Grant Report

Maternal and Child Health Bureau Performance Measures for Discretionary Grant Information System (DGIS)

Attachment C - Financial and Demographic Data Elements_Clean

Grant Report

OMB: 0915-0298

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0915-0298 can be found here:

2024-04-17 - No material or nonsubstantive change to a currently approved collection

Document [docx]

Download: docx | pdf

OMB Number: 0915-0298

Expiration Date: [Insert Date]

Health Resources and Services Administration

Maternal and Child Health Bureau

Discretionary Grant Performance Measures

OMB No. 0915-0298

Expires: ________

Attachment C:

Financial and Demographic Data Elements

OMB Clearance Package

Public Burden Statement: 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. The OMB control number for this project is 0915-0298. Public reporting burden for this collection of information is estimated to average 36 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N-39, Rockville, Maryland, 20857.

Attachment C:
Financial and Demographic Data Elements

Form 1 – MCHB Project Budget Details for FY 3

Form 3 – Budget Details by Types of Individuals Served 4

Form 5 – Number of Individuals Served (unduplicated) 6

Form 6 – Maternal & Child Health Discretionary Grant 8

Form 7 – Discretionary Grant Project 13

Form 8 – MCH Discretionary Grant Project Abstract for FY

(For Research Projects ONLY) 18

Form 9 - Tracking Project Performance Measures 21

Form 10 - Project Performance Outcome Measure 23

FORM 1

MCHB PROJECT BUDGET DETAILS FOR FY _______

1.	MCHB GRANT AWARD AMOUNT		$
2.	MATCHING FUNDS (Required: Yes [ ] No [ ] If yes, amount)		$
2.
	A. Local funds	$
	B. State funds	$
	C. Program Income	$
	D. Applicant/Grantee Funds	$
	E. Other funds:	$
3.	OTHER PROJECT FUNDS (Not included in 3 above)		$
	A. Local funds	$
	B. State funds	$
	C. Program Income (Clinical or Other)	$
	D. Applicant/Grantee Funds (includes in-kind)	$
	E. Other funds (including private sector, e.g., Foundations)	$
4.	TOTAL PROJECT FUNDS (Total lines 1 through 4)		$
5.	FEDERAL COLLABORATIVE FUNDS (Source(s) of additional Federal funds contributing to the project including Other MCHB Funds, Other HRSA Funds, and Other Federal Funds)		$
5.

INSTRUCTIONS FOR COMPLETION OF FORM 1

MCH BUDGET DETAILS FOR FY ____

Line 1. Enter the amount of the Federal MCHB grant award for this project.

Line 2. If matching funds are required for this grant program list the amounts by source on lines 2A through 2E as appropriate. Where appropriate, include the dollar value of in-kind contributions.

Line 3. Enter the amount of other funds received for the project, by source on Lines 3A through 3E, specifying amounts from each source. Also include the dollar value of in-kind contributions.

Line 4. Displays the sum of lines 1 through 3.

Line 5. Enter the total amount of other Federal funds received on Line 5 other than the MCHB grant award for the project. Such funds would include those from other Departments, other components of the Department of Health and Human Services, or other MCHB grants or contracts

FORM 3

BUDGET DETAILS BY TYPES OF INDIVIDUALS SERVED

For Projects Providing Direct Health Care, Enabling, or Population-based Services

	FY________
Target Population(s)	$ Budgeted
Pregnant Women (All Ages)
Infants <1 year
Children 1 through 21 years
CSHCN
Non-pregnant Women (Age 22 and over)
Other
TOTAL

INSTRUCTIONS FOR COMPLETION OF FORM 3

BUDGET DETAILS BY TYPES OF INDIVIDUALS SERVED

For Projects Providing Direct Services, Enabling, or Public Health Services and Systems

If the project provides direct services, complete all required data cells for all years of the grant. If an actual number is not available make an estimate. Please explain all estimates in a note.

All ages are to be read from x to y, not including y. For example, infants are those from birth to 1, and

children and youth are from age 1 to 21.

Enter the budgeted amounts for the appropriate fiscal year, for each targeted population group.

