1 2020 UDS Tables REDLINE

Reporting Tables for 2020 Health Center Data

• roject supported under the CHC (330(e)) program.

The EHBs reporting system will automatically identify all the required reports needed to complete the UDS reporting requirements. Please contact the Health Center Program Support line at 877-464-4772 if there appear to be errors.

The Universal Report is an unduplicated count of all patients served by the health center regardless of funding source; the Grant Report is a subset of patients reported on the Universal Report served under a special population funding authority. Thus, no cell in a Grant Report may have a number larger than the same cell in the Universal Report.

Report all the data for any patient who receives services under sections 330(g), (h), or (i) in the proper Grant Report. Include services provided to these patients, regardless of the funding source. For example, if patients experiencing homelessness receive medical services in the homeless medical van and all dental services at the clinic, their dental services and diagnoses would be reported on the Homeless Grant Report Tables 5 and 6A regardless of the dental funding source.

In summary, health centers that receive funds under only one BPHC funding authority complete the Universal Report and no Grant Reports. Health centers funded through multiple BPHC funding authorities complete a Universal Report for the combined projects and a separate Grant Report for activity covered by their MHC, HCH, and/or PHPC program grant(s).

Examples include the following:

• A CHC awardee (section 330(e)) that also has HCH funding (section 330(h)) completes a Universal Report for all in-scope activity and a Grant Report for activity under the HCH program but does not complete a Grant Report for the CHC funding.

• A CHC awardee (section 330(e)) that also has MHC (section 330(g)) and HCH (section 330(h)) funding completes a Universal Report, a Grant Report for the HCH program, and a Grant Report for the MHC program.

• An HCH awardee (section 330(h)) that also receives PHPC (section 330(i)) funding completes a Universal Report and two Grant Reports—one for the HCH program and one for the PHPC program.

• An HCH awardee (section 330(h)) that receives no other Health Center Program funding will file a Universal Report and will not file a Grant Report.

Table: Patients by ZIP Code

Reporting Period: January 1, 2020, through December 31, 2020

ZIP Code (a)	None/ Uninsured (b)	Medicaid/ CHIP/Other Public (c)	Medicare (d)	Private (e)	Total Patients (f)
[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]
[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]
Other ZIP Codes	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]
Unknown Residence	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]
Total	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]	[Blank for demonstration]

Note: This is a representation of the form. The actual online output from the EHBs will display ZIP codes entered by the health center in Column A.

Table 3A: Patients by Age and by Sex Assigned at Birth

Reporting Period: January 1, 2020, through December 31, 2020

Line	Age Groups	Male Patients (a)	Female Patients (b)
1	Under age 1	<blank for demonstration>	<blank for demonstration>
2	Age 1	<blank for demonstration>	<blank for demonstration>
3	Age 2	<blank for demonstration>	<blank for demonstration>
4	Age 3	<blank for demonstration>	<blank for demonstration>
5	Age 4	<blank for demonstration>	<blank for demonstration>
6	Age 5	<blank for demonstration>	<blank for demonstration>
7	Age 6	<blank for demonstration>	<blank for demonstration>
8	Age 7	<blank for demonstration>	<blank for demonstration>
9	Age 8	<blank for demonstration>	<blank for demonstration>
10	Age 9	<blank for demonstration>	<blank for demonstration>
11	Age 10	<blank for demonstration>	<blank for demonstration>
12	Age 11	<blank for demonstration>	<blank for demonstration>
13	Age 12	<blank for demonstration>	<blank for demonstration>
14	Age 13	<blank for demonstration>	<blank for demonstration>
15	Age 14	<blank for demonstration>	<blank for demonstration>
16	Age 15	<blank for demonstration>	<blank for demonstration>
17	Age 16	<blank for demonstration>	<blank for demonstration>
18	Age 17	<blank for demonstration>	<blank for demonstration>
19	Age 18	<blank for demonstration>	<blank for demonstration>
20	Age 19	<blank for demonstration>	<blank for demonstration>
21	Age 20	<blank for demonstration>	<blank for demonstration>
22	Age 21	<blank for demonstration>	<blank for demonstration>
23	Age 22	<blank for demonstration>	<blank for demonstration>
24	Age 23	<blank for demonstration>	<blank for demonstration>
25	Age 24	<blank for demonstration>	<blank for demonstration>
26	Ages 25–29	<blank for demonstration>	<blank for demonstration>
27	Ages 30–34	<blank for demonstration>	<blank for demonstration>
28	Ages 35–39	<blank for demonstration>	<blank for demonstration>
29	Ages 40–44	<blank for demonstration>	<blank for demonstration>
30	Ages 45–49	<blank for demonstration>	<blank for demonstration>
31	Ages 50–54	<blank for demonstration>	<blank for demonstration>
32	Ages 55–59	<blank for demonstration>	<blank for demonstration>
33	Ages 60–64	<blank for demonstration>	<blank for demonstration>
34	Ages 65–69	<blank for demonstration>	<blank for demonstration>
35	Ages 70–74	<blank for demonstration>	<blank for demonstration>
36	Ages 75–79	<blank for demonstration>	<blank for demonstration>
37	Ages 80–84	<blank for demonstration>	<blank for demonstration>
38	Age 85 and over	<blank for demonstration>	<blank for demonstration>
39	Total Patients (Sum of Lines 1-38)	<blank for demonstration>	<blank for demonstration>

Table 3B: Demographic Characteristics

Reporting Period: January 1, 2020, through December 31, 2020

Patients by Race and Hispanic or Latino/a Ethnicity

Line	Patients by Race	Hispanic or Latino/a (a)	Non-Hispanic or Latino/a (b)	Unreported/Refused to Report Ethnicity (c)	Total (d) (Sum Columns a+b+c)
1	Asian	<blank for demonstration>	<blank for demonstration>	<cell not reported>	<blank for demonstration>
2a	Native Hawaiian	<blank for demonstration>	<blank for demonstration>	<cell not reported>	<blank for demonstration>
2b	Other Pacific Islander	<blank for demonstration>	<blank for demonstration>	<cell not reported>	<blank for demonstration>
2	Total Native Hawaiian/Other Pacific Islander (Sum Lines 2a + 2b)	<blank for demonstration>	<blank for demonstration>	<cell not reported>	<blank for demonstration>
3	Black/African American	<blank for demonstration>	<blank for demonstration>	<cell not reported>	<blank for demonstration>
4	American Indian/Alaska Native	<blank for demonstration>	<blank for demonstration>	<cell not reported>	<blank for demonstration>
5	White	<blank for demonstration>	<blank for demonstration>	<cell not reported>	<blank for demonstration>
6	More than one race	<blank for demonstration>	<blank for demonstration>	<cell not reported>	<blank for demonstration>
7	Unreported/Refused to report race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
8	Total Patients (Sum of Lines 1 + 2 + 3 to 7)	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>

Line	Patients Best Served in a Language Other than English	Number (a)
12	Patients Best Served in a Language Other than English	<blank for demonstration>

Line	Patients by Sexual Orientation	Number (a)	divider	Line	Patients by Gender Identity	Number (a)
13	Lesbian or Gay	<blank >	divider	20	Male	<blank>
14	Heterosexual (or straight)	<blank >	divider	21	Female	<blank >
15	Bisexual	<blank >	divider	22	Transgender Man/Transgender Male	<blank >
16	Something else	<blank >	divider	23	Transgender Woman/Transgender Female	<blank >
17	Don’t know	<blank >	divider	24	Other	<blank >
18	Chose not to disclose	<blank n>	divider	25	Chose not to disclose	<blank >
18a	Unknown			25a	Unknown
19	Total Patients (Sum of Lines 13 to 18a)	<blank >	divider	26	Total Patients (Sum of Lines 20 to 25a)	<blank>

