Form 0920-1046 NBCCEDP Quarterly Program Update

Form Approved

OMB Control No. 0920-1046

Expiration Date: xx/xx/xxxx

Attachment 7: NBCCEDP Quarterly Program Update

Welcome to the DP22-2202 National Breast and Cervical Cancer Early Detection Program (NBCCEDP) Program Year X - Quarter X Program Update. In this short survey, you will provide information related to spending, vacancies, program successes, and program challenges for the time period MM/DD/YYYY- MM/DD/YYYY. Information you provide will be used to inform CDC’s technical assistance efforts.

Please submit your responses by close of business on [date]

If you have content-related questions, please contact [CDC staff member] at [email address] or [phone number]. If you have technical issues, please contact IMS at [email address].

Public reporting burden of this collection of information is estimated to average 22 minutes per completed survey, 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).

Section 1. Respondent Information

1. With which NBCCEDP program are you affiliated? [Dropdown list of all DP22-2202 CRCCP awardees]

2. Respondent role _________________________________________________________

Section 2. Award Spending

3. How much of your total CDC NBCCEDP federal award funds for program year X have you spent as of the end of this quarter (MM/DD/YYYY)? Include funds spent since the beginning of the program year, that is, cumulative since July 1 of the current PY. Spending refers to funds that have actually been paid out (expenditures) or funds that are obligated during the time period of interest but currently unspent (i.e., unpaid receipts). Do not include funds that you plan to spend in the future or funds for services that are not yet rendered. Likewise, do not include funds spent from sources other than the NBCCED federal award.

$______________

4. Have you experienced any challenges in spending your NBCCEDP federal funds?

Y/N [If no, skip to Q5]

4.a. Please describe your spending challenges: [free text]

5. Have you submitted any requests to the Office of Financial Resources (OFR) for the Breast and Cervical Cancer Program (e.g., redirection of funds) that are pending?

Y/N [If no, skip to Q7]

5.a. For each request to OFR please provide the following:

Type of request

Carryover/Unobligated Request

Budget Revision/Redirection

Staff change

Other

Date the request was submitted to OFR

Reason for the request

Section 3. Service Delivery

6. How many women have received at least one NBCCEDP-funded clinical service since the start of this program year? (Women who received at least one NBCCEDP funded mammogram, clinical breast exam, pap test, HPV test, or other diagnostic service. Do NOT include women who received patient navigation only.)

Count______________

6a. How many women have received at least one NBCCEDP-funded clinical service since the start of this program year by the following population(s) of focus:

[Awardee will be asked to report on the Population(s) of Focus they identified on their Service Delivery Projections Worksheet submitted with their competitive/continuing application]

1. Race/Ethnicity

   1. Hispanic, All Races

Count________

2. Black or African American

Count ________

3. Asian

Count ________

4. Native Hawaiian or Other Pacific Islander

Count ________

5. American Indian or Alaskan Native

Count ________

6. White/Middle Eastern/North African

Count ________

2. Rural/Urban

   1. Rural

Count ________

2. Urban

Count ________

3. Metro

Count ________

3. Optional Other

   1. [Applicant/Awardee] choice

Count ________

2. [Applicant/Awardee] choice

Count ________

3. [Applicant/Awardee] choice

Count ________

7. How many women have received at least one NBCCEDP-funded breast cancer service since the start of this program year? (Women who received at least one NBCCEDP funded mammogram or other breast diagnostic service. Count each woman only once.)

Count______________

8. How many women have received at least one NBCCEDP-funded cervical cancer service since the start of this program year? (Women who received at least one NBCCEDP funded pap test, HPV test, or other cervical diagnostic service. Count each woman only once.)

Count______________

9. How many women have been navigated only for breast or cervical cancer since the start of this program year? (Include additional unique women who have ONLY received NBCCEDP-funded patient navigation through the screening process AND were not included in the NBCCEDP-funded clinical service delivery estimates above. These are women whose screening or diagnostics was reimbursed through other sources (e.g., state funds, private insurance, Medicaid, Medicare) while receiving NBCCEDP-funded navigation-only services. Only include women for whom an abbreviated MDE record has been/will be completed.)

Count______________

10. Please describe any challenges related to screening, diagnostic, or patient navigation service delivery encountered during the past quarter (XX/XX/XXXX – XX/XX/XXXX). If none, leave blank.

[free text]

Section 4. Vacancies

11. Do you currently have any staffing vacancies for your NBCCEDP program?

Y/N [if no, skip to Q8]

12. Identify all positions funded under the CDC NBCCEDP award that are currently vacant and provide the date the position was vacated? [check all that apply]

__ Program Manager/Program Director Date Vacated: XX/XX/XXXX

__ Data Manager Date Vacated: XX/XX/XXXX

__ Program Evaluator Date Vacated: XX/XX/XXXX

__ Other: [provide title] Date Vacated: XX/XX/XXXX

__ Other: [provide title] Date Vacated: XX/XX/XXXX

__ Other: [provide title] Date Vacated: XX/XX/XXXX

__ Other: [provide title] Date Vacated: XX/XX/XXXX

__ Other: [provide title] Date Vacated: XX/XX/XXXX

__ Other: [provide title] Date Vacated: XX/XX/XXXX

Section 5. Accomplishments and Challenges

13. Please describe notable accomplishments or successes that were achieved during the past quarter (XX/XX/XXXX – XX/XX/XXXX) and how those accomplishments/successes contributed to program outcomes. If none, leave blank.

[free text]

14. Please describe any challenges that have limited program implementation or performance during the past quarter (XX/XX/XXXX – XX/XX/XXXX). Do not include any COVID-19 related challenges as there is a separate question addressing COVID-19 below. If none, leave blank.

[free text]

Section 6. Technical Assistance Needs

15. Please describe any current technical assistance needs.

[free text]

Section 7. COVID-19

16. Please describe any issues affecting your program or program operations due to COVID-19.

[free text]