FORM 5

NUMBER OF INDIVIDUALS SERVED (UNDUPLICATED)

By Type of Individual and Source of Primary Insurance Coverage

For Projects Providing Direct Health Care, Enabling or Population-based Services

Reporting Year________

Table 1

Individuals Served	(a) Number Served	(b) Total Served	(c) Title XIX %	(d) Title XXI %	(e) Private/ Other %	(f) None %	(g) Unknown %
Pregnant Women (All Ages)
Infants <1 year
Children 1 through 21 years
CSHCN
Non-pregnant Women (Age 22 and over)
Other
Unknown
TOTAL

TOTAL SERVED: ________________

INSTRUCTIONS FOR THE COMPLETION OF FORM 5

NUMBER OF INDIVIDUALS SERVED (UNDUPLICATED)

By Type of Individual and Source of Primary Insurance Coverage

For Projects Providing Direct Health Care, Enabling or Population-based Services

Enter data into all required (unshaded) data cells. If an actual number is not available, make an estimate. Please explain all estimates, in a note.

Note that ages are expressed as either x to y, (i.e., 1 to 25, meaning from age 1 up to age 25, but not including 25) or x – y (i.e., 1 – 4 meaning age 1 through age 4). Also, symbols are used to indicate directions. For example, <1 means less than 1, or from birth up to, but not including age 1.

1. At the top of the Form, the Line Reporting Year displays the year for which the data applies.

In Column (a), enter the unduplicated count of individuals who received a direct service from the project regardless of the primary source of insurance coverage. These services are those that are done by any non-capacity building services and would include individuals served by total dollars reported on Form 3, Line 7. Counts of Pregnant women and Non-pregnant women should be unduplicated and reported separately in their respective lines. Counts for CSHCN can be duplicative counts of Children 1 to 21 years.

In the remaining columns, report the percentage of those individuals receiving direct health care, enabling

or population-based services, who have as their primary source of coverage:

Column (c): Title XIX (includes Medicaid expansion under Title XXI)

Column (d): Title XXI

Column (e): Private or other coverage

Column (f): None

Column (g): Unknown

These may be estimates. If individuals are covered by more than one source of insurance, they should be listed under the column of their primary source.

FORM 6

MATERNAL & CHILD HEALTH DISCRETIONARY GRANT

PROJECT ABSTRACT

FOR FY____

PROJECT:__________________________________________________________________________________

I. PROJECT IDENTIFIER INFORMATION

1. Project Title:

2. Project Number:

3. E-mail address:

II. BUDGET

1. MCHB Grant Award $_____________

(Line 1, Form 1)

2. Matching Funds (if applicable) $_____________

(Line 2, Form 1)

3. Other Project Funds $_____________

(Line 3, Form 1)

4. Total Project Funds $_____________

(Line 4, Form 1)

III. TYPE(S) OF SERVICE PROVIDED (Choose all that apply)

[ ] Direct Services

Percent of Budget for Direct Services ____

[ ] Enabling Services

Percent of Budget for Enabling Services

[ ] Public Health Services and Systems

Percent of Budget for Public Health Services and Systems ____

DOMAIN SERVICES ARE PROVIDED TO

[ ] Maternal/ Women’s’ Health

[ ] Perinatal/ Infant Health

[ ] Child Health

[ ] Children with Special Health Care Needs

[ ] Adolescent Health

[ ] Life Course/ All Population Domains

[ ] Local/ State/ National Capacity Building

PROJECT DESCRIPTION OR EXPERIENCE TO DATE

A. Project Description

Problem (in 50 words, maximum):
Program Objectives and Key Activities: (List up to 5 major aims and key related activities for the project. These should reflect the aims from the NOFO, also these will be used for Grant Impact measurement at the end of your grant period.)

Objective 1:

Related Activity 1:

Related Activity 2:

Objective 2:

Related Activity 1:

Related Activity 2:

Objective 3:

Related Activity 1:

Related Activity 2:

Objective 4:

Related Activity 1:

Related Activity 2:

Objective 5:

Related Activity 1:

Related Activity 2:

Specify the primary Healthy People 2020 objectives(s) (up to three) which this project addresses:

4. Coordination (List the State, local health agencies or other organizations involved in the project and their roles)

5. Evaluation (briefly describe the methods which will be used to determine whether process and outcome objectives are met, be sure to tie to evaluation from NOFO.)

