place by the grantee or clinic, to improve breast cancer screening.

Section 5-1: EBI-Patient Reminder System

Indicates the clinic’s use of system(s) to remind patients when they are due for breast cancer screening. Patient reminders can be written (letter, postcard, email, text) or telephone messages (including automated messages).

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
A5-1a	R	A	NBCCEDP resources used toward a patient reminder system	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP grantee resources (e.g. funds, staff time, materials, contract) were used during this program year (July 1- June 30) to contribute to planning, developing, implementing, monitoring/evaluating or improving a patient reminder system for breast cancer screening.	List	Yes No
B5-1b A5-1b	R	B, A	Patient reminder system in place	Baseline Record: Indicates whether a patient reminder system for breast cancer screening was in place and operational (in use) in this clinic prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date), regardless of the quality, reach, or level of functionality. Annual Record: Indicates whether a patient reminder system for breast cancer screening was in place and operational (in use) in this clinic at the end of the program year (July 1- June 30), regardless of the quality, reach, or current level of functionality. If patient reminders were newly implemented during this program year, select “Yes, newly in place”. If patient reminders were in place prior to this program year, select “Yes, continuing” If yes, newly in place skip to A5-1e If yes, continuing, skip to A5-1d If no, answer A5-1c and then skip to the next EBI, A5-2a	List	Baseline Record: Yes No Annual Record: Yes, newly in place Yes, continuing No
A5-1c	R	A	Patient reminder system planning activities	Baseline Record: N/A Annual Record: If a patient reminder system was not in place (A5-1b is No), indicates whether planning activities were conducted this program year (July 1- June 30) for future implementation of a breast cancer screening patient reminder system. Skip to the next EBI, A5-2a.	List	Yes No
A5-1d	R	A	Patient reminder system enhancements	Baseline: N/A Annual: If a patient reminder system was in place prior to this program year and continuing (A5-1b is Yes, continuing), indicates whether the clinic made changes to enhance or improve implementation of patient reminders during the program year (July 1- June 30).	List	Yes No
A5-1e	R	A	Patient reminders sent multiple ways	Baseline Record: N/A Annual Record: If a patient reminder system was in place (A5-1b is “Yes, newly in place” or “Yes, continuing”), indicates whether an average patient at this clinic received breast cancer screening reminders in more than one way (e.g., same patient received reminders in 3 different ways: one by letter, another by text message, and a third by telephone) during this program year (July 1- June 30).	List	Yes No
A5-1f	R	A	Maximum number and/or frequency of patient reminders	Baseline Record: N/A Annual Record: If a patient reminder system was in place (A5-1b is “Yes, newly in place” or “Yes, continuing”), indicates the maximum number of different ways and times (activity conducted more than one time during the year) that a given patient could have received breast cancer screening reminders during this program year (July 1- June 30) (e.g., same patient received a total of 4 reminders – 2 by phone, 1 by text, 1 by mail).	List	1 2 3 4 5 or more
A5-1g	R	A	Patient reminder system sustainability	Baseline Record: N/A Annual Record: If a patient reminder system was in place at the end of the program year (July 1- June 30) (A5-1b is “Yes, newly in place” or “Yes, continuing”), indicates whether the breast cancer screening patient reminder system is considered to be fully integrated into health system and/or clinic operations and is sustainable without NBCCEDP resources. [The patient reminder system has become an institutionalized component of the health system and/or clinic operations.]	List	Yes No

Section 5-2: EBI -Provider Reminder System

Indicates the clinic’s use of system(s) to inform providers that a patient is due (or overdue) for screening. The reminders can be provided in different ways, such as placing reminders in patient charts, EHR alerts, e-mails to the provider, etc.

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
A5-2a	R	A	NBCCEDP resources used toward a provider reminder system	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP grantee resources (e.g. funds, staff time, materials, contract) were used during this program year (July 1- June 30) to contribute to planning, developing, implementing, monitoring/evaluating or improving a provider reminder system that addresses breast cancer screening.	List	Yes No
B5-2b A5-2b	R	B, A	Provider reminder system in place	Baseline Record: Indicates whether a provider reminder system that addresses breast cancer screening was in place and operational (in use) in this clinic prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date), regardless of the quality, reach, or level of functionality. Annual Record: Indicates whether a provider reminder system that addresses breast cancer screening was in place and operational (in use) in this clinic at the end of the program year (July 1- June 30), regardless of the quality, reach, or current level of functionality. If provider reminders were newly implemented during this program year, select “Yes, newly in place”. If provider reminders were in place prior to this program year, select “Yes, continuing” If yes, newly in place skip to A5-2e If yes, continuing, skip to A5-2d If no, answer A5-2c and then skip to the next EBI, item A5-3a	List	Baseline Record: Yes No Annual Record: Yes, newly in place Yes, continuing No
A5-2c	R	A	Provider reminder system planning activities	Baseline Record: N/A Annual Record: If a provider reminder system is not in place (A5-2b is No), indicates whether planning activities were conducted this program year (July 1- June 30) for future implementation of a provider reminder system for breast cancer screening. Skip to the next EBI, item A5-3a	List	Yes No
A5-2d	R	A	Provider reminder system enhancements	Baseline: N/A Annual: If a provider reminder system was in place prior to this program year and continuing (A5-2b is Yes, continuing), indicates whether the clinic made changes to enhance or improve implementation of provider reminders during the program year (July 1- June 30).	List	Yes No
A5-2e	R	A	Provider reminders sent multiple ways	Baseline Record: N/A Annual Record: If a provider reminder system was in place at the end of the program year (July 1- June 30) (A5-2b is “Yes, newly in place” or “Yes, continuing”), indicates whether providers at this clinic typically received breast cancer screening reminders for a given patient in more than one way (e.g., provider receives both an EHR pop-up message and a flagged patient chart for the same patient) during this program year.	List	Yes No
A5-2f	R	A	Maximum number and/or frequency of provider reminders	Baseline Record: N/A Annual Record: If a provider reminder system was in place at the end of the program year (July 1- June 30) (A5-2b is “Yes, newly in place” or “Yes, continuing”), indicates the maximum number of different ways and times (activity conducted more than one time during the year) that a given provider could have received breast cancer screening reminders for an individual patient during this program year (e.g., the provider received a total of 3 reminders for a given patient – 1 pop-up reminder in the patients electronic medical record, 1 reminder flagged in the patient chart, and 1 reminder via a list each day of patients due for screening) .	List	1 2 3 4 5 or more
A5-2g	R	A	Provider reminder system sustainability	Baseline Record: N/A Annual Record: If a provider reminder system was in place at the end of the program year (July 1- June 30) (A5-2b is “Yes, newly in place” or “Yes, continuing”), indicates whether the provider reminder system is considered to be fully integrated into health system and/or clinic operations and is sustainable without NBCCEDP resources. [The provider reminder system has become an institutionalized component of the health system and/or clinic operations.]	List	Yes No

Section 5-3: EBI -Provider Assessment and Feedback

Indicates the clinic’s use of system(s) to evaluate provider performance in delivering or offering screening to clients (assessment) and/or present providers, either individually or as a group, with information about their performance in providing screening services (feedback).

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
A5-3a	R	A	NBCCEDP resources used toward provider assessment and feedback	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP grantee resources (e.g. funds, staff time, materials, contract) were used during this program year (July 1- June 30) to contribute to planning, developing, implementing, monitoring/evaluating or improving provider assessment and feedback.	List	Yes No
B5-3b A5-3b	R	B, A	Provider assessment and feedback in place	Baseline Record: Indicates whether provider assessment and feedback processes for breast cancer screening were in place and operational (in use) in this clinic prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date), regardless of the quality, reach, or current level of functionality. Annual Record: Indicates whether provider assessment and feedback processes for breast cancer screening were in place and operational (in use) in this clinic at the end of the program year (July 1- June 30), regardless of the quality, reach, or current level of functionality. If provider assessment and feedback processes were newly implemented during this program year, select “Yes, newly in place”. If provider assessment and feedback processes were in place prior to this program year, select “Yes, continuing” If yes, newly in place skip to A5-3e If yes, continuing, skip to A5-3d If no, answer A5-3c and then skip to the next EBI, A5-4a	List	Baseline Record: Yes No Annual Record: Yes, newly in place Yes, continuing No
A5-3c	R	A	Provider assessment and feedback planning activities	Baseline Record: N/A Annual Record: If provider assessment and feedback were not in place and operational (A5-3b is No), indicates whether planning activities were conducted this program year for future implementation of provider assessment and feedback for breast cancer screening. Skip to the next EBI, A5-4a.	List	Yes No
A5-3d	R	A	Provider assessment and feedback enhancements	Baseline: N/A Annual: If a provider assessment and feedback system was in place prior to this program year and continuing (A5-3b is Yes, continuing), indicates whether the clinic made changes to enhance or improve implementation of provider assessment and feedback during the program year (July 1- June 30).	List	Yes No
A5-3e	R	A	Provider assessment and feedback frequency	Baseline Record: N/A Annual Record: If provider assessment and feedback were in place and operational at the end of the program year (July 1- June 30) (A5-3b is “Yes, newly in place” or “Yes, continuing”), indicates, on average, how often providers, either individually or as a group, were given feedback on their performance in providing breast cancer screening services during this program year.	List	Weekly Monthly Quarterly Annually
A5-3f	R	A	Provider assessment and feedback sustainability	Baseline Record: N/A Annual Record: If provider assessment and feedback were in place and operational at the end of the program year (July 1- June 30) (A5-3b is “Yes, newly in place” or “Yes, continuing”), indicates whether provider assessment and feedback is considered to be fully integrated into health system and/or clinic operations and is sustainable without NBCCEDP resources. [Provider assessment and feedback has become an institutionalized component of the health system and/or clinic operations.]	List	Yes No

Section 5-4: EBI -Reducing Structural Barriers

Indicates the clinic’s use of one or more interventions to address structural barriers to breast cancer screening. Structural barriers are non-economic burdens or obstacles that make it difficult for people to access cancer screening. Do not include patient navigation or community health workers as "reducing structural barriers."

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
A5-4a	R	A	NBCCEDP resources used toward reducing structural barriers	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP grantee resources (e.g. funds, staff time, materials, contract) were used during this program year (July 1- June 30) to contribute to planning, developing, implementing, monitoring/evaluating or improving reducing structural barriers activities.	List	Yes No
B5-4b A5-4b	R	B, A	Reducing structural barriers in place	Baseline Record: Indicates whether activities for reducing structural barriers to breast cancer screening were in place and operational (in use) in this clinic prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date), regardless of the quality, reach, or current level of functionality. Annual Record: Indicates whether activities for reducing structural barriers to breast cancer screening were in place and operational (in use) in this clinic at the end of the program year (July 1- June 30), regardless of the quality, reach, or current level of functionality. If activities for reducing structural barriers were newly implemented during this program year, select “Yes, newly in place”. If activities for reducing structural barriers were in place prior to this program year, select “Yes, continuing” If yes, newly in place skip to A5-4e If yes, continuing, skip to A5-4d If no, answer A5-4c and then skip to the next EBI, A5-5a	List	Baseline Record: Yes No Annual Record: Yes, newly in place Yes, continuing No
A5-4c	R	A	Reducing structural barriers planning activities	Baseline Record: N/A Annual Record: If reducing structural barriers was not in place at the end of the program year (July 1- June 30) (A5-4b is No), indicates whether planning activities were conducted this program year for future implementation of reducing structural barriers activities for breast cancer screening. Skip to the next EBI, A5-5a.	List	Yes No
A5-4d	R	A	Reducing structural barriers enhancements	Baseline: N/A Annual: If reducing structural barriers was in place prior to this program year and continuing (A5-4b is “Yes, continuing”), indicates whether the clinic made changes to enhance or improve implementation of reducing structural barriers during the program year (July 1- June 30).	List	Yes No
A5-4e	R	A	Reducing structural barriers more than one way	Baseline Record: N/A Annual Record: If reducing structural barriers was in place at the end of the program year (July 1- June 30) (A5-4b is “Yes, newly in place” or “Yes, continuing”), indicates whether this clinic reduced structural barriers for patients in multiple ways (e.g., offered evening clinic hours, offered assistance in scheduling appointments, provided free screenings for some patients) during this program year.	List	Yes No
A5-4f	R	A	Maximum ways reducing structural barriers	Baseline Record: N/A Annual Record: If reducing structural barriers was in place at the end of the program year (July 1- June 30) (A5-4b is “Yes, newly in place” or “Yes, continuing”), indicates the maximum number of different ways the clinic reduced structural barriers to breast cancer screening during this program year.	List	1 2 3 4 5 or more
A5-4g	R	A	Reducing structural barriers sustainability	Baseline Record: N/A Annual Record: If reducing structural barriers was in place at the end of the program year (July 1- June 30) (A5-4b is “Yes, newly in place” or “Yes, continuing”), indicates whether reducing structural barriers is considered to be fully integrated into health system and/or clinic operations and is sustainable without NBCCEDP resources. [ Reducing structural barriers has become an institutionalized component of the health system and/or clinic operations.]	List	Yes No

Section 5-5: EBI- Small Media

Indicates the clinic’s use of small media to improve breast cancer screening. Small media are materials used to inform and motivate people to be screened for cancer, including videos and printed materials (e.g., letters, brochures, and newsletters).

