1_revised DGIS OMB_SSA_Attachment B_Central Forms_nonsub_TC (revis

Maternal and Child Health Bureau Performance Measures for Discretionary Grant Information System (DGIS)

DGIS OMB_SSA_Attachment B_Central Forms_nonsub_TC

Attachment B Central Forms

OMB: 0915-0298

Document [docx]
Download: docx | pdf

OMB Number: 0915-0298 - Revision

Expiration Date: 12/31/2026


Health Resources and Services Administration

Maternal and Child Health Bureau



Discretionary Grant Information System


OMB No. 0915-0298 - Revision

Expires: 12/31/2026


Attachment B:

Central Forms


OMB Clearance Package









Public Burden Statement: The purpose of this information collection is to obtain performance data for the following: HRSA program participants, program operations and surveys. In addition, these data will facilitate the ability to demonstrate alignment between MCHB discretionary programs and the Discretionary Grant Information System (DGIS). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0298 and it is valid until 12/31/2026. Public reporting burden for this collection of information is estimated 1.90 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov. 

Table of Contents


Project Abstract

Project Abstract

Instructions

Section I – Project Identifier Information: These items will be auto-populated.


Section II – Budget: These figures will be auto-populated from Financial Form, Lines 1 through 4.

  • New Competing Performance Report: will auto-populate the budgeted amount for the first budget period

  • Non-Competing Continuation Performance Reports and Project Period End Report: will auto-populate the budgeted amount from the prior performance report


Section III – Types of Services

Indicate which type(s) of services your project provides, checking all that apply. For each type of service selected, indicated the percent of the Budget that is dedicated to that type of service (if you do not know the exact percent, provide your best estimate). Percents for all three service types should sum to 100%.


Comments: Enter any comments, if applicable.



Definitions:

Direct Services are preventive, primary, or specialty clinical services for which MCHB program funds are used to reimburse or fund providers for these services through a formal process similar to paying a medical billing claim or managed care contracts. Reporting on direct services should not include the costs of clinical services which are delivered with program dollars but reimbursed by Medicaid, CHIP or other public or private payers. Examples include, but are not limited to the following, paid for with program funds: preventive, primary, or specialty care visits, emergency department visits, inpatient services, outpatient and inpatient mental and behavioral health services, prescription drugs, occupational and physical therapy, speech therapy, durable medical equipment and medical supplies, medical foods, dental care, and vision care.


Enabling Services are non-clinical services (i.e., not included as direct or public health services) that enable individuals to access health care and improve health outcomes where MCHB program funds are used to finance these services. Enabling services include, but are not limited to: case management, care coordination, referrals, translation/interpretation, transportation, eligibility assistance, health education for individuals or families, environmental health risk reduction, health literacy, and beneficiary outreach. Reporting on enabling services should NOT include the costs for enabling services that are reimbursed by Medicaid, CHIP, or other public and private payers. Enabling services may include salary and operational support to a clinic that enable individuals to access health care or improve health outcomes. Examples include the salary of a public health nurse who provides prenatal care in a local clinic or compensation provided to a specialist pediatrician who provides services for children with special health care needs. In both cases the direct services might still be billed to Medicaid or other insurance, but providing for the availability of the provider enables individuals to access the services, and therefore counts as enabling services.


Public Health Services and Systems are activities and infrastructure to carry out the core public health functions of assessment, assurance, and policy development, and the 10 essential public health services. Examples include the development of standards and guidelines, needs assessment, program planning, implementation, and evaluation, policy development, quality assurance and improvement, workforce development, population-based outreach and education, and research.

Section IV – Grantee Organization Type: Choose the one that best applies to your organization.


Section V – Special Population(s) Served: If your program directly targets or serves any of the special populations listed, please select the population(s) that apply.


Section VI – Project Description OR Experience to Date (DO NOT EXCEED THE SPACE PROVIDED)

A. Project description, new projects only:

  1. A brief description of the project and the problem it addresses, such as preventive and primary care services for pregnant women, mothers, and infants; preventive and primary care services for children; and services for children with special health care needs.

  2. Displays up to 5 objectives of the program. The objectives are auto-populated with the objectives from the Notice of Funding Opportunity (NOFO). For each objective, describe the project activities used to reach objectives, and comment on innovation, cost, and other characteristics of the methodology that are proposed or are being implemented. Lists with numbered items can be used in this section.

  3. Describe the coordination planned and carried out, if applicable, with appropriate State and/or local health and other agencies in areas(s) served by the project.

  4. Briefly describe the evaluation methods that will be used to assess the success of the project in implementing activities and attaining its aims.


    1. Experience to date:

  1. For each program objective, select Yes or No to indicate if measurable progress towards the objective was made during the reporting period. Provide data and a brief description that supports the Yes/No selection (not to exceed 200 words).


Section VII – Key Words

Select the key words to describe the project. Choose key words from the included list. Select all that apply. If a key word is not listed, select Other and specify key word(s). You may select a sub-key word without also selecting the corresponding general key word. For example, you may select “Early Childhood - Newborn Screening” without selecting “Early Childhood - General”. In addition, you may select only the general key word if none of the sub-key words apply.


Comments: Enter any comments, if applicable.



I. PROJECT IDENTIFIER INFORMATION

1. Project Title: _____________

2. Project Number: _____________

3. Project Director/Principal Investigator as show on NoA: _________

4. E-mail Address: _____________


II. BUDGET

1. MCHB Grant Award $_____________

(Line 1, Financial Form)

2. Matching Funds (if applicable) $_____________

(Line 2, Financial Form)

3. Other Project Funds $_____________

(Line 3, Financial Form)

4. Total Project Funds $_____________

(Line 4, Financial Form)


III. TYPE(S) OF SERVICE PROVIDED (select all that apply)

ÿ Direct Services

Percent of Budget for Direct Services ____

ÿ Enabling Services

Percent of Budget for Enabling Services ____

ÿ Public Health Services and Systems

Percent of Budget for Public Health Services and Systems ____


  1. GRANTEE ORGANIZATION TYPE

ÿ State Agency

ÿ Community Government Agency

ÿ School District

ÿ University/Institution of Higher Learning (Non-Hospital Based)

ÿ Academic Medical Center

ÿ Community-Based Non-Governmental Organization (Health Care)

ÿ Community-Based Non-Governmental Organization (Non-Health Care)

ÿ Professional Membership Organization (Individuals Constitute Its Membership)

ÿ National Organization (Other Organizations Constitute Its Membership)

ÿ National Organization (Non-Membership Based)

ÿ Independent Research/Planning/Policy Organization

ÿ Other (specify) ______________


  1. SPECIAL POPULATION(S) SERVED (select all that apply)

  • Uninsured

  • Homeless

  • Rural

  • Tribal


  1. PROJECT DESCRIPTION OR EXPERIENCE TO DATE

  1. Project description, new projects only:


  1. Project Description and Problem (In 150 words or less, briefly describe the problem that your project addresses):


  1. Program Objectives and Key Project Activities: (Objectives auto-populated from the NOFO objectives. For each objective, list project activities used to reach objective, and comment on innovation, cost, and other characteristics of the methodology, proposed or are being implemented)

Objective 1:

Related Activity 1:

Related Activity 2:

Objective 2:

Related Activity 1:

Related Activity 2:

Objective 3:

Related Activity 1:

Related Activity 2:

Objective 4:

Related Activity 1:

Related Activity 2:

Objective 5:

Related Activity 1:

Related Activity 2:





  1. Coordination (List the state, local, or other organizations involved in the project and briefly describe their roles):



  1. Evaluation (Briefly describe the methods which will be used to determine whether process and outcome objectives are met; be sure to tie to evaluation requirements from NOFO):

B. Experience to date:


  1. Progress Towards Objectives to Date:

    1. Did you make measurable progress towards Objective 1 in the reporting period?

ÿ Yes ÿ No

      1. Provide data that support this: ______


    1. Did you make measurable progress towards Objective 2 in the reporting period?

ÿ Yes ÿ No

      1. Provide data that support this: ______


    1. Did you make measurable progress towards Objective 3 in the reporting period?

ÿ Yes ÿ No

      1. Provide data that support this: ______


    1. Did you make measurable progress towards Objective 4 in the reporting period?

ÿ Yes ÿ No

      1. Provide data that support this: ______


    1. Did you make measurable progress towards Objective 5 in the reporting period?

ÿ Yes ÿ No

      1. Provide data that support this: ______


  1. KEY WORDS (select all that apply)

  • Early Childhood – General

    • Early Childhood – Newborn Screening

    • Early Childhood – Safe Sleep

    • Early Childhood – Developmental Health (including developmental screening)

  • Adolescent Health

  • Maternal Health – General

    • Maternal Health – Maternal Mortality

    • Maternal Health – Perinatal/Postpartum Care

    • Maternal Health – Breastfeeding

    • Maternal Health – Maternal Depression

  • Children, Adolescents, and Young Adults with Special Health Care Needs

  • Developmental Disabilities

  • Mental/Behavioral Health – General

    • Mental/Behavioral Health – Autism

    • Mental/Behavioral Health – Substance Use Disorder(s)

  • Clinical Care

    • Sickle Cell Disease

    • Heritable Disorders (excluding sickle cell)

    • Epilepsy

    • Fetal Alcohol Syndrome

    • Oral Health

    • Medical Home

    • Health Care Transition

    • Immunizations

  • Injury Prevention – General

    • Injury Prevention – Poison/Toxin Exposure

  • Child Maltreatment

  • Emergency Services for Children – General

    • Emergency Services for Children – Emergency Preparedness

  • Health Equity

  • Social Determinants of Health

  • Telehealth

  • Preventive Services

  • Obesity

  • Health Insurance

  • Nutrition

  • Respiratory Health

  • Life Course Approach

  • Other (specify): _________



Comments: _____________________________________________________




Project Abstract (Research Programs ONLY)

Project Abstract (Research Programs ONLY)

Instructions

Section I – Project Identifier Information: These items will be auto-populated.


Section II – Budget: These figures will be auto-populated from the Financial Form, Lines 1 through 4.

  • New Competing Performance Report: will auto-populate the budgeted amount for the first budget period

  • Non-Competing Continuation Performance Reports and Project Period End Report: will auto-populate the budgeted amount from the prior performance report


Section III – Population Focus: Indicate which population(s) are the focus of the study. Select all that apply.


Section IV – Study Design: Indicate which type of design the study uses. Select all that apply.


Section V – Time Design: Indicate which type of design the study uses. Select all that apply.


Section VI – Priority Research Issues and Questions of Focus (DO NOT EXCEED THE SPACE PROVIDED)

Provide a brief statement of the primary and secondary (if applicable) areas to be addressed by the research.

The topic(s) should be aligned with those listed in the Maternal and Child Health Bureau (MCHB) Strategic

Research Issues (https://mchb.hrsa.gov/research/strategic-research-issues.asp).


Section VII – Research Abstract: Provide a three to five sentence description of your project that identifies the project's purpose, the needs and problems which are addressed, the objectives of the project, the related activities which will be used to meet the stated objectives, and the materials which will be developed.


Section VIII – Key Words

Select the key words to describe the project. Choose key words from the included list. Select all that apply. If a key word is not listed, select Other and specify key word(s). You may select a sub-key word without also selecting the corresponding general key word. For example, you may select “Early Childhood - Newborn Screening” without selecting “Early Childhood - General”. In addition, you may select only the general key word if none of the sub-key words apply.


Comments: Enter any comments, if applicable.


I. PROJECT IDENTIFIER INFORMATION

1. Project Title: _____________

2. Project Number: _____________

  1. Project Director/Principal Investigator as show on NoA: _____________

  2. Additional Principal Investigator(s), Discipline: _____________


II. BUDGET

1. MCHB Grant Award $_____________

(Line 1, Financial Form)

2. Matching Funds (if applicable) $_____________

(Line 2, Financial Form)

  1. Other Project Funds $_____________

(Line 3, Financial Form)

  1. Total Project Funds $_____________

(Line 4, Financial Form)


III. POPULATION FOCUS (select all that apply)

ÿ Neonates ÿ Pregnant Women

ÿ Infants ÿ Postpartum Women

ÿ Toddlers ÿ Parents/Mothers/Fathers

ÿ Preschool Children ÿ Adolescent Parents

ÿ School-Aged Children ÿ Grandparents

ÿ Adolescents ÿ Physicians

ÿ Adolescents (Pregnancy Related) ÿ Other (specify) ______

ÿ Young Adults (18-25)


IV. STUDY DESIGN (select all that apply)

ÿ Experimental

ÿ Quasi-experimental

ÿ Observational


V. TIME DESIGN (select all that apply)

ÿ Cross-sectional

ÿ Longitudinal

ÿ Mixed


VI. PRIORITY RESEARCH ISSUES AND QUESTIONS OF FOCUS

From the Maternal and Child Health Bureau (MCHB) Strategic Research Issues

Primary area addressed by research: _____________


Secondary area addressed by research (if applicable): _____________


  1. RESEARCH ABSTRACT
    _____________



  1. KEY WORDS (select all that apply)

  • Early Childhood – General

    • Early Childhood – Newborn Screening

    • Early Childhood – Safe Sleep

    • Early Childhood – Developmental Health (including developmental screening)

  • Adolescent Health

  • Maternal Health – General

    • Maternal Health – Maternal Mortality

    • Maternal Health – Perinatal/Postpartum Care

    • Maternal Health – Breastfeeding

    • Maternal Health – Maternal Depression

  • Children, Adolescents, and Young Adults with Special Health Care Needs

  • Developmental Disabilities

  • Mental/Behavioral Health – General

    • Mental/Behavioral Health – Autism

    • Mental/Behavioral Health – Substance Use Disorder(s)

  • Clinical Care

    • Sickle Cell Disease

    • Heritable Disorders (excluding sickle cell)

    • Epilepsy

    • Fetal Alcohol Syndrome

    • Oral Health

    • Medical Home

    • Health Care Transition

    • Immunizations

  • Injury Prevention – General

    • Injury Prevention – Poison/Toxin Exposure

  • Child Maltreatment

  • Emergency Services for Children – General

    • Emergency Services for Children – Emergency Preparedness

  • Health Equity

  • Social Determinants of Health

  • Telehealth

  • Preventive Services

  • Obesity

  • Health Insurance

  • Nutrition

  • Respiratory Health

  • Life Course Approach

  • Other (specify): _________



Comments: __________________________________________________



Financial Form


Financial Form

Instructions

Line 1 – MCHB Grant Award Amount: Enter the amount of the Federal MCHB grant award for this project.

