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ATTACHMENT B
Family Planning Annual Report: Forms and Instructions
(Reissued January 2011)
Attachment B - 2
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Attachment B - 3
TITLE X
FAMILY PLANNING
ANNUAL REPORT
•••••••••••••••••••••••••
FORMS AND INSTRUCTIONS
U.S. Department of Health and Human Services
Office of the Assistant Secretary for Health
Office of Population Affairs
Office of Family Planning
REISSUED JANUARY 2011
Attachment B - 4
Form Approved
OMB No. 0990-0221
Exp. Date 01/31/2014
EFFECTIVE JANUARY 2005
REISSUED OCTOBER 2007
REISSUED JANUARY 2011
Title X Family Planning Annual Report
– ii –
Attachment B - 5
TABLE OF CONTENTS
INTRODUCTION _______________________________________________________ 1
GENERAL INSTRUCTIONS ______________________________________________ 3
Who Submits an FPAR ................................................................................................................................. 3
Scope of Activities Reported in the FPAR................................................................................................... 3
Submitting the FPAR .................................................................................................................................... 3
Submitting Revised FPAR Tables................................................................................................................ 3
FPAR Consistency ......................................................................................................................................... 4
FPAR Identification ...................................................................................................................................... 4
TERMS AND DEFINITIONS ______________________________________________ 5
Family Planning User.................................................................................................................................... 5
Family Planning Provider............................................................................................................................. 5
Family Planning Encounter .......................................................................................................................... 5
Family Planning Service Site ........................................................................................................................ 6
Client Records ............................................................................................................................................... 6
Questions about FPAR Terms and Definitions ........................................................................................... 7
GRANTEE PROFILE COVER SHEET ______________________________________ 9
Instructions .................................................................................................................................................... 9
Questions about the Grantee Profile.......................................................................................................... 10
Grantee Profile Cover Sheet................................................................................................................. 11
FAMILY PLANNING USER DEMOGRAPHIC PROFILE _______________________ 13
Instructions .................................................................................................................................................. 13
Terms and Definitions ................................................................................................................................. 13
Questions about Tables 1 to 3 ..................................................................................................................... 14
Table 1 Unduplicated Number of Family Planning Users by Age and Sex ...................................... 15
Table 2 Unduplicated Number of Female Family Planning Users by Race and Ethnicity ............... 16
Table 3 Unduplicated Number of Male Family Planning Users by Race and Ethnicity ................... 17
Title X Family Planning Annual Report
– iii –
Attachment B - 6
FAMILY PLANNING USER ECONOMIC AND SOCIAL PROFILE _______________ 19
Instructions .................................................................................................................................................. 19
Terms and Definitions ................................................................................................................................. 19
Questions about Tables 4 to 6 ..................................................................................................................... 20
Table 4 Unduplicated Number of Family Planning Users by Income Level ..................................... 22
Table 5 Unduplicated Number of Family Planning Users by Principal Health Insurance
Coverage Status .................................................................................................................... 23
Table 6 Unduplicated Number of Family Planning Users with Limited English Proficiency
(LEP) .................................................................................................................................... 24
FAMILY PLANNING METHOD USE _______________________________________ 25
Instructions .................................................................................................................................................. 25
Terms and Definitions ................................................................................................................................. 25
Questions about Tables 7 and 8.................................................................................................................. 27
Table 7 Unduplicated Number of Female Family Planning Users by Primary Method and
Age ....................................................................................................................................... 29
Table 8 Unduplicated Number of Male Family Planning Users by Primary Method and Age ......... 30
CERVICAL AND BREAST CANCER SCREENING ___________________________ 31
Instructions .................................................................................................................................................. 31
Terms and Definitions ................................................................................................................................. 31
Questions about Tables 9 and 10 ................................................................................................................ 32
Table 9 Cervical Cancer Screening Activities ................................................................................... 35
Table 10 Clinical Breast Exams and Referrals .................................................................................... 36
SEXUALLY TRANSMITTED DISEASE (STD) SCREENING ____________________ 37
Instructions .................................................................................................................................................. 37
Terms and Definitions ................................................................................................................................. 37
Questions about Tables 11 and 12 .............................................................................................................. 37
Table 11 Unduplicated Number of Family Planning Users Tested for Chlamydia by Age and
Sex ........................................................................................................................................ 39
Table 12 Number of Gonorrhea, Syphilis, and HIV Tests .................................................................. 40
FAMILY PLANNING ENCOUNTERS AND UTILIZATION OF CLINICAL
SERVICES PROVIDERS _______________________________________________ 41
Instructions .................................................................................................................................................. 41
Terms and Definitions ................................................................................................................................. 41
Questions about Table 13............................................................................................................................ 42
Table 13 Number of Family Planning Encounters by Type of Provider ............................................. 44
Title X Family Planning Annual Report
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Attachment B - 7
Form Approved
OMB No. 0990-0221
Exp. Date 01/31/2014
REVENUE REPORT ___________________________________________________ 45
Instructions .................................................................................................................................................. 45
Terms and Definitions ................................................................................................................................. 45
Question about Table 14 ............................................................................................................................. 47
Table 14 Revenue Report .................................................................................................................... 48
ABBREVIATIONS AND ACRONYMS _____________________________________ 51
APPENDIX A: COLLECTING AND TABULATING MULTI-RACE RESPONSES __ A–1
PAPERWORK REDUCTION ACT (PRA) PUBLIC BURDEN STATEMENT
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0990-0221. The time required to complete this
information collection is estimated to average 40 hours per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health &
Human Services, OS/OIRM/PRA, 200 Independence Ave., S.W., Suite 336–E, Washington D.C.
20201, Attention: PRA Reports Clearance Officer.
Title X Family Planning Annual Report
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Attachment B - 8
Form Approved
OMB No. 0990-0221
Exp. Date 01/31/2014
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Title X Family Planning Annual Report
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Attachment B - 9
INTRODUCTION
This annual reporting requirement is for family planning services delivery projects authorized and funded
under the Population Research and Voluntary Family Planning Programs (Section 1001 of Title X of the
Public Health Service Act, 42 United States Code [USC] 300). 1 The Office of Family Planning (OFP)
within the Office of Population Affairs (OPA) administers the Title X Family Planning Program.
Annual submission of the Family Planning Annual Report (FPAR) is required of all Title X family
planning services grantees for purposes of monitoring and reporting program performance (45 Code of
Federal Regulations [CFR] Part 74 2 and 45 CFR Part 92 3 ). FPAR data are presented in summary form to
protect the confidentiality of individuals who receive Title X-funded services (42 CFR Part 59). 4
The FPAR is the only source of annual, uniform reporting by all Title X family planning services
grantees. It provides consistent, national-level data on the Title X Family Planning Program and its users.
Information from the FPAR is important to OPA for several reasons. First, OPA uses FPAR data to
monitor compliance with statutory requirements, regulations, and operational guidance set forth in the
Program Guidelines for Project Grants for Family Planning Services (“Program Guidelines”), 5 which
include
•
monitoring compliance with legislative mandates, such as giving priority in the provision of
services to low-income persons [42 USC 300 §1006(c)];1 and
•
ensuring that Title X grantees and their subcontractors provide a broad range of family
planning methods and services [42 USC 300 §1001(a)].1
Second, OPA uses FPAR data to comply with accountability and federal performance requirements for
Title X family planning funds as required by the 1993 Government Performance and Results Act
(GPRA). Current performance goals for the Title X Family Planning Program include priority in the
provision of family planning services to low-income individuals, access to and utilization of cervical
cancer screening as a means to reducing invasive cervical cancer, reducing infertility by screening for
chlamydia, and ensuring program efficiency as measured by the cost per user served.
Finally, OPA relies on FPAR data to guide strategic and financial planning, to monitor performance, and
to respond to inquiries from policymakers and Congress about the program. The FPAR allows OPA to
1
42 United States Code (USC) 300. Population research and voluntary family planning programs, section 1001 of
Title X of the Public Health Service Act. Retrieved March 1, 2011, from
http://www.hhs.gov/opa/familyplanning/toolsdocs/xstatut.pdf
2
45 Code of Federal Regulations (CFR) Part 74. Uniform administrative requirements for awards and subawards
to institutions of higher education, hospitals, other nonprofit organizations, and commercial organizations; and
certain grants and agreements with states, local governments, and Indian tribal governments. Retrieved March
1, 2011, from http://www.hhs.gov/opa/grants/toolsdocs/45cfr74.pdf
3
45 CFR Part 92. Uniform administrative requirements for grants and cooperative agreements to state and local
governments. Retrieved March 1, 2011, from http://www.hhs.gov/opa/grants/toolsdocs/45cfr92.pdf
4
42 CFR Part 59. Grants for family planning services. Retrieved March 1, 2011, from
http://www.hhs.gov/opa/familyplanning/toolsdocs/ofp_regs_42cfr59_10-1-2000.pdf
5
U.S. Department of Health and Human Services, Office of Public Health and Science, Office of Population
Affairs, Office of Family Planning. (2001, January). Program guidelines for project grants for family planning
services. Rockville, MD: OPA/OFP. Retrieved March 1, 2011, from
http://www.hhs.gov/opa/familyplanning/toolsdocs/index.html
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assemble comparable and relevant program data to answer questions about the characteristics of the
population served by Title X projects, utilization of services offered, composition of revenues, and
program impact. FPAR data are the basis for objective grant reviews, program evaluation, and assessment
of program technical needs.
This version (January 2011) of the FPAR consists of a Grantee Profile Cover Sheet and 14 tables. The
data collected include demographic, social, and economic user characteristics; utilization of family
planning and related preventive health services; utilization of health personnel; and project revenues.
Minor changes to the forms and instructions include
•
updates to the general instructions to reflect current FPAR submission practices and systems;
•
clarification of the family planning provider definitions to improve the quality of reporting;
•
review and update of the “Questions about…” sections for the Terms and Definitions and for
each FPAR table; and
•
minor modifications to FPAR Table 5 (user health insurance status), Table 7 and 8 (primary
contraceptive method use), Table 13 (staffing and encounters), and Table 14 (revenue) that
aim to simplify reporting and reduce post-submission validation queries.
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GENERAL INSTRUCTIONS
This section provides general instructions for completing the FPAR. Grantees should use the general
instructions in conjunction with the table-specific instructions; they are cross-referenced where
appropriate. If you need additional information or guidance, please refer to the Title X Program
Guidelines or the Program Instruction Series available on the OPA website at
http://www.hhs.gov/opa/familyplanning/toolsdocs/index.html.
WHO SUBMITS AN FPAR
Grantees funded under Section 1001 of the Title X Public Health Service Act (42 USC 300) should
prepare and submit the FPAR. The family planning services grantee is the direct recipient of the Title X
grant. Delegates or subcontractors to the grantee receive Title X funds via the grantee. Delegate or
subcontractor agencies should not submit an FPAR report; rather, they should follow the instructions
provided to them by the grantee.
SCOPE OF ACTIVITIES REPORTED IN THE FPAR
The purpose of the FPAR is to provide a comprehensive view of the family planning activities within the
scope of the grantee’s Title X-funded project. Family planning services grantees should report the total,
unduplicated number of users, encounters, and other outputs from activities that are within the scope of a
grantee’s approved grant application. If you have questions about whether to include certain data in
this report, contact your Regional Program Consultant (RPC). A current list of RPCs is available on
the OPA website at http://www.hhs.gov/opa/familyplanning/rcontacts/rcontacts_rpc.html.
SUBMITTING THE FPAR
Grantees should prepare and submit the FPAR no later than February 15 after the end of the reporting
period. If February 15 falls on a weekend, the FPAR is due on the following Monday.