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
A5-5a	R	A	NBCCEDP resources used toward small media	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP grantee resources (e.g. funds, staff time, materials, contract) were used during this program year (July 1- June 30) to contribute to planning, developing, implementing, monitoring/evaluating or improving small media to improve breast cancer screening.	List	Yes No
B5-5b A5-5b	R	B, A	Small media in place	Baseline Record: Indicates whether use of small media to improve breast cancer screening was in place and operational (in use) in this clinic prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date), regardless of the quality, reach, or current level of functionality. Annual Record: Indicates whether use of small media to improve breast cancer screening were in place and operational (in use) in this clinic at the end of the program year (July 1- June 30), regardless of the quality, reach, or current level of functionality. If activities for small media were newly implemented during this program year, select “Yes, newly in place”. If activities for small media were in place prior to this program year, select “Yes, continuing”. If yes, newly in place skip to A5-5e If yes, continuing, skip to A5-5d If no, answer A5-5c and then skip to the next EBI, A5-6a	List	Baseline Record: Yes No Annual Record: Yes, newly in place Yes, continuing No
A5-5c	R	A	Small media planning activities	Baseline Record: N/A Annual Record: If small media to improve breast cancer screening was not in place at the end of the program year (July 1- June 30) (A5-5b is No), indicates whether planning activities were conducted this year for future implementation of small media. Skip to the next EBI, A5-6a	List	Yes No
A5-5d	R	A	Small media enhancements	Baseline: N/A Annual: If small media was in place prior to this program year and continuing (A5-5b is “Yes, continuing”), indicates whether the clinic made changes to enhance or improve implementation of small media during the program year (July 1- June 30).	List	Yes No
A5-5e	R	A	Small media delivered in more than one way	If small media was in place prior to this program year and continuing (A5-5b is “Yes, continuing”), indicates whether a given patient received multiple forms of small media related to breast cancer screening (e.g., the same patient received a postcard, was exposed to posters in the office setting, received a clinic newsletter or brochure) during this PY.	List	Yes No
A5-5f	R	A	Maximum number of ways and times small media delivered	Baseline Record: N/A Annual Record: If small media was in place at the end of the program year (July 1- June 30) (A5-5b is “Yes, newly in place” or “Yes, continuing”), indicates the maximum number of different ways and times (activity conducted more than one time during the year) a given patient could have received small media about breast cancer screening during this PY.	List	1 2 3 4 5 or more
A5-5g	R	A	Small media sustainability	Baseline Record: N/A Annual Record: If small media was in place at the end of the program year (July 1- June 30) (A5-5b is “Yes, newly in place” or “Yes, continuing”), indicates whether small media is considered to be fully integrated into health system and/or clinic operations and sustainable. [ Small media has become an institutionalized component of the health system and/or clinic operations.]	List	Yes No

Section 5-6: EBI - Patient education for clinic patients

Indicates the clinic’s use of one or more interventions to provide group or individual education to clinic patients on indications for, benefits of, and ways to overcome barriers to breast cancer screening with the goal of informing, encouraging, and motivating participants to seek recommended screening. Patient education may include role modeling or other interactive learning formats

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
A5-6a	R	A	NBCCEDP resources used toward patient education	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP grantee resources (e.g. funds, staff time, materials, contract) were used during this program year (July 1- June 30) to contribute to planning, developing, implementing, monitoring/evaluating or improving patient education for breast cancer screening.	List	Yes No
B5-6b A5-6b	R	B, A	Patient education in place	Baseline Record: Indicates whether patient education activities for breast cancer screening were in place and operational (in use) in this clinic prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date), regardless of the quality, reach, or current level of functionality. Annual Record: Indicates whether patient education activities for breast cancer screening were in place and operational (in use) in this clinic at the end of the program year (July 1- June 30), regardless of the quality, reach, or current level of functionality. If patient education activities were newly implemented during this program year, select “Yes, newly in place”. If patient education activities were in place prior to this program year, select “Yes, continuing” If yes, newly in place skip to A5-6e If yes, continuing, skip to A5-6d If no, answer A5-6c and then skip to the next EBI, A5-7a	List	Baseline Record: Yes No Annual Record: Yes, newly in place Yes, continuing No
A5-6c	R	A	Patient education planning activities	Baseline Record: N/A Annual Record: If patient education activities were not in place at the end of the program year (July 1- June 30) (A5-6b is No), indicates whether planning activities were conducted this program year for future implementation of patient education activities for breast cancer screening. Skip to the next EBI, A5-7a.	List	Yes No
A5-6d	R	A	Patient education enhancements	Baseline: N/A Annual: If patient education activities were in place prior to this program year and continuing (A5-6b is “Yes, continuing”), indicates whether the clinic made changes to enhance or improve implementation of reducing structural barriers during the program year (July 1- June 30).	List	Yes No
A5-6e	R	A	Average amount of patient education	Baseline Record: N/A Annual Record: If patient education activities were in place at the end of the program year (July 1- June 30) (A5-6b is “Yes, newly in place” or “Yes, continuing”), If in place (9f3 is Yes), indicates, on average, the amount of breast cancer screening education received by a given patient during this PY.	List	Less than 15 minutes > 15 to 30 minutes > 30 minutes to 1 hour > 1 to 2 hours > 2 to 3 hours More than 3 hours
A5-6f	R	A	Patient education sustainability	Baseline Record: N/A Annual Record: If patient education activities were in place at the end of the program year (July 1- June 30) (A5-6b is “Yes, newly in place” or “Yes, continuing”), indicates whether reducing structural barriers is considered to be fully integrated into health system and/or clinic operations and is sustainable without NBCCEDP resources. [Patient education activities have become an institutionalized component of the health system and/or clinic operations.]	List	Yes No

Section 5-7: EBI- Reducing out-of-pocket costs

Indicates the clinic’s use of one or more interventions to reduce patient out-of-pocket costs to minimize or remove economic barriers that make it difficult for patients to access breast cancer screening services. Reducing costs may include vouchers or reimbursements for transportation/parking, reduction in co-pays, reimbursing for breast cancer screening and/or diagnostics, or adjustments in federal or state insurance coverage.

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
A5-7a	R	A	NBCCEDP resources used toward reducing out-of-pocket costs during this PY	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP grantee resources (e.g. funds, staff time, materials, contract) were used during this program year (July 1- June 30) to contribute to planning, developing, implementing, monitoring/evaluating or improving small media to improve breast cancer screening.	List	Yes No
B5-7b A5-7b	R	B, A	Reducing out-of-pocket costs in place	Baseline Record: Indicates whether interventions to reduce patient out-of-pocket costs to improve breast cancer screening were in place and operational (in use) in this clinic prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date), regardless of the quality, reach, or current level of functionality. Annual Record: Indicates whether interventions to reduce patient out-of-pocket costs to improve breast cancer screening were in place and operational (in use) in this clinic at the end of the program year (July 1- June 30), regardless of the quality, reach, or current level of functionality. If interventions to reduce patient out-of-pocket costs were newly implemented during this program year, select “Yes, newly in place”. If interventions to reduce patient out-of-pocket costs were in place prior to this program year, select “Yes, continuing”. If yes, newly in place skip to A5-7e If yes, continuing, skip to A5-7d If no, answer A5-7c and then skip to the next EBI, A5-8a	List	Baseline Record: Yes No Annual Record: Yes, newly in place Yes, continuing No
A5-7c	R	A	Reducing out-of-pocket costs planning activities	Baseline Record: N/A Annual Record: If interventions to reduce patient out-of-pocket costs to improve breast cancer screening was not in place at the end of the program year (July 1- June 30) (A5-7b is No), indicates whether planning activities were conducted this year for future implementation of small media. Skip to the next EBI, A5-8a.	List	Yes No
A5-7d	R	A	Reducing out-of-pocket costs enhancements	Baseline: N/A Annual: If interventions to reduce patient out-of-pocket costs was in place prior to this program year and continuing (A5-7b is “Yes, continuing”), indicates whether the clinic made changes to enhance or improve implementation of small media during the program year (July 1- June 30).	List	Yes No
A5-7e	R	A	Reducing out-of-pocket costs in more than one way	If interventions to reduce patient out-of-pocket costs was in place at the end of the program year (July 1- June 30) (A5-7b is “Yes, newly in place” or “Yes, continuing”), indicates whether this clinic reduced out-of-pocket costs for patients in multiple ways during this PY.	List	Yes No
A5-7f	R	A	Maximum number of ways and times used to reduce out-of- pocket costs	Baseline Record: N/A Annual Record: If interventions to reduce patient out-of-pocket costs was in place at the end of the program year (July 1- June 30) (A5-7b is “Yes, newly in place” or “Yes, continuing”), indicates the maximum number of different ways and times (activity conducted more than one time during the year) a given patient could have received these interventions for breast cancer screening during this PY.	List	1 2 3 4 5 or more
A5-7g	R	A	Reducing out-of-pocket costs sustainability	Baseline Record: N/A Annual Record: If interventions to reduce patient out-of-pocket costs was in place at the end of the program year (July 1- June 30) (A5-7b is “Yes, newly in place” or “Yes, continuing”), indicates whether these interventions are considered to be fully integrated into health system and/or clinic operations and sustainable. [ Small media has become an institutionalized component of the health system and/or clinic operations.]	List	Yes No

Section 5-8: EBI- PROFESSIONAL DEVELOPMENT AND PROVIDER EDUCATION

Indicates whether activities are in place to provide professional development/provider education to health care providers in this clinic on breast cancer screening. Activities may include distribution of provider education materials, including screening guidelines and recommendations, and/or continuing medical education (CMEs) opportunities.

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
A5-8a	R	A	NBCCEDP resources used toward professional development/provider education	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP grantee resources (e.g. funds, staff time, materials, contract) were used during this program year (July 1- June 30) to contribute to planning, developing, implementing, monitoring/evaluating or improving professional development/provider education.	List	Yes No
B5-8b A5-8b	R	B, A	Professional development/provider education in place	Baseline Record: Indicates whether professional development/provider education for breast cancer screening was in place and operational (in use) in this clinic prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date), regardless of the quality, reach, or current level of functionality. Annual Record: Indicates whether professional development/provider education for breast cancer screening were in place and operational (in use) in this clinic at the end of the program year (July 1- June 30), regardless of the quality, reach, or current level of functionality. If professional development/provider education were newly implemented during this program year, select “Yes, newly in place”. If professional development/provider education were in place prior to this program year, select “Yes, continuing” If yes, newly in place skip to A5-8e If yes, continuing, skip to A5-8d If no, answer A5-8c and then skip to the next EBI, A5-9a	List	Baseline Record: Yes No Annual Record: Yes, newly in place Yes, continuing No
A5-8e	R	A	Average amount of professional development/provider education	If in place (10a3 is Yes), indicates on average, the amount of breast cancer screening professional development training or education were received by a given provider during this PY.	List	Less than 15 minutes > 15 to 30 minutes > 30 minutes to 1 hour > 1 to 2 hours > 2 to 3 hours More than 3 hours

Section 5-9: EBI -Community outreach, education, and support

Indicates whether community outreach and education activities are in place with the goal of linking women in the community to breast cancer screening services at this clinic. An example is using community health workers (CHWs) for community outreach. CHWs are lay health educators with a deep understanding of the community and are often members of the community being served. CHWs work in community settings to educate people about cancer screening, promote cancer screening, and provide peer support to people referred to cancer screening.

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
A5-9a	R	A	NBCCEDP resources used toward community outreach	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP grantee resources (e.g. funds, staff time, materials, contract) were used during this program year (July 1- June 30) to contribute to planning, developing, implementing, monitoring/evaluating or improving community outreach activities.	List	Yes No
B5-9b A5-9b	R	B, A	Community outreach in place	Baseline Record: Indicates whether community outreach activities for breast cancer screening were in place and operational (in use) in this clinic prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date), regardless of the quality, reach, or current level of functionality. Annual Record: Indicates whether community outreach activities for breast cancer screening were in place and operational (in use) in this clinic at the end of the program year (July 1- June 30), regardless of the quality, reach, or current level of functionality. If professional development/provider education were newly implemented during this program year, select “Yes, newly in place”. If professional development/provider education were in place prior to this program year, select “Yes, continuing” If yes, newly in place skip to A5-9e If yes, continuing, skip to A5-9d If no, answer A5-9c and then skip to the next EBI, A5-10a.	List	Baseline Record: Yes No Annual Record: Yes, newly in place Yes, continuing No
A5-9c	R	A	Community outreach planning activities	Baseline Record: N/A Annual Record: If community outreach activities to improve breast cancer screening was not in place at the end of the program year (July 1- June 30) (A5-9b is No), indicates whether planning activities were conducted this year for future implementation of community outreach. Skip to the next EBI, A5-10a.	List	Yes No
A5-9d	R	A	Community outreach activities enhancements	Baseline Record: N/A Annual Record: If community outreach activities to improve breast cancer screening was in place prior to this program year and continuing (A5-9b is “Yes, continuing”), indicates whether the clinic made changes to enhance or improve implementation of community outreach activities during the program year (July 1- June 30).	List	Yes No
A5-9e	R	A	Average duration of community outreach activities	Baseline Record: N/A Annual Record: If community outreach was in place at the end of the program year (July 1- June 30) (A5-9b is “Yes, newly in place” or “Yes, continuing”), for persons in the clinic’s community who were exposed to outreach activities conducted by the clinic, indicates the average amount of time a given person received those activities during this PY.	List	Less than 15 minutes > 15 to 30 minutes > 30 minutes to 1 hour > 1 to 2 hours > 2 to 3 hours More than 3 hours
A5-9f	R	A	Community outreach sustainability	Baseline Record: N/A Annual Record: If community outreach was in place at the end of the program year (July 1- June 30) (A5-9b is “Yes, newly in place” or “Yes, continuing”), indicates whether these interventions are considered to be fully integrated into health system and/or clinic operations and sustainable. [ Community outreach has become an institutionalized component of the health system and/or clinic operations.]	List	Yes No
A5-9g	R	A	Number of FTE CHWs	Baseline Record: N/A Annual Record: If community outreach was in place at the end of the program year (July 1- June 30) (A5-9b is “Yes, newly in place” or “Yes, continuing”), indicates the number of CHW full time equivalents (FTEs) employed at or by the clinic during the program year for breast cancer screening. For this number, please provide the total sum of whole and partial FTEs to the nearest tenths decimal place. For example, if 2 CHWs work a total of 50% time, then enter 0.5. If no CHWs are being used for NBCCEDP-Breast activities then enter 0.	Num	00.0-999.0
A5-9h	R	B,A	Other community-clinical linkage (CCL) activities	Community-clinical linkage (CCL) activities refer to activities in place at or employed by the clinic to link priority population members in the community to breast cancer screening services at this clinic. Baseline Record: Describes any other CCL activities used by the clinic prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date), to link women in the community to breast cancer screening services at this clinic. Annual Record: Describe any other CCL activities this clinic conducted during the program year (July 1-June 30) to link women in the community to breast cancer screening services at this clinic.	Char	Free text 256 Char limit

Section 5-10: Patient Navigation

Indicates whether patient navigators (PNs) are in place at or employed by the clinic. PNs typically assist clients in overcoming individual barriers to cancer screening. Patient navigation includes assessment of client barriers, client education and support, resolution of client barriers, client tracking and follow-up. Patient navigation should involve multiple contacts with a client.

