Form 2 Tribal MIECHV Reporting Form 2

OMB Control Number 0970-0500

Expiration date

TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING (MIECHV)

HOME VISITING FORM 2

GRANTEE PERFORMANCE MEASURES

1. PERFORMANCE MEASURE
Benchmark Area:
Construct:
Indicator:
2. STANDARDIZED DEFINITIONS
Numerator:
Denominator:
Type of Measure:		Unit of analysis:
Target Population:
Data Source:
3. GRANTEE SPECIFICATIONS
Definitions of Key Terms:
Data Collection Tool(s) or Form(s) and Question(s):
Data Collection Time Points:
Numerator Inclusion/Exclusion Criteria:
Denominator Inclusion/Exclusion Criteria:
4. CONTEXT OF MEASUREMENT
Date first data point was collected:		Number of people assessed:
5. DATA VALUES AND CONSIDERATIONS
Numerator value:	Denominator value:		Value for reporting period:
Data quality considerations:
Performance considerations:

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13). The purpose of this information collection is to collect legislatively mandated performance data. The 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 mandatory collection of information under Section 511 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. If you have any comments on this collection of information, please contact Anne Bergan, (202) 260-8515 or [email protected].

Instructions for the Completion of Home Visiting Form 2

Grantee Performance Measures

Sections 1 (Performance Measure) and 2 (Standardized Definitions) of Form 2 have been provided for all measures and are not modifiable, as these items have been standardized across all grantees.

Please complete Sections 3, 4, and 5 for each performance measure.

3. Grantee Specifications

Definitions of key terms: Clarify the meaning of the terms utilized in the measure definition (e.g., what counts as a “home visit”?). The terms that require clarification are listed in the Performance Measurement Plan.

Data collection tool(s) or form(s) and question(s): Include any tools utilized to collect the data. If no measurement tool or scale is needed, state the question(s) posed to collect the needed information.

Data collection time points: Specify the time(s) when the data will be collected (e.g., 3-months post enrollment, after each home visit). If multiple data elements are used to calculate the numerator and denominator, include the time points for all data elements.

Numerator inclusion/exclusion criteria: Describe the criteria you will use to determine what data are included in the numerator and/or what data are not included (beyond the parameters set in the measure definition). You are not required to provide both inclusion and exclusion criteria for each measure.

Denominator inclusion/exclusion criteria: Describe the criteria you will use to determine what data are included in the denominator and/or what data are not included (beyond the parameters set in the measure definition). You are not required to provide both inclusion and exclusion criteria for each measure.

3. Context of Measurement

Date first data point was collected: Specify the first date (MM/DD/YYYY) that any performance measurement data were collected for each measure (e.g., if a measure specifies that data are first collected from primary caregivers at 3-months post enrollment, then the date provided would be the first date that any participating primary caregiver reached this target and was assessed). These data are only entered the first time data are reported.

Number of people assessed: Indicate the number of individual participants who were assessed for the measure during the reporting period. If the unit of analysis (indicated in Section 1) is “Participant,” this number will be the same as the denominator.

3. Data Values and Considerations

Numerator value: Enter the value obtained for the numerator during the reporting period.

Denominator value: Enter the value obtained for the denominator during the reporting period.

Value for reporting period: The value for the reporting period will be auto calculated by the Federal Data Reporting System. The value will be calculated as the numerator divided by the denominator.

Data quality considerations: Explain any factors that affected your ability to report complete and accurate data (e.g., missing data because a home visitor left the team and data was not collected at the specified time point).

Performance considerations: Explain any factors that affected your ability to demonstrate improved performance for the measure (e.g., a major health clinic closed affecting the ability of program participants to receive well-child visits).