Form 1 Quarterly Data Collection Form

OMB Control Number 0906-XXXX

Expiration data XX/XX/201X

Service Utilization and Improvement Action Benchmark Instructions and Forms

U.S. Department of Health and Human Services

Health Resources and Services Administration

Administration for Children and Families

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 0906-XXXX.  Public reporting burden for this collection of information is estimated to average 24 hours per response for Section A and 40 hours per response for Section B, 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 10C-03I, Rockville, Maryland, 20857.

DGIS-HV FORM: MIECHV Quarterly Data

Maternal, Infant, and Early Childhood Home Visiting (MIECHV) and Tribal MIECHV grantees are required to submit the information outlined below on a quarterly basis.

Quarterly reporting periods are defined as follows. Reports are due 60 days after the end of each reporting period:

• Q1 - October 1-December 31;

• Q2 - January 1-March 31;

• Q3 – April 1-June 30;

• Q4 – July 1-September 30

Definitions for key terms are included in Appendix A. Please carefully consult key term definitions before completing this form.

Grant Number(s): ________________________________

Section A:

Table A.1: Program Capacity

Column A	Column B	Column C	Column D	Column E
Number of New Households Enrolled	Number of Continuing Households	Current Caseload (A+B) (Auto-Calculate)	Maximum Service Capacity	Capacity Percentage (C÷D) (Auto-Calculate)

Table A.2: Place-Based Services

Add a row for each additional community served during the reporting period.

Column A	Column B	Column C
Community	Zip Codes within Community	Number of Households Served
Total		Sum of Column C (all rows)

Table A.3: Family Engagement

Column A1	Column B	Column C	Column D	Column E2	Column F
Number of Households Currently Receiving Services	Number of Households who Completed Program	Number of Households who Stopped Services Before Completion	Other	Total (A+B+C+D) (Auto-Calculate)	Attrition Rate (C÷E) (Auto-Calculate)

Table A.4.1: Staff Recruitment and Retention

Column A	Column B	Column C	Column D	Column E	Column F	Column G	Column H	Column I
Number of New FTE MIECHV Home Visitors	Number of Continuing FTE MIECHV Home Visitors	Number of FTE MIECHV Home Visitors (A+B) (Auto-Calculate)	Number of New FTE MIECHV Supervisors	Number of Continuing FTE MIECHV Supervisors	Number of FTE MIECHV Supervisors (D+E) (Auto-Calculate)	Number of New FTE MIECHV Other Staff	Number of Continuing FTE MIECHV Other Staff	Number of FTE MIECHV Other Staff (G+H) (Auto-Calculate)

Table A.4.2: Staff Vacancies

Column A	Column B	Column C	Column D
Number of Vacant FTE MIECHV Home Visitors	Number of Vacant FTE MIECHV Supervisors	Number of Vacant FTE MIECHV Other Staff	Number of FTE MIECHV Staff Vacancies (A+B+C) (Auto-Calculate)

Section B:

Section B is only applicable to grantees that are currently on an Improvement Action Plan related to the formal assessment of improvement conducted after Year 3 of their MIECHV grant. Grantees are required to submit data for all constructs within the benchmark areas where they did not show improvement at the end of Year 3. Grantees should only complete the benchmark areas applicable to them.

Table B.1: Benchmark Area 1

Construct	Performance Measure	Numerator	Denominator	Percent/Average/Count
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8

Table B.2: Benchmark Area 2

Construct	Performance Measure	Numerator	Denominator	Percent/Average/Count
2.1
2.2
2.3
2.4
2.5
2.6
2.7

Table B.3: Benchmark Area 3

Construct	Performance Measure	Numerator	Denominator	Percent/Average/Count
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9

Table B.4: Benchmark Area 4

Construct	Performance Measure	Numerator	Denominator	Percent/Average/Count
4.1
4.2
4.3
4.4
4.5

Table B.5: Benchmark Area 5

Construct	Performance Measure	Numerator	Denominator	Percent/Average/Count
5.1
5.2
5.3

Table B.6: Benchmark Area 6

Construct	Performance Measure	Numerator	Denominator	Percent/Average/Count
6.1
6.2
6.3
6.4
6.5

Appendix A: Definitions of Key Terms

Capacity Percentage: Capacity percentage is a calculated indicator that results from dividing the current caseload by the maximum service capacity and multiplying by 100.

Community: A community is a geographically distinct area that is defined by the MIECHV grantee. Communities should be areas that hold local salience and can be defined as a neighborhood, town, city, or other geographic area. Services provided within a particular community should be distinguishable from other communities.

Completed Program: The number of households who completed the program refers to families who have completed the program or transitioned to another program according to home visiting model-specific definitions and criteria during the quarterly reporting period.

Continuing Household: A household, including a pregnant woman, female caregiver, and/or male caregiver who were signed up and actively enrolled in the home visiting program prior to the beginning of the quarterly reporting period and continues enrollment through the reporting period. The household may include multiple caregivers depending on model-specific definitions.

Continuing FTE Home Visitor/Supervisor/Other Staff: A full time equivalent home visitor(s)/supervisor(s)/other staff who was employed by a contracted local implementing agency in the previous quarterly reporting period. Grantees should only report the proportion of the FTE is that is supported by MIECHV grant funds.

Current Caseload: The number of households actively enrolled at the end of the quarterly reporting period. All members of one household represent a single caseload slot.

Currently Receiving Services: The number of households currently receiving services refers to households that are participating in services at the end of the quarterly reporting period.

Maximum Service Capacity: The highest number of households that could potentially be enrolled at the end of the quarterly reporting period if the program were operating with a full complement of hired and trained home visitors.

New Household: A household, including a pregnant woman, female caregiver, and/or male caregiver who signs up to participate in the home visiting program at any time during the quarterly reporting period and continues enrollment through the reporting period. The household may include multiple caregivers depending on model-specific definitions.

New FTE Home Visitors/Supervisors/Other Staff: A full time equivalent home visitor(s)/supervisor(s)/other staff who begins employment with a contracted local implementing agency during the quarterly reporting period. Grantees should only report the proportion of the FTE that is supported by MIECHV grant funds.

Stopped Services before Completion: The number of households who stopped services before completion refers to households who left the program or were lost to follow-up for any reason prior to completion.

1 Validation: Column A should equal Table A.1. columns A and B

2 Validation: Column E should equal Table A.2 sum of all rows in Column C