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
A5-10a	R	A	NBCCEDP resources used toward patient navigation	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP grantee resources (e.g. funds, staff time, materials, contract) were used during this program year (July 1- June 30) to contribute to planning, developing, implementing, monitoring/evaluating or improving patient navigation to support breast cancer screening (including completion of any diagnostic tests following an abnormal screening mammography result).	List	Yes No
B5-10b A5-10b	R	B, A	Patient navigation in place	Baseline Record: Indicates whether patient navigation to support breast cancer screening was in place and operational (in use) in this clinic prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date), regardless of the quality, reach, or current level of functionality. Annual Record: Indicates whether patient navigation to support breast cancer screening (including completion of any diagnostic tests following an abnormal screening mammography result) was in place and operational (in use) in this clinic at the end of the program year (July 1- June 30), regardless of the quality, reach, or current level of functionality. If yes, newly in place skip to A5-10d If yes, continuing, skip to A5-10d If no, answer A5-10c and then skip to the next section A6-1.	List	Baseline Record: Yes No Annual Record: Yes, newly in place Yes, continuing No
A5-10c	R	A	Patient navigation planning	Baseline Record: N/A Annual Record: If patient navigation was not in place at the end of the program year (July 1- June 30) (A5-10b is “No”), indicates whether planning activities were conducted this program year for future implementation of patient navigation for breast cancer screening. skip to the next section, A6-1.	List	Yes No
B5-10d A5-10d	R	B&A	Patient Navigation Purpose	Baseline Record: Indicates the focus of patient navigation in this clinic before your NBCCEDP begins implementation (item B1-2), Annual Record: Indicates whether patient navigation supported breast cancer screening, follow-up diagnostic tests, or both in this clinic at the end of the program year (July 1- June 30). If A5-10b is “yes, newly in place” then skip to A5-10f	List	Breast Cancer screening Follow-up diagnostic tests Both
A5-10e	R	A	Patient Navigation Enhancements	Baseline: N/A Annual: If patient navigation was in place and continuing (A5-10b is “Yes, continuing”), indicates whether the clinic made changes to enhance or improve implementation of patient navigation during the program year (July 1- June 30).	List	Yes No
A5-10f	R	A	Average amount of patient navigation time	Baseline Record: N/A Annual Record: If patient navigation was in place at the end of the program year (July 1- June 30) (A5-10b is “Yes, newly in place” or “Yes, continuing”), for persons at this clinic who received navigation this program year (July 1- June 30), indicates the average amount of navigation time a patient received to overcome breast cancer screening barriers during this PY. If detailed monitoring data are not available, an estimate of the average time is sufficient.	List	Less than 15 minutes >15 to 30 minutes >30 minutes to 1 hour >1 to 2 hours >2 to 3 hours More than 3 hours
A5-10g	R	A	Patient navigators for EBIs	Baseline Record: N/A Annual Record: If patient navigation was in place at the end of the program year (July 1- June 30) (A5-10b is “Yes, newly in place” or “Yes, continuing”), indicates whether patient navigator(s) at this clinic assisted or facilitated implementation of any of the clinic’s breast cancer screening EBIs.	List	Yes No
A5-10h	R	A	Patient navigation sustainability	Baseline Record: N/A Annual Record: If patient navigation was in place at the end of the program year (July 1- June 30) (A5-10b is “Yes, newly in place” or “Yes, continuing”), indicates whether patient navigation for breast cancer screening is considered to be fully integrated into health system and/or clinic operations and is sustainable without NBCCEDP resources. [Patient navigation has become an institutionalized component of the health system and/or clinic operations.]	List	Yes No
B5-10i A5-10i	R	B, A	Number of FTEs delivering patient navigation	Baseline Record: If patient navigation was in place at baseline (item B5-10b=Yes), indicates the number of full-time equivalents (FTEs) conducting patient navigation (e.g., navigators, nurse navigators, nurses, peer health advisors, health navigators) for breast cancer in this clinic during this program year. Annual Record: If patient navigation was in place at the end of the program year (July 1- June 30) (item A5-10b is “Yes, newly in place” or “Yes, continuing”), indicates the number of full-time equivalents (FTEs) conducting patient navigation (e.g., navigators, nurse navigators, nurses, peer health advisors, health navigators) for breast cancer in this clinic during this program year. For this number, please provide the total sum of whole and partial FTEs to the nearest tenths decimal place. For example, if 2 patient navigators work a total of 50% time to deliver navigation for breast cancer, then enter 0.5.	Num	00.0-999.0
A5-10j	R	A	Number of patients navigated	Baseline Record: N/A Annual Record: If patient navigation was in place at the end of the program year (July 1- June 30) (A5-6b is Yes), indicates the number of patients receiving navigation services for breast cancer screening (including follow-up colonoscopies) during this program year.	Num	1-99998 99999 (Unk)
B5-11 A5-11	O	B, A	Section 5 Comments	Optional comments for Section 5.	Char	Free text 200 Char limit

Section 6: Other Baseline and Annual Breast Cancer Activities and Comments

Indicates whether other/additional breast cancer -related strategies are used in the clinic to improve screening levels such as clinic workflow assessment and data driven optimization, other data driven quality improvement strategies, 5 rights of clinical decision support (5 R’s), etc.

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
B6-1 A6-1	O	B, A	Other breast cancer Activity 1	Baseline and Annual Records: Description of other BREAST activity or strategy #1.	Char	Free text 200 Char limit
A6-1a	O	A	NBCCEDP resources used toward Activity 1	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP resources were used during the program year to support activity #1	List	Yes No
B6-2 A6-2	O	B, A	Other breast cancer Activity 2	Baseline and Annual Records: Description of other BREAST activity or strategy #2.	Char	Free text 200 Char limit
A6-2a	O	A	NBCCEDP resources used toward Activity 2	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP resources were used during the program year to support activity #2.	List	Yes No
B6-3 A6-3	O	B, A	Other breast cancer Activity 3	Baseline and Annual Records: Description of other BREAST activity or strategy #3.	Char	Free text 200 Char limit
A6-3a	O	A	NBCCEDP resources used toward Activity 3	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP resources were used during the program year to support activity #3.	List	Yes No
B6-4 A6-4	O	B, A	Section 6 Comments	Optional comments for Section 6.	Char	Free text 200 Char limit

NBCCEDP NOFO DP22-2202

OMB # 0920-1046

Expiration Date: XX/XX/XXXX

National Breast and Cervical Cancer Early Detection Program (NBCCEDP)

Cervical Clinic Data Dictionary

Public reporting burden of this collection of information is estimated to average 45 minutes 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 NE, MS D‐74, Atlanta, Georgia 30333; ATTN: PRA (0920-1046).

NBCCEDP-Cervical Clinic Data Dictionary (NOFO DP22-2202)

Contents

Part I: Partner and Record Identifiers

NBCCEDP DP22-2202

Program Years (PY)

	Start Date	end date
PY 1	July 1, 2022	June 30, 2023
PY 2	July 1, 2023	June 30, 2024
PY 3	July 1, 2024	June 30, 2025
PY 4	July 1, 2025	June 30, 2026
PY 5	July 1, 2026	June 30, 2027

Part II: Baseline and Annual Record Data Items

Section 1. Baseline and Annual Clinic NBCCEDP-Cervical Activity and Status

Section 2. Baseline and Annual Health System and Clinic Characteristics and Clinic Patient Population

Section 3. Baseline and Annual Cervical Cancer Screening Rates

• Screening Rate Status

• Chart Review Screening Rates

• EHR Screening Rates

Section 4. Baseline and Annual Monitoring and Quality Improvement Activities

Section 5. Baseline and Annual Evidence-based Interventions (EBIs) and Other Clinic Activities

• 5-1: EBI-Patient Reminder System

• 5-2: EBI-Provider Reminder System

• 5-3: EBI-Provider Assessment and Feedback

• 5-4: EBI-Reducing Structural Barriers

• 5-5: EBI-Small Media

• 5-6: Patient Education for Clinic Patients

• 5-7: EBI- Reducing out-of-pocket costs

• 5-8: Professional Development and Provider Education

• 5-9: EBI -Community Outreach, Education, and Support

• 5-10: EBI- Patient Navigation

Section 6. Other Baseline and Annual Cervical Cancer Activities and Comments

Data Collection Notes:

• Baseline data are required for all clinics participating in NBCCEDP- NOFO DP22-2202.

• For clinics enrolled during the previous NBCCEDP funding period (NOFO DP17-1701) for cervical activities and still active, awardees must re-submit baseline data using the clinics’ NOFO DP17-1701 program year 5 reported screening rates as the current baseline screening rates.

• For new clinics, baseline data are reported when new clinics are enrolled to participate in NBCCEDP-cervical activities and reflect activities prior to NBCCEDP-cervical activity implementation (Item B1-2: Clinic NBCCEDP-Cervical Activities Start Date).

Part I. Partner and Record Identifiers

Identifying information for the partner clinic and health system.

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
P1	R	B	Recipient code	Baseline Record: Two-character Grantee Code (assigned by CDC) Annual Record: N/A	List	TBD- 2-character code
P2	R	B	NBCCEDP Partner Entity	Baseline Record: Indicates the organizational level of the partner entity working with the grantee to implement cervical cancer screening EBIs and the associated population used for calculating screening rates. Clinic partnerships are the preferred action. When reporting clinic-level data, the clinic/grantee must report clinic-specific screening rates and population counts (not health system rates and counts). To report Health System-level data, you must have approval from CDC's Evaluation Team before enrolling the Health System. In addition, four criteria must be met: All Clinics within the health system must be participating in NBCCEDP. The same EBIs must be implemented uniformly across ALL clinics within the health system The reported screening rate and population counts must be Health System-wide for ALL eligible patients at all clinics within the health system. Data for any individual clinic within the health system must not be reported separately. Thus, you will have only one record reported for the entire health system in B&C-BARS. Within the record, information at the health system level will be reported for both the Health System and the individual Clinic fields. Contact CDC’s evaluation team for help with reporting these data. Annual Record: N/A	List	Clinic Health System Other:________________
P3	R	B, A	Partner Agreement	Baseline Record: The initial type of formal agreement the grantee made with the partner health system and/or clinic for NBCCEDP activities. Annual Record: The type of formal agreement the grantee had in place with the partner health system and/or clinic for NBCCEDP activities at the end of the program year (July 1- June 30).	List	MOU/MOA Contract Other None
P4	R	B	Date of Partner Agreement	Baseline Record: The original date the formal agreement was finalized between the grantee and partner clinic or health system for NBCCEDP DP22-2202 activities. Annual Record: N/A	Date	MM/DD/YYYY
HS1	R	B	Health system name	Baseline Record: Name of the partner health system under which the clinic (intervention/partner site) operates. Annual Record: N/A	Char	Free text 100 Char limit
HS2	R	B	Health system ID	Baseline Record: Unique three-digit identification code for the partner health system assigned by the grantee. Start with “001” and continue assigning numbers sequentially as health system partnerships are established. If this health system was recruited during NOFO DP17-1701, continue to use the existing three-digit health system ID that was assigned during NOFO DP17-1701. If this is a clinic where CDC’s CRCCP activities are also being implemented, we encourage using the same three-digit health system identification code assigned by the CRCCP staff. Contact the CRCCP staff in your state for a list of clinics participating in the CRCCP. Annual Record: N/A	Num	001-999
HS3	R	B	Health system Address	Baseline Record: Street address for the partner health system. If the street address is more than two lines, use a comma for separation. Annual Record: N/A	Char	Street, City, State, Zip, County
CL1	R	B	Clinic name	Baseline Record: Name of the partner health clinic (intervention site). If the partner is a health system (item P2 is “Health System”) then re-enter the Health System information as the clinic name Annual Record: N/A	Char	Free text 100 Char limit
CL2	R	B	Clinic ID	Baseline Record: Unique three-digit identification code for the partner clinic assigned by the grantee. Start with “001” and continue assigning numbers sequentially as health system partnerships are established. If this clinic was recruited during NOFO DP17-1701, continue to use the existing 3-digit clinic ID that was assigned during NOFO DP17-1701. If this is a clinic where CDC’s CRCCP activities are also being implemented, we encourage using the same three-digit clinic identification code assigned by the CRCCP staff. Contact the CRCCP staff in your state for a list of clinics participating in the CRCCP. Annual Record: N/A	Num	001-999
CL3	R	B	Clinic Address	Baseline Record: Street address for the partner clinic. If the street address is more than two lines, use a comma for separation. If the partner is a health system (item P2 is “Health System”) then re-enter the Health System information as the clinic street Annual Record: N/A	Char	Street, City, State, Zip, county
P5	O	B	Part 1 Comments	Optional comments for Part 1.	Char	Free text 200 Char limit

Part II. Baseline and Annual Record Data Items

Section 1. Baseline and Annual Clinic NBCCEDP Activity and Status

If the partner is a health system (P2=” Health System”) then clinic data reported must represent the entire Health System