Table 4: Selected Patient Characteristics

Reporting Period: January 1, 2020, through December 31, 2020

Line	Income as Percent of Poverty Guideline	Number of Patients (a)
1	100% and below	<blank for demonstration>
2	101–150%	<blank for demonstration>
3	151–200%	<blank for demonstration>
4	Over 200%	<blank for demonstration>
5	Unknown	<blank for demonstration>
6	TOTAL (Sum of Lines 1–5)	<blank for demonstration>

Line	Principal Third-Party Medical Insurance	0-17 years old (a)	18 and older (b)
7	None/Uninsured	<blank for demonstration>	<blank for demonstration>
8a	Medicaid (Title XIX)	<blank for demonstration>	<blank for demonstration>
8b	CHIP Medicaid	<blank for demonstration>	<blank for demonstration>
8	Total Medicaid (Line 8a + 8b)	<blank for demonstration>	<blank for demonstration>
9a	Dually Eligible (Medicare and Medicaid)	<blank for demonstration>	<blank for demonstration>
9	Medicare (Inclusive of dually eligible and other Title XVIII beneficiaries)	<blank for demonstration>	<blank for demonstration>
10a	Other Public Insurance (Non-CHIP) (specify___)	<blank for demonstration>	<blank for demonstration>
10b	Other Public Insurance CHIP	<blank for demonstration>	<blank for demonstration>
10	Total Public Insurance (Line 10a + 10b)	<blank for demonstration>	<blank for demonstration>
11	Private Insurance	<blank for demonstration>	<blank for demonstration>
12	TOTAL (Sum of Lines 7 + 8 + 9 +10 +11)	<blank for demonstration>	<blank for demonstration>

Line	Managed Care Utilization	Medicaid (a)	Medicare (b)	Other Public Including Non-Medicaid CHIP (c)	Private (d)	TOTAL (e)
13a	Capitated Member Months	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
13b	Fee-for-service Member Months	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
13c	Total Member Months (Sum of Lines 13a + 13b)	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>

Table 4: Selected Patient Characteristics (continued)

Reporting Period: January 1, 2020, through December 31, 2020

Line	Special Populations	Number of Patients (a)
14	Migratory (330g awardees only)	<blank for demonstration>
15	Seasonal (330g awardees only)	<blank for demonstration>
16	Total Agricultural Workers or Dependents (All health centers report this line)	<blank for demonstration>
17	Homeless Shelter (330h awardees only)	<blank for demonstration>
18	Transitional (330h awardees only)	<blank for demonstration>
19	Doubling Up (330h awardees only)	<blank for demonstration>
20	Street (330h awardees only)	<blank for demonstration>
21a	Permanent Supportive Housing (330h awardees only)
21	Other (330h awardees only)	<blank for demonstration>
22	Unknown (330h awardees only)	<blank for demonstration>
23	Total Homeless (All health centers report this line)	<blank for demonstration>
24	Total School-Based Health Center Patients (All health centers report this line)	<blank for demonstration>
25	Total Veterans (All health centers report this line)	<blank for demonstration>
26	Total Patients Served at a Health Center Located In or Immediately Accessible to a Public Housing Site (All health centers report this line)	<blank for demonstration>

Table 5: Staffing and Utilization

Reporting Period: January 1, 2020, through December 31, 2020

Line	Personnel by Major Service Category	FTEs (a)	Clinic Visits (b)	Virtual Visits (b2)	Patients (c)
1	Family Physicians	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
2	General Practitioners	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
3	Internists	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
4	Obstetrician/Gynecologists	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
5	Pediatricians	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
7	Other Specialty Physicians	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
8	Total Physicians (Lines 1–7)	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
9a	Nurse Practitioners	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
9b	Physician Assistants	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
10	Certified Nurse Midwives	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
10a	Total NPs, PAs, and CNMs (Lines 9a–10)	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
11	Nurses	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
12	Other Medical Personnel	<blank for demonstration>	<cell not reported>	<cell not reported>	<cell not reported>
13	Laboratory Personnel	<blank for demonstration>	<cell not reported>	<cell not reported>	<cell not reported>
14	X-ray Personnel	<blank for demonstration>	<cell not reported>	<cell not reported>	<cell not reported>
15	Total Medical Care Services (Lines 8 + 10a through 14)	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
16	Dentists	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
17	Dental Hygienists	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
17a	Dental Therapists	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
18	Other Dental Personnel	<blank for demonstration>	<cell not reported>	<cell not reported>	<cell not reported>
19	Total Dental Services (Lines 16–18)	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
20a	Psychiatrists	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
20a1	Licensed Clinical Psychologists	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
20a2	Licensed Clinical Social Workers	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
20b	Other Licensed Mental Health Providers	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
20c	Other Mental Health Staff	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
20	Total Mental Health Services (Lines 20a–c)	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
21	Substance Use Disorder Services	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
22	Other Professional Services (specify___)	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>

Table 5: Staffing and Utilization (continued)

Reporting Period: January 1, 2020, through December 31, 2020

Line	Personnel by Major Service Category	FTEs (a)	Clinic Visits (b)	Virtual Visits (b2)	Patients (c)
22a	Ophthalmologists	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
22b	Optometrists	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
22c	Other Vision Care Staff	<blank for demonstration>	<cell not reported>	<cell not reported>	<cell not reported>
22d	Total Vision Services (Lines 22a–c)	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
23	Pharmacy Personnel	<blank for demonstration>	<cell not reported>	<cell not reported>	<cell not reported>
24	Case Managers	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
25	Patient and Community Education Specialists	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>
26	Outreach Workers	<blank for demonstration>	<cell not reported>	<cell not reported>	<cell not reported>
27	Transportation Staff	<blank for demonstration>	<cell not reported>	<cell not reported>	<cell not reported>
27a	Eligibility Assistance Workers	<blank for demonstration>	<cell not reported>	<cell not reported>	<cell not reported>
27b	Interpretation Staff	<blank for demonstration>	<cell not reported>	<cell not reported>	<cell not reported>
27c	Community Health Workers	<blank for demonstration>	<cell not reported>	<cell not reported>	<cell not reported>
28	Other Enabling Services (specify___)	<blank for demonstration>	<cell not reported>	<cell not reported>	<cell not reported>
29	Total Enabling Services (Lines 24–28)	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
29a	Other Programs and Services (specify___)	<blank for demonstration>	<cell not reported>	<cell not reported>	<cell not reported>
29b	Quality Improvement Staff	<blank for demonstration>	<cell not reported>	<cell not reported>	<cell not reported>
30a	Management and Support Staff	<blank for demonstration>	<cell not reported>	<cell not reported>	<cell not reported>
30b	Fiscal and Billing Staff	<blank for demonstration>	<cell not reported>	<cell not reported>	<cell not reported>
30c	IT Staff	<blank for demonstration>	<cell not reported>	<cell not reported>	<cell not reported>
31	Facility Staff	<blank for demonstration>	<cell not reported>	<cell not reported>	<cell not reported>
32	Patient Support Staff	<blank for demonstration>	<cell not reported>	<cell not reported>	<cell not reported>
33	Total Facility and Non-Clinical Support Staff (Lines 30a–32)	<blank for demonstration>	<cell not reported>	<cell not reported>	<cell not reported>
34	Grand Total (Lines 15+19+20+21+22+22d+23+29+29a+29b+33)	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<cell not reported>