Line 2 – Required Matching Funds: If matching funds are required for this grant program list the total amount of matching funds. These can include local, state, program, applicant/grantee, or other funds. Where appropriate, include the dollar value of in-kind contributions.

Line 3 – Other Project Funds: Enter the total amount of other funds received for the project. These can include local, state, program, applicant/grantee, or other funds leveraged. Also include the dollar value of in-kind contributions.

Line 4 – Total Project Funds: Displays the sum of lines 1 through 3, which is auto-calculated.

Line 5 – Federal Collaborative Funds: Enter the total amount of other Federal funds received other than the MCHB grant award for the project. Such funds include those from other Departments, other components of the Department of Health and Human Services, or other MCHB grants or contracts.


For all lines:

  • New Competing Performance Report: enter the budgeted amount for the first budget period

  • Non-Competing Continuation Performance Reports: enter the expended amount for the prior budget period and the budgeted amount for the upcoming budget period

  • Project Period End Report: enter the expended amount for the last budget period


Comments: Enter any comments, if applicable.





Budget Period ___


Budget Period ___



Budgeted

Expended

Budgeted

Expended







1.

MCHB GRANT AWARD AMOUNT

$ ___

$ ___

$ ___

$ ___

2.

REQUIRED MATCHING FUNDS

(Are matching funds required?

Yes ÿ No ÿ

If yes, please enter amount)

$ ___

$ ___

$ ___

$ ___

3.

OTHER PROJECT FUNDS

(Not included in Line 1 or Line 2 above)

$ ___

$ ___

$ ___

$ ___

4.

TOTAL PROJECT FUNDS

(Total of Lines 1 through 3)

$ ___

$ ___

$ ___

$ ___

5.

FEDERAL COLLABORATIVE FUNDS

(Additional federal funds contributing to the project)



Comments: _______________________

$ ___

$ ___

$ ___

$ ___
































Health Equity


Health Equity

Instructions

Select Yes or No to indicate whether your program advanced health equity during the reporting period. If Yes is selected, continue and complete Part A. If No is selected, the form is complete.


Part A. Health Equity

            1. Select the MCHB funded activity/activities that were conducted through your programming during the reporting period to advance health equity. Select all that apply.

            2. Select the MCHB funded activity/activities that your program/organization conducted internally during the reporting period to create or maintain an internal culture of equity. Select all that apply. If none of the options are close to the topic of your activity, select “Other” and specify. This question is optional; if internal activities were not conducted, you may skip this question.

            3. Select which equity topics your activities (through programming and/or internally) targeted and/or covered. If the specific equity topic of your activity is not listed, select the topic area closest to your topic area. Select all that apply. If none of the equity topics are close to the equity topic of your activity, select “Other” and specify.

            4. Select Yes or No to indicate if your program has established stated goals/objectives for health equity. Goals/objectives should have specific health equity components. Goals/objectives may apply to programming and/or internally. If No is selected, the form is complete.

              1. If Yes is selected, enter your stated goals/objectives and describe progress made on those goals/objectives during the reporting period.


Comments: Enter any comments, if applicable.



Definitions:

Health Equity is the attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.



  1. During the reporting period, did your program advance health equity?


ÿ Yes [complete Part A]

ÿ No

  1. Health Equity


      1. How has your program advanced health equity during the reporting period? (select all that apply)

ÿ Creating and supporting collaborations and partnerships with other health and non-health sectors that influence the well-being of individuals in order to advance health equity.

ÿ Engaging persons with lived experience in active roles that influence program planning and implementation, with a focus on advancing health equity.

ÿ Accounting for and addressing social and structural determinants of health to drive health equity in our program’s area of focus.

ÿ Creating and supporting the infrastructure and capacity for equity by improving data collection capacity, promoting cultural responsiveness, and promoting policies and procedures that advance equity.

ÿ Centering equity in data use and performance measurement, including disaggregating data across various demographic indicators and compiling and integrating diverse forms of quantitative and qualitative data.

ÿ Providing services to individuals and communities with the greatest need in order to promote equity in a culturally responsive manner, specifically focused on those disproportionately impacted by health outcomes.

ÿ Other (specify): _____


      1. How has your program/organization created or maintained an internal culture of equity? (select all that apply) [OPTIONAL]

ÿ Hiring policies and practices to advance staff diversity

ÿ Staff inclusion, belonging, and retention—with a focus on staff from diverse backgrounds

ÿ Staff capacity to effectively advance health equity

ÿ Organizational policies and practices that intentionally promote equity

ÿ Other (specify): _____

      1. Which equity topic(s) did your program’s activities target? (select all that apply)

      • Race/ethnicity

      • Sex/gender/sexual orientation/gender identity

      • Income/socioeconomic status

      • Disability

      • Age

      • Language

      • Geography – rural/urban

      • Other (specify): ________________

      1. Has your program established stated goals/objectives for health equity?

ÿ Yes

ÿ No

        1. If yes, enter the stated health equity goals/objectives and describe what progress your program made on those goals/objectives in the reporting period.





Comments: ________________________________

___________


Direct and Enabling Services


Direct and Enabling Services

Instructions

Select Yes or No to indicate whether your program provided direct and/or enabling services during the reporting period. If your program provided both direct and enabling services, select Yes for both, and complete Part A and Part B. If your program only provided direct services, select Yes for direct services only and complete Part A. If your program only provided enabling services, select Yes for enabling services and complete Part B. If your program did not provide either, select No and the form is complete.


Part A. Direct Services

  1. Select the types of direct services provided during the reporting period. Select all that apply.

  2. For outputs:

    1. Complete the table and fill in each of the cells as appropriate to calculate the total number served by direct services in the reporting period. For reporting on children, adolescents, and young adults, select EITHER “Children, Adolescents, and Young Adults (age 1-25)” OR the subcategories of “Children and Adolescents (age 1-17)” and “Young Adults (age 18-25).” Children, Adolescents, and Young Adults with Special Health Care Needs (CYSHCN) is a subset of Infants (age <1 year) and Children, Adolescents, and Young Adults (age 1-25) and will not be used to calculate the total served. Total columns and rows will be auto-calculated based on data entered into the cells. Within each reporting category, the count of individuals served should be unduplicated to the fullest extent possible. For example, if an individual receives multiple direct services such as screening and oral health care, the individual would only be counted once in the table. If data are provided in the row for “Children, Adolescents, and Young Adults”, “Children and Adolescents (age 1-17)”, and/or “Young Adults (age 18-25)”, please indicate the age range (minimum age and maximum age) of children, adolescents, and/or young adults served.

    2. If applicable, enter the number served by direct services using telehealth during the reporting period. Telehealth means that the direct service was provided using telehealth modalities. This number is a subset of the total number served by direct services. The count of individuals served via telehealth should be unduplicated to the fullest extent possible. For example, if an individual receives multiple direct services via telehealth, the individual would only be counted once.


Part B. Enabling Services

  1. Select the types of enabling services provided during the reporting period. Select all that apply.

  2. For outputs:

    1. Complete the table and fill in each of the cells as appropriate to calculate the total number served by enabling services in the reporting period. For reporting on children, adolescents, and young adults, report EITHER “Children, Adolescents, and Young Adults (age 1-25)” OR the subcategories of “Children and Adolescents (age 1-17)” and “Young Adults (age 18-25).” Children, Adolescents, and Young Adults with Special Health Care Needs (CYSHCN) is a subset of Infants (age <1 year) and Children, Adolescents, and Young Adults (age 1-25) and will not be used to calculate total served. Total columns and rows will be auto-calculated based on data entered into the cells. Within each reporting category, the count of individuals served should be unduplicated to the fullest extent possible. For example, if an individual receives multiple enabling services, the individual would only be counted once in the table. If data are provided in the row for “Children, Adolescents, and Young Adults”, “Children and Adolescents (age 1-17)”, and/or “Young Adults (age 18-25)”, please indicate the age range (minimum age and maximum age) of children, adolescents, and/or young adults served.

  1. If applicable, enter the number served by enabling services using telehealth during the reporting period. Telehealth means that the enabling service was provided using telehealth modalities. This number is a subset of the total number served by enabling services. The count of individuals served via telehealth should be unduplicated to the fullest extent possible. For example, if an individual receives multiple enabling services via telehealth, the individual would only be counted once.

Note: A program participant may receive both a direct and enabling service. If a participant receives both direct and enabling services, they should be included in the tables for Part A and Part B.


Comments: Enter any comments, if applicable.



Definitions:

Direct Services are preventive, primary, or specialty clinical services, where MCHB program funds are used to reimburse or fund individually delivered services through a formal process similar to paying a medical billing claim or managed care contracts. Reporting on direct services should NOT include the costs of clinical services which are delivered with program dollars but reimbursed by Medicaid, CHIP, or other public or private payers. (Definition Source: Adapted from TVIS Glossary https://mchb.tvisdata.hrsa.gov/Glossary/Glossary)

  • Services may be provided by clinical or non-clinical professionals and paraprofessionals.

  • Examples include, but are not limited to (where MCHB program funds are used to reimburse or fund individually delivered services through a formal process similar to paying a medical billing claim or managed care contracts), preventive, primary, or specialty care visits, emergency department visits, inpatient services, outpatient and inpatient mental and behavioral health services, prescription drugs, occupational and physical therapy, speech therapy, durable medical equipment and medical supplies (purchased directly for a person to use themselves at home), medical foods, oral health care, and vision care.

  • The recipients of these services are individuals or members of families


Enabling Services are non-clinical services that aid individuals to access health care and supportive care and improve health and well-being outcomes. (Definition Source: Adapted from TVIS Glossary https://mchb.tvisdata.hrsa.gov/Glossary/Glossary)

  • Enabling services include, but are not limited to: case management, care coordination, referrals, services to support transition from pediatric to adult health care, consultation, translation/interpretation, transportation, eligibility assistance, health education for individuals or families, environmental health risk reduction, health literacy, beneficiary outreach, and purchase of equipment and medical supplies (to support the care of people in a care setting). 

  • The recipients of these services are individuals or members of families.


Families include individuals in traditional or non-traditional family structures and may include biological, foster, or adoptive parents and/or siblings, spouses or partners, or members of an extended family.


Telehealth is the use of electronic information and telecommunication technologies to support long-distance clinical health care, patient and professional health-related education, health administration, and public health.

1. During the reporting period, did your program provide direct or enabling services? (select all that apply)


ÿ Yes, direct services [complete Part A]

ÿ Yes, enabling services [complete Part B]

ÿ No

  1. Direct Services


  1. Types of direct services provided in the reporting period (select all that apply)

ÿ Clinical assessments

ÿ Screening

ÿ Preventive care visits

ÿ Primary care visits

ÿ Specialty care visits

ÿ Emergency department visits

ÿ Inpatient services

ÿ Outpatient and/or inpatient mental and behavioral health services

ÿ Oral health care

ÿ Vision care

ÿ Prescription drugs

ÿ Occupational and/or physical therapy

ÿ Speech therapy

ÿ Purchase of durable medical equipment and medical supplies (for use at a person’s home)

ÿ Purchase of medical foods

ÿ Other (specify): _________________________

  1. Outputs

  1. Total # served by direct services in the reporting period

<TABLE BY POPULATION GROUPS AND RACE, ETHNICITY, AND INSURANCE>


    1. # served by direct services using telehealth in the reporting period (Note: this number is a subset of Total # served by direct services) _____

  1. Enabling Services


  1. Types of enabling services provided in the reporting period (select all that apply)

ÿ Care management

ÿ Care coordination

ÿ Referrals

ÿ Health education

ÿ Transition services

ÿ Consultation

ÿ Translation/interpretation

ÿ Transportation

ÿ Eligibility assistance

ÿ Environmental health risk reduction

ÿ Health literacy and outreach

ÿ Purchase of equipment and medical supplies (for use in a care setting)

ÿ Other (specify): _________________________

  1. Outputs

  1. Total # served by enabling services in the reporting period

<TABLE BY POPULATION GROUPS AND RACE, ETHNICITY, AND INSURANCE >


    1. # served by enabling services using telehealth in the reporting period (Note: this number is a subset of Total # served by enabling services) _____

Comments: _________________________________________________________________________________________



























<TABLE BY POPULATION GROUPS AND RACE, ETHNICITY, AND INSURANCE>

RACE


ETHNICITY

INSURANCE


American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

More than One Race

Unknown/Unrecorded

Total

Hispanic or Latino

Not Hispanic or Latino

Unknown/Unrecorded

Total

Public

Private

Uninsured

Unknown/Unrecorded

Total

Infants (age <1 year)


















Children, Adolescents, and Young Adults (age 1-25)


















Children and Adolescents (age 1-17)


















Young Adults (age 18-25)


















CYSHCN (age 0-25)


















Pregnant/ postpartum persons (all ages)


















Non-pregnant women (age 26+)


















Men (age 26+)


















Families


















Other (specify): _________


















Unknown


















TOTALS



















If served “Children, Adolescents, and Young Adults (age 1-25)”, “Children and Adolescents (age 1-17)”, and/or “Young Adults (age 18-25)”, and reported them in the table above, please indicate the age range of children, adolescents, and/or young adults served.

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Training and Workforce Development

Training and Workforce Development

Instructions

Select Yes or No to indicate whether your program conducted training and workforce development through a degree, certification, or formal course AND/OR through continuing education during the reporting period. If your program provided both, select Yes for both, and complete Part A and Part B. If your program only provided training and workforce development through a degree, certification, or formal course, only select Yes for training and workforce development through a degree, certification, or formal course and complete Part A. If your program only provided continuing education, select Yes for continuing education and complete Part B. If your program did not provide either, select No and the form is complete.


Part A. Degree, Certification, or Formal Course

  1. Select the type(s) of trainees reached during the reporting period. Select all that apply.

  2. Select the focus area(s) of the training(s) provided. Select all that apply.

  3. Select the topic area(s) of the training(s) provided. Select all that apply. If the specific topic area of your training is not listed, select the topic area closest to your topic area. If none of the topic areas are close to your topic area, select “none of the above.” You may select a subtopic without also selecting the corresponding general topic. For example, you may select “Early Childhood - Newborn Screening” without selecting “Early Childhood - General”. In addition, you may select only the general topic if none of the subtopics apply.

  4. For outputs:

    1. Enter the number of trainees trained during the reporting period. This number should be an unduplicated count.


Part B. Continuing Education

  1. Select the type(s) of continuing education participants reached during the reporting period. Select all that apply.

  2. Select the subject area(s) of the continuing education provided. Select all that apply. If the specific subject area of your training is not list, select the subject area closest to your subject area. If none of the subject areas are close to your subject area, select “none of the above.”

  3. If applicable, select the topic area(s) of the continuing education provided. Select all that apply. If the specific topic area of your training is not list, select the topic area closest to your topic area. If none of the topic areas are close to your topic area, select “none of the above.” You may select a subtopic without also selecting the corresponding general topic. For example, you may select “Early Childhood - Newborn Screening” without selecting “Early Childhood - General”. In addition, you may select only the general topic if none of the subtopics apply.

  4. For outputs:

    1. Enter the number of continuing education sessions/activities conducted during the reporting period.

    2. Enter the number of continuing education participants during the reporting period. This number may be duplicated.


Comments: Enter any comments, if applicable.



Definitions:

Degree, Certification, or Formal Course refers to training provided through a standard curriculum that may result in a degree or certification. Post-graduates and early research investigators are also included, even though they will not receive a degree or certificate. Also included are individuals that receive a portion of the curriculum but do not complete all of the curriculum or receive a degree or certificate. This may include:

  • Short-term, medium-term, and long-term Division of Maternal and Child Health Workforce Development training program trainees

  • Research network mentees

  • Individuals receiving EMS certification

  • Individuals receiving doula certification


Continuing Education refers to trainings that maintain or strengthen knowledge and skills of the MCH workforce (including community outreach workers, families, and other members who directly serve the community), and are not part of a degree, certification, or formal course. This includes trainings that may be used to maintain the credentials and licensure of health care providers, public health practitioners, other members of the practicing MCH workforce.


Differentiation between Training and Workforce Development, Technical Assistance, and Outreach and Education:


Activity

Is the Purpose of the Activity to Address Needs at the Individual, Organizational, or General Population Level?

Recipient Level

Goal

Included Activities

Training and Workforce Development

Individual trainees or practicing MCH workforce professionals

Individual trainees or practicing MCH workforce professionals

To improve the knowledge, skills, and capacity of future and practicing MCH workforce members

  • Undergraduate, graduate, and post-graduate education and training

  • Continuing education

  • Applied learning

  • ECHO, if it includes training sections

Technical Assistance

Organizational

Individual(s) in the organization

To improve the knowledge and skills of organizational members in order to meet organizational outcomes

Provide support, training, education, etc. with the intent of facilitating and achieving organizational goals and outcomes.


Activities

  • Training

  • TA

  • Site visits

  • Collaborative networks

  • Running peer-to-peer forums

Outreach and Education

General population

Individuals in the population at large

To improve knowledge of the target population by providing information, messaging, and discussion

Provide information and messaging to MCH populations through more generalized and passive mechanisms. (If program funds are used to create resources and tools, but not provide direct one-on-one support and contact, this would count here).


Activities

  • Public health campaigns

  • Educational pamphlets, fact sheets, etc.

  • Webinars available to the public



  1. During the reporting period, did your program provide training and workforce development through a degree, certification, or formal course OR through continuing education?

(select all that apply)


ÿ Yes, provided training and workforce development through a degree, certification, or formal course [complete Part A]

ÿ Yes, provided training and workforce development through continuing education [complete Part B]

ÿ No

  1. Degree, Certification, or Formal Course


  1. Trainee Type reached in the reporting period (select all that apply)

ÿ Undergraduate

ÿ Graduate

ÿ Post-graduate

ÿ Non-degree seeking

ÿ Other (specify): ________________________

  1. Training Focus (select all that apply)

ÿ Clinical care

ÿ Care support (including allied health)

ÿ Research

ÿ Public health, non-research (for example, policy, planning, leadership, etc.)

ÿ Other (specify): ___________

  1. Training Topic Area (select all that apply)

  • Early Childhood – General

    • Early Childhood – Newborn Screening

    • Early Childhood – Safe Sleep

    • Early Childhood – Developmental Health (including developmental screening)

  • Adolescent Health

  • Maternal Health – General

    • Maternal Health – Maternal Mortality

    • Maternal Health – Perinatal/Postpartum Care

    • Maternal Health – Breastfeeding

    • Maternal Health – Maternal Depression

  • Children, Adolescents, and Young Adults with Special Health Care Needs

  • Developmental Disabilities

  • Mental/Behavioral Health – General

    • Mental/Behavioral Health – Autism

    • Mental/Behavioral Health – Substance Use Disorder(s)

  • Clinical Care

  • Sickle Cell Disease

  • Heritable Disorders (excluding sickle cell)

  • Epilepsy

  • Fetal Alcohol Syndrome

  • Oral Health

  • Medical Home

  • Health Care Transition

  • Immunizations

  • Injury Prevention – General

    • Injury Prevention – Poison/Toxin Exposure

  • Child Maltreatment

  • Emergency Services for Children – General

    • Emergency Services for Children – Emergency Preparedness

  • Health Equity

  • Social Determinants of Health

  • Telehealth

  • Preventive Services

  • Obesity

  • Health Insurance

  • Nutrition

  • Respiratory Health

  • Life Course Approach

  • None of the above

  1. Outputs

  1. # trained during the reporting period ____

  1. Continuing Education


  1. Continuing Education Participant Type reached in the reporting period (select all that apply)

ÿ Clinical care provider (for example, MD, DO, NP, PA, etc.)

ÿ Care support provider (including allied health)

ÿ Researcher

ÿ Public health professional, non-researcher

ÿ Community-based participant (for example, community outreach worker, family advocate, etc.)

ÿ Other (specify): _____

  1. Continuing Education Subject Area (select all that apply)

  • Clinical Care Related (including medical home)

  • Equity, Diversity, or Cultural Responsiveness Related

  • Data, Research, Evaluation Methods

  • Family Involvement

  • Interdisciplinary Teaming

  • Health Care Workforce Leadership

  • Policy

  • Systems Development/Improvement (including capacity building, planning, and financing)

  • Emerging Issues (specify): _____

  • None of the above



  1. Continuing Education Topic Area (select all that apply)

  • Early Childhood – General

    • Early Childhood – Newborn Screening

    • Early Childhood – Safe Sleep

    • Early Childhood – Developmental Health (including developmental screening)

  • Adolescent Health

  • Maternal Health – General

    • Maternal Health – Maternal Mortality

    • Maternal Health – Perinatal/Postpartum Care

    • Maternal Health – Breastfeeding

    • Maternal Health – Maternal Depression

  • Children, Adolescents, and Young Adults with Special Health Care Needs

  • Developmental Disabilities

  • Mental/Behavioral Health – General

    • Mental/Behavioral Health – Autism

    • Mental/Behavioral Health – Substance Use Disorder(s)

  • Clinical Care

  • Sickle Cell Disease

  • Heritable Disorders (excluding sickle cell)

  • Epilepsy

  • Fetal Alcohol Syndrome

  • Oral Health

  • Medical Home

  • Health Care Transition

  • Immunizations

  • Injury Prevention – General

    • Injury Prevention – Poison/Toxin Exposure

  • Child Maltreatment

  • Emergency Services for Children – General

    • Emergency Services for Children – Emergency Preparedness

  • Health Equity

  • Social Determinants of Health

  • Telehealth

  • Preventive Services

  • Obesity

  • Health Insurance

  • Nutrition

  • Respiratory Health

  • Life Course Approach

  • None of the above

  1. Outputs (complete both a and b)


  1. # of continuing education sessions/activities conducted during the reporting period ___

  2. # of participants in continuing education activities during the reporting period ___

Comments: ___________________________________________________________________________________________________


Partnerships and Collaboration

Partnerships and Collaborations

Instructions

Select Yes or No to indicate whether your program engaged in or supported partnerships and collaborations during the reporting period. If Yes is selected, continue and complete Part A. If No is selected, the form is complete.


Part A. Partnerships and Collaborations

  1. Select the purpose of the partnership(s)/collaboration(s). This should be the main reason(s) for establishing, supporting, engaging in, and continuing partnership(s)/collaboration(s). Select all that apply.

  2. For outputs: For each applicable partner/collaborator category, select all the types of partnership/collaboration that apply, and report the number of partnerships/collaborations in the reporting period. The number of partnerships/collaborations should be an unduplicated count. For example, if a program had multiple types of partnerships/collaborations with one Title V agency in the reporting period, the number of Title V partnerships would be one. If a program had partnerships with two Title V agencies, the number of Title V partnerships would be two. Partners/Collaborators can be organizations or individuals.


Comments: Enter any comments, if applicable.



Definitions:

Partnership and Collaboration refers to activities that build and strengthen connections between organizations and individuals with similar interests, missions, and activities to allow for information sharing, learning, and capacity building across organizations/individuals. These activities include creation or strengthening of relevant organizational relationships that serve to expand the capacity and reach of a program in meeting the needs of its MCH population. Partnerships and collaborations are intended to be mutually beneficial relationships for all parties involved. Programs that build partnerships and collaboration between organizations, but themselves are not active in or beneficiaries of the partnerships (for example, a TA center that sets up a peer-to-peer network but does NOT participate as a recipient or beneficiary), should not complete this form.


  1. During the reporting period, did your program engage in or support partnerships and collaboration to expand capacity and reach to meet the needs of the program’s MCH population?



  • Yes [complete Part A]

  • No

  1. Partnerships and Collaborations


    1. Purpose of partnerships/ collaborations (select all that apply)

  • Improve program quality

  • Increase reach of program activities or messaging

  • Increase funding or other resources to advance program goals

  • Increase political will/“buy-in” for program activities or goals

  • Establish or implement shared goals, activities, data collection, or measurement

  • Reach and engage communities/potential service recipients

  • Other (specify): ___________

    1. Outputs: Types and numbers of partnerships and collaborations in reporting period, by partner/collaborator category

Partner/Collaborator Category

Type of partnership/collaboration (select all that apply)

Number of partnerships/ collaborations for the partner/collaborator category in the reporting period

Title V

  • Memoranda of understanding or other written agreements

  • Working groups or committees (including advisory boards, steering committees)

  • Peer-to-peer learning

  • Provider-to-provider consultations

  • Information-sharing networks

  • Shared resources (for example, funding, staff, etc.)

  • Referral and care coordination networks

  • Other (specify): ____________________










Social service agency

  • Memoranda of understanding or other written agreements

  • Working groups or committees (including advisory boards, steering committees)

  • Peer-to-peer learning

  • Provider-to-provider consultations

  • Information-sharing networks

  • Shared resources (for example, funding, staff, etc.)

  • Referral and care coordination networks

  • Other (specify): ____________________


Medicaid agency

  • Memoranda of understanding or other written agreements

  • Working groups or committees (including advisory boards, steering committees)

  • Peer-to-peer learning

  • Provider-to-provider consultations

  • Information-sharing networks

  • Shared resources (for example, funding, staff, etc.)

  • Referral and care coordination networks

  • Other (specify): ____________________


Other state/local agencies

  • Memoranda of understanding or other written agreements

  • Working groups or committees (including advisory boards, steering committees)

  • Peer-to-peer learning

  • Provider-to-provider consultations

  • Information-sharing networks

  • Shared resources (for example, funding, staff, etc.)

  • Referral and care coordination networks

  • Other (specify): ____________________


Health care providers/ clinical providers

  • Memoranda of understanding or other written agreements

  • Working groups or committees (including advisory boards, steering committees)

  • Peer-to-peer learning

  • Provider-to-provider consultations

  • Information-sharing networks

  • Shared resources (for example, funding, staff, etc.)

  • Referral and care coordination networks

  • Other (specify): ____________________


Community/family groups

  • Memoranda of understanding or other written agreements

  • Working groups or committees (including advisory boards, steering committees)

  • Peer-to-peer learning

  • Provider-to-provider consultations

  • Information-sharing networks

  • Shared resources (for example, funding, staff, etc.)

  • Referral and care coordination networks

  • Other (specify): ____________________


Educational institutions

  • Memoranda of understanding or other written agreements

  • Working groups or committees (including advisory boards, steering committees)

  • Peer-to-peer learning

  • Provider-to-provider consultations

  • Information-sharing networks

  • Shared resources (for example, funding, staff, etc.)

  • Referral and care coordination networks

  • Other (specify): ____________________


Health insurance (non-public)

  • Memoranda of understanding or other written agreements

  • Working groups or committees (including advisory boards, steering committees)

  • Peer-to-peer learning

  • Provider-to-provider consultations

  • Information-sharing networks

  • Shared resources (for example, funding, staff, etc.)

  • Referral and care coordination networks

  • Other (specify): ____________________


Tribal entities

  • Memoranda of understanding or other written agreements

  • Working groups or committees (including advisory boards, steering committees)

  • Peer-to-peer learning

  • Provider-to-provider consultations

  • Information-sharing networks

  • Shared resources (for example, funding, staff, etc.)

  • Referral and care coordination networks

  • Other (specify): ____________________


Federal partners

  • Memoranda of understanding or other written agreements

  • Working groups or committees (including advisory boards, steering committees)

  • Peer-to-peer learning

  • Provider-to-provider consultations

  • Information-sharing networks

  • Shared resources (for example, funding, staff, etc.)

  • Referral and care coordination networks

  • Other (specify): ____________________


Other (specify): ___________

  • Memoranda of understanding or other written agreements

  • Working groups or committees (including advisory boards, steering committees)

  • Peer-to-peer learning

  • Provider-to-provider consultations

  • Information-sharing networks

  • Shared resources (for example, funding, staff, etc.)

  • Referral and care coordination networks

  • Other (specify): ____________________





Comments: ______________________________________________________________________________________




Engagement of Persons with Lived Experience

Engagement of Persons with Lived Experience

Instructions

Select Yes or No to indicate whether your program supported engagement of family members and/or other persons with lived experience during the reporting period. If your program supported both, select Yes for both, and complete Part A and Part B. If your program only supported engagement of family members, select Yes for family members only and complete Part A. If your program only supported engagement of other persons with lived experience, select Yes for other persons with lived experience and complete Part B. If your program did not support either, select No and the form is complete.


Part A. Family Engagement

  1. For each engagement area, indicate whether your program engaged family members during the reporting period and, if yes, enter the number of family members engaged during the reporting period. Multiple individuals from within the same family unit should be counted separately (i.e., if a program engaged two parents, they should each be counted separately). The number engaged may be duplicated across rows (i.e., if a family member is engaged in both Program Development, Planning and Evaluation, as well as Leadership Training, the family member would be counted in each row).

  2. If able, complete the table and fill in each of the cells as appropriate. This item is optional. The unduplicated row totals for race and ethnicity will be auto-calculated and may not align with the duplicated numbers presented in Table A.i. When reporting data pertaining to participants’ race, ethnicity, or membership in social or demographic groups—particularly groups those that are underrepresented—awardees should ensure that those data are accurate and collected validly and sensitively. Do not infer or guess individuals’ membership in a particular group.

  3. If able, enter the number engaged during the reporting period from other demographic groups that are underrepresented (for example, underrepresented factors include sexual orientation, gender identity, income/socioeconomic status, health status/disability, age, language, geography). This item is optional and should only be completed if data are collected in a valid manner that recognizes the sensitive nature of these topics.

  4. Select Yes or No to indicate if family members were compensated for their engagement during the reporting period. Select Yes if at least one family member was compensated. If yes, and if able, enter the number of family members compensated; the item for number of family members compensated is optional.

  5. Select Yes or No to indicate whether engaging family members resulted in any changes to your program. If yes, select all the ways engagement resulted in changes to your program. Note that the form does not require you to measure or quantify the degree of change, only that it occurred. Select all that apply.


Part B. Other Persons with Lived Experience Engagement

  1. For each engagement area, indicate whether your program engaged other persons with lived experience during the reporting period and, if yes, enter the number of other persons with lived experience engaged during the reporting period. The number engaged may be duplicated across rows (i.e., if a person with lived experience is engaged in both Program Development, Planning and Evaluation, as well as Leadership Training, the person would be counted for each row).

  2. Indicate the population categories of persons with lived experience that the program engaged. Select all that apply.

  3. If able, complete the table and fill in each of the cells as appropriate. This item is optional. The unduplicated row totals for race and ethnicity will be auto-calculated and may not align with the duplicated numbers presented in Table B.i. When reporting data pertaining to participants’ race, ethnicity, or membership in social or demographic groups—particularly groups those that are underrepresented—awardees should ensure that those data are accurate and collected validly and sensitively. Do not infer or guess individuals’ membership in a particular group.

  4. If able, enter the number engaged during the reporting period from other demographic groups that are underrepresented (for example, underrepresented factors include sexual orientation, gender identity, income/socioeconomic status, health status/disability, age, language, geography). This item is optional and should only be completed if data are collected in a valid manner that recognizes the sensitive nature of these topics.

  5. Select Yes or No to indicate if persons with lived experience were compensated for their engagement during the reporting period. Select Yes if at least one person with lived experience was compensated. If yes, and if able, enter the number of persons with lived experience compensated; the item for number of persons with lived experience compensated is optional.

  6. Select Yes or No to indicate whether engaging other persons with lived experience resulted in any changes to your program. If yes, select all the ways engagement resulted in changes to your program. Note that the form does not require you to measure or quantify the degree of change, only that it occurred. Select all that apply.


Comments: Enter any comments, if applicable.



Definitions:

Persons with Lived Experience refers to individuals with knowledge and experience on health or social issues relevant to a particular program that is gained through direct, first-hand involvement in everyday events rather than through representations constructed by other people.1 Community-based organizations, for example, would not be included under this definition. For the purposes of this form, engagement of persons with lived experience is measured through two categories: “Family Engagement” and “Other Persons with Lived Experience.” Family members often navigate systems and services on behalf of individuals, so their lived experience is collected separately. Therefore, for data collection purposes, the term “Other Persons with Lived Experience” is used to delineate from family engagement and avoid duplicated counts.


Family Engagement: Family members include individuals in traditional or non-traditional family structures and may include biological, foster, or adoptive parents and/or siblings, spouses or partners, or members of an extended family. These family members have lived experience through their first-hand knowledge of navigating systems and services either on behalf of a family member or for the family as a whole (for example, parents of infants and toddlers, family members of children and youth with special health care needs, etc.). Family engagement refers to family members serving as representatives or leaders who build and strengthen programs and systems rather than being the direct recipient of services.

Other Persons with Lived Experience: This subcategory excludes family members, as defined above. Engaging other individual persons with lived experience entails actively and intentionally seeking and implementing input from individuals with personal knowledge pertaining to the issue the program is trying to address. For the purpose of this form, individuals with lived experiences represent their own personal history and experience navigating systems and services for themselves, rather than on behalf of a family member. Examples of persons with lived experience include self-advocates or individuals with direct experience on a health issue (for example, youth self-advocates with special health care needs, pregnant or postpartum persons, individual community members affected by a public health emergency, etc.).



1. Chandler, D., & Munday, R. (2016). Oxford: A dictionary of media and communication (2nd ed.). New York, NY: Oxford University Press.



  1. During the reporting period, did your program support engagement of persons with lived experience? (select all that apply)



  • Yes, engaged with or supported family members to expand the capacity and reach of a program in meeting the needs of the program’s MCH population [complete Part A]

  • Yes, engaged with or supported other persons with lived experience to expand the capacity and reach of a program in meeting the needs of the program’s MCH population [complete Part B]

  • No

  1. Family Engagement



    1. Number engaged in the reporting period, by engagement area

Engagement Area

Has your program engaged family members in this engagement area in the reporting period?


Number engaged in the reporting period

Program Development, Planning, and Evaluation

Family members participate in and provide feedback on the planning, implementation, and/or evaluation of the program (for example, strategic planning, program planning, materials development, program activities, teaching, mentoring, measurement, etc.).


  • Yes

  • No


Leadership Training

Within your program, family members are trained or mentored for leadership roles (for example, advisory committees, task forces, teaching, etc.).


  • Yes

  • No


Active Leadership

Within your program, family members have leadership roles on advisory committees or task forces.

  • Yes

  • No






    1. Number engaged by race and ethnicity in the reporting period

(OPTIONAL)

RACE

ETHNICITY

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

More than One Race

Unknown/Unrecorded

Total

Hispanic or Latino

Not Hispanic or Latino

Unknown/Unrecorded

Total














    1. Number engaged from other demographic groups that are underrepresented (for example, underrepresented factors include sexual orientation, gender identity, income/socioeconomic status, health status/disability, age, language, geography), in the reporting period

(OPTIONAL)

Number engaged from other underrepresented groups





    1. In the reporting period, were family members compensated for their engagement (for example, paid faculty or staff, consultants, honoraria, etc.)?



  • Yes

  • No

  1. If yes, number compensated in the reporting period ?

(OPTIONAL)

Number compensated in the reporting period



    1. In the reporting period, did engagement of family members result in any changes to your program?

      1. If yes, as a result of engaging family members, what did the program achieve in the reporting period? (select all that apply)

  • Yes

  • No



  • Influenced focus or priorities of programming

  • Improved program quality

  • Increased reach of the program’s messaging

  • Increased enrollment or participation in program activities

  • Increased funding or other tangible resources to advance program goals

  • Increased community will/“buy-in” for program activities or goals

  • Established or implemented shared goals, activities, or measurement

  • Other (specify): ___________





  1. Other Persons with Lived Experience Engagement





    1. Number engaged in the reporting period, by engagement area

Engagement Area

Has your program engaged other persons with lived experience in this engagement area in the reporting period?


Number engaged in the reporting period

Program Development, Planning, and Evaluation

Other persons with lived experience participate in and provide feedback on the planning, implementation and/or evaluation of the program (for example, strategic planning, program planning, materials development, program activities, teaching, mentoring, measurement, etc.).


  • Yes

  • No


Leadership Training

Within your program, other persons with lived experience are trained or mentored for leadership roles (for example, advisory committees, task forces, teaching, etc.).


  • Yes

  • No


Active Leadership

Within your program, other persons with lived experience have leadership roles on advisory committees or task forces.

  • Yes

  • No




    1. Were the other persons with lived experience from any of the following population categories? (select all that apply)



  • Children, adolescents, young adults (age 1-25)

  • Children, adolescents, and young adults (age 1-25) with special health care needs

  • Pregnant/postpartum persons

  • Non-pregnant women (age 26+)

  • Men (age 26+)

  • Representatives from community of interest

  • Self-advocates

  • Other (specify): _______




    1. Number engaged by race and ethnicity in the reporting period

(OPTIONAL)

RACE

ETHNICITY

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

More than One Race

Unknown/Unrecorded

Total

Hispanic or Latino

Not Hispanic or Latino

Unknown/Unrecorded

Total














    1. Number engaged from other demographic groups that are underrepresented (for example, underrepresented factors include sexual orientation, gender identity, income/ socioeconomic status, health status/disability, age, language, geography), in the reporting period

(OPTIONAL)

Number engaged from other underrepresented groups





    1. In the reporting period, were other persons with lived experienced compensated for their engagement (for example, paid faculty or staff, consultants, honoraria, etc.)?



  • Yes

  • No

  1. If yes, number compensated in the reporting period (OPTIONAL)

Number compensated in the reporting period



    1. In the reporting period, did engagement of other persons with lived experience result in any changes to your program?

  • Yes

  • No

    1. If yes, as a result of engaging other persons with lived experience, what did the program achieve? (select all that apply)

  • Influenced focus or priorities of programming

  • Improved program quality

  • Increased reach of the program’s messaging

  • Increased enrollment or participation in program activities

  • Increased funding or other tangible resources to advance program goals

  • Increased community will/“buy-in” for program activities or goals

  • Established or implemented shared goals, activities, or measurement

  • Other (specify): ___________





Comments: ___________________________________________________________________________________________________



Technical Assistance

Technical Assistance

Instructions

Select Yes or No to indicate whether your program provided technical assistance (TA) during the reporting period. If Yes is selected, continue and complete Part A and Part B. If No is selected, the form is complete.


Part A. Technical Assistance

  1. Select the subject area(s) of the most significant TA activities during the reporting period. Select all that apply. If the specific subject area of your TA is not listed, select the subject area closest to your subject area. If none of the subject areas are close to your subject area, select “none of the above.”

  2. Select the topic area(s) of the most significant TA activities during the reporting period. Select all that apply. If the specific topic area of your TA is not listed, select the topic area closest to your topic area. If none of the topic areas are close to your topic area, select “none of the above.” You may select a subtopic without also selecting the corresponding general topic. For example, you may select “ Early Childhood - Newborn Screening” without selecting “Early Childhood - General”. In addition, you may select only the general topic if none of the subtopics apply.

  3. For outputs:

    1. a. Enter the total number of TA activities provided during the reporting period.

b. Enter the total number of TA recipients during the reporting period. This number may be duplicated (i.e., a recipient participates in more than one TA activity and is counted more than once), though an unduplicated count is encouraged if possible.

c. Enter the total number of organizations assisted during the reporting period. If there were multiple TA recipients from one organization, the organization should only be counted once. This should be an unduplicated count.

    1. Enter the number of TA activities provided during the reporting period to each target audience. Complete for applicable target audiences. TA activities should be counted at the level of the organization. For example, if three individuals from a Title V agency attend the same TA activity, then there would be one TA activity for Title V counted. If three individuals from a Title V agency attend three different TA activities, then there would be three TA activities for Title V counted. The total number of activities in this column may sum to more than the number reported in 1.a., as multiple audiences may participate in the same TA activity.

    2. Enter the number of TA activities provided during the reporting period by TA method of the activity. Complete for applicable methods. Methods are listed in order of intensity, from most intensive to least intensive TA method. The total number of activities in this column should sum to the number reported in 1.a.


Part B. Satisfaction with TA

  1. Select Yes or No to indicate whether your program collected data on TA participant satisfaction during the reporting period. If Yes is selected, enter the number of recipients reporting that they were satisfied by TA and the total number of TA participants asked about satisfaction that provided a response. Satisfaction with TA is defined by the program. If No is selected, the form is complete.


Comments: Enter any comments, if applicable.



Definitions:

Technical Assistance (TA) includes a range of targeted support activities that build skills or capacities and increase knowledge, with the intention to address organizational needs or accelerate programmatic outcomes. TA is the process of providing guidance, assistance, and training by an expert with specific technical/content knowledge to address an identified need. TA relationships are program- or initiative-focused, and may use an interactive, on-site/hands-on approach, as well as telephone or email assistance.


Differentiation between Training and Workforce Development, Technical Assistance, and Outreach and Education:


Activity

Is the Purpose of the Activity to Address Needs at the Individual,

Organizational, or General Population Level?

Recipient Level

Goal

Included Activities

Training and Workforce Development

Individual trainees or practicing MCH workforce professionals

Individual trainees or practicing MCH workforce professionals

To improve the knowledge, skills, and capacity of future and practicing MCH workforce members

  • Undergraduate, graduate and post-graduate education and training

  • Continuing education

  • Applied learning

  • ECHO, if it includes training sections

Technical Assistance

Organizational

Individual(s) in the organization

To improve the knowledge and skills of organizational members in order to meet organizational outcomes

Provide support, training, education, etc. with the intent of facilitating and achieving organizational goals and outcomes.


Activities

  • Training

  • TA

  • Site visits

  • Collaborative networks

  • Running peer-to-peer forums

Outreach and Education

General population

Individuals in the population at large

To improve knowledge of the target population by providing information, messaging, and discussion.

Provide information and messaging to MCH populations through more generalized and passive mechanisms. (If program funds are used to create resources and tools, but not provide direct one-on-one support and contact, this would count here).


Activities

  • Public health campaigns

  • Educational pamphlets, fact sheets, etc.

  • Webinars available to the public






1. During the reporting period, did your program provide technical assistance (TA)?


ÿ Yes [complete Part A and Part B]

ÿ No

  1. Technical Assistance



  1. Subject area(s) of your most significant TA activities in the reporting period (select all that apply)

  • Clinical Care Related (including medical home)

  • Equity, Diversity, or Cultural Responsiveness Related

  • Data, Research, Evaluation Methods

  • Family Involvement

  • Interdisciplinary Teaming

  • Health Care Workforce Leadership

  • Policy

  • Systems Development/Improvement (including capacity building, planning, and financing)

  • Emerging Issues _____

  • None of the above


  1. Topics of your most significant TA activities in the reporting period (select all that apply)

  • Early Childhood – General

    • Early Childhood – Newborn Screening

    • Early Childhood – Safe Sleep

    • Early Childhood – Developmental Health (including developmental screening)

  • Adolescent Health

  • Maternal Health – General

    • Maternal Health – Maternal Mortality

    • Maternal Health – Perinatal/Postpartum Care

    • Maternal Health – Breastfeeding

    • Maternal Health – Maternal Depression

  • Children, Adolescents, and Young Adults with Special Health Care Needs

  • Developmental Disabilities

  • Mental/Behavioral Health – General

    • Mental/Behavioral Health – Autism

    • Mental/Behavioral Health – Substance Use Disorder(s)

  • Clinical Care

  • Sickle Cell Disease

  • Heritable Disorders (excluding sickle cell)

  • Epilepsy

  • Fetal Alcohol Syndrome

  • Oral Health

  • Medical Home

  • Health Care Transition

  • Immunizations

  • Injury Prevention – General

    • Injury Prevention – Poison/Toxin Exposure

  • Child Maltreatment

  • Emergency Services for Children – General

    • Emergency Services for Children – Emergency Preparedness

  • Health Equity

  • Social Determinants of Health

  • Telehealth

  • Preventive Services

  • Obesity

  • Health Insurance

  • Nutrition

  • Respiratory Health

  • Life Course Approach

  • None of the above

  1. Outputs


    1. Number of TA activities, recipients, and organizations assisted in the reporting period



  1. Total number of TA activities ___

  2. Total number of TA recipients ___

  3. Total number of organizations assisted ___


    1. Number of TA activities in the reporting period, by target audience


Target Audience

Number of TA Activities (total may sum to more than reported in 1.a. as activity could be provided to multiple audiences)

Title V


Social service agency


Medicaid agency


Other state/local agencies


Health care providers/clinical providers


Community/family groups


Educational institutions


Health insurance (non-public)


Tribal entities


Federal partners


Other (specify) ___________


Unknown



    1. Number of TA activities in the reporting period, by TA method

Method

(listed by order of relative intensity of method, from most intensive to least intensive)

Number of TA Activities (must sum to total reported in 1.a.)

One-on-one consultation, training, or site visits


Group consultation or training (for example, workshops, continuing education courses, etc.)


Peer-to-peer networks or collaborative networks


Presentations (for example, webinars, invited speaking engagements, etc.)



  1. Satisfaction with TA


      1. Did you collect data regarding recipient satisfaction with TA in the reporting period?



ÿ Yes

ÿ No


  1. If yes, number/percent of TA recipients who reported they were satisfied


      1. Number of TA recipients asked about satisfaction who provided a response, in the reporting period ___

    1. Number of TA recipients who reported they were satisfied with TA provided, in the reporting period ___

    2. Percent satisfied (auto-calculated) ___



Comments: ___________________________________________________________________


































Outreach and Education

Outreach and Education

Instructions

Select Yes or No to indicate whether your program provided outreach and education during the reporting period. If Yes is selected, continue and complete Part A and Part B. If No is selected, the form is complete.


Part A – Outreach and Education: Information on outreach and education activities, excluding information on web and social media analytics (captured in Part B).

  1. Select the mechanism(s) used to provide outreach and education during the reporting period. Select all that apply.

  2. Select the subject area(s) covered by outreach and education activities during the reporting period. Select all that apply. If the specific subject area of your outreach and education is not listed, select the subject area closest to your subject area. If none of the subject areas are close to your subject area, select “none of the above.”

  3. Select the topic area(s) covered by outreach and education activities during the reporting period. Select all that apply. If the specific topic area of your outreach and education is not listed, select the topic area closest to your topic area. If none of the topics are close to your topic area, select “none of the above.” You may select a subtopic without also selecting the corresponding general topic. For example, you may select “Early Childhood - Newborn Screening” without selecting “Early Childhood - General”. In addition, you may select only the general topic if none of the subtopics apply.

  4. Enter the number of individuals (for example, participants, families, providers, etc.) reached by outreach and education activities. This may be a duplicated count of individuals.



Part B – Web and Social Media Analytics

  1. If applicable, enter the number of web hits, number of unique website visitors, number of social media views, and number of unique viewers of social media content for outreach and education materials and resources.


Comments: Enter any comments, if applicable.



Definitions:

Outreach and Education refers to activities to inform, generate interest, and provide more in-depth messaging on topics of interest. Outreach can be seen as a way to introduce the topic during brief interactions. Education can be seen as those activities that allow messaging and discussion to be tailored to individuals and small groups, as staff respond to questions and address concerns about a topic.


Differentiation between Training and Workforce Development, Technical Assistance, and Outreach and Education:


Activity

Is the Purpose of the Activity to Address Needs at the Individual, Organizational, or General Population Level?

Recipient Level

Goal

Included Activities

Training and Workforce Development

Individual trainees or practicing MCH workforce professionals

Individual trainees or practicing MCH workforce professionals

To improve the knowledge, skills, and capacity of future and practicing MCH workforce members

  • Undergraduate, graduate and post-graduate education and training

  • Continuing education

  • Applied learning

  • ECHO, if it includes training sections

Technical Assistance

Organizational

Individual(s) in the organization

To improve the knowledge and skills of organizational members in order to meet organizational outcomes

Provide support, training, education, etc. with the intent of facilitating and achieving organizational goals and outcomes.


Activities

  • Training

  • TA

  • Site visits

  • Collaborative networks

  • Running peer-to-peer forums

Outreach and Education

General population

Individuals in the population at large

To improve knowledge of the target population by providing information, messaging, and discussion.

Provide information and messaging to MCH populations through more generalized and passive mechanisms. (If program funds are used to create resources and tools, but not provide direct one-on-one support and contact, this would count here).


Activities

  • Public health campaigns

  • Educational pamphlets, fact sheets, etc.

  • Webinars available to the public






    1. During the reporting period, did your program provide outreach and education?



  • Yes [complete Part A and Part B]

  • No

  1. Outreach and Education

(excluding web and social media analytics)


      1. Mechanism of outreach/education (select all that apply)

  • Webinars

  • Educational materials

  • Community/public events

  • Conference presentations

  • Other (specify): ___________________________

      1. Subject area(s) of outreach/education (select all that apply)


  • Clinical Care Related (including medical home)

  • Equity, Diversity or Cultural Responsiveness Related

  • Data, Research, Evaluation Methods

  • Family Involvement

  • Interdisciplinary Teaming

  • Health Care Workforce Leadership

  • Policy

  • Systems Development/Improvement (including capacity building, planning, and financing)

  • Emerging Issues _____

  • None of the above




      1. Topics of outreach/education (select all that apply)

  • Early Childhood – General

    • Early Childhood – Newborn Screening

    • Early Childhood – Safe Sleep

    • Early Childhood – Developmental Health (including developmental screening)

  • Adolescent Health

  • Maternal Health – General

    • Maternal Health – Maternal Mortality

    • Maternal Health – Perinatal/Postpartum Care

    • Maternal Health – Breastfeeding

    • Maternal Health – Maternal Depression

  • Children, Adolescents, and Young Adults with Special Health Care Needs

  • Developmental Disabilities

  • Mental/Behavioral Health – General

    • Mental/Behavioral Health – Autism

    • Mental/Behavioral Health – Substance Use Disorder(s)

  • Clinical Care

  • Sickle Cell Disease

  • Heritable Disorders (excluding sickle cell)

  • Epilepsy

  • Fetal Alcohol Syndrome

  • Oral Health

  • Medical Home

  • Health Care Transition

  • Immunizations

  • Injury Prevention – General

    • Injury Prevention – Poison/Toxin Exposure

  • Child Maltreatment

  • Emergency Services for Children – General

    • Emergency Services for Children – Emergency Preparedness

  • Health Equity

  • Social Determinants of Health

  • Telehealth

  • Preventive Services

  • Obesity

  • Health Insurance

  • Nutrition

  • Respiratory Health

  • Life Course Approach

  • None of the above

      1. Outputs

# of individuals reached (duplicated count) ____

  1. Web and Social Media Analytics

(complete applicable outputs)

# of web hits____

# of unique website visitors ____

# of social media views____

# of unique viewers of social media content ____



Comments: _____________________________________________________



Research

Research

Instructions

Select Yes or No to indicate whether your program conducted research and/or provided infrastructure support for research during the reporting period. If your program supported one or both, select Yes for the applicable supported activities (both Yes can be selected), and complete Part A. If your program did not conduct research or provide infrastructure support for research, select No and the form is complete.


