Public Burden
Statement: The purpose of this information collection is
to obtain performance data for the following: HRSA program
participants, program operations and surveys. In addition, these data
will facilitate the ability to demonstrate alignment between MCHB
discretionary programs and the Discretionary Grant Information System
(DGIS). 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 information collection is 0915-0298 and it is valid until
12/31/2026. Public reporting burden for this collection of
information is estimated 1.90 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 14N136B,
Rockville, Maryland, 20857 or [email protected].
Section
I –Project
Identifier Information:
These items will be auto-populated.
Section
II – Budget:
These figures will be auto-populated from Financial Form, Lines 1
through 4.
New
Competing Performance Report: will auto-populate the budgeted
amount for the first budget period
Non-Competing
Continuation Performance Reports and Project Period End Report:
will auto-populate the budgeted amount from the prior performance
report
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 (if you do
not know the exact percent, provide your best estimate). Percents
for all three service types should sum to 100%.
Comments:
Enter
any comments, if applicable.
Definitions:
Direct
Services
are preventive, primary, or specialty clinical services for which
MCHB program funds are used to reimburse or fund providers for
these services through a formal process similar to paying a
medical billing claim or managed care contracts. Reporting on
direct services should not include the costs of clinical services
which are delivered with program dollars but reimbursed by
Medicaid, CHIP or other public or private payers. Examples
include, but are not limited to the following, paid for with
program funds: preventive, primary, or specialty care visits,
emergency department visits, inpatient services, outpatient and
inpatient mental and behavioral health services, prescription
drugs, occupational and physical therapy, speech therapy, durable
medical equipment and medical supplies, medical foods, dental
care, and vision care.
Enabling
Services
are
non-clinical services (i.e., not included as direct or public
health services) that enable individuals to access health care and
improve health outcomes where MCHB program funds are used to
finance these services. Enabling services include, but are not
limited to: case management, care coordination, referrals,
translation/interpretation, transportation, eligibility
assistance, health education for individuals or families,
environmental health risk reduction, health literacy, and
beneficiary outreach. Reporting on enabling services should NOT
include the costs for enabling services that are reimbursed by
Medicaid, CHIP, or other public and private payers. Enabling
services may include salary and operational support to a clinic
that enable individuals to access health care or improve health
outcomes. Examples include the salary of a public health nurse who
provides prenatal care in a local clinic or compensation provided
to a specialist pediatrician who provides services for children
with special health care needs. In both cases the direct services
might still be billed to Medicaid or other insurance, but
providing for the availability of the provider enables individuals
to access the services, and therefore counts as enabling services.
Public
Health Services and Systems
are
activities and infrastructure to carry out the core public health
functions of assessment, assurance, and policy development, and
the 10 essential public health services. Examples include the
development of standards and guidelines, needs assessment, program
planning, implementation, and evaluation, policy development,
quality assurance and improvement, workforce development,
population-based outreach and education, and research.
Section
IV – Grantee Organization Type: Choose
the one that best applies to your organization.
Section
V – Special Population(s) Served: If
your program directly targets or serves any of the special
populations listed, please select the population(s) that apply.
Section
VI – Project Description OR Experience to Date (DO NOT
EXCEED THE SPACE PROVIDED)
A. Project
description, new projects only:
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.
Displays
up to 5 objectives of the program. The
objectives are auto-populated
with the objectives from the Notice of Funding Opportunity
(NOFO).
For each objective, describe the project activities used to
reach objectives, and comment on innovation, cost, and other
characteristics of the methodology that are proposed or are being
implemented. Lists with numbered items can be used in this
section.
Describe
the coordination planned and carried out, 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 implementing activities and attaining
its aims.
Experience
to date:
For
each program objective, select Yes or 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).
Section
VII – Key Words
Select
the key words to describe the project. Choose key words from the
included list. Select all that apply. If a key word is not listed,
select Other and specify key word(s). You may select a sub-key
word without also selecting the corresponding general key word.
For example, you may select “Early Childhood - Newborn
Screening” without selecting “Early Childhood -
General”. In addition, you may select only the general key
word if none of the sub-key words apply.
Comments:
Enter
any comments, if applicable.
I.
PROJECT IDENTIFIER INFORMATION
1. Project
Title: _____________
2. Project
Number: _____________
3. Project
Director/Principal Investigator as show on NoA: _________
4.
E-mail Address: _____________
II. BUDGET
1. MCHB
Grant Award $_____________
(Line
1, Financial Form)
2. Matching
Funds (if applicable) $_____________
(Line
2, Financial Form)
3. Other
Project Funds $_____________
(Line
3, Financial Form)
4. Total
Project Funds $_____________
(Line
4, Financial Form)
III. TYPE(S)
OF SERVICE PROVIDED (select all that apply)
ÿ Direct
Services
Percent of Budget for Direct Services ____
ÿ Enabling
Services
Percent of Budget for Enabling Services ____
ÿ Public
Health Services and Systems
Percent of Budget for Public Health Services and Systems ____
GRANTEE
ORGANIZATION TYPE
ÿ
State Agency
ÿ
Community Government Agency
ÿ
School District
ÿ
University/Institution of Higher Learning (Non-Hospital Based)
SPECIAL
POPULATION(S) SERVED (select all that apply)
Uninsured
Homeless
Rural
Tribal
PROJECT
DESCRIPTION OR EXPERIENCE TO DATE
Project
description, new projects only:
Project
Description and Problem (In 150 words or less, briefly
describe the problem that your project addresses):
Program
Objectives and Key Project Activities: (Objectives
auto-populated from the NOFO objectives. For each objective, list
project activities used to reach objective, and comment on
innovation, cost, and other characteristics of the methodology,
proposed or are being implemented)
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:
Coordination
(List the state, local, or other organizations involved in the
project and briefly describe their roles):
Evaluation
(Briefly describe the methods which will be used to determine
whether process and outcome objectives are met; be sure to tie to
evaluation requirements from NOFO):
B. Experience
to date:
Progress
Towards Objectives to Date:
Did
you make measurable progress towards Objective 1 in the
reporting period?
ÿ
Yes ÿ No
Provide
data that support this: ______
Did
you make measurable progress towards Objective 2 in the
reporting period?
ÿ
Yes ÿ No
Provide
data that support this: ______
Did
you make measurable progress towards Objective 3 in the
reporting period?
ÿ
Yes ÿ No
Provide
data that support this: ______
Did
you make measurable progress towards Objective 4 in the
reporting period?
ÿ
Yes ÿ No
Provide
data that support this: ______
Did
you make measurable progress towards Objective 5 in the
reporting period?
ÿ
Yes ÿ No
Provide
data that support this: ______
KEY
WORDS (select all that apply)
Early
Childhood – General
Early
Childhood – Newborn Screening
Early
Childhood – Safe Sleep
Early
Childhood – Developmental Health (including developmental
screening)
Adolescent
Health
Maternal
Health – General
Maternal
Health – Maternal Mortality
Maternal
Health – Perinatal/Postpartum Care
Maternal
Health – Breastfeeding
Maternal
Health – Maternal Depression
Children,
Adolescents, and Young Adults with Special Health Care Needs
Developmental
Disabilities
Mental/Behavioral
Health – General
Mental/Behavioral
Health – Autism
Mental/Behavioral
Health – Substance Use Disorder(s)
Clinical
Care
Sickle
Cell Disease
Heritable
Disorders (excluding sickle cell)
Epilepsy
Fetal
Alcohol Syndrome
Oral
Health
Medical
Home
Health
Care Transition
Immunizations
Injury
Prevention – General
Injury
Prevention – Poison/Toxin Exposure
Child
Maltreatment
Emergency
Services for Children – General
Emergency
Services for Children – Emergency Preparedness
Section
VII – Research Abstract: Provide a three to five
sentence description of your project that identifies the project's
purpose, the needs and problems which are addressed, the
objectives of the project, the related activities which will be
used to meet the stated objectives, and the materials which will
be developed.
Section
VIII – Key Words
Select
the key words to describe the project. Choose key words from the
included list. Select all that apply. If a key word is not listed,
select Other and specify key word(s). You may select a sub-key
word without also selecting the corresponding general key word.
For example, you may select “Early Childhood - Newborn
Screening” without selecting “Early Childhood -
General”. In addition, you may select only the general key
word if none of the sub-key words apply.
Comments:
Enter any comments, if applicable.
I.
PROJECT IDENTIFIER INFORMATION
1. Project
Title: _____________
2. Project
Number: _____________
Project
Director/Principal Investigator as show on NoA: _____________
Additional
Principal Investigator(s), Discipline: _____________
II. BUDGET
1. MCHB
Grant Award $_____________
(Line
1, Financial Form)
2.
Matching Funds (if applicable) $_____________
(Line
2, Financial Form)
Other
Project Funds $_____________
(Line
3, Financial Form)
Total
Project Funds $_____________
(Line
4, Financial Form)
III. POPULATION
FOCUS (select all that apply)
ÿ
Neonates ÿ Pregnant Women
ÿ
Infants ÿ Postpartum Women
ÿ
Toddlers ÿ
Parents/Mothers/Fathers
ÿ
Preschool Children ÿ
Adolescent Parents
ÿ
School-Aged Children ÿ
Grandparents
ÿ
Adolescents ÿ Physicians
ÿ
Adolescents (Pregnancy Related) ÿ
Other (specify) ______
ÿ
Young Adults (18-25)
IV. STUDY
DESIGN(select all that apply)
ÿ
Experimental
ÿ
Quasi-experimental
ÿ
Observational
V. TIME
DESIGN (select all that apply)
ÿ
Cross-sectional
ÿ
Longitudinal
ÿ
Mixed
VI. PRIORITY
RESEARCH ISSUES AND QUESTIONS OF FOCUS
From
the Maternal and Child Health Bureau (MCHB) Strategic Research
Issues
Primary
area addressed by research: _____________
Secondary
area addressed by research (if applicable): _____________
RESEARCH
ABSTRACT _____________
KEY
WORDS (select all that apply)
Early
Childhood – General
Early
Childhood – Newborn Screening
Early
Childhood – Safe Sleep
Early
Childhood – Developmental Health (including developmental
screening)
Adolescent
Health
Maternal
Health – General
Maternal
Health – Maternal Mortality
Maternal
Health – Perinatal/Postpartum Care
Maternal
Health – Breastfeeding
Maternal
Health – Maternal Depression
Children,
Adolescents, and Young Adults with Special Health Care Needs
Developmental
Disabilities
Mental/Behavioral
Health – General
Mental/Behavioral
Health – Autism
Mental/Behavioral
Health – Substance Use Disorder(s)
Clinical
Care
Sickle
Cell Disease
Heritable
Disorders (excluding sickle cell)
Epilepsy
Fetal
Alcohol Syndrome
Oral
Health
Medical
Home
Health
Care Transition
Immunizations
Injury
Prevention – General
Injury
Prevention – Poison/Toxin Exposure
Child
Maltreatment
Emergency
Services for Children – General
Emergency
Services for Children – Emergency Preparedness
Line
1
– MCHB
Grant Award Amount:
Enter the amount of the Federal MCHB grant award for this project.
Line
2
– Required
Matching Funds:
If matching
funds are required
for this grant program list the total amount of matching funds.
These can include local, state, program,
applicant/grantee,
or other funds. Where appropriate, include the dollar value of
in-kind contributions.
Line
3
– Other
Project Funds:
Enter the total amount of other funds received for the project.
These can include local, state, program, applicant/grantee,
or other funds leveraged. Also include the dollar value of in-kind
contributions.
Line
4
– Total
Project Funds:
Displays the sum of lines 1 through 3, which is auto-calculated.
Line
5
– Federal
Collaborative Funds:
Enter the total amount of other Federal funds received other than
the MCHB grant award for the project. Such funds include those
from other Departments, other components of the Department of
Health and Human Services, or other MCHB grants or contracts.
For
all lines:
New
Competing Performance Report: enter the budgeted amount for the
first budget period
Non-Competing
Continuation Performance Reports: enter the expended amount for
the prior budget period and the budgeted amount for the upcoming
budget period
Project
Period End Report: enter the expended amount for the last budget
period
Comments:
Enter
any comments, if applicable.
Budget
Period ___
Budget
Period ___
Budgeted
Expended
Budgeted
Expended
1.
MCHB
GRANT AWARD AMOUNT
$
___
$
___
$
___
$
___
2.
REQUIRED
MATCHING FUNDS
(Are
matching funds required?
Yes
ÿ
No ÿ
If
yes, please enter amount)
$
___
$
___
$
___
$
___
3.