Table 5: Selected Service Detail Addendum

Reporting Period: January 1, 2020, through December 31, 2020

Line	Personnel by Major Service Category: Mental Health Service Detail	Personnel (a1)	Clinic Visits (b)	Virtual Visits (b2)	Patients (c)
20a01	Physicians (other than Psychiatrists)	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
20a02	Nurse Practitioners	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
20a03	Physician Assistants	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
20a04	Certified Nurse Midwives	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
Line	Personnel by Major Service Category: Substance Use Disorder Detail	Personnel (a1)	Clinic Visits (b)	Virtual Visits (b2)	Patients (c)
21a	Physicians (other than Psychiatrists)	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
21b	Nurse Practitioners (Medical)	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
21c	Physician Assistants	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
21d	Certified Nurse Midwives	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
21e	Psychiatrists	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
21f	Licensed Clinical Psychologists	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
21g	Licensed Clinical Social Workers	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
21h	Other Licensed Mental Health Providers	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>

Table 6A: Selected Diagnoses and Services Rendered

Reporting Period: January 1, 2020, through December 31, 2020

Selected Diagnoses

Line	Diagnostic Category	Applicable ICD-10-CM Code	Number of Visits by Diagnosis Regardless of Primacy (a)	Number of Patients with Diagnosis (b)
Selected Infectious and Parasitic Disease	Selected Infectious and Parasitic Diseases	Selected Infectious and Parasitic Diseases	Selected Infectious and Parasitic Diseases	Selected Infectious and Parasitic Diseases
1-2	Symptomatic/Asymptomatic human immunodeficiency virus (HIV)	B20, B97.35, O98.7-, Z21	<blank for demonstration>	<blank for demonstration>
3	Tuberculosis	A15- through A19-, O98.0-	<blank for demonstration>	<blank for demonstration>
4	Sexually transmitted infections	A50- through A64-	<blank for demonstration>	<blank for demonstration>
4a	Hepatitis B	B16.0 through B16.2, B16.9, B17.0, B18.0, B18.1, B19.1-, O98.4-	<blank for demonstration>	<blank for demonstration>
4b	Hepatitis C	B17.1-, B18.2, B19.2-	<blank for demonstration>	<blank for demonstration>
4c	Novel coronavirus (SARS-CoV-2) disease	U07.1	<blank for demonstration>	<blank for demonstration>
Selected Diseases of the Respiratory System	Selected Diseases of the Respiratory System	Selected Diseases of the Respiratory System	Selected Diseases of the Respiratory System	Selected Diseases of the Respiratory System
5	Asthma	J45-	<blank for demonstration>	<blank for demonstration>
6	Chronic lower respiratory diseases	J40 (count only when code U07.1 is not present), J41- through J44-, J47-	<blank for demonstration>	<blank for demonstration>
6a	Acute respiratory illness due to novel coronavirus (SARS-CoV-2) disease	J12.89, J20.8, J40, J22, J98.8, J80 (count only when code U07.1 is present)	<blank for demonstration>	<blank for demonstration>
Selected Other Medical Conditions	Selected Other Medical Conditions	Selected Other Medical Conditions	Selected Other Medical Conditions	Selected Other Medical Conditions
7	Abnormal breast findings, female	C50.01-, C50.11-, C50.21-, C50.31-, C50.41-, C50.51-, C50.61-, C50.81-, C50.91-, C79.81, D05-, D48.6-, D49.3, N60-, N63-, R92-	<blank for demonstration>	<blank for demonstration>
8	Abnormal cervical findings	C53-, C79.82, D06-, R87.61-, R87.629, R87.810, R87.820	<blank for demonstration>	<blank for demonstration>
9	Diabetes mellitus	E08- through E13-, O24- (exclude O24.41-)	<blank for demonstration>	<blank for demonstration>
10	Heart disease (selected)	I01-, I02- (exclude I02.9), I20- through I25-, I27-, I28-, I30- through I52-	<blank for demonstration>	<blank for demonstration>
11	Hypertension	I10- through I16-, O10-, O11-	<blank for demonstration>	<blank for demonstration>
12	Contact dermatitis and other eczema	L23- through L25-, L30- (exclude L30.1, L30.3, L30.4, L30.5), L58-	<blank for demonstration>	<blank for demonstration>
13	Dehydration	E86-	<blank for demonstration>	<blank for demonstration>
14	Exposure to heat or cold	T33-, T34-, T67-, T68-, T69-, W92-, W93-	<blank for demonstration>	<blank for demonstration>
14a	Overweight and obesity	E66-, Z68- (exclude Z68.1, Z68.20 through Z68.24, Z68.51, Z68.52)	<blank for demonstration>	<blank for demonstration>
Selected Childhood Conditions (limited to ages 0 thru 17)	Selected Childhood Conditions (limited to ages 0 through 17)	Selected Childhood Conditions (limited to ages 0 thru 17)	Selected Childhood Conditions (limited to ages 0 thru 17)	Selected Childhood Conditions (limited to ages 0 thru 17)
15	Otitis media and Eustachian tube disorders	H65- through H69-	<blank for demonstration>	<blank for demonstration>
16	Selected perinatal/neonatal medical conditions	A33-, P19-, P22- through P29- (exclude P29.3), P35- through P96- (exclude P54-, P91.6-, P92-, P96.81), R78.81, R78.89	<blank for demonstration>	<blank for demonstration>
17	Lack of expected normal physiological development (such as delayed milestone, failure to gain weight, failure to thrive); nutritional deficiencies in children only. Does not include sexual or mental development.	E40- through E46-, E50- through E63-, P92-, R62- (exclude R62.7), R63.3	<blank for demonstration>	<blank for demonstration>
Selected Mental Health and Substance Abuse Conditions	Selected Mental Health Conditions, Substance Use Disorders, and Exploitations	Selected Mental Health and Substance use Conditions	Selected Mental Health and Substance use Conditions	Selected Mental Health and Substance use Conditions
18	Alcohol-related disorders	F10-, G62.1, O99.31-	<blank for demonstration>	<blank for demonstration>
19	Other substance-related disorders (excluding tobacco use disorders)	F11- through F19- (exclude F17-), G62.0, O99.32-	<blank for demonstration>	<blank for demonstration>
19a	Tobacco use disorder	F17-, O99.33-	<blank for demonstration>	<blank for demonstration>
20a	Depression and other mood disorders	F30- through F39-	<blank for demonstration>	<blank for demonstration>
20b	Anxiety disorders, including post-traumatic stress disorder (PTSD)	F06.4, F40- through F42-, F43.0, F43.1-, F93.0	<blank for demonstration>	<blank for demonstration>
20c	Attention deficit and disruptive behavior disorders	F90- through F91-	<blank for demonstration>	<blank for demonstration>
20d	Other mental disorders, excluding drug or alcohol dependence	F01- through F09- (exclude F06.4), F20- through F29-, F43- through F48- (exclude F43.0- and F43.1-), F50- through F99- (exclude F55-, F84.2, F90-, F91-, F93.0, F98-), O99.34-, R45.1, R45.2, R45.5, R45.6, R45.7, R45.81, R45.82, R48.0	<blank for demonstration>	<blank for demonstration>
20e	Human trafficking	T74.5- through T74.6-, T76.5- through T76.6-, Z04.8-, Z62.813, Z91.42	<blank for demonstration>	<blank for demonstration>
20f	Intimate partner violence	T74.11, T74.21, T74.31, Z69.11, Y07.0	<blank for demonstration>	<blank for demonstration>

