Form Annual Quarterly B Annual Quarterly B Annual Quarterly Benchmark Data Collection Forms

Attachment F: IECMHC Annual and Quarterly Benchmark Data Collection Forms

OMB

No. 0930-0xxx

Expiration Date:  xx/xx/xx

  

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0930-0xxx.  Public reporting burden for this collection of information is estimated to average 360 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.

IECMHC ANNUAL BENCHMARK DATA COLLECTION FORM

This form is designed to collect data from the 12-15 States/Tribes that are working with the SAMHSA-sponsored National Center of Excellence (CoE) to pilot the Early Childhood Mental Health Consultation (IECMHC) initiative. Questions focus on the progress of the implementation as well as key benchmark information, including establishment of training standards, development of sustainable financing, and progress toward reducing expulsion rates in childcare and pre-school programs. The purpose of this data collection is to monitor the reach, implementation, and impact of the Center of Excellence for IECMHC’s multiple efforts, learn which practices work for which populations, and gauge overall applicability and utility of the IECMHC Toolkit to infant and early childhood mental health consultation.

Mentors: You will need to work with your state or tribal representative(s) annually to update this State- or Tribe-level data for the IECMHC Toolkit. Some of this data can be compiled from your quarterly reports. You can correspond by phone or, in cases where your representative(s) are especially engaged with the Center of Excellence, you can forward this form directly to them and ask them to complete it.

To meet the project’s year-end reporting requirement to SAMHSA, it is important that you supply this information by <date>.

1. In the past year, did your State or Tribe identify a dedicated lead for the IECMHC pilot project?

<Yes, No>

If YES, please provide that person’s contact information:

<Name> <Title> <Agency/Organization> <email address> <Telephone Number>

IF NO, what was the main reason a lead was not designated—or, if a lead was designated, why didn’t they work on the project?

<box for open-ended responses>

2. Did you develop and/or distribute marketing materials for IECMHC with the aim of increasing utilization of IECMHC services?

<Yes, No>

IF YES, please briefly describe the content and format (e.g., paper, online) of the marketing materials you developed over the past year. How many of each type (e.g., brochures, email blasts, newsletters, tweets, Facebook posts) were distributed? How often were they distributed? To what agencies and/or organizations were they distributed?

<box for open-ended responses>

IF NO, why didn’t you develop and/or distribute marketing materials? Do you plan to develop and distribute them in the future?

<box for open-ended responses>

3. Did your State or Tribe establish or adopt standards (e.g., core competencies, credentials) for the training of IECMHC consultants?

<Yes, No>

IF YES, please briefly describe what standards were adopted. How many consultants passed these standards in the past year? FOR OPTION YEARS 2 AND 3: How does this number differ from that of previous project year(s)? Why does it differ?

<box for open-ended responses>

IF NO, why didn’t you establish or adopt any training standards? Do you intend to establish or adopt such standards in the future? What efforts will support you in adopting such standards either fully or in part?

<box for open-ended responses>

4. Did your State or Tribe develop a formal evaluation of the impact of IECMHC on provider practices and child and/or parent outcomes?

<Yes, No>

IF YES, please briefly describe your evaluation and its findings related to the program’s impact on your population of interest.

<box for open-ended responses>

IF NO, why didn’t you develop such an evaluation? Do you intend to develop this evaluation in the future?

<box for open-ended responses>

5. Has your State or Tribe developed sustainable financing, business, and/or payment models for the continuation of IECMHC in its communities?

<Yes, No>

IF YES, please briefly describe the source and amount of this financing. How was it established? How did you work with stakeholders to secure this funding? What barriers did you encounter? How did you address them?

<box for open-ended responses>

IF NO, why didn’t you develop any financing for IECMHC? Please describe any finance-related activities your state or tribe has initiated.

<box for open-ended responses>

6. Did your State or Tribe receive MIECHV (Maternal Infant and Early Childhood Home Visiting) funding in the last year?

<Yes, No>

IF NO, skip the benchmark questions, and proceed to #7.

IF YES, how did your state perform on the following 3 MIECHV benchmark performance measures:

A. [MIECHV Measure 3] Benchmark Area: Maternal and Newborn Health.

Construct: Depression Screening:

Percent of primary caregivers enrolled in home visiting who are screened for depression using a validated tool within 3 months of enrollment (for those not enrolled prenatally) or within 3 months of delivery (for those enrolled prenatally)

Did your performance on this benchmark meet or exceed the standard?

<Yes, No>

B. [MIECHV Measure 12] Benchmark Area: School Readiness and Achievement.

Construct: Developmental Screening

Percent of children enrolled in home visiting with a timely screen for developmental delays using a validated parent-completed tool

Did your performance on this benchmark meet or exceed the standard?

<Yes, No>

C. [MIECHV Measure 13] Benchmark Area: School Readiness and Achievement.

Construct: Behavioral Concerns

Percent of home visits where primary caregivers were asked if they have any concerns regarding their child’s development, behavior, or learning

Did your performance on this benchmark meet or exceed the standard?