Grantees can submit the FPAR electronically or in hardcopy. The two options for electronic submission
include the web-based FPAR Data System (encouraged) or as an electronic file attached to an e-mail
message. Grantees should select one of the following methods:
FPAR DATA SYSTEM SUBMISSION – Follow the instructions for preparing and submitting the FPAR in
the user’s guide for the FPAR Data System.
PAPER SUBMISSION – Submit three (3) paper copies of the completed FPAR to the RPC for your
region.
E-MAIL SUBMISSION – Attach one (1) electronic file to an e-mail message and mail one (1) paper copy
of the complete FPAR to the RPC for your region.
Current RPC postal and e-mail addresses are available on the OPA website at
http://www.hhs.gov/opa/familyplanning/rcontacts/rcontacts_rpc.html.
SUBMITTING REVISED FPAR TABLES
Grantees submitting revised FPAR tables may submit the revised table(s) using any of the methods listed
above (“Submitting the FPAR”), regardless of the method used initially to submit the tables. Furthermore,
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grantees should consult with their RPC regarding any region-specific requirements or deadlines for
submitting revised FPAR tables. Grantees should submit revised tables by April 1 to ensure that data
from revised tables are included in the national and regional reports.
FPAR CONSISTENCY
To improve FPAR consistency, do not leave any cells blank. If the value for a cell is zero, enter “0.” In
addition, do not report percentages; enter only whole numbers.
The numbers reported in Table 1, Row 10 of the FPAR will serve as a reference for consistency
checkpoints in subsequent tables in the report. The values in these tables are identified with unique,
double-letter identifiers (AA, BB, and CC). For FPARs submitted through the FPAR Data System, the
system will perform a set of automated validation procedures to ensure consistency within and across
tables. The automated procedures include calculation of row and column totals and cross-table
comparisons of selected cell values, including but not limited to the FPAR checkpoints (AA =
unduplicated number of female family planning users, BB = unduplicated number of male family
planning users, and CC = unduplicated number of all family planning users).
If additional written information accompanies the table, or if one or more figures in the table are
estimated rather than actual, use the table-specific “Notes” field to enter a comment. Please indicate the
table and cell to which the comment applies. For estimated figures, describe the rationale and method for
generating the estimate.
FPAR IDENTIFICATION
Grantees must report key identifying information in the header for each FPAR table, including the
Grantee Profile Cover Sheet. For grantees that submit the FPAR using the FPAR Data System, these
fields will populate automatically. The identifying information includes the following:
FPAR NUMBER – Enter the four-digit number assigned to the grantee by the regional Department of
Health and Human Services (HHS) office. Do not use your HHS grant number.
DATE SUBMITTED – Enter the report submission date.
REPORTING PERIOD – The reporting period for the FPAR is the calendar year (i.e., January 1
through December 31). Title X grantees that begin operating after January 1, stop operating before
December 31, or are reporting data for a different 12-month period (e.g., December to November)
should use the alternative date range fields in the header to enter the time period during which their
Title X project was active and for which they are reporting data. For grantees that submit the FPAR
using the FPAR Data System, please enter information about the alternative date range using the
“Notes” field for the Grantee Profile Cover Sheet.
INITIAL SUBMISSION OR REVISION – Check the appropriate box in the header of each table to indicate
whether the table is an initial or revised submission. For grantees that submit the FPAR using the
FPAR Data System, the system will automatically update the submission status (initial or revised) of
each table.
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TERMS AND DEFINITIONS
OPA provides definitions for key FPAR terms to ensure uniform reporting among Title X grantees. The
terms describe the individuals receiving family planning and related preventive health services at Title Xfunded service sites, the range and scope of the services provided, and the family planning providers who
deliver care.
FAMILY PLANNING USER
A family planning user is an individual who has at least one family planning encounter at a Title X
service site during the reporting period. The same individual may be counted as a family planning user
only once during a reporting period. Grantees should follow the table-specific instructions to identify
applicable users.
FAMILY PLANNING PROVIDER
A family planning provider is the individual who assumes primary responsibility for assessing a client
and documenting services in the client record. Providers include those agency staff that exercise
independent judgment as to the services rendered to the client during an encounter. Two general types of
providers deliver Title X family planning services: clinical services providers and other services
providers.
CLINICAL SERVICES PROVIDER – Includes physicians (family and general practitioners, specialists),
physician assistants, nurse practitioners, certified nurse midwives, and registered nurses with an
expanded scope of practice who are trained and permitted by state-specific regulations to perform all
aspects of the user (male and female) physical assessment, as described in the Program Guidelines.
Clinical services providers are able to offer client education, counseling, referral, follow-up, and
clinical services (physical assessment, treatment, and management) relating to a client’s proposed or
adopted method of contraception, general reproductive health, or infertility treatment, in accordance
with the Program Guidelines.
OTHER SERVICES PROVIDER – Includes other agency staff (e.g., registered nurses, public health nurses,
licensed vocational or licensed practical nurses, certified nurse assistants, health educators, social
workers, or clinic aides) that offer client education, counseling, referral, or follow-up services relating
to the client’s proposed or adopted method of contraception, general reproductive health, or infertility
treatment, as described in the Program Guidelines. Other services providers may also perform or
obtain samples for routine laboratory tests (e.g., urine, pregnancy, STD, and cholesterol and lipid
analysis), give contraceptive injections (e.g., Depo-Provera), and perform routine clinical procedures
that may include some aspects of the user physical assessment (e.g., blood pressure evaluation), in
accordance with the Program Guidelines.
FAMILY PLANNING ENCOUNTER
A family planning encounter is a documented, face-to-face contact between an individual and a family
planning provider that takes place in a Title X service site. The purpose of a family planning encounter is
to provide family planning and related preventive health services to female and male clients who want to
avoid unintended pregnancies or achieve intended pregnancies. To be counted for purposes of the FPAR,
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a written record of the service(s) provided during the family planning encounter must be documented in
the client record.
There are two types of family planning encounters at Title X service sites: (1) family planning encounters
with a clinical services provider and (2) family planning encounters with an other services provider. The
type of family planning provider who renders the care, regardless of the services rendered, determines the
type of family planning encounter. Although a client may meet with both clinical and other services
providers during an encounter, the provider with the highest level of training who takes ultimate
responsibility for the client’s clinical or non-clinical assessment and care during the visit is credited with
the encounter.
FAMILY PLANNING ENCOUNTER WITH A CLINICAL SERVICES PROVIDER – A face-to-face, documented
encounter between a family planning client and a clinical services provider that takes place in a Title
X service site.
FAMILY PLANNING ENCOUNTER WITH AN OTHER SERVICES PROVIDER – A face-to-face, documented
encounter between a family planning client and an other services provider that takes place in a Title X
service site.
Laboratory tests and related counseling and education, in and of themselves, do not constitute a family
planning encounter unless there is face-to-face contact between the client and provider, the provider
documents the encounter in the client’s record, and the test(s) are accompanied by family planning
counseling or education.
FAMILY PLANNING SERVICE SITE
A family planning service site refers to an established unit where grantee or delegate agency staff provide
Title X services (clinical, counseling, educational, or referral) that comply with the Title X Program
Guidelines, and where at least some of the encounters between the family planning provider(s) and the
individual(s) served meet the requirements of a family planning encounter. Established units include
clinics, hospital outpatient departments, homeless shelters, detention and correctional facilities, and other
locations where Title X agency staff provide these family planning services. Service sites may also
include equipped mobile vans or schools.
CLIENT RECORDS
Title X projects must establish a medical record for every client who obtains clinical services or other
screening or laboratory services (e.g., blood pressure check, urine-based pregnancy, or STD test). The
medical record contains personal data; a medical history; physical exam data; laboratory test orders,
results, and follow-up; treatment and special instructions; scheduled revisits; informed consent forms;
documentation of refusal of services; and information on allergies and untoward reactions to identified
drug(s). The medical record also contains clinical findings; diagnostic and therapeutic orders; and
documentation of continuing care, referral, and follow-up. The medical record allows for entries by
counseling and social service staff. The medical record is a confidential record, accessible only to
authorized staff and secured by lock when not in use. The client medical record must contain sufficient
information to identify the client, indicate where and how the client can be contacted, justify the clinical
impression or diagnosis, and warrant the treatment and end results.
If a family planning user receives no clinical services, a record still must be established for that client.
Like a medical record, this client record must contain sufficient information to identify the client, indicate
where and how the client can be contacted, and fully document the encounter. This record is confidential,
accessible only to authorized staff, and secured by lock when not in use.
Attachment B - 15
QUESTIONS ABOUT FPAR TERMS AND DEFINITIONS
1. QUESTION – Can a client have more than one family planning encounter during a single family
planning visit?
ANSWER – A client may have only one family planning encounter per visit. In the family
planning services setting, the term “encounter” is synonymous with “visit.” Although a client
may meet with both clinical and other services providers during an encounter, only one provider
is credited with the encounter. The provider with the highest level of training who takes ultimate
responsibility for the client’s clinical or non-clinical assessment and care during the visit is
credited with the encounter.
2. QUESTION – If an individual receives gynecological or related preventive health services (e.g.,
pelvic exam, Pap test, pregnancy test, STD screening) in a Title X-funded clinic, but does not
receive services aimed at avoiding unintended pregnancy or achieving intended pregnancy (e.g.,
contraceptive or fertility counseling), is the encounter considered a family planning encounter?
ANSWER – If a client is an ongoing family planning user who visits the clinic to obtain any type of
family planning or related preventive health services, the encounter is considered a family
planning encounter.
If a client of reproductive age has been sterilized but continues to seek gynecological or related
preventive health services, the encounter is considered a family planning encounter and the
agency may continue to count the client as a family planning user.
If a client obtains gynecological or related preventive health services, but the client is neither an
ongoing family planning user nor seeks or receives services (clinical, counseling, educational,
and/or referral) to help avoid unintended pregnancy or achieve intended pregnancy, the encounter
is not a family planning encounter and the client is not a family planning user.
If a post-menopausal client obtains gynecological or related preventive health services, the
encounter is not a family planning encounter and the client is not a family planning user.
3. QUESTION – If a clinic aide or nurse is trained and authorized to give contraceptive injections
(e.g., Depo-Provera), should an agency report the encounter as an encounter with a clinical
services provider?
ANSWER – No. For FPAR reporting purposes, a clinic aide is classified as an other services
provider even though he or she may be trained and authorized to give contraceptive injections.
Regarding nurses, only advanced practice nurses (certified nurse midwife or nurse practitioner) or
registered nurses with an expanded scope of practice who are trained and permitted by statespecific regulations to perform all aspects of the user (male and female) physical assessment as
described in the Program Guidelines, may be reported as clinical services providers. Report fulltime equivalents (FTEs) for each type of clinical services provider in Table 13, Rows 1a to 1c,
and the number of encounters with a clinical services providers in Table 13, Row 1. Report the
number of encounters with other services providers in Table 13, Row 2.
Attachment B - 16
Form Approved
OMB No. 0990-0221
Exp. Date 01/31/2014
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Attachment B - 17
GRANTEE PROFILE COVER SHEET
The Grantee Profile Cover Sheet provides important contact and summary information about each grantee
and the network of service providers supported through the Title X grant. A completed Grantee Profile
Cover Sheet must accompany the initial submission of the FPAR, as well as submission of any revised
tables.
INSTRUCTIONS
If you are submitting the FPAR using the web-based FPAR Data System, the system will automatically
populate the following fields: grantee legal name; address of grantee administrative offices; and name,
title, and contact information for the Title X Project Director. To correct the information in these fields,
please contact the RPC for the region. Enter the corrected information in the “Notes” field of the Grantee
Profile Cover Sheet. Grantees can modify all other fields.
GRANTEE LEGAL NAME – Enter the name of the legal recipient of the Title X family planning services
grant.