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
B1-1	R	B	Clinic Enrollment NOFO-Cervical Activities	Baseline Record: Indicates the NOFO during which the clinic was first enrolled into NBCCEDP. Identifies the clinic as new to NBCCEDP and newly enrolled during NOFO DP22-2202 or if the clinic was recruited prior to this funding cycle and is continuing from DP17-1701 and if so, its status at the end of DP17-1701. DP22-2202: Clinic is new to NBCCEDP (did not participate in NOFO DP17-1701) DP17-1701 never terminated: Clinic is continuing on from NOFO DP17-1701 for cervical cancer activities (never terminated) DP17-1701 previously terminated: Clinic enrolled during NOFO DP17-1701 for cervical cancer activities but ended NBCCEDP participation during that NOFO and is being re-enrolled into NBCCEDP as part of DP22-XXXX. If unknown, select DP22-2202. Annual Record: N/A	List	DP22-2202 DP17-1701 never terminated DP17-1701 previously terminated
B1-2	R	B	Clinic NBCCEDP-Cervical Activities Start Date	Baseline Record: Indicates the date the clinic (or health system if reporting health system-level data) began actively implementing NBCCEDP [NOFO DP22-2202] cervical activities. Enter the date that the clinic started implementing NBCCEDP [NOFO DP22-2202] cervical program activities to increase clinic-level cervical cancer screening rates. Activities can include: Enhancing existing EBIs for cervical cancer screening Implementing new NBCCEDP-cervical EBI activities Conducting quality improvement activities to increase cervical cancer screening rates such as: Improving the quality of EHR screening data to produce an accurate cervical cancer screening rate, integrate patient and provider reminder systems, or produce feedback reports; Process mapping to identify areas where cervical cancer screening can best be promoted or implemented; Other activities that improve service delivery in ways to increase cervical cancer screening. Note: For clinics enrolled during the previous NBCCEDP funding period (NOFO DP17-1701,), grantees must re-submit baseline data using the clinic's NOFO DP17-1701, PY5 screening rates for NOFO DP20-2022 baseline screening rates. In such cases, the same 12-month screening rate measurement period and the same screening rate measure (e.g., UDS) must be used for reporting under DP20-2022. For active clinics continuing from NOFO DP17-1701, (item B1-1, Clinic Enrollment NOFO is “DP17-1701 not terminated”) the clinic NBCCEDP activities start date will be automatically entered by B&C-BARS as 07/01/2022. Annual Record: N/A	Date	MM/DD/YYYY
B1-3	Comp	B	Baseline PY	Baseline Record: Baseline PY (based on activities start date) - auto-calculated based on NBCCEDP-Cervical Activities Start Date (item, B1-2) Annual Record: N/A	List	NBCCEDP 2022-2202-py1 NBCCEDP 2022-2202-py2 NBCCEDP 2022-2202-py3 NBCCEDP 2022-2202-py4 NBCCEDP 2022-2202-py5
B1-4	R	B	Partner Type	Baseline Record: Organizational classification of partner clinic/health system. Community Health Center/Federally Qualified Heath Center (CHC/FQHC) includes “FQHC look-alikes” that meet program requirements but do not receive funding from the HRSA Health Center Program. Tribal health clinic includes IHS, Tribal or Urban Indian clinics (I/T/U) that serve AI/AN. Annual Record: N/A	List	CHC/FQHC Health system/Hospital owned Private/Physician owned Health department Tribal health Primary Care Facility (non-CHC/FQHC) Other
A1-1	Comp	A	Annual Report Period	Baseline Record: N/A Annual Record: Indicates the reporting period represented in the data submission Annual data are reported at the end of each NBCCEDP program year (PY) and reflect activities conducted during that completed program year. Select the PY that matches the data that are being reported. Screening rates reported at baseline and annually use a consistent 12-month measurement period that may be different from the NBCCEDP PY.	List	NBCCEDP 2022-2202-py1 NBCCEDP 2022-2202-py2 NBCCEDP 2022-2202-py3 NBCCEDP 2022-2202-py4 NBCCEDP 2022-2202-py5
A1-2	R	A	Annual Partner Status	Baseline Record: N/A Annual Record: Indicates the status of NBCCEDP supported cervical cancer EBI implementation and screening rate monitoring activities at this clinic or health system during the program year. Select only one response. Active: Grantee actively worked with the clinic or health system to 1) plan and/or implement NBCCEDP cervical cancer EBI activities and 2) monitor the cervical cancer screening rate. If any NBCCEDP activities were planned or conducted at any point during the PY with support from the grantee, enter “Active”. Monitoring: Grantee did not provide NBCCEDP cervical cancer EBI planning or implementation support (no active technical assistance provided) to the clinic during the PY but continued to monitor its screening rate and EBI implementation. Suspended: Partnership with the clinic was temporarily stopped for the PY with no NBCCEDP EBI cervical cancer planning or implementation or screening rate monitoring activities conducted during any time of this PY, but the clinic intends to resume NBCCEDP EBI activities at some time before the end of the current cooperative agreement. Note: If any NBCCEDP activities were conducted during the PY, enter “Active” and submit a full annual record for this PY. Only use the response “Suspended” if NBCCEDP implementation was halted for the full year. Terminated: Partnership with the clinic or health system has ended with no NBCCEDP cervical cancer EBI implementation or screening rate monitoring activities conducted during the PY or planned through the end of the cooperative agreement. Note: If any NBCCEDP activities were conducted during the PY, enter “Active” and submit a full annual record for this PY. Only use the response “Terminated” if NBCCEDP implementation was terminated for the full year. If active or monitoring, skip to COV-1 If suspended or terminated, indicate date and reason in A1-2a through A1-2i *Full annual record required for active or monitoring	List	Active Monitoring Suspended Terminated
A1-2a	R	A	Suspension/Termination date	Baseline Record: N/A Annual Record: Indicates the date when the clinic partnership for NBCCEDP cervical cancer EBI activities and screening rate monitoring activities were suspended or terminated. If the day is unknown use “15”	Date	MM/DD/YYYY
A1-2b	R	A	Reason for Suspension	Baseline Record: N/A Annual Record: Reason that NBCCEDP cervical EBI planning or implementation and screening rate monitoring activities have been suspended or terminated at this clinic.	Check all that apply	Clinic implementation completed-no longer monitoring screening rates Clinic non-performance Clinic does not have resources/capacity to participate Clinic EHR problems or unable to collect clinic data Clinic merged with another clinic Clinic closed Other ______________
COV-1	R	B, A	COVID-19 clinic closure or hours/days reduced	Baseline Record: Indicates whether the clinic closed for an extended period of time (a full week or more) or reduced hours/days because of COVID-19 at any time during the year prior to NBCCEDP-cervical activity implementation (Item B1-2: Clinic NBCCEDP-Cervical Activities Start Date) Response option notes: Closed= the clinic was completely closed to patients for an extended period of time (at least a full week or more) because of COVID-19. Hours reduced= the clinic was partially closed to patients for a set number of days per week or a set number of hours per day because of COVID-19. If closed, specify # of weeks in item COV-2 If reduced hours/days, specify amount in item COV-3 through COV-6 If both closed and reduced hours/days, specify amount in COV-2 through COV-6 If no, skip to COV-7 Annual Record: Indicates whether the clinic closed for an extended period of time (a full week or more) or reduced hours/days because of COVID-19 at any time during the program year (July 1- June 30). Response option notes: Closed= the clinic was completely closed to patients for an extended period of time (at least a full week or more) because of COVID-19. Hours reduced= the clinic was partially closed to patients for a set number of days per week or a set number of hours per day because of COVID-19. If closed, specify # of weeks in item COV-2 If reduced hours/days, specify amount in item COV-3 through COV-6 If both closed and reduced hours/days, specify amount in COV-2 through COV-6 If no, skip to COV-7	List	Yes, closed Yes, reduced hours/days Yes, both closed and reduced hours/days No, clinic did not close or reduce hours/days
COV-2	R	B, A	COVID-19 closure amount	Baseline Record: Indicates the amount of weeks, in total, the clinic was closed because of COVID-19 at any time during the year prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date). Annual Record: Indicates the amount of weeks, in total, the clinic was closed because of COVID-19 at any time during the program year (July 1- June 30).	Num	_# of weeks
COV-3	R	B, A	Clinic Hours – pre COVID-19	Baseline Record: Indicates the typical number of hours a week the clinic was open before closing and/or reducing hours due to COVID-19 during the year prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date). Example: For a clinic that was normally open eight hours each day, five days a week prior to COVID-19, you would enter ‘40 hours’ to indicate the normal clinic hours. Annual Record: Indicates the typical number of hours a week the clinic was open before closing and/or reducing hours due to COVID-19. Example: For a clinic that was normally open eight hours each day, five days a week prior to COVID-19, you would enter ‘40 hours’ to indicate the normal clinic hours.	Num	_#__ hours each week
COV-4	R	B, A	COVID-19 Hours reduced	Baseline Record: Indicates the number of hours, in total, the clinic reduced hours/days because of COVID-19 at any time during a given week during the year prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date). Note: You will be entering number of hours reduced and the number of weeks for these reduced hours. If the reduction in hours changed over time, you can enter an average for the number of hours per week. If the clinic reduced hours for a set amount of hours per day, provide the number of hours reduced for the entire week during the year prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date). Example: For a clinic that is normally open eight hours each day, five days a week and it closed for one day a week because of COVID-19, you would enter ‘8 hours’ to indicate the reduction in hours each week. If this clinic was closed for one day a week and open for two less hours each remaining day, you would enter ’16 hours’. Annual Record: Indicates the number of hours, in total, the clinic reduced hours/days because of COVID-19 at any time during a given week during the program year (July 1- June 30). Note: You will be entering number of hours reduced and the number of weeks for these reduced hours. If the reduction in hours changed over time, you can enter an average for the number of hours per week. If the clinic reduced hours for a set amount of hours per day, provide the number of hours reduced for the entire week during the program year. Example: For a clinic that is normally open eight hours each day, five days a week and it closed for one day a week because of COVID-19, you would enter ‘8 hours’ to indicate the reduction in hours each week. If this clinic was closed for one day a week and open for two less hours each remaining day, you would enter ’16 hours’.	Num	_#__ hours each week for __#__weeks
COV-5	R	B, A	COVID-19 screening/diagnostic impact	Baseline: Indicates whether COVID-19 negatively impacted the clinic’s delivery of cervical cancer screening and diagnostic services during the year prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date). If yes, indicate how the clinic was impacted in items COV-5a If no, skip to COV-6 Annual: Indicates whether COVID-19 negatively impacted the clinic’s delivery of cervical cancer screening and diagnostic services during the program year (July 1- June 30). If yes, indicate how the clinic was impacted in items COV-5a If no, skip to COV-6	List	Yes No
COV-5a	R	B, A	Clinic activities impacted	Baseline: Indicates the ways COVID-19 negatively impacted the clinic’s delivery of cervical cancer screening and diagnostic services during the year prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). Check all that apply Annual: Indicates the ways COVID-19 negatively impacted the clinic’s delivery of cervical cancer screening and diagnostic services during the program year (July 1- June 30). Check all that apply		Clinic visits were restricted to sick patients, with limited or no preventive care available Clinic visits were limited to patients at high risk or with symptoms for cervical cancer Clinic visits were restricted to telehealth/telemedicine only Clinic could not refer patients with abnormal screening results for follow-up testing due to limited availability of diagnostic services Patients cancelled or did not schedule appointments due to COVID concerns Patients fearful of getting COVID-19. If patients were not fearful of getting COVID-19 or If the clinic was unable to capture/collect/note this information, select ‘No’. Clinic cervical cancer screening activities were limited due to the clinic’s prioritization of COVID-19 vaccination of patients COVID-19 negatively impacted the clinic’s delivery of cervical cancer screening and diagnostic services that cannot be categorized in the above options. Specify: _________________
COV-6	R	B, A	COVID-19 EBI impact	Baseline: Indicates whether COVID-19 negatively impacted the clinic’s implementation of evidence-based interventions (EBIs) or Patient Navigation activities for cervical cancer screening during the year prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date). (e.g., implementation of some or all EBIs were suspended) If yes, indicate all activities negatively impacted by COVID-19 in COV-6a If no, skip to COV-7 Annual: Indicates whether COVID-19 negatively impacted the clinic’s implementation of evidence-based interventions (EBIs) or Patient Navigation activities for cervical cancer screening during the program year (July 1-June 30). (e.g., implementation of some or all EBIs were suspended) If yes, indicate all activities negatively impacted by COVID-19 in COV-6a If no, skip to COV-7	List	Yes No
COV-6a	R	B, A	EBIs impacted	Baseline: Indicates which of the clinic’s evidence-based interventions (EBIs) for cervical cancer screening were impacted by COVID-19 during the year prior to NBCCEDP-breast activity implementation (item B1-2: Clinic NBCCEDP-Breast Activities Start Date). (e.g., implementation of some or all EBIs were suspended) Check all that apply Annual: Indicates which of the clinic’s evidence-based interventions (EBIs) for cervical cancer screening were impacted by COVID-19 during the program year (July 1-June 30). (e.g., implementation of some or all EBIs were suspended) Check all that apply		Patient Reminders Provider Reminders Provider Assessment and Feedback Reducing Structural Barriers Small Media impact Patient Education impact Reducing Out-of-Pocket Costs impact Professional Development/Provider Education Patient Navigation
COV-7	O	B, A	COVID-19 Comments	Optional comments for COVID-19 Section	Char	Free text 200 char limit

Section 2. Baseline and Annual Health System and Clinic Characteristics and Clinic Patient Population

If the partner is a health system (P2=” Health System”) then clinic data reported must represent the entire Health System

