Form 4 Tribal MIECHV Quarterly Performance Reporting Form

OMB Control Number 0970-0490

Expiration date: 01/31/2023

TRIBAL MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING PROGRAM

FORM 4

QUARTERLY PERFORMANCE REPORTING FORM

U.S. Department of Health and Human Services

Administration for Children and Families

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, ACF is gathering information to collect data in order to determine the caseload capacity grantees are achieving, where services are being delivered, the retention and attrition of enrolled families, and the retention and attrition of program staff on a quarterly basis. Public reporting burden for this collection of information is estimated to average 12 hours per grantee annually, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This collection of information is required to retain a benefit of Tittle V of the Social Security Act. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. If you have any comments on this collection of information, please contact Anne Bergan at Anne.Bergan@acf.hhs.gov.

TRIBAL HOME VISITING REPORTING SYSTEM FORM: Tribal MIECHV Quarterly Data

Tribal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) grantees are required to submit the information outlined below on a quarterly basis.

Quarterly reporting periods are defined as follows. Reports are due 30 days after the end of each reporting period:

• Q1 - October 1-December 31;

• Q2 - January 1-March 31;

• Q3 – April 1-June 30;

• Q4 – July 1-September 30

Definitions for key terms are included in Appendix A. Please carefully consult key term definitions before completing this form.

Grant Number(s): ________________________________

Section A:

Table A.1: Program Capacity

Column A	Column B	Column C	Column D	Column E
Number of New Households Enrolled	Number of Continuing Households	Current Caseload (A+B) (Auto-Calculate)	Maximum Service Capacity	Capacity Percentage (C÷D) (Auto-Calculate)

Table A.2: Family Engagement

Column A	Column B	Column C	Column D	Column E	Column F
Number of Households Currently Receiving Services	Number of Households who Completed Program	Number of Households who Stopped Services Before Completion	Other	Total (A+B+C+D) (Auto-Calculate)	Attrition Rate (C÷E) (Auto-Calculate)

Table A.3: Place-Based Services

Add a row for each additional community served during the reporting period.

Column A	Column B	Column C
Community	Zip Codes within Community	Number of Households Served
Total		Sum of Column C (all rows)

Table A.4.1: Staff Recruitment and Retention

Column A	Column B	Column C	Column D	Column E	Column F	Column G	Column H	Column I
Number of New FTE MIECHV Home Visitors	Number of Continuing FTE MIECHV Home Visitors	Number of FTE MIECHV Home Visitors (A+B) (Auto-Calculate)	Number of New FTE MIECHV Supervisors	Number of Continuing FTE MIECHV Supervisors	Number of FTE MIECHV Supervisors (D+E) (Auto-Calculate)	Number of New FTE MIECHV Other Staff	Number of Continuing FTE MIECHV Other Staff	Number of FTE MIECHV Other Staff (G+H) (Auto-Calculate)
Column J	Column K	Column L
Total Number of MIECHV Home Visitors (Headcount)	Total Number of MIECHV Supervisors (Headcount)	Total Number of MIECHV Other Staff (Headcount)

Table A.4.2: Staff Vacancies

Column A	Column B	Column C	Column D
Number of Vacant FTE MIECHV Home Visitors	Number of Vacant FTE MIECHV Supervisors	Number of Vacant FTE MIECHV Other Staff	Number of FTE MIECHV Staff Vacancies (A+B+C) (Auto-Calculate)

Notes

Appendix A: Definitions of Key Terms

Capacity Percentage: Capacity percentage is a calculated indicator that results from dividing the current caseload by the maximum service capacity and multiplying by 100.

Community: A community is a geographically distinct area that is defined by the Tribal MIECHV grantee. Communities should be areas that hold local salience and can be defined as a neighborhood, town, city, or other geographic area. Services provided within a particular community should be distinguishable from other communities.

Completed Program: The number of households who completed the program refers to families who have completed the program or transitioned to another program according to home visiting model-specific definitions and criteria during the quarterly reporting period.

Continuing Household: A household, including a pregnant person, female caregiver, and/or male caregiver who were actively enrolled in the home visiting program prior to the beginning of the quarterly reporting period, continued enrollment through the reporting period, and had at least one home visit during the quarter. The household may include multiple caregivers depending on model-specific definitions.

Continuing FTE Home Visitor/Supervisor/Other Staff: All staff who were employed at any time during the reporting period should be included. This includes staff that left the team during the reporting period. Grantees should only report the proportion of the full-time equivalent (FTE) that is supported by MIECHV grant funds. Below are common staff definitions:

Home Visitors: A home visitor employed or contracted by the Tribal MIECHV program, regardless of the percentage of his/her personnel costs paid for with Tribal MIECHV funding.

Supervisors: Staff that play a key oversight role for the Tribal MIECHV grant, directly employed or contracted by the grantee, regardless of the percentage of his/her personnel costs paid for with Tribal MIECHV funding.

Other Staff: Staff involved in data entry support, reporting and evaluation, and other supportive and administrative activities, directly employed or contracted by the grantee, regardless of the percentage of his/her personnel costs paid for with Tribal MIECHV funding.

Current Caseload: The number of households actively enrolled at the end of the quarterly reporting period. All members of one household represent a single caseload slot.

Currently Receiving Services: The number of households currently receiving services refers to households that received at least one home visit during the reporting period and are participating in services at the end of the quarterly reporting period.

Family Engagement Column D/Other: refers to those households that do not fall into the previous categories and may include unreachable participants (e.g. the family is not regularly participating but did not disenroll nor respond to outreach attempts made by home visiting program staff)

Maximum Service Capacity: The highest number of households that could potentially be enrolled at the end of the quarterly reporting period if the program were operating with a full complement of hired and trained home visitors.

Note: The maximum service capacity is equivalent to the caseload of family slots indicated in your approved implementation plan.

Caseload of Family Slots: The highest number of families (or households) that could potentially be enrolled at any given time if the program were operating with a full complement of hired and trained home visitors.  Family slots are those enrollment slots served by a trained home visitor implementing services with fidelity to the model for whom at least 25% of his/her personnel costs (salary/wages including benefits) are paid for with MIECHV funding.  All members of one family or household represent a single caseload slot.  The count of slots should be distinguished from the cumulative number of enrolled families during the grant period.

New Household: A household, including a pregnant person, female caregiver, and/or male caregiver who enrolls during the quarter, is enrolled on the last day of the quarter, and has received at least one home visit during the quarter. The household may include multiple caregivers depending on model-specific definitions.

New FTE Home Visitors/Supervisors/Other Staff: All staff who were newly employed at any time during the reporting period and are employed by the program at the end of reporting period. This includes staff that joined mid-way through the reporting period. If a staff member both joined and left during the reporting period, they should not be included. Grantees should only report the proportion of the FTE is that is supported by MIECHV grant funds. Below are common staff definitions:

Home Visitors: A home visitor employed or contracted by the Tribal MIECHV program, regardless of the percentage of his/her personnel costs paid for with Tribal MIECHV funding.

Supervisors: Staff that play a key oversight role for the Tribal MIECHV grant, directly employed or contracted by the grantee, regardless of the percentage of his/her personnel costs paid for with Tribal MIECHV funding.

Other Staff: Staff involved in data entry support, reporting and evaluation, and other supportive and administrative activities, directly employed or contracted by the grantee, regardless of the percentage of his/her personnel costs paid for with Tribal MIECHV funding.

Staff Vacancies: All staff positions that were vacant at the end of the reporting period, regardless of when the position became vacant.

Stopped Services before Completion: The number of households who stopped services before completion refers to households who left the program or were lost to follow-up for any reason prior to completion.