Block Grant Information System (BGIS) Work Plan Data Collection Instruments
Advisory Committee Data Collection Instrument 2
Budget Data Collection Instrument 5
Program Data Collection Instrument 6
Objectives and Activities Data Collection Instrument 11
In this UIC, users will add/edit members of the Advisory Committee and add information about meetings and public hearings. This UIC can be accessed at any time.
If the user has selected “Edit A Member,” the system displays a list of names to choose which one to edit. Block Grant Coordinators can edit any members of their own Advisory Committee. When a name is chosen, the system opens that entry for editing. If the user has selected “Add A Member,” the system opens a blank form for them to complete. They will complete all the questions for each member of the committee.
Member Name: [Short Text]
Member Title: [Short Text]
Organization Name: [Short Text]
Please select all the relevant constituencies, organizations, or perspectives represented by this member. (check as many as apply) [Multiple selection list with the following options:]
Community-based organization
Community resident
County and/or local health department
Minority-related organization
Schools of public health
Other (please specify below)
[If “Other” is chosen above, answer this question. Otherwise skip to question 6] Other constituencies, organizations, or perspectives represented by this member: [text field, 250 character limit.]
Is this member the chair of the Advisory Committee? [Yes/No] (If no, skip to question 8)
[If “Yes” is chosen above, answer this question. Otherwise skip to question 8] Is this member the Lead Health Official of this jurisdiction? [Yes/No]
Year this member first joined the Advisory Committee: [Year]
Year this member left the Advisory Committee: [Year]
(Optional) Deactivate/Reactivate this Member
Block Grant Coordinators can edit any meetings of their own Advisory Committee in the current or upcoming federal fiscal year. After close-out, the Advisory Committee information for that federal fiscal year can no longer be edited.
If the user has selected “Edit A Meeting,” the system displays a list of previously entered and editable meetings to choose which one to edit. When a name is chosen, the system opens that entry for editing. If the user has selected “Add A Meeting,” the system opens a blank form for them to complete.
Title of Meeting: [Short Text]
Date of Meeting: [date, day/month/year]
Federal Fiscal Year(s) of the Work Plan discussed at this meeting: [date, 4-digit year only] *Allow multiple entries
Type of Meeting: *Choose one
Advisory Committee Meeting (skip to question 7)
Public Hearing
[If the answer to 4 was “Public Hearing,” answer questions 5 and 6. Otherwise, skip to question 7.] How was the public invited to the Public Hearing? *Select all that apply
Email Announcement
Flyers
Phone Calls
Mass Text Message
In Person
Press Release
Website
Mailings
Radio
TV
Social Media (e.g. Facebook and Twitter)
Other; please specify ________________
How was the draft Work Plan made available for public viewing?
Email Announcement
Flyers
Phone Calls
Mass Text Message
In Person
Press Release
Website
Mailings
Radio
TV
Social Media (e.g. Facebook and Twitter)
Other; please specify ________________
Please select all the committee members who attended this meeting: *Select all that apply [Multiple selection list that is populated by the names of all current active members of the advisory committee for that federal fiscal year]
Firstname Lastname 1
Firstname Lastname 2…
Did the chair of the Advisory Committee chair this meeting? [Yes/No]
If NO, answer questions 9 & 10
If YES, skip to question 10
[If the answer to 8 was YES, skip to question 10] Who chaired this meeting under delegated authority from the chair of the Advisory Committee? *Choose one [Single Option Selection List that is populated with the names of every member selected in question 5]
Firstname Lastname 1
Firstname Lastname 2…
Please upload the minutes from this meeting. [File Upload]
Federal Fiscal Year of this budget: [Auto-populated from Allocation Table UIC]
Recipient: [Auto-Populated from User Profile UIC]
Total Allocation for the current federal fiscal year: [Auto-Populated from Allocation Table UIC] *Auto-populated from Allocation Tale from table field [Recipient Name] Total Allocation. If there is no finalized Allocation Table, the system will give an error.
Annual Basic Allocation for the current federal fiscal year: [Auto-Populated from Allocation Table UIC] *Auto-populated from Allocation Tale from table field [Recipient Name] Basic Allocation. If there is no finalized Allocation Table, the system will give an error.
Sex Offense Allocation for the current federal fiscal year: [Auto-Populated from Allocation Table UIC] *Auto-populated from the Allocation Table field [Recipient Name] Sex Offense Allocation. If there is no finalized Allocation Table, the system will give an error.
