Form 1 Demographic and Service Utilization Data and Service

Tribal Maternal, Infant, and

Early Childhood

Home Visiting Program

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OMB No.: 0970-0389

Expiration: 04/30/

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Form 1: Demographic and Service Utilization Data

TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING PROGRAM

FORM 1

DEMOGRAPHIC AND SERVICE UTILIZATION DATA

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, ACF is gathering information to report activities associated with grants to the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. The purpose of this information collection is to submit demographic and service utilization data to HHS. Public reporting burden for this collection of information is estimated to average 500 hours per grantee, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a collection of information through section 511(e)(8)(A) of the Social Security Act. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0389 and the expiration date is 4/30/2025.

SECTION A: PARTICIPANT DEMOGRAPHICS AND SERVICE UTILIZATION

A.1: Participant Demographics during Reporting Period (Newly Enrolled and Continuing)

Table 1. Unduplicated Count of Adult Participants and Index Children Served by Tribal MIECHV Home Visitors during Reporting Period (Newly Enrolled and Continuing)

	Number Newly Enrolled	Number Continuing	Total
Adult Participants
Pregnant Women
Female Caregivers
Male Caregivers
All Adult Participants (Auto Calculate)
Index Children
Female Index Children
Male Index Children
All Index Children (Auto Calculate)

Table 1(a). Female Caregivers in the Current Reporting Period who Were Counted as Pregnant Women in the Prior Reporting Period

Adult Participants	Number
Number of Female Caregivers in the Current Reporting Period who were Counted as Pregnant Women in the Prior Reporting Period

Table 2. Unduplicated Count of Households Served by Tribal MIECHV Home Visitors (Newly Enrolled and Continuing)

Households	Number Newly Enrolled	Number Continuing	Total
Number of Households

Table 3. Adult Participants by Current Educational Status (Newly Enrolled and Continuing)

Adult Participants	Student/trainee	Not a student/trainee	Unknown/Did not Report	Total
Newly Enrolled Pregnant Women
Newly Enrolled Female Caregivers
Newly Enrolled Male Caregivers
All Newly Enrolled Adults (Auto Calculate)
Continuing Pregnant Women
Continuing Female Caregivers
Continuing Male Caregivers
All Continuing Adults (Auto Calculate)
All Adult Participants (Auto Calculate)

Table 4. Adult Participants by Employment Status (Newly Enrolled and Continuing)

Adult Participants	Employed Full Time	Employed Part-Time	Not employed	Unknown/Did not Report	Total
Newly Enrolled Pregnant Women
Newly Enrolled Female Caregivers
Newly Enrolled Male Caregivers
All Newly Enrolled Adults (Auto Calculate)
Continuing Pregnant Women
Continuing Female Caregivers
Continuing Male Caregivers
All Continuing Adults (Auto Calculate)
All Adult Participants (Auto Calculate)

Table 5. Household Income in Relation to Federal Poverty Guidelines (Newly Enrolled and Continuing)

Households	Newly Enrolled Households	Percent	Continuing Households	Percent	Total Households	Percent
50% and under
51-100%
101-133%
134-200%
201-300%
>300%
Unknown/Did not Report
All Households (Auto Calculate)		100		100		100

Table 6. Index Children by Age (Newly Enrolled and Continuing)

Index Children	Under 12 months	12-24 months	25-36 months	37-60 months	61-72 months	Unknown/Did not Report	Total
Newly Enrolled Female Index Children
Newly Enrolled Male Index Children
All Newly Enrolled Index Children (Auto Calculate)
Continuing Female Index Children
Continuing Male Index Children
All Continuing Index Children (Auto Calculate)
All Index Children (Auto Calculate)

Table 7. Adult Participants by Housing Status (Newly Enrolled and Continuing)

Adult Participants	Not Homeless	Homeless				Unknown/ Did not Report	Total
	Not Homeless	Homeless and sharing housing	Homeless and living in an emergency or transitional shelter	Homeless with some other arrangement	Total Homeless (Auto Calculate)
Newly Enrolled Pregnant Women
Newly Enrolled Female Caregivers
Newly Enrolled Male Caregivers
All Newly Enrolled Adult Participants (Auto Calculate)
Continuing Pregnant Women
Continuing Female Caregivers
Continuing Male Caregivers
All Continuing Adult Participants (Auto Calculate)
All Adult Participants (Auto Calculate)

