Form 1 RHP Program Data Indicators Form

Generic Performance Progress Report

RHP Program Data Indicators Form

Refugee Health Promotion Data Indicators

OMB: 0970-0490

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REFUGEE HEALTH PROMOTION
Program Data Indicators
The Program Data Points are reported on an annual basis and are to be submitted on September 14,
along with the semi-annual Performance Progress Report (PPR) and Federal Financial Report (FFR).
For more detailed instruction of the below data points, see the Refugee Health Promotion Program
Data Indicators User Guide. For more information about general program reporting requirements,
please refer to the FOA that aligns with current funding.
Legal Organization Name

DUNS Number

Federal Grant Number

EIN

Reporting Period
Start Date:
(MM/DD/YYYY)

End Date:
(MM/DD/YYYY)

I. DEMOGRAPHICS & LOCALITIES SERVED
Where applicable, provide the number of unduplicated individual clients served for each demographic in the ‘Total’
column. Do not leave any blanks; indicate ‘0’ where applicable.
Data Indicator
Total
1. Number of unduplicated of clients served by immigration status
Refugee
Asylee
SIV
Cuban or Haitian Entrant
Trafficking Victim
Amerasian
Total unduplicated number of clients served
0
2. Number of unduplicated clients served by country of origin List the top 5 countries.

All other countries (combined)
Total unduplicated number of clients served from all countries
0
3. Number of organization(s) funded and location(s) served
Number of organization(s) funded by RHP
Number of location(s) served
II. SERVICES
Provide the total number of recipients for each service in the ‘Total’ column and a description for each service in the
space provided. Do not leave any blanks; indicate ‘0’ and ‘N/A’ where applicable.
*For Pro Bono Services, provide the number of hours instead of the number of clients.
Data Indicator
Total
1. Case management Includes medical and mental health case management and coordination of community resources for the provision of
medically necessary health care services.

Number of clients who received medical case management services
Number of clients who received mental health case management services

OMB Control Number: 0970-0490
Expiration date: 1/31/2020

Total unduplicated number of clients receiving case management services
2. Adjustment or support groups Includes community adjustment groups, support groups, or other similar activities
Number of clients who attended adjustment or support groups
3. Health orientation and education Includes U.S. healthcare orientation workshops and other health
education classes.

Number of clients who received initial health orientation services
Number of clients who received additional health education services
Number of clients who received mental health education/training
4. Service provider education Includes education on refugee health, mental health training, and National
Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care.

5. Interpretation services
6. Translation services

Number of service providers that received training
Number of hours of interpretation services provided

Number of clients who received translated materials
7. Pro Bono Services For each service area, indicate the total number of pro-bono hours contributed by providers and other volunteers
during the reporting period.

Interpreters/translators
Medical
Mental health
Social
General volunteer hours
Other
Total hours contributed

0

Medical Case Management
Mental Health Case Management
Interpretation/Translation
Health Orientation/Education
Adjustment or Support Groups
Administrative
Other Activities
Total

0

8. Please provide a breakdown by percentage of RHP grant activities:

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)
Public reporting burden for this collection of information is estimated to average 3 hours per response, including the time
for reviewing instructions, gathering and maintaining the data needed, 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.

OMB Control Number: 0970-0490
Expiration date: 1/31/2020


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