Basic Admin Cost: [Number]
Are you receiving Direct Assistance?
Yes
No (Skip to Question 9)
[If the answer to question 7 was Yes, answer this question. Otherwise skip to question 9] Direct Assistance Amount: [Number]
Sex Offense Admin Cost: [Number]
Remaining Basic Allocations for Programs: [Number] *This is auto-generated by subtracting the Basic Admin Cost from the Annual Basic Allocation for the current federal fiscal year
Remaining Sex Offense Allocations for Programs: [Number] *This is auto-generated by subtracting the Sex Offense Admin Cost from the Sex Offense Allocation for the current federal fiscal year
Would you like to continue funding a previous program funded by PHHS Block Grant in a previous year?
If Yes, answer question 13, skip question 14
If No, skip question 13, answer question 14
[If the answer to question 12 was Yes, answer this question and skip question 14] Select the previous program you wish to continue funding: *choose one
Program x
Program y…
Program z…
[If the answer to question 12 was No, skip question 13 and answer this question] Enter the name of a new program you wish to fund: [Short Text]
Once the recipient answers question 13 or 14, this program allocation data table will appear to fill out the information for that program. Once complete, the recipient can choose *Add Another Program* and answer questions 12-18 about each program they plan to fund with PHHS Block Grant funds.
Program Name: [Auto-populated]
Program Manager assigned to this program: *Select one option from list of all users with role Program Manager assigned to this recipient
Lastname, Firstname 1
Lastname, Firstname 2…
Current Year Basic Funds budgeted to this program: [Number]
Current Year Sex Offense Funds budgeted to this program: [Number]
In this UIC, the BG Coordinator or Program Manager will fill out the information for each program funded by the PHHS Block Grant. The Program UIC is connected to several other entities which contains pertinent information about the recipient’s program plan.
Program Name: [auto-populated from Program Allocation unit of Budget UIC]
Assigned Program Manager: [auto-populated from Program Allocation unit of Budget UIC]
Federal Fiscal Year: [auto-populated from Budget UIC]
Healthy People 2030 Objective: *Choose one of the Healthy People 2030 Objectives
(List of all objectives)
Recipient Health Objective for this Program: *Choose one of the Recipient Health Objectives that were entered into the Recipient Health Objective UIC
Recipient Health Objective 1
Recipient Health Objective 2
Amount of funding to populations disproportionately affected by the problem: [Number}
Amount of funding to local agencies or organizations: [Number]
Type of supported local agency/organization: *Choose one
Local Health Department
Tribal Health Department/Agency
Other Local Government
Local Organization
Other, please specify ____________
Were PHHS Block Grant funds used to respond to an emerging need or outbreak as part of the program? [Yes/No]
What was the funding role of the PHHS Block Grant for this program? *Choose one
Total source of funding (skip to question 13)
Supplement other existing funds
(If the answer to question 10 was “Total Source of Funding”, skip this question, if it was “Supplement other existing funds”, answer this question) What percentage of the funding for this program is PHHS Block Grant funding? [Number (percentage)]
Less than 10% - Minimal source of funding
10-49% - Partial source of funding
50-74% - Significant source of funding
75-99% - Primary source of funding
(If the answer to question 10 was “Total Source of Funding”, skip this question, if it was “Supplement other existing funds”, answer this question) What existing funding source(s) will PHHS Block Grant funds supplement?
State or local funding
Other federal funding (CDC); please specify ___________
Other federal funding (non-CDC)
Funding from NGO or non-profit organization
Funding from for-profit organization
Tribal, district (i.e. DC) or territorial funding
Other; please specify _________
Role of PHHS Block Grant Funds in Supporting this Program: *Choose one
Startup of a new program
Maintain existing program (as is)
Enhance or expand the program
Restore program
Are there any positions funded by the PHHS Block Grant? [Yes/No]
If Yes, continue
If No, skip to question 22
User will ‘Add New Position’ and answer the following questions for each position funded with PHHSBG money.