Table 8. Adult Participants and Index Children by Type of Health Insurance Coverage (Newly Enrolled and Continuing)

	Not Insured			Insured
	Has access to IHS, CHS, or UIHP facility	Does not have access to IHS, CHS, or UIHP facility	Total Not Insured (Auto Calculate)	Medicaid or CHIP	TriCare	Private Insurance	Total Insured (Auto Calculate)	Unknown/Did not Report		Total
Adult Participants
Newly Enrolled Pregnant Women
Newly Enrolled Female Caregivers
Newly Enrolled Male Caregivers
All Newly Enrolled Adult Participants (Auto Calculate)
Continuing Pregnant Women
Continuing Female Caregivers
Continuing Male Caregivers
All Continuing Adult Participants (Auto Calculate)
All Adult Participants (Auto Calculate)
Index Children
	Has access to IHS, CHS, or UIHP facility	Does not have access to IHS, CHS, or UIHP facility	Total Not Insured (Auto Calculate)	Medicaid or CHIP	TriCare	Private Insurance	Total Insured (Auto Calculate)	Unknown/Did not Report	Total
Newly Enrolled Female Index Children
Newly Enrolled Male Index Children
All Newly Enrolled Index Children (Auto Calculate)
Continuing Female Index Children
Continuing Male Index Children
All Continuing Index Children (Auto Calculate)
All Index Children (Auto Calculate)

A.1 NOTES:

A.2: Participant Demographics during Reporting Period (Newly Enrolled Only)

Table 9. Adult Participants by Age (Newly Enrolled)

Adult Participants	≤17	18-19	20-21	22-24	25-29	30-34	35-44	45-54	55-64	≥65	Unknown/Did not Report	Total
Pregnant Women
Female Caregivers
Male Caregivers
All Adults (Auto Calculate)

Table 10. Participants by Ethnicity (Newly Enrolled)

Participants	Hispanic or Latino	Not Hispanic or Latino	Unknown/Did not Report	Total
Pregnant Women
Female Caregivers
Male Caregivers
All Adults (Auto Calculate)
Female Index Children
Male Index Children
All Index Children (Auto Calculate)

Table 11. Participants by Race (Newly Enrolled)

Participants	American Indian or Alaska Native	Asian	Black or African American	Native Hawaiian or Other Pacific Islander	White	More than one race including AI/AN	More than one race not including AI/AN	Unknown/Did not Report	Total
Pregnant Women
Female Caregivers
Male Caregivers
All Adults (Auto Calculate)
Female Index Children
Male Index Children
All Index Children (Auto Calculate)

Table 12. Adult Participants by Marital Status (Newly Enrolled)

Adult Participants	Single	Legally Married	Not married but living together with partner	Separated/Divorced/Widowed	Unknown/Did not Report	Total
Pregnant Women
Female Caregivers
Male Caregivers
All Adults (Auto Calculate)

Table 13. Adult Participants by Educational Attainment (Newly Enrolled)

Adult Participants	Less than HS diploma	HS Diploma/ GED	Some college/ training	Technical training or certification	Associate’s Degree	Bachelor’s Degree or higher	Other	Unknown/Did not Report	Total
Pregnant Women
Female Caregivers
Male Caregivers
All Adults (Auto Calculate)

Table 14. Primary Language Spoken at Home of Index Children (Newly Enrolled)

Index Children	Number Newly Enrolled	Percent
English
Spanish
Any Native American Language
Other
Unknown/Did Not Report
All Index Children (Auto Calculate)		100

Table 15. Secondary Language Spoken at Home of Index Children (Newly Enrolled)

Index Children	Number Newly Enrolled	Percent
English
Spanish
Any Native American Language
Other
None
Unknown/Did Not Report
All Index Children (Auto Calculate)		100

Table 16. Priority Population Household Characteristics (Newly Enrolled)

Households	Yes	No	Unknown/Did not Report	Total
Low income household
Household contains an enrollee who is pregnant and under age 21
Household has a history of child abuse or neglect or has had interactions with child welfare services
Household has a history of substance abuse or needs substance abuse treatment
Someone in the household uses tobacco products in the home
Someone in the household has attained low student achievement or has a child with low student achievement
Household has a child with developmental delays or disabilities
Household includes individuals who are serving or formerly served in the US armed forces

A.2 NOTES:

