Form 1 DEMOGRAPHIC, SERVICE UTILIZATION, AND SELECT CLINICAL IN

OMB No: 0906-0017

Expiration Date: XX/XX/XXXX

THE MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING PROGRAM

FORM 1

DEMOGRAPHIC, SERVICE UTILIZATION, AND SELECT CLINICAL INDICATORS

Public Burden Statement: The purpose of this collection is to collect demographic, performance, and system outcomes measures from Maternal, Infant, and Early Childhood Home Visiting (MIECHV) awardees. HRSA will use the proposed information to demonstrate program accountability and annually monitor and provide oversight to MIECHV Program awardees. The information will also be used to provide quality improvement guidance and technical assistance to awardees and help inform the development of early childhood systems at the national, state, and local level. 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 0906-0017 and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit (42 U.S.C. 701). Data will be private to the extent permitted by the law. Public reporting burden for this collection of information is estimated to average 440 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or paperwork@hrsa.gov.  Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement. 

SECTION A: PARTICIPANT DEMOGRAPHICS

Table 1: Unduplicated Count of New and Continuing Program Participants Served by MIECHV

Participants	Number Newly Enrolled	Number Continuing During Reporting Period	Total
Pregnant Participants
Caregivers – Female
Caregivers – Male
Caregivers – Gender Non-Binary
Caregivers – Unknown/Did Not Report Gender*
All Adults (Auto Calculate)
Index Children – Female
Index Children – Male
Index Children – Gender Non-Binary
Index Children – Unknown/Did Not Report Gender*
All Index Children (Auto Calculate)

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting

Notes:

Table 2: Unduplicated Count of Households Served by MIECHV

Households	Number Newly Enrolled	Number Continuing During Reporting Period	Total
Number of Households

Notes:

Table 3: Unduplicated Count of Participants and Households Served by State Home Visiting Programs (non-MIECHV)

Participants and Households	Total Number Served during Reporting Period
Pregnant Participants
Caregivers
All Adults (Auto Calculate)
All Index Children
Number of Households

Notes:

Table 4: Adult Participants by Age

	Adult Participants	≤17	18-19	20-21	22-24	25-29	30-34	35-44	45-54	55-64	≥65	Unknown/Did not Report*	Total
Newly Enrolled	Pregnant Participants
	Caregivers
Continuing	Pregnant Participants
	Caregivers
	All Adults (Auto Calculate)

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

Table 5: Index Children by Age

Index Children	<1 year	1-2 years	3-4 years	5-6 years	Unknown/Did not Report*	Total
Newly Enrolled Index Children
Continuing Index Children
All Index Children (Auto Calculate)

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

Table 6: Participants by Ethnicity

Participants	Hispanic or Latino	Not Hispanic or Latino	Unknown/Did not Report*	Total
Pregnant Participants
Caregivers
All Adults (Auto Calculate)
All Index Children

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

Table 7: Participants by Race

Participants	American Indian or Alaska Native	Asian	Black or African American	Native Hawaiian or Other Pacific Islander	White	More than one race	Unknown/Did not Report*	Total
Pregnant Participants
Caregivers
All Adults (Auto Calculate)
All Index Children

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

Table 8: Adult Participants by Marital Status

Adult Participants	Never Married (Excluding Not Married but Living Together with Partner)	Married	Not Married but Living Together with Partner	Separated/Divorced/Widowed	Unknown/Did not Report*	Total
Pregnant Participants
Caregivers
All Adults (Auto Calculate)

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

Table 9: Adult Participants by Educational Attainment

	Adult Participants	Less than HS diploma	HS Diploma/GED	Some college/ training	Technical training or certification	Associate’s Degree	Bachelor’s Degree or higher	Other	Unknown/Did not Report*	Total
Newly Enrolled	Pregnant Participants
	Caregivers
Continuing	Pregnant Participants
	Caregivers
	All Adults (Auto Calculate)

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

Table 10: Adult Participants by Employment Status

	Adult Participants	Employed Full Time	Employed Part-Time	Not employed	Unknown/Did not Report*	Total
Newly Enrolled	Pregnant Participants
	Caregivers
Continuing	Pregnant Participants
	Caregivers
	All Adults (Auto Calculate)

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

Table 11: Adult Participants by Housing Status

Not Homeless

Total Not Homele ss

Homeless

Total Homele ss

Unknown/D id not Report*

Tota l

Adult Participan ts

Owns or shares own home, condominiu m, or apartment

Rents or shares own home or apartme nt

Lives in public housin g

Lives with parent or family membe r

Some other arrangeme nt

Homele ss and sharing housing

Homeless and living in an emergenc y or transition al shelter

Some other arrangeme nt

Pregnant Participants

Caregivers

All Adults (Auto Calculate)

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

Table 12: Primary Language Spoken at Home

Index Children	Number	Percent
English
Spanish
Other
Unknown/Did Not Report*
All Index Children (Auto Calculate)		100

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

Table 13: Household Income in Relation to Federal Poverty Guidelines

Households	Number of Households	Percent
50% and under
51-100%
101-133%
134-200%
201-300%
>300%
Unknown/Did not Report*
All Households (Auto Calculate)		100

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

Table 14: For Each Household Indicate the Priority Population Characteristics

Households	Yes	No	Unknown/Did not Report*	Total
1. Low income household
2. Household contains an enrollee who is pregnant and under age 21
3. Household has a history of child abuse or neglect or has had interactions with child welfare services
4. Household has a history of substance abuse or needs substance abuse treatment
5. Someone in the household uses tobacco products in the home
6. Someone in the household has attained low student achievement or has a child with low student achievement
7. Household has a child with developmental delays or disabilities
8. Household includes individuals who are serving or formerly served in the US armed forces

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

SECTION B: SERVICE UTILIZATION

Table 15: Home Visits

Home Visiting Model (Select One per Row – Add Rows for Additional Models)	In-person Home Visits	Virtual Home Visits	Unknown/Did Not Report	Total
Percent (Auto Calculate)

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

Table 16: Family Engagement by Household

Households	Number of Households	Percent
Currently receiving services
Completed program
Stopped services before completion
Enrolled but not currently receiving services/Other
Unknown/Did not Report*
All Categories (Auto Calculate)

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

Table 17: Unduplicated Count of Households by Evidence-Based Home Visiting Model or Promising Approach

Home Visiting Model (Select One per Row – Add Rows for Additional Models)	Number Newly Enrolled	Number Continuing During Reporting Period	Total
Notes:

SECTION C: INSURANCE AND CLINICAL INDICATORS

Table 18: Participants by Type of Health Insurance Coverage

	Participants	No Insurance Coverage	Medicaid or CHIP	Tri- Care	Private or Other	Unknown/Did not Report*	Total
Newly Enrolled	Pregnant Participants
	Caregivers
Continuing	Pregnant Participants
	Caregivers
	All Adults (Auto Calculate)
	All Index Children

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

Table 19: Index Children by Usual Source of Medical Care

Index Children	Doctor’s/Nurse Practitioner’s Office	Hospital Emergency Room	Hospital Outpatient	Federally Qualified Health Center	Retail Store or Minute Clinic	Other	None	Unknown/Did not Report*	Total
Newly Enrolled Index Children
Continuing Index Children
All Index Children (Auto Calculate)

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

Table 20: Index Children (≥ 12 months of age) by Usual Source of Dental Care

Index Children	Have a Usual Source of Dental Care	Do not have a Usual Source of Dental Care	Unknown/Did not Report*	Total
Newly Enrolled Index Children
Continuing Index Children
All Index Children (Auto Calculate)

* When the percent of data that is “Unknown/Did not Report” is ≥10%, a table note should be provided that addresses the reason for the missing data, and if possible, plans to reduce the amount of missing data in future reporting.

Notes:

DEFINITIONS OF KEY TERMS

Table Number	Field	Key Terms Requiring Definitions
All Tables		MIECHV Household: For the purposes of reporting to HRSA on Form 1, a “MIECHV household” is defined as a family served during the reporting period by a trained home visitor implementing services with fidelity to the model and that is identified as a MIECHV household at enrollment. HRSA has identified two different methods that can be used to identify MIECHV households that are described below: Home Visitor Personnel Cost Method (preferred method): Households are designated as MIECHV at enrollment based on the designation of the home visitor they are assigned. Using this methodology, recipients designate all households as MIECHV that are served by home visitors for whom at least 25 percent of his/her personnel costs (salary/wages including benefits) are paid for with MIECHV funding. Enrollment Slot Method (temporary option): Households are designated as MIECHV households based on the slot they are assigned to at enrollment. Using this methodology, recipients identify certain slots as MIECHV-funded and assign households to these slots at enrollment in accordance with the terms of the contractual agreement between the MIECHV state recipient and the LIA regardless of the percentage of the slot funded by MIECHV. Once designated as a MIECHV household, the household is tracked for the purposes of data collection through the tenure of household participation in the program.
1	Unduplicated Count of New and Continuing Program Participants Served by MIECHV	New Participant: A participant, including a pregnant participant or caregiver, who signs up to participate in the home visiting program at any time during the reporting period who was identified as being part of a MIECHV household at enrollment (see definition of a MIECHV Household included at the beginning of the Definition of Key Terms). Continuing Participant: A participant including a pregnant participant or caregiver, who was signed up and actively enrolled in the home visiting program prior to the beginning of the reporting period who was identified as being part of a MIECHV household at enrollment (see definition of a MIECHV Household included at the beginning of the Definition of Key Terms). Pregnant participants are participants who were either pregnant at enrollment or pregnant at the annual update of information in a subsequent reporting period. Note on Gender Reporting: Responses regarding gender should reflect participant gender identity. See below for additional information on category definitions. Female caregivers are those household members who identify as female and who are enrolled in the program during the reporting period, are considered a caregiver of the index child, and were not pregnant at the time of enrollment or the annual update of this information (e.g., biological parent, adoptive parent, foster parent, grandparent who identifies as female). Male caregivers include those household members who identify as male and who are enrolled in the program during the reporting period, are considered a caregiver of the index child, and (e.g. biological parent, step-parent, and partners who identify as male) who also meet the definition of an enrollee. Gender Non-Binary (Caregivers and Index Children): includes those enrolled participants who also meet the definition of an enrollee and who do not identify as either male or female, which may include participants who identify as gender non-binary and/or genderqueer. Unknown/Did Not Report Gender (Caregivers and Index Children): If gender is unknown or not reported for caregivers or index children enter that count in the respective “Unknown/Did not Report Gender” columns. Index Child (Birth – Kindergarten Entry): the child (or children) in an individual household who is under the care of the enrollee(s) and who is enrolled in the program and was identified as being part of a MIECHV household at enrollment (see definition of a MIECHV Household included at the beginning of the Definition of Key Terms). More than one index child per household can be identified.
2	Unduplicated Count of Household Served by MIECHV	New Household: A household, including a pregnant participant and/or caregiver who signs up to participate in the home visiting program at any time during the reporting period. The household may include multiple caregivers depending on model-specific definitions. Continuing Household: A household, including a pregnant participant and/or caregiver who were signed up and actively enrolled in the home visiting program prior to the beginning of the reporting period. The household may include multiple caregivers depending on model-specific definitions.
3	Unduplicated Count of Participants and Households Served by State Home Visiting Programs (non-MIECHV)	Participant Served by a State Home Visiting Program (non-MIECHV): A participant, including a pregnant participant or caregiver, who signs up to participate in the home visiting program at any time during the reporting period who was identified as being part of a non-MIECHV household at enrollment (see definition of a MIECHV Household included at the beginning of the Definition of Key Terms).
4	Adult Participants by Age	Adult Participants: includes the person or persons in the household who signed up to participate in the home visiting program (e.g., a teenage parent would be counted as an adult participant but not an index child). The category can include more than one member of the household if more than one individual are enrolled in the program (e.g., a father and a mother have both signed up to participate). It should include at a minimum for every household the primary caregiver of the index child.
5	Index Children by Age	Index Child (Birth – Kindergarten Entry): the child (or children) in an individual household who is under the care of the enrollee(s) and who is enrolled in the program and who was identified as being part of a MIECHV household at enrollment (see definition of a MIECHV Household included at the beginning of the Definition of Key Terms). More than one index child per household can be identified.