Position Title: [Position Title]
Is this position vacant? [Yes/No]
If Yes, skip questions 17/18 and answer question 19
If No, answer questions 17/18 and skip question 19
(If answer to question 16 is yes, skip this question, if no, answer this question) Staff Name in Position: [Staff Name]
(If answer to question 16 is yes, skip this question, if no, answer this question) Percent of staff member’s time spent working in each area (funded with PHHS Block Grant dollars):
Jurisdiction-level: [% Time]
Local: [% Time]
Other: [% Time]
Total: [% Total time funded with PHHSBG dollars]
(If answer to question 16 is yes, answer this question, if no, skip this question) Describe the recruitment/hiring plan to fill the vacant position: [Short Text]
Total Positions in this program Funded by the PHHS Block Grant: [Number]
Number of FTEs in this Program funded by the PHHS Block Grant (this is how many full-time positions your total number of positions is equivalent to; e.g. two 50% positions would equal one FTE): [Number]
One-sentence summary of the problem this program will address: [Text]
One-paragraph description of the problem this program will address: [Text]
How was the public health problem prioritized? *Select all that apply
Conducted, monitored, or updated a jurisdiction health assessment (e.g., state health assessment)
Conducted a topic- or program-specific assessment (e.g., tobacco assessment, environmental health assessment)
Identified via surveillance systems or other data sources
Prioritized within a strategic plan
Declared as an emergency within your jurisdiction
Governor (or other political leader) established as a priority
Legislature established as a priority
Tribal government/elected official established as a priority
Other (please specify): __________
Describe in one paragraph the key indicator(s) affected by this problem: [Text]
Baseline value of the key indicator described above: [Number]
Data source for key indicator baseline: [Text]
Date key indicator baseline data was last collected: [Date – either year or full date]
One-sentence program goal: [Short Text]
Is this program specifically addressing a Social Determinant of Health (SDOH)? [Yes/No]
If Yes, continue
If No, skip to question 32
[If answer question 30 was Yes, answer this question, otherwise skip to question 32] Which SDOH are you addressing with this program? *Select all that apply
Economic Stability (e.g. poverty, unemployment, food insecurity, housing instability)
Education (e.g. low high school graduation rates, low literacy levels, poor early childhood education)
Social and Community Context (e.g. discrimination, low civic participation, poor workplace conditions, incarceration)
Health and Health Care (e.g. poor access to healthcare, low health insurance coverage, low health literacy)
Neighborhood and Built Environment (e.g. poor quality of housing, limited access to transportation, food desert, poor water/air quality, neighborhood crime and violence)
Adverse Childhood Experiences (ACEs)
One-paragraph summary of program strategy: [Text]
List of primary strategic partners: [Text]
(OPTIONAL) Planned non-monetary support to local agencies or organizations: *Select all that apply
Technical Assistance
Training
Resources/Job Aids
Other (please specify) ____________
One-paragraph summary of evaluation methodology: [Text]
Program Setting(s): *Select all that apply
Business, corporation or industry
Child care center
Community based organization
Faith based organization
Home
Local health department
Medical or clinical site
Parks or playgrounds
Rape crisis center
Schools or school district
Senior residence or center
State health department
Tribal nation or area
University or college
Work site
Other, please specify___________________
In the target population section, only answer the questions that apply to your overall target population of the Program. You will be able to specify your target population to each Program SMART Objective in the Objectives and Activities UIC.
Target population data source (Include Date): [Short Text]
Number of people served: [Number]
Ethnicity:
Race: *Select all that apply
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Age: *Select all that apply
Under 1 year
1 - 4 years
5 - 14 years
15 - 24 years
25 - 34 years
35 - 44 years
45 – 54 years
55 - 64 years
65 – 74 years
75 – 84 years
85 years and older
Sexual Orientation: *Select all that apply
Gay (lesbian or gay)
Straight, this is not gay (or lesbian or gay)
Bisexual
Something else
I don’t know the answer
Gender Identity: *Select all that apply
Geography: *Choose one
Rural
Urban
Both
Location (e.g. close to a factory, specific zip code, county): [Short Text]
Occupation: [Short Text]
Educational Attainment: *Select all that apply
Some High School
High School Diploma
Some College
College Degree
Graduate Degree
Health Insurance Status: *Select all that apply
Uninsured
Medicaid
Medicare
Private Health Insurance
Affordable Care Act Plan
Other, please specify ______________
Primarily Low Income: *Choose one
Yes
No
Are members of this target population disproportionately affected by the problem? [Yes/No]
If Yes, answer question 51
If No, complete
(If answer to question 40 was Yes, answer this question, otherwise skip) Is the entire target population disproportionately affected by the Problem, or only part? *Choose one
The Block Grant Coordinator or Program Manager will fill in the following information about Program SMART Objectives and Activities for each program funded by the PHHS Block Grant. The Objective and Activity UIC is connected to several other entities which contains pertinent information about the recipient’s program plan.