OTHER
PROJECT FUNDS
(Not
included in Line 1 or Line 2 above)
$
___
$
___
$
___
$
___
4.
TOTAL
PROJECT FUNDS
(Total
of Lines 1 through 3)
$
___
$
___
$
___
$
___
5.
FEDERAL
COLLABORATIVE FUNDS
(Additional
federal funds contributing to the project)
Comments:
_______________________
$
___
$
___
$
___
$
___
Health Equity
Health
Equity
Instructions
Select
Yes or No to indicate whether your program advanced health equity
during the reporting period. If Yes is selected, continue and
complete Part A. If No is selected, the form is complete.
PartA. Health Equity
Select
the MCHB funded activity/activities that were conducted
through your programming during the reporting period
to advance health equity. Select all that apply.
Select
the MCHB funded activity/activities that your
program/organization conducted internally during the
reporting period to create or maintain an internal culture
of equity. Select all that apply. If none of the options
are close to the topic of your activity, select “Other”
and specify. This question is optional; if internal
activities were not conducted, you may skip this question.
Select
which equity topics your activities (through programming
and/or internally) targeted and/or covered. If the specific
equity topic of your activity is not listed, select the
topic area closest to your topic area. Select all that
apply. If none of the equity topics are close to the equity
topic of your activity, select “Other” and
specify.
Select
Yes or No to indicate if your program has established stated
goals/objectives for health equity. Goals/objectives should
have specific health equity components. Goals/objectives may
apply to programming and/or internally. If No is selected,
the form is complete.
If
Yes is selected, enter your stated goals/objectives and
describe progress made on those goals/objectives during the
reporting period.
Comments:
Enter any comments, if applicable.
Definitions:
Health
Equity is
the attainment of the highest level of health for all people.
Achieving health equity requires valuing everyone equally with
focused and ongoing societal efforts to address avoidable
inequalities, historical and contemporary injustices, and the
elimination of health and health care disparities.
During
the reporting period, did your program advance health equity?
ÿ
Yes [complete Part A]
ÿ
No
Health
Equity
How
has your program advanced health equity during the reporting
period? (select all that apply)
ÿ
Creating and supporting collaborations and partnerships
with other health and non-health sectors that influence the
well-being of individuals in order to advance health equity.
ÿ
Engaging persons with lived experience in active roles that
influence program planning and implementation, with a focus on
advancing health equity.
ÿ
Accounting for and addressing social and structural
determinants of health to drive health equity in our program’s
area of focus.
ÿ
Creating and supporting the infrastructure and capacity for
equity by improving data collection capacity, promoting
cultural responsiveness, and promoting policies and procedures
that advance equity.
ÿ
Centering equity in data use and performance measurement,
including disaggregating data across various demographic
indicators and compiling and integrating diverse forms of
quantitative and qualitative data.
ÿ
Providing services to individuals and communities with the
greatest need in order to promote equity in a culturally
responsive manner, specifically focused on those
disproportionately impacted by health outcomes.
ÿ
Other (specify): _____
How
has your program/organization created or maintained an internal
culture of equity? (select all that apply) [OPTIONAL]
ÿ
Hiring policies and practices to advance staff diversity
ÿ
Staff inclusion, belonging, and retention—with a focus on
staff from diverse backgrounds
ÿ
Staff capacity to effectively advance health equity
ÿ
Organizational policies and practices that intentionally promote
equity
ÿ
Other (specify): _____
Which
equity topic(s) did your program’s activities target?
(select all that apply)
Race/ethnicity
Sex/gender/sexual
orientation/gender identity
Income/socioeconomic
status
Disability
Age
Language
Geography
– rural/urban
Other
(specify): ________________
Has
your program established stated goals/objectives for health
equity?
ÿ
Yes
ÿ
No
If
yes, enter the stated health equity goals/objectives and
describe what progress your program made on those
goals/objectives in the reporting period.
Comments:
________________________________
___________
Direct and Enabling Services
Direct
and Enabling Services
Instructions
Select
Yes or No to indicate whether your program provided direct
and/or enabling services during the reporting period. If your
program provided both direct and enabling services, select Yes
for both, and complete Part A and Part B. If your program only
provided direct services, select Yes for direct services only
and complete Part A. If your program only provided enabling
services, select Yes for enabling services and complete Part B.
If your program did not provide either, select No and the form
is complete.
Part
A. Direct Services
Select
the types of direct services provided during the reporting
period. Select all that apply.
For
outputs:
Complete
the table and fill in each of the cells as appropriate to
calculate the total number served by direct services in the
reporting period. For reporting on children, adolescents, and
young adults, select EITHER “Children, Adolescents, and
Young Adults (age 1-25)” OR the subcategories of
“Children and Adolescents (age 1-17)” and “Young
Adults (age 18-25).” Children, Adolescents, and Young
Adults with Special Health Care Needs (CYSHCN) is a subset of
Infants (age <1 year) and Children, Adolescents, and Young
Adults (age 1-25) and will not be used to calculate the total
served. Total columns and rows will be auto-calculated based
on data entered into the cells. Within each reporting
category, the count of individuals served should be
unduplicated to the fullest extent possible. For example, if
an individual receives multiple direct services such as
screening and oral health care, the individual would only be
counted once in the table. If data are provided in the row
for “Children, Adolescents, and Young Adults”,
“Children and Adolescents (age 1-17)”, and/or
“Young Adults (age 18-25)”, please indicate the
age range (minimum age and maximum age) of children,
adolescents, and/or young adults served.
If
applicable, enter the number served by direct services using
telehealth during the reporting period. Telehealth means that
the direct service was provided using telehealth modalities.
This number is a subset of the total number served by direct
services. The count of individuals served via telehealth
should be unduplicated to the fullest extent possible. For
example, if an individual receives multiple direct services
via telehealth, the individual would only be counted once.
Part
B. Enabling Services
Select
the types of enabling services provided during the reporting
period. Select all that apply.
For
outputs:
Complete
the table and fill in each of the cells as appropriate to
calculate the total number served by enabling services in the
reporting period. For reporting on children, adolescents, and
young adults, report EITHER “Children, Adolescents, and
Young Adults (age 1-25)” OR the subcategories of
“Children and Adolescents (age 1-17)” and “Young
Adults (age 18-25).” Children, Adolescents, and Young
Adults with Special Health Care Needs (CYSHCN) is a subset of
Infants (age <1 year) and Children, Adolescents, and Young
Adults (age 1-25) and will not be used to calculate total
served. Total columns and rows will be auto-calculated based
on data entered into the cells. Within each reporting
category, the count of individuals served should be
unduplicated to the fullest extent possible. For example, if
an individual receives multiple enabling services, the
individual would only be counted once in the table. If data
are provided in the row for “Children, Adolescents, and
Young Adults”, “Children and Adolescents (age
1-17)”, and/or “Young Adults (age 18-25)”,
please indicate the age range (minimum age and maximum age)
of children, adolescents, and/or young adults served.
If
applicable, enter the number served by enabling services using
telehealth during the reporting period. Telehealth means that
the enabling service was provided using telehealth modalities.
This number is a subset of the total number served by enabling
services. The count of individuals served via telehealth
should be unduplicated to the fullest extent possible. For
example, if an individual receives multiple enabling services
via telehealth, the individual would only be counted once.
Note:
A program participant may receive both a direct and enabling
service. If a participant receives both direct and enabling
services, they should be included in the tables for Part A and
Part B.
Comments:
Enter any comments, if applicable.
Definitions:
Direct
Services are preventive, primary, or specialty clinicalservices, where MCHB program funds are used
to reimburse or fund individually delivered services through a
formal process similar to paying a medical billing claim or
managed care contracts. Reporting on direct services
should NOT include the costs of clinical services which are
delivered with program dollars but reimbursed by Medicaid,
CHIP, or other public or private payers. (Definition Source:
Adapted from TVIS Glossary
https://mchb.tvisdata.hrsa.gov/Glossary/Glossary)
Services
may be provided by clinical or non-clinical professionals and
paraprofessionals.
Examples
include, but are not limited to (where MCHB
program funds are used to reimburse or fund individually
delivered services through a formal process similar to paying
a medical billing claim or managed care contracts),
preventive, primary, or specialty care visits, emergency
department visits, inpatient services, outpatient and
inpatient mental and behavioral health services, prescription
drugs, occupational and physical therapy, speech therapy,
durable medical equipment and medical supplies (purchased
directly for a person to use themselves at home), medical
foods, oral health care, and vision care.
The
recipients of these services are individuals or members of
families
Enabling
Services
are non-clinical services that aid individuals to access health
care and supportive care and improve health and well-being
outcomes. (Definition Source: Adapted from TVIS
Glossary https://mchb.tvisdata.hrsa.gov/Glossary/Glossary)
Enabling
services include, but are not limited to: case management,
care coordination, referrals, services to support transition
from pediatric to adult health care, consultation,
translation/interpretation, transportation, eligibility
assistance, health education for individuals or families,
environmental health risk reduction, health literacy,
beneficiary outreach, and purchase of equipment and medical
supplies (to support the care of people in a care setting).
The
recipients of these services are individuals or members of
families.
Families
include individuals in traditional or non-traditional family
structures and may include biological, foster, or adoptive
parents and/or siblings, spouses or partners, or members of an
extended family.
Telehealth
is the use of electronic information and telecommunication
technologies to support long-distance clinical health care,
patient and professional health-related education, health
administration, and public health.
1.
During the reporting period, did your program provide direct or
enabling services? (select all that apply)
ÿ
Yes, direct services [complete Part A]
ÿ
Yes, enabling services [complete Part B]
ÿ
No
Direct
Services
Types
of direct services provided in the reporting period (select
all that apply)
ÿ
Clinical assessments
ÿ
Screening
ÿ
Preventive care visits
ÿ
Primary care visits
ÿ
Specialty care visits
ÿ
Emergency department visits
ÿ
Inpatient services
ÿ
Outpatient and/or inpatient mental and behavioral health
services
ÿ
Oral health care
ÿ
Vision care
ÿ
Prescription drugs
ÿ
Occupational and/or physical therapy
ÿ
Speech therapy
ÿ
Purchase of durable medical equipment and medical supplies
(for use at a person’s home)
ÿ
Purchase of medical foods
ÿ
Other (specify): _________________________
Outputs
Total
# served by direct services in the reporting period
<TABLE
BY POPULATION GROUPS AND RACE, ETHNICITY, AND INSURANCE>
#
served by direct services using telehealth in the reporting
period (Note: this number is a subset of Total # served by
direct services) _____
Enabling
Services
Types
of enabling services provided in the reporting period (select
all that apply)
ÿ
Care management
ÿ
Care coordination
ÿ
Referrals
ÿ
Health education
ÿ
Transition services
ÿ
Consultation
ÿ
Translation/interpretation
ÿ
Transportation
ÿ
Eligibility assistance
ÿ
Environmental health risk reduction
ÿ
Health literacy and outreach
ÿ
Purchase of equipment and medical supplies (for use in a care
setting)
ÿ
Other (specify): _________________________
Outputs
Total
# served by enabling services in the reporting period
<TABLE
BY POPULATION GROUPS AND RACE, ETHNICITY, AND INSURANCE >
#
served by enabling services using telehealth in the reporting
period (Note: this number is a subset of Total # served by
enabling services) _____
<TABLE
BY POPULATION GROUPS AND RACE, ETHNICITY, AND INSURANCE>
RACE
ETHNICITY
INSURANCE
American
Indian or Alaska Native
Asian
Black
or African American
Native
Hawaiian or Other Pacific Islander
White
More
than One Race
Unknown/Unrecorded
Total
Hispanic
or Latino
Not
Hispanic or Latino
Unknown/Unrecorded
Total
Public
Private
Uninsured
Unknown/Unrecorded
Total
Infants
(age <1 year)
Children,
Adolescents, and Young Adults (age 1-25)
Children
and Adolescents (age 1-17)
Young
Adults (age 18-25)
CYSHCN
(age 0-25)
Pregnant/
postpartum persons (all ages)
Non-pregnant
women (age 26+)
Men
(age 26+)
Families
Other
(specify): _________
Unknown
TOTALS
If
served “Children, Adolescents, and Young Adults (age 1-25)”,
“Children and Adolescents (age 1-17)”, and/or “Young
Adults (age 18-25)”, and reported them in the table above,
please indicate the age range of children, adolescents, and/or young
adults served.
to
Training and Workforce
Development
Training
and Workforce Development
Instructions
Select
Yes or No to indicate whether your program conducted training and
workforce development through a degree, certification, or formal
course AND/OR through continuing education during the reporting
period. If your program provided both, select Yes for both, and
complete Part A and Part B. If your program only provided
training and workforce development through a degree,
certification, or formal course, only select Yes for training and
workforce development through a degree, certification, or formal
course and complete Part A. If your program only provided
continuing education, select Yes for continuing education and
complete Part B. If your program did not provide either, select No
and the form is complete.