6. Quality Improvement Activities

B. Continuing Grants and Ending Grants ONLY

Progress Towards Objectives to Date :
1. Did you make measurable progress towards Objective 1 in the past year?

 Yes  No

Provide data that support this: ______

Did you make measurable progress towards Objective 2 in the past year?

 Yes  No

Provide data that support this: ______

Did you make measurable progress towards Objective 3 in the past year?

 Yes  No

Provide data that support this: ______

Did you make measurable progress towards Objective 4 in the past year?

 Yes  No

Provide data that support this: ______

Did you make measurable progress towards Objective 5 in the past year?

 Yes  No

Provide data that support this: ______

Website URL and annual number of hits
1. __________ Number of web hits
2. __________ Number of unique visitors

KEY WORDS
ANNOTATION

INSTRUCTIONS FOR THE COMPLETION OF FORM 6

PROJECT ABSTRACT

NOTE: All information provided should fit into the space provided in the form. The completed form should be no more than 3 pages in length. Where information has previously been entered in forms 1 through 5, the information will automatically be transferred electronically to the appropriate place on this form.

Section I – Project Identifier Information

Project Title: Displays the title for the project.

Project Number: Displays the number assigned to the project (e.g., the grant number)

E-mail address: Displays the electronic mail address of the project director

Section II – Budget - These figures will be transferred from Form 1, Lines 1 through 4.

Section III - Types of Services

Indicate which type(s) of services your project provides, checking all that apply. For each type of service selected, indicated the percent of the Budget that is dedicated to that type of service. Percents for all three service types should sum to 100%.

Direct Health Care Services - enter the budgeted and expended amounts for the appropriate fiscal year completed and budget estimates only for all other years.

Direct Health Care Services are those services generally delivered one-on-one between a health professional and a patient in an office, clinic or emergency room which may include primary care physicians, registered dietitians, public health or visiting nurses, nurses certified for obstetric and pediatric primary care, medical social workers, nutritionists, dentists, sub-specialty physicians who serve children with special health care needs, audiologists, occupational therapists, physical therapists, speech and language therapists, specialty registered dietitians. Basic services include what most consider ordinary medical care, inpatient and outpatient medical services, allied health services, drugs, laboratory testing, x-ray services, dental care, and pharmaceutical products and services. State Title V programs support - by directly operating programs or by funding local providers - services such as prenatal care, child health including immunizations and treatment or referrals, school health and family planning. For CSHCN, these services include specialty and sub-specialty care for those with HIV/AIDS, hemophilia, birth defects, chronic illness, and other conditions requiring sophisticated technology, access to highly trained specialists, or an array of services not generally available in most communities.

Enabling Services - enter the budgeted and expended amounts for the appropriate fiscal year completed and budget estimates only for all other years.

Enabling Services allow or provide for access to and the derivation of benefits from, the array of basic health care services and include such things as transportation, translation services, outreach, respite care, health education, family support services, purchase of health insurance, case management, coordination of with Medicaid, WIC and educations. These services are especially required for the low income, disadvantaged, geographically or culturally isolated, and those with special and complicated health needs. For many of these individuals, the enabling services are essential - for without them access is not possible. Enabling services most commonly provided by agencies for CSHCN include transportation, care coordination, translation services, home visiting, and family outreach. Family support activities include parent support groups, family training workshops, advocacy, nutrition and social work.

Public Health Services and Systems - enter the budgeted and expended amounts for the appropriate fiscal year completed and budget estimates only for all other years.

Public Health Services and Systems include preventive interventions and personal health services, developed and available for the entire MCH population of the State rather than for individuals in a one-on-one situation. Disease prevention, health promotion, and statewide outreach are major components. Common among these services are newborn screening, lead screening, immunization, Sudden Infant Death Syndrome counseling, oral health, injury prevention, nutrition and outreach/public education. These services are generally available whether the mother or child receives care in the private or public system, in a rural clinic or an HMO, and whether insured or not. The other critical aspect of Public Health Services and Systems are activities directed at improving and maintaining the health status of all women and children by providing support for development and maintenance of comprehensive health services systems and resources such as health services standards/guidelines, training, data and planning systems. Examples include needs assessment, evaluation, planning, policy development, coordination, quality assurance, standards development, monitoring, training, applied research, information systems and systems of care. In the development of systems of care it should be assured that the systems are family centered, community based and culturally competent.