<Yes, No>

D. [MIECHV Measure 19] Benchmark Area: Coordination and Referrals for Other Community Resources and Supports

Construct: Completed Developmental Referrals

Percent of children enrolled in home visiting with positive screens for developmental delays (measured using a validated tool) who receive services in a timely manner

Did your performance on this benchmark meet or exceed the standard?

<Yes, No>

How were data collected? How does this outcome compare with that of the previous year? What are possible reasons for any differences?

7. As a result of technical assistance provided by the Center of Excellence…

A. How many MIECHV program models (e.g., Early Head Start, Healthy Families America, Head Start, Parents as Teachers) are implementing IECMHC?

<insert number>

B. How many pre-K programs in your state or tribe of the following types are implementing IECMHC…

State-funded programs? <insert number>

Federally-funded programs? <insert number>

Privately-funded programs? <insert number>

C. How many childcare programs in your State or Tribe of the following types are implementing IECMHC…

State-funded programs? <insert number>

Federally-funded programs? <insert number>

Privately-funded programs? <insert number>

8. Has your State or Tribe implemented a system to collect data on the number of children who were expelled from any childcare program?

<Yes, No>

If YES, how many children were expelled from childcare programs in your State or Tribe over the past year?

<insert number>

If data are available, how many children were expelled from the following types of programs…

State-funded programs? <insert number>

Federally-funded programs? <insert number>

Privately-funded programs? <insert number>

How does this number of expelled children compare with that of last year?

IF NO, why is your state or tribe not collecting expulsion data? Please describe any data-collection activities your state or tribe has initiated.

<box for open-ended responses>

9. Has your State or Tribe implemented a system to collect data on the number of children who were expelled from any pre-K program?

<Yes, No>

If YES, how many children were expelled from pre-K programs in your State or Tribe over the past year?

<insert number>

If data are available, how many children were expelled from the following types of programs…

State-funded programs? <insert number>

Federally-funded programs? <insert number>

Privately-funded programs? <insert number>

How does this number of expelled children compare with that of last year?

IF NO, why is your state or tribe not collecting expulsion data? Please describe any data-collection activities your state or tribe has initiated.

<box for open-ended responses>

IECMHC QUARTERLY DATA COLLECTION FORM

This form is designed to collect data from the 12-15 States/Tribes that are working with the SAMHSA-sponsored National Center of Excellence (CoE) to pilot the Early Childhood Mental Health Consultation (IECMHC) initiative. Questions focus on progress achieved during the previous quarter, including development of marketing materials, establishment of training standards, and delivery of training and technical assistance to program providers. The purpose of this data collection is to gauge the State/Tribe’s interim progress toward project milestones and identify gaps and emerging needs, which will inform ongoing training and technical assistance efforts.

Mentors: You will need to work with your state or tribal representative(s) quarterly to update this State- or Tribe-level data for the IECMHC Toolkit. You can correspond by phone or, in cases where your representative(s) are especially engaged with the Center of Excellence, you can forward this form directly to them and ask them to complete it.

To meet the project’s reporting requirement to SAMHSA, it is important that you supply this information by <date>.

1. Does your State or Tribe have a dedicated lead for IECMHC?

<Yes, No>

If YES, please provide that person’s contact information:

<Name> <Title> <Agency/Organization> <email address> <Telephone Number>

IF NO, what was the main reason a lead has not been designated—or, if a lead was designated, why didn’t they work on the project?

<box for open-ended responses>

Has this lead changed in the past quarter?

<Yes, No>

2. In the past quarter, did you develop and/or distribute marketing materials for IECMHC with the aim of increasing utilization of IECMHC services?

<Yes, No>

IF YES, please briefly describe the content and format (e.g., paper, online) of the marketing materials you developed over the past quarter. How many of each type (e.g., brochures, email blasts, newsletters, tweets, Facebook posts) were distributed? How often were they distributed? To what agencies and/or organizations were they distributed?

<box for open-ended responses>

IF NO, why didn’t you develop and/or distribute marketing materials in the past quarter? Do you plan to develop and distribute them in the near future?

<box for open-ended responses>

3. How many providers in the following types of early care and education programs have received CoE-sponsored training and/or technical assistance?

State-funded programs? <insert number>

Federally-funded programs? <insert number>

Privately-funded programs? <insert number>

4. Has your State or Tribe established or adopted standards (e.g., core competencies, credentials) for the training of IECMHC consultants?

<Yes, No>

IF YES, please briefly describe what standards were adopted. How many consultants passed these standards in the past quarter?

<box for open-ended responses>

IF NO, why didn’t you establish or adopt any training standards? Do you intend to establish or adopt such standards in the near future? What efforts will support you in adopting such standards either fully or in part?

<box for open-ended responses>