Additional Data Elements

OMB Number: 0915-0298

Expiration Date: [Insert Date]

Health Resources and Services Administration

Maternal and Child Health Bureau

Discretionary Grant Performance Measures

OMB No. 0915-0298

Expires: ________

Attachment D:

Additional Data Elements

OMB Clearance Package

Table of Contents

Attachment D:
Additional Data Elements

Technical Assistance/ Collaboration Form 3

Products, Publications and Submissions Data Collection Form 6

Division of MCH Workforce Development Forms 12

Healthy Start Site Form 29

TECHNICAL ASSISTANCE/COLLABORATION FORM

DEFINITION: Technical Assistance/Collaboration refers to mutual problem solving and collaboration on a range of issues, which may include program development, clinical services, collaboration, program evaluation, needs assessment, and policy & guidelines formulation. It may include administrative services, site visitation and review/advisory functions. Collaborative partners might include State or local health agencies, and education or social service agencies. Faculty may serve on advisory boards to develop &/or review policies at the local, State, regional, national or international levels. The technical assistance (TA) effort may be a one-time or on-going activity of brief or extended frequency. The intent of the measure is to illustrate the reach of the training program beyond trainees.

TA recipients are counted as the number of individual recipients engaged in each TA or collaborative activity. For example, if your organization provides TA to five (5) individuals within a Title V agency, the number of TA recipients is 5.

Provide the following summary information on ALL TA provided.

Total Number of Technical Assistance/ Collaboration Activities	Total Number of TA Recipients	TA Activities by Type of Recipient	Number of TA Activities by Target Audience
_________	____________	Other Divisions/ Departments in a University Title V (MCH Programs) State Health Dept. Health Insurance/ Organization Education Medicaid agency Social Service Agency Mental Health Agency Juvenile Justice or other Legal Entity State Adolescent Health Developmental Disability Agency Early Intervention Other Govt. Agencies Mixed Agencies Professional Organizations/Associations Family and/or Consumer Group Foundations Clinical Programs/ Hospitals Other: Please Specify__________	Local Title V Within State Another State Regional National International	_____ _____ _____ _____ _____ _____ _____ _____

B. Provide information below on the 5-10 most significant technical assistance/ collaborative activities in the past year. In the notes, briefly state why these were the most significant TA events.

Title		Topic of Technical Assistance/Collaboration Select one from list A and all that apply from List B.		Recipient of TA/ Collaborator	Intensity of TA	Primary Target Audience
		List A (select one) Clinical care related (including medical home) Cultural Responsiveness Related Data, Research, Evaluation Methods (Knowledge Translation) Family Involvement Interdisciplinary Teaming Healthcare Workforce Leadership Policy Prevention Systems Development/ Improvement	List B (select all that apply) CSHCN/ Developmental Disabilities Autism Prenatal Care Perinatal/ Postpartum Care Well Woman Visit/ Preventive Health Care Depression Screening Safe Sleep Breastfeeding Newborn Screening Quality of Well Child Visit Child Well Visit Injury Prevention Family Engagement Medical Home (Access to and use of medical home) Transition Adolescent Well Visit Injury Prevention Screening for Major Depressive Disorder Health Equity Adequate health insurance coverage Tobacco and eCigarette Use Oral Health Nutrition Respiratory Health Adolescent Health Other	Other Divisions/ Departments in a University Title V (MCH Programs) State Health Dept. Health Insurance/ Organization Education Medicaid agency Social Service Agency Mental Health Agency Juvenile Justice or other Legal Entity State Adolescent Health Developmental Disability Agency Early Intervention Other Govt. Agencies Mixed Agencies Professional Organizations/ Associations Family and/or Consumer Group Foundations Clinical Programs/ Hospitals Other (specify)	One time brief (single contact) One time extended (multi-day contact provided one time) On-going infrequent (3 or less contacts per year) On-going frequent (more than 3 contacts per year)	Local Title V Within State Another State Regional National International
1	Example	G- Policy	21- Oral Health	E - Education	2	2

C. In the past year have you provided technical assistance on emerging issues that are not represented in the topic list above? YES/ NO.

If yes, specify the topic(s):_____________________________________________________________________

Products, Publications and Submissions Data Collection Form

Part 1

Instructions: Please list the number of products, publications and submissions addressing maternal and child health that have been published or produced with grant support (either fully or partially) during the reporting period. Count the original completed product, not each time it is disseminated or presented.

Type	Number
In Press peer-reviewed publications in scholarly journals Please include peer reviewed publications addressing maternal and child health that have been published by project faculty and/or staff during the reporting period. Faculty and staff include those listed in the budget form and narrative and others that your program considers to have a central and ongoing role in the project whether they are supported or not supported by the grant.
Submission(s) of peer-reviewed publications to scholarly journals
Books
Book chapters
Reports and monographs (including policy briefs and best practices reports)
Conference presentations and posters presented
Web-based products (Blogs, podcasts, Web-based video clips, wikis, RSS feeds, news aggregators, social networking sites)
Electronic products (CD-ROMs, DVDs, audio or videotapes)
Press communications (TV/Radio interviews, newspaper interviews, public service announcements, and editorial articles)
Newsletters (electronic or print)
Pamphlets, brochures, or fact sheets
Academic course development
Distance learning modules
Doctoral dissertations/ Master’s theses
Other

Part 3

Instructions: For each product, publication and submission listed in Part 1, complete all elements marked with an “*.”