ADDRESS OF GRANTEE ADMINISTRATIVE OFFICES – Enter the grantee’s complete address, including
nine-digit ZIP code.
TITLE X PROJECT DIRECTOR – Enter the name, title, mailing address, phone and fax numbers, and
e-mail address for the agency representative responsible for directing the grantee’s Title X project.
GRANTEE CONTACT PERSON (PERSON COMPLETING FPAR) – Enter the name, title, mailing address,
phone and fax numbers, and e-mail address for the agency representative with primary responsibility
for preparing the FPAR.
NUMBER OF DELEGATES/SUBCONTRACTORS SUPPORTED BY THE TITLE X GRANT – Report the number of
delegate or subcontractor agencies that receive funding through the grantee’s Title X service grant.
NUMBER OF FAMILY PLANNING SERVICE SITES SUPPORTED BY THE TITLE X GRANT – Report the total
number of family planning service sites supported by the Title X grant and represented in the FPAR
data. If the number of service sites supported by the Title X grant is different from the number
provided in the grant application, check the box and explain the reason for this difference using the
“Notes” field for the Grantee Profile Cover Sheet.
Attachment B - 18
Form Approved
OMB No. 0990-0221
Exp. Date 01/31/2014
QUESTIONS ABOUT THE GRANTEE PROFILE
1. QUESTION – If Title X services are provided at a clinic and two non-clinic sites, should the grantee
include one or three sites in the total number of service sites reported on the Grantee Profile
Cover Sheet?
ANSWER – For purposes of the FPAR, the grantee should count and report any established unit,
clinic or non-clinic, where staff provide Title X services and where at least some of the
encounters between the family planning provider(s) and the individual(s) served meet the
requirements of a family planning encounter. OPA assumes that each of the sites reported in the
Grantee Profile contributes data to the grantee’s FPAR. If all three sites in this example contribute
data to the FPAR, the grantee should include these three service sites in the total number of sites
reported on the Grantee Profile Cover Sheet.
Title X Family Planning Annual Report
– 10 –
Attachment B - 19
Date Submitted:
Reporting Period:
January 1, 20________through December 31, 20_________
___________________through _______________________
(Month/day/year) (Month/day/year)
Check One:
Initial Submission
Revision
See Notes
Grantee Profile Cover Sheet
Grantee Legal Name
Name
Address of Grantee
Administrative Offices
Street
City
State
ZIP + 4
–
ZIP + 4
–
ZIP + 4
–
Name
Title X Project Director
Title
Street
City
State
Phone
Fax
E-Mail
Name
Grantee Contact Person
(Person completing FPAR)
Title
Street
City
State
Phone
Fax
E-Mail
Number of Delegates/Subcontractors
Supported by the Title X Grant
Number of Family Planning Service
Sites Supported by the Title X Grant
Check if total number of sites is different
from application
Title X Family Planning Annual Report
– 11 –
Attachment B - 20
Form Approved
OMB No. 0990-0221
Exp. Date 01/31/2014
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Attachment B - 21
FAMILY PLANNING USER DEMOGRAPHIC PROFILE
Data reported in Tables 1 through 3 allow program administrators to monitor access to and use of Title X
services among the diverse population these projects aim to serve. These FPAR tables describe the
demographic characteristics of family planning users, including the distribution of users by age, sex,
ethnicity, and race.
The numbers reported in Table 1 serve as a reference for consistency checkpoints in subsequent tables in
the report. The values in these tables are identified with unique, double-letter identifiers (AA, BB, and
CC).
INSTRUCTIONS
TABLE 1 –
Report the unduplicated number of family planning users by age group and sex.
TABLE 2 –
Report the unduplicated number of female family planning users by race and ethnicity.
TABLE 3 –
Report the unduplicated number of male family planning users by race and ethnicity.
TERMS AND DEFINITIONS
AGE GROUP – Categorize family planning users based on their age as of June 30th of the reporting period.
RACE AND ETHNICITY – The categories for reporting ethnicity and race in the FPAR conform to the Office
of Management and Budget (OMB) 1997 Revisions to the Standards for the Classification of Federal
Data on Race and Ethnicity, 6 and are used by other HHS programs and compilers of such national data
sets as the National Survey of Family Growth. If an agency wants to collect data for ethnicity or race
subcategories, the agency must be able to aggregate the data reported into the OMB minimum standard
set of ethnicity and race categories.
OMB encourages self-identification of race. When respondents are allowed to self-identify or self-report
their race, agencies should adopt a method that allows respondents to mark or select more than one of the
five minimum race categories. Appendix A to this form provides general guidance and a list of resources
regarding collection of multi-race responses.
The two minimum OMB categories for reporting ethnicity are as follows:
HISPANIC OR LATINO (ALL RACES) – A person of Cuban, Mexican, Puerto Rican, South or Central
American, or other Spanish culture or origin, regardless of race.
NOT HISPANIC OR LATINO (ALL RACES) – A person not of Cuban, Mexican, Puerto Rican, South or
Central American, or other Spanish culture or origin, regardless of race.
The five minimum categories for reporting race are as follows:
AMERICAN INDIAN OR ALASKA NATIVE – A person having origins in any of the original peoples of North
and South America (including Central America), and who maintains tribal affiliation or community
attachment.
6
Office of Management and Budget. (October 30, 1997). Revisions to the standards for the classification of
federal data on race and ethnicity, Federal Register notice. Retrieved March 1, 2011, from
http://www.whitehouse.gov/omb/fedreg_race-ethnicity
Attachment B - 22
Form Approved
OMB No. 0990-0221
Exp. Date 01/31/2014
ASIAN – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands, Thailand, and Vietnam.
BLACK OR AFRICAN AMERICAN – A person having origins in any of the black racial groups of Africa.
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER – A person having origins in any of the original peoples
of Hawaii, Guam, Samoa, or other Pacific islands.
WHITE – A person having origins in any of the original peoples of Europe, the Middle East, or North
Africa.
QUESTIONS ABOUT TABLES 1 TO 3
1. QUESTION – Are Tables 1 through 3 different from the previous FPAR?
ANSWER – No. There are no changes to Tables 1 through 3.
2. QUESTION – What if a client does not self-identify with any of the OMB minimum standard race
categories?
ANSWER – According to the 1997 OMB guidance, all races are represented in Tables 2 and 3, and
technically every client should be included in one of these categories. Nevertheless, a client has
the right not to report his or her race. Service providers should consider providing the definition
of each race category in their data collection forms (if space and formatting permit) and becoming
familiar with the OMB definitions for each race category so that they can assist clients who may
have questions. Grantees should report the number of users with missing or unknown race
information in the “unknown/not reported” race category.
Hispanic or Latino clients account for a high proportion of family planning users for whom race
data are unknown or not reported. The structure of Tables 2 and 3 allows OPA to identify the
number of female and male Hispanic or Latino clients who do not report race data.
3. QUESTION – What if a client self-identifies with more than one of the OMB minimum race
categories?
ANSWER – According to the 1997 OMB guidance, when self-identification is used the data
collection method should allow respondents to self-report more than one race. Grantees should
report the number of users who self-report more than one race in Row 6 of Table 2 (female users)
or Table 3 (male users). Appendix A to this form provides general guidelines and a sample
question for collecting multi-race responses. Please note that the information in Appendix A is
not comprehensive and serves only to highlight important considerations and ideas for handling
multi-race response. Grantees interested in issues surrounding collection of race data should
consult the resource list in Appendix A.
Title X Family Planning Annual Report
– 14 –
Attachment B - 23
Date Submitted:
Reporting Period:
January 1, 20________through December 31, 20_________
___________________through _______________________
(Month/day/year) (Month/day/year)
Check One:
Initial Submission
Revision
See Notes
Table 1
Unduplicated Number of Family Planning Users by Age and Sex
Age Group
(Years)
1
Under 15
2
15 to 17
3
18 to 19
4
20 to 24
5
25 to 29
6
30 to 34
7
35 to 39
8
40 to 44
9
Over 44
10
Total Users
Female Users
(A)
Male Users
(B)
(Sum Cols A + B)
Checkpoint
Reference
AA
Checkpoint
Reference
BB
Checkpoint
Reference
CC
(C)
Total Users
(sum rows 1 to 9)
Title X Family Planning Annual Report
– 15 –
Attachment B - 24
Date Submitted:
Reporting Period:
January 1, 20________through December 31, 20_________
___________________through _______________________
(Month/day/year) (Month/day/year)
Check One:
Initial Submission
Revision
See Notes
Table 2
Unduplicated Number of Female Family Planning Users by Race and Ethnicity
Race
1
American Indian or
Alaska Native
2
Asian
3
Black or African
American
4
Native Hawaiian or
Other Pacific Islander
5
White
6
More than one race
7
Unknown/not reported
8
Hispanic
or Latino
(A)
Not Hispanic
or Latino
(B)
Unknown/
Not Reported
(C)
Total
Female Users
(Sum Cols A +
B + C)
(D)
Total Female Users
(sum rows 1 to 7)
Checkpoint
Reference
AA
Title X Family Planning Annual Report
– 16 –
Attachment B - 25
Form Approved
OMB No. 0990-0221
Exp. Date 01/31/2014
FPAR Number:
Date Submitted:
Reporting Period:
January 1, 20________through December 31, 20_________
___________________through _______________________
(Month/day/year) (Month/day/year)
Check One:
Initial Submission
Revision
See Notes
Table 3
Unduplicated Number of Male Family Planning Users by Race and Ethnicity
Race
1
American Indian or
Alaska Native
2
Asian
3
Black or African American
4
Native Hawaiian or
Other Pacific Islander
5
White
6
More than one race
7
Unknown/not reported
8
Hispanic
or Latino
(A)
Not Hispanic
or Latino
(B)
Unknown/
Not Reported
(C)
Total
Male Users
(Sum Cols A +
B + C)
(D)
Total Male Users
(sum rows 1 to 7)
Checkpoint
Reference
BB
Title X Family Planning Annual Report
– 17 –
Attachment B - 26
Form Approved
OMB No. 0990-0221
Exp. Date 01/31/2014
This page intentionally left blank.
Attachment B - 27
FAMILY PLANNING USER ECONOMIC AND SOCIAL PROFILE
The data reported in Tables 4 through 6 provide OPA with information on key social and economic
characteristics of individuals who receive family planning and related preventive health care in Title Xfunded clinics. OPA uses these data to monitor the program’s role in supporting the health care safety net
for individuals who confront financial or sociocultural barriers to care due to low income, lack of health
insurance, or limited English proficiency (LEP). In addition, OPA uses these data to assess the program’s
compliance with legislative or regulatory mandates, including priority care to individuals who are lowincome and ensuring meaningful access to clients with LEP. 7
INSTRUCTIONS
TABLE 4 –
Report the unduplicated number of family planning users by income level.
TABLE 5 –
Report the unduplicated number of family planning users by their principal health
insurance coverage status.
TABLE 6 –
Report the unduplicated number of family planning users with LEP.
TERMS AND DEFINITIONS
INCOME LEVEL AS A PERCENTAGE OF THE HHS POVERTY GUIDELINES – Grantees are required to collect
family income data from all users at least annually. In determining a user’s family income, agencies
should refer to the poverty guidelines updated periodically in the Federal Register by HHS under the
authority of 42 USC 9902(2). 8 Report the unduplicated number of users by income level, using the most
current income information available. For additional guidance, see OPA Program Instruction Series
documents OPA 08-1: Verification of Income for Title X Clients and OPA 97-1: Fees and Charges to
Title X Low-Income Clients and Teenagers (Revised), which are available on the OPA website at
http://www.hhs.gov/opa/familyplanning/toolsdocs/xinstruction.html.