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
B2-1 A2-1	R	B, A	Total # of primary care clinics in health system	Baseline Record: The total number of primary health care clinics that operate under the partner health system, including those serving specific populations such as pediatric clinics, prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date). A clinic is defined as a location where primary care services are delivered. Clinics may also be referred to as "sites" or “practices”. Annual Record: The total number of primary health care clinics that operated under the partner health system, including those serving specific populations such as pediatric clinics during the program year (July 1-June 30). A clinic is defined as a location where primary care services are delivered. Clinics may also be referred to as "sites" or “practices”.	Num	1-9999999
B2-2 A2-2	R	B, A	Total # of primary care providers in health system	Baseline Record: Total number of primary care providers who are delivering services for the parent health system prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date). Primary care providers include physicians (e.g., internists, family practice, OB/GYN, attending physicians, fellows and residents), nurses, nurse practitioners, and physician assistants. Do not include specialty providers in this number. Report on individuals, not full-time equivalents (FTEs). Annual Record: Total number of primary care providers who were delivering services for the parent health system during the program year (July 1-June 30). Primary care providers include physicians (e.g., internists, family practice, OB/GYN, attending physicians, fellows and residents) nurses, nurse practitioners, and physician assistants. Do not include specialty providers in this number. Report on individuals, not full-time equivalents (FTEs).	Num	1-99999
B2-3 A2-3	R	B, A	# of primary care providers at clinic	Baseline Record: Indicates the total number of primary care providers who were delivering primary care services at the clinic prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date). Primary care providers include physicians (e.g., internists, family practice, OB/GYN attending physicians, fellows and residents), nurses, nurse practitioners, and physician assistants. Do not include specialty providers in this number. Report on individuals, not full-time equivalents (FTEs). If the partner is a health system (P2=” Health System”) then re-enter the number of primary care providers at the Health System Annual Record: Indicates the total number of primary care providers who were delivering primary care services at the clinic during the program year (July 1-June 30). Primary care providers include physicians (e.g., internists, family practice, OB/GYN attending physicians, fellows and residents), nurses, nurse practitioners, and physician assistants. Do not include specialty providers in this number. Report on individuals, not full-time equivalents (FTEs). If the partner is a health system (P2=” Health System”) then re-enter the number of primary care providers at the Health System	Num	1-99999
B2-4 A2-4	R	B, A	Total # of clinic patients	Baseline Record: The total number of clinic patients who had at least one medical visit to the clinic in the last complete calendar year prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date). If the partner is a health system (P2=” Health System”) then enter the number of clinic patients at the Health System Annual Record: The total number of clinic patients who had at least one medical visit to the clinic in the last complete program year (July 1-June 30). If the partner is a health system (P2=” Health System”) then enter the number of clinic patients at the Health System.	Num	1-9999999
B2-5 A2-5	R	B, A	Total # of clinic patients, women age 21-64	Baseline Record: The total number of clinic patients who had at least one medical visit to the clinic in the last complete calendar year (January-December) prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date) AND were women age 21-64. If unavailable, it is acceptable to report on a similar age range used by the clinic for measuring screening rates (e.g., 24-64 used for calculating a HEDIS screening rate). Annual Record: The total number of clinic patients who had at least one medical visit to the clinic during the program year (July 1- June 30) AND were women age 21-64. If unavailable, it is acceptable to report on a similar age range used by the clinic for measuring screening rates (e.g., 24-64 used for calculating a HEDIS screening rate).	Num	1-9999999
B2-5a A2-5a	R	B, A	% of women patients age 21-64, uninsured	Baseline Record: Indicates the percent of the total # of clinic patients, women age 21-64, who had at least one medical visit to the clinic in the year prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date) who did not have any form of public or private health insurance. Report as a whole number percent. For example, enter 67 for 67%, not 0.67. It is acceptable to report the percent based on the total clinic population if unknown for those age 21-64. Annual Record: Indicates the percent of the total # of clinic patients, women age 21-64, who had at least one medical visit to the clinic during the program year (July 1- June 30) (item A2-5) who did not have any form of public or private health insurance. Report as a whole number percent. For example, enter 67 for 67%, not 0.67. Leave blank if unknown. It is acceptable to report the percent based on the total clinic population if unknown for those age 21-64.	Num	00-100
B2-5b	O	B	% of women patients age 21-64, Hispanic	Baseline Record: Indicates the percent of the total number of clinic patients, women age 21-64 who had at least one medical visit to the clinic in the year prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date) who are of Hispanic or Latino ethnicity (i.e., persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race). Report as a whole number percent. For example, enter 67 for 67%, not 0.67. Leave blank if unknown. It is acceptable to report the percent based on the total clinic population if unknown for those age 21-64. Annual Record: N/A	Num	00-100
B2-5d	O	B	% of women patients age 21-64, White	Baseline Record: Indicates the percent of the total number of clinic patients, women age 21-64 who had at least one medical visit to the clinic in the year prior to starting NBCCECP (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date) who are White/Caucasian (i.e., persons having origins in any of the original peoples of Europe, the Middle East, or North Africa.) Report as a whole number percent. For example, enter 67 for 67%, not 0.67. Leave blank if unknown. It is acceptable to report the percent based on the total clinic population if unknown for those age 21-64. Annual Record: N/A	Num	00-100
B2-5e	O	B	% of women patients age 21-64, Black or African American	Baseline Record: Indicates the percent of the total number of clinic patients, women age 21-64 who had at least one medical visit to the clinic in the year prior to starting NBCCECP (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date) who are Black or African American (i.e., persons having origins in any of the black racial groups of Africa). Report as a whole number percent. For example, enter 67 for 67%, not 0.67. Leave blank if unknown. It is acceptable to report the percent based on the total clinic population if unknown for those age 21-64. Annual Record: N/A	Num	00-100
B2-5f	O	B	% of women patients age 21-64, Asian	Baseline Record: Indicates the percent of the total number of clinic patients, women age 21-64 who had at least one medical visit to the clinic in the year prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date) who are Asian (i.e., 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, Thailand, and Vietnam). Report as a whole number percent. For example, enter 67 for 67%, not 0.67. Leave blank if unknown. It is acceptable to report the percent based on the total clinic population if unknown for those age 21-64. Annual Record: N/A	Num	00-100
B2-5g	O	B	% of women patients age 21-64, Native Hawaiian or other Pacific Islander	Baseline Record: Indicates the percent of the total number of clinic patients, women age 21-64 who had at least one medical visit to the clinic in the year prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date) who are Native Hawaiian or other Pacific Islander (i.e., persons having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands). Report as a whole number percent. For example, enter 67 for 67%, not 0.67. Leave blank if unknown. It is acceptable to report the percent based on the total clinic population if unknown for those age 21-64. Annual Record: N/A	Num	00-100
B2-5h	O	B	% of women patients age 21-64, American Indian or Alaskan Native	Baseline Record: Indicates the percent of the total number of clinic patients, women age 21-64 who had at least one medical visit to the clinic in the year prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date) who are American Indian or Alaskan Native (i.e., persons having origins in any of the original peoples of North and South America, including Central America, and who maintain tribal affiliation or community attachment). Report as a whole number percent. For example, enter 67 for 67%, not 0.67. Leave blank if unknown. It is acceptable to report the percent based on the total clinic population if unknown for those age 21-64. Annual Record: N/A	Num	00-100
B2-5i	O	B	% of women patients age 21-64, more than one race	Baseline Record: Indicates the percent of the total number of clinic patients, women age 21-64 who had at least one medical visit to the clinic in the year prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date) who are of more than one race (i.e., persons having origins in two or more of the federally designated racial categories). Report as a whole number percent. For example, enter 67 for 67%, not 0.67. Leave blank if unknown. It is acceptable to report the percent based on the total clinic population if unknown for those age 21-64. Annual Record: N/A	Num	00-100
B2-6 A2-6	R	B, A	Name of primary EHR vendor at clinic	Baseline Record: Indicates the primary EHR that was in use at the clinic prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date). Annual Record: Indicates the primary EHR that was in use at the clinic during the program year (July 1-June 30).	List	Allscripts Athenahealth Cerner eClinicalWorks Epic GE Healthcare Greenway Health Kareo McKesson Meditech NextGen (Quality Systems, Inc.) Practice Fusion Other:___________ None
B2-7 A2-7	R	B, A	Primary EHR home	Level of EHR implementation and functionality: EHR system unique to the clinic versus health-system wide EHR system shared by all clinics. Baseline Record: Indicates the breadth and functionality of the clinic EHR system that was in use prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date). Annual Record: Indicates the breadth and functionality of the primary EHR system that was in use at the clinic during the program year (July 1-June 30).	List	EHR specific to the clinic Health system wide EHR Other: _____________
B2-7a A2-7a	R	B, A	Other EHR home specify	Specify other EHR home	Char	Free text 100 Char limit
B2-8	R	B	Newly screening or opened	Baseline Record: Identifies clinics that have recently started providing cervical cancer screening services and/or are newly opened prior to time of NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date). Recently started providing cervical cancer screening services: clinic has started providing cervical cancer screening within 1 year of the Clinic NBCCEDP-Cervical Activities Start Date (item B1-2). Newly opened clinic: clinic has been in operation for less than 1 year at the time of Clinic NBCCEDP-Cervical Activities Start Date (itemB1-2). If yes (<1 year), do not report baseline screening rates or baseline screening practices and outcomes (Section 3) Annual Record: N/A	List	Yes (< 1 year) No (1 or more years)
B2-9 A2-9	O	B, A	Section 2 Comments	Optional comments for section 2	Char	Free text 200 char limit

Section 3. Baseline and Annual Cervical Cancer Screening Rates

If the partner is a health system (P2=” Health System”) then clinic data reported must represent the entire Health System

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
B3-1 A3-1	R	B, A	Cervical Cancer Screening Rate Status	Baseline Record: Indicates the availability of baseline cervical cancer screening rate data and associated information on data sources/approach for calculating the screening rates. If “Chart review rate only” skip to B3-2 and skip EHR section. If “EHR rate only” skip to B3-2, then skip to B3-5a (skip CR section). If “Both Chart Review rate and EHR rate”, skip to B3-2 and complete both the CR section (B3-4a to B3-4l) and the EHR rate section (B3-5a to B3-5l). If “No, not yet available” go to B3-1a and enter date available and then skip to Section 4: Baseline and Annual Monitoring and Quality Improvement Activities If “No, cannot obtain” skip to Section 4: Baseline and Annual Monitoring and Quality Improvement Activities Annual Record: Indicates the availability of annual cervical cancer screening rate data and associated information on data sources/approach for calculating the screening rates. If “Yes, chart review rate only” skip to A3-2 and skip EHR section. If “Yes, EHR rate only” skip to A3-2, then skip to A3-5a (skip CR section). If “Yes, both Chart Review rate and EHR rate”, skip to A3-2 and complete both the CR section (A3-4a to A3-4l) and the EHR rate section (A3-5a to A3-5l). If “No. not yet available” go to A3-1a and enter date available and then skip to Section 4: Baseline and Annual Monitoring and Quality Improvement Activities If “No, cannot obtain” skip to Section 4: Baseline and Annual Monitoring and Quality Improvement Activities.	List	Chart Review rate only EHR rate only Both Chart Review and EHR Rate No, not yet available No, cannot obtain
B3-1a A3-1a	R	B, A	Cervical cancer screening rate date available	Baseline Record: If a baseline cervical cancer screening rate is not yet available, provide the approximate date that the screening rate will be available. skip to Section 4: Baseline and Annual Monitoring and Quality Improvement Activities Annual Record: If an annual cervical cancer screening rate cannot be obtained or is not yet available when submitting the annual clinic data, provide the approximate date that the screening rate will be available. skip to Section 4: Baseline and Annual Monitoring and Quality Improvement Activities	Date	MM/DD/YYYY
B3-2 A3-2	R	B, A	Start date of 12-month cervical cancer SR measurement period	Baseline Record: The start date of the 12-month screening rate measurement period used to calculate the clinic’s baseline cervical cancer screening rate. The 12-month measurement period does not need to coincide with the program year. Any 12-month period may be used as the measurement period. The measurement period for the baseline screening rate should be the most recent 12-month measurement period prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date). Note that the date that implementation activities started (Item B1-2: Clinic NBCCEDP-Cervical Activities Start Date) must be after the end of the baseline 12-month measurement period. This same 12-month measurement period must be used for reporting subsequent annual cervical cancer screening rates for this clinic. Annual Record: The start date of the annual cervical cancer screening rate 12-month measurement period. The 12-month measurement period for all annual records for this clinic should be consistent over time and match that used for the baseline screening rate. Measurement periods, starting with the baseline measurement period, should represent consecutive years. For example, if the baseline measurement period was 01/01/2021- 12/31/2021, then the first annual screening rate measurement period should be 01/01/2022 - 12/31/2022. The first annual measurement period (year 1 for the clinic) should include the date that implementation activities started (Item B1-2: Clinic NBCCEDP-Cervical Activities Start Date).	Date	MM/DD/YYYY
B3-3 A3-3	comp	B, A	End date of 12-month cervical cancer SR measurement period	Baseline Record: This date will be automatically calculated from the 12-month start date. Indicates the end date of the 12-month measurement period used to calculate the clinic’s baseline cervical cancer screening rate. The measurement period for the baseline screening rate should be the most recent 12-month measurement period available prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date). This same 12-month measurement period must be used for reporting subsequent annual cervical cancer screening rates for this clinic. Annual Record: Indicates the end date of the annual cervical cancer screening rate 12-month measurement period. The 12-month measurement period for all annual records for this clinic should be consistent over time and match that used for the baseline screening rate. Measurement periods, starting with the baseline measurement period, should represent consecutive years. For example, if the baseline measurement period was 01/01/2021 - 12/31/2021, then the first annual screening rate measurement period should be 01/01/2022 - 12/31/2022.	Date	MM/DD/YYYY
Chart Review Screening Rates ***This section should be skipped at baseline for clinics that are newly screening or newly opened***
B3-4a A3-4a	comp	B, A	CR- Cervical Cancer screening rate (%)	Cervical Cancer Screening Rate via Chart Review Baseline Record: Numerator and Denominator are dependent on the measure used (e.g., UDS, HEDIS). Please see Appendix 3 in CDC Guidance for Measuring Breast, Cervical, and Colorectal Cancer Screening Rates in Health System Clinics. Annual Record: Numerator and Denominator are dependent on the measure used (e.g., UDS, HEDIS). Please see Appendix 3 in CDC Guidance for Measuring Breast, Cervical, and Colorectal Cancer Screening Rates in Health System Clinics.	Num	Rate:__computed___ Numerator: _____ Denominator: _____
B3-4d A3-4d	R	B, A	CR- cervical cancer SR quality measure	Quality Measure followed to calculate the Cervical Cancer Screening Rate via Chart Review Baseline Record: Indicates the measure that was used to calculate the numerator and denominator for the clinic’s cervical cancer screening rate. If an existing quality measure (e.g., UDS, HEDIS, GPRA) was not used, the CDC Guidance for Measuring Breast, Cervical, and Colorectal Cancer Screening Rates in Health System Clinics provides information on calculating an NQF-endorsed measure. If this is used, "NQF" should be selected. The same measure reported at baseline must be used for reporting subsequent annual cervical cancer screening rates for this clinic. Annual Record: If an existing quality measure (e.g. UDS, HEDIS, GPRA) was not used, the CDC Guidance for Measuring Breast, Cervical, and Colorectal Cancer Screening Rates in Health System Clinics provides information on calculating an NQF-endorsed measure. If this is used, "NQF" should be selected. The same measure reported at baseline must be used for reporting subsequent annual cervical cancer screening rates for this clinic.	List	GPRA HEDIS NQF UDS Other
B3-4e A3-4e	Comp	B, A	% of charts reviewed	Baseline and Annual Records: Indicates the percent of medical charts that were reviewed for the cervical cancer screening rate. A minimum of 10% or 100 charts should be reviewed. THIS % WILL BE AUTOMATICALLY CALCULATED USING THE DENOMINATOR AND TOTAL # OF CLINIC PATIENTS, WOMEN AGE 21-64 (ITEM B2-5 & A2-5).	Num	auto-calculated
B3-4f A3-4f	R	B, A	Sampling Method	Baseline and Annual Records: Indicates if records were selected through either a random or systematic sampling method to generate a representative sample of the entire population of patients who meet the inclusion/selection criteria for the measure used. See CDC Guidance for Measuring Breast, Cervical, and Colorectal Cancer Screening Rates in Health System Clinics. A random sample takes a randomly assigned subset of the population identified in the sampling frame. This is typically accomplished through generating a random number that will be assigned to each patient in the sampling frame. This can be accomplished in many ways (e.g., random number table, web-based software, computer software). A systematic sample orders every patient (e.g., alphabetically, by ID) in the sampling frame and then selects every nth patient.	List	Yes No Unknown
B3-4g A3-4g	R	B, A	CR- cervical cancer SR confidence	Baseline and Annual Records: Indicates the grantee's confidence in the accuracy of the CR-calculated cervical cancer screening rate. Accuracy of CR-calculated screening rates can vary depending on how charts are sampled and the information available in the charts.	List	Not confident Somewhat confident Very confident
B3-4h A3-4h	R	B, A	CR- cervical cancer SR problem	Baseline and Annual Records: Indicates if there are known unresolved problems with the CR reported cervical cancer screening rate or screening data quality.	List	Yes No Unknown Other:_______
B3-4i A3-4i	O	B, A	Comments for CR rates	Optional Comments for CR rates.	Char	Free text 200 char limit
EHR Screening Rates ***This section should be skipped at baseline for clinics that are newly screening or newly opened***
B3-5a A3-5a	comp	B, A	EHR- cervical cancer screening rate (%)	Cervical Cancer Screening Rate via EHR Baseline Record: Numerator and Denominator are dependent on the measure used (e.g., UDS, HEDIS). Please see Appendix 3 in CDC Guidance for Measuring Breast, Cervical, and Colorectal Cancer Screening Rates in Health System Clinics. Annual Record: Numerator and Denominator are dependent on the measure used (e.g., UDS, HEDIS). Please see Appendix 3 in CDC Guidance for Measuring Breast, Cervical, and Colorectal Cancer Screening Rates in Health System Clinics.	Num	Rate:__computed___ Numerator: _____ Denominator: _____
B3-5d A3-5d	R	B, A	EHR- cervical cancer SR quality measure	Baseline and Annual Records: Indicates the measure that was used to calculate the numerator and denominator for the clinic’s cervical cancer screening rate. If an existing quality measure (e.g. UDS, HEDIS, GPRA) was not used, the CDC Guidance for Measuring Breast, Cervical, and Colorectal Cancer Screening Rates in Health System Clinics (Appendix 3) provides information on calculating a NQF-endorsed measure. If this is used, "NQF" should be selected. The same measure reported at baseline must be used for reporting subsequent annual cervical cancer screening rates for this clinic.	List	GPRA HEDIS NQF UDS Other
B3-5e A3-5e	N/A	N/A	N/A for EHR	N/A for EHR	N/A for EHR	N/A for EHR
B3-5f A3-5f	N/A	N/A	N/A for EHR	N/A for EHR	N/A for EHR	N/A for EHR
B3-5g A3-5g	R	B, A	EHR- cervical cancer SR confidence	Baseline and Annual Records: Indicates the grantee's confidence in the accuracy of the EHR-calculated cervical cancer screening rate. Accuracy of EHR-calculated screening rates can vary depending on how data are documented and entered into the EHR. For additional information, see the National Colorectal Cancer Roundtable’s summary report, “Use of Electronic Medical Records to Facilitate Colorectal Cancer Screening in Community Health Centers" and "CDC Guidance for Measuring Breast, Cervical, and Colorectal Cancer Screening Rates in Health System Clinics."	List	Not confident Somewhat confident Very confident
B3-5h A3-5h	R	B, A	EHR- cervical cancer SR problem	Baseline and Annual Records: Indicates if there are known unresolved problems with the EHR reported cervical cancer screening rate or screening data quality.	List	Yes No Unknown Other
B3-5i A3-5i	R	B, A	EHR rate reporting source	Baseline and Annual Records: Indicates the source of the denominator and numerator data reported for the EHR cervical cancer screening rate	List	HCCN data warehouse Clinic EHR Health system EHR EHR Vendor Other
B3-5j A3-5j	O	B, A	Comments for EHR rates	Optional comments for EHR rates	Char	Free text 200 char limit
B3-6 A3-6	R	B, A	Clinic cervical cancer SR target for next year	Baseline Record: Indicates the clinic-level cervical cancer screening rate target established by the clinic for its first NBCCEDP annual clinic record. Considering the Chart Review and/or EHR-reported baseline cervical cancer screening rate, specify a targeted clinic-level cervical cancer screening rate (i.e., the screening rate you want to achieve) for the clinic’s first annual record, i.e. the cervical cancer screening rate for the next 12-month measurement period after the baseline screening rate measurement period. Do not enter the expected additional % increase. Targets should be: Clinic-level targets. Do no report targets for the health system unless the partner is the health system (item P2= Health System). Unique to each clinic. Ambitious but realistic and achievable Annual Record: Indicates the clinic-level cervical cancer screening rate target established by the clinic for its next subsequent NBCCEDP annual clinic record. Considering the Chart Review and/or EHR-reported annual cervical cancer screening rate, specify a targeted clinic-level cervical cancer screening rate (i.e., the screening rate you want to achieve) for the next annual record, i.e. the cervical cancer screening rate for the next 12-month measurement period. Do not enter the expected additional % increase. Targets should be: Clinic-level targets. Do no report targets for the health system unless the partner is the health system (item P2= Health System). Unique to each clinic. Ambitious but realistic and achievable	Num	1-100 999 (no target set)
B3-7 A3-7	O	B, A	Section 3 Comments	Optional Comments for Section 3.	Char	Free text 200 char limit