Data collection form for: primary author in peer-reviewed publications in scholarly journals – published

*Title: ________________________________________________________________________

*Author(s): ____________________________________________________________________

*Publication: __________________________________________________________________

*Volume: ______ *Number: _______ Supplement: _____ *Year: _______ *Page(s):________

*Target Audience: Consumers/Families ___ Professionals ___ Policymakers ___ Students ____

*To obtain copies (URL): ________________________________________________________

*Dissemination Vehicles: TV/ Radio Interview___ Newspaper/ Print Interview___ Press Release___

Social Networking Sites/ Social Media___ Listservs___ Conference Presentation___

Key Words (No more than 5): _____________________________________________________

Notes: ________________________________________________________________________

Data collection form for: contributing author in peer-reviewed publications in scholarly journals – published

*Title: ________________________________________________________________________

*Author(s): ____________________________________________________________________

*Publication: __________________________________________________________________

*Volume: ______ *Number: _______ Supplement: _____ *Year: _______ *Page(s):________

*Target Audience: Consumers/Families ___ Professionals ___ Policymakers ___ Students ____

*To obtain copies (URL): ________________________________________________________

*Dissemination Vehicles: TV/ Radio Interview___ Newspaper/ Print Interview___ Press Release___

Social Networking Sites/ Social Media___ Listservs___ Conference Presentation___

Key Words (No more than 5): _____________________________________________________

Notes: ________________________________________________________________________

Data collection form: Peer-reviewed publications in scholarly journals – submitted, not yet published

*Title: ________________________________________________________________________

*Author(s): ____________________________________________________________________

*Publication: __________________________________________________________________

*Year Submitted: _______

*Target Audience: Consumers/Families ___ Professionals ___ Policymakers ___ Students ____

Key Words (No more than 5): _____________________________________________________

Notes: ________________________________________________________________________

Data collection form: Books

*Title: ________________________________________________________________________

*Author(s): ____________________________________________________________________

*Publisher: ____________________________________________________________________

*Year Published: _______

*Target Audience: Consumers/Families ___ Professionals ___ Policymakers ___ Students ____

Key Words (No more than 5): _____________________________________________________

Notes: ________________________________________________________________________

Data collection form for: Book chapters

Note: If multiple chapters are developed for the same book, list them separately.

*Chapter Title: ________________________________________________________________

*Chapter Author(s): _____________________________________________________________

*Book Title: __________________________________________________________________

*Book Author(s): ______________________________________________________________

*Publisher: ___________________________________________________________________

*Year Published: ______

*Target Audience: Consumers/Families ___ Professionals ___ Policymakers ___ Students ____

Key Words (no more than 5): _____________________________________________________

Notes: _______________________________________________________________________

Data collection form: Reports and monographs

*Title: ________________________________________________________________________

*Author(s)/Organization(s): _______________________________________________________

*Year Published: _________

*Target Audience: Consumers/Families ___ Professionals ___ Policymakers ___ Students ____

*To obtain copies (URL or email): _________________________________________________

Key Words (no more than 5): _____________________________________________________

Notes: _______________________________________________________________________

Data collection form: Conference presentations and posters presented

(This section is not required for MCHB Training grantees.)

*Title: ________________________________________________________________________

*Author(s)/Organization(s): _______________________________________________________

*Meeting/Conference Name: ______________________________________________________

*Year Presented: _________

*Type:

Presentation

Poster

*Target Audience: Consumers/Families ___ Professionals ___ Policymakers ___ Students ____

*To obtain copies (URL or email): _________________________________________________

Key Words (no more than 5): _____________________________________________________

Notes: ________________________________________________________________________

Data collection form: Web-based products

*Product: _____________________________________________________________________

*Year: _________

*Type:	Blogs	Podcasts	Web-based video clips
	Wikis	RSS feeds	News aggregators
	Social networking sites	Other (Specify)

*Target Audience: Consumers/Families ___ Professionals ___ Policymakers ___ Students ____

*To obtain copies (URL): ________________________________________________________

Key Words (no more than 5): _____________________________________________________

Notes: ________________________________________________________________________

Data collection form: Electronic Products

*Title: ________________________________________________________________________

*Author(s)/Organization(s): _______________________________________________________

*Year: _________

*Type:	CD-ROMs	DVDs	Audio tapes
	Videotapes	Other (Specify)

*Target Audience: Consumers/Families ___ Professionals ___ Policymakers ___ Students ____

*To obtain copies (URL or email): _________________________________________________

Key Words (no more than 5): _____________________________________________________

Notes: ________________________________________________________________________

Data collection form: Press Communications

*Title: ________________________________________________________________________

*Author(s)/Organization(s): _______________________________________________________

*Year: _________

*Type:	TV interview	Radio interview	Newspaper interview
	Public service announcement	Editorial article	Other (Specify)

*Target Audience: Consumers/Families ___ Professionals ___ Policymakers ___ Students ____