Section IV – Program Description OR Current Status (DO NOT EXCEED THE SPACE PROVIDED)

A. New Projects only are to complete the following items:

A brief description of the project and the problem it addresses, such as preventive and primary care services for pregnant women, mothers, and infants; preventive and primary care services for children; and services for Children with Special Health Care Needs.
Provide up to 5 aims of the project, in priority order. Examples are: To reduce the barriers to the delivery of care for pregnant women, to reduce the infant mortality rate for minorities and “services or system development for children with special healthcare needs.” MCHB will capture annually every project’s top aims in an information system for comparison, tracking, and reporting purposes; you must list at least 1 and no more than 5 aims. For each goal, list the key related activities. The aims and activities must be specific and time limited (i.e., Aim 1: increase providers in area trained in providing quality well-child visits by 10% by 2017 through 1. trainings provided at state pediatric association and 2. on-site technical assistance).
Displays the primary Healthy People 2020 goal(s) that the project addresses.
Describe the programs and activities used to reach aims, and comment on innovation, cost, and other characteristics of the methodology, proposed or are being implemented. Lists with numbered items can be used in this section.
Describe the coordination planned and carried out, in the space provided, if applicable, with appropriate State and/or local health and other agencies in areas(s) served by the project.
Briefly describe the evaluation methods that will be used to assess the success of the project in attaining its aims and implementing activities.

For continuing and ending projects ONLY:

For each program objective, select Yes/No to indicate if measurable progress towards the objective was made during the reporting period. Provide data and a brief description that supports the Yes/No selection. (not to exceed 200 words).
If applicable, provide the number of hits by unique visitors to the website (or section of website) funded by MCHB for the past year.

Section V – Key Words

Provide up to 10 key words to describe the project, including populations served. Choose key words from the included list.

Section VI – Annotation

Provide a three- to five-sentence description of your project that identifies the project’s purpose, the needs and problems, which are addressed, the aims of the project, the related activities which will be used to meet the aims, and the materials, which will be developed.

FORM 7

DISCRETIONARY GRANT PROJECT

SUMMARY DATA

Project Service Focus

[ ] Urban/Central City [ ] Suburban [ ] Metropolitan Area (city & suburbs)

[ ] Rural [ ] Frontier [ ] Border (US-Mexico)

Project Scope

[ ] Local [ ] Multi-county [ ] State-wide

[ ] Regional [ ] National

Grantee Organization Type

[ ] State Agency

[ ] Community Government Agency

[ ] School District

[ ] University/Institution Of Higher Learning (Non-Hospital Based)

[ ] Academic Medical Center

[ ] Community-Based Non-Governmental Organization (Health Care)

[ ] Community-Based Non-Governmental Organization (Non-Health Care)

[ ] Professional Membership Organization (Individuals Constitute Its Membership)

[ ] National Organization (Other Organizations Constitute Its Membership)

[ ] National Organization (Non-Membership Based)

[ ] Independent Research/Planning/Policy Organization

[ ] Other _________________________________________________________

Project Infrastructure Focus (from MCH Pyramid) if applicable

[ ] Guidelines/Standards Development And Maintenance

[ ] Policies And Programs Study And Analysis

[ ] Synthesis Of Data And Information

[ ] Translation Of Data And Information For Different Audiences

[ ] Dissemination Of Information And Resources

[ ] Quality Assurance

[ ] Technical Assistance

[ ] Training

[ ] Systems Development

[ ] Other

5. Demographic Characteristics of Project Participants

Indicate the service level:

Shape1 Direct Health Care Services

Shape2 Enabling Services

Shape3 Public Health Services and Systems

RACE (Indicate all that apply)

ETHNICITY

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

More than One Race

Unrecorded

Total

Hispanic or Latino

Not Hispanic or Latino

Unrecorded

Total

Pregnant Women (All Ages)

Infants <1 year

Children 1 to 12 years

Adolescents 12-18 years

Young Adults 18-21 years

CSHCN

Non-Pregnant Women

22+ years

Other 22+

Unknown

TOTALS

6. Clients’ Primary Language(s)

__________________________________

__________________________________

Population Served
[ ] Homeless

[ ] Incarcerated

[ ] Severely Depressed

[ ] Migrant Worker/ Population

[ ] Uninsured

[ ] Adolescent Pregnancy

[ ] Food Stamp Eligible

[ ] Other

8. Resource/TA and Training Centers ONLY

Answer all that apply.