A.3: Participant Service Utilization during Reporting Period

Table 17. Number of Home Visits

Home Visits	Number
Total Number of In-Person Home Visits Completed
Total Number of Virtual Home Visits Completed
All Categories (Auto Calculate)

Table 18. Family Engagement by Household (Newly Enrolled and Continuing)

Households	Number of Newly Enrolled Households	Number of Continuing Households	All Households (Auto Calculate)
Currently receiving services
Completed program
Stopped services before completion
Enrolled but not currently receiving services/Other
Unknown/Did not Report
All Categories (Auto Calculate)

Table 19: Unduplicated Count of Households by Evidence-Based Home Visiting Model

Home Visiting Model (Select One per Row – Add Rows for Additional Models)	Households
All Models (Auto Calculate)

A.3 NOTES:

SECTION B: PROGRAM STAFF DEMOGRAPHICS

Table 20. Program Staff by Age

Program Staff	≤29	30-39	40-49	50-64	≥65	Unknown/ Did not Report	Total
Home Visitors
Project Directors/ Managers/Coordinators
All Staff (Auto Calculate)

Table 21. Program Staff by Gender

Program Staff	Female	Male	Unknown/Did not Report	Total
Home Visitors
Project Directors/ Managers/Coordinators
All Staff (Auto Calculate)

Table 22. Program Staff by Ethnicity

Program Staff	Hispanic or Latino	Not Hispanic or Latino	Unknown/Did not Report	Total
Home Visitors
Project Directors/ Managers/Coordinators
All Staff (Auto Calculate)

Table 23. Program Staff by Race

Program Staff	American Indian or Alaska Native	Asian	Black or African American	Native Hawaiian or Other Pacific Islander	White	More than one race including AI/AN	More than one race not including AI/AN	Unknown/Did not Report	Total
Home Visitors
Project Directors/ Managers/ Coordinators
All Staff (Auto Calculate)

Table 24. Program Staff by Educational Attainment

Program Staff	Less than HS Diploma	HS Diploma /GED	Some college/ training	Technical training or certification	Associate’s Degree	Bachelor’s Degree	Master’s Degree or Higher	Other	Unknown/ Did Not Report	Total
Home Visitors
Project Directors/Managers/Coordinators
All Staff (Auto Calculate)

Table 25. Unduplicated Count of Home Visiting Staff Full Time Equivalents

Home Visiting Program Staff	Number
Number of FTE Home Visitors
Number of FTE Project Directors /Managers/Coordinators
All Tribal MIECHV Staff FTE (Auto Calculate)

SECTION B NOTES:

INSTRUCTIONS AND DEFINITIONS OF KEY TERMS

Tribal MIECHV Form 1 Instructions

Data for Tribal MIECHV Form 1: Demographic and Service Utilization Data should be collected at enrollment (as defined by grantee or per model developer guidelines) for newly enrolled participants/households and once during the reporting period (as determined by grantee) for continuing participants/households. Grantees may determine the method of and individuals responsible for data collection based on their own policies and procedures, and as guided by model developers and in consultation with ACF. Technical assistance is available to grantees to determine the method and timing of data collection and to ensure high quality data collection and reporting.

The form is organized into two sections. Section A includes Participant Demographics and Service Utilization and contains three sub-sections (A.1: Participant Demographics during Reporting Period (Newly Enrolled and Continuing); A.2: Participant Demographics during Reporting Period (Newly Enrolled Only); and A.3 Participant Service Utilization during Reporting Period (Newly Enrolled and Continuing) and requests demographic and service utilization data for program participants and households. When reporting on Form 1, grantees may decide to report on data through the following data sources. Please note that the data sources selected should be consistent over time for each data element:

1. Program data: data collected by the home visiting program. This may include data self-reported by the adult participant.

2. Administrative data: data collected by another agency, organization, or program. Grantees may elect to use administrative data if it applies directly to the item being reported on and can be acquired within reporting deadlines.

ACF will use this data to better understand the population receiving services from Tribal MIECHV grantees and the degree to which they are using services.

Section B includes Program Staff Demographics and requests information on demographics of program staff, which will be used by ACF to better understand the Tribal MIECHV workforce. All information is collected to support improved knowledge of Tribal MIECHV grantee programs and guide technical assistance provided through the cooperative agreement.

After each sub-section, the form includes a “Notes” field. Grantees should use this field to explain the reasons for missing data if more than 10 percent of data are missing (i.e., Unknown/Did Not Report) for a particular data element, and to provide any other contextual information that may be helpful to ACF in understanding the data reported. For each explanation of missing data, include the Table number for ease of reference.