PRINCIPAL HEALTH INSURANCE COVERING PRIMARY MEDICAL CARE – Refers to public and private health
insurance plans that provide a broad set of primary medical care benefits to enrolled individuals.
Report the most current health insurance coverage information available for the client even though he or
she may not have used this health insurance to pay for family planning services received during his or her
last encounter. For individuals who have coverage under more than one health plan, principal insurance
is defined as the insurance plan that the agency would bill first (i.e., primary) if a claim were to be filed.
Categories of health insurance covering primary medical care include public and private sources of
coverage.
PUBLIC HEALTH INSURANCE COVERING PRIMARY MEDICAL CARE – Refers to federal, state, or local
government health insurance programs that provide a broad set of primary medical care benefits
7
U.S. Department of Health and Human Services. (August 8, 2003). Guidance to federal financial assistance
recipients regarding Title VI prohibition against national origin discrimination affecting limited English
proficient persons (“Revised HHS LEP guidance”). Federal Register, 68(153), 47311-47323. Retrieved March 1,
2011, from http://www.hhs.gov/ocr/civilrights/resources/specialtopics/lep/policyguidancedocument.html
8
U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation,
(2010). Poverty guidelines, research, and measurement. Retrieved March 1, 2011, from
http://aspe.hhs.gov/poverty/index.shtml
Attachment B - 28
for eligible individuals. Examples of such programs include Medicaid (both regular and managed
care), Medicare, state Children’s Health Insurance Programs (CHIPs), health plans for military
personnel and their dependents (e.g., TRICARE or CHAMPVA), and state-sponsored health
insurance programs.
PRIVATE HEALTH INSURANCE COVERING PRIMARY MEDICAL CARE – Refers to health insurance coverage
through an employer, union, or direct purchase that provides a broad set of primary medical care
benefits for the enrolled individual (beneficiary or dependent).
UNINSURED – Refers to clients who do not have a public or private health insurance plan that covers
broad, primary medical care benefits. Clients whose services are subsidized through state or local
indigent care programs, or clients insured through the Indian Health Service who obtain care in a nonparticipating facility, are considered uninsured.
LIMITED ENGLISH PROFICIENT (LEP) USERS – Refers to family planning users who do not speak English as
their primary language and who have a limited ability to read, write, speak, or understand English.7
Because of their limited English proficiency, LEP users derive little benefit from Title X services and
information provided in English. In Table 6, report the unduplicated number of family planning users who
required language assistance services (interpretation or translation) to optimize their use of Title X
services. Include those users who received Title X services from bilingual staff or who were assisted by a
competent agency or contracted interpreter. Also, include users who opted to use a family member or
friend as an interpreter after refusing an offer for a qualified interpreter at no cost. Service providers
should consult the Revised HHS LEP Guidance7 for further information about identifying LEP individuals
and complying with language assistance requirements.
QUESTIONS ABOUT TABLES 4 TO 6
1. QUESTION – Are tables 4 through 6 different from the previous FPAR?
ANSWER – There are no changes to Table 4. In Table 5, OPA has eliminated rows 2a, 2b, and 2c
(level of private health insurance coverage for family planning) and modified the instructions to
reflect this change. In addition, OPA has simplified the definition of an LEP user and the
instructions for reporting LEP users in Table 6.
2. QUESTION – If a client has health insurance that covers a broad set of primary medical care
benefits, including some or all family planning services, but he or she chooses not to use his or
her health insurance plan to pay for some or all of the cost of services, how should an agency
classify this client for purposes of Table 5 reporting?
ANSWER – Although an insured client may elect not to use his or her health insurance to pay for
services, he or she is considered insured and should be reported in either Row 1 or Row 2 of the
table according to the type of health insurance coverage (public or private) that he or she has.
3. QUESTION – Are Title X agencies required to verify client health insurance status and, if insured,
the level of family planning service coverage under the health plan?
ANSWER – No. The information required to complete Table 5 is based on clients’ self-reported
insurance coverage. However, as stipulated in the program regulations (see 42 CFR Part 59),4
service providers are required to bill all third parties authorized or legally obligated to pay for
services and to make reasonable efforts to collect charges without jeopardizing client
confidentiality.
Attachment B - 29
Form Approved
OMB No. 0990-0221
Exp. Date 01/31/2014
4. QUESTION – How do I classify a client who has coverage for a specific type of care or health
condition—for example, dental services or expanded Medicaid coverage under the Breast and
Cervical Cancer Prevention and Treatment Act of 2000—but has no health insurance that
provides a broad set of primary medical care benefits?
ANSWER – Users who do not have a health insurance plan that provides a broad set of primary
medical care benefits, even though they may have coverage for a specific condition, are
considered uninsured.
5. QUESTION – If a client has coverage for family planning services under a Medicaid family
planning expansion program (i.e., 1115 waiver demonstration project), is he or she considered
insured for purposes of FPAR reporting?
ANSWER – A client is insured if (1) he or she is enrolled in a Medicaid family planning
expansion program that covers a broad set of primary medical care benefits, in addition to
family planning, or (2) he or she is enrolled in a Medicaid expansion program that covers only
family planning services and he or she has coverage under another plan that covers a broad set of
primary medical care benefits.
A client is uninsured if he or she is enrolled in a Medicaid family planning expansion program
that covers only family planning services and he or she has no coverage under another plan that
covers a broad set of primary medical care benefits.
6. QUESTION – In Table 6, should a user be reported as LEP if he or she receives care from a
bilingual provider in their preferred, non-English language or if he or she receives language
assistance from a trained (agency, contracted, or telephonic) or informal (friend or family
member) interpreter?
ANSWER – In Table 6, report the number of users who are best served in a language other than
English, including clients who received care from bilingual providers in their preferred, nonEnglish language or received language assistance from trained or informal interpreters.
Confidentiality, privacy, conflicts of interest, and competence as medical services interpreters are
several limitations of using family members or friends as interpreters in the Title X clinic setting.
While in some cases an LEP client may feel more comfortable when a trusted family member or
friend acts as an interpreter, the family member or friend may not be competent to provide quality
and accurate interpretations, particularly if the service provided is complex or not of a routine
nature. If a client opts to provide his or her own interpreter, and the service provider determines at
any point during the service that the client’s interpreter is not competent in this role, the service
provider should obtain the services of a competent interpreter.7
Title X Family Planning Annual Report
– 21 –
Attachment B - 30
Date Submitted:
Reporting Period:
January 1, 20________through December 31, 20_________
___________________through _______________________
(Month/day/year) (Month/day/year)
Check One:
Initial Submission
Revision
See Notes
Table 4
Unduplicated Number of Family Planning Users by Income Level
Income Level as a Percentage of the HHS Poverty Guidelines
1
100% and below
2
101% to 150%
3
151% to 200%
4
201% to 250%
5
Over 250%
6
Unknown/not reported
7
Number of Users
(A)
Total Users (sum rows 1 to 6)
Checkpoint
Reference
CC
Title X Family Planning Annual Report
– 22 –
Attachment B - 31
Date Submitted:
Reporting Period:
January 1, 20________through December 31, 20_________
___________________through _______________________
(Month/day/year) (Month/day/year)
Check One:
Initial Submission
Revision
See Notes
Table 5
Unduplicated Number of Family Planning Users by Principal Health Insurance Coverage Status
Principal Health Insurance Covering Primary Medical Care
1
Public health insurance covering primary medical care
2
Private health insurance covering primary medical care
3
Uninsured (no public or private health insurance)
4
Unknown/not reported
5
Number of Users
(A)
Total Users (sum rows 1 to 4)
Checkpoint
Reference
CC
Title X Family Planning Annual Report
– 23 –
Attachment B - 32
Form Approved
OMB No. 0990-0221
Exp. Date 01/31/2014
FPAR Number:
Date Submitted:
Reporting Period:
January 1, 20________through December 31, 20_________
___________________through _______________________
(Month/day/year) (Month/day/year)
Check One:
Initial Submission
Revision
See Notes
Table 6
Unduplicated Number of Family Planning Users with Limited English Proficiency (LEP)
Number of
Users
(A)
1
Number of users with limited English proficiency (LEP)
Title X Family Planning Annual Report
– 24 –
Attachment B - 33
FAMILY PLANNING METHOD USE
Title X projects are required to provide a broad range of acceptable and effective family planning
methods and services.4 Tables 7 and 8 provide sex- and age-specific information on the types of family
planning methods that clients use to prevent unintended pregnancy. Information on the distribution of
methods by age group for female (Table 7) and male (Table 8) users allows OPA to compare the data
from Title X clinics with other sources of information, including the National Survey of Family Growth.
These data also permit OPA to track patterns in method use over time at the state, regional, and national
levels; to examine the extent to which Title X providers contribute to increased access to and use of newer
family planning technologies; and to assess the program’s contribution to national health objectives (i.e.,
HHS’s Healthy People) for family planning and disease prevention.
INSTRUCTIONS
TABLE 7 –
Report the unduplicated number of female family planning users by primary method and
age.
TABLE 8 –
Report the unduplicated number of male family planning users by primary method and
age.
TERMS AND DEFINITIONS
AGE – Use the client’s age as of June 30th of the reporting period.
PRIMARY METHOD OF FAMILY PLANNING – The primary method of family planning is the user’s method—
adopted or continued—at the time of exit from his or her last encounter in the reporting period. If the user
reports that he or she is using more than one family planning method, report the most effective one as the
primary method. Family planning methods include the following:
FEMALE STERILIZATION – In Table 7, report the number of female users who rely on female
sterilization as their primary family planning method. Female sterilization refers to surgical (tubal
ligation) or non-surgical (implant) sterilization procedures performed on a female user in the current
or any previous reporting period.
INTRAUTERINE DEVICE (IUD) – In Table 7, report the number of female users who use a long-term
hormonal or other type of intrauterine device (IUD) or system as their primary family planning
method.
HORMONAL IMPLANT – In Table 7, report the number of female users who use a long-term, subdermal
hormonal implant as their primary family planning method.
1- MONTH HORMONAL INJECTION – In Table 7, report the number of female users who use 1-month
injectable hormonal contraception as their primary family planning method.
3- MONTH HORMONAL INJECTION – In Table 7, report the number of female users who use 3-month
injectable hormonal contraception as their primary family planning method.
ORAL CONTRACEPTIVE – In Table 7, report the number of female users who use any oral contraceptive,
including combination and progestin-only (“mini-pills”) formulations, as their primary family
planning method.
CONTRACEPTIVE PATCH – In Table 7, report the number of female users who use a transdermal
contraceptive patch as their primary family planning method.
Attachment B - 34
VAGINAL RING – In Table 7, report the number of female users who use a hormonal vaginal ring as
their primary family planning method.
CERVICAL CAP/DIAPHRAGM – In Table 7, report the number of female users who use a cervical cap or
diaphragm (with or without spermicidal jelly or cream) as their primary family planning method.
CONTRACEPTIVE SPONGE – In Table 7, report the number of female users who use a contraceptive
sponge as their primary family planning method.
FEMALE CONDOM – In Table 7, report the number of female users who use female condoms (with or
without spermicidal foam or film) as their primary family planning method.
SPERMICIDE (USED ALONE) – In Table 7, report the number of female users who use only spermicidal
jelly, cream, foam, or film (i.e., not in conjunction with another method of contraception) as their
primary family planning method.
FERTILITY AWARENESS METHOD (FAM) OR LACTATIONAL AMENORRHEA METHOD (LAM) – Fertility
awareness methods (FAMs) refer to family planning methods that rely on identifying potentially
fertile days in each menstrual cycle when intercourse is most likely to result in a pregnancy. FAMs
include Calendar Rhythm, Standard Days, TwoDay, Billings Ovulation, and SymptoThermal
methods. In Table 7, report the number of female users who use one or a combination of the FAMs
listed above or who rely on the Lactational Amenorrhea Method (LAM) as their primary family
planning method. In Table 8, Row 3 report male users who rely on a FAM as their primary method.