Name of Program SMART Objective (this is the SMART Objective at the program level): [Text]
Is the problem for this objective the same as the problem for the program as a whole, or is it a subset of the larger problem?
The problem is the same (Skip to question 9 - SMART Objective)
This Program SMART Objective focuses on a subset of the larger problem (Answer questions 3-8)
Please provide a one-sentence summary of the problem for this objective: [Text]
Please provide a one-paragraph description of the problem for this objective: [Text]
Describe in one paragraph the key indicator(s) affected by this problem: [Text]
Baseline value for the key indicator described above: [Number]
Data source for key indicator baseline: [Text]
Date key indicator baseline data was last collected: [Date – can be full date or just year]
Program SMART Objective: [Text]
One-sentence summary of intervention: [Text]
One-paragraph description of intervention: [Text]
Is this an evidence-based intervention, or an innovative/promising practice? *Choose one
Evidence-Based Intervention
Innovative/Promising Practice (Skip question 13)
(If answer to question 12 was “Innovative/Promising Practice, skip this question) Evidence Source for Intervention: *Select all that apply
Best Practice Initiative (U.S. Department of Health and Human Services)
Guide to Clinical Preventive Services (Task Force on Community Preventive Services)
MMWR Recommendations and Reports (Centers for Disease Control and Prevention)
Model Practices Database (National Association of City and County Health Officials)
National Guideline Clearinghouse (Agency for Healthcare Research and Quality)
Promising Practices Network (RAND Corporation)
Other (describe) ________________________
Rationale for choosing the intervention: [Text]
Item to be Measured: [Short Text]
Unit of Measurement: [Short Text]
Baseline value for the item to be measured: [Number]
Data source for baseline value: [Text
Date baseline was last collected: [Date]
Interim target value to be achieved by the Annual Progress Report: [Number]
Final target value to be achieved by the Final Progress Report: [Number]
In the target population section, only answer the questions that apply to your target population of the Program SMART Objective.
Is the Target Population of this Program SMART Objective the same as the Target Population of the Program or a subset of the Program Target Population?
Same as the Program (Skip to question 36)
Sub-set of the Program (Answer questions 23-35)
Target Population Data Source (Include Date): [Short Text]
Number of People Served: [Number]
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Race: *Select all that apply
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Age: *Select all that apply
Under 1 year
1 - 4 years
5 - 14 years
15 - 24 years
25 - 34 years
35 - 44 years
45 – 54 years
55 - 64 years
65 – 74 years
75 – 84 years
85 years and older
Sexual Orientation: *Select all that apply
Straight, this is not gay (or lesbian or gay)
Gay (lesbian or gay); Bisexual
Something else; please specify_______________
Gender Identity: *Select all that apply
Female
Male
Transgender
Additional gender category (or other); please specify ______________
Geography: *Choose one
Rural
Urban
Both
Location (e.g. close to a factory, specific zip code, county): [Short Text]
Occupation: [Short Text]
Educational Attainment: *Select all that apply
Some High School
High School Diploma
Some College
College Degree
Graduate Degree
Health Insurance Status:
Uninsured
Medicaid
Medicare
Private Health Insurance
Affordable Care Act Plan
Other, please specify ______________
Primarily Low Income: *Choose one
Yes
No
Are any members of this target population disproportionately affected by the Problem described above?
Yes
No (Skip question to 38)
Does the entire target population experience health disparities, or only part? *Choose one
All
Part (Present a disparate population form that contains the same fields as the target population)
Recipients will add multiple activities for each Program SMART Objective. They will push “Add New Activity” and answer questions 38-44 for each activity.
Activity Title: [Activity Title]
One-sentence summary of the Activity: [Short Text]
One-paragraph description of the Activity: [Text]
Does the activity include the collection, generation, or analysis of data? [Yes/No]
Does the data collection involve public health data? [Yes/No]
If Yes, you will need to complete and upload a DMP
If No, you will be contacted by your PO to provide additional information about the data collection by x date.
(If YES to question 42) Upload DMP file: [File Upload]
(Optional) Additional information about the activity: [Text]
CDC estimates the average public reporting burden for this collection of information as 12 hours per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0879).
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| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |