**All long-term training programs complete the following Performance
Measures:**

Form 10: Project Performance/Outcome Measure Detail Sheet (See
Individual PM\'s below)

-   Performance Measure 07: The degree to which MCHB supported programs
    ensure **family participation** in program and policy activities.

-   Performance Measure 08: The percent of graduates of MCHB long‑term
    training programs that **demonstrate field leadership** after
    graduation.

-   Performance Measure 09: The percent of participants in MCHB
    long-term training programs who are from **underrepresented
    groups**.

-   Performance Measure 11: The degree to which MCHB long‑term training
    grantees include **cultural competency** in their
    curricula/training.

-   Program Performance Measure 62: **Products and Publications**

    Additional forms and performance measures are required of certain
    long-term training programs. These are listed under the name of the
    program.

**T71-Adolescent Health (LEAH)**

Program Performance Measure (PPM) 59: Collaboration with State Title V
Agencies

PPM 60: Long Term Trainees Working in Interdisciplinary Manner

PPM 64: Degree to Which LEAH Programs Incorporate Diverse Adolescents
and Parents into the Training Program

**T73-Leadership Education in Neurodevelopmental Disorders (LEND)**

PPM 59: Collaboration with State Title V Agencies

PPM 60: Long Term Trainees Working in Interdisciplinary Manner

PPM 61: Trainees Value Interdisciplinary Training (Developmental Measure
to be reported 2006)

PPM 63: Degree to Which LEND Programs Incorporate Medical Home Concepts

**T72-Pediatric Pulmonary Centers (PPC)**

PPM 58: Percentage of PPC Faculty Who Demonstrate Field Leadership

PPM 59: Collaboration with State Title V Agencies

PPM-PPC1: Impact of Training on Medium Term Trainees (developmental
measure)

**T79-Nutrition (NUT)**

PPM 65: Nutrition Trainees Practicing in the MCH Field

**T76-Schools of Public Health (SPH)**

PPM-SPH1: Active Community Partnerships (developmental measure)

PART 1

Performance Measures-All Long Term Training Programs

+-----------------------------------+-----------------------------------+
| #### 07 PERFORMANCE MEASURE       | The degree to which MCHB          |
|                                   | supported programs ensure family  |
| **Goal 1: Provide National        | participation in program and      |
| Leadership for MCHB**             | policy activities.                |
|                                   |                                   |
| **(Promote family participation   |                                   |
| in care)**                        |                                   |
|                                   |                                   |
| **Level: Grantee**                |                                   |
|                                   |                                   |
| **Category: Family                |                                   |
| Participation**                   |                                   |
+-----------------------------------+-----------------------------------+
| **GOAL**                          | To increase family participation  |
|                                   | in MCHB programs.                 |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **MEASURE**                       | The degree to which MCHB          |
|                                   | supported programs ensure family  |
|                                   | participation in program and      |
|                                   | policy activities.                |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **DEFINITION**                    | Attached is a checklist of 6      |
|                                   | elements that demonstrate family  |
|                                   | participation. Please check the   |
|                                   | degree to which the elements have |
|                                   | been implemented.                 |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **HEALTHY PEOPLE 2010 OBJECTIVE** | Related to Objective 16.23.       |
|                                   | Increase the proportion of        |
|                                   | Territories and States that have  |
|                                   | service systems for Children with |
|                                   | Special Health Care Needs to 100  |
|                                   | percent.                          |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **DATA SOURCE(S) AND ISSUES**     | Attached data collection form to  |
|                                   | be completed by grantees.         |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **SIGNIFICANCE**                  | Over the last decade, policy      |
|                                   | makers and program administrators |
|                                   | have emphasized the central role  |
|                                   | of families as advisors and       |
|                                   | participants in policy-making     |
|                                   | activities. In accordance with    |
|                                   | this philosophy, MCHB is          |
|                                   | facilitating such partnerships at |
|                                   | the local, state and national     |
|                                   | levels. Family/professional       |
|                                   | partnerships have been:           |
|                                   | incorporated into the MCHB Block  |
|                                   | Grant Application, the MCHB       |
|                                   | strategic plan and is a           |
|                                   | requirement in the Omnibus Budget |
|                                   | Reconciliation Act of 1989 (OBRA  |
|                                   | '89), the legislative mandate     |
|                                   | that health programs supported by |
|                                   | Maternal and Child Health Bureau  |
|                                   | (MCHB) Children with Special      |
|                                   | Health Care Needs (CSHCN) provide |
|                                   | and promote family centered,      |
|                                   | community‑based, coordinated      |
|                                   | care.                             |
+-----------------------------------+-----------------------------------+

DATA COLLECTION FORM FOR DETAIL SHEET #07

Using a scale of 0-3, please rate the degree to which our grant program
has included families into their program and planning activities.

+------+------+------+------+------------------------------------------+
| *    | *    | *    | *    | **Element**                              |
| *0** | *1** | *2** | *3** |                                          |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 1.  Family members participate on        |
|      |      |      |      |     advisory committees or task forces   |
|      |      |      |      |     and are offered training, mentoring  |
|      |      |      |      |     and reimbursement.                   |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 2.  Financial support (financial grants, |
|      |      |      |      |     technical assistance, travel, and    |
|      |      |      |      |     child care) is offered for parent    |
|      |      |      |      |     activities or parent groups.         |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 3.  Family members participate in the    |
|      |      |      |      |     planning, implementation and         |
|      |      |      |      |     evaluation of the program's          |
|      |      |      |      |     activities.                          |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 4.  Families members work with their     |
|      |      |      |      |     professional partners to provide     |
|      |      |      |      |     training ( pre‑service, in-service   |
|      |      |      |      |     and professional development) to     |
|      |      |      |      |     MCH/CSHCN staff and providers.       |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 5.  Family members are hired as paid     |
|      |      |      |      |     staff or consultants to the program  |
|      |      |      |      |     (a family member is hired for his or |
|      |      |      |      |     her expertise as a family member).   |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 6.  Family members of diverse cultures   |
|      |      |      |      |     are involved in all of the above     |
|      |      |      |      |     activities.                          |
+------+------+------+------+------------------------------------------+

0=Not Met

1=Partially Met

2=Mostly Met

3=Completely Met

Total the numbers in the boxes (possible 0‑18 score) \_\_\_\_\_\_\_\_\_

+-----------------------------------+-----------------------------------+
| **08 PERFORMANCE MEASURE**        | The percent of graduates of MCHB  |
|                                   | long‑term training programs that  |
| **Goal 1: Provide National        | demonstrate field leadership      |
| Leadership for Maternal and Child | after graduation.                 |
| Health**                          |                                   |
|                                   |                                   |
| **(Provide both graduate level    |                                   |
| and continuing education training |                                   |
| to assure interdisciplinary MCH   |                                   |
| public health leadership          |                                   |
| nationwide)**                     |                                   |
|                                   |                                   |
| **Level: Grantee**                |                                   |
|                                   |                                   |
| **Category: Training**            |                                   |
+-----------------------------------+-----------------------------------+
| **GOAL**                          | > To increase the percent of      |
|                                   | > graduates of long‑term training |
|                                   | > programs that demonstrate field |
|                                   | > leadership five years after     |
|                                   | > graduation.[^1]                 |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **MEASURE**                       | The percent of graduates of MCHB  |
|                                   | long‑term training programs that  |
|                                   | demonstrate field leadership      |
|                                   | after graduation.                 |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **DEFINITION**                    | Attached is a checklist of 4      |
|                                   | elements that demonstrate field   |
|                                   | leadership. For each element,     |
|                                   | identify the number of graduates  |
|                                   | of MCHB long‑term training        |
|                                   | programs that demonstrate field   |
|                                   | leadership 5 years after          |
|                                   | graduation. Please keep the       |
|                                   | completed checklist attached.     |
+-----------------------------------+-----------------------------------+
|                                   | "Field leadership" refers to but  |
|                                   | is not limited to providing MCH   |
|                                   | leadership within the clinical,   |
|                                   | advocacy, academic, research,     |
|                                   | public health, public policy or   |
|                                   | governmental realms. Refer to     |
|                                   | attachment for complete           |
|                                   | definition.                       |
|                                   |                                   |
|                                   | Cohort is defined as those who    |
|                                   | graduate in a certain project     |
|                                   | period. Data form for each cohort |
|                                   | year will be collected for five   |
|                                   | years.                            |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **HEALTHY PEOPLE 2010 OBJECTIVE** | Related to Objective 1.7:         |
|                                   | (Developmental) Increase the      |
|                                   | proportion of schools of          |
|                                   | medicine, schools of nursing, and |
|                                   | other health professional         |
|                                   | training schools whose basic      |
|                                   | curriculum for health care        |
|                                   | providers includes the core       |
|                                   | competencies in health promotion  |
|                                   | and disease prevention.           |
|                                   |                                   |
|                                   | Related to Objective 23.8:        |
|                                   | (Developmental) Increase the      |
|                                   | proportion of Federal, Tribal,    |
|                                   | State, and local agencies that    |
|                                   | incorporate specific competencies |
|                                   | in the essential public health    |
|                                   | services into personnel systems.  |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **DATA SOURCE(S) AND ISSUES**     | Attached data collection form to  |
|                                   | be completed by grantees.         |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **SIGNIFICANCE**                  | An MCHB trained workforce is a    |
|                                   | vital participant in clinical,    |
|                                   | administrative, policy, public    |
|                                   | health and various other arenas.  |
|                                   | MCHB long‑term training programs  |
|                                   | assist in developing a public     |
|                                   | health workforce that addresses   |
|                                   | MCH concerns and fosters field    |
|                                   | leadership in the MCH arena.      |
+-----------------------------------+-----------------------------------+

###### DATA COLLECTION FORM FOR DETAIL SHEET #08

The total number of graduates, 5 years post graduation, included in this
report \_\_\_\_\_\_\_\_\_

The total number of graduates lost to follow-up \_\_\_\_\_\_\_\_\_

Percent of graduates (5 years post graduation) demonstrate MCH
leadership

in **at least one** of the following areas: \_\_\_\_\_\_\_\_%

-   Academics‑‑i.e. faculty member teaching‑mentoring in MCH related
    field; \_\_\_\_\_\_\_\_%

and/or conducting MCH related research; and /or providing consultation

or technical assistance in MCH; and/or publishing and presenting in key

MCH areas; and/or success in procuring grant and other funding in MCH

-   Clinical‑‑i.e. development of guidelines for specific MCH
    conditions; \_\_\_\_\_\_\_\_%

and/or participation as officer or chairperson of committees on State,

National, or local clinical organizations, task forces, community
boards,

etc.; and/or clinical preceptor for MCH trainees; and/or research,
publication,

and key presentations on MCH clinical issues; and/or serves in a
clinical

leadership position as director, team leader, chairperson, etc.

-   Public Health/Public Policy‑‑i.e. leadership position in local,
    State or \_\_\_\_\_\_\_\_%

National public organizations, government entity; and/or conducts

strategic planning; participates in program evaluation and public policy

development; and/or success in procuring grant and other funding;

and/or influencing MCH legislation; and/or publication, presentations

in key MCH issues.

-   Advocacy‑‑i.e. through efforts at the community, State, Regional and
    \_\_\_\_\_\_\_\_%

National levels influencing positive change in MCH through creative

promotion, support and activities‑‑both private and public. For example,

developing a city‑wide SIDS awareness and prevention program through

community churches.

+-----------------------------------+-----------------+-----------------+
| #### 09 PERFORMANCE MEASURE       | The percent of  |                 |
|                                   | participants in |                 |
| **Goal 2: Eliminate Health        | MCHB long-term  |                 |
| Barriers and Disparities (Train   | training        |                 |
| an MCH Workforce that is          | programs who    |                 |
| culturally competent and reflects | are from        |                 |
| an increasingly diverse           | u               |                 |
| population)**                     | nderrepresented |                 |
|                                   | groups.         |                 |
| **Level: Grantee**                |                 |                 |
|                                   |                 |                 |
| **Category: Training**            |                 |                 |
+-----------------------------------+-----------------+-----------------+
| **GOAL**                          | To increase the |                 |
|                                   | percent of      |                 |
|                                   | trainees        |                 |
|                                   | participating   |                 |
|                                   | in MCHB         |                 |
|                                   | long‑term       |                 |
|                                   | training        |                 |
|                                   | programs who    |                 |
|                                   | are from        |                 |
|                                   | u               |                 |
|                                   | nderrepresented |                 |
|                                   | groups.         |                 |
+-----------------------------------+-----------------+-----------------+
|                                   |                 |                 |
+-----------------------------------+-----------------+-----------------+
| **MEASURE**                       | The percent of  |                 |
|                                   | participants in |                 |
|                                   | MCHB long-term  |                 |
|                                   | training        |                 |
|                                   | programs who    |                 |
|                                   | are from        |                 |
|                                   | u               |                 |
|                                   | nderrepresented |                 |
|                                   | groups.         |                 |
+-----------------------------------+-----------------+-----------------+
|                                   |                 |                 |
+-----------------------------------+-----------------+-----------------+
| **DEFINITION**                    | **Numerator:**  |                 |
+-----------------------------------+-----------------+-----------------+
|                                   | Number of       |                 |
|                                   | trainees        |                 |
|                                   | reported by     |                 |
|                                   | MCHB long‑term  |                 |
|                                   | training        |                 |
|                                   | programs to be  |                 |
|                                   | from            |                 |
|                                   | u               |                 |
|                                   | nderrepresented |                 |
|                                   | groups.         |                 |
+-----------------------------------+-----------------+-----------------+
|                                   | *               |                 |
|                                   | *Denominator:** |                 |
+-----------------------------------+-----------------+-----------------+
|                                   | Total number of |                 |
|                                   | trainees        |                 |
|                                   | participating   |                 |
|                                   | in MCHB         |                 |
|                                   | long‑term       |                 |
|                                   | training        |                 |
|                                   | programs.       |                 |
+-----------------------------------+-----------------+-----------------+
|                                   | **Units:** 100  | **Text:**       |
|                                   |                 | Percent         |
+-----------------------------------+-----------------+-----------------+
|                                   | "U              |                 |
|                                   | nderrepresented |                 |
|                                   | groups" refer   |                 |
|                                   | to, but are not |                 |
|                                   | limited to,     |                 |
|                                   | groups based on |                 |
|                                   | race,           |                 |
|                                   | ethnicity,      |                 |
|                                   | geographic      |                 |
|                                   | location and    |                 |
|                                   | gender who are  |                 |
|                                   | u               |                 |
|                                   | nderrepresented |                 |
|                                   | in a field of   |                 |
|                                   | study.          |                 |
+-----------------------------------+-----------------+-----------------+
|                                   |                 |                 |
+-----------------------------------+-----------------+-----------------+
| **HEALTHY PEOPLE 2010 OBJECTIVE** | Related to      |                 |
|                                   | Objective 1.8:  |                 |
|                                   | In the health   |                 |
|                                   | professions,    |                 |
|                                   | allied and      |                 |
|                                   | associated      |                 |
|                                   | health          |                 |
|                                   | professions,    |                 |
|                                   | and the nursing |                 |
|                                   | field, increase |                 |
|                                   | the proportion  |                 |
|                                   | of all degrees  |                 |
|                                   | awarded to      |                 |
|                                   | members of      |                 |
|                                   | u               |                 |
|                                   | nderrepresented |                 |
|                                   | racial and      |                 |
|                                   | ethnic groups.  |                 |
+-----------------------------------+-----------------+-----------------+
|                                   |                 |                 |
+-----------------------------------+-----------------+-----------------+
| **DATA SOURCE(S) AND ISSUES**     | -   Data will   |                 |
|                                   |     be          |                 |
|                                   |     collected   |                 |
|                                   |     annually    |                 |
|                                   |     from        |                 |
|                                   |     grantees    |                 |
|                                   |     about       |                 |
|                                   |     enrolled    |                 |
|                                   |     students    |                 |
|                                   |     from the    |                 |
|                                   |     Minimum     |                 |
|                                   |     Data Set or |                 |
|                                   |     a data      |                 |
|                                   |     collection  |                 |
|                                   |     form will   |                 |
|                                   |     be          |                 |
|                                   |     developed   |                 |
|                                   |     if          |                 |
|                                   |     necessary.  |                 |
|                                   |                 |                 |
|                                   | -   MCHB does   |                 |
|                                   |     not         |                 |
|                                   |     maintain a  |                 |
|                                   |     master list |                 |
|                                   |     of all      |                 |
|                                   |     trainees    |                 |
|                                   |     who are     |                 |
|                                   |     supported   |                 |
|                                   |     by MCHB     |                 |
|                                   |     long‑term   |                 |
|                                   |     training    |                 |
|                                   |     programs.   |                 |
+-----------------------------------+-----------------+-----------------+
|                                   |                 |                 |
+-----------------------------------+-----------------+-----------------+
| **SIGNIFICANCE**                  | HRSA's MCHB     |                 |
|                                   | places special  |                 |
|                                   | emphasis on     |                 |
|                                   | improving       |                 |
|                                   | service         |                 |
|                                   | delivery to     |                 |
|                                   | women, children |                 |
|                                   | and youth from  |                 |
|                                   | communities     |                 |
|                                   | with limited    |                 |
|                                   | access to       |                 |
|                                   | comprehensive   |                 |
|                                   | care. Training  |                 |
|                                   | a diverse group |                 |
|                                   | of              |                 |
|                                   | professionals   |                 |
|                                   | is necessary in |                 |
|                                   | order to        |                 |
|                                   | provide a       |                 |
|                                   | diverse public  |                 |
|                                   | health          |                 |
|                                   | workforce to    |                 |
|                                   | meet the needs  |                 |
|                                   | of the changing |                 |
|                                   | demographics of |                 |
|                                   | the U.S. and to |                 |
|                                   | ensure access   |                 |
|                                   | to culturally   |                 |
|                                   | competent and   |                 |
|                                   | effective       |                 |
|                                   | services. This  |                 |
|                                   | performance     |                 |
|                                   | measure         |                 |
|                                   | provides the    |                 |
|                                   | necessary data  |                 |
|                                   | to report on    |                 |
|                                   | HRSA's          |                 |
|                                   | initiatives to  |                 |
|                                   | reduce          |                 |
|                                   | disparities.    |                 |
+-----------------------------------+-----------------+-----------------+