Definitions: The following table includes definitions for key terms listed in Tribal MIECHV Form 1 Tables.

Table Number	Field or Item	Definitions
General Definitions
N/A	Reporting Period	The most recent 12-month budget period during which a Tribal MIECHV grantee provided home visiting services.
N/A	Tribal MIECHV Home Visitor	A home visitor for whom at least 25 percent of his/her personnel costs (salary, wages, and benefits) are paid for with Tribal MIECHV funding.
N/A	Adult Participant	An adult (pregnant woman, female caregiver, male caregiver) who participates in the home visiting program during the reporting period and was served by a Tribal MIECHV home visitor. This could include teenage participants who have not yet reached age 18 but who meet the definition of either a pregnant woman, female caregiver, or male caregiver.
N/A	Household	Adult(s) who are caregivers for the same index child(ren) who participate in the home visiting program during the reporting period and were served by a Tribal MIECHV home visitor. A household may include one or multiple adult participants depending on model-specific definitions.
N/A	Newly Enrolled (Adult Participant or Household)	A participant or household who participates in the home visiting program for the first time at any time during the reporting period.
N/A	Continuing (Adult Participant or Household)	A participant or household who participated in the home visiting program prior to the beginning of the reporting period and continues enrollment during the reporting period. This includes any participants who had been enrolled in any prior reporting period, became inactive, and then enrolled again in the reporting period.
N/A	Pregnant Woman (Adult Participant)	A participant who participated in the program while pregnant at any time during the reporting period.
N/A	Female Caregiver (Adult Participant)	A female participant who participated in the program during the reporting period and is considered a primary caregiver of the index child (e.g., biological mother, adoptive mother, foster mother, grandmother). If a woman has been pregnant at any time during the reporting period, she should be considered a Pregnant Woman (not Female Caregiver).
N/A	Male Caregiver (Adult Participant)	A male participant who participated in the program during the reporting period and is considered a primary caregiver of the index child (e.g., expectant father, biological father, stepfather, foster parent, partner).
N/A	Index Child	The target child (male or female) in an individual household who is under the care of the participant. More than one index child can be identified (e.g., in the case of twins, triplets, or per model developer guidelines). Thus, there could be more than one female or male index child in a given household. A single child could have multiple primary caregivers reported in Tribal MIECHV Form 1.
A.1 Participant Demographics During Reporting Period (Newly Enrolled and Continuing)
1 (a)	Female Caregivers in the Current Reporting Period who Were Counted as Pregnant Women in the Prior Reporting Period	Those continuing participants who are counted as female caregivers in the reporting period who were counted as pregnant women in the most recent prior reporting period.
3	Adult Participants by Educational Status (Newly Enrolled and Continuing)	Student/trainee: a participant who is considered a full- or part-time student or trainee by the educational institution or training program he/she is attending during the reporting period. Not a student/trainee: a participant who is not enrolled in any type of educational or training programs during the reporting period.
4	Adult Participants by Employment Status (Newly Enrolled and Continuing)	Employed: a participant who works for pay during the reporting period. Employed Full Time: an employee who works an average of at least 30 hours per week, as per https://www.healthcare.gov/glossary/full-time-employee/ Employed Part Time: an employee who works an average of less than 30 hours per week Not Employed: a participant who is not working for pay (e.g., students, stay-at-home parents, and those actively seeking work but currently not employed)
5	Household Income in Relation to Federal Poverty Guidelines (Newly Enrolled and Continuing)	The appropriate category for a given household will depend both on household income and on the number of household members (both home visiting participants and non-participants). Household income refers to the annual gross income for the household as defined in programmatic guidance, recorded at enrollment and annually thereafter. Federal Poverty Guidelines: Annual income data can be estimated from monthly data (monthly income x 12). The Federal Poverty Guidelines are updated each year. See https://aspe.hhs.gov/poverty-guidelines for the guidelines (updated every year).
7	Adult Participants by Housing Status (Newly Enrolled and Continuing)	Homeless: participants who lack a fixed, regular, and adequate nighttime residence (within the meaning of section 103(a)(1) of the McKinney-Vento Homeless Assistance Act). Report the participant as homeless if they were homeless for 1 or more days during the month prior to data collection. Fixed nighttime residence: stationary, permanent, and not subject to change. Regular nighttime residence: used on a predictable, routine, or consistent basis. Adequate nighttime residence: sufficient for meeting both the physical and psychological needs typically met in home environments. Grantees must first determine whether each adult participant is homeless (i.e., whether they have a fixed, regular, and adequate nighttime residence).Adult participants who do not fit the definition of homeless should be marked “not homeless.” For