Attachment A - Measure and Survey Crosswalk - MCHB - MCH Jurisdictional Survey - Revision

Maternal and Child Health (MCH) Jurisdictional Survey Instrument for the Title V MCH Block Grant Program

Attachment A: Crosswalk of Survey Questions to National Outcome Measures, National Performance Measures, Standard Measures, and Additional Measures (i.e., “Form 11” Measures)

National Outcome Measure	Survey Questions
Percent of low birth weight deliveries (<2,500 grams)	C2
Percent of preterm births (<37 weeks)	C1
Percent of children, ages 1 through 17, who have decayed teeth or cavities in the past year	B3
Percent of children with special health care needs (CSHCN), ages 0 through 17, who receive care in a well-functioning system	D1, D7, D9, D10, E1, E2, E3, E4, E5, E6, E7, E8, F1, F3, F4, F5, F6, G1, G2, PR7, VI4
Percent of children, ages 3 through 17, with a mental/behavioral condition who receive treatment or counseling	B5, D9
Percent of children, ages 0 through 17, in excellent or very good health	B1
Percent of children, ages 2 through 4, and adolescents, ages 6 through 17, who are obese (BMI at or above the 95th percentile)	D3, D4
Percent of women who experience postpartum depressive symptoms	GM3, NM7
Rate of hospitalization for non-fatal injury per 100,000 children ages 0–9 and adolescents ages 10–19	D12
Percent of women, ages 18 through 44, in excellent or very good health	K1, K2, K7
Percent of children, ages 6 through 11, who have a behavioral or conduct disorder	B5k
Percent of adolescents, ages 12 through 17, who have depression or anxiety	B5f, B5g

National Performance Measure	Survey Questions
Percent of infants who are ever breastfed	C5
Percent of infants placed to sleep on their backs	C4
Percent of children, ages 9 through 35 months, who received a developmental screening using a parent-completed screening tool in the past year	D6
Percent of children ages 6–11 who are physically active at least 60 min per day	H10
Percent of adolescents with and without special health care needs, ages 12 through 17, who are bullied or who bully others	H7, H8
Percent of adolescents, ages 12–17, with a preventive medical visit in the past year	D1
Percent of women who had a dental visit during pregnancy	L1
Percent of children, ages 1 through 17, who had a preventive dental visit in the past year	D9
Percent of women who attended a postpartum checkup within 12 weeks after giving birth	GM2, NM8
Percent of children, ages 0 through 11, whose households were food sufficient in the past year	J6
Percent of adolescents, ages 12 through 17, who receive needed mental health treatment or counseling	D9
Percent of children with and without special health care needs, ages 0 through 17, who have a personal doctor or nurse	E1
Percent of children with and without special health care needs, ages 0 through 17, who have a usual source of sick care	D7
Percent of children with and without special health care needs, ages 0 through 17, who have family centered care	D1, E3
Percent of children with and without special health care needs, ages 0 through 17, who receive needed referrals	E2
Percent of children with and without special health care needs, ages 0 through 17, who receive needed care coordination	D1, E4, E6
Percent of children with and without special health care needs, ages 0 through 17, who have a medical home	D1, D7, E1, E2, E3, E4, E5, E6
Percent of adolescents with and without special health care needs, ages 12 through 17, who received services to prepare for the transitions to adult health care	E7, E8
Percent of pregnant women who receive prenatal care beginning in the first trimester	AS1, AS2, NM1, VI10, VI11
Percent of children, ages 0 through 17, without health insurance	F1, F2, F3
Percent of children, ages 0 through 17, who were not able to obtain needed health care in the last year	D10
Percent of women, ages 18 through 44, with a preventive medical visit in the past year	L1
Percent of adolescents, ages 12 through 17, who are physically active at least 60 minutes per day	H8
Percent of women who smoke during pregnancy	L7, L18
Percent of children, ages 0 through 17, who live in households where someone smokes	J1, J2
Percent of children, ages 0 through 17, who are continuously and adequately insured	F1, F3, F4, F5, F6, G1, G2

Additional Measures (i.e., “Form 11” Measures)	Survey Questions
Percent of children with special health care needs (CSHCN), ages 0 through 17	A10, A11, A12, A13, A14, A21, A22, A23, A24, A25, A32, A33, A34, A35, A36, A43, A44, A45, A46, A47
Percent of children, ages 3 through 17, diagnosed with an autism spectrum disorder	B5
Percent of children, ages 3 through 17, diagnosed with Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder (ADD/ADHD)	B5

NOTE: Survey questions not included in these tables will be used as covariates or have been requested specifically by the jurisdictions