*To obtain copies (URL or email): _________________________________________________

Key Words (no more than 5): _____________________________________________________

Notes: ________________________________________________________________________

Data collection form: Newsletters

*Title: ________________________________________________________________________

*Author(s)/Organization(s): _______________________________________________________

*Year: _________

*Type:

Electronic

Print

Both

*Target Audience: Consumers/Families ___ Professionals ___ Policymakers ___ Students ____

*To obtain copies (URL or email): _________________________________________________

*Frequency of distribution: Weekly Monthly Quarterly Annually Other (Specify)

Number of subscribers: __________________________________________________________

Key Words (no more than 5): _____________________________________________________

Notes: ________________________________________________________________________

Data collection form: Pamphlets, brochures or fact sheets

*Title: ________________________________________________________________________

*Author(s)/Organization(s): _______________________________________________________

*Year: _________

*Type:

Pamphlet

Brochure

Fact Sheet

*Target Audience: Consumers/Families ___ Professionals ___ Policymakers ___ Students ____

*To obtain copies (URL or email): _________________________________________________

Key Words (no more than 5): _____________________________________________________

Notes: ________________________________________________________________________

Data collection form: Academic course development

*Title: ________________________________________________________________________

*Author(s)/Organization(s): _______________________________________________________

*Year: _________

*Target Audience: Consumers/Families ___ Professionals ___ Policymakers ___ Students ____

*To obtain copies (URL or email): _________________________________________________

Key Words (no more than 5): _____________________________________________________

Notes: ________________________________________________________________________

Data collection form: Distance learning modules

*Title: ________________________________________________________________________

*Author(s)/Organization(s): _______________________________________________________

*Year: _________

*Media Type:	Blogs	Podcasts	Web-based video clips
	Wikis	RSS feeds	News aggregators
	Social media sites	CD-ROMs	DVDs
	Audio tapes	Videotapes	Other (Specify)

*Target Audience: Consumers/Families ___ Professionals ___ Policymakers ___ Students ____

*To obtain copies (URL or email): _________________________________________________

Key Words (no more than 5): _____________________________________________________

Notes: ________________________________________________________________________

Data collection form: Doctoral dissertations/Master’s theses

*Title: ________________________________________________________________________

*Author: ______________________________________________________________________

*Year Completed: _________

*Type:

Doctoral dissertation

Master’s thesis

*Target Audience: Consumers/Families ___ Professionals ___ Policymakers ___ Students ____

*To obtain copies (URL or email): _________________________________________________

Key Words (no more than 5): _____________________________________________________

Notes: ________________________________________________________________________

Other

(Note, up to 3 may be entered)

*Title: ________________________________________________________________________

*Author(s)/Organization(s): _______________________________________________________

*Year: _________

*Describe product, publication or submission: ________________________________________

_____________________________________________________________________________

*Target Audience: Consumers/Families ___ Professionals ___ Policymakers ___ Students ____

*To obtain copies (URL or email): _________________________________________________

Key Words (no more than 5): _____________________________________________________

Notes: ________________________________________________________________________

MCH TRAINING PROGRAM DATA FORMS

Faculty and Staff Information

List all personnel (faculty, staff, and others) contributing¹ to your training project, including those listed in the budget form and budget narrative and others that your program considers to have a central and ongoing role in the leadership training program whether they are supported or not supported by the grant.

	Personnel (Do not list trainees)
Name		Ethnicity (Hispanic or Latino, Not Hispanic or Latino, Unrecorded)	Race (American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, White, More than One Race, Unrecorded)	Gender (Male, Female, Transgender Man, Transgender Woman, Other (specify), Choose not to disclose/Unrecorded)2	Discipline		Year Hired in MCH Leadership Training Program	Former MCHB Trainee? (Yes/No)
Faculty
Staff
Other

Trainee Information (Long–term Trainees Only)

Definition: Long-term trainees (those with greater than or equal to 300 contact hours within the training program) benefiting from the training grant (including those who received MCH funds and those who did not).

Total Number of long-term trainees participating in the training program* __________
Name
Ethnicity
Race
Gender

Gender3 (number not percent)

Male _____ Female ______ Other (specify) ____

Transgender Man _____ Transgender Woman _____ Choose not to disclose/unknown _____

Address (For supported trainees ONLY)

City

State

Country

Discipline(s) upon Entrance to the Program

Degree(s)

Degree Program in which enrolled

Received financial MCH support? [ ] Yes [ ] No Amount: $_________________

If yes…. [ ] Stipend [ ] Tuition [ ] Stipend and Tuition [ ] Other

Type: [ ] Non-Degree Seeking [ ] Undergraduate [ ] Masters

[ ] Pre-doctoral [ ] Doctoral [ ] Post-doctoral

Student Status: [ ] Part-time student [ ] Full-time student

Postdoctoral Fellows and Epidemiology Doctoral Training Program fellows, please specify: Length of time receiving support: ____________

Research Topic or Title________________________________________________________

*All long-term trainees participating in the program, whether receiving MCH stipend support or not.

Former Trainee Information

The following information is to be provided for each long-term trainee who completed the Training Program 2 years and 5 years prior to the current reporting year.