Selected Services Rendered

Line	Service Category	Applicable ICD-10-CM, CPT-4/II, or HCPCS Code	Number of Visits (a)	Number of Patients (b)
Selected Diagnostic Tests/Screening/Preventive Services	Selected Diagnostic Tests/ Screening/Preventive Services	Selected Diagnostic Tests/Screening/Preventive Services	Selected Diagnostic Tests/Screening/Preventive Services	Selected Diagnostic Tests/Screening/Preventive Services
21	HIV test	CPT-4: 86689, 86701 through 86703, 87389 through 87391, 87534 through 87539, 87806	<blank for demonstration>	<blank for demonstration>
21a	Hepatitis B test	CPT-4: 86704 through 86707, 87340, 87341, 87350	<blank for demonstration>	<blank for demonstration>
21b	Hepatitis C test	CPT-4: 86803, 86804, 87520 through 87522	<blank for demonstration>	<blank for demonstration>
21c	Novel coronavirus (SARS-CoV-2) diagnostic test	CPT-4: 87635, 87426 HCPCS: U0001, U0002, U0003, U0004 CPT PLA: 0202U, 0223U, 0225U	<blank for demonstration>	<blank for demonstration>
21d	Novel coronavirus (SARS-CoV-2) antibody test	CPT-4: 86328, 86769, 86408, 86409 : 0CPT PLA224U, 0226U	<blank for demonstration>	<blank for demonstration>
21e	Pre-Exposure Prophylaxis (PrEP)-associated management of all PrEP patients	CPT-4: 99401-99404 ICD-10: Z11.3, Z11.4, Z20.2, Z20.6, Z51.81, Z71.51, Z71.7, Z79.899 Limit to emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) or emtricitabine/tenofovir alafenamide (FTC/TAF) for PrEP	<blank for demonstration>	<blank for demonstration>
22	Mammogram	CPT-4: 77065, 77066, 77067 ICD-10: Z12.31	<blank for demonstration>	<blank for demonstration>
23	Pap test	CPT-4: 88141 through 88153, 88155, 88164 through 88167, 88174, 88175 ICD-10: Z01.41-, Z01.42, Z12.4 (exclude Z01.411 and Z01.419)	<blank for demonstration>	<blank for demonstration>
24	Selected immunizations: hepatitis A; haemophilus influenzae B (HiB); pneumococcal, diphtheria, tetanus, pertussis (DTaP) (DTP) (DT); measles, mumps, rubella (MMR); poliovirus; varicella; hepatitis B	CPT-4: 90632, 90633, 90634, 90636, 90643, 90644, 90645, 90646, 90647, 90648, 90669, 90670, 90696, 90697, 90698, 90700, 90701, 90702, 90703, 90704, 90705, 90706, 90707, 90708, 90710, 90712, 90713, 90714, 90715, 90716, 90718, 90720, 90721, 90723, 90730, 90731, 90732, 90740, 90743, 90744, 90745, 90746, 90747, 90748	<blank for demonstration>	<blank for demonstration>
24a	Seasonal flu vaccine	CPT-4: 90630, 90653 through 90657, 90658, 90661, 90662, 90672, 90673, 90674, 90682, 90685 through 90689, 90756	<blank for demonstration>	<blank for demonstration>
25	Contraceptive management	ICD-10: Z30-	<blank for demonstration>	<blank for demonstration>
26	Health supervision of infant or child (ages 0 through 11)	CPT-4: 99381 through 99383, 99391 through 99393 ICD-10: Z00.1-	<blank for demonstration>	<blank for demonstration>
26a	Childhood lead test screening (9 to 72 months)	ICD-10: Z13.88 CPT-4: 83655	<blank for demonstration>	<blank for demonstration>
26b	Screening, Brief Intervention, and Referral to Treatment (SBIRT)	CPT-4: 99408, 99409 HCPCS: G0396, G0397, G0443, H0050	<blank for demonstration>	<blank for demonstration>
26c	Smoke and tobacco use cessation counseling	CPT-4:  99406, 99407 HCPCS: S9075 CPT-II: 4000F, 4001F, 4004F	<blank for demonstration>	<blank for demonstration>
26d	Comprehensive and intermediate eye exams	CPT-4: 92002, 92004, 92012, 92014	<blank for demonstration>	<blank for demonstration>

Line	Service Category	Applicable ADA Code	Number of Visits (a)	Number of Patients (b)
Selected Dental Services	Selected Dental Services	Selected Dental Services	Selected Dental Services	Selected Dental Services
27	Emergency services	CDT: D0140, D9110	<blank for demonstration>	<blank for demonstration>
28	Oral exams	CDT: D0120, DO145, D0150, D0160, D0170, D0171, D0180	<blank for demonstration>	<blank for demonstration>
29	Prophylaxis—adult or child	CDT: D1110, D1120	<blank for demonstration>	<blank for demonstration>
30	Sealants	CDT: D1351	<blank for demonstration>	<blank for demonstration>
31	Fluoride treatment—adult or child	CDT: D1206, D1208 CPT-4: 99188	<blank for demonstration>	<blank for demonstration>
32	Restorative services	CDT: D21xx through D29xx	<blank for demonstration>	<blank for demonstration>
33	Oral surgery (extractions and other surgical procedures)	CDT: D7xxx	<blank for demonstration>	<blank for demonstration>
34	Rehabilitative services (Endo, Perio, Prostho, Ortho)	CDT: D3xxx, D4xxx, D5xxx, D6xxx, D8xxx	<blank for demonstration>	<blank for demonstration>

Sources of Codes

• ICD-10-CM (2020)–National Center for Health Statistics (NCHS)

• CPT (2020)–American Medical Association (AMA)

• Code on Dental Procedures and Nomenclature CDT Code (2020)–Dental Procedure Codes. American Dental Association (ADA)

Note: “X” in a code denotes any number, including the absence of a number in that place. Dashes (-) in a code indicate that additional characters are required. ICD-10-CM codes all have at least four digits. These codes are not intended to reflect whether or not a code is billable. Instead, they are used to point out that other codes in the series are to be considered.

Table 6B: Quality of Care Measures

Reporting Period: January 1, 2020, through December 31, 2020

0	Prenatal Care Provided by Referral Only (Check if Yes)	[blank for demonstration]

Section A—Age Categories for Prenatal Care Patients:

Demographic Characteristics of Prenatal Care Patients

Line	Age	Number of Patients (a)
1	Less than 15 years	[blank for demonstration]
2	Ages 15-19	[blank for demonstration]
3	Ages 20-24	[blank for demonstration]
4	Ages 25-44	[blank for demonstration]
5	Ages 45 and over	[blank for demonstration]
6	Total Patients (Sum of Lines 1-5)	[blank for demonstration]

Section B—Early Entry into Prenatal Care

Line	Early Entry into Prenatal Care	Patients Having First Visit with Health Center (a)	Patients Having First Visit with Another Provider (b)
7	First Trimester	[blank for demonstration]	[blank for demonstration]
8	Second Trimester	[blank for demonstration]	[blank for demonstration]
9	Third Trimester	[blank for demonstration]	[blank for demonstration]

Section C—Childhood Immunization Status

Line	Childhood Immunization Status	Total Patients with 2nd Birthday (a)	Number Charts Sampled or EHR Total (b)	Number of Patients Immunized (c)
10	MEASURE: Percentage of children 2 years of age who received age appropriate vaccines by their 2nd birthday	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Section D—Cervical and Breast Cancer Screening

Line	Cervical Cancer Screening	Total Female Patients Aged 23 through 64 (a)	Number Charts Sampled or EHR Total (b)	Number of Patients Tested (c)
11	MEASURE: Percentage of women 23–64 years of age who were screened for cervical cancer	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
Line	Breast Cancer Screening	Total Female Patients Aged 51 through 73 (a)	Number Charts Sampled or EHR Total (b)	Number of Patients with Mammogram (c)
11a	MEASURE: Percentage of women 51–73 years of age who had a mammogram to screen for breast cancer	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Section E—Weight Assessment and Counseling for Nutrition and Physical Activity of Children and Adolescents