Part
A. Degree, Certification, or Formal Course
Select
the type(s) of trainees reached during the reporting period.
Select all that apply.
Select
the focus area(s) of the training(s) provided. Select all that
apply.
Select
the topic area(s) of the training(s) provided. Select all that
apply. If the specific topic area of your training is not listed,
select the topic area closest to your topic area. If none of the
topic areas are close to your topic area, select “none of
the above.” You may select a subtopic without also
selecting the corresponding general topic. For example, you may
select “Early Childhood - Newborn Screening” without
selecting “Early Childhood - General”. In addition,
you may select only the general topic if none of the subtopics
apply.
For
outputs:
Enter
the number of trainees trained during the reporting period. This
number should be an unduplicated count.
Part
B. Continuing Education
Select
the type(s) of continuing education participants reached during
the reporting period. Select all that apply.
Select
the subject area(s) of the continuing education provided. Select
all that apply. If the specific subject area of your training is
not list, select the subject area closest to your subject area.
If none of the subject areas are close to your subject area,
select “none of the above.”
If
applicable, select the topic area(s) of the continuing education
provided. Select all that apply. If the specific topic area of
your training is not list, select the topic area closest to your
topic area. If none of the topic areas are close to your topic
area, select “none of the above.” You may select a
subtopic without also selecting the corresponding general topic.
For example, you may select “Early Childhood - Newborn
Screening” without selecting “Early Childhood -
General”. In addition, you may select only the general
topic if none of the subtopics apply.
For
outputs:
Enter
the number of continuing education sessions/activities conducted
during the reporting period.
Enter
the number of continuing education participants during the
reporting period. This number may be duplicated.
Comments:
Enter any comments, if applicable.
Definitions:
Degree,
Certification, or Formal Course refers to training provided
through a standard curriculum that may result in a degree or
certification. Post-graduates and early research investigators are
also included, even though they will not receive a degree or
certificate. Also included are individuals that receive a portion
of the curriculum but do not complete all of the curriculum or
receive a degree or certificate. This may include:
Short-term,
medium-term, and long-term Division of Maternal and Child Health
Workforce Development training program trainees
Research
network mentees
Individuals
receiving EMS certification
Individuals
receiving doula certification
Continuing
Education refers to trainings that maintain or strengthen
knowledge and skills of the MCH workforce (including community
outreach workers, families, and other members who directly serve
the community), and are not part of a degree, certification, or
formal course. This includes trainings that may be used to
maintain the credentials and licensure of health care providers,
public health practitioners, other members of the practicing MCH
workforce.
Differentiation
between Training and Workforce Development, Technical Assistance,
and Outreach and Education:
Activity
Is
the Purpose of the Activity to Address Needs at the Individual,
Organizational, or General Population Level?
Recipient
Level
Goal
Included
Activities
Training
and Workforce Development
Individual
trainees or practicing MCH workforce professionals
Individual
trainees or practicing MCH workforce professionals
To
improve the knowledge, skills, and capacity of future and
practicing MCH workforce members
Undergraduate,
graduate, and post-graduate education and training
Continuing
education
Applied
learning
ECHO,
if it includes training sections
Technical
Assistance
Organizational
Individual(s)
in the organization
To
improve the knowledge and skillsof organizational
members in order to meet organizational outcomes
Provide
support, training, education, etc. with the intent of
facilitating and achieving organizational goals and
outcomes.
Activities
Training
TA
Site
visits
Collaborative
networks
Running
peer-to-peer forums
Outreach
and Education
General
population
Individuals
in the population at large
To
improve knowledge of the target population by providing
information, messaging, and discussion
Provide
information and messaging to MCH populations through more
generalized and passive mechanisms. (If program funds are used
to create resources and tools, but not provide direct
one-on-one support and contact, this would count here).
Activities
Public
health campaigns
Educational
pamphlets, fact sheets, etc.
Webinars
available to the public
During
the reporting period, did your program provide training and
workforce development through a degree, certification, or formal
course OR through continuing education?
(select
all that apply)
ÿ
Yes, provided training and
workforce development through a degree, certification, or formal
course
[complete
Part A]
ÿ
Yes, provided training and workforce developmentthrough
continuing education
[complete
Part B]
ÿ
No
Degree,
Certification, or Formal Course
Trainee
Type reached in the reporting period (select
all that apply)
ÿ
Undergraduate
ÿ
Graduate
ÿ
Post-graduate
ÿ
Non-degree seeking
ÿ
Other (specify): ________________________
Training
Focus (select
all that apply)
ÿ
Clinical care
ÿ
Care support (including allied health)
ÿ
Research
ÿ
Public health, non-research (for example, policy, planning,
leadership, etc.)
ÿ
Other (specify): ___________
Training
Topic Area (select
all that apply)
Early
Childhood – General
Early
Childhood – Newborn Screening
Early
Childhood – Safe Sleep
Early
Childhood – Developmental Health (including developmental
screening)
Adolescent
Health
Maternal
Health – General
Maternal
Health – Maternal Mortality
Maternal
Health – Perinatal/Postpartum Care
Maternal
Health – Breastfeeding
Maternal
Health – Maternal Depression
Children,
Adolescents, and Young Adults with Special Health Care Needs
Developmental
Disabilities
Mental/Behavioral
Health – General
Mental/Behavioral
Health – Autism
Mental/Behavioral
Health – Substance Use Disorder(s)
Clinical
Care
Sickle
Cell Disease
Heritable
Disorders (excluding sickle cell)
Epilepsy
Fetal
Alcohol Syndrome
Oral
Health
Medical
Home
Health
Care Transition
Immunizations
Injury
Prevention – General
Injury
Prevention – Poison/Toxin Exposure
Child
Maltreatment
Emergency
Services for Children – General
Emergency
Services for Children – Emergency Preparedness
Health
Equity
Social
Determinants of Health
Telehealth
Preventive
Services
Obesity
Health
Insurance
Nutrition
Respiratory
Health
Life
Course Approach
None
of the above
Outputs
#
trained during the reporting period ____
Continuing
Education
Continuing
Education Participant Type reached in the reporting period
(select
all that apply)
ÿ
Clinical care
provider (for example, MD, DO, NP, PA, etc.)
ÿ
Care support provider (including allied health)
ÿ
Researcher
ÿ
Public health professional, non-researcher
ÿ
Community-based participant (for example, community outreach
worker, family advocate, etc.)
ÿ
Other (specify): _____
Continuing
Education Subject Area (select
all that apply)
Clinical
Care Related (including medical home)
Equity,
Diversity, or Cultural Responsiveness Related
Data,
Research, Evaluation Methods
Family
Involvement
Interdisciplinary
Teaming
Health
Care Workforce Leadership
Policy
Systems
Development/Improvement (including capacity building,
planning, and financing)
Emerging
Issues (specify): _____
None
of the above
Continuing
Education Topic Area (select
all that apply)
Early
Childhood – General
Early
Childhood – Newborn Screening
Early
Childhood – Safe Sleep
Early
Childhood – Developmental Health (including developmental
screening)
Adolescent
Health
Maternal
Health – General
Maternal
Health – Maternal Mortality
Maternal
Health – Perinatal/Postpartum Care
Maternal
Health – Breastfeeding
Maternal
Health – Maternal Depression
Children,
Adolescents, and Young Adults with Special Health Care Needs
Developmental
Disabilities
Mental/Behavioral
Health – General
Mental/Behavioral
Health – Autism
Mental/Behavioral
Health – Substance Use Disorder(s)
Clinical
Care
Sickle
Cell Disease
Heritable
Disorders (excluding sickle cell)
Epilepsy
Fetal
Alcohol Syndrome
Oral
Health
Medical
Home
Health
Care Transition
Immunizations
Injury
Prevention – General
Injury
Prevention – Poison/Toxin Exposure
Child
Maltreatment
Emergency
Services for Children – General
Emergency
Services for Children – Emergency Preparedness
Health
Equity
Social
Determinants of Health
Telehealth
Preventive
Services
Obesity
Health
Insurance
Nutrition
Respiratory
Health
Life
Course Approach
None
of the above
Outputs
(complete
both a and b)
#
of continuing education sessions/activities conducted during the
reporting period ___
#
of participants in continuing education activities during the
reporting period ___
Select
Yes or No to indicate whether your program engaged in or supported
partnerships and collaborations during the reporting period. If
Yes is selected, continue and complete Part A. If No is selected,
the form is complete.
Part
A. Partnerships and Collaborations
Select
the purpose of the partnership(s)/collaboration(s). This should
be the main reason(s) for establishing, supporting, engaging in,
and continuing partnership(s)/collaboration(s). Select all that
apply.
For
outputs: For each applicable partner/collaborator category,
select all the types of partnership/collaboration that apply, and
report the number of partnerships/collaborations in the
reporting period. The number of partnerships/collaborations
should be an unduplicated count. For example, if a program had
multiple types of partnerships/collaborations with one Title V
agency in the reporting period, the number of Title V
partnerships would be one. If a program had partnerships with two
Title V agencies, the number of Title V partnerships would be
two. Partners/Collaborators can be organizations or individuals.
Comments:
Enter any comments, if applicable.
Definitions:
Partnership
and Collaboration refers to activities that build and
strengthen connections between organizations and individuals with
similar interests, missions, and activities to allow for
information sharing, learning, and capacity building across
organizations/individuals. These activities include creation or
strengthening of relevant organizational relationships that serve
to expand the capacity and reach of a program in meeting the needs
of its MCH population. Partnerships and collaborations are
intended to be mutually beneficial relationships for all parties
involved. Programs that build partnerships and collaboration
between organizations, but themselves are not active in or
beneficiaries of the partnerships (for example, a TA center that
sets up a peer-to-peer network but does NOT participate as a
recipient or beneficiary), should not complete this form.
During
the reporting period, did your program engage in or support
partnerships and collaboration to expand capacity and reach to
meet the needs of the program’s MCH population?
Yes
[complete Part A]
No
Partnerships
and Collaborations
Purpose
of partnerships/ collaborations (select all that apply)
Improve
program quality
Increase
reach of program activities or messaging
Increase
funding or other resources to advance program goals
Increase
political will/“buy-in” for program activities or
goals
Establish
or implement shared goals, activities, data collection, or
measurement
Reach
and engage communities/potential service recipients
Other
(specify): ___________
Outputs:
Types and numbers of partnerships and collaborations in
reporting period, by partner/collaborator category
Partner/Collaborator
Category
Type
of partnership/collaboration (select all that apply)
Number
of partnerships/ collaborations for the partner/collaborator
category in the reporting period
Title
V
Memoranda
of understanding or other written agreements
Working
groups or committees (including advisory boards, steering
committees)
Peer-to-peer
learning
Provider-to-provider
consultations
Information-sharing
networks
Shared
resources (for example, funding, staff, etc.)
Referral
and care coordination networks
Other
(specify): ____________________
Social
service agency
Memoranda
of understanding or other written agreements
Working
groups or committees (including advisory boards, steering
committees)
Peer-to-peer
learning
Provider-to-provider
consultations
Information-sharing
networks
Shared
resources (for example, funding, staff, etc.)
Referral
and care coordination networks
Other
(specify): ____________________
Medicaid
agency
Memoranda
of understanding or other written agreements
Working
groups or committees (including advisory boards, steering
committees)
Peer-to-peer
learning
Provider-to-provider
consultations
Information-sharing
networks
Shared
resources (for example, funding, staff, etc.)
Referral
and care coordination networks
Other
(specify): ____________________
Other
state/local agencies
Memoranda
of understanding or other written agreements
Working
groups or committees (including advisory boards, steering
committees)
Peer-to-peer
learning
Provider-to-provider
consultations
Information-sharing
networks
Shared
resources (for example, funding, staff, etc.)
Referral
and care coordination networks
Other
(specify): ____________________
Health
care providers/ clinical providers
Memoranda
of understanding or other written agreements
Working
groups or committees (including advisory boards, steering
committees)
Peer-to-peer
learning
Provider-to-provider
consultations
Information-sharing
networks
Shared
resources (for example, funding, staff, etc.)