Characteristics of Primary Intended Audience(s)

[ ] Providers/ Professionals

[ ] Local/ Community partners

[ ] Title V

[ ] Other state agencies/ partners

[ ] Regional

[ ] National

[ ] International

b. Number of Requests Received/Answered: ___/____

Number of Continuing Education credits provided: _______
Number of Individuals/ Participants Reached: _______
Number of Organizations Assisted: _______
Major Type of TA or Training Provided:

[ ] continuing education courses,

[ ] workshops,

[ ] on-site assistance,

[ ] distance learning classes

[ ] one-on-one remote consultation

[ ] other, Specify: ____________

INSTRUCTIONS FOR THE COMPLETION OF FORM 7

PROJECT SUMMARY

Section 1 – Project Service Focus

Select all that apply

Section 2 – Project Scope

Choose the one that best applies to your project.

Section 3 – Grantee Organization Type

Choose the one that best applies to your organization.

Section 4 – Project Infrastructure Focus

If applicable, choose all that apply.

Section 5 – Demographic Characteristics of Project Participants

Indicate the service level for the grant program. Multiple selections may be made. Please fill in each of the cells as appropriate.

Section 6 – Clients Primary Language(s)

Indicate which languages your clients speak as their primary language, other than English, for the data provided in Section 6. List up to three languages.

Section 7 – Check all population served

Section 8 – Resource/TA and Training Centers (Only)

Answer all that apply.

FORM 8

(For Research Projects ONLY)

MATERNAL & CHILD HEALTH DISCRETIONARY GRANT

PROJECT ABSTRACT

FOR FY____

I. PROJECT IDENTIFIER INFORMATION

1. Project Title:

2. Project Number:

Project Director:
Principle Investigator(s), Discipline

II. BUDGET

1. MCHB Grant Award $_____________

(Line 1, Form 1)

2. Matching Funds (if applicable) $_____________

(Line 2, Form 1)

Other Project Funds $_____________

(Line 3, Form 1)

Total Project Funds $_____________

(Line 4, Form 1)

III. CARE EMPHASIS

[ ] Interventional

[ ] Non-interventional

IV. POPULATION FOCUS

[ ] Neonates [ ] Pregnant Women

[ ] Infants [ ] Postpartum Women

[ ] Toddlers [ ] Parents/Mothers/Fathers

[ ] Preschool Children [ ] Adolescent Parents

[ ] School-Aged Children [ ] Grandparents

[ ] Adolescents [ ] Physicians

[ ] Adolescents (Pregnancy Related) [ ] Others

[ ] Young Adults (>20)

V. STUDY DESIGN

[ ] Experimental

[ ] Quasi-Experimental

[ ] Observational

VI. TIME DESIGN

[ ] Cross-sectional

[ ] Longitudinal

[ ] Mixed

VII. PRIORITY RESEARCH ISSUES AND QUESTIONS OF FOCUS

From the Maternal and Child Health Bureau (MCHB) Strategic Research Issues: Fiscal Years (FYs) 2004 – 2009.

Primary area addressed by research:

Secondary area addressed by research:

ABSTRACT
KEY WORDS

X. ANNOTATION

INSTRUCTIONS FOR THE COMPLETION OF FORM 8

MATERNAL & CHILD HEALTH

RESEARCH PROJECT ABSTRACT

NOTE: All information provided should fit into the space provided in the form. Do not exceed the space provided.

Where information has previously been entered in forms 1 through 4, the information will automatically be transferred electronically to the appropriate place on this form.

Section I – Project Identifier Information

Project Title: Displays the title for the project.

Project Number: Displays the number assigned to the project (e.g., the grant number).

Project Director: Displays the name and degree(s) of the project director as listed on the grant application.