Line	Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents	Total Patients Aged 3 through 16 (a)	Number Charts Sampled or EHR Total (b)	Number of Patients with Counseling and BMI Documented (c)
12	MEASURE: Percentage of patients 3–16 years of age with a BMI percentile and counseling on nutrition and physical activity documented	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Section F—Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

Line	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Total Patients Aged 18 and Older (a)	Number Charts Sampled or EHR Total (b)	Number of Patients with BMI Charted and Follow-Up Plan Documented as Appropriate (c)
13	MEASURE: Percentage of patients 18 years of age and older with (1) BMI documented and (2) follow-up plan documented if BMI is outside normal parameters	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Section G—Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Line	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Total Patients Aged 18 and Older (a)	Number Charts Sampled or EHR Total (b)	Number of Patients Assessed for Tobacco Use and Provided Intervention if a Tobacco User (c)
14a	MEASURE: Percentage of patients aged 18 years of age and older who (1) were screened for tobacco use one or more times within 24 months, and (2) if identified to be a tobacco user received cessation counseling intervention	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Section H—Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

Line	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Total Patients Aged 21 and Older at High Risk of Cardiovascular Events (a)	Number Charts Sampled or EHR Total (b)	Number of Patients Prescribed or On Statin Therapy (c)
17a	MEASURE: Percentage of patients 21 years of age and older at high risk of cardiovascular events who were prescribed or were on statin therapy	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Section I—Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet

Line	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet	Total Patients Aged 18 and Older with IVD Diagnosis or AMI, CABG, or PCI Procedure (a)	Number Charts Sampled or EHR Total (b)	Number of Patients with Documentation of Aspirin or Other Antiplatelet Therapy (c)
18	MEASURE: Percentage of patients 18 years of age and older with a diagnosis of IVD or AMI, CABG, or PCI procedure with aspirin or another antiplatelet	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Section J—Colorectal Cancer Screening

Line	Colorectal Cancer Screening	Total Patients Aged 50 through 74 (a)	Number Charts Sampled or EHR Total (b)	Number of Patients with Appropriate Screening for Colorectal Cancer(c)
19	MEASURE: Percentage of patients 50 through 74 years of age who had appropriate screening for colorectal cancer	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Section KL—HIV Measures

Line	HIV Linkage to Care	Total Patients First Diagnosed with HIV (a)	Number Charts Sampled or EHR Total (b)	Number of Patients Seen Within 30 Days of First Diagnosis of HIV (c)
20	MEASURE: Percentage of patients whose first-ever HIV diagnosis was made by health center staff between December 1 of the prior year and November 30 of the measurement year and who were seen for follow-up treatment within 30 days of that first-ever diagnosis	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
Line	HIV Screening	Total Patients Aged 15 through 65 (a)	Number Charts Sampled or EHR Total (b)	Number of Patients Tested for HIV (c)
20a	MEASURE: Percentage of patients 15 through 65 years of age who were tested for HIV when within age range	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Section L—Depression Measures

Line	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Total Patients Aged 12 and Older (a)	Number Charts Sampled or EHR Total (b)	Number of Patients Screened for Depression and Follow-Up Plan Documented as Appropriate (c)
21	MEASURE: Percentage of patients 12 years of age and older who were (1) screened for depression with a standardized tool and, if screening was positive, (2) had a follow-up plan documented	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
Line	Depression Remission at Twelve Months	Total Patients Aged 12 and Older with Major Depression or Dysthymia (a)	Number Charts Sampled or EHR Total (b)	Number of Patients who Reached Remission (c)
21a	MEASURE: Percentage of patients 12 years of age and older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Section M—Dental Sealants for Children between 6–9 Years

Line	Dental Sealants for Children between 6–9 Years	Total Patients Aged 6 through 9 at Moderate to High Risk for Caries (a)	Number Charts Sampled or EHR Total (b)	Number of Patients with Sealants to First Molars (c)
22	MEASURE: Percentage of children 6 through 9 years of age at moderate to high risk of caries who received a sealant on a first permanent molar	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Table 7: Health Outcomes and Disparities

Reporting Period: January 1, 2020, through December 31, 2020

Section A: Deliveries and Birth Weight

Line	Description	Patients (a)
0	HIV-Positive Pregnant Patients	<blank for demonstration>
2	Deliveries Performed by Health Center’s Providers	<blank for demonstration>

Line	Race and Ethnicity	Prenatal Care Patients Who Delivered During the Year (1a)	Live Births: <1500 grams (1b)	Live Births: 1500–2499 grams (1c)	Live Births: ≥2500 grams (1d)
<section divider cell>	Hispanic or Latino/a	<section divider cell>	<section divider cell>	<section divider cell>	<section divider cell>
1a	Asian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1b1	Native Hawaiian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1b2	Other Pacific Islander	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1c	Black/African American	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1d	American Indian/Alaska Native	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1e	White	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1f	More than One Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1g	Unreported/Refused to Report Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
subtotal	Subtotal Hispanic or Latino/a	<cell not reported>	<cell not reported>	<cell not reported>	<cell not reported>
<blank for demonstration>	Non-Hispanic or Latino/a	<section divider cell>	<section divider cell>	<section divider cell>	<section divider cell>
2a	Asian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2b1	Native Hawaiian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2b2	Other Pacific Islander	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2c	Black/African American	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2d	American Indian/Alaska Native	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2e	White	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2f	More than One Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2g	Unreported/Refused to Report Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
subtotal	Subtotal Non-Hispanic or Latino/a	<cell not reported>	<cell not reported>	<cell not reported>	<cell not reported>
<blank for demonstration>	Unreported/Refused to Report Race & Ethnicity	<section divider cell>	<section divider cell>	<section divider cell>	<section divider cell>
h	Unreported/Refused to Report Race and Ethnicity	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
i	Total	<cell not reported>	<cell not reported>	<cell not reported>	<cell not reported>

Section B: Controlling High Blood Pressure

Line	Race and Ethnicity	Total Patients 18 through 84 Years of Age with Hypertension (2a)	Number Charts Sampled or EHR Total (2b)	Patients with Hypertension Controlled (2c)
<blank for demonstration>	Hispanic or Latino/a	<section divider cell>	<section divider cell>	<section divider cell>
1a	Asian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1b1	Native Hawaiian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1b2	Other Pacific Islander	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1c	Black/African American	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1d	American Indian/Alaska Native	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1e	White	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1f	More than One Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1g	Unreported/Refused to Report Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
subtotal	Subtotal Hispanic or Latino/a	<cell not reported>	<cell not reported>	<cell not reported>
<blank for demonstration>	Non-Hispanic or Latino/a	<section divider cell>	<section divider cell>	<section divider cell>
2a	Asian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2b1	Native Hawaiian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2b2	Other Pacific Islander	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2c	Black/African American	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2d	American Indian/Alaska Native	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2e	White	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2f	More than One Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2g	Unreported/Refused to Report Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
subtotal	Subtotal Non-Hispanic or Latino/a	<cell not reported>	<cell not reported>	<cell not reported>
<blank for demonstration>	Unreported/Refused to Report Race and Ethnicity	<section divider cell>	<section divider cell>	<section divider cell>
h	Unreported/Refused to Report Race and Ethnicity	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
i	Total	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>