Definition of Former Trainee = Long-term trainees who completed a long-term (greater than or equal to 300 contact hours) MCH Training Program 2 years and 5 years ago, including those who received MCH funds and those who did not. 

Project does not have any trainees who have completed the Training Program 2 years prior to current reporting year.

Project does not have any trainees who have completed the Training Program 5 years prior to current reporting year.

Name

Year Graduated

Gender4

Ethnicity5

Race6

Degree(s) Earned with MCH support (if applicable)

Was University able to contact the trainee?

City of Residence

State of Residence

Country of Residence

Current Employment Setting 7

Working in Public Health organization or agency (including Title V)? (Yes/No)

Working in MCH? (Yes/No)

Working with populations that are underserved or have been marginalized8?(Yes/No)

Met criteria for Leadership in Performance Measure Training 10? (Yes/No)

Met criteria for interdisciplinary practice in Performance Measure Training 12? (Yes/No)

MCH TRAINING PROGRAM TRAINEE FOLLOW-UP SURVEY

Contact / Background Information

*Name (first, middle, last):
Previous Name (if used while enrolled in the training program):
*Address:
	City	State	Zip
Phone:
Primary Email:

Permanent Contact Information (someone at a different address who will know how to contact you in the future, e.g., parents)

*Name of Contact:
Relationship:
*Address:
	City	State	Zip
Phone:

What year did you complete the MCH Training Program? _________

Degree(s) earned while participating in the MCH Training Program _____________

Gender⁹: (choose one)

__ Male

__Female

__Transgender Man

__Transgender Woman

__Choose not to disclose/unrecorded

Other, please specify:_______________________________________

Ethnicity: (choose one)

Hispanic is an ethnic category for people whose origins are in the Spanish-speaking countries of Latin America or who identify with a Spanish-speaking culture. Individuals who are Hispanic may be of any race.

__ Hispanic or Latino

__ Not Hispanic or Latino

__ Prefer not to say

Race: (choose one)

__ American Indian and Alaskan Native includes all individuals who identify with any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment. It includes people who identify as “American Indian” or “Alaska Native” and includes groups such as Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, and Nome Eskimo Community.

__ Asian includes all individuals who identify with one or more nationalities or ethnic groups originating in the Far East, Southeast Asia, or the Indian subcontinent. Examples of these groups include, but are not limited to, Chinese, Filipino, Asian Indian, Vietnamese, Korean, and Japanese. The category also includes groups such as Pakistani, Cambodian, Hmong, Thai, Bengali, Mien, etc.

__ Black or African American includes all individuals who identify with one or more nationalities or ethnic groups originating in any of the black racial groups of Africa. Examples of these groups include, but are not limited to, African American, Jamaican, Haitian, Nigerian, Ethiopian, and Somali. The category also includes groups such as Ghanaian, South African, Barbadian, Kenyan, Liberian, and Bahamian..

__ Native Hawaiian and Other Pacific Islander includes all individuals who identify with one or more nationalities or ethnic groups originating in Hawaii, Guam, Samoa, or other Pacific Islands. Examples of these groups include, but are not limited to, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, and Marshallese. The category also includes groups such as Palauan, Tahitian, Chuukese, Pohnpeian, Saipanese, Yapese, etc.

__ White includes all individuals who identify with one or more nationalities or ethnic groups originating in Europe, the Middle East, or North Africa. Examples of these groups include, but are not limited to, German, Irish, English, Italian, Lebanese, Egyptian, Polish, French, Iranian, Slavic, Cajun, and Chaldean.

__ More than One Race includes individuals who identify with more than one racial designation.

__ Prefer not to say is included for individuals who do not indicate their racial category.

Survey

Please answer all of the following questions as thoroughly as possible. When you have filled out the entire survey, return it to your Center/Program.

1. What best describes your current employment setting:

__ Student

__ Schools or school system (includes EI programs, elementary and secondary)

__ Post-secondary setting

__ Government agency

__ Clinical health care setting (includes hospitals, health centers and clinics)

__ Private sector

__ Other: please specify: ____________________________________

2. Do you currently work in a public health organization or agency (including Title V)? Y/N

3. Does your current work focus on Maternal and Child Health (MCH) populations (i.e., women, infants and children, adolescents, young adults, and their families including fathers, and children or young adults with special health care needs?)

__ yes

__ no

4. Does your current work focus on populations that are underserved or have been marginalized ¹⁰ (e.g., immigrant, tribal, migrant, or uninsured populations, individuals who have experienced family violence, homeless, foster care, HIV/AIDS, people with disabilities)

__ yes

__ no

5. Have you done any of the following activities since completing your training program? (check all that apply)

__	a. Participated on any of the following as a group leader, initiator, key contributor or in a position of influence/authority: committees of state, national or local organizations; task forces; community boards; advocacy groups; research societies; professional societies; etc.
__	b. Served in a clinical position of influence (e.g. director, senior therapist, team leader, etc.)
__	c. Provided consultation or technical assistance in MCH areas
__	d. Taught/mentored in my discipline or other MCH related field
__	e. Conducted research or quality improvement on MCH issues
__	f. Disseminated information on MCH Issues (e.g., Peer reviewed publications, key presentations, training manuals, issue briefs, best practices documents, standards of care)
__	g. Served as a reviewer (e.g., for a journal, conference abstracts, grant, quality assurance process) (ac, c)
__	h. Procured grant and other funding in MCH areas
__	i. Conducted strategic planning or program evaluation
__	j. Participated in public policy development activities (e.g., Participated in community engagement or coalition building efforts, written policy or guidelines, provided testimony, educated policymakers, etc.)
__	k. None