Referral
and care coordination networks
Other
(specify): ____________________
Community/family
groups
Memoranda
of understanding or other written agreements
Working
groups or committees (including advisory boards, steering
committees)
Peer-to-peer
learning
Provider-to-provider
consultations
Information-sharing
networks
Shared
resources (for example, funding, staff, etc.)
Referral
and care coordination networks
Other
(specify): ____________________
Educational
institutions
Memoranda
of understanding or other written agreements
Working
groups or committees (including advisory boards, steering
committees)
Peer-to-peer
learning
Provider-to-provider
consultations
Information-sharing
networks
Shared
resources (for example, funding, staff, etc.)
Referral
and care coordination networks
Other
(specify): ____________________
Health
insurance (non-public)
Memoranda
of understanding or other written agreements
Working
groups or committees (including advisory boards, steering
committees)
Peer-to-peer
learning
Provider-to-provider
consultations
Information-sharing
networks
Shared
resources (for example, funding, staff, etc.)
Referral
and care coordination networks
Other
(specify): ____________________
Tribal
entities
Memoranda
of understanding or other written agreements
Working
groups or committees (including advisory boards, steering
committees)
Peer-to-peer
learning
Provider-to-provider
consultations
Information-sharing
networks
Shared
resources (for example, funding, staff, etc.)
Referral
and care coordination networks
Other
(specify): ____________________
Federal
partners
Memoranda
of understanding or other written agreements
Working
groups or committees (including advisory boards, steering
committees)
Peer-to-peer
learning
Provider-to-provider
consultations
Information-sharing
networks
Shared
resources (for example, funding, staff, etc.)
Referral
and care coordination networks
Other
(specify): ____________________
Other
(specify): ___________
Memoranda
of understanding or other written agreements
Working
groups or committees (including advisory boards, steering
committees)
Peer-to-peer
learning
Provider-to-provider
consultations
Information-sharing
networks
Shared
resources (for example, funding, staff, etc.)
Select
Yes or No to indicate whether your program supported engagement of
family members and/or other persons with lived experience during
the reporting period. If your program supported both, select Yes
for both, and complete Part A and Part B. If your program only
supported engagement of family members, select Yes for family
members only and complete Part A. If your program only supported
engagement of other persons with lived experience, select Yes for
other persons with lived experience and complete Part B. If your
program did not support either, select No and the form is
complete.
Part
A. Family Engagement
For
each engagement area, indicate whether your program engaged
family members during the reporting period and, if yes, enter the
number of family members engaged during the reporting period.
Multiple individuals from within the same family unit should be
counted separately (i.e., if a program engaged two parents, they
should each be counted separately). The number engaged may be
duplicated across rows (i.e., if a family member is engaged in
both Program Development, Planning and Evaluation, as well as
Leadership Training, the family member would be counted in each
row).
If
able, complete the table and fill in each of the cells as
appropriate. This item is optional. The unduplicated row totals
for race and ethnicity will be auto-calculated and may not align
with the duplicated numbers presented in Table A.i. When
reporting data pertaining to participants’ race, ethnicity,
or membership in social or demographic groups—particularly
groups those that are underrepresented—awardees should
ensure that those data are accurate and collected validly and
sensitively. Do not infer or guess individuals’ membership
in a particular group.
If
able, enter the number engaged during the reporting period from
other demographic groups that are underrepresented (for example,
underrepresented factors include sexual orientation, gender
identity, income/socioeconomic status, health status/disability,
age, language, geography). This item is optional and should only
be completed if data are collected in a valid manner that
recognizes the sensitive nature of these topics.
Select
Yes or No to indicate if family members were compensated for
their engagement during the reporting period. Select Yes if at
least one family member was compensated. If yes, and if able,
enter the number of family members compensated; the item for
number of family members compensated is optional.
Select
Yes or No to indicate whether engaging family members resulted in
any changes to your program. If yes, select all the ways
engagement resulted in changes to your program. Note that the
form does not require you to measure or quantify the degree of
change, only that it occurred. Select all that apply.
Part
B.Other Persons with Lived Experience Engagement
For
each engagement area, indicate whether your program engaged other
persons with lived experience during the reporting period and, if
yes, enter the number of other persons with lived experience
engaged during the reporting period. The number engaged may be
duplicated across rows (i.e., if a person with lived experience
is engaged in both Program Development, Planning and Evaluation,
as well as Leadership Training, the person would be counted for
each row).
Indicate
the population categories of persons with lived experience that
the program engaged. Select all that apply.
If
able, complete the table and fill in each of the cells as
appropriate. This item is optional. The unduplicated row totals
for race and ethnicity will be auto-calculated and may not align
with the duplicated numbers presented in Table B.i. When
reporting data pertaining to participants’ race, ethnicity,
or membership in social or demographic groups—particularly
groups those that are underrepresented—awardees should
ensure that those data are accurate and collected validly and
sensitively. Do not infer or guess individuals’ membership
in a particular group.
If
able, enter the number engaged during the reporting period from
other demographic groups that are underrepresented (for example,
underrepresented factors include sexual orientation, gender
identity, income/socioeconomic status, health status/disability,
age, language, geography). This item is optional and should only
be completed if data are collected in a valid manner that
recognizes the sensitive nature of these topics.
Select
Yes or No to indicate if persons with lived experience were
compensated for their engagement during the reporting period.
Select Yes if at least one person with lived experience was
compensated. If yes, and if able, enter the number of persons
with lived experience compensated; the item for number of persons
with lived experience compensated is optional.
Select
Yes or No to indicate whether engaging other persons with lived
experience resulted in any changes to your program. If yes,
select all the ways engagement resulted in changes to your
program. Note that the form does not require you to measure or
quantify the degree of change, only that it occurred. Select all
that apply.
Comments:
Enter any comments, if applicable.
Definitions:
Persons
with Lived Experience refers to individuals with knowledge and
experience on health or social issues relevant to a particular
program that is gained through direct, first-hand involvement in
everyday events rather than through representations constructed by
other people.1 Community-based organizations, for
example, would not be included under this definition. For the
purposes of this form, engagement of persons with lived experience
is measured through two categories: “Family Engagement”
and “Other Persons with Lived Experience.” Family
members often navigate systems and services on behalf of
individuals, so their lived experience is collected separately.
Therefore, for data collection purposes, the term “Other
Persons with Lived Experience” is used to delineate from
family engagement and avoid duplicated counts.
Family
Engagement: Family members include individuals in traditional
or non-traditional family structures and may include biological,
foster, or adoptive parents and/or siblings, spouses or partners,
or members of an extended family. These family members have lived
experience through their first-hand knowledge of navigating
systems and services either on behalf of a family member or for
the family as a whole (for example, parents of infants and
toddlers, family members of children and youth with special health
care needs, etc.). Family engagement refers to family members
serving as representatives or leaders who build and strengthen
programs and systems rather than being the direct recipient of
services.
Other
Persons with Lived Experience: This subcategory excludes
family members, as defined above.Engaging other individual
persons with lived experience entails actively and intentionally
seeking and implementing input from individuals with personal
knowledge pertaining to the issue the program is trying to
address. For the purpose of this form, individuals with lived
experiences represent their own personal history and experience
navigating systems and services for themselves, rather than on
behalf of a family member. Examples of persons with lived
experience include self-advocates or individuals with direct
experience on a health issue (for example, youth self-advocates
with special health care needs, pregnant or postpartum persons,
individual community members affected by a public health
emergency, etc.).
1.
Chandler, D., & Munday, R. (2016). Oxford: A dictionary of
media and communication (2nd ed.). New York, NY: Oxford University
Press.
During
the reporting period, did your program support engagement of
persons with lived experience? (select all that apply)
Yes,
engaged with or supported family members to expand the
capacity and reach of a program in meeting the needs of the
program’s MCH population [complete Part A]
Yes,
engaged with or supported other persons with lived experience
to expand the capacity and reach of a program in meeting the
needs of the program’s MCH population [complete Part B]
No
Family
Engagement
Number
engaged in the reporting period, by engagement area
Engagement
Area
Has
your program engaged family members in this engagement area in
the reporting period?
Number
engaged in the reporting period
Program
Development, Planning, and Evaluation
Family
members participate in and provide feedback on the planning,
implementation, and/or evaluation of the program (for example,
strategic planning, program planning, materials development,
program activities, teaching, mentoring, measurement, etc.).
Yes
No
Leadership
Training
Within
your program, family members are trained or mentored for
leadership roles (for example, advisory committees, task
forces, teaching, etc.).
Yes
No
Active
Leadership
Within
your program, family members have leadership roles on advisory
committees or task forces.
Yes
No
Number
engaged by race and ethnicity in the reporting period
(OPTIONAL)
RACE
ETHNICITY
American
Indian or Alaska Native
Asian
Black
or African American
Native
Hawaiian or Other Pacific Islander
White
More
than One Race
Unknown/Unrecorded
Total
Hispanic
or Latino
Not
Hispanic or Latino
Unknown/Unrecorded
Total
Number
engaged from other demographic groups that are underrepresented
(for example, underrepresented factors include sexual
orientation, gender identity, income/socioeconomic status,
health status/disability, age, language, geography), in the
reporting period
(OPTIONAL)
Number
engaged from other underrepresented groups
In
the reporting period, were family members compensated for their
engagement (for example, paid faculty or staff, consultants,
honoraria, etc.)?
Yes
No
If
yes, number compensated in the reporting period ?
(OPTIONAL)
Number
compensated in the reporting period
In
the reporting period, did engagement of family members result in
any changes to your program?
If
yes, as a result of engaging family members, what did the
program achieve in the reporting period? (select all that
apply)
Yes
No
Influenced
focus or priorities of programming
Improved
program quality
Increased
reach of the program’s messaging
Increased
enrollment or participation in program activities
Increased
funding or other tangible resources to advance program goals
Increased
community will/“buy-in” for program activities or
goals
Established
or implemented shared goals, activities, or measurement
Other
(specify): ___________
Other
Persons with Lived Experience Engagement
Number
engaged in the reporting period, by engagement area
Engagement
Area
Has
your program engaged other persons with lived experience in
this engagement area in the reporting period?
Number
engaged in the reporting period
Program
Development, Planning, and Evaluation
Other
persons with lived experience participate in and provide
feedback on the planning, implementation and/or evaluation of
the program (for example, strategic planning, program planning,
materials development, program activities, teaching, mentoring,
measurement, etc.).
Yes
No
Leadership
Training
Within
your program, other persons with lived experience are trained
or mentored for leadership roles (for example, advisory
committees, task forces, teaching, etc.).
Yes
No
Active
Leadership
Within
your program, other persons with lived experience have
leadership roles on advisory committees or task forces.
Yes
No
Were
the other persons with lived experience from any of the
following population categories? (select all that apply)
Children,
adolescents, young adults (age 1-25)
Children,
adolescents, and young adults (age 1-25) with special health care
needs
Pregnant/postpartum
persons
Non-pregnant
women (age 26+)
Men
(age 26+)
Representatives
from community of interest
Self-advocates
Other
(specify): _______
Number
engaged by race and ethnicity in the reporting period
(OPTIONAL)
RACE
ETHNICITY
American
Indian or Alaska Native
Asian
Black
or African American
Native
Hawaiian or Other Pacific Islander
White
More
than One Race
Unknown/Unrecorded
Total
Hispanic
or Latino
Not
Hispanic or Latino
Unknown/Unrecorded
Total
Number
engaged from other demographic groups that are underrepresented
(for example, underrepresented factors include sexual
orientation, gender identity, income/ socioeconomic status,
health status/disability, age, language, geography), in the
reporting period
(OPTIONAL)
Number
engaged from other underrepresented groups
In
the reporting period, were other persons with lived experienced
compensated for their engagement (for example, paid faculty or
staff, consultants, honoraria, etc.)?
Yes
No
If
yes, number compensated in the reporting period (OPTIONAL)
Number
compensated in the reporting period
In
the reporting period, did engagement of other persons with lived
experience result in any changes to your program?
Yes
No
If
yes, as a result of engaging other persons with lived
experience, what did the program achieve? (select all that
apply)
Influenced
focus or priorities of programming
Improved
program quality
Increased
reach of the program’s messaging
Increased
enrollment or participation in program activities
Increased
funding or other tangible resources to advance program goals
Increased
community will/“buy-in” for program activities or
goals
Established
or implemented shared goals, activities, or measurement
Select
Yes or No to indicate whether your program provided technical
assistance (TA) during the reporting period. If Yes is selected,
continue and complete Part A and Part B. If No is selected, the
form is complete.
