Form 8 Grantee Data Collection Form

Grantee Data Collection Form

Frontier Community Health Care Network Coordination Grant

Data Collection Strategy

Community Health Workers or other staff from the grantee organization will complete an Excel® Spreadsheet including the following fields on a monthly basis about program activities at the implementation site and about all clients/patients who have participated in the program.

Public Burden Statement: 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 project is 0915-XXXX. Public reporting burden for this collection of information is estimated to average 4 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 10-29, Rockville, Maryland, 20857.

Data Element	Response Options
Information about Clients Active during the month Data will be collected using one row per participant.
Client (Medicare) Identification Number
Qualifying Chronic Condition	Mark all that are applicable: Diabetes Mellitus Type II (DM) Cardiovascular Disease (CVD) including hypertension Congestive Heart Failure (CHF) Coronary Artery Disease (CAD) Chronic Obstructive Pulmonary Disease (COPD)
Payer	Mark all that are applicable: Medicare Medicaid Private/commercial insurer Other (open text) None
Intervention Start Date
Intervention Goal
Intervention Activities/ Design
Update on achievement of goal
Partners involved in intervention
Did the intervention involve any resources beyond that supplied by the grant?	Mark all that apply None Financial – source (open text) Equipment – describe and source (open text) Volunteer work – explain (open text)
Intervention Completion Date	Date
Reason for Completion	Achieved intervention goal Loss of interest by client Moved Death Other (open text)
Grant Design and Implementation during Month These data will be collected using one row per program site
Client recruitment attempts
Source of attempts
Method of recruitment
Number of new enrollments
Understood reason(s) for unsuccessful attempts
Total hours spent by CHWs on program
Did the overall program (not including specific interventions) require any resources beyond that supplied by the grant?	Mark all that apply None Financial – source (open text) Equipment – describe and source (open text) Volunteer work – explain (open text)

OMB Control Number 0915-XXXX Expiration Date XX/XX/201X