QIF TJI Evaluative Measures Report

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Quality Improvement Fund (QIF)-TJI Evaluative Measures Report

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) are patient-directed organizations that deliver affordable, accessible, quality, and cost-effective primary health care services to patients and adjust fees based on income and family size. 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. 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 0915-0285 and it is valid until 06/30/2029. 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 13N82, Rockville, Maryland, 20857 or [email protected].  Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.