Report male users who rely on LAM as their primary method in Table 8, Row 6, “Rely on female
method(s).”
ABSTINENCE – For purposes of FPAR reporting, abstinence is defined as refraining from oral, vaginal,
and anal intercourse. In Table 7, report the number of female users who rely on abstinence as their
primary family planning method or who are not currently sexually active and therefore not using
contraception. In Table 8, report the number of male users who rely on abstinence as their primary
family planning method or who are not currently sexually active.
WITHDRAWAL AND OTHER METHODS – In Tables 7 and 8, report the number of female and male users,
respectively, who use withdrawal or other methods not listed in the tables as their primary family
planning method.
METHOD UNKNOWN OR NOT REPORTED – In Tables 7 and 8, report the number of female and male users
for whom the primary family planning method at exit from the last family planning encounter is
unknown or not reported.
NO METHOD–[PARTNER] PREGNANT OR SEEKING PREGNANCY – In Tables 7 and 8, report the number of
users who are not using any family planning method because they (Table 7) or their partners (Table 8)
are pregnant or seeking pregnancy.
NO METHOD–OTHER REASON – In Tables 7 and 8, report the number of users who are not using any
family planning method to avoid pregnancy due to reasons other than pregnancy or seeking
pregnancy, including if either partner is sterile without having been sterilized surgically or if either
partner has had a non-contraceptive surgical procedure that has rendered him or her unable to
conceive or impregnate.
VASECTOMY – Refers to conventional incisional or no-scalpel vasectomy performed on a male user, or
the male partner of a female user, in the current or any previous reporting period. In Table 7, report
the number of female users who rely on vasectomy as their (partner’s) primary family planning
method. In Table 8, report the number of male users on whom a vasectomy was performed in the
current or any previous reporting period.
Attachment B - 35
MALE CONDOM – In Table 7, report the number of female users who rely on their sexual partner to use
male condoms (with or without spermicidal foam or film) as their primary family planning method. In
Table 8, report the number of male users who use male condoms (with or without spermicidal foam
or film) as their primary family planning method.
RELY ON FEMALE METHOD(S) – In Table 8, report the number of male family planning users who rely
on their female partner’s family planning method(s) as their primary method. “Female” contraceptive
methods include female sterilization, IUDs, hormonal implants, 1- and 3-month hormonal injections,
oral contraceptives, the contraceptive patch, the vaginal ring, cervical cap/diaphragms, the
contraceptive sponge, female condoms, LAM, and spermicides.
QUESTIONS ABOUT TABLES 7 AND 8
1. QUESTION – Are tables 7 and 8 different from the previous FPAR?
ANSWER – Yes. OPA has made several minor changes to Tables 7 and 8.
In Table 7, OPA changed the Row 7 heading from “Hormonal contraceptive patch” to
“Contraceptive patch,” the Row 13 heading from “Fertility awareness method (FAM)” to
“Fertility awareness method (FAM)/Lactational Amenorrhea Method (LAM),” the Row 15
heading from “Other methods” to “Withdrawal or other method,” and the Row 20 heading from
“Method unknown” to “Method unknown/not reported.”
In Table 8, OPA changed the Row 5 heading from “Other methods” to “Withdrawal or other
method” and the Row 9 heading from “Method unknown” to “Method unknown/not reported.” In
addition, OPA has added LAM to the list of methods in the reporting category “Rely on female
methods.” Grantees should report male users who rely on LAM (used by their female sexual
partners) as their primary method in Table 8, Row 6 (“Rely on female method[s]”) instead of
Table 8, Row 3 (“Fertility awareness method”).
In both tables, OPA has reordered the row groupings so that the “No Method” rows follow the
“Primary Method” rows and the “Method unknown/not reported” row follows the “No Method”
rows. OPA also has updated the list of FAM methods and expanded the “Other reason” category
under “No Method” to include users or their partners who have had a non-contraceptive surgical
procedure that has rendered them unable to conceive or impregnate. Furthermore, OPA has
revised the definition for “Method unknown/not reported” such that users in this category are no
longer assumed to be using a method and will not, therefore, be counted as using a method.
2. QUESTION – If family planning users, male or female, rely on their partners’ family planning
method for pregnancy prevention, how should the grantee report this information in Tables 7 or
8?
ANSWER – If a female family planning user relies on a male family planning method (e.g.,
vasectomy or male condoms) for pregnancy prevention, report this user in Table 7, Row 16 or 17.
If the female user relies on withdrawal, report this user in Table 7, Row 15 (“Withdrawal or other
method”).
If a male family planning user relies on a “female” family planning method for pregnancy
prevention (i.e., female sterilization, IUD, hormonal implant, 1- or 3-month hormonal injection,
oral contraceptives, contraceptive patch, vaginal ring, cervical cap or diaphragm, contraceptive
sponge, female condoms, LAM, or spermicides), report this user in Table 8, Row 6.
Attachment B - 36
Form Approved
OMB No. 0990-0221
Exp. Date 01/31/2014
If a male client and his female sexual partner rely on pills (for pregnancy prevention) and
condoms (for STD or pregnancy prevention), record the method that is most effective in terms of
pregnancy prevention (i.e., pills). In this example, the male user’s family planning method would
be “Rely on female method(s)” (Table 8, Row 6). If this same male client were to report that he
relies on condoms for pregnancy prevention because of his partner’s inconsistent pill use, report
male condoms (Table 8, Row 2) as this client’s primary contraceptive method.
3. QUESTION – How should grantees report a female or male user who has had a non-contraceptive
surgical procedure that has rendered her or him unable to conceive or impregnate?
ANSWER – Report female users who have had a non-contraceptive surgical procedure that has
rendered them unable to conceive in Table 7, Row 19 (“No method–Other reason”). Report male
users who have had a non-contraceptive surgical procedure that has rendered them unable to
impregnate a female sexual partner in Table 8, Row 8 (“No method–Other reason”).
Title X Family Planning Annual Report
– 28 –
Attachment B - 37
Form Approved
OMB No. 0990-0221
Exp. Date 01/31/2014
FPAR Number:
Date Submitted:
Reporting Period:
January 1, 20________through December 31, 20_________
___________________through _______________________
(Month/day/year) (Month/day/year)
Check One:
Initial Submission
Revision
See Notes
Table 7
Unduplicated Number of Female Family Planning Users by Primary Method and Age
Primary Method
1
Female sterilization
2
Intrauterine device (IUD)
3
Hormonal implant
4
1-Month hormonal injection
5
3-Month hormonal injection
6
Oral contraceptive
7
Contraceptive patch
8
Vaginal ring
9
Cervical cap or diaphragm
10
Contraceptive sponge
11
Female condom
12
Spermicide (used alone)
13
Fertility Awareness or
Lactational Amenorrhea Method
14
Abstinence
15
Withdrawal or other method
Total
Female Users
(Sum Cols
A to I)
Under 15 15 to 17 18 to 19 20 to 24 25 to 29 30 to 34 35 to 39 40 to 44 Over 44
(J)
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
Rely on Male Method
16
Vasectomy
17
Male condom
No Method
18
19
Pregnant or seeking pregnancy
Other reason
Method Unknown/
Not Reported
20
21
Method unknown/not reported
Total Female Users
(sum rows 1 to 20)
See
Checkpoint
Reference
AA
Title X Family Planning Annual Report
– 29 –
Attachment B - 38
Form Approved
OMB No. 0990-0221
Exp. Date 01/31/2014
FPAR Number:
Date Submitted:
Reporting Period:
January 1, 20________through December 31, 20_________
___________________through _______________________
(Month/day/year) (Month/day/year)
Check One:
Initial Submission
Revision
See Notes
Table 8
Unduplicated Number of Male Family Planning Users by Primary Method and Age
Primary Method
1
Vasectomy
2
Male condom
3
Fertility Awareness Method
4
Abstinence
5
Withdrawal or other method
Under 15 15 to 17 18 to 19 20 to 24 25 to 29 30 to 34 35 to 39 40 to 44
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
Over 44
(I)
Total Male
Users
(Sum Cols
A to I)
(j)
Rely on Female Method
6
Rely on female method(s)
No Method
7
Partner pregnant or seeking
pregnancy
8
Other reason
Method Unknown/
Not Reported
9
10
Method unknown/not reported
Total Male Users
(sum rows 1 to 9)
See
Checkpoint
Reference
BB
Title X Family Planning Annual Report
– 30 –
Attachment B - 39
CERVICAL AND BREAST CANCER SCREENING
Tables 9 and 10 provide information on the cervical and breast cancer screening activities that are
performed in Title X-funded clinics. Data from these tables permit OPA to monitor compliance with
legislative mandates, measure achievement of program performance objectives, and assess the program’s
contribution to national health objectives (i.e., HHS’s Healthy People) related to early cancer detection
and health promotion. OPA also uses the data from these tables to monitor the number of abnormal
results that require further follow-up by Title X providers.
INSTRUCTIONS
TABLE 9 –
Report the following information on cervical cancer screening activities. Refer to the
chart in Exhibit 1 for reporting information on Pap test results.
• Unduplicated number of users who obtained a Pap test.
• Number of Pap tests performed.
• Number of Pap tests with an ASC or higher result according to the 2001 Bethesda
System 9 (see Exhibit 1). ASC or higher results include: ASC-US; ASC-H; LSIL;
HSIL; squamous cell carcinoma; AGC; AGC, favor neoplastic; AIS;
adenocarcinoma; or other (e.g., endometrial cells in a woman ≥ 40 years of age).
• Number of Pap tests with an HSIL or higher result according to the 2001
Bethesda System (see Exhibit 1). HSIL or higher results include: HSIL; squamous
cell carcinoma; AGC; AGC, favor neoplastic; AIS; adenocarcinoma; or other (e.g.,
endometrial cells in a woman ≥ 40 years of age).
TABLE 10 – Report the following information on breast health screening and referral activities.
•
•
Unduplicated number of users receiving a clinical breast exam (CBE).
Unduplicated number of users referred for further evaluation based on CBE results.
TERMS AND DEFINITIONS
TESTS – Report Pap tests and CBEs performed during the reporting period that are provided within the
scope of the agency’s Title X project.
ATYPICAL SQUAMOUS CELLS (ASC) – ASC refers to cytological changes that are suggestive of a squamous
intraepithelial lesion. The 2001 Bethesda System (see Exhibit 1) subdivides atypical squamous cells into
two categories:
•
Atypical squamous cells of undetermined significance (ASC-US) – ASC-US refers to
cytological changes that are suggestive of a squamous intraepithelial lesion, but lack criteria
for a definitive interpretation. 10
9
Solomon, D., Davey, D., Kurman, R., Moriarty, A., O’Connor, D., Prey, M. et al. (2002). The 2001 Bethesda
System: Terminology for reporting results of cervical cytology. Journal of the American Medical Association,
287(16), 2116.
10
Apgar, B. S., Zoschnick, L., & Wright, T. C. (2003). The 2001 Bethesda System terminology. American
Academy of Family Physicians, 2003(68), 1992–1998.