6	Participants by Ethnicity	The responses regarding ethnicity should reflect what the person considers themselves to be and are not based on percentages of ancestry. If ethnicity is unknown or not reported for some participants, enter that count in the respective “Unknown/Did not report” column.
7	Participants by Race	The responses regarding race should reflect what the person considers themselves to be and are not based on percentages of ancestry. Participants who select more than one race should be reported in the “More than one race” category. If ethnicity and race are unknown or not reported for some participants, enter that count in the respective “Unknown/Did not Report” columns.
8	Adult Participants by Marital Status	Adult Participants: includes the person or persons in the household who signed up to participate in the home visiting program (e.g., a teenage parent would be counted as an adult participant but not an index child). The category can include more than one member of the household if more than one individual are enrolled in the program (e.g., a father and a mother have both signed up to participate). It should include at a minimum for every household the primary caregiver of the index child. If more than one individual is enrolled in the program, enter the status for all enrollees. For example, if a pregnant woman is enrolled with her spouse in the program, both participants would be counted under the married category.
9	Adult Participants by Educational Attainment	Adult Participants: includes the person or persons in the household who signed up to participate in the home visiting program (e.g., a teenage parent would be counted as an adult participant but not an index child). The category can include more than one member of the household if more than one individual are enrolled in the program (e.g., a father and a mother have both signed up to participate). It should include at a minimum for every household the primary caregiver of the index child. Less than high school diploma includes individuals who have not completed their high school education. The Some college/training category includes those who are currently enrolled and those who attended in the past. The Technical training or certification category includes those who received technical training or certification in the past. The Associate’s Degree category includes those who obtained an Associate’s Degree. The Bachelor’s Degree category includes those who obtained a Bachelor’s Degree. The Other category includes those individuals who did not fall into the specified categories.
10	Adult Participants by Employment Status	Employed: refers to whether the person is currently working for pay. Employed Full Time: an employee who works an average of at least 30 hours per week Employed Part Time: an employee who works an average of less than 30 hours per week1 Not Employed: indicates that the person is not working for pay (this category may include, for example, students, homemakers and those enrollees actively seeking work but currently not employed)
11	Adult Participants by Housing Status	Not homeless: individuals who have a fixed, regular, and adequate nighttime residence (within the meaning of section 103(a)(1) of the McKinney-Vento Homeless Assistance Act); and Not homeless and lives in public housing: individuals who live in a public housing unit that is administered by a public housing agency (excludes individuals who utilize housing voucher programs) Homeless: individuals who lack a fixed, regular, and adequate nighttime residence (within the meaning of section 103(a)(1) of the McKinney-Vento Homeless Assistance Act); and Homeless and sharing housing: individuals who are sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason Homeless and living in an emergency or transitional shelter: individuals who are living in emergency or transitional shelters; are abandoned in hospitals; or are awaiting foster care placement Homeless and some other arrangement: individuals who are living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations; individuals who have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings (within the meaning of section 103(a)(2)(C)); individuals who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings2
12	Primary Language Spoken at Home	Primary language: the language used in the home the majority of the time. Index Child (Birth – Kindergarten Entry): the child (or children) in an individual household who is under the care of the enrollee(s) and who is enrolled in the program and was served by a trained home visitor implementing services with fidelity to the model who was identified as being part of a MIECHV household at enrollment (see definition of a MIECHV Household included at the beginning of the Definition of Key Terms). More than one index child per household can be identified.
13	Household Income in Relation to Federal Poverty Guidelines	The appropriate category for a given family will depend both on household income and on the number of household members counted in the household (both home visiting enrollees and non-enrollees). Household income refers to the annual gross income for the household as defined in programmatic guidance, recorded at enrollment and annually thereafter. Federal Poverty Guidelines: Annual income data can be estimated from monthly data (monthly income x 12). The HHS Poverty Guidelines are updated annually in February and published in the Federal Register. See https://aspe.hhs.gov/poverty-guidelines .
