Form 11 QIF Evaluative Measures Report

Evaluative Measures Report – Quality Improvement Fund (QIF)

Introduction

This document contains a form for QIF award recipients to report on their project’s progress. Award recipients will use this form to report information related to overall project implementation.

The questions in this form are intended to gather information on recipients’ progress and are applicable to QIF topics across fiscal years. Grant recipients will share information about their progress towards project-specific goals and evaluative measures based on the QIF Notice of Funding Opportunity.

Evaluative Measures Report

Recipient Organization Name	Grant Number	Reporting Period

QIF Evaluative Domains

You will report data for QIF core domains based on the QIF Notice of Funding Opportunity.

Domain #: Determined in the Notice of Funding Opportunity

Each QIF may request quantitative and/or qualitative information specific to this domain.

Domain #: Determined in the Notice of Funding Opportunity

Each QIF may request quantitative and/or qualitative information specific to this domain.

Domain #: Determined in the Notice of Funding Opportunity

Each QIF may request quantitative and/or qualitative information specific to this domain.

Domain #: Determined in the Notice of Funding Opportunity

Each QIF may request quantitative and/or qualitative information specific to this domain.

[internal note: the number of domains may increase or decrease depending on the Notice of Funding Opportunity]

Recipient Evaluative Measures

Provide the current data available for each evaluative measure proposed in your project plan form. If you have added measures that were not included in your application, report those as well.

Evaluative Measure	Data	Included in proposed project plan form?
Describe measure	Provide current data	☐Yes ☐No
Describe measure	Provide current data	☐Yes ☐No

[internal note: the number of measures may increase or decrease depending on the grant recipient’s project]

Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. The Health Center Program application forms provide essential information to HRSA staff and objective review committee panels for application evaluation; funding recommendation and approval; designation; and monitoring. The OMB control number for this information collection is 0915-0285 and it is valid until XX/XX/XXXX. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of information is estimated to average 1.5 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].

2