Principal Investigator: Enter the name(s) and discipline(s) of the principal investigator(s).

Section II – Budget

The amounts for Lines 1 through 4 will be transferred from Form 1, Lines 1 through 4.

Section III – Care Emphasis

Indicate whether the study is interventional or non-interventional.

Section IV – Population Focus

Indicate which population(s) are the focus of the study. Check all that apply.

Section V – Study Design

Indicate which type of design the study uses.

Section VI – Time Design

Indicate which type of design the study uses.

Section VII – Priority Research Issues and Questions of Focus (DO NOT EXCEED THE SPACE PROVIDED)

Provide a brief statement of the primary and secondary (if applicable) areas to be addressed by the research. The topic(s) should be from those listed in the Maternal and Child Health Bureau (MCHB) Strategic Research Issues: Fiscal Years (FYs) 2004 – 2009).

Section VIII – Abstract

Section IX - -Key Words

Provide up to 10 key words to describe the project, including populations served. A list of key words used to classify active projects is included. Choose keywords from this list when describing your project.

Section X – Annotation

Provide a three- to five-sentence description of your project that identifies the project’s purpose, the needs and problems which are addressed, the aims of the project, the related activities which will be used to meet the stated aims, and the materials, which will be developed.

FORM 9

TRACKING PROJECT PERFORMANCE MEASURES

Annual Objective and Performance Data

FY___ FY___ FY___ FY___ FY___

PERFORMANCE MEASURE # 1

Annual Performance Objective ______ ______ ______ ______ ______

Annual Performance Indicator ______ ______ ______ ______ ______

Numerator ______ ______ ______ ______ ______

Denominator ______ ______ ______ ______ ______

PERFORMANCE MEASURE # 2

Annual Performance Objective ______ ______ ______ ______ ______

Annual Performance Indicator ______ ______ ______ ______ ______

Numerator ______ ______ ______ ______ ______

Denominator ______ ______ ______ ______ ______

PERFORMANCE MEASURE # 3

Annual Performance Objective ______ ______ ______ ______ ______

Annual Performance Indicator ______ ______ ______ ______ ______

Numerator ______ ______ ______ ______ ______

Denominator ______ ______ ______ ______ ______

INSTRUCTIONS FOR THE COMPLETION OF FORM 9

PERFORMANCE MEASURE TRACKING

General Instructions:

Complete all required data cells. If an actual number is not available, make an estimate. Please explain all estimates in a footnote. If neither actual data nor an estimate can be provided, the State must provide a footnote that describes a time framed plan for providing the required data. In such cases, the Annual Performance Objective and Annual Performance Indicator lines are to be left blank.

This form serves two purposes: 1) to show performance measures with 5-year planned performance objective targets for the application, and 2) the performance Annual Performance Indicator,@ values actually achieved each year for the annual report for each performance measure.

For each program (i.e., Healthy Start, Research, LEND, etc.) there are appropriate, required Performance Measures. Under the applicable AFY@ heading, each project will complete the Annual Performance Objectives, the Annual Performance Indicators, and numerator and denominator data for each measure as described below under Specific Instructions. For project developed additional performance measures, enter these data on the form beginning with the first blank Performance Measure area under the national measure(s).

Specific Instructions:

In the first available space under “Performance Measure" on the appropriate form, enter the brief title of the project performance measure that has been selected. The titles are to be numbered consecutively with notations of "PP 1, PP 2, etc. Titles are to be written exactly as they appear on Form 10, "Project Performance/Outcome Measure Detail Sheet."

For both national and project measures, in the lines labeled Annual Performance Objective enter a numerical value for the target the project plans to meet for the next 5 years. These values may be expressed as a number, a rate, a percentage, or yes - no

For both national and project measures, in the lines labeled Annual Performance Indicator, enter the numerical value that expresses the progress the project has made toward the accomplishment of the performance objective for the appropriate reporting year. Note that the indicator data are to go in the years column from which they were actually derived even if the data are a year behind the "reporting" year. This value is to be expressed in the same units as the performance objective: a number, a rate, a percentage, or a yes - no.

If there are numerator and denominator data for the performance measures, enter those data on the appropriate lines for the appropriate fiscal year. If there are no numerator and denominator data leave these lines empty. NOTE: Do not enter numerator and denominator data for scale measures.