Attachment B - 40
•
Atypical squamous cells, cannot exclude HSIL (ASC-H) – ASC-H refers to cytological
changes that are suggestive of a high-grade squamous intraepithelial lesion (HSIL), but lack
criteria for a definitive interpretation.10
LOW-GRADE SQUAMOUS INTRAEPITHELIAL LESIONS (LSIL) – LSIL refers to low-grade squamous
intraepithelial lesions encompassing human papillomavirus, mild dysplasia, and cervical intraepithelial
neoplasia (CIN) 1.10
HIGH-GRADE SQUAMOUS INTRAEPITHELIAL LESIONS (HSIL) – HSIL refers to high-grade squamous
intraepithelial lesions encompassing moderate and severe dysplasia, carcinoma in situ, CIN 2, and
CIN 3.10
ATYPICAL GLANDULAR CELLS (AGC) – AGC refers to glandular cell abnormalities, including
adenocarcinoma. The 2001 Bethesda System (see Exhibit 1) classifies AGC less severe than
adenocarcinoma into three categories. 11
•
Atypical glandular cells, either endocervical, endometrial, or “glandular cells” not otherwise
specified.
•
Atypical glandular cells, either endocervical or “glandular cells” favor neoplasia (AGC, favor
neoplastic).
•
Endocervical adenocarcinoma in situ (AIS).
QUESTIONS ABOUT TABLES 9 AND 10
1. QUESTION – Are tables 9 or 10 different from the previous FPAR?
ANSWER – There are minor changes to Table 9 instructions and no changes to Table 10. For Table
9, the list of Pap test results that are ASC or higher or HSIL or higher have been changed to
include squamous cell carcinoma; AGC, favor neoplastic; and AIS.
2. QUESTION – How should grantees count and report a CBE that appears on the clinic encounter
form or “super bill” as part of a “bundled” billing or service code (e.g., as part of a
comprehensive exam)?
ANSWER – If grantees do not have a count of the actual number of CBEs performed due to the
structure of the “bundled” billing/service code, they should report the estimated number of CBEs
performed in Table 10, Row 1, and provide a brief explanation about the reported figure in the
Table 10 “Notes” field.
3. QUESTION – In Table 9, does the total number of Pap tests reported in Row 3 include tests
reported in Row 4?
ANSWER – Yes. Table 9, Row 3 will include the tests reported in Row 4 because tests with a result
of HSIL or higher are also tests with a result of ASC or higher.
11
Wright, T. C., Cox, J. T., Massad, L. S., Twiggs, L. B., & Wilkinson, E. J. (2002). 2001 consensus guidelines for
the management of women with cervical cytological abnormalities. Journal of the American Medical
Association, 287, 2120–2129. For updated consensus guidelines for managing women with abnormal tests, see
Wright, T. C., Massad, L. S., Dunton, C. J., Spitzer, M., Wilkinson, E. J., & Solomon, D. (2007, October). 2006
consensus guidelines for the management of women with abnormal cervical cancer screening tests. American
Journal of Obstetrics & Gynecology, 197(4), 337–339.
Attachment B - 41
4. QUESTION – How should a grantee complete Table 9, Rows 3 and 4, if the results of Pap tests
performed at the end of the reporting period are not received in time to include in the FPAR?
ANSWER – A grantee has two options for dealing with delayed Pap test results. Under the first
option, the grantee can report the Pap testing (Table 9, Rows 1 and 2) and results (Table 9, Rows
3 and 4) figures that are available at the time it submits the FPAR. The grantee should use the
Table 9 “Notes” field to explain that the figures reported in Rows 3 and 4 are estimated rather
than actual due to delayed laboratory reporting.
Under the second option, the grantee can report testing and results data for a 12-month period that
has complete results data and is close in time to the reporting period. For example, if Pap testing
and results data are complete for the 12-month period from December to November, but not for
January to December, report the figures for December to November and use the Table 9 “Notes”
field to explain that Table 9 data are for a different 12-month period (specify period). Consult
your RPC if you have any questions about reporting Table 9 data when Pap testing results are
delayed.
Attachment B - 42
Form Approved
OMB No. 0990-0221
Exp. Date 01/31/2014
Exhibit 1. The 2001 Bethesda System (Abridged)
SPECIMEN ADEQUACY
Satisfactory for evaluation (note presence/absence of endocervical/
transformation zone component)
Unsatisfactory for evaluation … (specify reason)
Specimen rejected/not processed (specify reason)
Specimen processed and examined, but unsatisfactory for evaluation of
epithelial abnormality because of (specify reason)
GENERAL CATEGORIZATION (Optional)
Negative for intraepithelial lesion or malignancy
Epithelial cell abnormality
Other
INTERPRETATION/RESULT
Negative for Intraepithelial Lesion or Malignancy
Organisms
Trichomonas vaginalis
Fungal organisms morphologically consistent with Candida species
Shift in flora suggestive of bacteria vaginosis
Bacteria morphologically consistent with Actinomyces species
Cellular changes consistent with herpes simplex virus
Other non-neoplastic findings (Optional to report; list not comprehensive)
Reactive cellular changes associated with
inflammation (includes typical repair)
radiation
intrauterine contraceptive device
Glandular cells status posthysterectomy
Atrophy
Epithelial Cell Abnormalities
Squamous cell
Atypical squamous cells (ASC)
of undetermined significance (ASC-US)
cannot exclude HSIL (ASC-H)
Low-grade squamous intraepithelial lesion (LSIL)
encompassing: human papillomavirus/mild dysplasia/cervical
intraepithelial neoplasia (CIN) 1
High-grade squamous intraepithelial lesion (HSIL)
encompassing: moderate and severe dysplasia, carcinoma in situ;
CIN 2 and CIN 3
Squamous cell carcinoma
Glandular cell
Atypical glandular cells (AGC) (specify endocervical, endometrial, or not
otherwise specified)
Atypical glandular cells, favor neoplastic (specify endocervical
or not otherwise specified)
Endocervical adenocarcinoma in situ (AIS)
Adenocarcinoma
Report in
Table 9
Row 3
Report in
Table 9
Row 4
Other (List not comprehensive)
Endometrial cells in a woman ≥ 40 years of age
AUTOMATED REVIEW and ANCILLARY TESTING (Include as appropriate)
EDUCATIONAL NOTES and SUGGESTIONS (Optional)
Source: Solomon, D., Davey, D., Kurman, R., Moriarty, A., O’Connor, D., Prey, M., et al. (2002). The 2001 Bethesda System:
Terminology for reporting results of cervical cytology. Journal of the American Medical Association, 287(16), 2116. (Copyright
2002, American Medical Association. All rights reserved. Reprinted with permission.)
Title X Family Planning Annual Report
– 34 –
Attachment B - 43
Date Submitted:
Reporting Period:
January 1, 20________through December 31, 20_________
___________________through _______________________
(Month/day/year) (Month/day/year)
Check One:
Initial Submission
Revision
See Notes
Table 9
Cervical Cancer Screening Activities
Screening Activity
1
Unduplicated number of users who obtained a Pap test
2
Number of Pap tests performed
3
Number of Pap tests with an ASC or higher result
4
Number of Pap tests with an HSIL or higher result
Title X Family Planning Annual Report
– 35 –
Number of Users or
Number of Tests
(A)
Attachment B - 44
Form Approved
OMB No. 0990-0221
Exp. Date 01/31/2014
FPAR Number:
Date Submitted:
Reporting Period:
January 1, 20________through December 31, 20_________
___________________through _______________________
(Month/day/year) (Month/day/year)
Check One:
Initial Submission
Revision
See Notes
Table 10
Clinical Breast Exams and Referrals
Screening Activity
1
Unduplicated number of users who received a clinical breast exam
(CBE)
2
Unduplicated number of users referred for further evaluation based on
their CBE
Title X Family Planning Annual Report
– 36 –
Number of Users
(A)
Attachment B - 45
SEXUALLY TRANSMITTED DISEASE (STD) SCREENING
Tables 11 and 12 provide information on the utilization of STD testing services provided in Title X
clinics. Data from these tables permit OPA to monitor compliance with legislative mandates, measure
achievement of program performance objectives, and assess the program’s contribution to national health
objectives (i.e., HHS’s Healthy People) for disease prevention (e.g., STDs and HIV) and health
promotion.
INSTRUCTIONS
TABLE 11 – Report the unduplicated number of family planning users tested for chlamydia, by age
group (under 15, 15–17, 18–19, 20–24, and 25 and over) and sex.
TABLE 12 – Report the following STD testing information:
•
•
•
•
•
Number of gonorrhea tests performed, by sex.
Number of syphilis tests performed, by sex.
Number of confidential HIV tests performed, by sex.
Number of positive confidential HIV tests.
Number of anonymous HIV tests.
TERMS AND DEFINITIONS
AGE – Use the client’s age as of June 30th of the reporting period.
TESTS – Report STD (chlamydia, gonorrhea, and syphilis) and HIV (confidential and anonymous) tests
performed during the reporting period that are provided within the scope of the grantee’s Title X project.
Do not report tests performed in an STD clinic operated by the Title X-funded agency, unless the
activities of the STD clinic are within the defined scope of the agency’s Title X project.
QUESTIONS ABOUT TABLES 11 AND 12
1. QUESTION – Are tables 11 or 12 different from the previous FPAR?
ANSWER – No. There are no changes to Tables 11 or 12.
2. QUESTION – How should grantees that fund agencies operating co-located Title X and STD clinics
report STD tests?
ANSWER – Do not report tests performed in an STD clinic operated by the Title X-funded agency
or co-located with the Title X-funded service site unless the activities of the STD clinic are within
the defined scope of the grantee’s Title X project and the STD tests are provided to family
planning users.
3. QUESTION – How should a grantee complete Table 12 if the results for HIV tests performed at the
end of the reporting period are not received in time to be included in the FPAR?
ANSWER – A grantee has two options for dealing with delayed HIV test results. Under the first
option, the grantee can report the HIV testing (Table 12, Row 3) and results (Table 12, Row 4)
figures that are available at the time they submit the FPAR and use the Table 12 “Notes” field to
Title X Family Planning Annual Report
– 37 –
Attachment B - 46
Form Approved
OMB No. 0990-0221
Exp. Date 01/31/2014
explain that the figure reported in Row 4 is estimated rather than actual due to delayed laboratory
reporting.
Under the second option, the grantee can report testing and results data for a 12-month period that
has complete results data and is close in time to the reporting period. For example, if HIV testing
and results data are complete for the period December to November, but not for January to
December, report the figures for December to November, and use the Table 12 “Notes” field to
explain that Table 12 data are for a different 12-month period (specify period). Consult your RPC
if you have any questions about reporting Table 12 data when HIV testing results are delayed.
4. QUESTION – In Table 12, Row 3, should grantees count and report confirmatory HIV tests
separately from initial HIV tests (i.e., one versus two tests)?
ANSWER – To the extent possible, grantees should report all HIV tests—initial and confirmatory—
performed within the scope of their Title X projects, including HIV tests performed onsite and
tests for which a specimen is collected onsite and analyzed offsite (e.g., laboratory). If an offsite
laboratory performs a confirmatory test using the same specimen obtained for the initial test,
grantees should not count the confirmatory test unless (1) it has billing or other transaction
records to document that the laboratory performed a second/confirmatory test and (2) compiling
and reporting confirmatory test counts do not pose an undue burden. Grantees should use the
Table 12 “Notes” field to explain if HIV test counts exclude confirmatory tests.
5. QUESTION – Should grantees include preliminary positive rapid HIV tests in the total number of
positive HIV test results reported in Table 12, Row 4?
ANSWER – No. The total number of confidential positive HIV tests should only include the
number of standard (i.e., not rapid) HIV tests with a positive result and the number of preliminary
positive rapid HIV tests confirmed to be positive.
