4 Program Data Collection Activity

Attachment D. Program Data Collection Activity

Administrative Data

This protocol will be used to ask home visiting programs to record information about the families and services provided between March 1, 2020 and September 30, 2022. This protocol collects data for each month of the study period when possible. The study team will provide support and technical assistance to local programs in completing this request.

Newly Enrolled Participants

1. For each month, month 1 (March 1, 2020) – month 32 (September 30, 2022), please enter:

a) the number of newly enrolled participants in the month and the number of continuing participants in the month for each of the MIECHV Form 1 categories listed below.

	MIECHV Form 1 category	Number of newly enrolled participants	Number of continuing participants
Race
	American Indian or Alaska Native
	Asian
	Black or African American
	Native Hawaiian or Other Pacific Islander
	White
	More than one race
	Unknown/Did not report
Ethnicity
	Hispanic or Latino
	Not Hispanic or Latino
	Unknown/Did not report
Primary Language Spoken at Home
	English
	Spanish
	Other
	Unknown/Did not report
Educational Attainment
	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
Employment Status
	Employed full-time
	Employed part-time
	Not employed
	Unknown/Did not Report
Type of Health Insurance Coverage
	No insurance coverage
	Medicaid or CHIP
	Tri-Care
	Private or Other
	Unknown/Did not Report
Housing status
	Not Homeless
	Owns or shares own home, condominium, or apartment
	Rents or shares own home or apartment
	Lives in public housing
	Lives with parent or family member
	Some other arrangement
	Homeless
	Homeless and sharing housing
	Homeless and living in an emergency or transitional shelter
	Some other arrangement
	Unknown/Did not Report

Visits

2. How does your program collect information on number of home visits completed? For example, does your program collect information on visits completed in-person? Visits completed by phone? [Record types of visit modalities.]

For each month, month 1 (March 1, 2020) – month 32 (September 30, 2022), please enter:

a) for all active participants, the number of visits for each of the categories your program uses to record completed visits. Categories included below are examples.

	Example category	Number of visits
Modality
	In-person visits
	Phone visits
	Video visits
	Text messages

Referrals

3. How does your program collect information on number of referrals provided? For example, does your program collect information on referrals for mental health? For substance use? [Record types of referrals.]

For each month, month 1 (March 1, 2020) – month 32 (September 30, 2022), please enter:

a) for all active participants, the number of referrals for each of the categories your program uses to record referrals. These may include referrals for adult and child participants. Categories included below are examples.

	Example category	Number of referrals
Health care
	OB provider
Social services
	WIC
Housing
	Section 8
Behavioral health
	Mental health
Child services
	Child care
F. Other referral type
	Legal services

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