6. If you checked any of the activities above, in which of the following settings or capacities would you say these activities occurred? (check all that apply)

__ a. Academic

__ b. Clinical

__ c. Public Health

__ d. Public Policy & Advocacy

7. Have you done any of the following interdisciplinary activities since completing your training program? (check all that apply)

• a. Sought input or information from other professions or disciplines to address a need in your work

• b. Provided input or information to other professions or disciplines.

• c. Developed a shared vision, roles and responsibilities within an interdisciplinary group.

• d. Utilized that information to develop a coordinated, prioritized plan across disciplines to address a need in your work

• e. Established decision-making procedures in an interdisciplinary group.

• f. Collaborated with various disciplines across agencies/entities

• g. Advanced policies & programs that promote collaboration with other disciplines or professions

• h. None

(end of survey)

Confidentiality Statement

Thank you for agreeing to provide information that will enable your training program to track your training experience and follow up with you after the completion of your training. Your input is critical to our own improvement efforts and our compliance with Federal reporting requirements. Please know that your participation in providing information is entirely voluntary. The information you provide will only be used for monitoring and improvement of the training program. Please also be assured that we take the confidentiality of your personal information very seriously. We very much appreciate your time and assistance in helping to document outcomes of the Training Program. We look forward to learning about your academic and professional development.

Medium-Term Trainees

DEFINITION: Medium-term trainees are trainees with 40 - 299 contact hours in the current reporting year.

Medium-term Trainees with 40-149 contact hours during the past 12-month grant period

Total Number ______

Disciplines (check all that apply):

Audiology

Dentistry-Pediatric

Dentistry – Other

Education/Special Education

Family Member/Community Member

Genetics/Genetic Counseling

Health Administration

Medicine-General

Medicine-Adolescent Medicine

Medicine-Developmental-Behavioral Pediatrics

Medicine-Neurodevelopmental Disabilities

Medicine-Pediatrics

Medicine-Pediatric Pulmonology

Medicine – Other

Nursing-General

Nursing-Family/Pediatric Nurse Practitioner

Nursing-Midwife

Nursing – Other

Nutrition

Occupational Therapy

Person with a disability or special health care need

Physical Therapy

Psychiatry

Psychology

Public Health

Respiratory Therapy

Social Work

Speech-Language Pathology

Other (Specify)

Medium-Term Trainees with 150-299 contact hours The totals for gender, ethnicity, race and discipline must equal the total number of medium-term trainees with 150-299 contact hours
Total Number ________
Gender 11 (number not percent)	Male _____ Transgender Man ______ Other (specify) _____	Female _____ Transgender Woman ______ Choose not to disclose/unrecorded ______
Ethnicity12 (number not percent)	Hispanic or Latino _____	Not Hispanic or Latino ______	Unrecorded _______
Race 13 (number not percent)	American Indian or Alaska Native: _____ Asian: _____ Black or African American: _____ Native Hawaiian or Other Pacific Islander: ______ White: ______ More than One Race: ______ Unrecorded:______
Discipline Number Discipline ____ Audiology ____ Dentistry-Pediatric ____ Dentistry – Other ____ Education/Special Education ____ Family Member/Community Member ____ Genetics/Genetic Counseling ____ Health Administration ____ Medicine-General ____ Medicine-Adolescent Medicine ____ Medicine-Developmental-Behavioral Pediatrics ____ Medicine-Neurodevelopmental Disabilities ____ Medicine-Pediatrics ____ Medicine-Pediatric Pulmonology ____ Medicine – Other ____ Nursing-General ____ Nursing-Family/Pediatric Nurse Practitioner ____ Nursing-Midwife ____ Nursing – Other ____ Nutrition ____ Occupational Therapy ____ Person with a disability or special health care need ____ Physical Therapy ____ Psychiatry ____ Psychology ____ Public Health ____ Respiratory Therapy ____ Social Work ____ Speech-Language Pathology ____ Other (Specify)_________

TOTAL Number of Medium-term Trainees: _________

Short-Term Trainees

DEFINITION: Short-term trainees are trainees with less than 40 contact hours in the current reporting year. (Continuing Education participants are not counted in this category)

Total number of short term trainees during the past 12-month grant period________

Indicate disciplines (check all that apply)

Audiology

Dentistry-Pediatric

Dentistry – Other

Education/Special Education

Family Member/Community Member

Genetics/Genetic Counseling

Health Administration

Medicine-General

Medicine-Adolescent Medicine

Medicine-Developmental-Behavioral Pediatrics

Medicine-Neurodevelopmental Disabilities

Medicine-Pediatrics

Medicine-Pediatric Pulmonology

Medicine – Other

Nursing-General

Nursing-Family/Pediatric Nurse Practitioner

Nursing-Midwife

Nursing – Other

Nutrition

Occupational Therapy

Person with a disability or special health care need

Physical Therapy

Psychiatry

Psychology

Public Health

Respiratory Therapy

Social Work

Speech-Language Pathology

Other (Specify)

Continuing Education Form

Continuing Education is defined as continuing education programs or trainings that serve to enhance the knowledge and/or maintain the credentials and licensure of professional providers. Training may also serve to enhance the knowledge base of community outreach workers, families, and other members who directly serve the community. Additional details about CE activities will be collected in the annual progress report.

