7a Patient Impact Form

OMB No.: 0915-0285. Expiration Date: xx/xx/20xx

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration PATIENT IMPACT FORM
Patients by Service Category - Instructions
This form is used to collect baseline and estimated patient information. If you are not currently open and operational at your proposed SBHC location, enter 0 for all baseline information and provide estimates. Physical health services is defined as comprehensive health assessments, diagnosis, and treatment of minor, acute, and chronic medical conditions. Mental health services is defined as mental health and substance use disorder assessments, crisis intervention, counseling, and treatment. Unduplicated patients are children and adolescents that receive one or both services (physical health services and/or mental health services) within the given timeframe. If a patient received or is estimated to receive both services, count them only once for the given timeframe. Baseline Patients: Indicate the number of patients served at your SBHC location from January 1, 2021 through December 31, 2021. Provide the number of child and adolescent patients that: Received physical health services through the SBHC (may be 0). Received mental health services through the SBHC (may be 0). Calculate the total unduplicated patients served at your SBHC location from January 1, 2021 through December 31, 2021. If a patient received both services, count them only once. Estimated Patients: Indicate the estimated number of patients who will be served at the proposed SBHC location from January 1, 2023 through December 31, 2023. Provide the estimated number of child and adolescent patients that: Will receive physical health services through the SBHC (must be greater than 0 and must be greater than the baseline). Will receive mental health services through the SBHC (must be greater than 0 and must be greater than the baseline). Calculate the total estimated unduplicated patients to be served at your SBHC location from January 1, 2023 through December 31, 2023. If a patient is estimated to receive both services, count them only once.
Service Category			Baseline Patients served in calendar year 2021		Estimated Patients to be served in calendar year 2023
Physical Health Services
Mental Health Services
Total Unduplicated Patients
School-Based Health Center Progress
This section is used to collect SBHC progress. Enter the number of children and adolescents served at the SBHC in the calendar year.
Service Category	Baseline Patients served in calendar year 2021	Estimated Patients to be served in calendar year 2023		Actual Number of Patients served in 20XX		Actual Number of Visits in 20XX
Physical Health Services	From application	From application
Mental Health Services	From application	From application
Total Unduplicated Patients	From application	From application

Referrals by Type	Number of Referrals in 20XX
Specialty Care
Vision Services
Oral Health Services
Emergency Psychiatric Care
Mental Health Community Support Programs
Mental Health Inpatient Care
Mental Health Outpatient Programs

Patients by Age and by Sex Assigned at Birth

Line	Age Groups	Male Patients (a)	Female Patients (b)
1	Under age 3	<blank for demonstration>	<blank for demonstration>
2	Age 3
3	Age 4	<blank for demonstration>	<blank for demonstration>
4	Age 5	<blank for demonstration>	<blank for demonstration>
5	Age 6	<blank for demonstration>	<blank for demonstration>
6	Age 7	<blank for demonstration>	<blank for demonstration>
7	Age 8	<blank for demonstration>	<blank for demonstration>
8	Age 9	<blank for demonstration>	<blank for demonstration>
9	Age 10	<blank for demonstration>	<blank for demonstration>
10	Age 11	<blank for demonstration>	<blank for demonstration>
11	Age 12	<blank for demonstration>	<blank for demonstration>
12	Age 13	<blank for demonstration>	<blank for demonstration>
13	Age 14	<blank for demonstration>	<blank for demonstration>
14	Age 15	<blank for demonstration>	<blank for demonstration>
15	Age 16	<blank for demonstration>	<blank for demonstration>
16	Age 17	<blank for demonstration>	<blank for demonstration>
17	Age 18	<blank for demonstration>	<blank for demonstration>
18	Age 19	<blank for demonstration>	<blank for demonstration>
19	Age 20	<blank for demonstration>	<blank for demonstration>
20	Age 21	<blank for demonstration>	<blank for demonstration>
21	Total Patients (Sum of Lines 1–19)	<blank for demonstration>	<blank for demonstration>

Demographic Characteristics

	Patients by Race and Hispanic or Latino/a Ethnicity
Line	Patients by Race	Hispanic or Latino/a (a)	Non-Hispanic or Latino/a (b)	Unreported (c)	Total (d)
1	Asian	<blank for demonstration>	<blank for demonstration>	<cell not reported>	<blank for demonstration>
2	Native Hawaiian	<blank for demonstration>	<blank for demonstration>	<cell not reported>	<blank for demonstration>
3	Other Pacific Islander	<blank for demonstration>	<blank for demonstration>	<cell not reported>	<blank for demonstration>
4	Black/African American	<blank for demonstration>	<blank for demonstration>	<cell not reported>	<blank for demonstration>
5	American Indian/Alaska Native	<blank for demonstration>	<blank for demonstration>	<cell not reported>	<blank for demonstration>
6	White	<blank for demonstration>	<blank for demonstration>	<cell not reported>	<blank for demonstration>
7	More than one race	<blank for demonstration>	<blank for demonstration>	<cell not reported>	<blank for demonstration>
8	Unreported/Chose not to disclose	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
9	Total Patients (Sum of Lines 1–8)	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>

Line	Patients Best Served in a Language Other than English	Number (a)
10	Patients Best Served in a Language Other than English	<blank for demonstration>

Selected Quality Measures (TBD)

Line	Measures to be defined by SBHC and/or HRSA	Percentage of Patients
1	Well child visit/Routine child health exam
2	Risk Assessment (e.g., Pediatric Symptom Checklist, Rapid Assessment for Adolescent Preventive Services)
3	BMI screening and nutrition/physical activity counseling
4	Depression screening and follow-up
5	Other TBD
6	Other TBD
7	Other TBD

Public Burden Statement: The OMB control number for this information collection is 0915-0285 and it is valid until xx/xx/20xx. Public reporting burden for this collection of information is estimated to average 1 hour 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].