Performance Data: Quarterly Report Template

REPORT PERIOD

GRANT NUMBER

ORGANIZATION NAME

PROJECT NAME

PROGRAM NAME

One-on-one Patient TA: What is the total number of encounters with patients, clients, customers, their families or other individuals who participated in Individualized/one-on-one education; Training; TA; Mentoring; Counseling; Consultation; Case-management sessions?

One-on-one Patient TA (PARTNERS): What is the total number of encounters with patients, clients, customers, their families or other individuals who participated in Individualized/one-on-one education; Training; TA; Mentoring; Counseling; Consultation; Case-management sessions provided by your project PARTNERS?

One-on-one Provider TA: What is the total number of encounters with health care providers, other service providers, or other professionals who participated in: Individualized/one-on-one education; Training; TA; Mentoring; Counseling; Consultation; Case-management sessions?

One-on-one Provider TA (PARTNERS): What is the total number of encounters with health care providers, other service providers, or other professionals who participated in: Individualized/one-on-one education; Training; TA; Mentoring; Counseling; Consultation; Case-management sessions provided by your project PARTNERS?

Group patients TA: What is the total number of encounters with patients, clients, customers, their families or other individuals who participated in: Group education; Training; TA; Mentoring; Counseling; Consultation; Case-management sessions ?

Group patients TA (PARTNERS): What is the total number of encounters with patients, clients, customers, their families or other individuals who participated in: Group education; Training; TA; Mentoring; Counseling; Consultation; Case-management sessions provided by your project PARTNERS?

Group provider TA: What is the total number of individuals that attended who participated in each of the group education, training, TA, mentoring, counseling, consultation or case-management sessions for health care providers, other service providers, or other professionals?

Group provider TA (PARTNER): What is the total number of individuals that attended who participated in each of the group education, training, TA, mentoring, counseling, consultation or case-management sessions for health care providers, other service providers, or other professionals provided by your project PARTNERS?

Language Interpretation:What is the total number of encounters with individuals during which the individuals received language interpretation and/or other verbal language assistance?

Language Interpretation (PARTNERS):What is the total number of encounters with individuals during which the individuals received language interpretation and/or other verbal language assistance provided by your project PARTNERS?

Non-English materials: What is the total number of encounters with individuals during which any printed or written instructional/educational materials, forms, and other documents translated into languages other than English were received by individuals served by your program?

Non-English materials (PARTNERS): What is the total number of encounters with individuals during which any printed or written instructional/educational materials, forms, and other documents translated into languages other than English were received by individuals served by your project PARTNERS?

Community Screenings: What is the total number of community-based health screenings (e.g., screening for high blood pressure, high cholesterol, diabetes, or HIV/AIDS) received by individuals provided by your OMH-funded project during this reporting period?

Community Screenings (PARTNERS): What is the total number of community-based health screenings (e.g., screening for high blood pressure, high cholesterol, diabetes, or HIV/AIDS) received by individuals provided by your OMH-funded project PARTNERS during this reporting period?

Health Fairs: What is the total number of encounters with individuals at OMH-funded project community-based health fairs, expositions, and other similar public events that you sponsored, led or managed?

Health Fairs (PARTNERS): What is the total number of encounters with individuals at OMH-funded project community-based health fairs, expositions, and other similar public events that your project PARTNERS sponsored, led or managed?

Booths at other events: What is the total number of encounters with individuals at any OMH-funded project exhibit booths at broader community-based health fairs, expositions, and other public events?

Booths at other events (PARTNERS): What is the total number of encounters with individuals at any OMH-funded project PARTNERS exhibit booths at broader community-based health fairs, expositions, and other public events?

Public meetings: What is the total number of encounters with individuals at the conferences or other large scale meetings you planned, managed and/or conducted as part of your OMH-funded project?

Public meetings (PARTNERS): What is the total number of encounters with individuals at the conferences or other large scale meetings your PARTNERS planned, managed and/or conducted as part of your OMH-funded project?

Language Access Services (LAS). What is the total number of encounters of individuals served under your LAS? Comprehensive LAS includes all of the following: audio interpretation, non-English materials, effective communication, sight translation, and in-language communication.

Language Access Services (LAS) (PARTNERS). What is the total number of encounters of individuals served under LAS provided by your PARTNERS? Comprehensive LAS includes all of the following: audio interpretation, non-English materials, effective communication, sight translation, and in-language communication.

Total De-Duplicated Program Participants (Quarter): What is the total number of individuals participating in your OMH-funded project? Include only individuals who are participating in your project this quarter.

Total De-Duplicated Program Participants (Annual): What is the total number of individuals participating in your OMH-funded project during this year ?

**INSERT GRANT NUMBER**

**INSERT ORGANIZATION NAME**

**INSERT PROJECT NAME**

**INSERT PROGRAM NAME**

**INSERT GRANT NUMBER**

**INSERT ORGANIZATION NAME**

**INSERT PROJECT NAME**

**INSERT PROGRAM NAME**

**INSERT GRANT NUMBER**

**INSERT ORGANIZATION NAME**

**INSERT PROJECT NAME**

**INSERT PROGRAM NAME**

**INSERT GRANT NUMBER**

**INSERT ORGANIZATION NAME**

**INSERT PROJECT NAME**

**INSERT PROGRAM NAME**

Key

Tips

Report Period (format: MMM-MMM, YYYY)

1. Submit your Performance Data Report as an Excel Document through GrantSolutions.

Keep Consistent Across quarters

2. Complete one row per reporting period.

Number Required (no text)

3. Do not rename, reorder, or transpose any rows or columns.

4. Ensure a number is in every light yellow cell (columns F to AC).

5. Do not enter "N/A" or leave any cells blank, instead enter 0.

6. If an explanation is needed, add a comment to column AD (no text in columns F through AC allowed).

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 data collection is 0990-0275.

The time required to complete this information collection

is estimated at 45 minutes per response, including the time to

review instructions, search existing data sources, gather 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/OCIO/PRA,

200 Independence Ave., S.W. Suite 336-E, Washington D.C. 20201.

Attention: PRA Reports Clearance Officer