+-----------------------------------+-----------------------------------+
| #### 11 PERFORMANCE MEASURE       | The degree to which MCHB          |
|                                   | long‑term training grantees       |
| **Goal 2: Eliminate Health        | include cultural competency in    |
| Barriers & Disparities (Train and | their curricula/training.         |
| MCH Workforce that is culturally  |                                   |
| competent and reflect an          |                                   |
| increasingly diverse              |                                   |
| population)**                     |                                   |
|                                   |                                   |
| **Level: Grantee**                |                                   |
|                                   |                                   |
| **Category: Cultural Competence** |                                   |
+-----------------------------------+-----------------------------------+
| **GOAL**                          | To increase the number of MCHB    |
|                                   | long‑term training programs that  |
|                                   | include each element of cultural  |
|                                   | competency in their               |
|                                   | curricula/training.               |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **MEASURE**                       | The degree to which MCHB          |
|                                   | long‑term training grantees       |
|                                   | include cultural competency in    |
|                                   | their curricula/training.         |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **DEFINITION**                    | Attached is a checklist of nine   |
|                                   | elements that demonstrate         |
|                                   | cultural competency. Please check |
|                                   | the degree to which the elements  |
|                                   | have been implemented. The answer |
|                                   | scale is 0-27. Please keep the    |
|                                   | completed checklist attached.     |
+-----------------------------------+-----------------------------------+
|                                   | Cultural competency training is   |
|                                   | defined as including the          |
|                                   | following elements: written       |
|                                   | cultural competence plan;         |
|                                   | cultural and linguistic           |
|                                   | competency policies; cultural and |
|                                   | linguistic competence knowledge   |
|                                   | and skills; research data on      |
|                                   | populations served according to   |
|                                   | racial, ethnic, and linguistic    |
|                                   | groupings; participation of       |
|                                   | community and family members of   |
|                                   | diverse cultures; faculty/staff   |
|                                   | with expertise in cultural and    |
|                                   | linguistic competence;            |
|                                   | faculty/staff trained in cultural |
|                                   | and linguistic competence issues; |
|                                   | and periodic assessment and       |
|                                   | planning.                         |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **HEALTHY PEOPLE 2010 OBJECTIVE** | Related to Objective 23.9:        |
|                                   | (Developmental) Increase the      |
|                                   | proportion of schools for public  |
|                                   | health workers that integrate     |
|                                   | into their curricula specific     |
|                                   | content to develop competency in  |
|                                   | the essential public health       |
|                                   | services.                         |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **DATA SOURCE(S) AND ISSUES**     | -   Attached data collection form |
|                                   |     to be completed by grantee.   |
|                                   |                                   |
|                                   | -   Data will be collected from   |
|                                   |     competitive and continuation  |
|                                   |     applications as part of the   |
|                                   |     grant application process and |
|                                   |     annual reports. The elements  |
|                                   |     of a quality cultural         |
|                                   |     competency program needs to   |
|                                   |     be operationally defined and  |
|                                   |     a draft checklist is          |
|                                   |     attached.                     |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **SIGNIFICANCE**                  | Certain racial and ethnic groups  |
|                                   | and low-income communities lag    |
|                                   | behind the overall U.S.           |
|                                   | population on virtually all       |
|                                   | health status indicators. Access  |
|                                   | to health care that is culturally |
|                                   | appropriate is part of this a     |
|                                   | problem. A lack of understanding  |
|                                   | by providers creates barriers to  |
|                                   | care for racial/ethnic groups. To |
|                                   | effective reduce cultural         |
|                                   | barriers, providers need cultural |
|                                   | competency training. This will    |
|                                   | help to provide an effective      |
|                                   | public health workforce that      |
|                                   | meets the needs of the changing   |
|                                   | demographics of the US.           |
+-----------------------------------+-----------------------------------+

DATA COLLECTION FORM FOR DETAIL SHEET #11

Using a scale of 0-3, please rate the degree to which your training
program has addressed the following cultural competence elements.

  ------- ------- ------- ------- -------------------------------------------
  **0**   **1**   **2**   **3**   **Element**

                                  1\. A written cultural competence plan for
                                  your training program emphasizes your
                                  commitment to delivering a culturally
                                  competent training experience to your
                                  trainees.

                                  2\. Cultural and linguistic competency
                                  policies are incorporated into the overall
                                  administration of your training program
                                  (recruitment plan and other policies and
                                  procedures).

                                  3\. Cultural and linguistic competence
                                  knowledge and skills building are included
                                  in the didactic portion of your training
                                  experience.

                                  4\. Cultural and linguistic competence
                                  knowledge and skills building are included
                                  in the practicum/field/clinical experience
                                  portion of your training experience.

                                  5\. Research conducted by trainees and
                                  faculty includes the collection and
                                  analysis of data on populations served
                                  according to racial, ethnic, and linguistic
                                  groupings, where appropriate.

                                  6\. Community and family members of diverse
                                  cultures are involved in partnerships and
                                  collaborations for the planning, delivery,
                                  and evaluation of your training program.

                                  7\. Faculty/staff are culturally diverse
                                  and linguistically and culturally
                                  competent.

                                  8\. Faculty and staff are regularly trained
                                  on cultural and linguistic competency
                                  issues.

                                  9\. A process is in place for periodic
                                  assessment and planning related to the
                                  cultural and linguistic competence of your
                                  trainees.
  ------- ------- ------- ------- -------------------------------------------

0=Not Met

1=Partially Met

2=Mostly Met

3=Completely Met

Total the numbers in the boxes (possible 0‑27 score)
\_\_\_\_\_\_\_\_\_\_\_

+---------------------------------+--------+---------------------------+
| PROGRAM PERFORMANCE MEASURE 62  | The    |                           |
|                                 | number |                           |
|                                 | of     |                           |
|                                 | pr     |                           |
|                                 | oducts |                           |
|                                 | and    |                           |
|                                 | public |                           |
|                                 | ations |                           |
|                                 | that   |                           |
|                                 | were   |                           |
|                                 | pr     |                           |
|                                 | oduced |                           |
|                                 | by a   |                           |
|                                 | tr     |                           |
|                                 | aining |                           |
|                                 | pro    |                           |
|                                 | gram's |                           |
|                                 | f      |                           |
|                                 | aculty |                           |
|                                 | and    |                           |
|                                 | tr     |                           |
|                                 | ainees |                           |
|                                 | each   |                           |
|                                 | year.  |                           |
+---------------------------------+--------+---------------------------+
| **GOAL**                        | To     |                           |
|                                 | i      |                           |
|                                 | mprove |                           |
|                                 | the    |                           |
|                                 | d      |                           |
|                                 | issemi |                           |
|                                 | nation |                           |
|                                 | of new |                           |
|                                 | kno    |                           |
|                                 | wledge |                           |
|                                 | to the |                           |
|                                 | MCH    |                           |
|                                 | field  |                           |
|                                 | by     |                           |
|                                 | incr   |                           |
|                                 | easing |                           |
|                                 | the    |                           |
|                                 | number |                           |
|                                 | of     |                           |
|                                 | p      |                           |
|                                 | ublica |                           |
|                                 | tions, |                           |
|                                 | inc    |                           |
|                                 | luding |                           |
|                                 | art    |                           |
|                                 | icles, |                           |
|                                 | cha    |                           |
|                                 | pters, |                           |
|                                 | books  |                           |
|                                 | and    |                           |
|                                 | other  |                           |
|                                 | mat    |                           |
|                                 | erials |                           |
|                                 | pr     |                           |
|                                 | oduced |                           |
|                                 | by     |                           |
|                                 | tr     |                           |
|                                 | aining |                           |
|                                 | staff  |                           |
|                                 | (with  |                           |
|                                 | em     |                           |
|                                 | phasis |                           |
|                                 | on     |                           |
|                                 | those  |                           |
|                                 | that   |                           |
|                                 | add    |                           |
|                                 | ressed |                           |
|                                 | the    |                           |
|                                 | tr     |                           |
|                                 | aining |                           |
|                                 | pro    |                           |
|                                 | gram's |                           |
|                                 | str    |                           |
|                                 | ategic |                           |
|                                 | plan   |                           |
|                                 | goals) |                           |
|                                 | and    |                           |
|                                 | tra    |                           |
|                                 | inees. |                           |
|                                 | This   |                           |
|                                 | does   |                           |
|                                 | not    |                           |
|                                 | i      |                           |
|                                 | nclude |                           |
|                                 | pamp   |                           |
|                                 | hlets, |                           |
|                                 | han    |                           |
|                                 | douts, |                           |
|                                 | indi   |                           |
|                                 | vidual |                           |
|                                 | web    |                           |
|                                 | pages, |                           |
|                                 | or     |                           |
|                                 | confer |                           |
|                                 | ences. |                           |
+---------------------------------+--------+---------------------------+
| **MEASURE**                     | The    |                           |
|                                 | number |                           |
|                                 | of     |                           |
|                                 | pr     |                           |
|                                 | oducts |                           |
|                                 | and    |                           |
|                                 | public |                           |
|                                 | ations |                           |
|                                 | that   |                           |
|                                 | were   |                           |
|                                 | pr     |                           |
|                                 | oduced |                           |
|                                 | by a   |                           |
|                                 | tr     |                           |
|                                 | aining |                           |
|                                 | pro    |                           |
|                                 | gram's |                           |
|                                 | f      |                           |
|                                 | aculty |                           |
|                                 | and    |                           |
|                                 | tr     |                           |
|                                 | ainees |                           |
|                                 | each   |                           |
|                                 | year.  |                           |
+---------------------------------+--------+---------------------------+
| **DEFINITION**                  | Public |                           |
|                                 | ations |                           |
|                                 | are    |                           |
|                                 | art    |                           |
|                                 | icles, |                           |
|                                 | books  |                           |
|                                 | or     |                           |
|                                 | ch     |                           |
|                                 | apters |                           |
|                                 | pub    |                           |
|                                 | lished |                           |
|                                 | during |                           |
|                                 | the    |                           |
|                                 | year   |                           |
|                                 | being  |                           |
|                                 | rep    |                           |
|                                 | orted, |                           |
|                                 | espe   |                           |
|                                 | cially |                           |
|                                 | public |                           |
|                                 | ations |                           |
|                                 | that   |                           |
|                                 | are    |                           |
|                                 | peer   |                           |
|                                 | rev    |                           |
|                                 | iewed. |                           |
|                                 | Pr     |                           |
|                                 | oducts |                           |
|                                 | i      |                           |
|                                 | nclude |                           |
|                                 | video  |                           |
|                                 | tr     |                           |
|                                 | aining |                           |
|                                 | tapes, |                           |
|                                 | CD     |                           |
|                                 | roms,  |                           |
|                                 | curr   |                           |
|                                 | iculum |                           |
|                                 | m      |                           |
|                                 | odules |                           |
|                                 | for    |                           |
|                                 | tr     |                           |
|                                 | aining |                           |
|                                 | pur    |                           |
|                                 | poses, |                           |
|                                 | mat    |                           |
|                                 | erials |                           |
|                                 | c      |                           |
|                                 | reated |                           |
|                                 | for    |                           |
|                                 | con    |                           |
|                                 | sumers |                           |
|                                 | (pa    |                           |
|                                 | rents/ |                           |
|                                 | childr |                           |
|                                 | en/com |                           |
|                                 | munity |                           |
|                                 | agen   |                           |
|                                 | cies), |                           |
|                                 | dev    |                           |
|                                 | eloped |                           |
|                                 | by the |                           |
|                                 | tr     |                           |
|                                 | aining |                           |
|                                 | pro    |                           |
|                                 | gram's |                           |
|                                 | fa     |                           |
|                                 | culty. |                           |
|                                 |        |                           |
|                                 | D      |                           |
|                                 | etails |                           |
|                                 | on     |                           |
|                                 | these  |                           |
|                                 | public |                           |
|                                 | ations |                           |
|                                 | and    |                           |
|                                 | pr     |                           |
|                                 | oducts |                           |
|                                 | are    |                           |
|                                 | re     |                           |
|                                 | ported |                           |
|                                 | on a   |                           |
|                                 | data   |                           |
|                                 | coll   |                           |
|                                 | ection |                           |
|                                 | form.  |                           |
|                                 | These  |                           |
|                                 | pr     |                           |
|                                 | oducts |                           |
|                                 | are    |                           |
|                                 | summed |                           |
|                                 | by     |                           |
|                                 | ca     |                           |
|                                 | tegory |                           |
|                                 | and    |                           |
|                                 | the    |                           |
|                                 | total  |                           |
|                                 | number |                           |
|                                 | of all |                           |
|                                 | public |                           |
|                                 | ations |                           |
|                                 | and    |                           |
|                                 | pr     |                           |
|                                 | oducts |                           |
|                                 | are    |                           |
|                                 | re     |                           |
|                                 | ported |                           |
|                                 | on a   |                           |
|                                 | perfo  |                           |
|                                 | rmance |                           |
|                                 | m      |                           |
|                                 | easure |                           |
|                                 | tr     |                           |
|                                 | acking |                           |
|                                 | form   |                           |
|                                 | for a  |                           |
|                                 | rep    |                           |
|                                 | orting |                           |
|                                 | year.  |                           |
|                                 |        |                           |
|                                 | The    |                           |
|                                 | tr     |                           |
|                                 | aining |                           |
|                                 | pro    |                           |
|                                 | gram's |                           |
|                                 | f      |                           |
|                                 | aculty |                           |
|                                 | is     |                           |
|                                 | d      |                           |
|                                 | efined |                           |
|                                 | as any |                           |
|                                 | indiv  |                           |
|                                 | iduals |                           |
|                                 | who    |                           |
|                                 | r      |                           |
|                                 | eceive |                           |
|                                 | MCHB   |                           |
|                                 | tr     |                           |
|                                 | aining |                           |
|                                 | grant  |                           |
|                                 | f      |                           |
|                                 | unding |                           |
|                                 | or are |                           |
|                                 | listed |                           |
|                                 | as a   |                           |
|                                 | f      |                           |
|                                 | aculty |                           |
|                                 | m      |                           |
|                                 | embers |                           |
|                                 | in a   |                           |
|                                 | MCHB   |                           |
|                                 | tr     |                           |
|                                 | aining |                           |
|                                 | grant  |                           |
|                                 | (not   |                           |
|                                 | only   |                           |
|                                 | those  |                           |
|                                 | di     |                           |
|                                 | rectly |                           |
|                                 | sup    |                           |
|                                 | ported |                           |
|                                 | by     |                           |
|                                 | grant  |                           |
|                                 | dol    |                           |
|                                 | lars). |                           |
+---------------------------------+--------+---------------------------+
|                                 | **     | **Text:** This will be a  |
|                                 | Units: | numerical count of        |
|                                 | \# 1** | publications and products |
+---------------------------------+--------+---------------------------+
| **HEALTHY PEOPLE 2010           | R      |                           |
| OBJECTIVE**                     | elated |                           |
|                                 | to     |                           |
|                                 | Goal   |                           |
|                                 | 1:     |                           |
|                                 | I      |                           |
|                                 | mprove |                           |
|                                 | access |                           |
|                                 | to     |                           |
|                                 | co     |                           |
|                                 | mprehe |                           |
|                                 | nsive, |                           |
|                                 | high-q |                           |
|                                 | uality |                           |
|                                 | health |                           |
|                                 | care   |                           |
|                                 | se     |                           |
|                                 | rvices |                           |
|                                 | (Obje  |                           |
|                                 | ctives |                           |
|                                 | 1.1-   |                           |
|                                 | 1.16). |                           |
|                                 |        |                           |
|                                 | R      |                           |
|                                 | elated |                           |
|                                 | to     |                           |
|                                 | Goal 7 |                           |
|                                 | --     |                           |
|                                 | Educa  |                           |
|                                 | tional |                           |
|                                 | and    |                           |
|                                 | com    |                           |
|                                 | munity |                           |
|                                 | -based |                           |
|                                 | pro    |                           |
|                                 | grams: |                           |
|                                 | In     |                           |
|                                 | crease |                           |
|                                 | the    |                           |
|                                 | qu     |                           |
|                                 | ality, |                           |
|                                 | availa |                           |
|                                 | bility |                           |
|                                 | and    |                           |
|                                 | e      |                           |
|                                 | ffecti |                           |
|                                 | veness |                           |
|                                 | of     |                           |
|                                 | educa  |                           |
|                                 | tional |                           |
|                                 | and    |                           |
|                                 | com    |                           |
|                                 | munity |                           |
|                                 | -based |                           |
|                                 | pr     |                           |
|                                 | ograms |                           |
|                                 | de     |                           |
|                                 | signed |                           |
|                                 | to     |                           |
|                                 | p      |                           |
|                                 | revent |                           |
|                                 | d      |                           |
|                                 | isease |                           |
|                                 | and    |                           |
|                                 | i      |                           |
|                                 | mprove |                           |
|                                 | health |                           |
|                                 | and    |                           |
|                                 | q      |                           |
|                                 | uality |                           |
|                                 | of     |                           |
|                                 | life.  |                           |
|                                 | Sp     |                           |
|                                 | ecific |                           |
|                                 | objec  |                           |
|                                 | tives: |                           |
|                                 | 7-7    |                           |
|                                 | t      |                           |
|                                 | hrough |                           |
|                                 | 7-11.  |                           |
|                                 |        |                           |
|                                 | R      |                           |
|                                 | elated |                           |
|                                 | to     |                           |
|                                 | Goal   |                           |
|                                 | 23 --  |                           |
|                                 | Public |                           |
|                                 | Health |                           |
|                                 | Inf    |                           |
|                                 | rastru |                           |
|                                 | cture: |                           |
|                                 | Ensure |                           |
|                                 | that   |                           |
|                                 | Fe     |                           |
|                                 | deral, |                           |
|                                 | T      |                           |
|                                 | ribal, |                           |
|                                 | State, |                           |
|                                 | and    |                           |
|                                 | local  |                           |
|                                 | health |                           |
|                                 | ag     |                           |
|                                 | encies |                           |
|                                 | have   |                           |
|                                 | the    |                           |
|                                 | in     |                           |
|                                 | frastr |                           |
|                                 | ucture |                           |
|                                 | to     |                           |
|                                 | p      |                           |
|                                 | rovide |                           |
|                                 | ess    |                           |
|                                 | ential |                           |
|                                 | public |                           |
|                                 | health |                           |
|                                 | se     |                           |
|                                 | rvices |                           |
|                                 | effect |                           |
|                                 | ively. |                           |
|                                 | Sp     |                           |
|                                 | ecific |                           |
|                                 | objec  |                           |
|                                 | tives: |                           |
|                                 | 23-8   |                           |
|                                 | t      |                           |
|                                 | hrough |                           |
|                                 | 23-10  |                           |
+---------------------------------+--------+---------------------------+
| **DATA SOURCE(S) AND ISSUES**   | Data   |                           |
|                                 | will   |                           |
|                                 | be     |                           |
|                                 | col    |                           |
|                                 | lected |                           |
|                                 | by the |                           |
|                                 | tr     |                           |
|                                 | aining |                           |
|                                 | pr     |                           |
|                                 | ograms |                           |
|                                 | thro   |                           |
|                                 | ughout |                           |
|                                 | the    |                           |
|                                 | year   |                           |
|                                 | and    |                           |
|                                 | re     |                           |
|                                 | ported |                           |
|                                 | in     |                           |
|                                 | their  |                           |
|                                 | annual |                           |
|                                 | r      |                           |
|                                 | eports |                           |
|                                 | and    |                           |
|                                 | via    |                           |
|                                 | this   |                           |
|                                 | mea    |                           |
|                                 | sure's |                           |
|                                 | data   |                           |
|                                 | coll   |                           |
|                                 | ection |                           |
|                                 | form.  |                           |
+---------------------------------+--------+---------------------------+
| **SIGNIFICANCE**                | Adv    |                           |
|                                 | ancing |                           |
|                                 | the    |                           |
|                                 | field  |                           |
|                                 | of     |                           |
|                                 | ma     |                           |
|                                 | ternal |                           |
|                                 | and    |                           |
|                                 | child  |                           |
|                                 | health |                           |
|                                 | based  |                           |
|                                 | on     |                           |
|                                 | scie   |                           |
|                                 | ntific |                           |
|                                 | advan  |                           |
|                                 | cement |                           |
|                                 | and    |                           |
|                                 | d      |                           |
|                                 | issemi |                           |
|                                 | nation |                           |
|                                 | of     |                           |
|                                 | these  |                           |
|                                 | advanc |                           |
|                                 | ements |                           |
|                                 | is an  |                           |
|                                 | imp    |                           |
|                                 | ortant |                           |
|                                 | role   |                           |
|                                 | for    |                           |
|                                 | lead   |                           |
|                                 | ership |                           |
|                                 | tr     |                           |
|                                 | aining |                           |
|                                 | pro    |                           |
|                                 | grams. |                           |
|                                 | Coll   |                           |
|                                 | ection |                           |
|                                 | of the |                           |
|                                 | types  |                           |
|                                 | of and |                           |
|                                 | d      |                           |
|                                 | issemi |                           |
|                                 | nation |                           |
|                                 | of MCH |                           |
|                                 | pr     |                           |
|                                 | oducts |                           |
|                                 | and    |                           |
|                                 | public |                           |
|                                 | ations |                           |
|                                 | is     |                           |
|                                 | c      |                           |
|                                 | rucial |                           |
|                                 | for    |                           |
|                                 | adv    |                           |
|                                 | ancing |                           |
|                                 | the    |                           |
|                                 | field. |                           |
|                                 | This   |                           |
|                                 | perfo  |                           |
|                                 | rmance |                           |
|                                 | m      |                           |
|                                 | easure |                           |
|                                 | add    |                           |
|                                 | resses |                           |
|                                 | the    |                           |
|                                 | obj    |                           |
|                                 | ective |                           |
|                                 | of     |                           |
|                                 | MCHB   |                           |
|                                 | to     |                           |
|                                 | disse  |                           |
|                                 | minate |                           |
|                                 | new    |                           |
|                                 | kno    |                           |
|                                 | wledge |                           |
|                                 | of     |                           |
|                                 | signif |                           |
|                                 | icance |                           |
|                                 | to the |                           |
|                                 | field  |                           |
|                                 | and    |                           |
|                                 | gauges |                           |
|                                 | the    |                           |
|                                 | s      |                           |
|                                 | uccess |                           |
|                                 | of     |                           |
|                                 | d      |                           |
|                                 | issemi |                           |
|                                 | nation |                           |
|                                 | to     |                           |
|                                 | target |                           |
|                                 | audi   |                           |
|                                 | ences. |                           |
+---------------------------------+--------+---------------------------+