Section C: Diabetes: Hemoglobin A1c Poor Control

Line	Race and Ethnicity	Total Patients 18 through 74 Years of Age with Diabetes (3a)	Number Charts Sampled or EHR Total (3b)	Patients with HbA1c >9% or No Test During Year (3f)
<blank for demonstration>	Hispanic or Latino/a	<section divider cell>	<section divider cell>	<section divider cell>
1a	Asian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1b1	Native Hawaiian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1b2	Other Pacific Islander	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1c	Black/African American	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1d	American Indian/Alaska Native	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1e	White	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1f	More than One Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
1g	Unreported/Refused to Report Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
Subtotal	Subtotal Hispanic or Latino/a	<cell not reported>	<cell not reported>	<cell not reported>
<blank for demonstration>	Non-Hispanic or Latino/a	<section divider cell>	<section divider cell>	<section divider cell>
2a	Asian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2b1	Native Hawaiian	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2b2	Other Pacific Islander	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2c	Black/African American	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2d	American Indian/Alaska Native	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2e	White	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2f	More than One Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
2g	Unreported/Refused to Report Race	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
Subtotal	Subtotal Non-Hispanic or Latino/a	<cell not reported>	<cell not reported>	<cell not reported>
<blank for demonstration>	Unreported/Refused to Report Race and Ethnicity	<section divider cell>	<section divider cell>	<section divider cell>
h	Unreported/Refused to Report Race and Ethnicity	<blank for demonstration>	<blank for demonstration>	<blank for demonstration>
i	Total	<cell not reported>	<cell not reported>	<cell not reported>

Table 8A: Financial Costs

Reporting Period: January 1, 2020, through December 31, 2020

Line	Cost Center	Accrued Cost (a)	Allocation of Facility and Non-Clinical Support Services (b)	Total Cost After Allocation of Facility and Non-Clinical Support Services (c)
[section divide]	Financial Costs of Medical Care	[section divide]	[section divide]	[section divide]
1	Medical Staff	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
2	Lab and X-ray	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
3	Medical/Other Direct	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
4	Total Medical Care Services (Sum of Lines 1 through 3)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
[blank for section divide]	Financial Costs of Other Clinical Services	[blank for section divide]	[blank for section divide]	[blank for section divide]
5	Dental	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
6	Mental Health	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
7	Substance Use Disorder	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
8a	Pharmacy (not including pharmaceuticals)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
8b	Pharmaceuticals	[blank for demonstration]	[Cell not reported]	[blank for demonstration]
9	Other Professional (specify___)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
9a	Vision	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
10	Total Other Clinical Services (Sum of Lines 5 through 9a)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
[blank for section divide]	Financial Costs of Enabling and Other Services	[blank for section divide]	[blank for section divide]	[blank for section divide]
11a	Case Management	[blank for demonstration]	[Cell not reported]	[blank for demonstration]
11b	Transportation	[blank for demonstration]	[Cell not reported]	[blank for demonstration]
11c	Outreach	[blank for demonstration]	[Cell not reported]	[blank for demonstration]
11d	Patient and Community Education	[blank for demonstration]	[Cell not reported]	[blank for demonstration]
11e	Eligibility Assistance	[blank for demonstration]	[Cell not reported]	[blank for demonstration]
11f	Interpretation Services	[blank for demonstration]	[Cell not reported]	[blank for demonstration]
11g	Other Enabling Services (specify ___)	[blank for demonstration]	[Cell not reported]	[blank for demonstration]
11h	Community Health Workers	[blank for demonstration]	[Cell not reported]	[blank for demonstration]
11	Total Enabling Services (Sum of Lines 11a through 11h)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
12	Other Program-Related Services (specify___)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
12a	Quality Improvement	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]
13	Total Enabling and Other Services (Sum of Lines 11, 12, and 12a)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Line	Cost Center	Accrued Cost (a)	Allocation of Facility and Non-Clinical Support Services (b)	Total Cost After Allocation of Facility and Non-Clinical Support Services (c)
[blank for section divide]	Facility and Non-Clinical Support Services and Totals	[blank for section divide]	[blank for section divide]	[blank for section divide]
14	Facility	[blank for demonstration]	[Cell not reported]	[Cell not reported]
15	Non-Clinical Support Services	[blank for demonstration]	[Cell not reported]	[Cell not reported]
16	Total Facility and Non-Clinical Support Services (Sum of Lines 14 and 15)	[blank for demonstration]	[Cell not reported]	[Cell not reported]
17	Total Accrued Costs (Sum of Lines 4 + 10 + 13 + 16)	[blank for demonstration]	[Cell not reported]	[blank for demonstration]
18	Value of Donated Facilities, Services, and Supplies (specify___)	[Cell not reported]	[Cell not reported]	[blank for demonstration]
19	Total with Donations (Sum of Lines 17 and 18)	[Cell not reported]	[Cell not reported]	[blank for demonstration]

Table 9D: Patient-Related Revenue

Reporting Period: January 1, 2020, through December 31, 2020

				Retroactive S	ettlements, Receipts	, and Paybacks	(c)
Line	Payer Category	Full Charges This Period (a)	Amount Collected This Period (b)	Collection of Reconciliation/ Wraparound Current Year (c1)	Collection of Reconciliation/ Wraparound Previous Years (c2)	Collection of Other Payments: P4P, Risk Pools, etc. (c3)	Penalty/ Payback (c4)	Adjustments (d)	Sliding Fee Discounts (e)	Bad Debt Write-Off (f)
1	Medicaid Non-Managed Care	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
2a	Medicaid Managed Care (capitated)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
2b	Medicaid Managed Care (fee-for-service)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
3	Total Medicaid (Sum of Lines 1 + 2a + 2b)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
4	Medicare Non-Managed Care	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
5a	Medicare Managed Care (capitated)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
5b	Medicare Managed Care (fee-for-service)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
6	Total Medicare (Sum of Lines 4 + 5a + 5b)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
7	Other Public, including Non-Medicaid CHIP, Non-Managed Care	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
8a	Other Public, including Non-Medicaid CHIP, Managed Care (capitated)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
8b	Other Public, including Non-Medicaid CHIP, Managed Care (fee-for-service)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
8c	Other Public, including COVID-19 Uninsured Program	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
9	Total Other Public (Sum of Lines 7 + 8a + 8b + 8c)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
10	Private Non-Managed Care	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
11a	Private Managed Care (capitated)	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
11b	Private Managed Care (fee-for-service)	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
12	Total Private (Sum of Lines 10 + 11a + 11b)	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]
13	Self-Pay	[blank for demonstration]	[blank for demonstration]	[not reported]	[not reported]	[not reported]	[not reported]	[not reported]	[blank for demonstration]	[blank for demonstration]
14	TOTAL (Sum of Lines 3 + 6 + 9 + 12 + 13)	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]	[blank for demonstration]

Table 9E: Other Revenues

Reporting Period: January 1, 2020, through December 31, 2020

Line	Source	Amount (a)
[blank]	BPHC Grants (Enter Amount Drawn Down—Consistent with PMS 272)	[blank]
1a	Migrant Health Center	[blank]
1b	Community Health Center	[blank]
1c	Health Care for the Homeless	[blank]
1e	Public Housing Primary Care	[blank]
1g	Total Health Center (Sum of Lines 1a through 1e)	[blank]
1k	Capital Development Grants, including School-Based Health Center Capital Grants	[blank]
1l	Coronavirus Preparedness and Response Supplemental Appropriations Act (H8C)	[blank]
1m	Coronavirus Aid, Relief, and Economic Security Act (CARES) (H8D)	[blank]
1n	Expanding Capacity for Coronavirus Testing (ECT) Funding (H8E)	[blank]
1o	Health and Economic Recovery Omnibus Emergency Solutions Act (HEROES)/ (HEALS)Health, Economic Assistance, Liability Protection and Schools Act
1p	Other COVID-19 Related Funding from BPHC (specify___________)
1q	Total COVID-19 Supplemental (Sum of Lines 1l through 1p)	[blank]
1	Total BPHC Grants (Sum of Lines 1g + 1k + 1o)	[blank]
[blank]	Other Federal Grants	[blank]
2	Ryan White Part C HIV Early Intervention	[blank]
3	Other Federal Grants (specify _______)	[blank]
3a	Medicare and Medicaid EHR Incentive Payments for Eligible Providers	[blank]
3b	Provider Relief Fund (specify _______)	[blank]
5	Total Other Federal Grants (Sum of Lines 2 through 3b)	[blank]
[blank]	Non-Federal Grants or Contracts	[blank]
6	State Government Grants and Contracts (specify_______)	[blank]
6a	State/Local Indigent Care Programs (specify_______)	[blank]
7	Local Government Grants and Contracts (specify_______)	[blank]
8	Foundation/Private Grants and Contracts (specify_______)	[blank]
9	Total Non-Federal Grants and Contracts (Sum of Lines 6 + 6a + 7 + 8)	[blank]
10	Other Revenue (non-patient related revenue not reported elsewhere) (specify _______)	[blank]
11	Total Revenue (Sum of Lines 1 + 5 + 9 + 10)	[blank]