Part
A. Technical Assistance
Select
the subject area(s) of the most significant TA activities during
the reporting period. Select all that apply. If the specific
subject area of your TA is not listed, select the subject area
closest to your subject area. If none of the subject areas are
close to your subject area, select “none of the above.”
Select
the topic area(s) of the most significant TA activities during
the reporting period. Select all that apply. If the specific
topic area of your TA is not listed, select the topic area
closest to your topic area. If none of the topic areas are close
to your topic area, select “none of the above.” You
may select a subtopic without also selecting the corresponding
general topic. For example, you may select “ Early
Childhood - Newborn Screening” without selecting “Early
Childhood - General”. In addition, you may select only the
general topic if none of the subtopics apply.
For
outputs:
a.
Enter the total number of TA activities provided during the
reporting period.
b.
Enter the total number of TA recipients during the reporting
period. This number may be duplicated (i.e., a recipient
participates in more than one TA activity and is counted more than
once), though an unduplicated count is encouraged if possible.
c.
Enter the total number of organizations assisted during the
reporting period. If there were multiple TA recipients from one
organization, the organization should only be counted once. This
should be an unduplicated count.
Enter
the number of TA activities provided during the reporting period
to each target audience. Complete for applicable target
audiences. TA activities should be counted at the level of the
organization. For example, if three individuals from a Title V
agency attend the same TA activity, then there would be one TA
activity for Title V counted. If three individuals from a Title
V agency attend three different TA activities, then there would
be three TA activities for Title V counted. The total number of
activities in this column may sum to more than the number
reported in 1.a., as multiple audiences may participate in the
same TA activity.
Enter
the number of TA activities provided during the reporting period
by TA method of the activity. Complete for applicable methods.
Methods are listed in order of intensity, from most intensive to
least intensive TA method. The total number of activities in
this column should sum to the number reported in 1.a.
Part
B. Satisfaction with TA
Select
Yes or No to indicate whether your program collected data on TA
participant satisfaction during the reporting period. If Yes is
selected, enter the number of recipients reporting that they were
satisfied by TA and the total number of TA participants asked
about satisfaction that provided a response. Satisfaction with TA
is defined by the program. If No is selected, the form is
complete.
Comments:
Enter any comments, if applicable.
Definitions:
Technical
Assistance (TA) includes a range of targeted support
activities that build skills or capacities and increase knowledge,
with the intention to address organizational needs or accelerate
programmatic outcomes. TA is the process of providing guidance,
assistance, and training by an expert with specific
technical/content knowledge to address an identified need. TA
relationships are program- or initiative-focused, and may use an
interactive, on-site/hands-on approach, as well as telephone or
email assistance.
Differentiation
between Training and Workforce Development, Technical Assistance,
and Outreach and Education:
Activity
Is
the Purpose of the Activity to Address Needs at the Individual,
Organizational,
or General Population Level?
Recipient
Level
Goal
Included
Activities
Training
and Workforce Development
Individual
trainees or practicing MCH workforce professionals
Individual
trainees or practicing MCH workforce professionals
To
improve the knowledge, skills, and capacity of future and
practicing MCH workforce members
Undergraduate,
graduate and post-graduate education and training
Continuing
education
Applied
learning
ECHO,
if it includes training sections
Technical
Assistance
Organizational
Individual(s)
in the organization
To
improve the knowledge and skillsof organizational
members in order to meet organizational outcomes
Provide
support, training, education, etc. with the intent of
facilitating and achieving organizational goals and
outcomes.
Activities
Training
TA
Site
visits
Collaborative
networks
Running
peer-to-peer forums
Outreach
and Education
General
population
Individuals
in the population at large
To
improve knowledge of the target population by providing
information, messaging, and discussion.
Provide
information and messaging to MCH populations through more
generalized and passive mechanisms. (If program funds are used
to create resources and tools, but not provide direct
one-on-one support and contact, this would count here).
Activities
Public
health campaigns
Educational
pamphlets, fact sheets, etc.
Webinars
available to the public
1.
During the reporting period, did your program provide technical
assistance (TA)?
ÿ
Yes [complete Part A and Part B]
ÿ
No
Technical
Assistance
Subject
area(s) of your most significant TA activities in the reporting
period (select all that apply)
Clinical
Care Related (including medical home)
Equity,
Diversity, or Cultural Responsiveness Related
Data,
Research, Evaluation Methods
Family
Involvement
Interdisciplinary
Teaming
Health
Care Workforce Leadership
Policy
Systems
Development/Improvement (including capacity building,
planning, and financing)
Emerging
Issues _____
None
of the above
Topics
of your most significant TA activities in the reporting period
(select all that apply)
Early
Childhood – General
Early
Childhood – Newborn Screening
Early
Childhood – Safe Sleep
Early
Childhood – Developmental Health (including developmental
screening)
Adolescent
Health
Maternal
Health – General
Maternal
Health – Maternal Mortality
Maternal
Health – Perinatal/Postpartum Care
Maternal
Health – Breastfeeding
Maternal
Health – Maternal Depression
Children,
Adolescents, and Young Adults with Special Health Care Needs
Developmental
Disabilities
Mental/Behavioral
Health – General
Mental/Behavioral
Health – Autism
Mental/Behavioral
Health – Substance Use Disorder(s)
Clinical
Care
Sickle
Cell Disease
Heritable
Disorders (excluding sickle cell)
Epilepsy
Fetal
Alcohol Syndrome
Oral
Health
Medical
Home
Health
Care Transition
Immunizations
Injury
Prevention – General
Injury
Prevention – Poison/Toxin Exposure
Child
Maltreatment
Emergency
Services for Children – General
Emergency
Services for Children – Emergency Preparedness
Health
Equity
Social
Determinants of Health
Telehealth
Preventive
Services
Obesity
Health
Insurance
Nutrition
Respiratory
Health
Life
Course Approach
None
of the above
Outputs
Number
of TA activities, recipients, and organizations assisted in the
reporting period
Total
number of TA activities ___
Total
number of TA recipients ___
Total
number of organizations assisted ___
Number
of TA activities in the reporting period, by target audience
Target
Audience
Number
of TA Activities (total may sum
to more than reported in 1.a. as activity could be provided to
multiple audiences)
Title
V
Social
service agency
Medicaid
agency
Other
state/local agencies
Health
care providers/clinical providers
Community/family
groups
Educational
institutions
Health
insurance (non-public)
Tribal
entities
Federal
partners
Other
(specify) ___________
Unknown
Number
of TA activities in the reporting period, by TA method
Method
(listed
by order of relative intensity of method, from most intensive
to least intensive)
Number
of TA Activities (must
sum to total reported in 1.a.)
One-on-one
consultation, training, or site visits
Group
consultation or training (for example, workshops, continuing
education courses, etc.)
Peer-to-peer
networks or collaborative networks
Presentations
(for example, webinars, invited speaking engagements, etc.)
Satisfaction
with TA
Did
you collect data regarding recipient satisfaction with TA in
the reporting period?
ÿ
Yes
ÿ
No
If
yes, number/percent of TA recipients who reported they were
satisfied
Number
of TA recipients asked about satisfaction who provided a
response, in the reporting period ___
Number
of TA recipients who reported they were satisfied with TA
provided, in the reporting period ___
Select
Yes or No to indicate whether your program provided outreach
and education during the reporting period. If Yes is selected,
continue and complete Part A and Part B. If No is selected, the
form is complete.
Part
A – Outreach and Education: Information on outreach
and education activities, excluding information on web and
social media analytics (captured in Part B).
Select
the mechanism(s) used to provide outreach and education during
the reporting period. Select all that apply.
Select
the subject area(s) covered by outreach and education
activities during the reporting period. Select all that apply.
If the specific subject area of your outreach and education is
not listed, select the subject area closest to your subject
area. If none of the subject areas are close to your subject
area, select “none of the above.”
Select
the topic area(s) covered by outreach and education activities
during the reporting period. Select all that apply. If the
specific topic area of your outreach and education is not
listed, select the topic area closest to your topic area. If
none of the topics are close to your topic area, select “none
of the above.” You may select a subtopic without also
selecting the corresponding general topic. For example, you
may select “Early Childhood - Newborn Screening”
without selecting “Early Childhood - General”. In
addition, you may select only the general topic if none of the
subtopics apply.
Enter
the number of individuals (for example, participants,
families, providers, etc.) reached by outreach and education
activities. This may be a duplicated count of individuals.
Part
B – Web and Social Media Analytics
If
applicable, enter the number of web hits, number of unique
website visitors, number of social media views, and number of
unique viewers of social media content for outreach and
education materials and resources.
Comments:
Enter any comments, if applicable.
Definitions:
Outreach
and Education refers to activities to inform, generate
interest, and provide more in-depth messaging on topics of
interest. Outreach can be seen as a way to introduce the topic
during brief interactions. Education can be seen as those
activities that allow messaging and discussion to be tailored
to individuals and small groups, as staff respond to questions
and address concerns about a topic.
Differentiation
between Training and Workforce Development, Technical
Assistance, and Outreach and Education:
Activity
Is
the Purpose of the Activity to Address Needs at the
Individual, Organizational, or General Population Level?
Recipient
Level
Goal
Included
Activities
Training
and Workforce Development
Individual
trainees or practicing MCH workforce professionals
Individual
trainees or practicing MCH workforce professionals
To
improve the knowledge, skills, and capacity of future and
practicing MCH workforce members
Undergraduate,
graduate and post-graduate education and training
Continuing
education
Applied
learning
ECHO,
if it includes training sections
Technical
Assistance
Organizational
Individual(s)
in the organization
To
improve the knowledge and skillsof organizational
members in order to meet organizational outcomes
Provide
support, training, education, etc. with the intent of
facilitating and achieving organizational goals and
outcomes.
Activities
Training
TA
Site
visits
Collaborative
networks
Running
peer-to-peer forums
Outreach
and Education
General
population
Individuals
in the population at large
To
improve knowledge of the target population by providing
information, messaging, and discussion.
Provide
information and messaging to MCH populations through more
generalized and passive mechanisms. (If program funds are
used to create resources and tools, but not provide direct
one-on-one support and contact, this would count here).
Activities
Public
health campaigns
Educational
pamphlets, fact sheets, etc.
Webinars
available to the public
During
the reporting period, did your program provide outreach and
education?
Yes
[complete Part A and Part B]
No
Outreach
and Education
(excluding
web and social media analytics)
Mechanism
of outreach/education (select all that apply)
Webinars
Educational
materials
Community/public
events
Conference
presentations
Other
(specify): ___________________________
Subject
area(s) of outreach/education (select
all that apply)
Clinical
Care Related (including medical home)
Equity,
Diversity or Cultural Responsiveness Related
Data,
Research, Evaluation Methods
Family
Involvement
Interdisciplinary
Teaming
Health
Care Workforce Leadership
Policy
Systems
Development/Improvement (including capacity building,
planning, and financing)
Emerging
Issues _____
None
of the above
Topics
of outreach/education (select all that apply)
Early
Childhood – General
Early
Childhood – Newborn Screening
Early
Childhood – Safe Sleep
Early
Childhood – Developmental Health (including developmental
screening)
Adolescent
Health
Maternal
Health – General
Maternal
Health – Maternal Mortality
Maternal
Health – Perinatal/Postpartum Care
Maternal
Health – Breastfeeding
Maternal
Health – Maternal Depression
Children,
Adolescents, and Young Adults with Special Health Care Needs
Developmental
Disabilities
Mental/Behavioral
Health – General
Mental/Behavioral
Health – Autism
Mental/Behavioral
Health – Substance Use Disorder(s)
Clinical
Care
Sickle
Cell Disease
Heritable
Disorders (excluding sickle cell)
Epilepsy
Fetal
Alcohol Syndrome
Oral
Health
Medical
Home
Health
Care Transition
Immunizations
Injury
Prevention – General
Injury
Prevention – Poison/Toxin Exposure
Child
Maltreatment
Emergency
Services for Children – General
Emergency
Services for Children – Emergency Preparedness
Select
Yes or No to indicate whether your program conducted research
and/or provided infrastructure support for research during the
reporting period. If your program supported one or both, select
Yes for the applicable supported activities (both Yes can be
selected), and complete Part A. If your program did not conduct
research or provide infrastructure support for research, select No
and the form is complete.
Part
A. Research and Infrastructure Support for Research
Select
the type(s) of research conducted or supported during the
reporting period. Select all that apply.
Select
the topic area(s) of research conducted or supported during the
reporting period. Select all that apply. If the specific topic
area of your research is not listed, select the topic area
closest to your topic area. If none of the topics are close to
your topic area, select “none of the above.” You may
select a subtopic without also selecting the corresponding
general topic. For example, you may select “Early Childhood
- Newborn Screening” without selecting “Early
Childhood - General”. In addition, you may select only the
general topic if none of the subtopics apply.