Part A. Research and Infrastructure Support for Research

  1. Select the type(s) of research conducted or supported during the reporting period. Select all that apply.

  2. Select the topic area(s) of research conducted or supported during the reporting period. Select all that apply. If the specific topic area of your research is not listed, select the topic area closest to your topic area. If none of the topics are close to your topic area, select “none of the above.” You may select a subtopic without also selecting the corresponding general topic. For example, you may select “Early Childhood - Newborn Screening” without selecting “Early Childhood - General”. In addition, you may select only the general topic if none of the subtopics apply.

  3. For outputs: Complete applicable outputs of your research in the reporting period.

    1. For number of participants, complete the table and fill in each of the cells as appropriate. For reporting on children, adolescents, and young adults, EITHER report “Children, Adolescents, and Young Adults (age 1-25)” OR the subcategories of “Children and Adolescents (age 1-17)” and/or “Young Adults (age 18-25).” Children and youth with special health care needs (CYSHCN) should be reported as a subset of all infants and children ages 0 through 25. The count for CYSHCN will not be added to the overall total because their inclusion would result in a duplicated count. The row and column totals will be auto-calculated to capture total number of participants.

    2. Researchers involved includes all principal investigators and co-investigators from across all MCHB-funded or supported studies.

    3. Research network sites includes all sites where research is currently/actively being conducted.

    4. The count of clinical practice guidelines (or other products that inform clinical practice) informed by research findings may include guidelines developed by non-awardees using awardee research.


Comments: Enter any comments, if applicable.



Definitions:

Research refers to activities that support the systematic investigation of topics related to the health of maternal and child health (MCH) populations. This includes programs that provide direct funding for research studies.


Infrastructure Support refers to providing resources, logistical support, or the coordination of services for researchers to conduct research and foster innovation (for example, research networks, etc.). A grantee can have both research and infrastructure support activities.


Intervention is defined as a manipulation of the subject or subject’s environment to modify one or more health-related biomedical or behavioral processes and/or endpoints or outcomes for MCH populations.



  1. During the reporting period, did your program conduct research or provide infrastructure support for research? (select all that apply)





  • Yes, conducted research [complete Part A]

  • Yes, provided infrastructure support for research [complete Part A]

  • No

  1. Research and Infrastructure Support for Research


i. Type(s) of research conducted or supported in the reporting period (select all that apply)

  • Intervention research

  • Other primary research (for example, research that involves collection of own data, including experimental, quasi-experimental, observational studies, etc.)

  • Secondary data analysis

ii. Topic(s) of research conducted or supported in the reporting period (select all that apply)

  • Early Childhood – General

    • Early Childhood – Newborn Screening

    • Early Childhood – Safe Sleep

    • Early Childhood – Developmental Health (including developmental screening)

  • Adolescent Health

  • Maternal Health – General

    • Maternal Health – Maternal Mortality

    • Maternal Health – Perinatal/Postpartum Care

    • Maternal Health – Breastfeeding

    • Maternal Health – Maternal Depression

  • Children, Adolescents, and Young Adults with Special Health Care Needs

  • Developmental Disabilities

  • Mental/Behavioral Health – General

    • Mental/Behavioral Health – Autism

    • Mental/Behavioral Health – Substance Use Disorder(s)

  • Clinical Care

  • Sickle Cell Disease

  • Heritable Disorders (excluding sickle cell)

  • Epilepsy

  • Fetal Alcohol Syndrome

  • Oral Health

  • Medical Home

  • Health Care Transition

  • Immunizations

  • Injury Prevention – General

    • Injury Prevention – Poison/Toxin Exposure

  • Child Maltreatment

  • Emergency Services for Children – General

    • Emergency Services for Children – Emergency Preparedness

  • Health Equity

  • Social Determinants of Health

  • Telehealth

  • Preventive Services

  • Obesity

  • Health Insurance

  • Nutrition

  • Respiratory Health

  • Life Course Approach

  • None of the above

  1. Outputs for programs conducting or supporting research in the reporting period

(complete applicable outputs)

  1. # of studies supported by MCHB funding ____


  1. # of participants recruited in intervention research studies (complete if selected Intervention research in A.i. “Type of Research”)

<TABLE BY POPULATION GROUPS AND RACE ETHNICITY>


  1. # of participants recruited in other primary research studies (complete if selected Other primary research in A.i. “Type of Research”)

<TABLE BY POPULATION GROUPS AND RACE ETHNICITY>


  1. # of individuals included in secondary data analyses (complete if selected Secondary data analysis in A.i. “Type of Research”)

<TABLE BY POPULATION GROUPS AND RACE ETHNICITY>


  1. # of researchers involved ____


  1. # of research network sites ____


  1. # of clinical practice guidelines (or other products that inform clinical practice) informed by research findings ____


  1. Have you provided technical assistance, responded to data requests, or participated in a joint project with a Title V agency?

  • Yes

  • No

  1. # of external funding applications submitted ____


  1. # of external funding applications awarded funding ____



Comments: _________________________________________________________________________










<TABLE BY POPULATION GROUPS AND RACE ETHNICITY>

RACE


ETHNICITY


American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

More than One Race

Unknown/

Unrecorded

Total

Hispanic or Latino

Not Hispanic or Latino

Unknown/

Unrecorded

Total

Infants (age <1 year)













Children, Adolescents, and Young Adults (age 1-25)













Children and Adolescents (age 1-17)













Young Adults (age 18-25)













CYSHCN (age 0-

25)













Pregnant/postpartum persons (all ages)













Non-pregnant women (age 26+)













Men (age 26+)













Families













Other (specify):

___________













Unknown













TOTALS














If “Children, Adolescents, and Young Adults (age 1-25)”, “Children and Adolescents (age 1-17)”, and/or “Young Adults (age 18-25)” were included in research and reported in the tables above, please indicate the age range of children, adolescents, and/or young adults included.

Shape4 Shape3

to

Guidelines and Policy

Guidelines and Policy

Instructions

Select Yes or No to indicate whether your program developed or increased the use of guidelines and/or policies during the reporting period. If your program supported both, select Yes for both, and complete Part A and Part B. If your program only focused on guidelines, select Yes for guidelines only and complete Part A. If your program only focused on policies, select Yes for policies and complete Part B. If your program did not support either, select No and the form is complete.


Part A. Guidelines

  1. Select the level of intended change of the guideline(s). This indicates the level the guideline(s) targets and expects to see change. Select all that apply.

  2. Complete applicable outputs for guideline development/usage during the reporting period.


Part B. Policies

  1. Select the level of intended change of the policy(ies). This indicates the level the policy(ies) targets and expects to see change. Select all that apply.

  2. Complete applicable outputs for policy development/usage during the reporting period.


Comments: Enter any comments, if applicable.



Definitions:

Guidelines refer to activities that develop, modify, or implement guidelines within or between organizations and/or institutions, or at the local, state, or national level. Guidelines are guidance that is recommended but not mandatory (for example, Bright Futures, Women’s Preventive Services Initiative, etc.)


Policies refer to activities that develop, modify, or implement policies within or between organizations and/or institutions, or at the local, state, or national level. Policies outline the requirements or rules that must be met. Policies frequently refer to standards or guidelines as the basis for their existence (for example, state policy that Medicaid cover recommended preventive services, etc.).



1. During the reporting period, did your program develop or increase use of guidelines and/or policies (select all that apply)



  • Yes, guidelines [complete Part A]

  • Yes, policies [complete Part B]

  • No

  1. Guidelines


  1. Level of intended change of guideline(s) (select all that apply)

  • Organizational/institutional

  • Local

  • State

  • National

  1. Outputs

[complete applicable outputs]

  1. # of guidelines developed/proposed/modified in the reporting period ____


  1. # of guidelines implemented in the reporting period ______



  1. # implementing guidelines in the reporting period

  1. # of individuals/providers implementing guidelines ____

  2. # of organizations implementing guidelines____

  3. # of localities (for example, city, county, etc.) implementing guidelines ___

  4. # of states implementing guidelines ____

  1. Policies


  1. Level of intended change of the policy(ies) (select all that apply)

  • Organizational/institutional

  • Local

  • State

  • National

  1. Outputs

[complete applicable outputs]

  1. # of policies developed/proposed/modified in the reporting period____


  1. # of policies implemented/passed in the reporting period___

  1. # of organizations implementing/passing policies____

  2. # of localities implementing/passing policies ___

  3. # of states implementing/passing policies____



Comments: ________________________________________________________



Data and Information Systems

Data and Information Systems

Instructions

Select Yes or No to indicate whether your program worked to improve the data collection practices of other organizations, data access, or data linkages during the reporting period. If your program supported all three, select Yes for all three, and complete Part A, Part B, and Part C. If your program only focused on data collection practices, select Yes for data collection only and complete Part A. If your program only focused on data access, select Yes for data access and complete Part B. If your program only focused on data linkages, select Yes for data linkages and complete Part C. If your program did not support any of the three, select No and the form is complete.


Part A. Improving Data Collection Practices

  1. Select the activity(ies) conducted during the reporting period to improve another organization’s data collection practices. Select all that apply. If selected “facilitated submission of data to data collection system,” and if able, enter the number of entities submitting data during the reporting period. If the program supports multiple data collection systems, provide the cumulative number of entities submitting data across all systems. This number may be a duplicated count.


Part B. Improving Access to Data

  1. Select the activity(ies) conducted during the reporting period to improve data access. Select all that apply. If selected “created datasets” and/or “increased public access to datasets,” and if able, enter the number of datasets created and/or number of times datasets were accessed during the reporting period. If there are multiple datasets accessed, provide the cumulative number of times the datasets were accessed across all data sets. This number may be a duplicated count.


Part C. Creating Data Linkages

  1. Select the activity(ies) conducted during the reporting period to create data linkages. Select all that apply.


Comments: Enter any comments, if applicable.



Definitions:

Data and Information System activities include activities that improve the ability of other organizations to collect, access, and link data across multiple systems and programs. The purpose of these activities is to improve the overall public health infrastructure and not individual program process improvement or quality improvement around data.



  1. During the reporting period, did your program work to improve other organizations’ data collection practices, access to data, or create data linkages? (select all that apply)


ÿ Yes, program worked to improve data collection practices [complete Part A]

ÿ Yes, program worked to improve access to data [complete Part B]

ÿ Yes, program worked to create data linkages [complete Part C]

ÿ No


  1. Improving Data Collection Practices



  1. Type of activity in the reporting period (select all that apply)


ÿ Developed and/or tested new metrics for data collection

ÿ Created standardized data collection forms or definitions for key terms

ÿ Developed/enhanced/maintained information technology systems to house data (including registries)

ÿ Facilitated submission of data to data collection systems

  1. # of entities (for example, states, hospitals, partner centers, teams, etc.) submitting data to system _____

ÿ Conducted data quality checks

ÿ Identified and implemented interventions to improve data collection quality

ÿ Facilitated the collection of disaggregated data based on race, ethnicity, sexual and gender minority, or other underrepresented demographics

ÿ Other (specify): ___________________

B. Improving Access to Data



  1. Type of activity in the reporting period (select all that apply)


ÿ Created datasets or a common database for external use

  1. # created _____

ÿ Increased public access to datasets

  1. # of times dataset accessed (downloaded or requested) ____

ÿ Created or facilitated data use/exchange agreements

ÿ Other (specify): ___________________

C. Creating Data Linkages


i. Type of activity in the reporting period (select all that apply)

ÿ Linked two or more separate datasets

ÿ Facilitated integration of two or more datasets

ÿ Other (specify): ___________________



Comments: ________________________________________________



Quality Improvement and Evaluation

Quality Improvement and Evaluation

Instructions

Select Yes or No to indicate whether your program implemented or participated in quality improvement (QI) initiatives and/or conducted evaluation activities during the reporting period. If your program supported both, select Yes for both, and complete Part A and Part B. If your program only implemented or participated in QI, select Yes only for QI and complete Part A. If your program only conducted evaluation activities, select Yes only for evaluation and complete Part B. If your program did not support either, select No and the form is complete.


Part A. Quality Improvement

  1. Select Yes or No to indicate whether your program collected metrics to track QI during the reporting period.

  2. Select what action has been taken as a result of the QI process during the reporting period. Select all that apply.


Part B. Evaluation

  1. Select the type of evaluation activity that was conducted during the reporting period. Select all that apply.

  2. Select how your program has used evaluation activities in the reporting period. Select all that apply.

Comments: Enter any comments, if applicable.



Definitions:

Quality Improvement includes activities that use deliberate processes to improve the efficacy and impact of activities, programs, or systems (for example, PDSA cycles, etc.)


Evaluation includes activities that systematically collect information to assess a project, program, or system’s performance or outcomes.


1. During the reporting period, did your program implement or participate in quality improvement (QI) initiatives, or conduct activities to evaluate a program’s or system’s performance or outcomes? (select all that apply)


ÿ Yes, implemented or participated in QI [complete Part A]

ÿ Yes, conducted activities to evaluate performance or outcomes [complete Part B]

ÿ No

  1. Quality Improvement


    1. Did you collect metrics to track improvement as part of the QI process in the reporting period?

ÿ Yes

ÿ No

    1. What action have you taken as a result of the QI process in the reporting period?

ÿ Used findings to make improvements in your work (for example, improve existing services, ensure reaching the intended groups, review internal processes, etc.)

ÿ Used findings in your planning processes (for example, prioritize activities, identify unmet needs, scale-up of intervention, etc.)