Appendix D: Health Center Health Information Technology (HIT) Capabilities

Instructions

The HIT Capabilities Form includes a series of questions on HIT capabilities, including EHR interoperability and eligibility for CMS Promoting Interoperability programs. The HIT Form must be completed and submitted as part of the UDS submission. The form includes questions about the health center’s implementation of an EHR, certification of systems, and how widely adopted the system is throughout the health center and its providers.

Questions

The following questions appear in the EHBs. Complete them before you file the UDS Report. Instructions for the HIT questions are on-screen in the EHBs as you complete the form. Respond to each question based on your health center status as of December 31.

1. Does your center currently have an electronic health record (EHR) system installed and in use?

1. Yes, installed at all sites and used by all providers

2. Yes, but only installed at some sites or used by some providers

3. No

If the health center installed it, indicate if it was in use by December 31 by indicating:

1. Installed at all sites and used by all providers: For the purposes of this response, “providers” mean all medical providers, including physicians, nurse practitioners, physician assistants, and certified nurse midwives. Although some or all of the dental, mental health, or other providers may also be using the system, as may medical support staff, this is not required to choose response (a). For the purposes of this response, “all sites” means all permanent sites where medical providers serve health center medical patients. It does not include administrative-only locations, hospitals or nursing homes, mobile vans, or sites used on a seasonal or temporary basis. You may check this option if a few newly hired, untrained employees are the only ones not using the system.

2. Installed at some sites or used by some providers: Select option (b) if one or more permanent sites did not have the EHR installed or in use (even if this is planned), or if one or more medical providers (as defined on this page under [a]) do not yet use the system. When determining if all providers have access to the system, the health center should also consider part-time and locum providers who serve clinic patients. Do not select this option if the only medical providers who did not have access were those who were newly hired and still being trained on the system.

3. Select “no” if no EHR was in use on December 31, even if you had the system installed and training had started.

This question seeks to determine whether the health center installed an EHR by December 31 and, if so, which product was in use, how broad system access was, and what features were available and in use. Do not include PMS or other billing systems, even though they can often produce much of the UDS data. If the health center purchased an EHR but has not yet put it into use, answer “no.”

If a system is in use (i.e., if [a] or [b] has been selected), indicate that it has been certified by the Office of the National Coordinator—Authorized Testing and Certification Bodies.

1a. Is your system certified by the Office of the National Coordinator for Health IT (ONC) Health IT Certification Program?

1. Yes

2. No

Health centers are to indicate the vendor, product name, version number, and ONC-certified health IT product list number. (More information is available at https://chpl.healthit.gov/#/search.) If you have more than one EHR (if, for example, you acquired another practice with its own EHR), report the EHR that will be the successor system or the EHR used for capturing primary medical care.

1a1. Vendor

1a2. Product Name

1a3. Version Number

1a4. ONC-certified Health IT Product List Number

1b. Did you switch to your current EHR from a previous system this year?

1. Yes

2. No

If “yes, but only at some sites or for some providers” is selected, a box expands for health centers to identify how many sites have the EHR in use and how many (medical) providers are using it. Please enter the number of sites (as defined under question 1) where the EHR is in use and the number of providers who use the system (at all sites). Include part-time and locum medical providers who serve clinic patients. Count a provider who has separate login identities at more than one site as just one provider.

1c. Do you use more than one EHR or data system across your organization?

1. Yes

2. No

1c1. If yes, what is the reason?

1. Second EHR/data system is used during transition to primary EHR

2. Second EHR/data system is specific to one service type (e.g., dental, behavioral health)

3. Second EHR/data system is used at specific sites with no plan to transition

4. Other (please describe ______)

1d. Is your EHR up to date with the latest software and system patches?

1e. When do you plan to update/install the latest EHR software and system patches?

2. Question removed.

3. Question removed.

4. Which of the following key providers/health care settings does your center electronically exchange clinical information with? (Select all that apply.)

1. Hospitals/Emergency rooms

2. Specialty clinicians

3. Other primary care providers

4. Labs or imaging

5. Health information exchange (HIE)

6. None of the above

7. Other (please describe ______)

5. Does your center engage patients through health IT in any of the following ways? (Select all that apply.)

1. Patient portals

2. Kiosks

3. Secure messaging

4. Other (please describe _______)

5. No, we do not engage patients using HIT

6. Question removed.

7. How do you collect data for UDS clinical reporting (Tables 6B and 7)?

1. We use the EHR to extract automated reports

2. We use the EHR but only to access individual patient charts

3. We use the EHR in combination with another data analytic system

4. We do not use the EHR

8. Question removed.

9. Question removed.

10. How does your health center utilize HIT and EHR data beyond direct patient care? (Select all that apply.)

1. Quality improvement

2. Population health management

3. Program evaluation

4. Research

5. Other (please describe ______)

6. We do not utilize HIT or EHR data beyond direct patient care

11. Does your health center collect data on individual patients’ social risk factors, outside of the data reportable in the UDS?

1. Yes

2. No, but we are in planning stages to collect this information

3. No, we are not planning to collect this information

12. Which standardized screener(s) for social risk factors, if any, do you use? (Select all that apply.)

1. Accountable Health Communities Screening Tools

2. Upstream Risks Screening Tool and Guide

3. iHELLP

4. Recommend Social and Behavioral Domains for EHRs

5. Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)

6. Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education (WE CARE)

7. WellRx

8. Health Leads Screening Toolkit

9. Other (please describe __________)

10. We do not use a standardized screener

12a. Please provide the total number of patients that screened positive for the following:

1. Food insecurity ___________

2. Housing insecurity ___________

3. Financial strain ___________

4. Lack of transportation/access to public transportation ___________

12b. If you do not use a standardized assessment to collect this information, please indicate why. (Select all that apply.)

1. Have not considered/unfamiliar with assessments

2. Lack of funding for addressing these unmet social needs of patients

3. Lack of training for staff to discuss these issues with patients

4. Inability to include with patient intake and clinical workflow

5. Not needed

6. Other (please describe ___________)

13. Does your center integrate a statewide Prescription Drug Monitoring Program (PDMP) database into the health information systems, such as health information exchanges, EHRs, and/or pharmacy dispensing software (PDS) to streamline provider access to controlled substance prescriptions?

1. Yes

2. No

3. Not sure

Appendix E: Other Data Elements

Instructions

Health centers are becoming increasingly diverse and comprehensive in the care and services they provide. These questions capture the changing landscape of health care centers to include expanded services and delivery systems.

Questions

Report on these data elements as part of your UDS submission. Topics include medication-assisted treatment (MAT), telehealth, and outreach and enrollment assistance. Respond to each question based on your health center status as of December 31.

