Form 1 TRC Performance Indicator Data Collection Tool

DCP Measures July 2025

New Measure

1: Service Utilization by State and Type of Organization Requesting Service

Service Utilization

• Total # of clients served

• Total # of repeat clients

• Direct

  • Total # of clients served via technical assistance (ie. consultation)

  • Total # of clients served via training

  • List each state in your region and total number of clients served in each

  • DCP Form Example: State Acronym ____ Number of Clients Served via consultation____ via conference, meeting, or training ____

  • DCP Form creates automated: Total Clients Served in TRC Region

  • DCP Form creates automated: Total Clients Served in HRSA Region

• Indirect

  • Total # of clients served via education and outreach

Type of Organization Requesting Service

• Academic Institution/School

• Associations/Organizations (National, State or Regional)

  • Area Health Education Center (AHEC)

  • Rural Health Association

  • Other

• Clinic

  • Free Clinic ___

  • Federally Qualified Health Center (FQHC)

  • Rural Health Clinic (RHC)

  • Other

• Funders (Foundations/Health Plans)

• Hospital/Health System

  • Critical Access Hospital (CAH) (25 beds or less)

  • Small Rural Hospital (50 beds or less)

    • Medium Rural Hospital (50-99 beds)

    • Large Rural Hospital (100 or more beds)

    • Other

  • Health Resources and Services Administration (HRSA) Grant Funded Entity

  • Government Agency (Federal, State, Regional or Local)

    • Corrections

    • Health Department

    • Medicaid/Medicare

    • Mental Health

    • Public Health

    • Social Service

    • State Office of Rural Health (SORH)

    • VA

Tribal/IHS

• Other

• Legislator/Policy Maker /staffer(or office)

• Telehealth Resource Center

• Vendor

  • Clinical Service Provider ___

  • Technology

  • Telecommunications

  • Business solutions/consultants

  • Legal

  • Other

• Other (list other and provide total numbers)

2: TRC Technical Assistance Communication Method of Inquiry and Response

Method of Technical Assistance Inquiry

• Email

• Phone

• In-Person Contact at an event (ie. training, conference, meeting, other)

• TRC Website Form

• Referral from Another TRC

• Social Media (Twitter, Facebook, LinkedIn, etc.)

• TRC Initiated

• Other

Method Used to Respond to Inquiries

• Email

• Phone

• Videoconference

• In Person Visit

• Other

3: Topic of Inquiry

Category

• Financial (Reimbursement, Business Models, Grants)

• Policy/Legal

• Market Analysis

• About my TRC

• Broadband network infrastructure

• Readiness Assessment

• Distance Learning

  • Project ECHO

• Program Evaluation

• Strategic Planning

• Tools and Templates

• General Telehealth Information

• Clinical Service Program Development/Operations

  • Mental/Behavioral Health

• Equipment and Technology Assessment/Selection

• Other

4: Types of Services Provided by TRC

Training/Education and Outreach

• # of Conferences/Meetings ___

  • Total # of conferences/meetings hosted by TRC ____

  • Total # of participants ___

  • Total # of TRC presentations at conferences/meetings ____

• # of Trainings ___

  • Total # of trainings hosted by TRC ____

  • Total # of participants ___

• # of Webinars ___

  • Total # of webinars hosted by TRC ____

  • Total # of participants ___

  • Total # requested by HRSA

  • Total # requested by other Federal Agency ____

• # of Other ____

  • Describe other

Communications/Promotional Activities

• Exhibit booths at conferences

  • # of booths ___

  • # of contacts ___

  • # of hours managing exhibit ___

• General Media

  • # interviews ___ (decimal/fraction)

  • # articles ___ (decimal/fraction)

Tools/Materials/Resources

• Newsletter

  • # of newsletters ___

  • # of subscribers ___

• Website

  • # website visits ___

• Fact Sheets/One Pagers

  • # of fact sheets/one pagers ___

• Online Education

  • # Video Modules ___

    • # of views ____

  • # of Toolkits ____

    • # of views ____

  • # of Course Modules ____

    • # of people accessing ____

• Issue Briefs (# of issue briefs) ____ (decimal/fraction)

• Other (list type and #) ____

Public Burden Statement: The purpose of this collection is to collect grantee information for the Regional and National Telehealth Resource Center Grant Programs, collectively known as the TRCs. The measures enable HRSA to capture data that illustrate the impact and scope of federal funding, assess these efforts, and respond to change in technical assistance needs in a timely manner. 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 0915-0361 and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit (Sec. 301 of the Public Health Service Act (42 U.S.C. 241)). Data will be private to the extent permitted by the law. Public reporting burden for this collection of information is estimated to average 4.2 minutes 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14NWH04, Rockville, Maryland, 20857 or [email protected].  Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.