Title X Family Planning Annual Report
– 38 –
Attachment B - 47
Date Submitted:
Reporting Period:
January 1, 20________through December 31, 20_________
___________________through _______________________
(Month/day/year) (Month/day/year)
Check One:
Initial Submission
Revision
See Notes
Table 11
Unduplicated Number of Family Planning Users Tested for Chlamydia by Age and Sex
Age Group
(Years)
1
Under 15
2
15 to 17
3
18 to 19
4
20 to 24
5
25 and over
6
Female Users
(A)
Total Users
(sum rows 1 to 5)
Title X Family Planning Annual Report
– 39 –
Male Users
(B)
Attachment B - 48
Form Approved
OMB No. 0990-0221
Exp. Date 01/31/2014
FPAR Number:
Date Submitted:
Reporting Period:
January 1, 20________through December 31, 20_________
___________________through _______________________
(Month/day/year) (Month/day/year)
Check One:
Initial Submission
Revision
See Notes
Table 12
Number of Gonorrhea, Syphilis, and HIV Tests
Female
Tests
(A)
Test Type
1
Gonorrhea
2
Syphilis
3
HIV – All confidential tests
4
HIV – Positive confidential tests
5
HIV – Anonymous tests
Male
Tests
(B)
Title X Family Planning Annual Report
– 40 –
Total Tests
(Sum Cols A + B)
(C)
Attachment B - 49
FAMILY PLANNING ENCOUNTERS AND UTILIZATION OF
CLINICAL SERVICES PROVIDERS
Table 13 provides information on the number and type of family planning encounters, as well as the
utilization of clinical services providers in the delivery of Title X-funded family planning and related
preventive health services.
INSTRUCTIONS
TABLE 13 – Report the following provider utilization and encounter data:
•
•
•
Number of full-time equivalent (FTE) family planning clinical services
providers, by type of provider.
Number of family planning encounters with clinical services providers.
Number of family planning encounters with other services providers.
TERMS AND DEFINITIONS
FAMILY PLANNING PROVIDER – A family planning provider is the individual who assumes primary
responsibility for assessing a client and documenting services in the client record. Providers include those
agency staff that exercise independent judgment as to the services rendered to the client during an
encounter. Two general types of providers deliver Title X family planning services: clinical services
providers and other services providers.
CLINICAL SERVICES PROVIDER – Includes physicians (family and general practitioners, specialists),
physician assistants, nurse practitioners, certified nurse midwives, and registered nurses with an
expanded scope of practice who are trained and permitted by state-specific regulations to perform all
aspects of the user (male and female) physical assessment, as described in the Program Guidelines.
Clinical services providers are able to offer client education, counseling, referral, follow-up, and
clinical services (physical assessment, treatment, and management) relating to a client’s proposed or
adopted method of contraception, general reproductive health, or infertility treatment, in accordance
with the Program Guidelines.
OTHER SERVICES PROVIDER – Includes other agency staff (e.g., registered nurses, public health nurses,
licensed vocational or licensed practical nurses, certified nurse assistants, health educators, social
workers, or clinic aides) that offer client education, counseling, referral, or follow-up services relating
to the client’s proposed or adopted method of contraception, general reproductive health, or infertility
treatment, as described in the Program Guidelines. Other services providers may also perform or
obtain samples for routine laboratory tests (e.g., urine, pregnancy, STD, and cholesterol and lipid
analysis), give contraceptive injections (e.g., Depo-Provera), and perform routine clinical procedures
that may include some aspects of the user physical assessment (e.g., blood pressure evaluation), in
accordance with the Program Guidelines.
FAMILY PLANNING ENCOUNTER – A family planning encounter is a documented, face-to-face contact
between an individual and a family planning provider that takes place in a Title X service site. The
purpose of a family planning encounter—whether clinical or non-clinical—is to provide family planning
and related preventive health services to female and male clients who want to avoid unintended
pregnancies or achieve intended pregnancies. To be counted for purposes of the FPAR, a written record of
the service(s) provided during the family planning encounter must be documented in the client record.
Title X Family Planning Annual Report
– 41 –
Attachment B - 50
There are two types of family planning encounters at Title X service sites: (1) family planning encounters
with a clinical services provider and (2) family planning encounters with an other services provider. The
type of family planning provider who renders the care, regardless of the services rendered, determines the
type of family planning encounter. Although a client may meet with both clinical and other services
providers during an encounter, the provider with the highest level of training who takes ultimate
responsibility for the client’s clinical or non-clinical assessment and care during the visit is credited with
the encounter.
FAMILY PLANNING ENCOUNTER WITH A CLINICAL SERVICES PROVIDER – A face-to-face, documented
encounter between a family planning client and a clinical services provider that takes place in a
Title X service site.
FAMILY PLANNING ENCOUNTER WITH AN OTHER SERVICES PROVIDER – A face-to-face, documented
encounter between a family planning client and an other services provider that takes place in a Title X
service site.
Laboratory tests and related counseling and education, in and of themselves, do not constitute a family
planning encounter unless there is face-to-face contact between the client and provider, the provider
documents the encounter in the client’s record, and the test(s) is/are accompanied by family planning
counseling or education.
FULL-TIME EQUIVALENT (FTE) – For each type of clinical services provider, report the time in FTEs that
these providers are involved in the direct provision of Title X services (i.e., engaged in a family planning
encounter).
QUESTIONS ABOUT TABLE 13
1. QUESTION – Is table 13 different from the previous FPAR?
ANSWER – Yes. To improve the quality of provider FTE and encounter data, OPA has changed
the term “non-clinical services providers” to “other services providers.” OPA has also clarified
the definitions for clinical and other (formerly “non-clinical”) services providers. More
specifically, OPA has clarified that registered nurses are classified as clinical services providers
only if they have an expanded scope of practice and are trained and permitted by state-specific
regulations to perform all aspects of the user (male and female) physical assessment, as described
in the Program Guidelines. Otherwise, grantees should classify registered nurses without an
expanded scope of practice and all other nurses (e.g., LPNs/LVNs, public health nurses) as other
services providers.
2. QUESTION – Can a client have more than one family planning encounter during a single family
planning visit?
ANSWER – As noted in the “Terms and Definitions” section of the report, a client may have only
one family planning encounter per visit. In the family planning services setting, the term
“encounter” is synonymous with “visit.” Although a client may meet with both clinical and other
services providers during an encounter, only one provider is credited with the encounter. The
provider with the highest level of training who takes ultimate responsibility for the client’s
clinical or non-clinical assessment and care during the visit is credited with the encounter.
Title X Family Planning Annual Report
– 42 –
Attachment B - 51
Form Approved
OMB No. 0990-0221
Exp. Date 01/31/2014
3. QUESTION – If a nurse provides a contraceptive injection (e.g., Depo-Provera), should the grantee
report the encounter as an encounter with a clinical services provider?
ANSWER – If the nurse who provides the injection is a registered nurse with an expanded scope of
practice who is trained and permitted by state-specific regulations to perform all aspects of the
user (male and female) physical assessment as described in the Program Guidelines, then the
encounter is an encounter with a clinical services provider and should be reported in Table 13,
Row 1.
However, if the injection is provided by a registered nurse who does not have an expanded scope
of practice or by another type of nurse (e.g., LPN/LVN or public health nurse), then the encounter
should be reported as an encounter with an other services provider in Table 13, Row 2.
4. QUESTION – If an individual receives gynecological or related preventive health services (e.g.,
pelvic exam, Pap test, pregnancy test, STD screening) in a Title X-funded clinic, but does not
receive services aimed at avoiding unintended pregnancy or achieving intended pregnancy (e.g.,
contraceptive or fertility counseling), is the encounter considered a family planning encounter?
ANSWER – If a client is an ongoing family planning user who visits the clinic to obtain any type of
family planning or related preventive health services, the encounter is considered a family
planning encounter.
If a client of reproductive age has been sterilized, but continues to seek gynecological or related
preventive health services, the encounter is considered a family planning encounter and the
agency may continue to count the client as a family planning user.
If a client obtains gynecological or related preventive health services, but the client is neither an
ongoing family planning user nor seeks or receives services (clinical, counseling, educational,
and/or referral) to help avoid unintended pregnancy or achieve intended pregnancy, the encounter
is not a family planning encounter and the client is not a family planning user.
If a post-menopausal client obtains gynecological or related preventive health services, the
encounter is not a family planning encounter and the client is not a family planning user.
Title X Family Planning Annual Report
– 43 –
Attachment B - 52
Date Submitted:
Reporting Period:
January 1, 20________through December 31, 20_________
___________________through _______________________
(Month/day/year) (Month/day/year)
Check One:
Initial Submission
Revision
See Notes
Table 13
Number of Family Planning Encounters by Type of Provider
Number of
FTEs
(A)
Provider Type
1
Clinical Services Providers
1a
Physicians
1b
Physician assistants/nurse practitioners/
certified nurse midwives
1c
Registered nurses with an expanded scope of
practice who are trained and permitted by statespecific regulations to perform all aspects of the
user physical assessment
2
3
Other Services Providers
Total Family Planning Encounters
(sum rows 1 + 2)
Title X Family Planning Annual Report
– 44 –
Number of
Family Planning
Encounters
(B)
Attachment B - 53
REVENUE REPORT
Title X Section 1001 grantees are required to maintain a financial management system that meets the
standards for grant administration and to document and keep records of all income and expenditures.2, 3
Table 14 identifies the sources and amounts of financial support received during the reporting period that
support activities within the scope of the grantee’s Title X family planning services project (“Title X
project”).
INSTRUCTIONS
TABLE 14 – Report the revenues (i.e., actual cash receipts or drawdown amounts) received during the
reporting period from each funding source to support activities within the scope of the
grantee’s Title X services grant (Section 1001), even if the funds were not expended
during the reporting period. Include (1) all receipts from the Title X services grant;
(2) collections from patients and reimbursements from third parties for services rendered;
and (3) receipts from other sources, including block grants, state and local governments,
and other sources. If the value for a cell is zero, enter “0.” The agency must retain for
audit purposes all worksheets that document how the agency derived the reported
amounts.2, 3 Do not report the monetary value of in-kind contributions as revenue in
Table 14.
TERMS AND DEFINITIONS
TITLE X GRANT – Refers to funds received from the Title X Section 1001 family planning services grant.
Report the amount received (cash receipts or drawdown amounts) during the reporting period from the
Title X services grant. Do not report the amount of grant funds awarded unless this figure is the same as
the actual cash receipts or drawdown amounts.
PAYMENT FOR SERVICES – Refers to funds collected directly from clients and revenues received from
public and private third party payers (capitated or fee-for-service) for services provided within the scope
of the grantee’s Title X project.
TOTAL CLIENT COLLECTIONS/SELF-PAY – Report the amount collected directly from clients during the
reporting period for services provided within the scope of the grantee’s Title X project.
THIRD-PARTY PAYERS – For each third-party source listed, report the amount received (i.e.,
reimbursed) during the reporting period for services provided within the scope of the grantee’s Title
X project. Only revenue from pre-paid (capitated) managed care arrangements (e.g., capitated
Medicare, Medicaid, and private managed care contracts) should be reported as prepaid. Revenues
received after the date of service, even under managed care arrangements, should be reported as not
prepaid.
MEDICAID/TITLE XIX – Report the amount received from Medicaid (federal and state shares) during
the reporting period for services provided within the scope of the grantee’s Title X project,
regardless of whether the reimbursement was paid directly by Medicaid or through a fiscal
intermediary or a health maintenance organization (HMO). For example, in states with a capitated
Medicaid program (i.e., the grantee has a contract with a private plan like Blue Cross), the payer
is Medicaid, even though the actual payment may come from Blue Cross. Include revenue from
family planning waivers (both federal and state shares) in Row 3a, Column B. If the amount
Attachment B - 54
reported in Row 3a, Column B includes family planning waiver revenue, indicate this in the
Table 14 “Notes” field.