NOTE: Short-term trainees are not considered CE participants.

A. Provide information related to the total number of CE activities provided through your training program last year.
Total Number of CE Participants	_____
Total Number of CE Sessions/ Activities	_____
Number of CE Sessions/Activities by Primary Target Audience
	_____
Number of Within Your State CE Activities	_____
Number of CE Activities With Another State	_____
Number of Regional CE Activities	_____
Number of National CE Activities	_____
Number of International CE Activities	_____
Number of CE Sessions/Activities for which Credits are Provided	_____

B. Topics Covered in CE Activities Check all that apply
Clinical Care-Related (including medical home) Diversity or Cultural Responsiveness-Related Data, Research, Evaluation Methods (Knowledge Translation) Family Involvement Interdisciplinary Teaming Healthcare Workforce Leadership Policy Prevention Systems Development/ Improvement	Women’s Reproductive/ Perinatal Health Early Childhood Health/ Development (birth to school age) School Age Children Adolescent Health CSHCN/ Developmental Disabilities Autism Emergency Preparedness Health Information Technology Mental Health Nutrition Oral Health Patient Safety Respiratory Health Health Equity Health care financing Other (specify) ___________________________________

MCH LEAP PROGRAM GRADUATE FOLLOW-UP QUESTIONS

Please answer all of the following questions as thoroughly as possible. When you have filled out the entire survey, return it to your LEAP Program Director.

What year did you graduate from the MCH LEAP Program? _________

1. Are you currently enrolled or have you completed a graduate school program that is preparing you to work with the MCH population?

 Yes

 No

1b. If yes, which graduate programs have you enrolled in or completed?

 Medicine (e.g. Pediatric, Ob/Gyn, Primary Care)

 Public health

 Nutrition

 Social work

 Nursing

 Pediatric dentistry

 Psychology

 Pediatric occupational/physical therapy

 Speech language pathology

 Other MCH-related health profession (specify):_____

1c. If yes, did the MCH LEAP Training Program help in your admission to and/or being successful in your graduate program?

 Yes

 No

2. Have you worked with Maternal and Child Health (MCH) populations since graduating from the MCH LEAP Training Program? (i.e., women, infants and children, adolescents, young adults, and their families, including fathers, and children and youth with special health care needs)?

 Yes

 No

3. Have you worked with populations that are underserved or have been marginalized since graduating from the MCH LEAP Training program?

 Yes

 No

Maternal and Child Health Leadership, Education, and Advancement in Undergraduate Pathways (LEAP) Training Program: Trainee Information Form

Please provide aggregate data on medium-, and long-term LEAP trainees¹⁴ who are participating in the LEAP training program during the 12-month reporting period.

Total Number of LEAP Trainees: _____

Ethnicity:

Number of LEAP trainees who identify as:

• Hispanic/Latino: ______

• Non-Hispanic/Latino: _____

• Unrecorded: _____

Race¹⁵:

Number of LEAP trainees who identify as:

• American Indian or Alaska Native: ______

• Asian: _____

• Black or African American: _____

• Native Hawaiian or Pacific Islanders: _____

• White: ____

• More than one race:____

• Unrecorded: ____

Gender¹⁶:

Number of LEAP trainees who identify as:

• Male: _____

• Female: _____

• Transgender Man: _____

• Transgender Woman: _____

• Other (specify): _____

• Choose not to disclose/Unrecorded: _____

Age:

• 15 – 19: _____

• 20 – 24: _____

• 25 – 29: _____

• 30 – 34: _____

• 35 and older: ____

Number of LEAP trainees who are enrolled in college:

• Part-time: _____

• Full-time: _____

• Unrecorded: _____

Number of LEAP trainees who:

• Are the first in their family to attend college¹⁷: _____

• Work full-time (>35 hours/week) while enrolled in college¹⁸: _____

• Have a dependent(s) other than spouse: ______

HEALTHY START SITE FORM

Section 1. Grantee Primary Organization Information

Grant #____________________________________________

Grantee Name _______________________________________

Street Address_______________________________________

City_______________________________________ State _________ ZIP Code______________

Project Director Name______________________________________________________________

Phone 1___________________________ Phone 2________________________________________

Service area primarily defined by:  County  Zip Code

(Complete section below for each service delivery site)

Section 2. Healthy Start Sites

Site 1

Project Manager Name_______________________________________________________________

Project Name_______________________________________________________________________

Street Address______________________________________________________________________

City__________________________________ State__________ ZIP Code______________________

Enter the names of all of the counties covered by this site’s service area:_________________________________________________________________

Enter all of the ZIP codes covered by this site’s service area:_____________________________________________________________