1. Medication-Assisted Treatment (MAT) for Opioid Use Disorder

1. How many physicians, certified nurse practitioners, physician assistants, and certified nurse midwives,¹ on-site or with whom the health center has contracts, have obtained a Drug Addiction Treatment Act of 2000 (DATA) waiver to treat opioid use disorder with medications specifically approved by the U.S. Food and Drug Administration (FDA) for that indication?

2. How many patients received MAT for opioid use disorder from a physician, certified nurse practitioner, or physician assistant, with a DATA waiver working on behalf of the health center?

2. Did your organization use telemedicine to provide remote clinical care services?

(The term “telehealth” includes “telemedicine” services but encompasses a broader scope of remote health care services. Telemedicine is specific to remote clinical services, whereas telehealth may include remote non-clinical services, such as provider training, administrative meetings, and continuing medical education, in addition to clinical services.)

1. Yes

2a1. Who did you use telemedicine to communicate with? (Select all that apply.)

1. Patients at remote locations from your organization (e.g., home telehealth, satellite locations)

2. Specialists outside your organization (e.g., specialists at referral centers)

2a2. What telehealth technologies did you use? (Select all that apply.)

1. Real-time telehealth (e.g., live videoconferencing)

2. Store-and-forward telehealth (e.g., secure e-mail with photos or videos of patient examinations)

3. Remote patient monitoring

4. Mobile Health (mHealth)

2a3. What primary telemedicine services were used at your organization? (Select all that apply.)

1. Primary care

2. Oral health

3. Behavioral health: Mental health

4. Behavioral health: Substance use disorder

5. Dermatology

6. Chronic conditions

7. Disaster management

8. Consumer health education

9. Provider-to-provider consultation

10. Radiology

11. Nutrition and dietary counseling

12. Other (Please specify: ________________)

2. No. If you did not have telemedicine services, please comment why. (Select all that apply.)

1. Have not considered/unfamiliar with telehealth service options

2. Policy barriers (Select all that apply)

1. Lack of or limited reimbursement

2. Credentialing, licensing, or privileging

3. Privacy and security

4. Other (Please specify: __________________)

3. Inadequate broadband/ telecommunication service (Select all that apply)

1. Cost of service

2. Lack of infrastructure

3. Other (Please specify: __________________)

4. Lack of funding for telehealth equipment

5. Lack of training for telehealth services

6. Not needed

7. Other (Please specify: __________________)

3. Provide the number of all assists provided during the past year by all trained assisters (e.g., certified application counselor or equivalent) working on behalf of the health center (employees, contractors, or volunteers), regardless of the funding source that is supporting the assisters’ activities. Outreach and enrollment assists are defined as customizable education sessions about affordable health insurance coverage options (one-on-one or small group) and any other assistance provided by a health center assister to facilitate enrollment.

Enter number of assists _______________

Note: Assists do not count as visits on the UDS tables.

4: How many patients received a COVID-19 during the 2020 calendar year? _______________________vaccine

Appendix F: Workforce

Instructions

It is important to understand the current state of health center workforce training and different staffing models to better support recruitment and retention of health center professionals. This section includes a series of questions on health center workforce.

Questions

Report on these data elements as part of your UDS submission. Topics include health professional education/training (do not include continuing education units) and satisfaction surveys. Respond to each question based on your health center status as of December 31.

1. Does your health center provide health professional education/training that is a hands-on, practical, or clinical experience?

1. Yes

2. No

1a. If yes, which category best describes your health center’s role in the health professional education/training process? (Select all that apply.)

1. Sponsor²

2. Training site partner³

3. Other (please describe ________________)

2. Please indicate the range of health professional education/training offered at your health center and how many individuals you have trained in each category⁴ within the reporting year.

	a. Pre-Graduate/Certificate	b. Post-Graduate Training
Medical	[blank]	[blank]
1. Physicians	[blank for demonstration]	[blank for demonstration]
a. Family Physicians	[blank for demonstration]	[blank for demonstration]
b. General Practitioners	[blank for demonstration]	[blank for demonstration]
c. Internists	[blank for demonstration]	[blank for demonstration]
d. Obstetrician/Gynecologists	[blank for demonstration]	[blank for demonstration]
e. Pediatricians	[blank for demonstration]	[blank for demonstration]
f. Other Specialty Physicians	[blank for demonstration]	[blank for demonstration]
2. Nurse Practitioners	[blank for demonstration]	[blank for demonstration]
3. Physician Assistants	[blank for demonstration]	[blank for demonstration]
4. Certified Nurse Midwives	[blank for demonstration]	[blank for demonstration]
5. Registered Nurses	[blank for demonstration]	[blank for demonstration]
6. Licensed Practical Nurses/ Vocational Nurses	[blank for demonstration]	[blank for demonstration]
7. Medical Assistants	[blank for demonstration]	[blank for demonstration]
Dental	[blank]	[blank]
8. Dentists	[blank for demonstration]	[blank for demonstration]
9. Dental Hygienists	[blank for demonstration]	[blank for demonstration]
10. Dental Therapists	[blank for demonstration]	[blank for demonstration]
10a. Dental Assistants
Mental Health and Substance Use Disorder	[blank]	[blank]
11. Psychiatrists	[blank for demonstration]	[blank for demonstration]
12. Clinical Psychologists	[blank for demonstration]	[blank for demonstration]
13. Clinical Social Workers	[blank for demonstration]	[blank for demonstration]
14. Professional Counselors	[blank for demonstration]	[blank for demonstration]
15. Marriage and Family Therapists	[blank for demonstration]	[blank for demonstration]
16. Psychiatric Nurse Specialists	[blank for demonstration]	[blank for demonstration]
17. Mental Health Nurse Practitioners	[blank for demonstration]	[blank for demonstration]
18. Mental Health Physician Assistants	[blank for demonstration]	[blank for demonstration]
19. Substance Use Disorder Personnel	[blank for demonstration]	[blank for demonstration]
Vision	[blank]	[blank]
20. Ophthalmologists	[blank for demonstration]	[blank for demonstration]
21. Optometrists	[blank for demonstration]	[blank for demonstration]
Other Professionals	[blank]	[blank]
22. Chiropractors	[blank for demonstration]	[blank for demonstration]
23. Dieticians/Nutritionists	[blank for demonstration]	[blank for demonstration]
24. Pharmacists	[blank for demonstration]	[blank for demonstration]
25. Other (please specify ________)	[blank for demonstration]	[blank for demonstration]

3. Provide the number of health center staff serving as preceptors at your health center: ____

4. Provide the number of health center staff (non-preceptors) supporting ongoing health center training programs: ____

5. How often does your health center implement satisfaction surveys for providers? (Select one.)

1. Monthly

2. Quarterly

3. Annually

4. We do not currently conduct provider satisfaction surveys

5. Other (please describe _________)

6. How often does your health center implement satisfaction surveys for general staff (report provider surveys in question 5 only)? (Select one.)

1. Monthly

2. Quarterly

3. Annually

4. We do not currently conduct staff satisfaction surveys

5. Other (please describe _________)

1 With the enactment of the Comprehensive Addiction and Recovery Act of 2016, PL 114-198, opioid treatment prescribing privileges have been extended beyond physicians to include certain qualifying nurse practitioners (NPs), physician assistants (PAs), and certified nurse midwives (CNMs).

2 A sponsor hosts a comprehensive health profession education and/or training program, the implementation of which may require partnerships with other entities that deliver focused, time-limited education and/or training (e.g., a teaching health center with a family medicine residency program).

3 A training site partner delivers focused, time-limited education and/or training to learners in support of a comprehensive curriculum hosted by another health profession education provider (e.g., month-long primary care dentistry experience for dental students).

4 Examples of pre-gcertificate training include student clinical rotations or externships. A residency, fellowship, or practicum would be examples of post-graduate training. Include non-health-center individuals trained by your health center.