MEDICARE/TITLE XVIII – Report the amount received from Medicare during the reporting period
for services provided within the scope of the grantee’s Title X project, regardless of whether the
reimbursement was paid directly by Medicare or through a fiscal intermediary or an HMO. For
clients enrolled in a capitated Medicare program (i.e., where the grantee has a contract with a
private plan like Blue Cross), the payer is Medicare, even though the actual payment may come
from Blue Cross.
STATE CHILDREN’S HEALTH INSURANCE PROGRAM (SCHIP) – Report the amount of funds received
during the reporting period from SCHIP for services provided within the scope of the grantee’s
Title X project. If the grantee is unable to report SCHIP revenue separately from Medicaid (Row
3a), indicate this in the Table 14 “Notes” field.
OTHER PUBLIC HEALTH INSURANCE – Report the amount reimbursed by other federal, state, or local
government health insurance programs during the reporting period for services provided within
the scope of the grantee’s Title X project. Examples of other sources of public third-party
insurance programs include health insurance plans for military personnel and their dependents
(e.g., TRICARE, CHAMPVA) and state health insurance plans.
PRIVATE HEALTH INSURANCE – Report the amount of funds received from private third-party health
insurance plans during the reporting period for services provided within the scope of the grantee’s
Title X project.
OTHER REVENUE – Refers to revenue received from other sources during the reporting period that
supported services provided within the scope of the grantee’s Title X project. Other revenue sources
include block grants, TANF, state and local governments (e.g., contracts, state and local indigent care
programs), the Bureau of Primary Health Care, private and client donations, or other public or private
revenues.
MATERNAL AND CHILD HEALTH (MCH) BLOCK GRANT/TITLE V – Report the amount of Title V funds
received during the reporting period that supported services provided within the scope of the
grantee’s Title X project.
SOCIAL SERVICES BLOCK GRANT/TITLE XX – Report the amount of Title XX funds received in the
reporting period that supported services provided within the scope of the grantee’s Title X
project.
TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) – Report the amount of TANF funds
received in the reporting period that supported services provided within the scope of the grantee’s
Title X project.
LOCAL GOVERNMENT REVENUE – Report the amount of funds from local government sources
(including county and city grants or contracts) that were received during the reporting period and
that supported services provided within the scope of the grantee’s Title X project.
STATE GOVERNMENT REVENUE – Report the amount of funds from state government sources
(including grants or contracts) that were received during the reporting period and that supported
services provided within the scope of the grantee’s Title X project. Do not report as “state
government revenue” funding from sources like the Centers for Disease Control and Prevention
(CDC) (e.g., Infertility Prevention Project) or block grant funds that are awarded to and
distributed by the state. Report these revenues as “Other revenue” and specify their source(s).
Attachment B - 55
Form Approved
OMB No. 0990-0221
Exp. Date 01/31/2014
BUREAU OF PRIMARY HEALTH CARE (BPHC) – Report the amount of revenue received from BPHC
grants (e.g., Section 330) during the reporting period that supported services provided within the
scope of the grantee’s Title X project.
OTHER REVENUE – Report the amount and specify the source of funds received during the
reporting period from other sources that supported services provided within the scope of the
grantee’s Title X project. This may include revenue from such sources as the CDC (infertility,
STD, or HIV prevention; breast and cervical cancer detection), private grants and donations,
fundraising, interest income, or other sources.
QUESTION ABOUT TABLE 14
1. QUESTION – Is Table 14 different from the previous FPAR?
ANSWER – Yes. OPA has made minor changes to the structure of Table 14. The “Federal Grants”
section has been reduced to one row for reporting revenue from the Title X services grant, and the
three other rows that were previously included under “Federal Grants,” specifically the row for
reporting grants from BPHC and two rows for reporting “Other” federal grants, have been moved
to “Other Revenue.” The “Federal Grants” section has been renamed “Title X Services Grant”
and the row for reporting BPHC grant revenue is now row 11. All rows in Table 14 have been
renumbered to reflect these changes.
2. QUESTION – Can a grantee report an estimate of the monetary value of in-kind donations of goods,
services, or other noncash contributions as revenue in Table 14?
ANSWER – No. In Table 14, revenues include actual cash receipts or drawdown amounts only. Do
not report the monetary value of in-kind contributions as revenue in Table 14.
Title X Family Planning Annual Report
– 47 –
Attachment B - 56
Date Submitted:
Reporting Period:
January 1, 20________through December 31, 20_________
___________________through _______________________
(Month/day/year) (Month/day/year)
Check One:
Initial Submission
Revision
See Notes
Table 14
Revenue Report
Revenue Source
Amount
Title X
1
Title X grant (Section 1001: family planning services)
Payment for Services
2
Total client collections/self-pay
3
Third-party payers
Amount Prepaid
(A)
3a
Medicaid (Title XIX)
3b
Medicare (Title XVIII)
3c
State Children’s Health Insurance Program (SCHIP)
3d
Other public health insurance
3e
Private health insurance
Total – Third-Party Payers
(sum rows 3a to 3e)
Total – Payment for Services
(sum row 2 + cell 4a + cell 4b)
4
5
Other Revenue
6
Title V (MCH Block Grant)
7
Title XX (Social Services Block Grant)
8
Temporary Assistance for Needy Families (TANF)
9
Local government revenue
10
State government revenue
11
Bureau of Primary Health Care (BPHC)
12
Other (Specify:__________________ )
13
Other (Specify:__________________ )
14
Other (Specify:__________________ )
15
Other (Specify:__________________ )
16
Other (Specify:__________________ )
17
18
Total– Other Revenue
(sum rows 6 to 16)
Total Revenue
(sum rows 1 + 5 + 17)
Title X Family Planning Annual Report
– 48 –
Amount
Not Pre-paid
(B)
Attachment B - 57
NOTES
Attachment B - 58
NOTES (CONTINUED)
Attachment B - 59
ABBREVIATIONS AND ACRONYMS
AGC
AIS
ASC
ASC-H
ASC-US
BPHC
CBE
CDC
CFR
CHAMPVA
CIN
FAM
FPAR
FTE
GPRA
HHS
HIV
HMO
HSIL
IUD
LAM
LEP
LPN
LVN
LSIL
MCH
OFP
OMB
OPA
PRA
SCHIP
RPC
STD
TANF
USC
atypical glandular cells
adenocarcinoma in situ
atypical squamous cells
atypical squamous cells, cannot exclude HSIL
atypical squamous cells of undetermined significance
Bureau of Primary Health Care
clinical breast exam
Centers for Disease Control and Prevention
Code of Federal Regulations
Civilian Health and Medical Program of the Department of Veterans Affairs
cervical intraepithelial neoplasia
fertility awareness method
Family Planning Annual Report
full-time equivalent
Government Performance and Results Act
Department of Health and Human Services
human immunodeficiency virus
health maintenance organization
high-grade squamous intraepithelial lesion
intrauterine device
Lactational Amenorrhea Method
limited English proficiency, limited English proficient
licensed practical nurse
licensed vocational nurse
low-grade squamous intraepithelial lesion
maternal and child health
Office of Family Planning
Office of Management and Budget
Office of Population Affairs
Paperwork Reduction Act
State Children's Health Insurance Program
regional program consultant
sexually transmitted disease
Temporary Assistance for Needy Families
United States Code
Attachment B - 60
Form Approved
OMB No. 0990-0221
Exp. Date 01/31/2014
This page intentionally left blank.
Title X Family Planning Annual Report
– 52 –
Attachment B - 61
APPENDIX A:
COLLECTING AND TABULATING MULTI-RACE RESPONSES
Background. On October 24, 1997, the Department of Health and Human Services (HHS) issued a Policy
Statement on Inclusion of Race and Ethnicity in DHHS Data Collection Activities. 12 This policy requires
the inclusion of racial and ethnic categories in HHS-funded and -sponsored data collection and reporting
systems. Implementation of this policy is intended to help to identify major health conditions of minority
populations, monitor progress in meeting their needs, and ensure nondiscrimination in access to and
provision of appropriate HHS services for various racial and ethnic groups. Although programs that are
directed to minority racial or ethnic populations have exemptions, these programs are encouraged to
collect and report data on subgroups within their target populations.
The HHS inclusion policy refers to the Office of Management and Budget (OMB) 1997 Revisions to the
Standards for the Classification of Federal Data on Race and Ethnicity, 13 and any subsequent revisions,
as the standard for racial and ethnic reporting categories in HHS-funded programs. The FPAR race and
ethnicity categories comply with the 1997 OMB revised minimum standards.
Reporting more than one race. According to the 1997 OMB revised standards, the following apply when
respondents are allowed to self-identify with or self-report more than one race:
•
Agencies should adopt a method that allows respondents to mark or select more than one of
the five minimum race categories.
•
The method for respondents to report more than one race should take the form of multiple
responses to a single question and not a single “multiracial” category.
•
When a list of races is provided to respondents, the list should not contain a “multiracial”
category.
•
Based on research conducted so far, two recommended forms for the instruction
accompanying the multiple-response question are “Mark one or more…” and “Select one or
more….”
•
If the criteria for data quality and confidentiality are met, provision should be made to report,
at a minimum, the number of individuals identifying with more than one race. Data producers
are encouraged to provide greater detail about the distribution of multiple responses.
Agencies are encouraged to consult with their Regional Program Consultant (RPC) if they have further
questions about collecting multi-race responses. On the following page is a sample question, designed to
be self-administered, for collecting race data. A list of references on this topic is also included.
12
U.S. Department of Health and Human Services. (October 24, 1997). Policy statement on inclusion of race and
ethnicity in DHHS data collection activities. Retrieved March 1, 2011, from
http://aspe.hhs.gov/datacncl/inclusn.htm
13
Office of Management and Budget. (October 30, 1997). Revisions to the standards for the classification of
federal data on race and ethnicity, Federal Register notice. Retrieved March 1, 2011, from
http://www.whitehouse.gov/omb/fedreg_race-ethnicity
Attachment B - 62
Form Approved
OMB No. 0990-0221
Exp. Date 01/31/2014
What is your race? Select one or more.
American Indian or Alaskan Native: A person having origins in any of the original peoples of North
and South America (including Central America), and who maintains tribal affiliation or community
attachment.
Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan,
the Philippine Islands, Thailand, and Vietnam.
Black or African American: A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Pacific Islander: A person having origins in any of the original peoples of Hawaii,
Guam, Samoa, or other Pacific Islands.
White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
REFERENCES
Office of Management and Budget. (March 9, 2000). Guidance on aggregation and allocation of data on
race for use in civil rights monitoring and enforcement. OMB Bulletin No. 00-02. Retrieved March 1,
2011, from http://www.whitehouse.gov/omb/bulletins/b00-02.html
Office of Management and Budget. (2000). Provisional guidance on the implementation of the 1997
standards for federal data on race and ethnicity. Retrieved March 1, 2011, from
http://www.ofm.wa.gov/pop/race/omb.pdf
Office of Management and Budget. (October 30, 1997). Revisions to the standards for the classification
of federal data on race and ethnicity, Federal Register notice. Retrieved March 1, 2011, from
http://www.whitehouse.gov/omb/fedreg_race-ethnicity
U.S. Census Bureau. (2001). The two or more races population: 2000. Census 2000 Brief No.
C2KBR/01-6. Retrieved March 1, 2011, from http://www.census.gov/prod/2001pubs/c2kbr01-6.pdf
U.S. Department of Health and Human Services. (October 24, 1997). Policy statement on inclusion of
race and ethnicity in DHHS data collection activities. Retrieved March 1, 2011, from
http://aspe.hhs.gov/datacncl/inclusn.htm
Title X Family Planning Annual Report
– A-2 –
| File Type | application/pdf |
| File Title | Microsoft Word - Attachment Title Pages_9-30.doc |
| Author | cfowler |
| File Modified | 2013-08-15 |
| File Created | 2010-09-29 |