**DATA COLLECTION FORM FOR DETAIL SHEET PM #62**

Please list the number of publications and products addressing maternal
and child health that have been published or produced by your training
program's faculty and trainees in the past year:

  --------------------------------------------------------- -------------
  Element                                                   Number

  Peer-reviewed publications in scholarly journals          

  Non peer-reviewed publications                            

  Books                                                     

  Book chapters                                             

  Reports/monographs                                        

  Electronic educational products (CD-ROM, audio or         
  videotapes, or Web-based) (not individual web pages)      

  Course development                                        

  Distance learning modules or materials                    

  Doctoral dissertations                                    

  **Total**                                                 
  --------------------------------------------------------- -------------

###### DATA COLLECTION FORM FOR DETAIL SHEET FOR PM #62

**Publications and Products Authored by MCHB Training Award Faculty or
Trainees**

**Data collection form for [Peer-reviewed publications in scholarly
journals]{.underline}**

TITLE:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

AUTHOR:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

PUBLICATION:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Volume: \_\_\_\_\_ Number:\_\_\_\_\_\_\_\_\_ Supplement:\_\_\_\_\_\_\_
Year:\_\_\_\_\_\_\_ Page(s):\_\_\_\_\_\_\_

Target Audience: Consumers \_\_\_\_\_ Professionals
\_\_\_\_\_\_\_Circulation: \_\_\_\_\_\_\_\_\_\_

**Data collection form for [Non peer-reviewed
publications]{.underline}**

TITLE:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

AUTHOR:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

PUBLICATION:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Volume: \_\_\_\_\_\_\_ Number: \_\_\_\_\_\_\_\_\_
Supplement:\_\_\_\_\_\_\_ Year:\_\_\_\_\_\_\_ Page(s):\_\_\_\_\_\_\_

Target Audience: Consumers \_\_\_\_\_ Professionals \_\_\_\_\_\_\_
Circulation: \_\_\_\_\_\_

To obtain copies (if not commercially available):

Contact Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_ Address1 :
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address2: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ City: \_\_\_\_\_\_\_\_\_\_\_
State: \_\_\_\_\_\_\_\_\_\_\_\_ Zip:\_\_\_\_\_\_\_\_\_\_

Telephone number: \_\_\_\_\_\_\_\_\_ URL: \_\_\_\_\_\_\_\_\_\_\_\_

**Data collection form for [Books]{.underline}**

TITLE:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

AUTHOR:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Publisher \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Location \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Year
\_\_\_\_\_\_\_

Target Audience: Consumers \_\_\_\_\_ Professionals \_\_\_\_\_\_\_

Number Printed: \_\_\_\_\_\_ Number Sold: \_\_\_\_\_\_\_\_\_

**Data collection form for [Book Chapters]{.underline}**

TITLE:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

AUTHOR:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

CHAPTER:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Publisher \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Location \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Year
\_\_\_\_\_\_\_

Target Audience: Consumers \_\_\_\_\_ Professionals \_\_\_\_\_\_\_

Number Printed: \_\_\_\_\_\_ Number Sold: \_\_\_\_\_\_\_\_\_

**Data collection form for [Reports/monographs]{.underline}**

TITLE:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

AUTHOR:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Year: \_\_\_\_\_\_\_\_\_ Target Audience: Consumers \_\_\_\_\_
Professionals \_\_\_\_\_\_\_

Number of copies: \_\_\_\_\_\_\_

To obtain copies: Contact Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Address1
: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address2: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ City: \_\_\_\_\_\_\_\_\_\_
State: \_\_\_\_\_\_\_\_\_\_\_\_ Zip:\_\_\_\_\_\_\_\_\_\_

Telephone number: \_\_\_\_\_\_\_\_\_\_ URL: \_\_\_\_\_\_\_\_\_\_\_\_

**Data collection form for [Electronic education products]{.underline}**

TITLE:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

AUTHOR:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Year: \_\_\_\_\_\_\_\_\_\_ Target Audience: Consumers \_\_\_\_\_
Professionals \_\_\_\_\_\_\_

Number of copies made: \_\_\_\_\_\_\_

To obtain copies: Contact Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Address1
: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address2: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ City: \_\_\_\_\_\_\_\_\_\_
State: \_\_\_\_\_\_\_\_\_\_\_\_ Zip:\_\_\_\_\_\_\_\_\_\_

Telephone number: \_\_\_\_\_\_\_\_\_\_ URL: \_\_\_\_\_\_\_\_\_\_\_\_

**Data collection form for [Course Development]{.underline}**

TITLE:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

AUTHOR:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Year: \_\_\_\_\_\_\_\_\_\_ Target Audience: Consumers \_\_\_\_\_
Professionals \_\_\_\_\_\_\_

Number of students: \_\_\_\_\_\_\_\_\_

To obtain copies: Contact Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Address1
: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address2: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ City: \_\_\_\_\_\_\_\_\_\_
State: \_\_\_\_\_\_\_\_\_\_\_\_ Zip:\_\_\_\_\_\_\_\_\_\_

Telephone number: \_\_\_\_\_\_\_\_\_\_ URL: \_\_\_\_\_\_\_\_\_\_\_\_

# Data collection form for Distance learning modules or materials

TITLE:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

AUTHOR:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Year: \_\_\_\_\_\_\_\_\_\_ Target Audience: Consumers \_\_\_\_\_
Professionals \_\_\_\_\_\_\_

Number of students: \_\_\_\_\_\_\_\_\_

To obtain copies: Contact Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Address1
: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address2: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ City: \_\_\_\_\_\_\_\_\_\_
State: \_\_\_\_\_\_\_\_\_\_\_\_ Zip:\_\_\_\_\_\_\_\_\_\_

Telephone number: \_\_\_\_\_\_\_\_\_\_ URL: \_\_\_\_\_\_\_\_\_\_\_\_

**Data collection form for [Doctoral dissertation]{.underline}**

TITLE:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

AUTHOR:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Year: \_\_\_\_\_\_\_\_\_\_

Number of copies made: \_\_\_\_\_\_\_

To obtain copies: Contact Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Address1
: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address2: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ City: \_\_\_\_\_\_\_\_\_\_
State: \_\_\_\_\_\_\_\_\_\_\_\_ Zip:\_\_\_\_\_\_\_\_\_\_

Telephone number: \_\_\_\_\_\_\_\_\_\_ URL: \_\_\_\_\_\_\_\_\_\_\_\_

Program Performance Measures (PPM) for MCH Training Programs

+----------------------+-----------------------------------------------+
| PROGRAM PERFORMANCE  | The percentage of PPC faculty who demonstrate |
| MEASURE 58           | field leadership in the areas of academic,    |
|                      | clinical, public health/policy, and advocacy. |
| PPM 58 (PPC)         |                                               |
+----------------------+-----------------------------------------------+
| Goal                 | To assure the highest quality of care of the  |
|                      | Maternal and Child Health Populations by      |
|                      | disseminating new knowledge to the field,     |
|                      | influencing systems of care, professional     |
|                      | organizations, and providers of health care   |
|                      | services.                                     |
+----------------------+-----------------------------------------------+
| Measure              | The percentage of PPC faculty who demonstrate |
|                      | field leadership in the areas of academic,    |
|                      | clinical, public health/policy, and advocacy. |
+----------------------+-----------------------------------------------+
| Definitions          | PPC faculty is defined as an individual who   |
|                      | receives PPC funding.                         |
|                      |                                               |
|                      | Leadership: MCH field leadership definitions  |
|                      | (from MCHB Performance Measure #8) of         |
|                      | Academics, Clinical, Public Health/Public     |
|                      | Policy, Advocacy.                             |
+----------------------+-----------------------------------------------+
| HP2010 Objectives    | 16-23: Service Systems for CSHCN              |
+----------------------+-----------------------------------------------+
| Data                 | MCHB Performance Measure #8 Detail Sheet will |
| Source(s)/Issues     | be used.                                      |
|                      |                                               |
|                      | Data Source is self-report of faculty from    |
|                      | faculty activity logs, performance            |
|                      | evaluations, and other local data sources.    |
+----------------------+-----------------------------------------------+
| Significance         | Leadership training requires mentors to be    |
|                      | recognized as leaders in their field.         |
|                      |                                               |
|                      | Current reporting of Technical Assistance,    |
|                      | Training, and Continuing Education activities |
|                      | does not fully capture PPC Faculty Leadership |
|                      | activities.                                   |
+----------------------+-----------------------------------------------+

###### DATA COLLECTION FORM FOR NEGOTIATED PERFORMANCE MEASURE PPM 58

The total number of PPC Faculty included in this report
\_\_\_\_\_\_\_\_\_

Percent of faculty that demonstrate MCH leadership in **at least one**
of the following areas:\_\_\_\_\_\_\_\_%

-   Academics‑‑i.e. faculty member teaching‑mentoring in MCH related
    field; \_\_\_\_\_\_\_\_%

and/or conducting MCH related research; and /or providing consultationor
technical assistance

in MCH; and/or publishing and presenting in key MCH areas; and/or
success in

procuring grant and other funding in MCH

-   Clinical‑‑i.e. development of guidelines for specific MCH
    conditions; \_\_\_\_\_\_\_\_%

and/or participation as officer or chairperson of committees on State,
National, or local

clinical organizations, task forces, community boards, etc.; and/or
clinical preceptor for

MCH trainees; and/or research, publication, and key presentations on MCH
clinical issues;

and/or serves in a clinical leadership position as director, team
leader, chairperson, etc.