Section 4: Baseline and Annual Monitoring and Quality Improvement Activities

Information on the clinic’s practices, policies, and support received to improve implementation of EBIs and/or monitoring of cervical cancer screening rates

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
B4-1 A4-1	R	B, A	Clinic cervical cancer screening policy	A credible policy should include a defined set of guidelines and procedures in place and in use at the clinic or parent health system to support cervical cancer screening, a team responsible for implementing the policy, and a quality assurance structure (e.g., professional screening guideline followed such as USPSTF, process to assess patient screening history/risk/preference/insurance, process for scheduling screening or referral, steps/procedures/roles to implement the office policy). Baseline Record: Indicates if the clinic had a written cervical cancer screening policy or protocol in use prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date). Annual Record: Indicates if the clinic had a written cervical cancer screening policy or protocol in use during the program year.	List	Yes No
B4-2 A4-2	R	B, A	Clinic cervical cancer champion	Baseline Record: Indicates if there was a known champion for cervical cancer screening internal to this clinic or parent health system prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date) Annual Record: Indicates if there was a known champion or champions for cervical cancer screening internal to this clinic or parent health system for at least 6 months during this program year (July 1- June 30).	List	Yes No
B4-3 A4-3	R	B, A	Utilizing health IT to improve data collection and quality	Baseline Record: Indicates if the clinic was using health information technology (health IT) to improve collection, accuracy and validity of cervical cancer screening data prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date). Activities may include standardization of data definitions used to document a patient’s cervical cancer screening, linkage of data to screening reports, EHR improvements and enhancements, provider training on proper EHR data entry and use, etc. Annual Record: Clinic used health information technology (health IT) to improve collection, accuracy, and validity of cervical cancer screening data during the program year (July 1- June 30). Activities may include standardization of data definitions used to document a patient’s cervical cancer screening, linkage of data to screening reports, EHR improvements and enhancements, provider training on proper EHR data entry and use, etc.	List	Yes No
B4-4 A4-4	R	B, A	Utilizing health IT tools for monitoring program performance	Baseline Record: Indicates if the clinic was using health IT to perform data analytics and reporting to monitor and improve their cervical cancer screening program and rates prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date). Examples include: EHR overlays, Population Health Management software, data visualization software and programs. Annual Record: Clinic used health information technology (health IT) tools to perform data analytics and reporting to monitor and improve their cervical cancer screening program and rates during the program year (July 1- June 30). Examples include: EHR overlays, Population Health Management software, data visualization software and programs.	List	Yes No
B4-5 A4-5	R	B, A	QA/QI support	Baseline Record: Indicates whether the clinic had a quality assurance/quality improvement specialist or team in place that addressed cervical cancer screening prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date). The person or team could work at the health system level and provide QA/QI support to the clinic. Annual Record: Indicates whether the clinic had a quality assurance/quality improvement specialist or team in place that addressed cervical cancer screening during the program year (July 1- June 30). The person or team could work at the health system level and provide QA/QI support to the clinic.	List	Yes No
A4-6	R	A	Process Improvements	Baseline Record: N/A Annual Record: Indicates whether process improvements were made at the clinic during the program year (July 1- June 30) to facilitate increased cervical cancer screening of patients. Examples include process mapping to identify points to improve screening, daily huddles or other daily processes to identify persons due for screening and use of QI processes to improve screening.	List	Yes No
A4-7	R	A	Frequency of monitoring cervical cancer screening rate	Baseline Record: N/A Annual Record: Indicates how often the clinic cervical cancer screening rate was monitored and reviewed by clinic personnel during the program year (July 1- June 30). Select the response that best matches monitoring frequency during this program year.	List	Monthly Quarterly Semi-annually Annually
A4-8	R	A	Validated screening rate	Baseline Record: N/A Annual Record: Indicates if the clinic-level cervical cancer screening rate data were validated using chart review or other methods during this program year (July 1- June 30). If yes, indicate all methods used to validate the screening rate in items A4-8a to A4-8d. If no, skip to A4-9.	List	Yes, indicate method Manual Chart Review Validation of the EHR system and/or its query algorithm Other:____________ No
A4-9	R	A	Health Center Controlled Network	Baseline Record: N/A Annual Record: For Community Health Centers/FQHCs only, indicates whether the clinic received technical assistance from a Health Center Controlled Network to implement EBIs or improve use of the clinic’s EHR to better measure and monitor cervical cancer screening rates during the program year (July 1- June 30).	List	Yes No
A4-10	R	A	Frequency of implementation support to clinic	Baseline Record: N/A Annual Record: Indicates the frequency of on-site or direct contacts (e.g., telephone) with the clinic to support and improve implementation activities for EBIs/SAs and cervical cancer screening data quality during this program year (PY). Support could be provided by a grantee or contracted agent. Examples of support activities include conducting a clinic workflow assessment, providing technical assistance to improve HIT, providing technical assistance on implementing an EBI/SA, training staff to support an EBI/SA, providing technical assistance to develop a cervical cancer screening policy, providing support to a champion, or providing feedback to staff from monitoring or evaluating an EBI/SA implementation. Select the response that best matches delivery of implementation support during this program year (July 1- June 30).	List	Weekly Monthly Quarterly Semi-annually Annually
B4-11 A4-11	R	B, A	BCCEDP clinical services	Baseline: Indicates if the grantee reimbursed for cervical cancer screening, diagnostics, and/or patient navigation services at this clinic in the year prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date. Funding could come from CDC, your state, or other sources. Annual: Indicates if the grantee reimbursed for cervical cancer screening, diagnostics, and/or patient navigation services at this clinic during the program year. Funding could come from CDC, your state, or other sources.	List	Yes No
A4-12	R	A	BCCEDP financial resources	Baseline Record: N/A Annual Record: Indicates whether the grantee or a subcontractor of the grantee provided financial resources to this clinic and/or its parent health system during the program year (July 1- June 30) to support NBCCEDP health system change activities. Funding could come from CDC, your state, or other sources. Funds for screening and clinical services should not be included here. If yes, answer items A4-12a and A4-12b If no, skip to A4-13	List	Yes, to the clinic Yes, to the parent health system No
A4-12a	R	A	Use of BCCEDP financial resources	If BCCEDP financial resources were provided (item A4-11 is Yes), indicates whether the funds were for Cervical Cancer activities only or for both Breast and Cervical Cancer activities.	List	Cervical Cancer only Breast and Cervical Cancer
A4-12b	R	A	Amount of BCCEDP financial resources	Baseline Record: N/A Annual Record: If BCCEDP financial resources were provided (item A4-11 is Yes), indicate the total amount of financial resources provided to the clinic during this program year (PY). Pro-rate funding, if needed, to associate with the PY. Do NOT include in-kind resources. If financial resources were provided to the parent health system (item A4-11 is “Yes, to the parent health system”) rather than directly to the clinic, and you do not know how much of those funds were used for this specific clinic, please divide the amount given to the health system by the number of clinics in that health system that were enrolled in NBCCEDP during the program year (July 1- June 30). If resources were given for both breast and cervical (item A4-11a= “Breast and Cervical Cancer”), then enter the total amount given to the clinic.	Num	Dollar amount 1-900000 999999 (UNK)
B4-13 A4-13	O	B, A	Section 4 Comments	Optional comments for section 4.	Char	Free text 200 char limit

Section 5: Baseline and Annual Evidence-based Interventions (EBIs) and Other Clinic Activities

Information on implementation status and sustainability of activities, put in place by the grantee or clinic, to improve cervical cancer screening.

Section 5-1: EBI-Patient Reminder System

Indicates the clinic’s use of system(s) to remind patients when they are due for cervical cancer screening. Patient reminders can be written (letter, postcard, email, text) or telephone messages (including automated messages).

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
A5-1a	R	A	NBCCEDP resources used toward a patient reminder system	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP grantee resources (e.g. funds, staff time, materials, contract) were used during this program year (July 1- June 30) to contribute to planning, developing, implementing, monitoring/evaluating or improving a patient reminder system for cervical cancer screening.	List	Yes No
B5-1b A5-1b	R	B, A	Patient reminder system in place	Baseline Record: Indicates whether a patient reminder system for cervical cancer screening was in place and operational (in use) in this clinic prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date), regardless of the quality, reach, or level of functionality. Annual Record: Indicates whether a patient reminder system for cervical cancer screening was in place and operational (in use) in this clinic at the end of the program year (July 1- June 30), regardless of the quality, reach, or current level of functionality. If patient reminders were newly implemented during this program year, select “Yes, newly in place”. If patient reminders were in place prior to this program year, select “Yes, continuing” If yes, newly in place skip to A5-1e If yes, continuing, skip to A5-1d If no, answer A5-1c and then skip to the next EBI, A5-2a	List	Baseline Record: Yes No Annual Record: Yes, newly in place Yes, continuing No
A5-1c	R	A	Patient reminder system planning activities	Baseline Record: N/A Annual Record: If a patient reminder system was not in place (A5-1b is No), indicates whether planning activities were conducted this program year (July 1- June 30) for future implementation of a cervical cancer screening patient reminder system. Skip to the next EBI, A5-2a.	List	Yes No
A5-1d	R	A	Patient reminder system enhancements	Baseline: N/A Annual: If a patient reminder system was in place prior to this program year and continuing (A5-1b is Yes, continuing), indicates whether the clinic made changes to enhance or improve implementation of patient reminders during the program year (July 1- June 30).	List	Yes No
A5-1e	R	A	Patient reminders sent multiple ways	Baseline Record: N/A Annual Record: If a patient reminder system was in place (A5-1b is “Yes, newly in place” or “Yes, continuing”), indicates whether an average patient at this clinic received cervical cancer screening reminders in more than one way (e.g., same patient received reminders in 3 different ways: one by letter, another by text message, and a third by telephone) during this program year (July 1- June 30).	List	Yes No
A5-1f	R	A	Maximum number and/or frequency of patient reminders	Baseline Record: N/A Annual Record: If a patient reminder system was in place (A5-1b is “Yes, newly in place” or “Yes, continuing”), indicates the maximum number of different ways and times (activity conducted more than one time during the year) that a given patient could have received cervical cancer screening reminders during this program year (July 1- June 30) (e.g., same patient received a total of 4 reminders – 2 by phone, 1 by text, 1 by mail).	List	1 2 3 4 5 or more
A5-1g	R	A	Patient reminder system sustainability	Baseline Record: N/A Annual Record: If a patient reminder system was in place at the end of the program year (July 1- June 30) (A5-1b is “Yes, newly in place” or “Yes, continuing”), indicates whether the cervical cancer screening patient reminder system is considered to be fully integrated into health system and/or clinic operations and is sustainable without NBCCEDP resources. [The patient reminder system has become an institutionalized component of the health system and/or clinic operations.]	List	Yes No

Section 5-2: EBI -Provider Reminder System

Indicates the clinic’s use of system(s) to inform providers that a patient is due (or overdue) for screening. The reminders can be provided in different ways, such as placing reminders in patient charts, EHR alerts, e-mails to the provider, etc.

