Form 0920-1046 NBCCEDP Service Delivery Projections

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Overview

Cover Page
Instructions
Served
Served for B
Served for C
PN Only
Definitions

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Sheet 1: Cover Page

Form Approved

OMB Control No. 0920-1046

Expiration Date: xx/xx/xxxx

Attachment 8: NBCCEDP Service Delivery Projection Worksheet

Public reporting burden of this collection of information is estimated to average 29 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).

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Sheet 2: Instructions

Instructions

Complete each yellow-highlighted box on the form to enter the Award Recipient name, name of person completing the form, and the program's service delivery projections. Programs should project the total number of women served, served for breast cancer, served for cervical cancer, and for women who will receive patient navigation-only services. Programs are also required to provide projections by race/ethnicity and/or rurla/urban/metro categories. Please provide these projections for total number of women to be served and for breast, cervical, and navigated-only. Programs may also enter population(s) of focus (e.g., religious group, additional races, LGBTQ+) and provide related projections. Definitions for race/ethnicity categories and rural/urban categories are provided on the Definitions tab. The race/ethnicity categories included in this projection worksheet are the minimum required categories from Office of Management and Budget and are those collected in CDC's minimum data elements (MDEs). Please note that the race/ethnicity categories will be totaled automatically and should equal the total estimated projection. Similarly, the rural/urban/metro categories will be totaled automatically and should equal the total estimated projection. For instance, a program projecting to serve a total of 700 women should provide projections by race/ethnicity that total 700. If the program also chooses to provide projections by rural/urban/metro, the total for these categories should also equal 700. Any projections you add for propulation(s) of focus (e.g., religious group, additional races, LGBTQ+) are considered a subset of the total projection and should not necessarily sum to the total projection (e.g., 700). Do not leave any yellow box empty. Enter 0 if the projection is zero. These projections should reflect the clinical and patient navigation-only services you project to provide using NBCCEDP-funds. Initially, these projections should be based on the amount of CDC funds requested in your application budget. Projections should be ambitious but realistic. If your CDC funding award differs considerably from your requested funding amount, you may need to revise your service delivery projections. Revised service delivery projections may be submitted to CDC through nbccedp.cdc.gov. Projections should be consistent with your work plan and budget. Projections should also be based on data, take into consideration the size of the eligible population, and consider the number of women served in the past. Contact your Program Consultant with any questions.

CDC-RFA-DP22-2202 (NBCCEDP) Program Year 2022–2023 Service Delivery Projections Page 1 of 6

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Sheet 3: Served

Program Year 2022–2023 (6/30/2022 - 6/29/2023) Service Delivery Projections
Award Recipient: Name of Person Completing Form:
NBCCEDP-funded Clinical Services	Total Estimated Projection
1-Proposed Number of Women who will receive at least one NBCCEDP-funded clinical service in Program Year 2022-2023: Project the number of women who will receive at least one NBCCEDP-funded clinical service: mammogram, clinical breast exam, Pap test, HPV test, or diagnostic service. These women may also receive NBCCEDP-funded patient navigation support. Count each woman once, regardless of how many NBCCEDP-funded clinical servcies she receives. For example, a woman receiving both a breast and a cervical cancer NBCCEDP-funded clinical service would only be counted once. Because some women receive multiple NBCCEDP-funded breast and cervical cancer clinical services, this projection may not equal the separate projections of the number of women served for breast cancer services and cervical cancer services when they are added together.
Population of Focus - Race and Ethnicity	Race & Ethnicity	Estimated Projection
Please enter the proposed Number of Women who will receive at least one NBCCEDP-funded clinical service in Program Year 2022-2023 by race and ethnicity. Projections by race and ethnicity should add up to the total projected Number of Women served above.	Hispanic, All Races
	Black or African American
	Asian
	Native Hawaiian or Other Pacific Islander
	American Indian or Alaskan Native
	White/Middle Eastern/North African
Total		0
Population of Focus - Rural and Urban	Rural & Urban	Estimated Projection
Please enter the proposed Number of Women who will receive at least one NBCCEDP-funded clinical service in Program Year 2022-2023 by rurality. Projections by rurality should add up to the total projected Number of Women served above.	Rural
	Urban
	Metro
Total		0
Additional Populations of Focus - Optional		Estimated Projection
Please enter the proposed Number of Women who will receive at least one NBCCEDP-funded clinical service in Program Year 2022-2023 by any additional poplulation of focus. You may also report projections for up to three populations of focus (if those populations of focus are different from the categories listed above). Providing these additional projections is OPTIONAL. Enter the population of focus in b22-24 and delete "[Enter another population of focus]". Projections for these additional populations of focus will NOT be summed; they are considered a subset of the total projection and should not necessarily sum to that number.	[Enter another population of focus]
	[Enter another population of focus]
	[Enter another population of focus]
CDC-RFA-DP22-2202 (NBCCEDP) Program Year 2022–2023 Service Delivery Projections Page 2 of 6