For
outputs: Complete applicable outputs of your research in the
reporting period.
For
number of participants, complete the table and fill in each of
the cells as appropriate. For reporting on children,
adolescents, and young adults, EITHER report “Children,
Adolescents, and Young Adults (age 1-25)” OR the
subcategories of “Children and Adolescents (age 1-17)”
and/or “Young Adults (age 18-25).” Children and
youth with special health care needs (CYSHCN) should be reported
as a subset of all infants and children ages 0 through 25. The
count for CYSHCN will not be added to the overall total because
their inclusion would result in a duplicated count. The row and
column totals will be auto-calculated to capture total number of
participants.
Researchers
involved includes all principal investigators and
co-investigators from across all MCHB-funded or supported
studies.
Research
network sites includes all sites where research is
currently/actively being conducted.
The
count of clinical practice guidelines (or other products that
inform clinical practice) informed by research findings may
include guidelines developed by non-awardees using awardee
research.
Comments:
Enter any comments, if applicable.
Definitions:
Research
refers to activities that support the systematic investigation of
topics related to the health of maternal and child health (MCH)
populations. This includes programs that provide direct funding
for research studies.
Infrastructure
Support refers to providing resources, logistical support, or
the coordination of services for researchers to conduct research
and foster innovation (for example, research networks, etc.). A
grantee can have both research and infrastructure support
activities.
Intervention
is defined as a manipulation of the subject or subject’s
environment to modify one or more health-related biomedical or
behavioral processes and/or endpoints or outcomes for MCH
populations.
During
the reporting period, did your program conduct research or
provide infrastructure support for research? (select
all that apply)
Yes,
conducted research [complete
Part A]
Yes,
provided infrastructure support for research [complete
Part A]
No
Research
and Infrastructure Support for Research
i.
Type(s) of research conducted or supported in the reporting period
(select
all that apply)
Intervention
research
Other
primary research (for example, research that involves collection
of own data, including experimental, quasi-experimental,
observational studies, etc.)
Secondary
data analysis
ii.
Topic(s) of research conducted or supported in the reporting
period (select
all that apply)
Early
Childhood – General
Early
Childhood – Newborn Screening
Early
Childhood – Safe Sleep
Early
Childhood – Developmental Health (including developmental
screening)
Adolescent
Health
Maternal
Health – General
Maternal
Health – Maternal Mortality
Maternal
Health – Perinatal/Postpartum Care
Maternal
Health – Breastfeeding
Maternal
Health – Maternal Depression
Children,
Adolescents, and Young Adults with Special Health Care Needs
Developmental
Disabilities
Mental/Behavioral
Health – General
Mental/Behavioral
Health – Autism
Mental/Behavioral
Health – Substance Use Disorder(s)
Clinical
Care
Sickle
Cell Disease
Heritable
Disorders (excluding sickle cell)
Epilepsy
Fetal
Alcohol Syndrome
Oral
Health
Medical
Home
Health
Care Transition
Immunizations
Injury
Prevention – General
Injury
Prevention – Poison/Toxin Exposure
Child
Maltreatment
Emergency
Services for Children – General
Emergency
Services for Children – Emergency Preparedness
Health
Equity
Social
Determinants of Health
Telehealth
Preventive
Services
Obesity
Health
Insurance
Nutrition
Respiratory
Health
Life
Course Approach
None
of the above
Outputs
for programs conducting or supporting research in the reporting
period
(complete
applicable outputs)
#
of studies supported by MCHB funding ____
#
of participants recruited in intervention research studies
(complete
if selected Intervention research in A.i. “Type of
Research”)
<TABLE
BY POPULATION GROUPS AND RACE ETHNICITY>
#
of participants recruited in other primary research studies
(complete
if selected Other primary research in A.i. “Type of
Research”)
<TABLE
BY POPULATION GROUPS AND RACE ETHNICITY>
#
of individuals included in secondary data analyses (complete
if selected Secondary data analysis in A.i. “Type of
Research”)
<TABLE
BY POPULATION GROUPS AND RACE ETHNICITY>
#
of researchers involved ____
#
of research network sites ____
#
of clinical practice guidelines (or other products that inform
clinical practice) informed by research findings ____
Have
you provided technical assistance, responded to data requests, or
participated in a joint project with a Title V agency?
Yes
No
#
of external funding applications submitted ____
#
of external funding applications awarded funding ____
Children,
Adolescents, and Young Adults (age 1-25)
Children
and Adolescents (age 1-17)
Young
Adults (age 18-25)
CYSHCN
(age 0-
25)
Pregnant/postpartum
persons (all ages)
Non-pregnant
women (age 26+)
Men
(age 26+)
Families
Other
(specify):
___________
Unknown
TOTALS
If
“Children, Adolescents, and Young Adults (age 1-25)”,
“Children and Adolescents (age 1-17)”, and/or “Young
Adults (age 18-25)” were included in research and reported in
the tables above, please indicate the age range of children,
adolescents, and/or young adults included.
to
Guidelines and Policy
Guidelines
and Policy
Instructions
Select
Yes or No to indicate whether your program developed or increased
the use of guidelines and/or policies during the reporting period.
If your program supported both, select Yes for both, and complete
Part A and Part B. If your program only focused on guidelines,
select Yes for guidelines only and complete Part A. If your
program only focused on policies, select Yes for policies and
complete Part B. If your program did not support either, select No
and the form is complete.
Part
A. Guidelines
Select
the level of intended change of the guideline(s). This indicates
the level the guideline(s) targets and expects to see change.
Select all that apply.
Complete
applicable outputs for guideline development/usage during the
reporting period.
Part
B. Policies
Select
the level of intended change of the policy(ies). This indicates
the level the policy(ies) targets and expects to see change.
Select all that apply.
Complete
applicable outputs for policy development/usage during the
reporting period.
Comments:
Enter any comments, if applicable.
Definitions:
Guidelines
refer to activities that develop, modify, or implement guidelines
within or between organizations and/or institutions, or at the
local, state, or national level. Guidelines are guidance that is
recommended but not mandatory (for example, Bright Futures,
Women’s Preventive Services Initiative, etc.)
Policies
refer to activities that develop, modify, or implement policies
within or between organizations and/or institutions, or at the
local, state, or national level. Policies outline the requirements
or rules that must be met. Policies frequently refer to standards
or guidelines as the basis for their existence (for example, state
policy that Medicaid cover recommended preventive services, etc.).
1.
During the reporting period, did your program develop or increase
use of guidelines and/or policies (select all that apply)
Yes,
guidelines [complete Part A]
Yes,
policies [complete Part B]
No
Guidelines
Level
of intended change of guideline(s) (select all that apply)
Organizational/institutional
Local
State
National
Outputs
[complete
applicable outputs]
#
of guidelines developed/proposed/modified in the reporting period
____
#
of guidelines implemented in the reporting period ______
#
implementing guidelines in the reporting period
#
of individuals/providers implementing guidelines ____
#
of organizations implementing guidelines____
#
of localities (for example, city, county, etc.) implementing
guidelines ___
#
of states implementing guidelines ____
Policies
Level
of intended change of the policy(ies) (select all that apply)
Organizational/institutional
Local
State
National
Outputs
[complete
applicable outputs]
#
of policies developed/proposed/modified in the reporting
period____
#
of policies implemented/passed in the reporting period___
#
of organizations implementing/passing policies____
Select
Yes or No to indicate whether your program worked to improve the
data collection practices of other organizations, data access, or
data linkages during the reporting period. If your program
supported all three, select Yes for all three, and complete Part
A, Part B, and Part C. If your program only focused on data
collection practices, select Yes for data collection only and
complete Part A. If your program only focused on data access,
select Yes for data access and complete Part B. If your program
only focused on data linkages, select Yes for data linkages and
complete Part C. If your program did not support any of the three,
select No and the form is complete.
Part
A.Improving Data Collection Practices
Select
the activity(ies) conducted during the reporting period to
improve another organization’s data collection practices.
Select all that apply. If selected “facilitated submission
of data to data collection system,” and if able, enter the
number of entities submitting data during the reporting period.
If the program supports multiple data collection systems, provide
the cumulative number of entities submitting data across all
systems. This number may be a duplicated count.
Part
B.Improving Access to Data
Select
the activity(ies) conducted during the reporting period to
improve data access. Select all that apply. If selected “created
datasets” and/or “increased public access to
datasets,” and if able, enter the number of datasets
created and/or number of times datasets were accessed during the
reporting period. If there are multiple datasets accessed,
provide the cumulative number of times the datasets were accessed
across all data sets. This number may be a duplicated count.
Part
C. Creating Data Linkages
Select
the activity(ies) conducted during the reporting period to create
data linkages. Select all that apply.
Comments:
Enter any comments, if applicable.
Definitions:
Data
and Information System activities include activities that
improve the ability of other organizations to collect, access, and
link data across multiple systems and programs. The purpose of
these activities is to improve the overall public health
infrastructure and not individual program process improvement or
quality improvement around data.
During
the reporting period, did your program work to improve other
organizations’ data collection practices, access to data,
or create data linkages? (select all that apply)
ÿ
Yes, program worked to improve data collection practices [complete
Part A]
ÿ
Yes, program worked to improve access to data [complete
Part B]
ÿ
Yes, program worked to create data linkages [complete
Part C]
ÿ
No
Improving
Data Collection Practices
Type
of activity in the reporting period (select all that apply)
ÿ
Developed and/or tested new metrics for data collection
ÿ
Created standardized data collection forms or definitions for key
terms
ÿ
Developed/enhanced/maintained information technology systems to
house data (including registries)
ÿ
Facilitated submission of data to data collection systems
#
of entities (for example, states, hospitals, partner centers,
teams, etc.) submitting data to system _____
ÿ
Conducted data quality checks
ÿ
Identified and implemented interventions to improve data
collection quality
ÿ
Facilitated the collection of disaggregated data based on race,
ethnicity, sexual and gender minority, or other underrepresented
demographics
ÿ
Other (specify): ___________________
B.Improving Access to Data
Type
of activity in the reporting period (select all that apply)
ÿ
Created datasets or a common database for external use
#
created _____
ÿ
Increased public access to datasets
#
of times dataset accessed (downloaded or requested) ____
ÿ
Created or facilitated data use/exchange agreements
ÿ
Other (specify): ___________________
C.
Creating Data Linkages
i.
Type of activity in the reporting period (select all that
apply)
Select
Yes or No to indicate whether your program implemented or
participated in quality improvement (QI) initiatives and/or
conducted evaluation activities during the reporting period. If
your program supported both, select Yes for both, and complete
Part A and Part B. If your program only implemented or
participated in QI, select Yes only for QI and complete Part A. If
your program only conducted evaluation activities, select Yes only
for evaluation and complete Part B. If your program did not
support either, select No and the form is complete.
Part
A. Quality Improvement
Select
Yes or No to indicate whether your program collected metrics to
track QI during the reporting period.
Select
what action has been taken as a result of the QI process during
the reporting period. Select all that apply.
Part
B. Evaluation
Select
the type of evaluation activity that was conducted during the
reporting period. Select all that apply.
Select
how your program has used evaluation activities in the reporting
period. Select all that apply.
Comments:
Enter any comments, if applicable.
Definitions:
Quality
Improvement includes activities that use deliberate processes
to improve the efficacy and impact of activities, programs, or
systems (for example, PDSA cycles, etc.)
Evaluation
includes activities that systematically collect information to
assess a project, program, or system’s performance or
outcomes.
1.
During the reporting period, did your program implement or
participate in quality improvement (QI) initiatives, or conduct
activities to evaluate a program’s or system’s
performance or outcomes? (select all that apply)
ÿ
Yes, implemented or participated in QI [complete
Part A]
ÿ
Yes, conducted activities to evaluate performance or outcomes
[complete Part B]
ÿ
No
Quality
Improvement
Did
you collect metrics to track improvement as part of the QI
process in the reporting period?
ÿ
Yes
ÿ
No
What
action have you taken as a result of the QI process in the
reporting period?
ÿ
Used findings to make improvements in your work (for example,
improve existing services, ensure reaching the intended groups,
review internal processes, etc.)
ÿ
Used findings in your planning processes
(for example, prioritize activities, identify unmet needs,
scale-up of intervention, etc.)