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
A5-2a	R	A	NBCCEDP resources used toward a provider reminder system	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP grantee resources (e.g. funds, staff time, materials, contract) were used during this program year (July 1- June 30) to contribute to planning, developing, implementing, monitoring/evaluating or improving a provider reminder system that addresses cervical cancer screening.	List	Yes No
B5-2b A5-2b	R	B, A	Provider reminder system in place	Baseline Record: Indicates whether a provider reminder system that addresses cervical cancer screening was in place and operational (in use) in this clinic prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date), regardless of the quality, reach, or level of functionality. Annual Record: Indicates whether a provider reminder system that addresses cervical cancer screening was in place and operational (in use) in this clinic at the end of the program year (July 1- June 30), regardless of the quality, reach, or current level of functionality. If provider reminders were newly implemented during this program year, select “Yes, newly in place”. If provider reminders were in place prior to this program year, select “Yes, continuing” If yes, newly in place skip to A5-2e If yes, continuing, skip to A5-2d If no, answer A5-2c and then skip to the next EBI, item A5-3a	List	Baseline Record: Yes No Annual Record: Yes, newly in place Yes, continuing No
A5-2c	R	A	Provider reminder system planning activities	Baseline Record: N/A Annual Record: If a provider reminder system is not in place (A5-2b is No), indicates whether planning activities were conducted this program year (July 1- June 30) for future implementation of a provider reminder system for cervical cancer screening. Skip to the next EBI, item A5-3a	List	Yes No
A5-2d	R	A	Provider reminder system enhancements	Baseline: N/A Annual: If a provider reminder system was in place prior to this program year and continuing (A5-2b is Yes, continuing), indicates whether the clinic made changes to enhance or improve implementation of provider reminders during the program year (July 1- June 30).	List	Yes No
A5-2e	R	A	Provider reminders sent multiple ways	Baseline Record: N/A Annual Record: If a provider reminder system was in place at the end of the program year (July 1- June 30) (A5-2b is “Yes, newly in place” or “Yes, continuing”), indicates whether providers at this clinic typically received cervical cancer screening reminders for a given patient in more than one way (e.g., provider receives both an EHR pop-up message and a flagged patient chart for the same patient) during this program year.	List	Yes No
A5-2f	R	A	Maximum number and/or frequency of provider reminders	Baseline Record: N/A Annual Record: If a provider reminder system was in place at the end of the program year (July 1- June 30) (A5-2b is “Yes, newly in place” or “Yes, continuing”), indicates the maximum number of different ways and times (activity conducted more than one time during the year) that a given provider could have received cervical cancer screening reminders for an individual patient during this program year (e.g., the provider received a total of 3 reminders for a given patient – 1 pop-up reminder in the patients electronic medical record, 1 reminder flagged in the patient chart, and 1 reminder via a list each day of patients due for screening) .	List	1 2 3 4 5 or more
A5-2g	R	A	Provider reminder system sustainability	Baseline Record: N/A Annual Record: If a provider reminder system was in place at the end of the program year (July 1- June 30) (A5-2b is “Yes, newly in place” or “Yes, continuing”), indicates whether the provider reminder system is considered to be fully integrated into health system and/or clinic operations and is sustainable without NBCCEDP resources. [The provider reminder system has become an institutionalized component of the health system and/or clinic operations.]	List	Yes No

Section 5-3: EBI -Provider Assessment and Feedback

Indicates the clinic’s use of system(s) to evaluate provider performance in delivering or offering screening to clients (assessment) and/or present providers, either individually or as a group, with information about their performance in providing screening services (feedback).

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
A5-3a	R	A	NBCCEDP resources used toward provider assessment and feedback	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP grantee resources (e.g. funds, staff time, materials, contract) were used during this program year (July 1- June 30) to contribute to planning, developing, implementing, monitoring/evaluating or improving provider assessment and feedback.	List	Yes No
B5-3b A5-3b	R	B, A	Provider assessment and feedback in place	Baseline Record: Indicates whether provider assessment and feedback processes for cervical cancer screening were in place and operational (in use) in this clinic prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date), regardless of the quality, reach, or current level of functionality. Annual Record: Indicates whether provider assessment and feedback processes for cervical cancer screening were in place and operational (in use) in this clinic at the end of the program year (July 1- June 30), regardless of the quality, reach, or current level of functionality. If provider assessment and feedback processes were newly implemented during this program year, select “Yes, newly in place”. If provider assessment and feedback processes were in place prior to this program year, select “Yes, continuing” If yes, newly in place skip to A5-3e If yes, continuing, skip to A5-3d If no, answer A5-3c and then skip to the next EBI, A5-4a	List	Baseline Record: Yes No Annual Record: Yes, newly in place Yes, continuing No
A5-3c	R	A	Provider assessment and feedback planning activities	Baseline Record: N/A Annual Record: If provider assessment and feedback were not in place and operational (A5-3b is No), indicates whether planning activities were conducted this program year for future implementation of provider assessment and feedback for cervical cancer screening. Skip to the next EBI, A5-4a.	List	Yes No
A5-3d	R	A	Provider assessment and feedback enhancements	Baseline: N/A Annual: If a provider assessment and feedback system was in place prior to this program year and continuing (A5-3b is Yes, continuing), indicates whether the clinic made changes to enhance or improve implementation of provider assessment and feedback during the program year (July 1- June 30).	List	Yes No
A5-3e	R	A	Provider assessment and feedback frequency	Baseline Record: N/A Annual Record: If provider assessment and feedback were in place and operational at the end of the program year (July 1- June 30) (A5-3b is “Yes, newly in place” or “Yes, continuing”), indicates, on average, how often providers, either individually or as a group, were given feedback on their performance in providing cervical cancer screening services during this program year.	List	Weekly Monthly Quarterly Annually
A5-3f	R	A	Provider assessment and feedback sustainability	Baseline Record: N/A Annual Record: If provider assessment and feedback were in place and operational at the end of the program year (July 1- June 30) (A5-3b is “Yes, newly in place” or “Yes, continuing”), indicates whether provider assessment and feedback is considered to be fully integrated into health system and/or clinic operations and is sustainable without NBCCEDP resources. [Provider assessment and feedback has become an institutionalized component of the health system and/or clinic operations.]	List	Yes No

Section 5-4: EBI -Reducing Structural Barriers

Indicates the clinic’s use of one or more interventions to address structural barriers to cervical cancer screening. Structural barriers are non-economic burdens or obstacles that make it difficult for people to access cancer screening. Do not include patient navigation or community health workers as "reducing structural barriers."

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
A5-4a	R	A	NBCCEDP resources used toward reducing structural barriers	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP grantee resources (e.g. funds, staff time, materials, contract) were used during this program year (July 1- June 30) to contribute to planning, developing, implementing, monitoring/evaluating or improving reducing structural barriers activities.	List	Yes No
B5-4b A5-4b	R	B, A	Reducing structural barriers in place	Baseline Record: Indicates whether activities for reducing structural barriers to cervical cancer screening were in place and operational (in use) in this clinic prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date), regardless of the quality, reach, or current level of functionality. Annual Record: Indicates whether activities for reducing structural barriers to cervical cancer screening were in place and operational (in use) in this clinic at the end of the program year (July 1- June 30), regardless of the quality, reach, or current level of functionality. If activities for reducing structural barriers were newly implemented during this program year, select “Yes, newly in place”. If activities for reducing structural barriers were in place prior to this program year, select “Yes, continuing” If yes, newly in place skip to A5-4e If yes, continuing, skip to A5-4d If no, answer A5-4c and then skip to the next EBI, A5-5a	List	Baseline Record: Yes No Annual Record: Yes, newly in place Yes, continuing No
A5-4c	R	A	Reducing structural barriers planning activities	Baseline Record: N/A Annual Record: If reducing structural barriers was not in place at the end of the program year (July 1- June 30) (A5-4b is No), indicates whether planning activities were conducted this program year for future implementation of reducing structural barriers activities for cervical cancer screening. Skip to the next EBI, A5-5a.	List	Yes No
A5-4d	R	A	Reducing structural barriers enhancements	Baseline: N/A Annual: If reducing structural barriers was in place prior to this program year and continuing (A5-4b is “Yes, continuing”), indicates whether the clinic made changes to enhance or improve implementation of reducing structural barriers during the program year (July 1- June 30).	List	Yes No
A5-4e	R	A	Reducing structural barriers more than one way	Baseline Record: N/A Annual Record: If reducing structural barriers was in place at the end of the program year (July 1- June 30) (A5-4b is “Yes, newly in place” or “Yes, continuing”), indicates whether this clinic reduced structural barriers for patients in multiple ways (e.g., offered evening clinic hours, offered assistance in scheduling appointments, provided free screenings for some patients) during this program year.	List	Yes No
A5-4f	R	A	Maximum ways reducing structural barriers	Baseline Record: N/A Annual Record: If reducing structural barriers was in place at the end of the program year (July 1- June 30) (A5-4b is “Yes, newly in place” or “Yes, continuing”), indicates the maximum number of different ways the clinic reduced structural barriers to cervical cancer screening during this program year.	List	1 2 3 4 5 or more
A5-4g	R	A	Reducing structural barriers sustainability	Baseline Record: N/A Annual Record: If reducing structural barriers was in place at the end of the program year (July 1- June 30) (A5-4b is “Yes, newly in place” or “Yes, continuing”), indicates whether reducing structural barriers is considered to be fully integrated into health system and/or clinic operations and is sustainable without NBCCEDP resources. [ Reducing structural barriers has become an institutionalized component of the health system and/or clinic operations.]	List	Yes No

Section 5-5: EBI- Small Media

Indicates the clinic’s use of small media to improve cervical cancer screening. Small media are materials used to inform and motivate people to be screened for cancer, including videos and printed materials (e.g., letters, brochures, and newsletters).

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
A5-5a	R	A	NBCCEDP resources used toward small media	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP grantee resources (e.g. funds, staff time, materials, contract) were used during this program year (July 1- June 30) to contribute to planning, developing, implementing, monitoring/evaluating or improving small media to improve cervical cancer screening.	List	Yes No
B5-5b A5-5b	R	B, A	Small media in place	Baseline Record: Indicates whether use of small media to improve cervical cancer screening was in place and operational (in use) in this clinic prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date), regardless of the quality, reach, or current level of functionality. Annual Record: Indicates whether use of small media to improve cervical cancer screening were in place and operational (in use) in this clinic at the end of the program year (July 1- June 30), regardless of the quality, reach, or current level of functionality. If activities for small media were newly implemented during this program year, select “Yes, newly in place”. If activities for small media were in place prior to this program year, select “Yes, continuing”. If yes, newly in place skip to A5-5e If yes, continuing, skip to A5-5d If no, answer A5-5c and then skip to the next EBI, A5-6a	List	Baseline Record: Yes No Annual Record: Yes, newly in place Yes, continuing No
A5-5c	R	A	Small media planning activities	Baseline Record: N/A Annual Record: If small media to improve cervical cancer screening was not in place at the end of the program year (July 1- June 30) (A5-5b is No), indicates whether planning activities were conducted this year for future implementation of small media. Skip to the next EBI, A5-6a	List	Yes No
A5-5d	R	A	Small media enhancements	Baseline: N/A Annual: If small media was in place prior to this program year and continuing (A5-5b is “Yes, continuing”), indicates whether the clinic made changes to enhance or improve implementation of small media during the program year (July 1- June 30).	List	Yes No
A5-5e	R	A	Small media delivered in more than one way	If small media was in place prior to this program year and continuing (A5-5b is “Yes, continuing”), indicates whether a given patient received multiple forms of small media related to cervical cancer screening (e.g., the same patient received a postcard, was exposed to posters in the office setting, received a clinic newsletter or brochure) during this PY.	List	Yes No
A5-5f	R	A	Maximum number of ways and times small media delivered	Baseline Record: N/A Annual Record: If small media was in place at the end of the program year (July 1- June 30) (A5-5b is “Yes, newly in place” or “Yes, continuing”), indicates the maximum number of different ways and times (activity conducted more than one time during the year) a given patient could have received small media about cervical cancer screening during this PY.	List	1 2 3 4 5 or more
A5-5g	R	A	Small media sustainability	Baseline Record: N/A Annual Record: If small media was in place at the end of the program year (July 1- June 30) (A5-5b is “Yes, newly in place” or “Yes, continuing”), indicates whether small media is considered to be fully integrated into health system and/or clinic operations and sustainable. [ Small media has become an institutionalized component of the health system and/or clinic operations.]	List	Yes No

Section 5-6: EBI - Patient Education for Clinic Patients

Indicates the clinic’s use of one or more interventions to provide group or individual education to clinic patients on indications for, benefits of, and ways to overcome barriers to cervical cancer screening with the goal of informing, encouraging, and motivating participants to seek recommended screening. Patient education may include role modeling or other interactive learning formats

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
A5-6a	R	A	NBCCEDP resources used toward patient education	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP grantee resources (e.g. funds, staff time, materials, contract) were used during this program year (July 1- June 30) to contribute to planning, developing, implementing, monitoring/evaluating or improving patient education for cervical cancer screening.	List	Yes No
B5-6b A5-6b	R	B, A	Patient education in place	Baseline Record: Indicates whether patient education activities for cervical cancer screening were in place and operational (in use) in this clinic prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date), regardless of the quality, reach, or current level of functionality. Annual Record: Indicates whether patient education activities for cervical cancer screening were in place and operational (in use) in this clinic at the end of the program year (July 1- June 30), regardless of the quality, reach, or current level of functionality. If patient education activities were newly implemented during this program year, select “Yes, newly in place”. If patient education activities were in place prior to this program year, select “Yes, continuing” If yes, newly in place skip to A5-6e If yes, continuing, skip to A5-6d If no, answer A5-6c and then skip to the next EBI, A5-7a	List	Baseline Record: Yes No Annual Record: Yes, newly in place Yes, continuing No
A5-6c	R	A	Patient education planning activities	Baseline Record: N/A Annual Record: If patient education activities were not in place at the end of the program year (July 1- June 30) (A5-6b is No), indicates whether planning activities were conducted this program year for future implementation of patient education activities for cervical cancer screening. Skip to the next EBI, A5-7a.	List	Yes No
A5-6d	R	A	Patient education enhancements	Baseline: N/A Annual: If patient education activities were in place prior to this program year and continuing (A5-6b is “Yes, continuing”), indicates whether the clinic made changes to enhance or improve implementation of reducing structural barriers during the program year (July 1- June 30).	List	Yes No
A5-6e	R	A	Average amount of patient education	Baseline Record: N/A Annual Record: If patient education activities were in place at the end of the program year (July 1- June 30) (A5-6b is “Yes, newly in place” or “Yes, continuing”), If in place (9f3 is Yes), indicates, on average, the amount of cervical cancer screening education received by a given patient during this PY.	List	Less than 15 minutes > 15 to 30 minutes > 30 minutes to 1 hour > 1 to 2 hours > 2 to 3 hours More than 3 hours
A5-6f	R	A	Patient education sustainability	Baseline Record: N/A Annual Record: If patient education activities were in place at the end of the program year (July 1- June 30) (A5-6b is “Yes, newly in place” or “Yes, continuing”), indicates whether reducing structural barriers is considered to be fully integrated into health system and/or clinic operations and is sustainable without NBCCEDP resources. [Patient education activities have become an institutionalized component of the health system and/or clinic operations.]	List	Yes No

Section 5-7: EBI- Reducing out-of-pocket costs

Indicates the clinic’s use of one or more interventions to reduce patient out-of-pocket costs to minimize or remove economic barriers that make it difficult for patients to access cervical cancer screening services. Reducing costs may include vouchers or reimbursements for transportation/parking, reduction in co-pays, reimbursing for cervical cancer screening and/or diagnostics, or adjustments in federal or state insurance coverage.