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Sheet 4: Served for B

Program Year 2022–2023 (6/30/2022 - 6/29/2023) Service Delivery Projections
Award Recipient: Name of Person Completing Form:
NBCCEDP-funded Clinical Services	Total Estimated Projection
2-Proposed Number of Women who will receive at least one NBCCEDP-funded breast cancer service in Program Year 2022-2023: Project the number of women served who will receive at least one NBCCEDP-funded breast cancer service: Mammogram, Clinical Breast Exam, or Breast diagnostic service. These women may also receive NBCCEDP-funded navigation support. Count each woman who will receive a NBCCEDP-funded breast cancer service only once, regardless of the number of NBCCEDP-funded breast cancer services she receives. Women receiving both NBCCEDP-funded breast cancer services and NBCCEDP-funded patient navigation support should also only be counted once in this projection.
Population of Focus - Race and Ethnicity	Race & Ethnicity	Estimated Projection
Please enter the proposed Number of Women who will receive at least one NBCCEDP-funded breast cancer service in Program Year 2022-2023 by race and ethnicity. Projections by race and ethnicity should add up to the total projected Number of Women receiving at least once NBCCEDP-funded breast cancer service above.	Hispanic, All Races
	Black or African American
	Asian
	Native Hawaiian or Other Pacific Islander
	American Indian or Alaskan Native
	White/Middle Eastern/North African
Total		0
Population of Focus - Rural and Urban	Rural & Urban	Estimated Projection
Please enter the proposed Number of Women who will receive at least one NBCCEDP-funded breast cancer service in Program Year 2022-2023 by rurality. Projections by rurality should add up to the total projected Number of Women receiving at least NBCCEDP-funded breast cancer service above.	Rural
	Urban
	Metro
Total		0
Additional Populations of Focus - Optional		Estimated Projection
Please enter the proposed Number of Women who will receive at least one NBCCEDP-funded breast cancer service in Program Year 2022-2023 by any additional optional category. You may also report projections for up to three populations of focus (if those populations of focus are different from the categories listed above). Providing these additional projections is OPTIONAL. Enter the population of focus in b22-24 and delete "[Enter another population of focus]". Projections for these additional populations of focus will NOT be summed; they are considered a subset of the total projection and should not necessarily sum to that number.	[Enter another population of focus]
	[Enter another population of focus]
	[Enter another population of focus]
CDC-RFA-DP22-2202 (NBCCEDP) Program Year 2022–2023 Service Delivery Projections Page 3 of 6

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Sheet 5: Served for C

Program Year 2022–2023 (6/30/2022 - 6/29/2023) Service Delivery Projections
Award Recipient: Name of Person Completing Form:
NBCCEDP-funded Clinical Services	Total Estimated Projection
3-Proposed Number of Women who will receive at least one NBCCEDP-funded cervical cancer service in Program Year 2022-2023: Project the number of women served who will receive at least one NBCCEDP-funded cervical cancer service: Pap test, HPV test, or cervical diagnostic service. These women may also receive NBCCEDP-funded patient navigation support. Count each woman who will receive a NBCCEDP-funded cervical cancer service only once, regardless of the number of NBCCEDP-funded cervical cancer services she receives. Women receiving both NBCCEDP-funded cervical cancer services and NBCCEDP-funded patient navigation support should also only be counted once in this projection.
Population of Focus - Race and Ethnicity	Race & Ethnicity	Estimated Projection
Please enter the proposed Number of Women who will receive at least one NBCCEDP-funded cervical cancer service in Program Year 2022-2023 by race and ethnicity. Projections by race and ethnicity should add up to the total projected Number of Women receiving at least one NBCCEDP-funded cervical cancer service above.	Hispanic, All Races
	Black or African American
	Asian
	Native Hawaiian or Other Pacific Islander
	American Indian or Alaskan Native
	White/Middle Eastern/North African
Total		0
Population of Focus - Rural and Urban	Rural & Urban	Estimated Projection
Please enter the proposed Number of Women who will receive at least one NBCCEDP-funded cervical cancer service in Program Year 2022-2023 by rurality. Projections by rurality should add up to the total projected Number of Women receiving at least once NBCCEDP-funded cervical cancer service above.	Rural
	Urban
	Metro
Total		0
Additional Populations of Focus - Optional		Estimated Projection
Please enter the proposed Number of Women who will receive at least one NBCCEDP-funded cervical cancer service in Program Year 2022-2023 by any additional optional category. You may also report projections for up to three populations of focus (if those populations of focus are different from the categories listed above). Providing these additional projections is OPTIONAL. Enter the population of focus in b22-24 and delete "[Enter another population of focus]". Projections for these additional populations of focus will NOT be summed; they are considered a subset of the total projection and should not necessarily sum to that number.	[Enter another population of focus]
	[Enter another population of focus]
	[Enter another population of focus]
CDC-RFA-DP22-2202 (NBCCEDP) Program Year 2022–2023 Service Delivery Projections Page 4 of 6