ÿ
Have not taken any action in the reporting period
Evaluation
Type
of evaluation activity in the reporting period (select all
that apply)
ÿ
Evaluation plan and design
ÿ
Evaluation of program processes and/or implementation
ÿ
Evaluation of program outcomes and/or impact
ÿ
Other (specify): _________________________
How
have you used the evaluation activities in the reporting
period? (select all that apply)
ÿ
Implemented evaluation plan/design
ÿ
Disseminated findings to stakeholders
ÿ
Used findings to make improvements in your work (for example,
improve existing services, ensure reaching the intended groups,
review internal processes, etc.)
ÿ
Used findings in your planning processes
(for example, prioritize activities, identify unmet needs,
scale-up of intervention, etc.)
ÿ
Have not used evaluation activities in the reporting period
This
form collects information on changes in knowledge in a target
population as a result of program activities/interventions.
Knowledge
Change - Measures and Data (to be completed only if you can
define a measure):
The
table captures data regarding knowledge change. For each knowledge
change measure with available data, complete one row of the table.
Additional rows may be added as needed to capture additional
measures.
Measure
Description: Enter a description of the measure for which you
have collected data. The measure should be as specific and
descriptive as possible (for example, % of pregnant persons from
county X with increased knowledge on safe sleep practices
[including alone, by themselves, and in a crib], # of clinicians
with increased knowledge on Bright Futures, etc.).
Target
Population: From
the drop-down menu, select which specific target population(s)
apply to the measure. This should be the population(s) whose
knowledge you are trying to change. Select all that apply.
Primary
Knowledge Change Subject Area: From the drop-down menu, select
which specific knowledge change subject area(s) apply to the
measure. Select all that apply. If the specific subject area of
your knowledge change subject area is not listed, select the
subject area closest to your knowledge change subject area. If
none of the subject areas are close to your knowledge change
subject area, select “none of the above”.
Knowledge
Change Topic Area: From the drop-down menu, select which specific
knowledge change topic area(s) apply to each measure. Select all
that apply. If the specific topic area of the knowledge change is
not listed, select the topic area closest to your topic area. If
none of the topics are close, select “none of the above.”
You may select a subtopic without also selecting the
corresponding general topic. For example, you may select “Early
Childhood - Newborn Screening” without selecting “Early
Childhood - General”. In addition, you may select only the
general topic if none of the subtopics apply.
Data
Available: Select Yes or No to indicate if you have data to
report for the reporting period.
Data
Source: From the drop-down menu, select your data source for the
reported data.
Measure
Type: From the drop-down menu, select whether the measure is a
count or percentage.
Numerator:
Enter the numerator value for the reporting period (i.e., number
of individuals in target population that report improved
knowledge in a given area). If you only have a count of those
reporting knowledge change, this will be entered into the
numerator field.
Denominator:
Enter denominator value for the reporting period (i.e., number of
individuals in target population). If you only have a count of
those reporting knowledge change, this field will be left blank.
Outcome:
The outcome will be auto-calculated.
Measure
Inactivated: If a previously established measure is being
inactivated, select the box and provide an explanation for
inactivation in the comments field. This section is only
applicable for measures established during a previous report.
Comments:
Enter any comments, if applicable.
Definitions:
Knowledge
Change: Immediate or initial changes in awareness,
familiarity, or understanding, which are the result of learning,
and can be observed and measured immediately after an
activity/intervention.
Knowledge
Change - Measures and Data
Measure
Description: (ex.
% of pregnant persons with increased knowledge on safe sleep; # of
clinicians with increased knowledge on Bright Futures)
Target
Population:
(Select
all that apply for each measure)
[Drop
Down List ]
Primary
Knowledge Change Subject Area:
(Select
all that apply for each measure)
[Drop
Down List ]
Knowledge
Change
Topic Area:
(Select
all that apply for each measure)
[Drop
Down List ]
Data
Available:
(Select
Yes or No)
Data
Source:
[Drop
Down List:
ÿ
Survey or self-report data
ÿ
Test
ÿ
Electronic health record data
ÿ
Paper-based health record data
ÿ
Registry data
ÿ
Claims data
ÿ
Other (specify):________]
Measure
Type:
[Drop
Down List:
ÿ
Count
ÿ
Percentage]
Numerator:
[Enter
the numerator value for this measure]
Denominator:
[Enter
the denominator value for this measure, if applicable]
Outcome:
#/%
[auto-calculated]
Measure
Inactivated:
(Select
if measure is inactivated)
Text
Drop
Down
Drop
Down
Drop
Down
Y/N
Drop
Down
Drop
Down
#
#
#(%)
☐ Comments:
______________
Text
Drop
Down
Drop
Down
Drop
Down
Y/N
Drop
Down
Drop
Down
#
#
#(%)
☐ Comments:
______________
Text
Drop
Down
Drop
Down
Drop
Down
Y/N
Drop
Down
Drop
Down
#
#
#(%)
☐ Comments:
______________
+
Add Row, if needed, for additional measures
Drop
Down Lists for:
Target
Population
Children,
Adolescents, and Young Adults (age 1-25)
Children,
Adolescents, and Youth with Special Health Care Needs (age 1-25)
Pregnant/Postpartum
Persons (all ages)
Non-Pregnant
Women (age 26+)
Men
(age 26+)
Family
Members
Providers
(clinical care and care support such as doctors, allied health
professionals, care coordinators)
Public
Health Professionals
Students/Trainees
Other
Organizational Members (such as faculty and staff of
organizations)
Primary
Knowledge Change Subject Area
Clinical
Care Related (including medical home)
Equity,
Diversity, or Cultural Responsiveness Related
Data,
Research, Evaluation Methods
Family
Involvement
Interdisciplinary
Teaming
Health
Care Workforce Leadership
Policy
Systems
Development/Improvement (including capacity building,
planning, and financing)
Emerging
Issues
Comprehensive
Curricula (ONLY applicable to Division of Maternal and Child
Health Workforce Development Training programs)
None
of the above
Knowledge
Change Topic Area
Early
Childhood – General
Early
Childhood – Newborn Screening
Early
Childhood – Safe Sleep
Early
Childhood – Developmental Health (including developmental
screening)
Adolescent
Health
Maternal
Health – General
Maternal
Health – Maternal Mortality
Maternal
Health – Perinatal/Postpartum Care
Maternal
Health – Breastfeeding
Maternal
Health – Maternal Depression
Children,
Adolescents, and Young Adults with Special Health Care Needs
Developmental
Disabilities
Mental/Behavioral
Health – General
Mental/Behavioral
Health – Autism
Mental/Behavioral
Health – Substance Use Disorder(s)
Clinical
Care
Sickle
Cell Disease
Heritable
Disorders (excluding sickle cell)
Epilepsy
Fetal
Alcohol Syndrome
Oral
Health
Medical
Home
Health
Care Transition
Immunizations
Injury
Prevention – General
Injury
Prevention – Poison/Toxin Exposure
Child
Maltreatment
Emergency
Services for Children – General
Emergency
Services for Children – Emergency Preparedness
Health
Equity
Social
Determinants of Health
Telehealth
Preventive
Services
Obesity
Health
Insurance
Nutrition
Respiratory
Health
Life
Course Approach
None
of the above
Behavior Change
Behavior
Change
Instructions
This
form collects information on changes in behavior in a target
population as a result of program activities/interventions.
NOTE:
The target population of the behavior change and observed change
must be the same to use this form. For example, if a program is
working to improve referral practices of providers, the target
population for the behavior change is providers. Therefore, the
corresponding measure should be at the provider-level (% of
providers that provide referrals) and not at the patient-level (%
of patients that receive referrals).
Behavior
Change - Measures and Data (to be completed only if you can
define a measure):
The
table captures data regarding behavior change. For each behavior
change measure with available data, complete one row of the table.
Additional rows may be added as needed to capture additional
measures.
Measure
Description: Enter a description of the measure for which you
have collected data. The measure should be as specific and
descriptive as possible (for example, % of medical providers
prescribing hydroxyurea to pediatric sickle cell patients in X
location).
Target
Population: From
the drop-down menu, select which specific target population(s)
apply to each measure. This
should be the population(s) whose behavior you are trying to
change. Select all that apply.
Primary
Behavior Change Subject Area: From
the drop-down menu, select which specific behavior change subject
area(s) apply to each measure. Select
all that apply. If the specific subject area of your behavior
change subject area is not listed, select the subject area
closest to your behavior change subject area. If none of the
subject areas are close to your behavior change subject area,
select “none of the above.”
Behavior
Change Topic Area: From
the drop-down menu, select which specific behavior change topic
area(s) apply to each measure. Select
all that apply. If the specific topic area of the behavior change
is not listed, select the topic area closest to your topic area.
If none of the topics are close, select “none of the
above.” You may select a subtopic without also
selecting the corresponding general
topic. For example, you may select “Early
Childhood - Newborn
Screening” without selecting “Early
Childhood-General”. In addition, you may select only the
general
topic if none of the subtopics apply.
Data
Available: Select Yes or No to indicate if you have data to
report for the reporting period.
Data
Source: From the drop-down menu, select your data source for the
reported data.
Measure
Type: From the drop-down menu, select whether the measure is a
count or percentage.
Numerator:
Enter the numerator value for the reporting period (i.e., number
of individuals in target population that report doing a
behavior). If you only have a count of those reporting behavior
change, this will be entered into the numerator field.
Denominator:
Enter denominator value for the reporting period (i.e., number of
individuals in the target population). If you only have a count
of those reporting behavior change, this field will be left
blank.
Outcome:
The outcome will be auto-calculated.
Measure
Inactivated: If a previously established measure is being
inactivated, select the box and provide an explanation for
inactivation in the comments field. This section is only
applicable for measures established during a previous report.
Comments:
Enter any comments, if applicable.
Definitions:
Behavior
Change: Intermediate changes in behavior/practice that result
from an action/intervention, taking some time to be observed after
an action/intervention.
Behavior
Change - Measures and Data
Measure
Description: (ex.
% of medical
providers prescribing hydroxyurea to pediatric sickle cell
patients in X location)
Target
Population:
(Select
all that apply for each measure)
[Drop
Down List]
Primary
Behavior Change Subject Area:
(Select
all that apply for each measure)
[Drop
Down List]
Behavior
Change
Topic Area:
(Select
all that apply for each measure)
[Drop
Down List]
Data
Available:
(Select
Yes or No)
Data
Source:
[Drop
Down List:
ÿ
Survey or self-report data
ÿ
Test
ÿ
Electronic health record data
ÿ
Paper-based health record data
ÿ
Registry data
ÿ
Claims data
ÿ
Other (specify):________]
Measure
Type:
[Drop
Down List:
ÿ
Count
ÿ
Percentage]
Numerator:
[Enter
the numerator value for this measure]
Denominator:
[Enter the
denominator value for this measure, if applicable]
Outcome:
#/%
[auto-calculated]
Measure
Inactivated:
(Select
if measure is inactivated)
Text
Drop
Down
Drop
Down
Drop
Down
Y/N
Drop
Down
Drop
Down
#
#
#(%)
☐ Comments:
______________
Text
Drop
Down
Drop
Down
Drop
Down
Y/N
Drop
Down
Drop
Down
#
#
#(%)
☐ Comments:
______________
Text
Drop
Down
Drop
Down
Drop
Down
Y/N
Drop
Down
Drop
Down
#
#
#(%)
☐ Comments:
______________
+
Add Row, if needed, for additional measures
Drop
Down Lists for:
Target
Population
Children,
Adolescents, and Young Adults (age 1-25)
Children,
Adolescents, and Youth with Special Health Care Needs (age 1-25)
Pregnant/Postpartum
Persons (all ages)
Non-Pregnant
Women (age 26+)
Men
(age 26+)
Family
Members
Providers
(clinical care and care support such as doctors, allied health
professionals, care coordinators)
Public
Health Professionals
Students/Trainees
Other
Organizational Members (such as faculty and staff of
organizations)
Primary
Behavior Change Subject Area
Clinical
Care Related (including medical home)
Equity,
Diversity, or Cultural Responsiveness Related
Data,
Research, Evaluation Methods
Family
Involvement
Interdisciplinary
Teaming
Health
Care Workforce Leadership
Policy
Systems
Development/Improvement (including capacity building,
planning, and financing)
Emerging
Issues
Comprehensive
Curricula (ONLY applicable to Division of Maternal and Child
Health Workforce Development Training programs)
None
of the above
Behavior
Change Topic Area
Early
Childhood – General
Early
Childhood – Newborn Screening
Early
Childhood – Safe Sleep
Early
Childhood – Developmental Health (including developmental
screening)
Adolescent
Health
Maternal
Health – General
Maternal
Health – Maternal Mortality
Maternal
Health – Perinatal/Postpartum Care
Maternal
Health – Breastfeeding
Maternal
Health – Maternal Depression
Children,
Adolescents, and Young Adults with Special Health Care Needs
Developmental
Disabilities
Mental/Behavioral
Health – General
Mental/Behavioral
Health – Autism
Mental/Behavioral
Health – Substance Use Disorder(s)
Clinical
Care
Sickle
Cell Disease
Heritable
Disorders (excluding sickle cell)
Epilepsy
Fetal
Alcohol Syndrome
Oral
Health
Medical
Home
Health
Care Transition
Immunizations
Injury
Prevention – General
Injury
Prevention – Poison/Toxin Exposure
Child
Maltreatment
Emergency
Services for Children – General
Emergency
Services for Children – Emergency Preparedness
Health
Equity
Social
Determinants of Health
Telehealth
Preventive
Services
Obesity
Health
Insurance
Nutrition
Respiratory
Health
Life
Course Approach
None
of the above
Products and Publications
Products
and Publications
Instructions
Part
A –
Number of Products and Publications:
Displays, by type, the number of products, publications, and
submissions addressing maternal and child health that have been
published or produced with grant support (either fully or
partially) during the reporting period. Numbers for each type are
auto-calculated from completion of Part B.