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
A5-7a	R	A	NBCCEDP resources used toward reducing out-of-pocket costs during this PY	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP grantee resources (e.g. funds, staff time, materials, contract) were used during this program year (July 1- June 30) to contribute to planning, developing, implementing, monitoring/evaluating or improving small media to improve cervical cancer screening.	List	Yes No
B5-7b A5-7b	R	B, A	Reducing out-of-pocket costs in place	Baseline Record: Indicates whether interventions to reduce patient out-of-pocket costs to improve cervical cancer screening were in place and operational (in use) in this clinic prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date), regardless of the quality, reach, or current level of functionality. Annual Record: Indicates whether interventions to reduce patient out-of-pocket costs to improve cervical cancer screening were in place and operational (in use) in this clinic at the end of the program year (July 1- June 30), regardless of the quality, reach, or current level of functionality. If interventions to reduce patient out-of-pocket costs were newly implemented during this program year, select “Yes, newly in place”. If interventions to reduce patient out-of-pocket costs were in place prior to this program year, select “Yes, continuing”. If yes, newly in place skip to A5-7e If yes, continuing, skip to A5-7d If no, answer A5-7c and then skip to the next EBI, A5-8a	List	Baseline Record: Yes No Annual Record: Yes, newly in place Yes, continuing No
A5-7c	R	A	Reducing out-of-pocket costs planning activities	Baseline Record: N/A Annual Record: If interventions to reduce patient out-of-pocket costs to improve cervical cancer screening was not in place at the end of the program year (July 1- June 30) (A5-7b is No), indicates whether planning activities were conducted this year for future implementation of small media. Skip to the next EBI, A5-8a.	List	Yes No
A5-7d	R	A	Reducing out-of-pocket costs enhancements	Baseline: N/A Annual: If interventions to reduce patient out-of-pocket costs was in place prior to this program year and continuing (A5-7b is “Yes, continuing”), indicates whether the clinic made changes to enhance or improve implementation of small media during the program year (July 1- June 30).	List	Yes No
A5-7e	R	A	Reducing out-of-pocket costs in more than one way	If interventions to reduce patient out-of-pocket costs was in place at the end of the program year (July 1- June 30) (A5-7b is “Yes, newly in place” or “Yes, continuing”), indicates whether this clinic reduced out-of-pocket costs for patients in multiple ways during this PY.	List	Yes No
A5-7f	R	A	Maximum number of ways and times used to reduce out-of- pocket costs	Baseline Record: N/A Annual Record: If interventions to reduce patient out-of-pocket costs was in place at the end of the program year (July 1- June 30) (A5-7b is “Yes, newly in place” or “Yes, continuing”), indicates the maximum number of different ways and times (activity conducted more than one time during the year) a given patient could have received these interventions for cervical cancer screening during this PY.	List	1 2 3 4 5 or more
A5-7g	R	A	Reducing out-of-pocket costs sustainability	Baseline Record: N/A Annual Record: If interventions to reduce patient out-of-pocket costs was in place at the end of the program year (July 1- June 30) (A5-7b is “Yes, newly in place” or “Yes, continuing”), indicates whether these interventions are considered to be fully integrated into health system and/or clinic operations and sustainable. [ Small media has become an institutionalized component of the health system and/or clinic operations.]	List	Yes No

Section 5-8: EBI- Professional Development and Provider Education

Indicates whether activities are in place to provide professional development/provider education to health care providers in this clinic on cervical cancer screening. Activities may include distribution of provider education materials, including screening guidelines and recommendations, and/or continuing medical education (CMEs) opportunities.

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
A5-8a	R	A	NBCCEDP resources used toward professional development/provider education	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP grantee resources (e.g. funds, staff time, materials, contract) were used during this program year (July 1- June 30) to contribute to planning, developing, implementing, monitoring/evaluating or improving professional development/provider education.	List	Yes No
B5-8b A5-8b	R	B, A	Professional development/provider education in place	Baseline Record: Indicates whether professional development/provider education for cervical cancer screening was in place and operational (in use) in this clinic prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date), regardless of the quality, reach, or current level of functionality. Annual Record: Indicates whether professional development/provider education for cervical cancer screening were in place and operational (in use) in this clinic at the end of the program year (July 1- June 30), regardless of the quality, reach, or current level of functionality. If professional development/provider education were newly implemented during this program year, select “Yes, newly in place”. If professional development/provider education were in place prior to this program year, select “Yes, continuing” If yes, newly in place skip to A5-8e If yes, continuing, skip to A5-8d If no, answer A5-8c and then skip to the next EBI, A5-9a	List	Baseline Record: Yes No Annual Record: Yes, newly in place Yes, continuing No
A5-8e	R	A	Average amount of professional development/provider education	If in place (10a3 is Yes), indicates on average, the amount of cervical cancer screening professional development training or education were received by a given provider during this PY.	List	Less than 15 minutes > 15 to 30 minutes > 30 minutes to 1 hour > 1 to 2 hours > 2 to 3 hours More than 3 hours

Section 5-9: EBI -Community Outreach, Education, and Support

Indicates whether community outreach and education activities are in place with the goal of linking women in the community to cervical cancer screening services at this clinic. An example is using community health workers (CHWs) for community outreach. CHWs are lay health educators with a deep understanding of the community and are often members of the community being served. CHWs work in community settings to educate people about cancer screening, promote cancer screening, and provide peer support to people referred to cancer screening.

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
A5-9a	R	A	NBCCEDP resources used toward community outreach	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP grantee resources (e.g. funds, staff time, materials, contract) were used during this program year (July 1- June 30) to contribute to planning, developing, implementing, monitoring/evaluating or improving community outreach activities.	List	Yes No
B5-9b A5-9b	R	B, A	Community outreach in place	Baseline Record: Indicates whether community outreach activities for cervical cancer screening were in place and operational (in use) in this clinic prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date), regardless of the quality, reach, or current level of functionality. Annual Record: Indicates whether community outreach activities for cervical cancer screening were in place and operational (in use) in this clinic at the end of the program year (July 1- June 30), regardless of the quality, reach, or current level of functionality. If professional development/provider education were newly implemented during this program year, select “Yes, newly in place”. If professional development/provider education were in place prior to this program year, select “Yes, continuing” If yes, newly in place skip to A5-9e If yes, continuing, skip to A5-9d If no, answer A5-9c and then skip to the next EBI, A5-10a.	List	Baseline Record: Yes No Annual Record: Yes, newly in place Yes, continuing No
A5-9c	R	A	Community outreach planning activities	Baseline Record: N/A Annual Record: If community outreach activities to improve cervical cancer screening was not in place at the end of the program year (July 1- June 30) (A5-9b is No), indicates whether planning activities were conducted this year for future implementation of community outreach. Skip to the next EBI, A5-10a.	List	Yes No
A5-9d	R	A	Community outreach activities enhancements	Baseline Record: N/A Annual Record: If community outreach activities to improve cervical cancer screening was in place prior to this program year and continuing (A5-9b is “Yes, continuing”), indicates whether the clinic made changes to enhance or improve implementation of community outreach activities during the program year (July 1- June 30).	List	Yes No
A5-9e	R	A	Average duration of community outreach activities	Baseline Record: N/A Annual Record: If community outreach was in place at the end of the program year (July 1- June 30) (A5-9b is “Yes, newly in place” or “Yes, continuing”), for persons in the clinic’s community who were exposed to outreach activities conducted by the clinic, indicates the average amount of time a given person received those activities during this PY.	List	Less than 15 minutes > 15 to 30 minutes > 30 minutes to 1 hour > 1 to 2 hours > 2 to 3 hours More than 3 hours
A5-9f	R	A	Community outreach sustainability	Baseline Record: N/A Annual Record: If community outreach was in place at the end of the program year (July 1- June 30) (A5-9b is “Yes, newly in place” or “Yes, continuing”), indicates whether these interventions are considered to be fully integrated into health system and/or clinic operations and sustainable. [ Community outreach has become an institutionalized component of the health system and/or clinic operations.]	List	Yes No
A5-9g	R	A	Number of FTE CHWs	Baseline Record: N/A Annual Record: If community outreach was in place at the end of the program year (July 1- June 30) (A5-9b is “Yes, newly in place” or “Yes, continuing”), indicates the number of CHW full time equivalents (FTEs) employed at or by the clinic during the program year for cervical cancer screening. For this number, please provide the total sum of whole and partial FTEs to the nearest tenths decimal place. For example, if 2 CHWs work a total of 50% time, then enter 0.5. If no CHWs are being used for NBCCEDP-Cervical activities then enter 0.	Num	00.0-999.0
A5-9h	R	B,A	Other community-clinical linkage (CCL) activities	Community-clinical linkage (CCL) activities refer to activities in place at or employed by the clinic to link priority population members in the community to cervical cancer screening services at this clinic. Baseline Record: Describes any other CCL activities used by the clinic prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date), to link women in the community to cervical cancer screening services at this clinic. Annual Record: Describe any other CCL activities this clinic conducted during the program year (July 1-June 30) to link women in the community to cervical cancer screening services at this clinic.	Char	Free text 256 Char limit

Section 5-10: Patient Navigation

Indicates whether patient navigators (PNs) are in place at or employed by the clinic. PNs typically assist clients in overcoming individual barriers to cancer screening. Patient navigation includes assessment of client barriers, client education and support, resolution of client barriers, client tracking and follow-up. Patient navigation should involve multiple contacts with a client.

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
A5-10a	R	A	NBCCEDP resources used toward patient navigation	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP grantee resources (e.g. funds, staff time, materials, contract) were used during this program year (July 1- June 30) to contribute to planning, developing, implementing, monitoring/evaluating or improving patient navigation to support cervical cancer screening (including completion of any diagnostic tests following an abnormal cervical cancer screening result).	List	Yes No
B5-10b A5-10b	R	B, A	Patient navigation in place	Baseline Record: Indicates whether patient navigation to support cervical cancer screening was in place and operational (in use) in this clinic prior to NBCCEDP-cervical activity implementation (item B1-2: Clinic NBCCEDP-Cervical Activities Start Date), regardless of the quality, reach, or current level of functionality. Annual Record: Indicates whether patient navigation to support cervical cancer screening (including completion of any diagnostic tests following an abnormal cervical cancer screening result) was in place and operational (in use) in this clinic at the end of the program year (July 1- June 30), regardless of the quality, reach, or current level of functionality. If yes, newly in place skip to A5-10d If yes, continuing, skip to A5-10d If no, answer A5-10c and then skip to the next section A6-1.	List	Baseline Record: Yes No Annual Record: Yes, newly in place Yes, continuing No
A5-10c	R	A	Patient navigation planning	Baseline Record: N/A Annual Record: If patient navigation was not in place at the end of the program year (July 1- June 30) (A5-10b is “No”), indicates whether planning activities were conducted this program year for future implementation of patient navigation for cervical cancer screening. skip to the next section, A6-1.	List	Yes No
A5-10d	R	B&A	Patient Navigation Purpose	Baseline Record: Indicates the focus of patient navigation in this clinic before your NBCCEDP begins implementation (item B1-2), Annual Record: Indicates whether patient navigation supported cervical cancer screening, follow-up diagnostic tests, or both in this clinic at the end of the program year (July 1- June 30). If A5-10b is “yes, newly in place” then skip to A5-10f	List	Cervical Cancer screening Follow-up diagnostic tests Both
A5-10e	R	A	Patient Navigation Enhancements	Baseline: N/A Annual: If patient navigation was in place and continuing (A5-10b is “Yes, continuing”), indicates whether the clinic made changes to enhance or improve implementation of patient navigation during the program year (July 1- June 30).	List	Yes No
A5-10f	R	A	Average amount of patient navigation time	Baseline Record: N/A Annual Record: If patient navigation was in place at the end of the program year (July 1- June 30) (A5-10b is “Yes, newly in place” or “Yes, continuing”), for persons at this clinic who received navigation this program year (July 1- June 30), indicates the average amount of navigation time a patient received to overcome cervical cancer screening barriers during this PY. If detailed monitoring data are not available, an estimate of the average time is sufficient.	List	Less than 15 minutes >15 to 30 minutes >30 minutes to 1 hour >1 to 2 hours >2 to 3 hours More than 3 hours
A5-10g	R	A	Patient navigators for EBIs	Baseline Record: N/A Annual Record: If patient navigation was in place at the end of the program year (July 1- June 30) (A5-10b is “Yes, newly in place” or “Yes, continuing”), indicates whether patient navigator(s) at this clinic assisted or facilitated implementation of any of the clinic’s cervical cancer screening EBIs.	List	Yes No
A5-10h	R	A	Patient navigation sustainability	Baseline Record: N/A Annual Record: If patient navigation was in place at the end of the program year (July 1- June 30) (A5-10b is “Yes, newly in place” or “Yes, continuing”), indicates whether patient navigation for cervical cancer screening is considered to be fully integrated into health system and/or clinic operations and is sustainable without NBCCEDP resources. [Patient navigation has become an institutionalized component of the health system and/or clinic operations.]	List	Yes No
B5-10i A5-6i	R	B, A	Number of FTEs delivering patient navigation	Baseline Record: If patient navigation was in place at baseline (item B5-10b=Yes), indicates the number of full-time equivalents (FTEs) conducting patient navigation (e.g., navigators, nurse navigators, nurses, peer health advisors, health navigators) for cervical cancer in this clinic during this program year. Annual Record: If patient navigation was in place at the end of the program year (July 1- June 30) (item A5-10b is “Yes, newly in place” or “Yes, continuing”), indicates the number of full-time equivalents (FTEs) conducting patient navigation (e.g., navigators, nurse navigators, nurses, peer health advisors, health navigators) for cervical cancer in this clinic during this program year. For this number, please provide the total sum of whole and partial FTEs to the nearest tenths decimal place. For example, if 2 patient navigators work a total of 50% time to deliver navigation for cervical cancer, then enter 0.5.	Num	00.0-999.0
A5-10j	R	A	Number of patients navigated	Baseline Record: N/A Annual Record: If patient navigation was in place at the end of the program year (July 1- June 30) (A5-6b is Yes), indicates the number of patients receiving navigation services for cervical cancer screening (including follow-up colonoscopies) during this program year.	Num	1-99998 99999 (Unk)
B5-11 A5-11	O	B, A	Section 5 Comments	Optional comments for Section 5.	Char	Free text 200 Char limit

Section 6: Other Baseline and Annual Cervical Cancer Activities and Comments

Indicates whether other/additional cervical cancer -related strategies are used in the clinic to improve screening levels such as clinic workflow assessment and data driven optimization, other data driven quality improvement strategies, 5 rights of clinical decision support (5 R’s), etc.

Item #	Item Type	Collected	NBCCEDP Data Item	Indication/ Definition	Field Type	Response Options
B6-1 A6-1	O	B, A	Other cervical cancer Activity 1	Baseline and Annual Records: Description of other cervical cancer activity or strategy #1.	Char	Free text 200 Char limit
A6-1a	O	A	NBCCEDP resources used toward Activity 1	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP resources were used during the program year to support activity #1	List	Yes No
B6-2 A6-2	O	B, A	Other cervical cancer Activity 2	Baseline and Annual Records: Description of other cervical cancer activity or strategy #2.	Char	Free text 200 Char limit
A6-2a	O	A	NBCCEDP resources used toward Activity 2	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP resources were used during the program year to support activity #2.	List	Yes No
B6-3 A6-3	O	B, A	Other cervical cancer Activity 3	Baseline and Annual Records: Description of other cervical cancer activity or strategy #3.	Char	Free text 200 Char limit
A6-3a	O	A	NBCCEDP resources used toward Activity 3	Baseline Record: N/A Annual Record: Indicates whether NBCCEDP resources were used during the program year to support activity #3.	List	Yes No
B6-4 A6-4	O	B, A	Section 7 Comments	Optional comments for Section 6.	Char	Free text 200 Char limit