-   Public Health/Public Policy‑‑i.e. leadership position in local,
    State or \_\_\_\_\_\_\_\_%

National public organizations, government entity; and/or conducts
strategic planning;

participates in program evaluation and public policy development; and/or
success in procuring

grant and other funding; and/or influencing MCH legislation; and/or
publication, presentations

in key MCH issues.

-   Advocacy‑‑i.e. through efforts at the community, State, Regional and
    \_\_\_\_\_\_\_\_%

National levels influencing positive change in MCH through creative
promotion, support

and activities‑‑both private and public. For example, developing a
city‑wide SIDS awareness

and prevention program through community churches.

+---------------------------------+------------------------------------+
| PROGRAM PERFORMANCE MEASURE 59  | The degree to which a training     |
|                                 | program collaborates with State    |
| PPM 59 (LEAH, LEND)             | Title V agencies, other MCH or     |
|                                 | MCH-related programs.              |
+---------------------------------+------------------------------------+
| **GOAL**                        | To assure that a training program  |
|                                 | has collaborative interactions     |
|                                 | related to training, technical     |
|                                 | assistance, continuing education,  |
|                                 | and other capacity-building        |
|                                 | services with relevant national,   |
|                                 | state and local programs, agencies |
|                                 | and organizations.                 |
+---------------------------------+------------------------------------+
| **MEASURE**                     | The degree to which a training     |
|                                 | program collaborates with State    |
|                                 | Title V agencies, other MCH or     |
|                                 | MCH-related programs and other     |
|                                 | professional organizations.        |
+---------------------------------+------------------------------------+
| **DEFINITION**                  | Attached is a list of the 6        |
|                                 | elements that describe activities  |
|                                 | carried out by training programs   |
|                                 | for or in collaboration with State |
|                                 | Title V and other agencies on a    |
|                                 | scale of 0 to 1. If a value of '1' |
|                                 | is selected, provide the number of |
|                                 | activities for the element. The    |
|                                 | total score for this measure will  |
|                                 | be determined by the sum of those  |
|                                 | elements noted as '1.'             |
+---------------------------------+------------------------------------+
| **HEALTHY PEOPLE 2010           | 1-7. Increase the proportion of    |
| OBJECTIVE**                     | schools of medicine, schools of    |
|                                 | nursing, and other health          |
|                                 | professional training schools      |
|                                 | whose basic curriculum for health  |
|                                 | care providers includes the core   |
|                                 | competencies in health promotion   |
|                                 | and disease prevention.            |
|                                 |                                    |
|                                 | 7-2. Increase the proportion of    |
|                                 | middle, junior high, and senior    |
|                                 | high schools that provide school   |
|                                 | health education to prevent health |
|                                 | problems...                        |
|                                 |                                    |
|                                 | 7-11. Increase the proportion of   |
|                                 | local health departments that have |
|                                 | established culturally appropriate |
|                                 | and linguistically competent       |
|                                 | community health promotion and     |
|                                 | disease prevention programs.       |
|                                 |                                    |
|                                 | 23-8, 23-10. Increase the          |
|                                 | proportion of Federal, Tribal,     |
|                                 | State, and local agencies that     |
|                                 | incorporate specific competencies  |
|                                 | and provide continuing education   |
|                                 | to develop competency in the       |
|                                 | essential public health            |
|                                 | services...                        |
+---------------------------------+------------------------------------+
| **DATA SOURCES AND ISSUES**     | The training program completes the |
|                                 | attached table which describes the |
|                                 | categories of collaborative        |
|                                 | activity.                          |
+---------------------------------+------------------------------------+
| # SIGNIFICANCE                  | As a SPRANS, a training program    |
|                                 | enhances the Title V State block   |
|                                 | grants that support the MCHB goal  |
|                                 | to promote comprehensive,          |
|                                 | coordinated, family-centered, and  |
|                                 | culturally-sensitive systems of    |
|                                 | health care that serve the diverse |
|                                 | needs of all families within their |
|                                 | own communities. Interactive       |
|                                 | collaboration between a training   |
|                                 | program and Federal, Tribal, State |
|                                 | and local agencies dedicated to    |
|                                 | improving the health of MCH        |
|                                 | populations will increase active   |
|                                 | involvement of many disciplines    |
|                                 | across public and private sectors  |
|                                 | and increase the likelihood of     |
|                                 | success in meeting the goals of    |
|                                 | relevant stakeholders.             |
|                                 |                                    |
|                                 | This measure will document a       |
|                                 | training program's abilities to:   |
|                                 |                                    |
|                                 | 1)  collaborate with State Title V |
|                                 |     and other agencies (at a       |
|                                 |     systems level) to support      |
|                                 |     achievement of the MCHB        |
|                                 |     Strategic Goals and CSHCN      |
|                                 |     Healthy People 2010 action     |
|                                 |     plan;                          |
|                                 |                                    |
|                                 | 2)  make the needs of MCH          |
|                                 |     populations more visible to    |
|                                 |     decision-makers and can help   |
|                                 |     states achieve best practice   |
|                                 |     standards for their systems of |
|                                 |     care;                          |
|                                 |                                    |
|                                 | 3)  reinforce the importance of    |
|                                 |     the value added to LEND        |
|                                 |     program dollars in supporting  |
|                                 |     faculty leaders to work at all |
|                                 |     levels of systems change; and  |
|                                 |                                    |
|                                 | 4)  internally use this data to    |
|                                 |     assure a full scope of these   |
|                                 |     program elements in all        |
|                                 |     regions.                       |
+---------------------------------+------------------------------------+

###### DATA COLLECTION FORM FOR DETAIL SHEET PM #59

Indicate the degree to which your training program collaborates with
State Title V (MCH) agencies and other MCH or MCH-related programs using
the following values:

0= The training program [does not]{.underline} collaborate on this
element.

> 1=The training program [does]{.underline} collaborate on this element.

If your program does collaborate, provide the total number of activities
for the element.

+-----------------------------------+---------+---------+-------------+
| **Element**                       | **0**   | **1**   | **Total     |
|                                   |         |         | Number**    |
|                                   |         |         |             |
|                                   |         |         | **of        |
|                                   |         |         | A           |
|                                   |         |         | ctivities** |
+-----------------------------------+---------+---------+-------------+
| 1.  **[Service]{.underline}**     |         |         |             |
|                                   |         |         |             |
| Examples might include: Clinics   |         |         |             |
| run by the training program and/  |         |         |             |
| or in collaboration with other    |         |         |             |
| agencies                          |         |         |             |
+-----------------------------------+---------+---------+-------------+
| 2.  **[Training]{.underline}**    |         |         |             |
|                                   |         |         |             |
| Examples might include: Training  |         |         |             |
| in *Bright Futures...*; Workshops |         |         |             |
| related to adolescent health      |         |         |             |
| practice; and Community-based     |         |         |             |
| practices. It would not include   |         |         |             |
| clinical supervision of long-term |         |         |             |
| trainees.                         |         |         |             |
+-----------------------------------+---------+---------+-------------+
| 3.  **[Continuing                 |         |         |             |
|     Education]{.underline}**      |         |         |             |
|                                   |         |         |             |
| Examples might include:           |         |         |             |
| Conferences; Distance learning;   |         |         |             |
| and Computer-based educational    |         |         |             |
| experiences. It would not include |         |         |             |
| formal classes or seminars for    |         |         |             |
| long-term trainees.               |         |         |             |
+-----------------------------------+---------+---------+-------------+
| 4.  **[Technical                  |         |         |             |
|     Assistance]{.underline}**     |         |         |             |
|                                   |         |         |             |
| Examples might include:           |         |         |             |
| Conducting needs assessments with |         |         |             |
| State programs; policy            |         |         |             |
| development; grant writing        |         |         |             |
| assistance; identifying           |         |         |             |
| best-practices; and leading       |         |         |             |
| collaborative groups. It would    |         |         |             |
| not include conducting needs      |         |         |             |
| assessments of consumers of the   |         |         |             |
| training program services.        |         |         |             |
+-----------------------------------+---------+---------+-------------+
| 5.  **[Product                    |         |         |             |
|     Development]{.underline}**    |         |         |             |
|                                   |         |         |             |
| Examples might include:           |         |         |             |
| Collaborataive development of     |         |         |             |
| journal articles and training or  |         |         |             |
| informational videos.             |         |         |             |
+-----------------------------------+---------+---------+-------------+
| 6.  **[Research]{.underline}**    |         |         |             |
|                                   |         |         |             |
| Examples might include:           |         |         |             |
| Collaborative submission of       |         |         |             |
| research grants, research teams   |         |         |             |
| that include Title V or other     |         |         |             |
| MCH-program staff and the         |         |         |             |
| training program's faculty.       |         |         |             |
+-----------------------------------+---------+---------+-------------+