ÿ Have not taken any action in the reporting period

  1. Evaluation


      1. Type of evaluation activity in the reporting period (select all that apply)

ÿ Evaluation plan and design

ÿ Evaluation of program processes and/or implementation

ÿ Evaluation of program outcomes and/or impact

ÿ Other (specify): _________________________

      1. How have you used the evaluation activities in the reporting period? (select all that apply)

ÿ Implemented evaluation plan/design

ÿ Disseminated findings to stakeholders

ÿ Used findings to make improvements in your work (for example, improve existing services, ensure reaching the intended groups, review internal processes, etc.)

ÿ Used findings in your planning processes (for example, prioritize activities, identify unmet needs, scale-up of intervention, etc.)

ÿ Have not used evaluation activities in the reporting period



Comments: _______________________________________________________



Knowledge Change

Knowledge Change

Instructions

This form collects information on changes in knowledge in a target population as a result of program activities/interventions.

Knowledge Change - Measures and Data (to be completed only if you can define a measure):

The table captures data regarding knowledge change. For each knowledge change measure with available data, complete one row of the table. Additional rows may be added as needed to capture additional measures.

  • Measure Description: Enter a description of the measure for which you have collected data. The measure should be as specific and descriptive as possible (for example, % of pregnant persons from county X with increased knowledge on safe sleep practices [including alone, by themselves, and in a crib], # of clinicians with increased knowledge on Bright Futures, etc.).

  • Target Population: From the drop-down menu, select which specific target population(s) apply to the measure. This should be the population(s) whose knowledge you are trying to change. Select all that apply.  

  • Primary Knowledge Change Subject Area: From the drop-down menu, select which specific knowledge change subject area(s) apply to the measure. Select all that apply. If the specific subject area of your knowledge change subject area is not listed, select the subject area closest to your knowledge change subject area. If none of the subject areas are close to your knowledge change subject area, select “none of the above”.


  • Knowledge Change Topic Area: From the drop-down menu, select which specific knowledge change topic area(s) apply to each measure. Select all that apply. If the specific topic area of the knowledge change is not listed, select the topic area closest to your topic area. If none of the topics are close, select “none of the above.” You may select a subtopic without also selecting the corresponding general topic. For example, you may select “Early Childhood - Newborn Screening” without selecting “Early Childhood - General”. In addition, you may select only the general topic if none of the subtopics apply.

  • Data Available: Select Yes or No to indicate if you have data to report for the reporting period.

  • Data Source: From the drop-down menu, select your data source for the reported data.

  • Measure Type: From the drop-down menu, select whether the measure is a count or percentage.

  • Numerator: Enter the numerator value for the reporting period (i.e., number of individuals in target population that report improved knowledge in a given area). If you only have a count of those reporting knowledge change, this will be entered into the numerator field.

  • Denominator: Enter denominator value for the reporting period (i.e., number of individuals in target population). If you only have a count of those reporting knowledge change, this field will be left blank.

  • Outcome: The outcome will be auto-calculated.

  • Measure Inactivated: If a previously established measure is being inactivated, select the box and provide an explanation for inactivation in the comments field. This section is only applicable for measures established during a previous report.


Comments: Enter any comments, if applicable.



Definitions:

Knowledge Change: Immediate or initial changes in awareness, familiarity, or understanding, which are the result of learning, and can be observed and measured immediately after an activity/intervention.





























Knowledge Change - Measures and Data


Measure Description: (ex. % of pregnant persons with increased knowledge on safe sleep; # of clinicians with increased knowledge on Bright Futures)

Target Population:

(Select all that apply for each measure)


[Drop Down List ]

Primary Knowledge Change Subject Area:

(Select all that apply for each measure)


[Drop Down List ]

Knowledge

Change Topic Area:

(Select all that apply for each measure)


[Drop Down List ]

Data Available:

(Select Yes or No)

Data Source:

[Drop Down List:

ÿ Survey or self-report data

ÿ Test

ÿ Electronic health record data

ÿ Paper-based health record data

ÿ Registry data

ÿ Claims data

ÿ Other (specify):________]

Measure Type:

[Drop Down List:

ÿ Count

ÿ Percentage]

Numerator:

[Enter the numerator value for this measure]

Denominator:

[Enter the denominator value for this measure, if applicable]

Outcome:

#/% [auto-calculated]

Measure Inactivated:

(Select if measure is inactivated)

Text

Drop Down

Drop Down

Drop Down

Y/N

Drop Down

Drop Down

#

#

#(%)

☐ Comments: ______________

Text

Drop Down

Drop Down

Drop Down

Y/N

Drop Down

Drop Down

#

#

#(%)

☐ Comments: ______________

Text

Drop Down

Drop Down

Drop Down

Y/N

Drop Down

Drop Down

#

#

#(%)

☐ Comments: ______________


+ Add Row, if needed, for additional measures

Drop Down Lists for:

Target Population

  • Children, Adolescents, and Young Adults (age 1-25)

  • Children, Adolescents, and Youth with Special Health Care Needs (age 1-25)

  • Pregnant/Postpartum Persons (all ages)

  • Non-Pregnant Women (age 26+)

  • Men (age 26+)

  • Family Members

  • Providers (clinical care and care support such as doctors, allied health professionals, care coordinators)

  • Public Health Professionals

  • Students/Trainees

  • Other Organizational Members (such as faculty and staff of organizations)

Primary Knowledge Change Subject Area

  • Clinical Care Related (including medical home)

  • Equity, Diversity, or Cultural Responsiveness Related

  • Data, Research, Evaluation Methods

  • Family Involvement

  • Interdisciplinary Teaming

  • Health Care Workforce Leadership

  • Policy

  • Systems Development/Improvement (including capacity building, planning, and financing)

  • Emerging Issues

  • Comprehensive Curricula (ONLY applicable to Division of Maternal and Child Health Workforce Development Training programs)

  • None of the above


Knowledge Change Topic Area

  • Early Childhood – General

    • Early Childhood – Newborn Screening

    • Early Childhood – Safe Sleep

    • Early Childhood – Developmental Health (including developmental screening)

  • Adolescent Health

  • Maternal Health – General

    • Maternal Health – Maternal Mortality

    • Maternal Health – Perinatal/Postpartum Care

    • Maternal Health – Breastfeeding

    • Maternal Health – Maternal Depression

  • Children, Adolescents, and Young Adults with Special Health Care Needs

  • Developmental Disabilities

  • Mental/Behavioral Health – General

    • Mental/Behavioral Health – Autism

    • Mental/Behavioral Health – Substance Use Disorder(s)

  • Clinical Care

  • Sickle Cell Disease

  • Heritable Disorders (excluding sickle cell)

  • Epilepsy

  • Fetal Alcohol Syndrome

  • Oral Health

  • Medical Home

  • Health Care Transition

  • Immunizations

  • Injury Prevention – General

    • Injury Prevention – Poison/Toxin Exposure

  • Child Maltreatment

  • Emergency Services for Children – General

    • Emergency Services for Children – Emergency Preparedness

  • Health Equity

  • Social Determinants of Health

  • Telehealth

  • Preventive Services

  • Obesity

  • Health Insurance

  • Nutrition

  • Respiratory Health

  • Life Course Approach

  • None of the above



Behavior Change

Behavior Change

Instructions

This form collects information on changes in behavior in a target population as a result of program activities/interventions.


NOTE: The target population of the behavior change and observed change must be the same to use this form. For example, if a program is working to improve referral practices of providers, the target population for the behavior change is providers. Therefore, the corresponding measure should be at the provider-level (% of providers that provide referrals) and not at the patient-level (% of patients that receive referrals).



Behavior Change - Measures and Data (to be completed only if you can define a measure):

The table captures data regarding behavior change. For each behavior change measure with available data, complete one row of the table. Additional rows may be added as needed to capture additional measures.

  • Measure Description: Enter a description of the measure for which you have collected data. The measure should be as specific and descriptive as possible (for example, % of medical providers prescribing hydroxyurea to pediatric sickle cell patients in X location).

  • Target Population: From the drop-down menu, select which specific target population(s) apply to each measure. This should be the population(s) whose behavior you are trying to change. Select all that apply.

  • Primary Behavior Change Subject Area: From the drop-down menu, select which specific behavior change subject area(s) apply to each measure. Select all that apply. If the specific subject area of your behavior change subject area is not listed, select the subject area closest to your behavior change subject area. If none of the subject areas are close to your behavior change subject area, select “none of the above.”

  • Behavior Change Topic Area: From the drop-down menu, select which specific behavior change topic area(s) apply to each measure. Select all that apply. If the specific topic area of the behavior change is not listed, select the topic area closest to your topic area. If none of the topics are close, select “none of the above.”  You may select a subtopic without also selecting the corresponding general topic. For example, you may select “Early Childhood - Newborn Screening” without selecting “Early Childhood-General”. In addition, you may select only the general topic if none of the subtopics apply. 

  • Data Available: Select Yes or No to indicate if you have data to report for the reporting period.

  • Data Source: From the drop-down menu, select your data source for the reported data.

  • Measure Type: From the drop-down menu, select whether the measure is a count or percentage.

  • Numerator: Enter the numerator value for the reporting period (i.e., number of individuals in target population that report doing a behavior). If you only have a count of those reporting behavior change, this will be entered into the numerator field.

  • Denominator: Enter denominator value for the reporting period (i.e., number of individuals in the target population). If you only have a count of those reporting behavior change, this field will be left blank.

  • Outcome: The outcome will be auto-calculated.

  • Measure Inactivated: If a previously established measure is being inactivated, select the box and provide an explanation for inactivation in the comments field. This section is only applicable for measures established during a previous report.


Comments: Enter any comments, if applicable.



Definitions:

Behavior Change: Intermediate changes in behavior/practice that result from an action/intervention, taking some time to be observed after an action/intervention.

















Behavior Change - Measures and Data


Measure Description: (ex. % of medical providers prescribing hydroxyurea to pediatric sickle cell patients in X location)

Target Population:

(Select all that apply for each measure)


[Drop Down List]

Primary Behavior Change Subject Area:

(Select all that apply for each measure)


[Drop Down List]

Behavior

Change Topic Area:

(Select all that apply for each measure)


[Drop Down List]

Data Available:

(Select Yes or No)

Data Source:

[Drop Down List:

ÿ Survey or self-report data

ÿ Test

ÿ Electronic health record data

ÿ Paper-based health record data

ÿ Registry data

ÿ Claims data

ÿ Other (specify):________]

Measure Type:

[Drop Down List:

ÿ Count

ÿ Percentage]

Numerator:

[Enter the numerator value for this measure]

Denominator: [Enter the denominator value for this measure, if applicable]

Outcome:

#/% [auto-calculated]

Measure Inactivated:

(Select if measure is inactivated)

Text

Drop Down

Drop Down

Drop Down

Y/N

Drop Down

Drop Down

#

#

#(%)

☐ Comments: ______________

Text

Drop Down

Drop Down

Drop Down

Y/N

Drop Down

Drop Down

#

#

#(%)

☐ Comments: ______________

Text

Drop Down

Drop Down

Drop Down

Y/N

Drop Down

Drop Down

#

#

#(%)

☐ Comments: ______________


+ Add Row, if needed, for additional measures



Drop Down Lists for:

Target Population

  • Children, Adolescents, and Young Adults (age 1-25)

  • Children, Adolescents, and Youth with Special Health Care Needs (age 1-25)

  • Pregnant/Postpartum Persons (all ages)

  • Non-Pregnant Women (age 26+)

  • Men (age 26+)

  • Family Members

  • Providers (clinical care and care support such as doctors, allied health professionals, care coordinators)

  • Public Health Professionals

  • Students/Trainees

  • Other Organizational Members (such as faculty and staff of organizations)

Primary Behavior Change Subject Area

  • Clinical Care Related (including medical home)

  • Equity, Diversity, or Cultural Responsiveness Related

  • Data, Research, Evaluation Methods

  • Family Involvement

  • Interdisciplinary Teaming

  • Health Care Workforce Leadership

  • Policy

  • Systems Development/Improvement (including capacity building, planning, and financing)

  • Emerging Issues

  • Comprehensive Curricula (ONLY applicable to Division of Maternal and Child Health Workforce Development Training programs)

  • None of the above


Behavior Change Topic Area

  • Early Childhood – General

    • Early Childhood – Newborn Screening

    • Early Childhood – Safe Sleep

    • Early Childhood – Developmental Health (including developmental screening)

  • Adolescent Health

  • Maternal Health – General

    • Maternal Health – Maternal Mortality

    • Maternal Health – Perinatal/Postpartum Care

    • Maternal Health – Breastfeeding

    • Maternal Health – Maternal Depression

  • Children, Adolescents, and Young Adults with Special Health Care Needs

  • Developmental Disabilities

  • Mental/Behavioral Health – General

    • Mental/Behavioral Health – Autism

    • Mental/Behavioral Health – Substance Use Disorder(s)

  • Clinical Care

  • Sickle Cell Disease

  • Heritable Disorders (excluding sickle cell)

  • Epilepsy

  • Fetal Alcohol Syndrome

  • Oral Health

  • Medical Home

  • Health Care Transition

  • Immunizations

  • Injury Prevention – General

    • Injury Prevention – Poison/Toxin Exposure

  • Child Maltreatment

  • Emergency Services for Children – General

    • Emergency Services for Children – Emergency Preparedness

  • Health Equity

  • Social Determinants of Health

  • Telehealth

  • Preventive Services

  • Obesity

  • Health Insurance

  • Nutrition

  • Respiratory Health

  • Life Course Approach

  • None of the above

Products and Publications

Products and Publications

Instructions


Part A – Number of Products and Publications: Displays, by type, 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. Numbers for each type are auto-calculated from completion of Part B.


