OMB Number: 0915-0193
Expiration date: 04/30/2026
Supporting Statement B
Uniform Data System
OMB Control No. 0915-0193
Revision
1. Respondent Universe and Sampling Methods
The respondent universe for the 2025 Uniform Data System (UDS) includes all Health Center Program awardees and look-alikes who receive Health Resources and Services Administration (HRSA) funding or designation in calendar year (CY) 2025. It also includes certain nursing workforce grant recipients funded by the Bureau of Health Workforce (BHW) within HRSA. High-quality accessible data are critical to strategically meeting the needs of patients and identifying opportunities for clinical process improvement. Likewise, BHW leverages the UDS to assess the impact of Nurse Education, Practice, Quality and Retention (NEPQR) and Advanced Nursing Education (ANE) recipients on patient health outcomes and to allocate funding and resources effectively.
The entire Bureau of Primary Health Care (BPHC) Health Center and BHW nursing workforce grant recipient universe will be included in the dataset, and as of CY 2024 this consisted of 1363 Health Center Program grant awardees, 133 HRSA-designated look-Alikes, and 42 NEPQR and ANE Program awardees. Look-alikes DO NOT receive regular federal funding under section 330 of the PHS Act, but meet the Health Center Program requirements for designation under the program (42 U.S.C. 1395x(aa)(4)(B) and 42 U.S.C. 1396d(l)(2)(B)(iii)). The expected response rate for the data collection effort is 100%. UDS data have been collected annually since 1996, and because all health centers are required to submit annual UDS reports to be compliant with their award or designation, the response rate has been nearly 100% (in CY 2024, all but two health centers submitted their UDS report). Since all health centers are required to submit data, no statistical methods are used to select respondents. The UDS is used to track health center performance and inform quality improvement effort.
2. Procedures for the Collection of Information
No statistical methods are needed for sample selection, because the entire universe of health centers is required to submit UDS data. Since the full universe is reported, HRSA is able to calculate the true population parameters, rather than estimating statistics based on a sample.
Data are collected through administrative, financial, and clinical records information. Data are not based on survey questionnaires, so interviewers are not applicable to the data collection process. The UDS instrument was developed as a standardized framework to capture consistent and comprehensive data on health center performance and patient outcomes for HRSA’s Health Center Program. Its development integrates data elements drawn from various established sources to ensure alignment with national standards and comparability across health care systems. Many clinical quality measures within the UDS are aligned with electronic clinical quality measures (eCQMs) established by the Centers for Medicare and Medicaid Services (CMS). This alignment ensures consistency with federal reporting programs, such as the Merit-based Incentive Payment System (MIPS). Additionally, the UDS incorporates standardized data elements and definitions from other federal partners, including the Assistant Secretary for Technology Policy (ASTP). By drawing from these established sources, the UDS promotes uniformity, supports interoperability, reduces reporting burden, and helps health centers track performance in line with national quality benchmarks—ensuring that health centers can report consistent data across multiple stakeholders without duplicating effort.
Health centers are given advance notice when the UDS is open for data submission via electronic interface, such as HRSA’s Electronic Handbooks. Health centers have 8 weeks of early access to electronic reporting system to prepare their data, 6 weeks to submit their data, and another 6 weeks to work with HRSA data reviewers to correct any errors, explain any data outliers, and finalize their report.
HRSA takes multiple steps for assuring data quality. The UDS Manual provides very specific written reporting instructions and is updated annually. HRSA also provides virtual and in-person technical assistance, including through a contractor. The contractor works with Primary Care Associations (PCAs) in all states to provide annual UDS data reporting instructor-led technical assistance. Each year, several webinars are streamed to large online audiences and then archived for additional review after the event. A contractor works with federal staff to support the management of a .gov webpage/microsite with a suite of additional technical assistance resources, specific measure guides, and strategies for successful reporting. There is also a helpline, which health centers can access, throughout the year and with additional coverage during the reporting window, if they require assistance with data reporting or submission. Once data have been submitted, the contractor performs numerous data checks to identify and resolve any data discrepancies. The contractor has numerous staff members who work one-on-one with health centers to support data accuracy. The contractor also conducts sensitivity analyses to determine the impact of any data edits. After each UDS report is reviewed, an additional analysis is completed on large health centers that could impact national averages and performance trends over time. HRSA staff also conduct spot checks on UDS submissions throughout the review period and a variety of in-depth analyses of UDS data that inform programmatic decisions.
3. Methods to Maximize Response Rates and Deal with Nonresponse
All Health Center Program awardees and look- alikes are required to complete and submit the annual UDS report, along with some BHW-funded awardees. Technical assistance is available for all health center programs to facilitate reporting for the UDS. Since the dataset includes the universe of health centers, the UDS provides accurate and reliable population parameters; there are no issues of reliability since this is not a sample.
The expected response rate is 100%. This is based on years of experience collecting UDS data. Follow-up procedures for getting all health centers to submit their data include email notifications and reminders and targeted outreach to health center administrators. Implementing targeted outreach strategies is essential to ensure health centers are fully aware of their UDS reporting obligations and the critical role their data plays in evaluating and enhancing the Health Center Program. This outreach offers health centers the necessary support and resources to navigate the reporting process effectively. Health centers that do not submit their UDS reports are excluded from the final data set, which reduces the overall universe of reporting health centers.
4. Tests of Procedures or Methods to be Undertaken
All UDS tables used for data collection and reporting are approved by OMB before they are implemented.
For the clinical performance measures, the data collection methods and requirements have not changed since they were implemented in 2008. For each measure, awardees report on all patients within the universe to which the measure specifications apply (i.e., based on age parameters, health condition, etc.) For example, with the blood pressure control measure CMS165v131 the universe is all patients aged 18 to 85 years who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period. HRSA encourages health centers to report on all patients that meet the identified criteria for each measure using their electronic records systems. HRSA considers this method to present a relatively low burden to awardees, especially in view of the value of the data for awardee quality improvement. Awardees have been very positive about reporting the clinical measures and express appreciation for its utility in informing quality improvement efforts within their organizations.
5. Individuals Consulted on Statistical Aspects and Individuals Collecting and/or
Analyzing Data
Consultation on data collection was obtained from multiple sources with expertise in health center operations and clinical quality reporting, and through both solicited and unsolicited feedback from health centers and other stakeholders.
HRSA has ongoing engagements with a contractor that has provided consultation on the proposed UDS changes and has worked with HRSA staff in developing and reviewing the UDS instructions and materials as well as providing valuable technical and analytical expertise. The contractor also assists with data integrity and review as described in Section 2.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Seleda.Perryman |
| File Modified | 0000-00-00 |
| File Created | 2025-07-01 |