**Total Score (possible 0‑6 score) \_\_\_\_\_\_\_\_**

**Total Number of Collaborative Activities \_\_\_\_\_\_\_\_\_**

+--------------------------------+-------+---+--------+------+--------+
| PROGRAM PERFORMANCE MEASURE 60 | The   |   |        |      |        |
|                                | pe    |   |        |      |        |
| PPM 60 (LEAH, LEND)            | rcent |   |        |      |        |
|                                | of    |   |        |      |        |
|                                | long  |   |        |      |        |
|                                | -term |   |        |      |        |
|                                | tra   |   |        |      |        |
|                                | inees |   |        |      |        |
|                                | who,  |   |        |      |        |
|                                | at 1, |   |        |      |        |
|                                | 5 and |   |        |      |        |
|                                | 10    |   |        |      |        |
|                                | years |   |        |      |        |
|                                | post  |   |        |      |        |
|                                | trai  |   |        |      |        |
|                                | ning, |   |        |      |        |
|                                | work  |   |        |      |        |
|                                | in an |   |        |      |        |
|                                | in    |   |        |      |        |
|                                | terdi |   |        |      |        |
|                                | scipl |   |        |      |        |
|                                | inary |   |        |      |        |
|                                | m     |   |        |      |        |
|                                | anner |   |        |      |        |
|                                | to    |   |        |      |        |
|                                | serve |   |        |      |        |
|                                | the   |   |        |      |        |
|                                | MCH   |   |        |      |        |
|                                | popul |   |        |      |        |
|                                | ation |   |        |      |        |
|                                | (     |   |        |      |        |
|                                | e.g., |   |        |      |        |
|                                | i     |   |        |      |        |
|                                | ndivi |   |        |      |        |
|                                | duals |   |        |      |        |
|                                | with  |   |        |      |        |
|                                | di    |   |        |      |        |
|                                | sabil |   |        |      |        |
|                                | ities |   |        |      |        |
|                                | and   |   |        |      |        |
|                                | their |   |        |      |        |
|                                | fami  |   |        |      |        |
|                                | lies, |   |        |      |        |
|                                | a     |   |        |      |        |
|                                | doles |   |        |      |        |
|                                | cents |   |        |      |        |
|                                | and   |   |        |      |        |
|                                | their |   |        |      |        |
|                                | fami  |   |        |      |        |
|                                | lies, |   |        |      |        |
|                                | e     |   |        |      |        |
|                                | tc.). |   |        |      |        |
+--------------------------------+-------+---+--------+------+--------+
| **GOAL**                       | To    |   |        |      |        |
|                                | inc   |   |        |      |        |
|                                | rease |   |        |      |        |
|                                | the   |   |        |      |        |
|                                | pe    |   |        |      |        |
|                                | rcent |   |        |      |        |
|                                | of    |   |        |      |        |
|                                | long  |   |        |      |        |
|                                | -term |   |        |      |        |
|                                | tra   |   |        |      |        |
|                                | inees |   |        |      |        |
|                                | who,  |   |        |      |        |
|                                | upon  |   |        |      |        |
|                                | compl |   |        |      |        |
|                                | eting |   |        |      |        |
|                                | their |   |        |      |        |
|                                | trai  |   |        |      |        |
|                                | ning, |   |        |      |        |
|                                | work  |   |        |      |        |
|                                | in an |   |        |      |        |
|                                | in    |   |        |      |        |
|                                | terdi |   |        |      |        |
|                                | scipl |   |        |      |        |
|                                | inary |   |        |      |        |
|                                | m     |   |        |      |        |
|                                | anner |   |        |      |        |
|                                | to    |   |        |      |        |
|                                | serve |   |        |      |        |
|                                | the   |   |        |      |        |
|                                | MCH   |   |        |      |        |
|                                | p     |   |        |      |        |
|                                | opula |   |        |      |        |
|                                | tion. |   |        |      |        |
+--------------------------------+-------+---+--------+------+--------+
| **MEASURE**                    | The   |   |        |      |        |
|                                | pe    |   |        |      |        |
|                                | rcent |   |        |      |        |
|                                | of    |   |        |      |        |
|                                | long  |   |        |      |        |
|                                | -term |   |        |      |        |
|                                | tra   |   |        |      |        |
|                                | inees |   |        |      |        |
|                                | who,  |   |        |      |        |
|                                | at 1, |   |        |      |        |
|                                | 5 and |   |        |      |        |
|                                | 10    |   |        |      |        |
|                                | years |   |        |      |        |
|                                | post  |   |        |      |        |
|                                | tra   |   |        |      |        |
|                                | ining |   |        |      |        |
|                                | work  |   |        |      |        |
|                                | in an |   |        |      |        |
|                                | in    |   |        |      |        |
|                                | terdi |   |        |      |        |
|                                | scipl |   |        |      |        |
|                                | inary |   |        |      |        |
|                                | m     |   |        |      |        |
|                                | anner |   |        |      |        |
|                                | to    |   |        |      |        |
|                                | serve |   |        |      |        |
|                                | the   |   |        |      |        |
|                                | MCH   |   |        |      |        |
|                                | p     |   |        |      |        |
|                                | opula |   |        |      |        |
|                                | tion. |   |        |      |        |
+--------------------------------+-------+---+--------+------+--------+
| **DEFINITION**                 | **Nu  |   | The    |      |        |
|                                | merat |   | number |      |        |
|                                | or:** |   | of     |      |        |
|                                |       |   | tr     |      |        |
|                                |       |   | ainees |      |        |
|                                |       |   | indi   |      |        |
|                                |       |   | cating |      |        |
|                                |       |   | that   |      |        |
|                                |       |   | they   |      |        |
|                                |       |   | co     |      |        |
|                                |       |   | ntinue |      |        |
|                                |       |   | to     |      |        |
|                                |       |   | work   |      |        |
|                                |       |   | in an  |      |        |
|                                |       |   | inter  |      |        |
|                                |       |   | discip |      |        |
|                                |       |   | linary |      |        |
|                                |       |   | s      |      |        |
|                                |       |   | etting |      |        |
|                                |       |   | s      |      |        |
|                                |       |   | erving |      |        |
|                                |       |   | the    |      |        |
|                                |       |   | MCH    |      |        |
|                                |       |   | popul  |      |        |
|                                |       |   | ation. |      |        |
+--------------------------------+-------+---+--------+------+--------+
|                                | *     |   | The    |      |        |
|                                | *Deno |   | total  |      |        |
|                                | minat |   | number |      |        |
|                                | or:** |   | of     |      |        |
|                                |       |   | tr     |      |        |
|                                |       |   | ainees |      |        |
|                                |       |   | resp   |      |        |
|                                |       |   | onding |      |        |
|                                |       |   | to the |      |        |
|                                |       |   | survey |      |        |
+--------------------------------+-------+---+--------+------+--------+
|                                | **Uni | 1 |        | *    | P      |
|                                | ts:** | 0 |        | *Tex | ercent |
|                                |       | 0 |        | t:** |        |
+--------------------------------+-------+---+--------+------+--------+
|                                | In    |   |        |      |        |
|                                | addi  |   |        |      |        |
|                                | tion, |   |        |      |        |
|                                | data  |   |        |      |        |
|                                | on    |   |        |      |        |
|                                | the   |   |        |      |        |
|                                | total |   |        |      |        |
|                                | n     |   |        |      |        |
|                                | umber |   |        |      |        |
|                                | of    |   |        |      |        |
|                                | the   |   |        |      |        |
|                                | tra   |   |        |      |        |
|                                | inees |   |        |      |        |
|                                | and   |   |        |      |        |
|                                | the   |   |        |      |        |
|                                | n     |   |        |      |        |
|                                | umber |   |        |      |        |
|                                | of    |   |        |      |        |
|                                | non-r |   |        |      |        |
|                                | espon |   |        |      |        |
|                                | dents |   |        |      |        |
|                                | for   |   |        |      |        |
|                                | each  |   |        |      |        |
|                                | year  |   |        |      |        |
|                                | will  |   |        |      |        |
|                                | be    |   |        |      |        |
|                                | colle |   |        |      |        |
|                                | cted. |   |        |      |        |
|                                |       |   |        |      |        |
|                                | Long  |   |        |      |        |
|                                | -term |   |        |      |        |
|                                | tra   |   |        |      |        |
|                                | inees |   |        |      |        |
|                                | are   |   |        |      |        |
|                                | de    |   |        |      |        |
|                                | fined |   |        |      |        |
|                                | as    |   |        |      |        |
|                                | those |   |        |      |        |
|                                | who   |   |        |      |        |
|                                | have  |   |        |      |        |
|                                | comp  |   |        |      |        |
|                                | leted |   |        |      |        |
|                                | a     |   |        |      |        |
|                                | long  |   |        |      |        |
|                                | -term |   |        |      |        |
|                                | (300+ |   |        |      |        |
|                                | h     |   |        |      |        |
|                                | ours) |   |        |      |        |
|                                | leade |   |        |      |        |
|                                | rship |   |        |      |        |
|                                | tra   |   |        |      |        |
|                                | ining |   |        |      |        |
|                                | pro   |   |        |      |        |
|                                | gram, |   |        |      |        |
|                                | incl  |   |        |      |        |
|                                | uding |   |        |      |        |
|                                | those |   |        |      |        |
|                                | who   |   |        |      |        |
|                                | rec   |   |        |      |        |
|                                | eived |   |        |      |        |
|                                | MCH   |   |        |      |        |
|                                | funds |   |        |      |        |
|                                | and   |   |        |      |        |
|                                | those |   |        |      |        |
|                                | who   |   |        |      |        |
|                                | did   |   |        |      |        |
|                                | not.  |   |        |      |        |
+--------------------------------+-------+---+--------+------+--------+
| **HEALTHY PEOPLE 2010          | 1-7:  |   |        |      |        |
| OBJECTIVE**                    | Inc   |   |        |      |        |
|                                | rease |   |        |      |        |
|                                | propo |   |        |      |        |
|                                | rtion |   |        |      |        |
|                                | of    |   |        |      |        |
|                                | sc    |   |        |      |        |
|                                | hools |   |        |      |        |
|                                | of    |   |        |      |        |
|                                | medi  |   |        |      |        |
|                                | cine, |   |        |      |        |
|                                | sc    |   |        |      |        |
|                                | hools |   |        |      |        |
|                                | of    |   |        |      |        |
|                                | nur   |   |        |      |        |
|                                | sing, |   |        |      |        |
|                                | and   |   |        |      |        |
|                                | other |   |        |      |        |
|                                | h     |   |        |      |        |
|                                | ealth |   |        |      |        |
|                                | pr    |   |        |      |        |
|                                | ofess |   |        |      |        |
|                                | ional |   |        |      |        |
|                                | tra   |   |        |      |        |
|                                | ining |   |        |      |        |
|                                | sc    |   |        |      |        |
|                                | hools |   |        |      |        |
|                                | whose |   |        |      |        |
|                                | basic |   |        |      |        |
|                                | curri |   |        |      |        |
|                                | culum |   |        |      |        |
|                                | for   |   |        |      |        |
|                                | h     |   |        |      |        |
|                                | ealth |   |        |      |        |
|                                | care  |   |        |      |        |
|                                | prov  |   |        |      |        |
|                                | iders |   |        |      |        |
|                                | inc   |   |        |      |        |
|                                | ludes |   |        |      |        |
|                                | the   |   |        |      |        |
|                                | core  |   |        |      |        |
|                                | co    |   |        |      |        |
|                                | mpete |   |        |      |        |
|                                | ncies |   |        |      |        |
|                                | in    |   |        |      |        |
|                                | h     |   |        |      |        |
|                                | ealth |   |        |      |        |
|                                | prom  |   |        |      |        |
|                                | otion |   |        |      |        |
|                                | and   |   |        |      |        |
|                                | di    |   |        |      |        |
|                                | sease |   |        |      |        |
|                                | p     |   |        |      |        |
|                                | reven |   |        |      |        |
|                                | tion. |   |        |      |        |
|                                |       |   |        |      |        |
|                                | 1     |   |        |      |        |
|                                | 6-23: |   |        |      |        |
|                                | Inc   |   |        |      |        |
|                                | rease |   |        |      |        |
|                                | the   |   |        |      |        |
|                                | propo |   |        |      |        |
|                                | rtion |   |        |      |        |
|                                | of    |   |        |      |        |
|                                | T     |   |        |      |        |
|                                | errit |   |        |      |        |
|                                | ories |   |        |      |        |
|                                | and   |   |        |      |        |
|                                | S     |   |        |      |        |
|                                | tates |   |        |      |        |
|                                | that  |   |        |      |        |
|                                | have  |   |        |      |        |
|                                | se    |   |        |      |        |
|                                | rvice |   |        |      |        |
|                                | sy    |   |        |      |        |
|                                | stems |   |        |      |        |
|                                | for   |   |        |      |        |
|                                | chi   |   |        |      |        |
|                                | ldren |   |        |      |        |
|                                | with  |   |        |      |        |
|                                | sp    |   |        |      |        |
|                                | ecial |   |        |      |        |
|                                | h     |   |        |      |        |
|                                | ealth |   |        |      |        |
|                                | care  |   |        |      |        |
|                                | n     |   |        |      |        |
|                                | eeds. |   |        |      |        |
|                                |       |   |        |      |        |
|                                | 23-9: |   |        |      |        |
|                                | Inc   |   |        |      |        |
|                                | rease |   |        |      |        |
|                                | the   |   |        |      |        |
|                                | propo |   |        |      |        |
|                                | rtion |   |        |      |        |
|                                | of    |   |        |      |        |
|                                | sc    |   |        |      |        |
|                                | hools |   |        |      |        |
|                                | for   |   |        |      |        |
|                                | p     |   |        |      |        |
|                                | ublic |   |        |      |        |
|                                | h     |   |        |      |        |
|                                | ealth |   |        |      |        |
|                                | wo    |   |        |      |        |
|                                | rkers |   |        |      |        |
|                                | that  |   |        |      |        |
|                                | inte  |   |        |      |        |
|                                | grate |   |        |      |        |
|                                | into  |   |        |      |        |
|                                | their |   |        |      |        |
|                                | curr  |   |        |      |        |
|                                | icula |   |        |      |        |
|                                | spe   |   |        |      |        |
|                                | cific |   |        |      |        |
|                                | co    |   |        |      |        |
|                                | ntent |   |        |      |        |
|                                | to    |   |        |      |        |
|                                | de    |   |        |      |        |
|                                | velop |   |        |      |        |
|                                | compe |   |        |      |        |
|                                | tency |   |        |      |        |
|                                | in    |   |        |      |        |
|                                | the   |   |        |      |        |
|                                | esse  |   |        |      |        |
|                                | ntial |   |        |      |        |
|                                | p     |   |        |      |        |
|                                | ublic |   |        |      |        |
|                                | h     |   |        |      |        |
|                                | ealth |   |        |      |        |
|                                | serv  |   |        |      |        |
|                                | ices. |   |        |      |        |
+--------------------------------+-------+---+--------+------+--------+
| **DATA SOURCE(S) AND ISSUES**  | The   |   |        |      |        |
|                                | tr    |   |        |      |        |
|                                | ainee |   |        |      |        |
|                                | foll  |   |        |      |        |
|                                | ow-up |   |        |      |        |
|                                | s     |   |        |      |        |
|                                | urvey |   |        |      |        |
|                                | is    |   |        |      |        |
|                                | used  |   |        |      |        |
|                                | to    |   |        |      |        |
|                                | co    |   |        |      |        |
|                                | llect |   |        |      |        |
|                                | these |   |        |      |        |
|                                | data. |   |        |      |        |
+--------------------------------+-------+---+--------+------+--------+
| **SIGNIFICANCE**               | Leade |   |        |      |        |
|                                | rship |   |        |      |        |
|                                | educ  |   |        |      |        |
|                                | ation |   |        |      |        |
|                                | is a  |   |        |      |        |
|                                | co    |   |        |      |        |
|                                | mplex |   |        |      |        |
|                                | in    |   |        |      |        |
|                                | terdi |   |        |      |        |
|                                | scipl |   |        |      |        |
|                                | inary |   |        |      |        |
|                                | field |   |        |      |        |
|                                | that  |   |        |      |        |
|                                | must  |   |        |      |        |
|                                | meet  |   |        |      |        |
|                                | the   |   |        |      |        |
|                                | needs |   |        |      |        |
|                                | of    |   |        |      |        |
|                                | MCH   |   |        |      |        |
|                                | po    |   |        |      |        |
|                                | pulat |   |        |      |        |
|                                | ions. |   |        |      |        |
|                                | This  |   |        |      |        |
|                                | me    |   |        |      |        |
|                                | asure |   |        |      |        |
|                                | addr  |   |        |      |        |
|                                | esses |   |        |      |        |
|                                | one   |   |        |      |        |
|                                | of a  |   |        |      |        |
|                                | tra   |   |        |      |        |
|                                | ining |   |        |      |        |
|                                | prog  |   |        |      |        |
|                                | ram's |   |        |      |        |
|                                | core  |   |        |      |        |
|                                | v     |   |        |      |        |
|                                | alues |   |        |      |        |
|                                | and   |   |        |      |        |
|                                | its   |   |        |      |        |
|                                | u     |   |        |      |        |
|                                | nique |   |        |      |        |
|                                | role  |   |        |      |        |
|                                | to    |   |        |      |        |
|                                | pr    |   |        |      |        |
|                                | epare |   |        |      |        |
|                                | pro   |   |        |      |        |
|                                | fessi |   |        |      |        |
|                                | onals |   |        |      |        |
|                                | for   |   |        |      |        |
|                                | com   |   |        |      |        |
|                                | prehe |   |        |      |        |
|                                | nsive |   |        |      |        |
|                                | sy    |   |        |      |        |
|                                | stems |   |        |      |        |
|                                | of    |   |        |      |        |
|                                | care. |   |        |      |        |
|                                | By    |   |        |      |        |
|                                | prov  |   |        |      |        |
|                                | iding |   |        |      |        |
|                                | in    |   |        |      |        |
|                                | terdi |   |        |      |        |
|                                | scipl |   |        |      |        |
|                                | inary |   |        |      |        |
|                                | c     |   |        |      |        |
|                                | oordi |   |        |      |        |
|                                | nated |   |        |      |        |
|                                | care, |   |        |      |        |
|                                | tra   |   |        |      |        |
|                                | ining |   |        |      |        |
|                                | pro   |   |        |      |        |
|                                | grams |   |        |      |        |
|                                | help  |   |        |      |        |
|                                | to    |   |        |      |        |
|                                | e     |   |        |      |        |
|                                | nsure |   |        |      |        |
|                                | that  |   |        |      |        |
|                                | all   |   |        |      |        |
|                                | MCH   |   |        |      |        |
|                                | p     |   |        |      |        |
|                                | opula |   |        |      |        |
|                                | tions |   |        |      |        |
|                                | re    |   |        |      |        |
|                                | ceive |   |        |      |        |
|                                | the   |   |        |      |        |
|                                | most  |   |        |      |        |
|                                | com   |   |        |      |        |
|                                | prehe |   |        |      |        |
|                                | nsive |   |        |      |        |
|                                | care  |   |        |      |        |
|                                | that  |   |        |      |        |
|                                | takes |   |        |      |        |
|                                | into  |   |        |      |        |
|                                | ac    |   |        |      |        |
|                                | count |   |        |      |        |
|                                | the   |   |        |      |        |
|                                | com   |   |        |      |        |
|                                | plete |   |        |      |        |
|                                | and   |   |        |      |        |
|                                | u     |   |        |      |        |
|                                | nique |   |        |      |        |
|                                | needs |   |        |      |        |
|                                | of    |   |        |      |        |
|                                | the   |   |        |      |        |
|                                | i     |   |        |      |        |
|                                | ndivi |   |        |      |        |
|                                | duals |   |        |      |        |
|                                | and   |   |        |      |        |
|                                | their |   |        |      |        |
|                                | fami  |   |        |      |        |
|                                | lies. |   |        |      |        |
+--------------------------------+-------+---+--------+------+--------+