Repeat this process for each performance measure. A continuation page is included. If the continuation page is used, be sure to enter the number for each listed performance measure. If there are more than six performance measures, make as many copies of the continuation page as necessary.

FORM 10

PROJECT PERFORMANCE/OUTCOME MEASURE

DETAIL SHEET

Form 10 - Option 1 (Single Measure):

PERFORMANCE MEASURE:

Level:

Domain:

GOAL:

MEASURE:

DEFINITIONS:

Numerator:

Denominator:

Units:

Number:

Text:

HEALTHY PEOPLE 2030 OBJECTIVE (or other benchmark data):

GRANTEE DATA SOURCES:

SIGNIFICANCE:

Form 10 - Option 2 (Tiered Measure):

PERFORMANCE MEASURE:

Level:

Domain:

GOAL:

MEASURE:

DEFINITION:

Tier 1:

Tier 2- Activities/ Activity Areas:

Tier 3- Process Measures:

Tier 4- Outcome Measures:

BENCHMARK DATA SOURCES:

GRANTEE DATA SOURCES:

SIGNIFICANCE:

FORM 10

DETAIL SHEET INSTRUCTIONS

PROJECT PERFORMANCE MEASURE

Instructions:

This form is to be used for both the required Program Performance Measures and any Project Outcome Measure the project chooses to add. The project can choose to add either a single component Performance measure, using Option 1, or a tiered measure, using Option 2. Complete each section as appropriate for the measure being described.

Performance

Measure: Enter the narrative description of the performance or outcome measure.

Level: Select from National, State, or Grantee the most appropriate classification for the measure being described.

Category: Select from Women’s and Maternal Health, Perinatal Infant Health, Child Health, Children with Special Health Care Needs, Adolescent Health, Life Course/ Crosscutting, or Capacity Building the most appropriate classification for the measure being described.

Goal: Enter a short statement indicating what the project hopes to accomplish by tracking this measure.

Measure: Enter a brief statement of the measure with information sufficient to interpret the meaning of a value associated with it (e.g., The percent of children with special health care needs age 0 to 18 whose families have adequate private and/or public insurance to pay for needed services). The measure statement should not indicate a desired direction (e.g., an increase).

Definition: Describe how the value of the measure is determined from the data. If the value of the measure is yes/no or some other narrative indicator such as a stage 1/stage 2/stage 3, a clear description of what those values mean and how they are determined should be provided.

If using Option 2:

Tier 1: Use dichotomous yes/no for respondents to state whether work is being done in the program

Tier 2: Enter a list of related process activities related to the area of measurement that projects can select from to demonstrate what activities are being done

Tier 3: Enter the same list as in Tier 2, but with space for reporting of numerical value for each process activity selected (e.g. if Technical Assistance is selected in Tier 2, then in Tier 3, space should be provided to report number of technical assistance encounters provided)

Tier 4 or Option 1: Enter the following for outcome measures to be reported.

Numerator: If the measure is a percentage, rate, or ratio, provide a clear description of the numerator.

Denominator: If the measure is a percentage, rate, or ratio, provide a clear description of the denominator.

Units: If the measure is a percentage, rate, ratio, or scale, indicate the units in which the measure is to be expressed (e.g., 1,000, 100) on the "Number" line and type of measure (e.g., percentage, rate, ratio or scale) on "Text" line. If the measure is a narrative, indicate yes/no or stage 1, stage 2", etc. on the "Text" line and make no entry on the "Number" line.

Healthy People

2030 Objective: If the measure is related to a Healthy People 2030 objective describe the objective and corresponding number. If it relates to another benchmark data source, please describe that and include relevant information.

Grantee Data

Sources: Enter the source(s) of the data used in determining the value of the measure and any issues concerning the methods of data collection or limitations of the data used.

Significance: Briefly describe why this measure is significant, especially as it relates to the Goal.

Note that the Performance Measure title and numerator and denominator data are to appear on Form 8 exactly as they appear on this Form.

Attachment C | 7

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	DGIS OMB Package
Author	HRSA
File Modified	0000-00-00
File Created	2023-08-21