Initial Year of Funding_____________________ Initial Funding Amount ______________________

Please check all services provided by this specific site/location:

	Adolescent Population		Doula Services		Interconception
	Breastfeeding Support		Fatherhood – Case Management		Mental & Behavioral Health (beyond screening)
	Case Management		Fatherhood – Group Services/Health Education		Outreach
	Children/Youth w/Special Health Care Needs		Food Insecurity Services		Preconception
			Health Education
	Direct Clinical Services		Incarcerated/Justice-System Involved Population		Prenatal

Site 2

Project Manager Name_______________________________________________________________

Project Name_______________________________________________________________________

Street Address______________________________________________________________________

City__________________________________ State__________ ZIP Code______________________

Enter the names of all of the counties covered by this site’s service area:_________________________________________________________________

Enter all of the ZIP codes covered by this site’s service area:s)_____________________________________________________________

Initial Year of Funding_____________________ Initial Funding Amount ______________________

Please check all services provided by this specific site/location:

	Adolescent Population		Doula Services		Interconception
	Breastfeeding Support		Fatherhood – Case Management		Mental & Behavioral Health (beyond screening)
	Case Management		Fatherhood – Group Services/Health Education		Outreach
	Children/Youth w/Special Health Care Needs		Food Insecurity Services		Preconception
			Health Education
	Direct Clinical Services		Incarcerated/Justice-System Involved Population		Prenatal

1 A ‘central’ role refers to those that regularly participate in on-going training activities such as acting as a preceptors; teaching core courses; and participating in other core leadership training activities that would be documented in the progress reports.

2 Male: Cisgender man, describes a person who was assigned male at birth and whose gender identity is a man/male.

Female: Cisgender woman, describes a person who was assigned female at birth and whose gender identity is a woman/female.

Transgender Man/Transgender Male/Transgender Masculine: Describes a person who is transgender and whose gender identity is boy/man/male.

Transgender Woman/Transgender Female/Transgender Feminine: Describes a person who is transgender and whose gender identity is girl/woman/female.

Other (specify): A gender identity that does not fit into the above categories, such as nonbinary (a person whose gender identity falls outside of the traditional gender binary structure of girl/woman and boy/man), agender (a person who identifies as having no gender, or who does not experience gender as a primary identity component), or another identity.

3 Male: Cisgender man, describes a person who was assigned male at birth and whose gender identity is a man/male.

Female: Cisgender woman, describes a person who was assigned female at birth and whose gender identity is a woman/female.

Transgender Man/Transgender Male/Transgender Masculine: Describes a person who is transgender and whose gender identity is boy/man/male.

Transgender Woman/Transgender Female/Transgender Feminine: Describes a person who is transgender and whose gender identity is girl/woman/female.

Other (specify): A gender identity that does not fit into the above categories, such as nonbinary (a person whose gender identity falls outside of the traditional gender binary structure of girl/woman and boy/man), agender (a person who identifies as having no gender, or who does not experience gender as a primary identity component), or another identity.

4 Gender Pick List: Male, Female, Transgender Man, Transgender Woman, Other (specify), Choose not to disclose/unknown

5 Ethnicity Pick List: Hispanic or Latino, Not Hispanic or Latino, Unrecorded

6 Race Pick List: American Indian and Alaska Native, Asian, Black or African American, Native Hawaiian and other Pacific Islander, White, More than One Race, Unrecorded

7 Employment Pick List: Student; Schools or school sustem (includes EI programs, elementatry, and secondary); Post-secondary setting; Government agency; Clinical health care setting (includes hospitals, health centers and clinics); Private sector; Other (specify)

8 Populations that are underserved or have been marginalized refer to groups of individuals at higher risk for health disparities by virtue of their race or ethnicity, socioeconomic status, geography, gender, age, disability status, or other risk factors including those associated with sex and gender.

9 Male: Cisgender man, describes a person who was assigned male at birth and whose gender identity is a man/male.

Female: Cisgender woman, describes a person who was assigned female at birth and whose gender identity is a woman/female.

Transgender Man/Transgender Male/Transgender Masculine: Describes a person who is transgender and whose gender identity is boy/man/male.

Transgender Woman/Transgender Female/Transgender Feminine: Describes a person who is transgender and whose gender identity is girl/woman/female.

Other (specify): A gender identity that does not fit into the above categories, such as nonbinary (a person whose gender identity falls outside of the traditional gender binary structure of girl/woman and boy/man), agender (a person who identifies as having no gender, or who does not experience gender as a primary identity component), or another identity.

10 Populations that are underserved or have been marginzlised refers to groups of individuals at higher risk for health disparities by virtue of their race or ethnicity, socio-economic status, geography, gender, age, disability status, or other risk factors including those associated with sex and gender.

11 Male: Cisgender man, describes a person who was assigned male at birth and whose gender identity is a man/male.

Female: Cisgender woman, describes a person who was assigned female at birth and whose gender identity is a woman/female.

Transgender Man/Transgender Male/Transgender Masculine: Describes a person who is transgender and whose gender identity is boy/man/male.

Transgender Woman/Transgender Female/Transgender Feminine: Describes a person who is transgender and whose gender identity is girl/woman/female.