+---------------------------------+------+---+-----+------------------+
| PROGRAM PERFORMANCE MEASURE 61  | The  |   |     |                  |
| PPM 61 (LEND)                   | de   |   |     |                  |
|                                 | gree |   |     |                  |
|                                 | to   |   |     |                  |
|                                 | w    |   |     |                  |
|                                 | hich |   |     |                  |
|                                 | MCH  |   |     |                  |
|                                 | long |   |     |                  |
|                                 | term |   |     |                  |
|                                 | i    |   |     |                  |
|                                 | nter |   |     |                  |
|                                 | disc |   |     |                  |
|                                 | ipli |   |     |                  |
|                                 | nary |   |     |                  |
|                                 | trai |   |     |                  |
|                                 | nees |   |     |                  |
|                                 | re   |   |     |                  |
|                                 | port |   |     |                  |
|                                 | val  |   |     |                  |
|                                 | uing |   |     |                  |
|                                 | t    |   |     |                  |
|                                 | heir |   |     |                  |
|                                 | i    |   |     |                  |
|                                 | nter |   |     |                  |
|                                 | disc |   |     |                  |
|                                 | ipli |   |     |                  |
|                                 | nary |   |     |                  |
|                                 | trai |   |     |                  |
|                                 | ning |   |     |                  |
|                                 | at   |   |     |                  |
|                                 | 1,   |   |     |                  |
|                                 | and  |   |     |                  |
|                                 | 5    |   |     |                  |
|                                 | ye   |   |     |                  |
|                                 | ars. |   |     |                  |
+---------------------------------+------+---+-----+------------------+
| **GOAL**                        | To   |   |     |                  |
|                                 | incr |   |     |                  |
|                                 | ease |   |     |                  |
|                                 | the  |   |     |                  |
|                                 | v    |   |     |                  |
|                                 | alue |   |     |                  |
|                                 | of   |   |     |                  |
|                                 | MCH  |   |     |                  |
|                                 | long |   |     |                  |
|                                 | term |   |     |                  |
|                                 | i    |   |     |                  |
|                                 | nter |   |     |                  |
|                                 | disc |   |     |                  |
|                                 | ipli |   |     |                  |
|                                 | nary |   |     |                  |
|                                 | trai |   |     |                  |
|                                 | ning |   |     |                  |
|                                 | as   |   |     |                  |
|                                 | p    |   |     |                  |
|                                 | erce |   |     |                  |
|                                 | ived |   |     |                  |
|                                 | by   |   |     |                  |
|                                 | trai |   |     |                  |
|                                 | ning |   |     |                  |
|                                 | p    |   |     |                  |
|                                 | arti |   |     |                  |
|                                 | cipa |   |     |                  |
|                                 | nts. |   |     |                  |
|                                 | To   |   |     |                  |
|                                 | uti  |   |     |                  |
|                                 | lize |   |     |                  |
|                                 | tra  |   |     |                  |
|                                 | inee |   |     |                  |
|                                 | feed |   |     |                  |
|                                 | back |   |     |                  |
|                                 | in   |   |     |                  |
|                                 | ev   |   |     |                  |
|                                 | alua |   |     |                  |
|                                 | ting |   |     |                  |
|                                 | i    |   |     |                  |
|                                 | nter |   |     |                  |
|                                 | disc |   |     |                  |
|                                 | ipli |   |     |                  |
|                                 | nary |   |     |                  |
|                                 | trai |   |     |                  |
|                                 | ning |   |     |                  |
|                                 | and  |   |     |                  |
|                                 | the  |   |     |                  |
|                                 | reby |   |     |                  |
|                                 | imp  |   |     |                  |
|                                 | rove |   |     |                  |
|                                 | the  |   |     |                  |
|                                 | capa |   |     |                  |
|                                 | city |   |     |                  |
|                                 | of   |   |     |                  |
|                                 | fu   |   |     |                  |
|                                 | ture |   |     |                  |
|                                 | lea  |   |     |                  |
|                                 | ders |   |     |                  |
|                                 | to   |   |     |                  |
|                                 | add  |   |     |                  |
|                                 | ress |   |     |                  |
|                                 | the  |   |     |                  |
|                                 | he   |   |     |                  |
|                                 | alth |   |     |                  |
|                                 | n    |   |     |                  |
|                                 | eeds |   |     |                  |
|                                 | of   |   |     |                  |
|                                 | chil |   |     |                  |
|                                 | dren |   |     |                  |
|                                 | and  |   |     |                  |
|                                 | adol |   |     |                  |
|                                 | esce |   |     |                  |
|                                 | nts. |   |     |                  |
+---------------------------------+------+---+-----+------------------+
| **MEASURE**                     | The  |   |     |                  |
|                                 | de   |   |     |                  |
|                                 | gree |   |     |                  |
|                                 | to   |   |     |                  |
|                                 | w    |   |     |                  |
|                                 | hich |   |     |                  |
|                                 | MCH  |   |     |                  |
|                                 | long |   |     |                  |
|                                 | term |   |     |                  |
|                                 | i    |   |     |                  |
|                                 | nter |   |     |                  |
|                                 | disc |   |     |                  |
|                                 | ipli |   |     |                  |
|                                 | nary |   |     |                  |
|                                 | trai |   |     |                  |
|                                 | nees |   |     |                  |
|                                 | re   |   |     |                  |
|                                 | port |   |     |                  |
|                                 | val  |   |     |                  |
|                                 | uing |   |     |                  |
|                                 | t    |   |     |                  |
|                                 | heir |   |     |                  |
|                                 | i    |   |     |                  |
|                                 | nter |   |     |                  |
|                                 | disc |   |     |                  |
|                                 | ipli |   |     |                  |
|                                 | nary |   |     |                  |
|                                 | trai |   |     |                  |
|                                 | ning |   |     |                  |
|                                 | at   |   |     |                  |
|                                 | 1,   |   |     |                  |
|                                 | and  |   |     |                  |
|                                 | 5    |   |     |                  |
|                                 | ye   |   |     |                  |
|                                 | ars. |   |     |                  |
+---------------------------------+------+---+-----+------------------+
| **DEFINITION**                  | **   |   | Dis |                  |
|                                 | Nume |   | tri |                  |
|                                 | rato |   | but |                  |
|                                 | r:** |   | ion |                  |
|                                 |      |   | of  |                  |
|                                 |      |   | a   |                  |
|                                 |      |   | ver |                  |
|                                 |      |   | age |                  |
|                                 |      |   | s   |                  |
|                                 |      |   | cor |                  |
|                                 |      |   | es. |                  |
+---------------------------------+------+---+-----+------------------+
|                                 | **De |   | To  |                  |
|                                 | nomi |   | tal |                  |
|                                 | nato |   | Num |                  |
|                                 | r:** |   | ber |                  |
|                                 |      |   | of  |                  |
|                                 |      |   | re  |                  |
|                                 |      |   | spo |                  |
|                                 |      |   | nde |                  |
|                                 |      |   | nts |                  |
|                                 |      |   | at  |                  |
|                                 |      |   | 1   |                  |
|                                 |      |   | and |                  |
|                                 |      |   | 5   |                  |
|                                 |      |   | yea |                  |
|                                 |      |   | rs. |                  |
+---------------------------------+------+---+-----+------------------+
|                                 | **   | \ | **T | Aggregate % from |
|                                 | Unit | % | ext | network data     |
|                                 | s:** |   | :** |                  |
+---------------------------------+------+---+-----+------------------+
| **HEALTHY PEOPLE 2010           | Rel  |   |     |                  |
| OBJECTIVE**                     | ated |   |     |                  |
|                                 | to   |   |     |                  |
|                                 | 16   |   |     |                  |
|                                 | -23: |   |     |                  |
|                                 | Incr |   |     |                  |
|                                 | ease |   |     |                  |
|                                 | the  |   |     |                  |
|                                 | pr   |   |     |                  |
|                                 | opor |   |     |                  |
|                                 | tion |   |     |                  |
|                                 | of   |   |     |                  |
|                                 | Ter  |   |     |                  |
|                                 | rito |   |     |                  |
|                                 | ries |   |     |                  |
|                                 | and  |   |     |                  |
|                                 | St   |   |     |                  |
|                                 | ates |   |     |                  |
|                                 | that |   |     |                  |
|                                 | have |   |     |                  |
|                                 | ser  |   |     |                  |
|                                 | vice |   |     |                  |
|                                 | sys  |   |     |                  |
|                                 | tems |   |     |                  |
|                                 | for  |   |     |                  |
|                                 | chil |   |     |                  |
|                                 | dren |   |     |                  |
|                                 | with |   |     |                  |
|                                 | spe  |   |     |                  |
|                                 | cial |   |     |                  |
|                                 | he   |   |     |                  |
|                                 | alth |   |     |                  |
|                                 | care |   |     |                  |
|                                 | ne   |   |     |                  |
|                                 | eds. |   |     |                  |
+---------------------------------+------+---+-----+------------------+
| **DATA SOURCE(S) AND ISSUES**   | This |   |     |                  |
|                                 | requ |   |     |                  |
|                                 | ires |   |     |                  |
|                                 | pri  |   |     |                  |
|                                 | mary |   |     |                  |
|                                 | data |   |     |                  |
|                                 | col  |   |     |                  |
|                                 | lect |   |     |                  |
|                                 | ion. |   |     |                  |
|                                 | The  |   |     |                  |
|                                 | co   |   |     |                  |
|                                 | llec |   |     |                  |
|                                 | tion |   |     |                  |
|                                 | t    |   |     |                  |
|                                 | ool, |   |     |                  |
|                                 | w    |   |     |                  |
|                                 | hich |   |     |                  |
|                                 | will |   |     |                  |
|                                 | be   |   |     |                  |
|                                 | the  |   |     |                  |
|                                 | tra  |   |     |                  |
|                                 | inee |   |     |                  |
|                                 | f    |   |     |                  |
|                                 | ollo |   |     |                  |
|                                 | w-up |   |     |                  |
|                                 | sur  |   |     |                  |
|                                 | vey, |   |     |                  |
|                                 | will |   |     |                  |
|                                 | ask  |   |     |                  |
|                                 | trai |   |     |                  |
|                                 | nees |   |     |                  |
|                                 | to   |   |     |                  |
|                                 | rate |   |     |                  |
|                                 | how  |   |     |                  |
|                                 | they |   |     |                  |
|                                 | have |   |     |                  |
|                                 | va   |   |     |                  |
|                                 | lued |   |     |                  |
|                                 | t    |   |     |                  |
|                                 | heir |   |     |                  |
|                                 | i    |   |     |                  |
|                                 | nter |   |     |                  |
|                                 | disc |   |     |                  |
|                                 | ipli |   |     |                  |
|                                 | nary |   |     |                  |
|                                 | trai |   |     |                  |
|                                 | ning |   |     |                  |
|                                 | on a |   |     |                  |
|                                 | s    |   |     |                  |
|                                 | cale |   |     |                  |
|                                 | of 1 |   |     |                  |
|                                 | to   |   |     |                  |
|                                 | 5.   |   |     |                  |
|                                 | Each |   |     |                  |
|                                 | pro  |   |     |                  |
|                                 | gram |   |     |                  |
|                                 | will |   |     |                  |
|                                 | then |   |     |                  |
|                                 | a    |   |     |                  |
|                                 | ggre |   |     |                  |
|                                 | gate |   |     |                  |
|                                 | repo |   |     |                  |
|                                 | rted |   |     |                  |
|                                 | data |   |     |                  |
|                                 | and  |   |     |                  |
|                                 | re   |   |     |                  |
|                                 | port |   |     |                  |
|                                 | the  |   |     |                  |
|                                 | dist |   |     |                  |
|                                 | ribu |   |     |                  |
|                                 | tion |   |     |                  |
|                                 | of   |   |     |                  |
|                                 | how  |   |     |                  |
|                                 | many |   |     |                  |
|                                 | res  |   |     |                  |
|                                 | pond |   |     |                  |
|                                 | ents |   |     |                  |
|                                 | r    |   |     |                  |
|                                 | ated |   |     |                  |
|                                 | t    |   |     |                  |
|                                 | heir |   |     |                  |
|                                 | trai |   |     |                  |
|                                 | ning |   |     |                  |
|                                 | a 1, |   |     |                  |
|                                 | how  |   |     |                  |
|                                 | many |   |     |                  |
|                                 | 2,   |   |     |                  |
|                                 | etc. |   |     |                  |
|                                 | thr  |   |     |                  |
|                                 | ough |   |     |                  |
|                                 | 5.   |   |     |                  |
|                                 | N    |   |     |                  |
|                                 | OTE: |   |     |                  |
|                                 | AUCD |   |     |                  |
|                                 | will |   |     |                  |
|                                 | pro  |   |     |                  |
|                                 | vide |   |     |                  |
|                                 | des  |   |     |                  |
|                                 | crip |   |     |                  |
|                                 | tors |   |     |                  |
|                                 | for  |   |     |                  |
|                                 | each |   |     |                  |
|                                 | nu   |   |     |                  |
|                                 | mber |   |     |                  |
|                                 | on   |   |     |                  |
|                                 | the  |   |     |                  |
|                                 | ra   |   |     |                  |
|                                 | ting |   |     |                  |
|                                 | sc   |   |     |                  |
|                                 | ale. |   |     |                  |
+---------------------------------+------+---+-----+------------------+
| **SIGNIFICANCE**                | As   |   |     |                  |
|                                 | king |   |     |                  |
|                                 | the  |   |     |                  |
|                                 | re   |   |     |                  |
|                                 | cipi |   |     |                  |
|                                 | ents |   |     |                  |
|                                 | of   |   |     |                  |
|                                 | any  |   |     |                  |
|                                 | ser  |   |     |                  |
|                                 | vice |   |     |                  |
|                                 | a    |   |     |                  |
|                                 | bout |   |     |                  |
|                                 | the  |   |     |                  |
|                                 | v    |   |     |                  |
|                                 | alue |   |     |                  |
|                                 | of   |   |     |                  |
|                                 | the  |   |     |                  |
|                                 | ser  |   |     |                  |
|                                 | vice |   |     |                  |
|                                 | prov |   |     |                  |
|                                 | ided |   |     |                  |
|                                 | to   |   |     |                  |
|                                 | them |   |     |                  |
|                                 | is   |   |     |                  |
|                                 | an   |   |     |                  |
|                                 | i    |   |     |                  |
|                                 | mpor |   |     |                  |
|                                 | tant |   |     |                  |
|                                 | p    |   |     |                  |
|                                 | rinc |   |     |                  |
|                                 | iple |   |     |                  |
|                                 | of   |   |     |                  |
|                                 | cust |   |     |                  |
|                                 | omer |   |     |                  |
|                                 | ser  |   |     |                  |
|                                 | vice |   |     |                  |
|                                 | and  |   |     |                  |
|                                 | eva  |   |     |                  |
|                                 | luat |   |     |                  |
|                                 | ion. |   |     |                  |
|                                 | U    |   |     |                  |
|                                 | nder |   |     |                  |
|                                 | stan |   |     |                  |
|                                 | ding |   |     |                  |
|                                 | the  |   |     |                  |
|                                 | de   |   |     |                  |
|                                 | gree |   |     |                  |
|                                 | to   |   |     |                  |
|                                 | w    |   |     |                  |
|                                 | hich |   |     |                  |
|                                 | MCH  |   |     |                  |
|                                 | long |   |     |                  |
|                                 | term |   |     |                  |
|                                 | i    |   |     |                  |
|                                 | nter |   |     |                  |
|                                 | disc |   |     |                  |
|                                 | ipli |   |     |                  |
|                                 | nary |   |     |                  |
|                                 | trai |   |     |                  |
|                                 | nees |   |     |                  |
|                                 | v    |   |     |                  |
|                                 | alue |   |     |                  |
|                                 | trai |   |     |                  |
|                                 | ning |   |     |                  |
|                                 | will |   |     |                  |
|                                 | have |   |     |                  |
|                                 | mult |   |     |                  |
|                                 | iple |   |     |                  |
|                                 | aff  |   |     |                  |
|                                 | ects |   |     |                  |
|                                 | on   |   |     |                  |
|                                 | the  |   |     |                  |
|                                 | l    |   |     |                  |
|                                 | ong- |   |     |                  |
|                                 | term |   |     |                  |
|                                 | ob   |   |     |                  |
|                                 | ject |   |     |                  |
|                                 | ives |   |     |                  |
|                                 | of   |   |     |                  |
|                                 | the  |   |     |                  |
|                                 | prog |   |     |                  |
|                                 | ram. |   |     |                  |
|                                 | Feed |   |     |                  |
|                                 | back |   |     |                  |
|                                 | from |   |     |                  |
|                                 | trai |   |     |                  |
|                                 | nees |   |     |                  |
|                                 | is   |   |     |                  |
|                                 | crit |   |     |                  |
|                                 | ical |   |     |                  |
|                                 | to   |   |     |                  |
|                                 | insu |   |     |                  |
|                                 | ring |   |     |                  |
|                                 | that |   |     |                  |
|                                 | trai |   |     |                  |
|                                 | ning |   |     |                  |
|                                 | a    |   |     |                  |
|                                 | ddre |   |     |                  |
|                                 | sses |   |     |                  |
|                                 | the  |   |     |                  |
|                                 | n    |   |     |                  |
|                                 | eeds |   |     |                  |
|                                 | of   |   |     |                  |
|                                 | fu   |   |     |                  |
|                                 | ture |   |     |                  |
|                                 | lea  |   |     |                  |
|                                 | ders |   |     |                  |
|                                 | in   |   |     |                  |
|                                 | the  |   |     |                  |
|                                 | fi   |   |     |                  |
|                                 | eld. |   |     |                  |
|                                 | The  |   |     |                  |
|                                 | inf  |   |     |                  |
|                                 | orma |   |     |                  |
|                                 | tion |   |     |                  |
|                                 | c    |   |     |                  |
|                                 | ould |   |     |                  |
|                                 | lead |   |     |                  |
|                                 | to   |   |     |                  |
|                                 | s    |   |     |                  |
|                                 | trat |   |     |                  |
|                                 | egic |   |     |                  |
|                                 | pro  |   |     |                  |
|                                 | gram |   |     |                  |
|                                 | impr |   |     |                  |
|                                 | ovem |   |     |                  |
|                                 | ents |   |     |                  |
|                                 | as   |   |     |                  |
|                                 | well |   |     |                  |
|                                 | as   |   |     |                  |
|                                 | incr |   |     |                  |
|                                 | ease |   |     |                  |
|                                 | the  |   |     |                  |
|                                 | re   |   |     |                  |
|                                 | spon |   |     |                  |
|                                 | sive |   |     |                  |
|                                 | ness |   |     |                  |
|                                 | of   |   |     |                  |
|                                 | i    |   |     |                  |
|                                 | nter |   |     |                  |
|                                 | disc |   |     |                  |
|                                 | ipli |   |     |                  |
|                                 | nary |   |     |                  |
|                                 | trai |   |     |                  |
|                                 | ning |   |     |                  |
|                                 | p    |   |     |                  |
|                                 | rogr |   |     |                  |
|                                 | ams. |   |     |                  |
|                                 | Ult  |   |     |                  |
|                                 | imat |   |     |                  |
|                                 | ely, |   |     |                  |
|                                 | the  |   |     |                  |
|                                 | li   |   |     |                  |
|                                 | keli |   |     |                  |
|                                 | hood |   |     |                  |
|                                 | that |   |     |                  |
|                                 | trai |   |     |                  |
|                                 | nees |   |     |                  |
|                                 | are  |   |     |                  |
|                                 | pr   |   |     |                  |
|                                 | acti |   |     |                  |
|                                 | cing |   |     |                  |
|                                 | in   |   |     |                  |
|                                 | an   |   |     |                  |
|                                 | i    |   |     |                  |
|                                 | nter |   |     |                  |
|                                 | disc |   |     |                  |
|                                 | ipli |   |     |                  |
|                                 | nary |   |     |                  |
|                                 | sy   |   |     |                  |
|                                 | stem |   |     |                  |
|                                 | co   |   |     |                  |
|                                 | nsis |   |     |                  |
|                                 | tent |   |     |                  |
|                                 | with |   |     |                  |
|                                 | the  |   |     |                  |
|                                 | pr   |   |     |                  |
|                                 | inci |   |     |                  |
|                                 | ples |   |     |                  |
|                                 | of   |   |     |                  |
|                                 | the  |   |     |                  |
|                                 | C    |   |     |                  |
|                                 | SHCN |   |     |                  |
|                                 | sy   |   |     |                  |
|                                 | stem |   |     |                  |
|                                 | sh   |   |     |                  |
|                                 | ould |   |     |                  |
|                                 | incr |   |     |                  |
|                                 | ease |   |     |                  |
|                                 | if   |   |     |                  |
|                                 | trai |   |     |                  |
|                                 | ning |   |     |                  |
|                                 | be   |   |     |                  |
|                                 | tter |   |     |                  |
|                                 | m    |   |     |                  |
|                                 | eets |   |     |                  |
|                                 | t    |   |     |                  |
|                                 | heir |   |     |                  |
|                                 | ne   |   |     |                  |
|                                 | eds. |   |     |                  |
|                                 |      |   |     |                  |
|                                 | Ch   |   |     |                  |
|                                 | alle |   |     |                  |
|                                 | nges |   |     |                  |
|                                 | inc  |   |     |                  |
|                                 | lude |   |     |                  |
|                                 | is   |   |     |                  |
|                                 | sues |   |     |                  |
|                                 | in   |   |     |                  |
|                                 | trac |   |     |                  |
|                                 | king |   |     |                  |
|                                 | g    |   |     |                  |
|                                 | radu |   |     |                  |
|                                 | ates |   |     |                  |
|                                 | in   |   |     |                  |
|                                 | the  |   |     |                  |
|                                 | fut  |   |     |                  |
|                                 | ure, |   |     |                  |
|                                 | o    |   |     |                  |
|                                 | btai |   |     |                  |
|                                 | ning |   |     |                  |
|                                 | a    |   |     |                  |
|                                 | high |   |     |                  |
|                                 | resp |   |     |                  |
|                                 | onse |   |     |                  |
|                                 | r    |   |     |                  |
|                                 | ate, |   |     |                  |
|                                 | and  |   |     |                  |
|                                 | i    |   |     |                  |
|                                 | ncor |   |     |                  |
|                                 | pora |   |     |                  |
|                                 | ting |   |     |                  |
|                                 | the  |   |     |                  |
|                                 | ev   |   |     |                  |
|                                 | alua |   |     |                  |
|                                 | tion |   |     |                  |
|                                 | in   |   |     |                  |
|                                 | me   |   |     |                  |
|                                 | anin |   |     |                  |
|                                 | gful |   |     |                  |
|                                 | pro  |   |     |                  |
|                                 | gram |   |     |                  |
|                                 | deci |   |     |                  |
|                                 | sion |   |     |                  |
|                                 | -mak |   |     |                  |
|                                 | ing. |   |     |                  |
+---------------------------------+------+---+-----+------------------+