Part
B–
Data Collection Forms:
For each product, publication, and submission addressing maternal
and child health that has been published or produced with grant
support (either fully or partially) during the reporting period,
complete the following forms. Complete one entry for each product,
publication, and submission. All elements marked with an “*”
are required.
Published
articles in peer-reviewed scholarly journals,
Include
peer-reviewed publications addressing maternal and child health
that have been published by project faculty and/or staff during
the reporting period, and directly supported by MCHB program
funds. Faculty and staff include those listed in the budget form
and narrative and others that your program considers to have a
central and ongoing role in the project whether or not they are
supported by the grant.
Reporting
of “Page(s)” for “Published articles in
peer-reviewed scholarly journals” is only optional for
online-only articles that do not have page numbers.
A.
Number of Products and Publications
Type
Number
Published
articles
in peer-reviewed scholarly journals
Submissions
of manuscripts to peer-reviewed scholarly journals
Books
Book
chapters
Reports
and monographs (including policy briefs and best practices
reports)
Conference
oral presentations and posters
Web-based
products (for example, blogs, podcasts, web-based video clips,
wikis, RSS feeds, news aggregators, social networking sites, etc.)
Press
communications (TV/radio interviews, newspaper interviews, public
service announcements, and editorial articles)
Newsletters
(electronic or print)
Pamphlets,
brochures, or fact sheets
Academic
course development
Distance
learning modules
Doctoral
dissertations/Master’s theses
Tools
or toolkits
Other
B.
Data Collection Forms
Data
collection form for: Published articles in peer-reviewed scholarly
journals
Tracking
Program-Specific (Training, EMSC, HS, and F2F) and
Project-Developed Measures
Instructions
General
Instructions:
This
is a generic data collection form to be used by awardees to report
annual objectives and data values for predefined DGIS
program-specific performance measures (i.e., Training, EMSC,
Healthy Start, and Family-to-Family forms) and/or
project-developed performance measures (i.e., measures created
using the detail sheet in Part 10.B.1). This data collection form
serves two purposes: 1) collects and displays planned, future year
(up to 5 years) Annual Performance Objective targets for each
program-specific measure and project-developed measure, as
applicable; and 2) collects and displays the Annual Performance
Indicator values actually achieved during the reporting period for
each program-specific measure and project-developed measure, as
applicable.
Part
10.A: Program-Specific Performance Measures: Part 10.A is
applicable only to awardees with predefined DGIS program-specific
performance measures (i.e., Training, EMSC, Healthy Start, or
Family-to-Family forms). Data collection for these measures is
built into the respective program-specific forms in the DGIS
system and does not appear as a separate form to complete.
Part
10.B: Project-Developed Performance Measures: Part 10.B is
only applicable to awardees developing their own performance
measures to report. This form is used to create detail sheets for
project measures that the awardee chooses to add. The purpose of
the detail sheet is to describe the project measures by completing
each section as appropriate. Data for the measures created using
Part 10.B.1 are captured using Part 10.B.2. Note that the
performance measure title, numerator, and denominator fields will
be displayed in DGIS in Part 10.B.2. exactly as they are defined
in Part 10.B.1. For project-developed performance measures,
awardees must first complete the Part 10.B.1 detail sheet. Once a
measure is created using Part 10.B.1, the awardee will then be
able to complete data cells in Part 10.B.2.
10.A:
PROGRAM-SPECIFIC PERFORMANCE MEASURES
Instructions
for Predefined Program-Specific Performance Measures
For
each applicable program-specific measure:
First
DGIS report:
Awardees
will establish Annual Performance Objective targets for all
future reporting periods. DGIS will auto-populate established
Annual Performance Objective targets in subsequent DGIS reports.
All
subsequent DGIS reports:
DGIS
will display previously established Annual Performance Objective
targets.
Awardees
will enter values for numerators and denominators, if
applicable. Annual Performance Indicators will auto-calculate
based on values from numerators and denominators.
Awardees
will complete all other necessary fields.
If
neither actual data nor an estimate can be provided, the Annual
Performance Objective and Annual Performance Indicator lines are
to be left blank.
Awardees
will complete the following data fields:
Field
Name
Instructions
Measure
Name
The
measure name is auto-populated from the assigned
program-specific measure (for example, Training 14, etc.).
Reporting
Period
The
reporting period is auto-populated.
Annual
Performance Objective
Enter
a value for the target the project plans to meet for each of
the reporting periods. The values may be expressed as a
number, a rate, a percentage, or yes/no. Note: Objectives only
need to be entered in the first DGIS report and will
auto-populate for subsequent reports.
Numerator
Enter
the numerator values for the reporting period. If you only
have a count for the measure, enter it into the numerator
field. If an actual number is not available, provide your best
estimate. Enter only numerator data for scale measures. If
there are no numerator data, leave this line blank.
Denominator
Enter
the denominator values for the reporting period. If you only
have a count for the measure, this will be entered in the
numerator field and the denominator field should remain blank.
If an actual number is not available, provide your best
estimate. Do not enter denominator data for scale measures. If
there are no denominator data, leave this line blank.
Annual
Performance Indicator
This
value is auto-calculated based on the numerator and
denominator (if applicable) entered.
Comment
Box
Explain
all estimates in the comment box provided. If the data
provided was not an estimate, you may leave this field blank.
If neither actual data nor an estimate can be provided, you
must provide a note in the comment box describing a plan and
timeframe for providing the required data. You may also use
the comment box to provide any additional information.
10.B:
PROJECT-DEVELOPED PERFORMANCE MEASURES
Instructions
for Project-Developed Performance Measures
10.b.1:
Measure development
This
form is used to create detail sheets for project measures that the
awardee chooses to add. The purpose of the detail sheet is to
describe the project measures by completing each section as
appropriate. Data for the measures created using Part 10.B.1 are
captured using Part 10.B.2. Note that the performance measure
title, numerator, and denominator fields will be displayed in DGIS
in Part 10.B.2. exactly as they are defined in Part 10.B.1.
Awardees
will complete the following data fields:
Measure
Number
DGIS
auto-populates the measure number.
Performance
Measure Title
Enter
a brief, narrative description of the performance measure (for
example, number of families that received education on topic,
etc.). The measure statement should not indicate a
desired direction (such as an increase or decrease).
Level
Select
the most appropriate classification for the measure being
described. This indicates at which level the measure captures
data and where you expect to see change.
Goal
Enter
a short statement indicating what the project hopes to
accomplish by tracking this measure.
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 Stage 1/Stage 2/Stage 3, a clear description
of what those values mean and how they are determined should
be provided.
Enter
the following for performance measures to be reported:
Numerator:
If the measure is a percentage, rate, or ratio, provide a
clear description of the numerator. In DGIS, this field is
used for count and scale, measures that do not have a
denominator. This field is not required for narrative
measures.
Denominator:
If the measure is a percentage, rate, or ratio, provide a
clear description of the denominator. In DGIS, leave this
field blank for count, scale, or narrative measures.
Type
of Measure
Unit
Type: Indicate type of measure (for example, percentage,
rate, ratio, scale, count, etc.).
Unit
Number: Indicate the units in which the measure is
expressed (for example, %, per 1000, etc.). If
the measure is a percentage, ratio, scale, or count this
indicates the maximum value for the measure. If the measure is
a rate, it indicates per 1,000; 10,000; or 100,000.If
the measure is a narrative, leave this field blank.
Grantee
Data
Sources
and
Issues
Enter
the source(s) of the data used in determining the value of the
measure and any issues concerning themethods of data
collection or limitations of the data used.
Significance
Briefly
describe why this measure is significant, especially as it
relates to the Goal.
10.b.2:
Measure reporting
Part
10.B.2 is only applicable to awardees developing their own
performance measures, who have completed Part 10.B.1.
For
each applicable project-developed measure:
First
DGIS report:
Awardees
will establish Annual Performance Objective targets for all
future reporting periods. DGIS will auto-populate established
Annual Performance Objective targets in subsequent DGIS reports.
All
subsequent DGIS reports:
DGIS
will display previously established Annual Performance Objective
targets.
Awardees
will enter values for numerators and denominators, if
applicable. Annual Performance Indicators will auto-calculate
based on values from numerators and denominators.
Awardees
will complete all other necessary fields.
If
neither actual data nor an estimate can be provided for a
reporting period, select “No” for Data Available and
the Annual Performance Indicator line for the reporting period is
to be left blank.
Awardees
will complete the following data fields:
Field
Name
Instructions
Measure
Number
The
measure number will auto-populate from the Part 10.B.1 detail
sheet.
Performance
Measure Title
The
measure name will auto-populate from the Part 10.B.1 detail
sheet.
Reporting
Period
The
reporting period is auto-populated.
Annual
Performance Objective
Enter
a value for the target the project plans to meet for each of
the reporting periods. The values may be expressed as a
number, a rate, a percentage, or a ratio. Do not enter
objectives for narrative measures. Note: Objectives only need
to be entered in the first DGIS report and will auto-populate
for subsequent reports.
Data
Available
Select
Yes or No to indicate if data is available for reporting in
the reporting period.
Numerator
Enter
the numerator values for the reporting period. If you only
have a count for the measure, enter it into the numerator data
entry field. If an actual number is not available, provide
your best estimate. Enter only numerator data for scale
measures. Do not enter numerator data for narrative measures.
If there are no numerator data, leave this line blank.
Denominator
Enter
the denominator values for the reporting period. If you only
have a count for the measure, this will be entered into the
numerator data entry field and the denominator field should
remain blank. If an actual number is not available, provide
your best estimate. Do not enter denominator data for scale or
narrative measures. If there are no denominator data, leave
this line blank.
Annual
Performance Indicator
For
count and scale measures, this value is auto-populated from
the narrative field. For percentage, ratio, and rate measures,
this value is auto-calculated based on the numerator and
denominator entered. For narrative measures, enter the results
for the reporting period.
Data
Source
Enter
the source(s) of the data used in determining the value of the
measure and the time period the data source reflects.
Comment
Box
Please
explain all estimates in the comment box provided. If the data
provided was not an estimate, you may leave this field blank.
If neither actual data nor an estimate can be provided, you
must provide a note in the comment box describing a plan and
timeframe for providing the required data. You may also use
the comment box to provide any additional information.
Definitions:
Performance
Measure: A measure defined in a DGIS detail sheet.
Annual
Performance Objective: Annual target that is set for a
performance measure.
Annual
Performance Indicator: Actual value of a performance measure
achieved during the reporting period.
10.A.
Program-Specific Measures – Annual Objective and Performance
Data
MEASURE
NAME
Annual
Performance Objective
Numerator
Denominator
Annual
Performance Indicator
Reporting
Period ____
______
______
______
______
Reporting
Period ____
______
______
______
______
Reporting
Period ____
______
______
______
______
Reporting
Period ____
______
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Reporting
Period ____
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Comment
box
10.B.1
Project-Developed Measures – Detail Sheet
Measure
Number
Performance
Measure Title
Level
*
National
*
State
*
Local
Organizational/institutional
Other
(specify): __________________
Goal
Definition
Numerator:
Denominator:
Type
of Measure
Unit
Type:
Unit
Number:
Grantee
Data
Sources
and
Issues
Significance
10.B.2.
Project-Developed Measures – Annual Objective and Performance
Data