adult participants who are homeless, grantees must then assess the current housing status of each adult participant. Definitions for the categories under “homeless” are provided below. Grantees should categorize participants according to the category that most closely matches the participant’s housing status. Homeless and sharing housing: individuals who are sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason Homeless and living in an emergency or transitional shelter: individuals who are living in emergency or transitional shelters, are abandoned in hospitals, or are awaiting foster care placement Homeless with some other arrangement: individuals who are living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations; individuals who have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings (within the meaning of section 103(a)(2)(C)); individuals who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings. For more: https://nche.ed.gov/mckinney-vento-definition/
8	Adult Participants and Index Children by Type of Health Insurance Coverage (Newly Enrolled and Continuing)	Not Insured: “Not insured” indicates that the individual is currently not covered by any source of insurance. This table is intended to capture insurance status, and for those not insured: access to Indian Health Services, UIHP or CHS health services. For example, receipt of care provided by the Indian Health Service or another safety net health care provider such as a Federally Qualified Health Center does not constitute insurance coverage. The not insured categories are mutually exclusive. Not insured but has access to Indian Health Services, Contract Health Services, or Urban Indian Health Program facility: The Indian Health Service is funded each year through appropriations by the U.S. Congress. The Indian Health Service is not an entitlement program, such as Medicare or Medicaid. The Indian Health Service is not an insurance program. The Indian Health Service is not an established benefits package. Two types of services are provided by the Indian Health Service: (1) Direct health care services, which are provided by an IHS facility, or (2) contract health services (CHS), which are provided by a non-IHS facility or provider through contracts with the IHS. CHS are provided principally for members of federally recognized tribes who reside on or near the reservation established for the local tribe(s) in geographic areas called contract health service delivery areas (CHSDAs). The eligibility requirements are stricter for CHS than they are for direct care. In addition, the IHS Urban Indian Health Program (UIHP) supports contracts and grants to 34 urban health programs funded under Title V of the Indian Health Care Improvement Act. Approximately 100,000 American Indians use 23 Title V Urban Indian health programs and are not able to access hospitals, health clinics, or contract health services administered by IHS and tribal health programs because they either do not meet IHS eligibility criteria or reside outside of IHS and tribal service areas. A member of a Federally recognized tribe may obtain care at any IHS hospital or clinic if the facility has the staff and capability to provide the medical care. One of the additional requirements for CHS is that the patient must reside in certain areas. One way to meet the residency requirement is to live on the reservation of any Federally recognized tribe. Another way to meet the residency requirement is to reside within the contract health service delivery area (CHSDA) for the patient's tribe. Many, or even most, people who move away from their home reservations are not eligible for CHS since they would be moving away from the CHSDA in which they have eligibility. Some programs or portions of programs are tribally operated instead of being operated by the Federal Government through the IHS. Some tribally operated hospitals or clinics restrict services to members of their own tribe. Consequently, although a patient may be a member of a Federally recognized tribe they may not be provided medical care at a tribally operated hospital or clinic. For more: https://www.ihs.gov/forpatients/faq Insured: The health insurance coverage categories are mutually exclusive. Medicaid or CHIP: “Medicaid” is a joint federal and state program that helps with medical costs for some people with limited income and resources. (https://www.medicare.gov/your-medicare-costs/get-help-paying-costs/medicaid ) “CHIP,” the Children’s Health Insurance Program is a joint federal and state program that provides health coverage to eligible children. (https://www.medicaid.gov/chip/chip-program-information.html) TriCare is the health care program for uniformed service members (includes active duty and retired members of the U.S. Army, U.S. Air Force, U.S. Coast Guard, U.S. Marine Corps, U.S. Navy, Commissioned Corps of the U.S. Public Health Service, Commissioned Corps of the National Oceanic and Atmospheric Association), and their families. (http://tricare.mil/About.aspx?utm_source=footer&utm_medium=organic&utm_campaign=about-us) Private Insurance includes supplemental insurance that is provided to an individual by a private insurer (whether purchased by an individual for him/herself and family, a tribe for tribal members, or an employer for employees).
A.2: Participant Demographics during Reporting Period (Newly Enrolled Only)
10	Participants by Ethnicity (Newly Enrolled)	Hispanic or Latino: individuals of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. The responses regarding ethnicity should reflect what the individual considers herself/himself to be and are not based on percentages of ancestry.