Part B – Data Collection Forms: For each product, publication, and submission addressing maternal and child health that has been published or produced with grant support (either fully or partially) during the reporting period, complete the following forms. Complete one entry for each product, publication, and submission. All elements marked with an “*” are required.

  • Published articles in peer-reviewed scholarly journals,

    • Include peer-reviewed publications addressing maternal and child health that have been published by project faculty and/or staff during the reporting period, and directly supported by MCHB program funds. 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 or not they are supported by the grant.

    • Reporting of “Page(s)” for “Published articles in peer-reviewed scholarly journals” is only optional for online-only articles that do not have page numbers.


A. Number of Products and Publications


Type

Number

Published articles in peer-reviewed scholarly journals


Submissions of manuscripts to peer-reviewed scholarly journals


Books


Book chapters


Reports and monographs (including policy briefs and best practices reports)


Conference oral presentations and posters


Web-based products (for example, blogs, podcasts, web-based video clips, wikis, RSS feeds, news aggregators, social networking sites, etc.)


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


Tools or toolkits


Other



B. Data Collection Forms


Data collection form for: Published articles in peer-reviewed scholarly journals

*Article DOI: ______________________________

*Article Title: ________________________________________________________________________

*Author(s): ____________________________________________________________________

*Journal Title: __________________________________________________________________

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

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

*To obtain copies (URL): ________________________________________________________

*Dissemination vehicles outside of the journal: 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: Publications under review in peer-reviewed scholarly journals – SUBMITTED, NOT YET PUBLISHED

*Article Title: ________________________________________________________________________

*Author(s): ____________________________________________________________________

*Journal Title: __________________________________________________________________

*Year Submitted: _______

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

Key Words (No more than 5): _____________________________________________________

Notes: ________________________________________________________________________


Data collection form for: 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)/Editor(s): ______________________________________________________________

*Publisher: ___________________________________________________________________

*Year Published: ______

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

Key Words (no more than 5): _____________________________________________________

Notes: _______________________________________________________________________


Data collection form for: 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 for: Conference oral presentations and posters

Note: This section is not required for MCHB Training grantees.

*Presentation/Poster Title: ________________________________________________________

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

*Meeting/Conference Name: ______________________________________________________

*Year Presented: _________

*Presentation Type:

Oral 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 for: Web-based products

*Product Title: _____________________________________________________________________

*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 for: Press communications

*Product 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 for: 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 for: 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 for: 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 for: 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 for: 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: ________________________________________________________________________


Data collection form for: Tools or toolkits

*Title: ________________________________________________________________________

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

*Year: _________

*Describe tool or toolkit: ________________________________________

_____________________________________________________________________________

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

*To obtain copies (URL or email): _________________________________________________

Key Words (no more than 5): _____________________________________________________

Notes: ________________________________________________________________________


Data collection form for: 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: ________________________________________________________________________



Form 10

Form 10

Tracking Program-Specific (Training, EMSC, HS, and F2F) and Project-Developed Measures

Instructions

General Instructions:

This is a generic data collection form to be used by awardees to report annual objectives and data values for predefined DGIS program-specific performance measures (i.e., Training, EMSC, Healthy Start, and Family-to-Family forms) and/or project-developed performance measures (i.e., measures created using the detail sheet in Part 10.B.1). This data collection form serves two purposes: 1) collects and displays planned, future year (up to 5 years) Annual Performance Objective targets for each program-specific measure and project-developed measure, as applicable; and 2) collects and displays the Annual Performance Indicator values actually achieved during the reporting period for each program-specific measure and project-developed measure, as applicable.


Part 10.A: Program-Specific Performance Measures: Part 10.A is applicable only to awardees with predefined DGIS program-specific performance measures (i.e., Training, EMSC, Healthy Start, or Family-to-Family forms). Data collection for these measures is built into the respective program-specific forms in the DGIS system and does not appear as a separate form to complete.


Part 10.B: Project-Developed Performance Measures: Part 10.B is only applicable to awardees developing their own performance measures to report. This form is used to create detail sheets for project measures that the awardee chooses to add. The purpose of the detail sheet is to describe the project measures by completing each section as appropriate. Data for the measures created using Part 10.B.1 are captured using Part 10.B.2. Note that the performance measure title, numerator, and denominator fields will be displayed in DGIS in Part 10.B.2. exactly as they are defined in Part 10.B.1. For project-developed performance measures, awardees must first complete the Part 10.B.1 detail sheet. Once a measure is created using Part 10.B.1, the awardee will then be able to complete data cells in Part 10.B.2.


10.A: PROGRAM-SPECIFIC PERFORMANCE MEASURES

Instructions for Predefined Program-Specific Performance Measures

For each applicable program-specific measure:

  1. First DGIS report:

    1. Awardees will establish Annual Performance Objective targets for all future reporting periods. DGIS will auto-populate established Annual Performance Objective targets in subsequent DGIS reports.

  2. All subsequent DGIS reports:

    1. DGIS will display previously established Annual Performance Objective targets.

    2. Awardees will enter values for numerators and denominators, if applicable. Annual Performance Indicators will auto-calculate based on values from numerators and denominators.

    3. Awardees will complete all other necessary fields.

  3. If neither actual data nor an estimate can be provided, the Annual Performance Objective and Annual Performance Indicator lines are to be left blank.


Awardees will complete the following data fields:


Field Name

Instructions

Measure Name

The measure name is auto-populated from the assigned program-specific measure (for example, Training 14, etc.).

Reporting Period

The reporting period is auto-populated.

Annual Performance Objective

Enter a value for the target the project plans to meet for each of the reporting periods. The values may be expressed as a number, a rate, a percentage, or yes/no. Note: Objectives only need to be entered in the first DGIS report and will auto-populate for subsequent reports.



Numerator

Enter the numerator values for the reporting period. If you only have a count for the measure, enter it into the numerator field. If an actual number is not available, provide your best estimate. Enter only numerator data for scale measures. If there are no numerator data, leave this line blank.

Denominator

Enter the denominator values for the reporting period. If you only have a count for the measure, this will be entered in the numerator field and the denominator field should remain blank. If an actual number is not available, provide your best estimate. Do not enter denominator data for scale measures. If there are no denominator data, leave this line blank.

Annual Performance Indicator

This value is auto-calculated based on the numerator and denominator (if applicable) entered.

Comment Box

Explain all estimates in the comment box provided. If the data provided was not an estimate, you may leave this field blank. If neither actual data nor an estimate can be provided, you must provide a note in the comment box describing a plan and timeframe for providing the required data. You may also use the comment box to provide any additional information.




10.B: PROJECT-DEVELOPED PERFORMANCE MEASURES

Instructions for Project-Developed Performance Measures


10.b.1: Measure development

This form is used to create detail sheets for project measures that the awardee chooses to add. The purpose of the detail sheet is to describe the project measures by completing each section as appropriate. Data for the measures created using Part 10.B.1 are captured using Part 10.B.2. Note that the performance measure title, numerator, and denominator fields will be displayed in DGIS in Part 10.B.2. exactly as they are defined in Part 10.B.1.


Awardees will complete the following data fields:


Measure

Number

DGIS auto-populates the measure number.

Performance Measure Title

Enter a brief, narrative description of the performance measure (for example, number of families that received education on topic, etc.). The measure statement should not indicate a desired direction (such as an increase or decrease).

Level

Select the most appropriate classification for the measure being described. This indicates at which level the measure captures data and where you expect to see change.

Goal

Enter a short statement indicating what the project hopes to accomplish by tracking this measure.

Definition

Describe how the value of the measure is determined from the data. If the value of the measure is yes/no or some other narrative indicator such as Stage 1/Stage 2/Stage 3, a clear description of what those values mean and how they are determined should be provided.

Enter the following for performance measures to be reported:

Numerator: If the measure is a percentage, rate, or ratio, provide a clear description of the numerator. In DGIS, this field is used for count and scale, measures that do not have a denominator. This field is not required for narrative measures.

Denominator: If the measure is a percentage, rate, or ratio, provide a clear description of the denominator. In DGIS, leave this field blank for count, scale, or narrative measures.


Type of Measure

Unit Type: Indicate type of measure (for example, percentage, rate, ratio, scale, count, etc.).

Unit Number: Indicate the units in which the measure is expressed (for example, %, per 1000, etc.). If the measure is a percentage, ratio, scale, or count this indicates the maximum value for the measure. If the measure is a rate, it indicates per 1,000; 10,000; or 100,000.If the measure is a narrative, leave this field blank.

Grantee Data

Sources and

Issues

Enter the source(s) of the data used in determining the value of the measure and any issues concerning the methods of data collection or limitations of the data used.

Significance

Briefly describe why this measure is significant, especially as it relates to the Goal.



10.b.2: Measure reporting

Part 10.B.2 is only applicable to awardees developing their own performance measures, who have completed Part 10.B.1.


For each applicable project-developed measure:

  1. First DGIS report:

    1. Awardees will establish Annual Performance Objective targets for all future reporting periods. DGIS will auto-populate established Annual Performance Objective targets in subsequent DGIS reports.

  2. All subsequent DGIS reports:

    1. DGIS will display previously established Annual Performance Objective targets.

    2. Awardees will enter values for numerators and denominators, if applicable. Annual Performance Indicators will auto-calculate based on values from numerators and denominators.

    3. Awardees will complete all other necessary fields.

  3. If neither actual data nor an estimate can be provided for a reporting period, select “No” for Data Available and the Annual Performance Indicator line for the reporting period is to be left blank.


Awardees will complete the following data fields:


Field Name

Instructions

Measure Number

The measure number will auto-populate from the Part 10.B.1 detail sheet.

Performance Measure Title

The measure name will auto-populate from the Part 10.B.1 detail sheet.

Reporting Period

The reporting period is auto-populated.

Annual Performance Objective

Enter a value for the target the project plans to meet for each of the reporting periods. The values may be expressed as a number, a rate, a percentage, or a ratio. Do not enter objectives for narrative measures. Note: Objectives only need to be entered in the first DGIS report and will auto-populate for subsequent reports.

Data Available

Select Yes or No to indicate if data is available for reporting in the reporting period.



Numerator

Enter the numerator values for the reporting period. If you only have a count for the measure, enter it into the numerator data entry field. If an actual number is not available, provide your best estimate. Enter only numerator data for scale measures. Do not enter numerator data for narrative measures. If there are no numerator data, leave this line blank.

Denominator

Enter the denominator values for the reporting period. If you only have a count for the measure, this will be entered into the numerator data entry field and the denominator field should remain blank. If an actual number is not available, provide your best estimate. Do not enter denominator data for scale or narrative measures. If there are no denominator data, leave this line blank.

Annual Performance Indicator

For count and scale measures, this value is auto-populated from the narrative field. For percentage, ratio, and rate measures, this value is auto-calculated based on the numerator and denominator entered. For narrative measures, enter the results for the reporting period.

Data Source

Enter the source(s) of the data used in determining the value of the measure and the time period the data source reflects.

Comment Box

Please explain all estimates in the comment box provided. If the data provided was not an estimate, you may leave this field blank. If neither actual data nor an estimate can be provided, you must provide a note in the comment box describing a plan and timeframe for providing the required data. You may also use the comment box to provide any additional information.



Definitions:

Performance Measure: A measure defined in a DGIS detail sheet.

Annual Performance Objective: Annual target that is set for a performance measure.

Annual Performance Indicator: Actual value of a performance measure achieved during the reporting period.






10.A. Program-Specific Measures – Annual Objective and Performance Data


MEASURE NAME


Annual Performance Objective

Numerator

Denominator

Annual Performance Indicator

Reporting Period ____


______


______


______


______

Reporting Period ____


______


______


______


______

Reporting Period ____


______


______


______


______

Reporting Period ____


______


______


______


______

Reporting Period ____


______


______


______


______


Comment box

Shape5













10.B.1 Project-Developed Measures – Detail Sheet


Measure Number


Performance Measure Title


Level

* National

* State

* Local

Organizational/institutional

Other (specify): __________________

Goal


Definition

Numerator:

Denominator:

Type of Measure

Unit Type:

Unit Number:

Grantee Data

Sources and

Issues


Significance











10.B.2. Project-Developed Measures – Annual Objective and Performance Data

MEASURE NUMBER ___

(Performance Measure Title)


Annual Performance Objective

Data Available

Numerator

Denominator

Annual Performance Indicator

Data Source

Reporting Period ____


______


______


______


______


______


______

Reporting Period ____


______


______


______


______


______


______

Reporting Period ____


______


______


______


______


______


______

Reporting Period ____


______


______


______


______


______


______

Reporting Period ____


______


______


______


______


______


______




Comment box

Shape6



Attachment B


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleDGIS OMB_SSA_Attachment B_Central Forms
AuthorAlexandra Joraanstad
File Modified0000-00-00
File Created2024-07-25
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