**PPM-PPC 1. The degree to which medium term trainees report increased
awareness or**

**positive impact on practice related to interdisciplinary care of
CSHCN**

**following training.**

**This negotiated performance measure is in development. Reporting
protocol will be developed as the tool is refined.**

+--------------------+-------------------------------------------------+
| Goal               | **To provide training experiences that          |
|                    | encourage participants to pursue                |
|                    | interdisciplinary practice in pediatrics**      |
+--------------------+-------------------------------------------------+
| Measure            | The degree to which medium trainees report      |
|                    | increased awareness or positive impact on       |
|                    | practice related to interdisciplinary care of   |
|                    | CSHCN following training.                       |
+--------------------+-------------------------------------------------+
| Definition         | [CSHCN]{.underline}: MCHB definition of CSHCN   |
|                    |                                                 |
|                    | [Medium term trainees]{.underline}: individuals |
|                    | counted as such on PPC continuation             |
|                    | application, regardless of receipt of MCHB      |
|                    | funding (40 [\>]{.underline} hours of PPC       |
|                    | training \< 300)                                |
+--------------------+-------------------------------------------------+
| HP2010             | 1:6: number of families experiencing            |
| Objective(s)       | difficulties or delays in                       |
|                    |                                                 |
|                    | receiving care                                  |
|                    |                                                 |
|                    | 1:7: training in core competencies for health   |
|                    | professions                                     |
|                    |                                                 |
|                    | 1:8: health professions training for members of |
|                    |                                                 |
|                    | underrepresented ethnic and minority groups     |
+--------------------+-------------------------------------------------+
| Data               | Only reasonable measure due to volume of        |
| Source(s)/Issues   | students, lack of tracking ability, etc., is a  |
|                    | brief end-of-training questionnaire.            |
+--------------------+-------------------------------------------------+
| Significance       | The PPCs provide thousands of hours of training |
|                    | to short- and medium-term trainees, investing   |
|                    | PPC resources and manpower. The impact of this  |
|                    | training should be measured and evaluated.      |
+--------------------+-------------------------------------------------+

**PPM PPC 1: PPC Medium Term Trainee Data Collection Form- Collated data
will be reported on this performance measure.**

This evaluation form should be filled out by all Pediatric Pulmonary
Center (PPC) trainees who rotated with this program for 40 or more hours
but less than 300 hours.

Was your internship for 40 or more hours but less than 300 hours?

\[ \] Yes \[ \] No

***If your answer was no, please return this survey to the person who
gave it to you and tell them that you believe you do not meet the
criteria to take it.***

Gender: \[ \] Female \[ \] Male

Ethnicity: \[ \] White, not Hispanic \[ \] Hispanic

\[ \] Black or African American \[ \] Native American/Alaskan

\[ \] Asian \[ \] Native Hawaiian or other Pacific Islander

\[ \] Mixed Ethnicity \[ \] Decline

\[ \] Other/Specify: .

Training start date: .

Training completion date: .

Did you receive a stipend from the PPC for your training? \[ \] Yes \[
\] No

Discipline: \[ \] Physician/medical \[ \] Nurse

\[ \] Respiratory therapist \[ \] Social work

\[ \] Nutritionist \[ \] Educator

\[ \] Pharmacist \[ \] Other/Specify: .

Degree being pursued: \[ \] PhD/MD \[ \] Post-Doc/Fellowship

\[ \] Masters \[ \] None

\[ \] BA/BS \[ \] Other/Specify: .

To what degree has this program provided you with skills in the areas
of:

***5 4 3 2 1 0***

***extremely somewhat not especially not helpful don't know/***

***helpful helpful neutral helpful at all not appropriate***

Children with special health care needs

*(children with chronic conditions or illness, children who are
technically dependent or children with disabilities)*

5 4 3 2 1 0

Family centered care

*(involving families in the decision-making process)*

5 4 3 2 1 0

Interdisciplinary care

*(working as a team with nutritionists, social workers, nurses,
physicians, respiratory care therapists and other allied health
professionals)*

5 4 3 2 1 0

Culturally competent care

*(the ability to provide services to clients that honor different
cultural beliefs)*

5 4 3 2 1 0

**Please use reverse side to provide written comments about the
program**.

Additional comments you would like to make about your experiences with
this program.\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

+---------------------------------+------------------------------------+
| PROGRAM PERFORMANCE MEASURE 63  | The degree to which LEND programs  |
|                                 | incorporate medical home concepts  |
| PPM 63 (LEND)                   | into their curricula/training.     |
+---------------------------------+------------------------------------+
| **GOAL**                        | To increase the number of LEND     |
|                                 | programs that incorporate medical  |
|                                 | home concepts into their           |
|                                 | interdisciplinary training         |
|                                 | programs.                          |
+---------------------------------+------------------------------------+
| **MEASURE**                     | The degree to which LEND programs  |
|                                 | incorporate medical home concepts  |
|                                 | into their curricula/training.     |
+---------------------------------+------------------------------------+
| **DEFINITION**                  | A medical home is defined by the   |
|                                 | AAP as an approach to care that is |
|                                 | "accessible, family-centered,      |
|                                 | continuous, comprehensive,         |
|                                 | coordinated, compassionate and     |
|                                 | culturally competent. This is the  |
|                                 | definition that the MCHB uses.     |
|                                 |                                    |
|                                 | Attached is a checklist of 6       |
|                                 | elements that are part of the      |
|                                 | medical home concept. Please check |
|                                 | the degree to which the elements   |
|                                 | have been incorporated by on a     |
|                                 | scale of 0-4. Please keep the      |
|                                 | completed checklist attached.      |
|                                 |                                    |
|                                 | \[Note: A baseline will be         |
|                                 | established and incremental goals  |
|                                 | set for the future.\]              |
+---------------------------------+------------------------------------+
| **HEALTHY PEOPLE 2010           | Related to 16.22 (developmental):  |
| OBJECTIVE**                     | Increase the proportion of CSHCN   |
|                                 | who have access to a medical home. |
+---------------------------------+------------------------------------+
| **DATA SOURCE(S) AND ISSUES**   | Data is collected via the data     |
|                                 | collection form that measures what |
|                                 | elements of a medical home have    |
|                                 | been incorporated into its         |
|                                 | training program curricula.        |
+---------------------------------+------------------------------------+
| **SIGNIFICANCE**                | Providing primary care to children |
|                                 | in a "medical home" is the         |
|                                 | standard of practice. Research     |
|                                 | indicates that children with a     |
|                                 | stable and continuous source of    |
|                                 | health care are more likely to     |
|                                 | receive appropriate preventative   |
|                                 | care and immunizations, are less   |
|                                 | likely to be hospitalized for      |
|                                 | preventable conditions, and are    |
|                                 | more likely to be diagnosed early  |
|                                 | for chronic or disabling           |
|                                 | conditions. The inclusion of       |
|                                 | medical home concepts in           |
|                                 | interdisciplinary training will    |
|                                 | ensure that professionals serving  |
|                                 | children with special health care  |
|                                 | needs and their families provide   |
|                                 | the best type of care possible and |
|                                 | involve the individual and/or his  |
|                                 | or her family in decision-making   |
|                                 | and care.                          |
+---------------------------------+------------------------------------+

DATA COLLECTION FORM FOR DETAIL SHEET PM #63

Using the following scale of 0-4, please rate your training program's
attention to medical home concepts in the six elements noted.

> 0=Not Taught
>
> 1=Taught at an awareness level---concept is presented
>
> 2=Taught at a knowledge level---reading, discussion and assignments on
> the concept
>
> 3=Taught at the skill level---students observe aspects of and get a
> chance to practice elements of a medical home
>
> 4=Concept woven throughout training program: information, knowledge
> and practice

+-------------------------------------+-----+-----+------+------+-----+
| **Element**                         | **  | **  | *    | *    | **  |
|                                     | 0** | 1** | *2** | *3** | 4** |
+-------------------------------------+-----+-----+------+------+-----+
| 1.  The importance of providing     |     |     |      |      |     |
|     accessible care is incorporated |     |     |      |      |     |
|     into your curricula and         |     |     |      |      |     |
|     clinical training experiences.  |     |     |      |      |     |
+-------------------------------------+-----+-----+------+------+-----+
| 2.  Family-centered care is         |     |     |      |      |     |
|     included in your curricula and  |     |     |      |      |     |
|     clinical training experiences   |     |     |      |      |     |
|     and trainees are taught to      |     |     |      |      |     |
|     include families in health care |     |     |      |      |     |
|     decisions.                      |     |     |      |      |     |
+-------------------------------------+-----+-----+------+------+-----+
| 3.  The importance of providing     |     |     |      |      |     |
|     continuous, comprehensive care  |     |     |      |      |     |
|     and the skills to do so are     |     |     |      |      |     |
|     incorporated in your curricula  |     |     |      |      |     |
|     and clinical training           |     |     |      |      |     |
|     experiences.                    |     |     |      |      |     |
+-------------------------------------+-----+-----+------+------+-----+
| 4.  Trainees are taught and         |     |     |      |      |     |
|     encouraged to provide           |     |     |      |      |     |
|     coordinated care across a range |     |     |      |      |     |
|     of disciplines.                 |     |     |      |      |     |
+-------------------------------------+-----+-----+------+------+-----+
| 5.  Cultural and linguistic         |     |     |      |      |     |
|     competence is a regular part of |     |     |      |      |     |
|     the training experience.        |     |     |      |      |     |
+-------------------------------------+-----+-----+------+------+-----+
| 6.  Faculty/staff who have          |     |     |      |      |     |
|     expertise in providing a        |     |     |      |      |     |
|     medical home are readily        |     |     |      |      |     |
|     accessible to your program      |     |     |      |      |     |
+-------------------------------------+-----+-----+------+------+-----+

Total Score (possible 0‑24) \_\_\_\_\_\_\_

+---------------------------------+------------------------------------+
| PROGRAM PERFORMANCE MEASURE 64  | The degree to which the LEAH       |
|                                 | program incorporates adolescents   |
| PPM 64 (LEAH)                   | and parents from diverse ethnic    |
|                                 | and cultural backgrounds as        |
|                                 | advisors and participants in       |
|                                 | program activities.                |
+---------------------------------+------------------------------------+
| **GOAL**                        | To increase appropriate            |
|                                 | involvement of adolescents and     |
|                                 | parents as consumers of LEAH       |
|                                 | program activities.                |
+---------------------------------+------------------------------------+
| **MEASURE**                     | The degree to which adolescents    |
|                                 | and parents are incorporated as    |
|                                 | consumers of LEAH program          |
|                                 | activities.                        |
+---------------------------------+------------------------------------+
| **DEFINITION**                  | Attached is a checklist of 4       |
|                                 | elements that document adolescent  |
|                                 | and parent participation.          |
|                                 | Respondents will note the presence |
|                                 | or absence of this participation   |
|                                 | on a scale of 0-1 for a total      |
|                                 | possible score of 4.               |
+---------------------------------+------------------------------------+
| **HEALTHY PEOPLE 2010           | 11-3. (Developmental) Increase the |
| OBJECTIVE**                     | proportion of health communication |
|                                 | activities that include research   |
|                                 | and evaluation                     |
|                                 |                                    |
|                                 | 11.6 (Developmental) Increase the  |
|                                 | proportion of persons who report   |
|                                 | that their health care providers   |
|                                 | have satisfactory communication    |
|                                 | skills.                            |
+---------------------------------+------------------------------------+
| **DATA SOURCE(S) AND ISSUES**   | Grantees report using a data       |
|                                 | collection form. These data may be |
|                                 | collected with the LEAH            |
|                                 | self-assessment activities.        |
|                                 | Participation should be defined to |
|                                 | permit assessment of youth and     |
|                                 | young adult involvement.           |
+---------------------------------+------------------------------------+
| **SIGNIFICANCE**                | Over the last decade, policy       |
|                                 | makers and program administrators  |
|                                 | have emphasized the central role   |
|                                 | of consumer of health services as  |
|                                 | advisors and participants in       |
|                                 | program activities. Satisfaction   |
|                                 | with health care is related to     |
|                                 | satisfaction with the quality of   |
|                                 | the communication with health      |
|                                 | providers. In accordance with this |
|                                 | philosophy, LEAH facilitates such  |
|                                 | partnerships and believes that     |
|                                 | consumers (adolescents and         |
|                                 | parents) from diverse backgrounds  |
|                                 | have important roles in the        |
|                                 | training of future leaders in      |
|                                 | adolescent health care delivery    |
|                                 | systems.                           |
+---------------------------------+------------------------------------+

**DATA COLLECTION FORM FOR DETAIL SHEET PM #64**

Indicate the degree to which your training program has the active
involvement of adolescents and parents in your program and planning
activities using the following values:

> 0 = The training program [does not]{.underline} have active
> involvement of adolescents and parents in your program and planning
> activities.
>
> 1 = The training program [does]{.underline} have active involvement of
> adolescents and parents in your program and planning activities.

If your program does collaborate, provide the total number of activities
for the element.