11	Participants by Race (Newly Enrolled)	White: individuals having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American: individuals having origins in any of the Black racial groups of Africa. American Indian and Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment. Asian: individuals having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Indonesia, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Native Hawaiian and Other Pacific Islander: individuals having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. More than one race: individuals who considers himself/herself to be of more than one race as defined above. The responses regarding race should reflect what the individual considers herself/himself to be and are not based on percentages of ancestry. If ethnicity and race are unknown or not reported for some participants, enter that count in the respective “Unknown/Did not Report” columns.
12	Adult Participants by Marital Status (Newly Enrolled)	If more than one adult participant is enrolled in the program in a single household, provide the status for all adult participants. For example, if a pregnant woman is enrolled with her spouse in the program, both participants would be counted under the married category. Single: individuals who have never married. Legally Married: individuals that have wed in manner legally recognized by their jurisdiction. Not Married but living together with partner: individuals living with a partner but not considered legally married. Separated/Divorced/Widowed: “Separated” refers to married individuals who are not living with their spouse due to marital discord. “Divorced” indicates individuals who reported being divorced and have not remarried. “Widowed” indicates individuals whose last marriage ended with the death of their spouse and they have not remarried. https://www.census.gov/prod/2003pubs/c2kbr-30.pdf
13	Adult Participants by Educational Attainment (Newly Enrolled)	Less than high school diploma: includes individuals who are older than high school age and who did not complete their high school education. For example, a 23-year-old mother who did not finish high school would be included in this category because she is not of high school age and did not finish her high school education. High school diploma/GED: includes individuals who completed their high school education or received a GED. Some college/training: includes individuals who are currently enrolled in an undergraduate degree or taking undergraduate coursework, or participate in a training program, and those who attended in the past but did not obtain a degree or certification. Technical training or certification: includes individuals who received technical training or certification in the past. Associate’s Degree: includes individuals who obtained an Associate’s Degree. Bachelor’s Degree or higher: includes individuals who obtained a Bachelor’s Degree or higher (e.g., Master’s Degree, graduate-level courses). Other: includes those individuals who did not fall into the other specified categories.
14	Primary Language Spoken at Home of Index Children (Newly Enrolled)	Primary language: the language spoken in the home the majority of the time. Any Native American language: includes any language indigenous to an American Indian or Alaska Native tribe or community.
15	Secondary Language Spoken at Home of Index Children (Newly Enrolled)	Secondary language: a language spoken in the home the minority of the time. Any Native American language: includes any language indigenous to an American Indian or Alaska Native tribe or community.
16	Priority Population Household Characteristics (Newly Enrolled)	Categories are not mutually exclusive. A household can be counted in more than one category. Low-Income household: A household with an income determined to be below the official poverty line defined by the Census Bureau. This is updated every year online: https://aspe.hhs.gov/poverty-guidelines. Household contains an enrollee who is pregnant and under age 21: A household where a primary caregiver is a pregnant woman under 21 years old at time of enrollment. Household has a history of child abuse or neglect or has had interactions with child welfare services: an adult participant or index child has a history of abuse or neglect or has had involvement with child welfare services either as a child or as an adult. Household has a history of substance abuse or needs substance abuse treatment: a household with at least one adult participant who has a history of substance abuse or who has been identified as needing substance abuse services. Someone in the household uses tobacco products in the home: a household with at least one adult participant who uses tobacco products in the home or who has been identified as using tobacco. Tobacco use is defined as combustibles (cigarettes, cigars, pipes, hookahs, bidis), non-combustibles (chew, dip, snuff, snus, and dissolvables), and electronic nicotine delivery systems (ENDS). Ceremonial use of tobacco is not considered “tobacco use.” Someone in the household has attained low student achievement or has a child with low student achievement: a household where an adult participant or their child(ren) (index child or another child in the household) is reported as having low student achievement. Household has a child with developmental delays or disabilities: a household with a child or children (index child or another child in the household) who is suspected of having a developmental delay or disability. Household includes individuals who are serving or formerly served in the US armed forces: a household that includes individuals who are serving or formerly served in the U.S. Armed Forces (Army, Navy, Air Force, Marine Corps, Coast Guard, National Guard and Reserve), including such families that have members of the Armed Forces who have had multiple deployments outside of the United States. For this criterion, the definition includes a military member’s dependent acquired through marriage, adoption, or other action during the course of a member’s current tour of assigned duty.