Other (specify): A gender identity that does not fit into the above categories, such as nonbinary (a person whose gender identity falls outside of the traditional gender binary structure of girl/woman and boy/man), agender (a person who identifies as having no gender, or who does not experience gender as a primary identity component), or another identity.

12 Hispanic or Latino is defined as a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. People who identify as Hispanic, Latino, or Spanish may be any race.

13 American Indian or Alaska Native: The category “American Indian or Alaska Native” includes all individuals who identify with any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment. It includes people who identify as “American Indian” or “Alaska Native” and includes groups such as Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, and Nome Eskimo Community.

Asian: The category “Asian” includes all individuals who identify with one or more nationalities or ethnic groups originating in the Far East, Southeast Asia, or the Indian subcontinent. Examples of these groups include, but are not limited to, Chinese, Filipino, Asian Indian, Vietnamese, Korean, and Japanese. The category also includes groups such as Pakistani, Cambodian, Hmong, Thai, Bengali, Mien, etc.

Black or African American: The category “Black or African American” includes all individuals who identify with one or more nationalities or ethnic groups originating in any of the black racial groups of Africa. Examples of these groups include, but are not limited to, African American, Jamaican, Haitian, Nigerian, Ethiopian, and Somali. The category also includes groups such as Ghanaian, South African, Barbadian, Kenyan, Liberian, and Bahamian.

Native Hawaiian and Pacific Islander: The category “Native Hawaiian or Other Pacific Islander” includes all individuals who identify with one or more nationalities or ethnic groups originating in Hawaii, Guam, Samoa, or other Pacific Islands. Examples of these groups include, but are not limited to, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, and Marshallese. The category also includes groups such as Palauan, Tahitian, Chuukese, Pohnpeian, Saipanese, Yapese, etc.

White: The category “White” includes all individuals who identify with one or more nationalities or ethnic groups originating in Europe, the Middle East, or North Africa. Examples of these groups include, but are not limited to, German, Irish, English, Italian, Lebanese, Egyptian, Polish, French, Iranian, Slavic, Cajun, and Chaldean.

More than one Race: This category includes individuals who identify with more than one race.

14 LEAP Trainees are defined as medium-term (40-299 program hours) and long-term (300+ hours) trainees enrolled in the LEAP training program.

15 American Indian or Alaska Native: The category “American Indian or Alaska Native” includes all individuals who identify with any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment. It includes people who identify as “American Indian” or “Alaska Native” and includes groups such as Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, and Nome Eskimo Community.

Asian: The category “Asian” includes all individuals who identify with one or more nationalities or ethnic groups originating in the Far East, Southeast Asia, or the Indian subcontinent. Examples of these groups include, but are not limited to, Chinese, Filipino, Asian Indian, Vietnamese, Korean, and Japanese. The category also includes groups such as Pakistani, Cambodian, Hmong, Thai, Bengali, Mien, etc.

Black or African American: The category “Black or African American” includes all individuals who identify with one or more nationalities or ethnic groups originating in any of the black racial groups of Africa. Examples of these groups include, but are not limited to, African American, Jamaican, Haitian, Nigerian, Ethiopian, and Somali. The category also includes groups such as Ghanaian, South African, Barbadian, Kenyan, Liberian, and Bahamian.

Native Hawaiian and Pacific Islander: The category “Native Hawaiian or Other Pacific Islander” includes all individuals who identify with one or more nationalities or ethnic groups originating in Hawaii, Guam, Samoa, or other Pacific Islands. Examples of these groups include, but are not limited to, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, and Marshallese. The category also includes groups such as Palauan, Tahitian, Chuukese, Pohnpeian, Saipanese, Yapese, etc.

White: The category “White” includes all individuals who identify with one or more nationalities or ethnic groups originating in Europe, the Middle East, or North Africa. Examples of these groups include, but are not limited to, German, Irish, English, Italian, Lebanese, Egyptian, Polish, French, Iranian, Slavic, Cajun, and Chaldean.

More than one Race: This category includes individuals who identify with more than one race.

First-generation college students are students who enrolled in postsecondary education and whose parents do not have any postsecondary education experience.

Includes LEAP trainees who have worked full-time (>35 hours/week) at any point during the 12-month reporting period.

16 Male: Cisgender man, describes a person who was assigned male at birth and whose gender identity is a man/male.

Female: Cisgender woman, describes a person who was assigned female at birth and whose gender identity is a woman/female.

Transgender Man/Transgender Male/Transgender Masculine: Describes a person who is transgender and whose gender identity is boy/man/male.

Transgender Woman/Transgender Female/Transgender Feminine: Describes a person who is transgender and whose gender identity is girl/woman/female.

Other (specify): A gender identity that does not fit into the above categories, such as nonbinary (a person whose gender identity falls outside of the traditional gender binary structure of girl/woman and boy/man), agender (a person who identifies as having no gender, or who does not experience gender as a primary identity component), or another identity.

17 First-generation college students are students who enrolled in postsecondary education and whose parents do not have any postsecondary education experience.

18 Includes LEAP trainees who have worked full-time (>35 hours/week) at any point during the 12-month reporting period.

Attachment D | 3