14	For Each Household Indicate the Priority Population Characteristics	Low-Income: An individual or family with an income determined to be below the Federal Poverty Guidelines. The HHS Poverty Guidelines are updated annually in February and published in the Federal Register. See https://aspe.hhs.gov/poverty-guidelines. Pregnant women under 21: Households with expectant mothers who enroll in the program and are under 21 years old during the reporting period. Have a history of child abuse or neglect or have had interactions with child welfare services: Based on self-report, a household with members who have a history of abuse or neglect and have had involvement with child welfare services either as a child or as an adult. Have a history of substance abuse or need substance abuse treatment: Based on self-report, a household with members who have a history of substance abuse or who have been identified as needing substance abuse services through a substance abuse screening administered upon enrollment. Are users of tobacco products in the home: Based on self-report, a household with members who use tobacco products in the home or who have been identified as using tobacco through a substance abuse screening administered during intake. Tobacco use is defined as combustibles (cigarettes, cigars, pipes, hookahs, bidis), non-combustibles (chew, dip, snuff, snus, and dissolvables), and electronic nicotine delivery systems (ENDS). Have, or have children with, low student achievement: Based on self-report, a household with members who have perceived themselves or their child(ren) as having low student achievement. Have a child or children with developmental delays or disabilities: Based on self-report or home visitor/staff observation, a household with members who have a child or children suspected of having a developmental delay or disability. Are in families that are or have served in the armed forces: Based on self-report, households that include individuals who are serving or formerly served in the Armed Forces, including such households that have members of the Armed Forces who have had multiple deployments outside of the United States. For this criterion, definition includes a military member’s dependent acquired through marriage, adoption, or other action during the course of a member’s current tour of assigned duty.
15	Home Visits	Home visit refers to the definition of a completed home visit enacted by the various evidence-based home visiting models approved for implementation through the MIECHV program or a Promising Approach. Please refer to model-specific guidance for specific definitions. Virtual Home Visits means a home visit, as described in an applicable service delivery model that is conducted solely by the use of electronic information and telecommunications technologies. Please refer to model-specific guidance for specific definitions.
16	Family Engagement by Household	Currently receiving services refers to families that are participating in services at the end of the reporting period. Completed program refers to families who have completed the program according to model-specific definitions and criteria during the reporting period. Stopped services before completion refers to families who left the program for any reason prior to completion. Enrolled but not currently receiving services/Other refers to those families who do not fall into the previous categories and may include unreachable participants (i.e. the family is not regularly participating but did not actively sever ties, etc.)
17	Unduplicated Count of Households by Evidence-Based Home Visiting Model or Promising Approach	A Household, including a pregnant participant and/or caregiver(s) who were signed up and actively enrolled in the home visiting program prior to the beginning of or during the reporting period and continues enrollment during the reporting period. The household may include multiple caregivers depending on model-specific definitions.
18	Participants by Type of Health Insurance Coverage	Index Child (Birth – Kindergarten Entry): the child (or children) in an individual household who is under the care of the enrollee(s) and who is enrolled in the program and who was identified as being part of a MIECHV household at enrollment (see definition of a MIECHV Household included at the beginning of the Definition of Key Terms). More than one index child per household can be identified. The insurance coverage categories are mutually exclusive. No insurance coverage indicates that the individual is currently not covered by any source of insurance. This table is intended to capture insurance status, not health care access: receipt of care provided for instance by the Indian Health Service or another safety net health care provider such as a Federally Qualified Health Center does not constitute insurance coverage.
19	Index Children by Usual Source of Medical Care	Index Child (Birth – Kindergarten Entry): the child (or children) in an individual household who is under the care of the enrollee(s) and who is enrolled in the program and who was identified as being part of a MIECHV household at enrollment (see definition of a MIECHV Household included at the beginning of the Definition of Key Terms). More than one index child per household can be identified. Usual source of care: the particular medical professional, doctor's office, clinic, health center, or other place where a person would usually go if sick or in need of advice about his or her health.
20	Index Children (≥ 12 months of age) by Usual Source of Dental Care	Index Child (Birth – Kindergarten Entry): the child (or children) in an individual household who is under the care of the enrollee(s) and who is enrolled in the program and who was identified as being part of a MIECHV household at enrollment (see definition of a MIECHV Household included at the beginning of the Definition of Key Terms). More than one index child per household can be identified. Usual source of dental care: a usual source of dental care, or dental home, is a place where a child can receive consistent, comprehensive, compassionate dental care. The concept of the Dental Home reflects the AAPD's clinical guidelines and best principles for the proper delivery of oral health care to all children, with a concentration on infant/age one patients and should be established no later than 12 months of age.3

1 Healthcare.gov Glossary. https://www.healthcare.gov/glossary/full-time-employee/

2 Administration for Children and Families. Early Childhood Learning and Knowledge Center, 2014. http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/family/family/Homelessness/hmls/definition/definition-legal.html

3 American Academy of Pediatric Dentistry. Dental Home Resource Center. http://www.aapd.org/advocacy/dentalhome/

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