A.3: Participant Service Utilization during Reporting Period (Newly Enrolled and Continuing)
17	Home Visits	Total Number of Home Visits Completed: refers to the total number of home visits per household at the end of the reporting period. Total Number of Virtual Home Visits Completed: refers to the total number of virtual home visits completed per household at the time of the reporting period. A virtual home visit, as described in an applicable service delivery model, is a home visit that is conducted solely by the use of electronic information and telecommunications technologies. Please refer to model-specific guidance for specific definitions.
18	Family Engagement by Household (Newly Enrolled and Continuing)	Currently receiving services: refers to a household that is participating in services at the end of the reporting period. Completed program: refers to a household that completed the program according to model-specific definitions and criteria, or grantee-defined criteria if the model does not provide guidance, during the reporting period. Stopped services before completion: refers to a household that left the program for any reason prior to completion. Enrolled but not currently receiving services/Other: refers to those households that do not fall into the previous categories and may include unreachable participants (i.e., the family is not regularly participating but did not actively sever ties, etc.) Please provide additional information about household reason for stopping services before completion, or for being enrolled but not currently receiving services/other in the A.3 Notes section.
SECTION B: PROGRAM STAFF DEMOGRAPHICS
Tables 20-24		All staff who were employed at any time during the reporting period should be included in Tables 20-24. This includes staff that joined mid-way through the reporting period and staff that left the team during the reporting period. Below are common staff definitions. When reporting staff that fall under the Data/Evaluation or Program Support Staff definition, include the data in the Project Directors/Managers/Coordinators fields in Section B, Tables 20-24 and add a note in the notes field. Home Visitors: A home visitor employed or contracted by the Tribal MIECHV program, regardless of the percentage of his/her personnel costs paid for with Tribal MIECHV funding. Project Directors/Managers/Coordinators: Staff that play a key oversight role for the Tribal MIECHV grant, directly employed or contracted by the grantee regardless of the percentage of his/her personnel costs paid for with Tribal MIECHV funding. Data/Evaluation Staff: Staff involved in data entry support, reporting and evaluation as part of the Tribal MIECHV grant, directly employed or contracted by the grantee, regardless of the percentage of his/her personnel costs paid for with Tribal MIECHV funding. Project Support Staff: All other positions that play a supportive role to the Tribal MIECHV grant, directly employed or contracted by the grantee, and do not fall under “Home Visitor,” “Project Directors/Managers/Coordinators,” and “Data/Evaluation Staff.”
22	Program Staff by Ethnicity	Hispanic or Latino: individuals of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. The responses regarding ethnicity should reflect what the individual considers herself/himself to be and are not based on percentages of ancestry.
23	Program Staff by Race	White: individuals having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American: individuals having origins in any of the Black racial groups of Africa. American Indian and Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment. Asian: individuals having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Indonesia, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Native Hawaiian and Other Pacific Islander: individuals having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. More than one race: individuals who considers himself/herself to be of more than one race as defined above. The responses regarding race should reflect what the individual considers herself/himself to be and are not based on percentages of ancestry. If ethnicity and race are unknown or not reported for some participants, enter that count in the respective “Unknown/Did not Report” columns.
24	Program Staff by Educational Attainment	Less than high school diploma: includes individuals who are older than high school age and who did not complete their high school education. High school diploma/GED: includes individuals who completed their high school education or received a GED. Some college/training: includes individuals who are currently enrolled in an undergraduate degree or taking undergraduate coursework, or participate in a training program, and those who attended in the past but did not obtain a degree or certification. Technical training or certification: includes individuals who received technical training or certification in the past. Associate’s Degree: includes individuals who obtained an Associate’s Degree. Bachelor’s Degree: includes individuals who obtained a Bachelor’s Degree. Master’s Degree or Higher: includes individuals who obtained a Master’s Degree or higher (e.g., PhD, MD, JD). Other: includes those individuals who did not fall into the other specified categories.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Department of Health and Human Services
File Modified	0000-00-00
File Created	2022-05-03