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Sheet 6: PN Only

Program Year 2022–2023 (6/30/2022 - 6/29/2023) Service Delivery Projections
Award Recipient: Name of Person Completing Form:
NBCCEDP-funded Patient Navigation Only Support	Total Estimated Projection
4-Proposed Number of Women who will receive NBCCEDP-funded patient navigation-only support for Breast or Cervical Cancer Screening in Program Year 2022– 2023: Project the number of women who will receive NBCCEDP-funded patient navigation-only support without any NBCCEDP-funded breast or cervical cancer screening services. These are women whose screening or diagnostics are paid for by other sources (e.g., state funds, private insurance, Medicaid, Medicare) while receiving NBCCEDP-funded navigation-only services. Count each woman who receives patient navigation only-support once, regardless of the number of contacts (e.g., phone calls, text messages, emails, traditional mail) she receives. The projected number of women to receive patient navigation-only support is the number of women for whom you will submit an abbreviated MDE record as part of your regular MDE submissions.
Population of Focus - Race and Ethnicity	Race & Ethnicity	Estimated Projection
Please enter the proposed Number of Women who will receive at least one NBCCEDP-funded patient navigation-only support for Breast or Cervical Cancer Screening in Program Year 2022-2023 by race and ethnicity. Projections by race and ethnicity should add up to the total projected Number of Women receving at least one NBCCEDP-funded pantient-navigation-only service above.	Hispanic, All Races
	Black or African American
	Asian
	Native Hawaiian or Other Pacific Islander
	American Indian or Alaskan Native
	White/Middle Eastern/North African
Total		0
Population of Focus - Rural and Urban	Rural & Urban	Estimated Projection
Please enter the proposed Number of Women who will receive at least one NBCCEDP-funded patient navigation-only support for Breast or Cervical Cancer Screening in Program Year 2022-2023 by rurality. Projections by rurality should add up to the total projected Number of Women receiving at least one NCCEDP-funded patient-navigatio-only service above.	Rural
	Urban
	Metro
Total		0
Additional Populations of Focus - Optional		Estimated Projection
Please enter the proposed Number of Women who will receive at least one NBCCEDP-funded patient navigation-only support for Breast or Cervical Cancer Screening in Program Year 2022-2023 by any additional optional category. You may also report projections for up to three populations of focus (if those populations of focus are different from the categories listed above). Providing these additional projections is OPTIONAL. Enter the population of focus in b22-24 and delete "[Enter another population of focus]". Projections for these additional populations of focus will NOT be summed; they are considered a subset of the total projection and should not necessarily sum to that number.	[Enter another population of focus]
	[Enter another population of focus]
	[Enter another population of focus]
CDC-RFA-DP22-2202 (NBCCEDP) Program Year 2022–2023 Service Delivery Projections Page 5 of 6

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Sheet 7: Definitions

Population of Focus	Category	Definition
Race/Ethnicity	Hispanic, All Races	A person of Cuban, Mexican, Puerto Rican, South or Central America, or Spanish culture or origin regardless of their race.1
Race/Ethnicity	Black or African American	A person having origins in any of the original people of the African Continent (i.e., Nigerian, Kenyan), African American, or Haiti, or Carribean Islands.
Race/Ethnicity	Asian	A person 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.2
Race/Ethnicity	Native hawaiian or Other Pacific Islander	A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.2
Race/Ethnicity	American Indian/Alaskan	A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.2
Race/Ethnicity	White	A person having origins in any of the original peoples of European, Middle Eastern, or North Africa.2
Rural/Urban	Rural	Completely rural or less than 2,500 urban population, adjacent to a metro area.3,4,5 Completely rural or less than 2,500 urban population, not adjacent to a metro area.3,4,5
Rural/Urban	Urban	Urban population of 20,000 or more, adjacent to a metro area.3,4,5 Urban population of 20,000 or more, not adjacent to a metro area.3,4,5 Urban population of 2,500 to 19,999, adjacent to a metro area.3,4,5 Urban populationof 2,500 to 19,999, not adjacent to a metro area.3,4,5
Rural/Urban	Metro	Counties in metro areas of 1 milllion population or more.3,4,5 Counties in metro areas of 250,000 to 1 million population.3,4,5 Counties in metro areas of fewer than 250,000 population.3,4,5
1. https://www.census.gov/quickfacts/fact/note/US/RHI725219
2. https://www.census.gov/topics/population/race/about.html
3. https://www.ers.usda.gov/data-products/rural-urban-continuum-codes/documentation/
4. A woman's location for Rural/Urban/Metro is determined using the womans zipcode or county, whichever is reported on the MDE record.
5. https://www.ers.usda.gov/data-products/rural-urban-continuum-codes// (2013 Rural-Urban Continuum Codes)
CDC-RFA-DP22-2202 (NBCCEDP) Program Year 2022–2023 Service Delivery Projections Page 6 of 6