+--------------------------------------------------------+------+-----+
| **Element**                                            | *    | **  |
|                                                        | *0** | 1** |
+--------------------------------------------------------+------+-----+
| 1.  Adolescents from diverse ethnic backgrounds and    |      |     |
|     cultures participate in an advisory capacity.      |      |     |
+--------------------------------------------------------+------+-----+
| 2.  Parents of adolescents from diverse ethnic         |      |     |
|     backgrounds and cultures participate in an         |      |     |
|     advisory capacity.                                 |      |     |
+--------------------------------------------------------+------+-----+
| 3.  Adolescents from diverse ethnic backgrounds and    |      |     |
|     cultures participate in the planning,              |      |     |
|     implementation and evaluation of program           |      |     |
|     activities related to adolescents as consumers     |      |     |
+--------------------------------------------------------+------+-----+
| 4.  Parents of adolescents from diverse ethnic         |      |     |
|     backgrounds and cultures participate in the        |      |     |
|     planning, implementation and evaluation of program |      |     |
|     activities related to parents as consumers         |      |     |
+--------------------------------------------------------+------+-----+
| Total Score (possible 0‑4 score) \_\_\_\_\_\_          |      |     |
+--------------------------------------------------------+------+-----+

+---------------------------------+--------+---+----+------+------------+
| PROGRAM PERFORMANCE MEASURE 65  | The    |   |    |      |            |
|                                 | p      |   |    |      |            |
| PPM 65 (Nutrition)              | ercent |   |    |      |            |
|                                 | of     |   |    |      |            |
|                                 | indiv  |   |    |      |            |
|                                 | iduals |   |    |      |            |
|                                 | who    |   |    |      |            |
|                                 | partic |   |    |      |            |
|                                 | ipated |   |    |      |            |
|                                 | in     |   |    |      |            |
|                                 | lon    |   |    |      |            |
|                                 | g-term |   |    |      |            |
|                                 | nut    |   |    |      |            |
|                                 | rition |   |    |      |            |
|                                 | tr     |   |    |      |            |
|                                 | aining |   |    |      |            |
|                                 | that   |   |    |      |            |
|                                 | are    |   |    |      |            |
|                                 | prac   |   |    |      |            |
|                                 | ticing |   |    |      |            |
|                                 | in a   |   |    |      |            |
|                                 | Ma     |   |    |      |            |
|                                 | ternal |   |    |      |            |
|                                 | and    |   |    |      |            |
|                                 | Child  |   |    |      |            |
|                                 | Health |   |    |      |            |
|                                 | (MCH)  |   |    |      |            |
|                                 | r      |   |    |      |            |
|                                 | elated |   |    |      |            |
|                                 | field  |   |    |      |            |
|                                 | within |   |    |      |            |
|                                 | 5      |   |    |      |            |
|                                 | years  |   |    |      |            |
|                                 | after  |   |    |      |            |
|                                 | rec    |   |    |      |            |
|                                 | eiving |   |    |      |            |
|                                 | tra    |   |    |      |            |
|                                 | ining. |   |    |      |            |
+---------------------------------+--------+---+----+------+------------+
| ## GOAL                         | To     |   |    |      |            |
|                                 | in     |   |    |      |            |
|                                 | crease |   |    |      |            |
|                                 | the    |   |    |      |            |
|                                 | number |   |    |      |            |
|                                 | of     |   |    |      |            |
|                                 | indiv  |   |    |      |            |
|                                 | iduals |   |    |      |            |
|                                 | who    |   |    |      |            |
|                                 | partic |   |    |      |            |
|                                 | ipated |   |    |      |            |
|                                 | in     |   |    |      |            |
|                                 | lon    |   |    |      |            |
|                                 | g-term |   |    |      |            |
|                                 | nut    |   |    |      |            |
|                                 | rition |   |    |      |            |
|                                 | tr     |   |    |      |            |
|                                 | aining |   |    |      |            |
|                                 | that   |   |    |      |            |
|                                 | pr     |   |    |      |            |
|                                 | actice |   |    |      |            |
|                                 | in the |   |    |      |            |
|                                 | MCH    |   |    |      |            |
|                                 | field. |   |    |      |            |
+---------------------------------+--------+---+----+------+------------+
| **MEASURE**                     | The    |   |    |      |            |
|                                 | p      |   |    |      |            |
|                                 | ercent |   |    |      |            |
|                                 | of     |   |    |      |            |
|                                 | indiv  |   |    |      |            |
|                                 | iduals |   |    |      |            |
|                                 | who    |   |    |      |            |
|                                 | partic |   |    |      |            |
|                                 | ipated |   |    |      |            |
|                                 | in     |   |    |      |            |
|                                 | lon    |   |    |      |            |
|                                 | g-term |   |    |      |            |
|                                 | nut    |   |    |      |            |
|                                 | rition |   |    |      |            |
|                                 | tr     |   |    |      |            |
|                                 | aining |   |    |      |            |
|                                 | that   |   |    |      |            |
|                                 | are    |   |    |      |            |
|                                 | prac   |   |    |      |            |
|                                 | ticing |   |    |      |            |
|                                 | in a   |   |    |      |            |
|                                 | Ma     |   |    |      |            |
|                                 | ternal |   |    |      |            |
|                                 | and    |   |    |      |            |
|                                 | Child  |   |    |      |            |
|                                 | Health |   |    |      |            |
|                                 | (MCH)  |   |    |      |            |
|                                 | r      |   |    |      |            |
|                                 | elated |   |    |      |            |
|                                 | field  |   |    |      |            |
|                                 | within |   |    |      |            |
|                                 | 5      |   |    |      |            |
|                                 | years  |   |    |      |            |
|                                 | after  |   |    |      |            |
|                                 | rec    |   |    |      |            |
|                                 | eiving |   |    |      |            |
|                                 | tra    |   |    |      |            |
|                                 | ining. |   |    |      |            |
+---------------------------------+--------+---+----+------+------------+
| **DEFINITION**                  | **     |   | T  |      |            |
|                                 | Numera |   | he |      |            |
|                                 | tor:** |   | nu |      |            |
|                                 |        |   | mb |      |            |
|                                 |        |   | er |      |            |
|                                 |        |   | of |      |            |
|                                 |        |   | i  |      |            |
|                                 |        |   | nd |      |            |
|                                 |        |   | iv |      |            |
|                                 |        |   | id |      |            |
|                                 |        |   | ua |      |            |
|                                 |        |   | ls |      |            |
|                                 |        |   | w  |      |            |
|                                 |        |   | ho |      |            |
|                                 |        |   | pa |      |            |
|                                 |        |   | rt |      |            |
|                                 |        |   | ic |      |            |
|                                 |        |   | ip |      |            |
|                                 |        |   | at |      |            |
|                                 |        |   | ed |      |            |
|                                 |        |   | in |      |            |
|                                 |        |   | lo |      |            |
|                                 |        |   | ng |      |            |
|                                 |        |   | te |      |            |
|                                 |        |   | rm |      |            |
|                                 |        |   | n  |      |            |
|                                 |        |   | ut |      |            |
|                                 |        |   | ri |      |            |
|                                 |        |   | ti |      |            |
|                                 |        |   | on |      |            |
|                                 |        |   | tr |      |            |
|                                 |        |   | ai |      |            |
|                                 |        |   | ni |      |            |
|                                 |        |   | ng |      |            |
|                                 |        |   | th |      |            |
|                                 |        |   | at |      |            |
|                                 |        |   | pr |      |            |
|                                 |        |   | ac |      |            |
|                                 |        |   | ti |      |            |
|                                 |        |   | ce |      |            |
|                                 |        |   | in |      |            |
|                                 |        |   | an |      |            |
|                                 |        |   | M  |      |            |
|                                 |        |   | CH |      |            |
|                                 |        |   | r  |      |            |
|                                 |        |   | el |      |            |
|                                 |        |   | at |      |            |
|                                 |        |   | ed |      |            |
|                                 |        |   | fi |      |            |
|                                 |        |   | el |      |            |
|                                 |        |   | d. |      |            |
|                                 |        |   | An |      |            |
|                                 |        |   | M  |      |            |
|                                 |        |   | CH |      |            |
|                                 |        |   | r  |      |            |
|                                 |        |   | el |      |            |
|                                 |        |   | at |      |            |
|                                 |        |   | ed |      |            |
|                                 |        |   | f  |      |            |
|                                 |        |   | ie |      |            |
|                                 |        |   | ld |      |            |
|                                 |        |   | co |      |            |
|                                 |        |   | ns |      |            |
|                                 |        |   | is |      |            |
|                                 |        |   | ts |      |            |
|                                 |        |   | of |      |            |
|                                 |        |   | a  |      |            |
|                                 |        |   | ny |      |            |
|                                 |        |   | he |      |            |
|                                 |        |   | al |      |            |
|                                 |        |   | th |      |            |
|                                 |        |   | ca |      |            |
|                                 |        |   | re |      |            |
|                                 |        |   | or |      |            |
|                                 |        |   | r  |      |            |
|                                 |        |   | el |      |            |
|                                 |        |   | at |      |            |
|                                 |        |   | ed |      |            |
|                                 |        |   | p  |      |            |
|                                 |        |   | ro |      |            |
|                                 |        |   | gr |      |            |
|                                 |        |   | am |      |            |
|                                 |        |   | or |      |            |
|                                 |        |   | s  |      |            |
|                                 |        |   | er |      |            |
|                                 |        |   | vi |      |            |
|                                 |        |   | ce |      |            |
|                                 |        |   | t  |      |            |
|                                 |        |   | ar |      |            |
|                                 |        |   | ge |      |            |
|                                 |        |   | ti |      |            |
|                                 |        |   | ng |      |            |
|                                 |        |   | wo |      |            |
|                                 |        |   | me |      |            |
|                                 |        |   | n, |      |            |
|                                 |        |   | c  |      |            |
|                                 |        |   | hi |      |            |
|                                 |        |   | ld |      |            |
|                                 |        |   | re |      |            |
|                                 |        |   | n, |      |            |
|                                 |        |   | a  |      |            |
|                                 |        |   | nd |      |            |
|                                 |        |   | f  |      |            |
|                                 |        |   | am |      |            |
|                                 |        |   | il |      |            |
|                                 |        |   | ie |      |            |
|                                 |        |   | s. |      |            |
+---------------------------------+--------+---+----+------+------------+
|                                 | **De   |   | T  |      |            |
|                                 | nomina |   | he |      |            |
|                                 | tor:** |   | t  |      |            |
|                                 |        |   | ot |      |            |
|                                 |        |   | al |      |            |
|                                 |        |   | nu |      |            |
|                                 |        |   | mb |      |            |
|                                 |        |   | er |      |            |
|                                 |        |   | of |      |            |
|                                 |        |   | i  |      |            |
|                                 |        |   | nd |      |            |
|                                 |        |   | iv |      |            |
|                                 |        |   | id |      |            |
|                                 |        |   | ua |      |            |
|                                 |        |   | ls |      |            |
|                                 |        |   | w  |      |            |
|                                 |        |   | ho |      |            |
|                                 |        |   | pa |      |            |
|                                 |        |   | rt |      |            |
|                                 |        |   | ic |      |            |
|                                 |        |   | ip |      |            |
|                                 |        |   | at |      |            |
|                                 |        |   | ed |      |            |
|                                 |        |   | in |      |            |
|                                 |        |   | lo |      |            |
|                                 |        |   | ng |      |            |
|                                 |        |   | te |      |            |
|                                 |        |   | rm |      |            |
|                                 |        |   | n  |      |            |
|                                 |        |   | ut |      |            |
|                                 |        |   | ri |      |            |
|                                 |        |   | ti |      |            |
|                                 |        |   | on |      |            |
|                                 |        |   | tr |      |            |
|                                 |        |   | ai |      |            |
|                                 |        |   | ni |      |            |
|                                 |        |   | ng |      |            |
|                                 |        |   | th |      |            |
|                                 |        |   | at |      |            |
|                                 |        |   | c  |      |            |
|                                 |        |   | om |      |            |
|                                 |        |   | pl |      |            |
|                                 |        |   | et |      |            |
|                                 |        |   | ed |      |            |
|                                 |        |   | t  |      |            |
|                                 |        |   | ra |      |            |
|                                 |        |   | in |      |            |
|                                 |        |   | in |      |            |
|                                 |        |   | g. |      |            |
|                                 |        |   | Tr |      |            |
|                                 |        |   | ai |      |            |
|                                 |        |   | ne |      |            |
|                                 |        |   | es |      |            |
|                                 |        |   | a  |      |            |
|                                 |        |   | re |      |            |
|                                 |        |   | he |      |            |
|                                 |        |   | al |      |            |
|                                 |        |   | th |      |            |
|                                 |        |   | ca |      |            |
|                                 |        |   | re |      |            |
|                                 |        |   | p  |      |            |
|                                 |        |   | ro |      |            |
|                                 |        |   | fe |      |            |
|                                 |        |   | ss |      |            |
|                                 |        |   | io |      |            |
|                                 |        |   | na |      |            |
|                                 |        |   | ls |      |            |
|                                 |        |   | r  |      |            |
|                                 |        |   | ec |      |            |
|                                 |        |   | ei |      |            |
|                                 |        |   | vi |      |            |
|                                 |        |   | ng |      |            |
|                                 |        |   | n  |      |            |
|                                 |        |   | ut |      |            |
|                                 |        |   | ri |      |            |
|                                 |        |   | ti |      |            |
|                                 |        |   | on |      |            |
|                                 |        |   | al |      |            |
|                                 |        |   | tr |      |            |
|                                 |        |   | ai |      |            |
|                                 |        |   | ni |      |            |
|                                 |        |   | ng |      |            |
|                                 |        |   | s  |      |            |
|                                 |        |   | up |      |            |
|                                 |        |   | po |      |            |
|                                 |        |   | rt |      |            |
|                                 |        |   | ed |      |            |
|                                 |        |   | by |      |            |
|                                 |        |   | MC |      |            |
|                                 |        |   | HB |      |            |
|                                 |        |   | n  |      |            |
|                                 |        |   | ut |      |            |
|                                 |        |   | ri |      |            |
|                                 |        |   | ti |      |            |
|                                 |        |   | on |      |            |
|                                 |        |   | tr |      |            |
|                                 |        |   | ai |      |            |
|                                 |        |   | ni |      |            |
|                                 |        |   | ng |      |            |
|                                 |        |   | gr |      |            |
|                                 |        |   | an |      |            |
|                                 |        |   | ts |      |            |
|                                 |        |   | i  |      |            |
|                                 |        |   | nc |      |            |
|                                 |        |   | lu |      |            |
|                                 |        |   | di |      |            |
|                                 |        |   | ng |      |            |
|                                 |        |   | t  |      |            |
|                                 |        |   | ho |      |            |
|                                 |        |   | se |      |            |
|                                 |        |   | r  |      |            |
|                                 |        |   | ec |      |            |
|                                 |        |   | ei |      |            |
|                                 |        |   | vi |      |            |
|                                 |        |   | ng |      |            |
|                                 |        |   | M  |      |            |
|                                 |        |   | CH |      |            |
|                                 |        |   | st |      |            |
|                                 |        |   | ip |      |            |
|                                 |        |   | en |      |            |
|                                 |        |   | ds |      |            |
|                                 |        |   | a  |      |            |
|                                 |        |   | nd |      |            |
|                                 |        |   | t  |      |            |
|                                 |        |   | ho |      |            |
|                                 |        |   | se |      |            |
|                                 |        |   | n  |      |            |
|                                 |        |   | ot |      |            |
|                                 |        |   | r  |      |            |
|                                 |        |   | ec |      |            |
|                                 |        |   | ei |      |            |
|                                 |        |   | vi |      |            |
|                                 |        |   | ng |      |            |
|                                 |        |   | M  |      |            |
|                                 |        |   | CH |      |            |
|                                 |        |   | s  |      |            |
|                                 |        |   | ti |      |            |
|                                 |        |   | pe |      |            |
|                                 |        |   | nd |      |            |
|                                 |        |   | s. |      |            |
+---------------------------------+--------+---+----+------+------------+
|                                 | **Un   | 1 |    | *    | Percent    |
|                                 | its:** | 0 |    | *Tex |            |
|                                 |        | 0 |    | t:** |            |
+---------------------------------+--------+---+----+------+------------+
| **HEALTHY PEOPLE 2010           | Obj    |   |    |      |            |
| OBJECTIVE**                     | ective |   |    |      |            |
|                                 | 7.7    |   |    |      |            |
|                                 | (De    |   |    |      |            |
|                                 | velopm |   |    |      |            |
|                                 | ental) |   |    |      |            |
|                                 | In     |   |    |      |            |
|                                 | crease |   |    |      |            |
|                                 | the    |   |    |      |            |
|                                 | prop   |   |    |      |            |
|                                 | ortion |   |    |      |            |
|                                 | of     |   |    |      |            |
|                                 | health |   |    |      |            |
|                                 | care   |   |    |      |            |
|                                 | o      |   |    |      |            |
|                                 | rganiz |   |    |      |            |
|                                 | ations |   |    |      |            |
|                                 | that   |   |    |      |            |
|                                 | p      |   |    |      |            |
|                                 | rovide |   |    |      |            |
|                                 | p      |   |    |      |            |
|                                 | atient |   |    |      |            |
|                                 | and    |   |    |      |            |
|                                 | family |   |    |      |            |
|                                 | edu    |   |    |      |            |
|                                 | cation |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 | Obj    |   |    |      |            |
|                                 | ective |   |    |      |            |
|                                 | 23.10  |   |    |      |            |
|                                 | (De    |   |    |      |            |
|                                 | velopm |   |    |      |            |
|                                 | ental) |   |    |      |            |
|                                 | In     |   |    |      |            |
|                                 | crease |   |    |      |            |
|                                 | the    |   |    |      |            |
|                                 | prop   |   |    |      |            |
|                                 | ortion |   |    |      |            |
|                                 | of     |   |    |      |            |
|                                 | Fe     |   |    |      |            |
|                                 | deral, |   |    |      |            |
|                                 | T      |   |    |      |            |
|                                 | ribal, |   |    |      |            |
|                                 | State, |   |    |      |            |
|                                 | and    |   |    |      |            |
|                                 | local  |   |    |      |            |
|                                 | public |   |    |      |            |
|                                 | health |   |    |      |            |
|                                 | ag     |   |    |      |            |
|                                 | encies |   |    |      |            |
|                                 | that   |   |    |      |            |
|                                 | p      |   |    |      |            |
|                                 | rovide |   |    |      |            |
|                                 | cont   |   |    |      |            |
|                                 | inuing |   |    |      |            |
|                                 | edu    |   |    |      |            |
|                                 | cation |   |    |      |            |
|                                 | to     |   |    |      |            |
|                                 | d      |   |    |      |            |
|                                 | evelop |   |    |      |            |
|                                 | comp   |   |    |      |            |
|                                 | etency |   |    |      |            |
|                                 | in     |   |    |      |            |
|                                 | ess    |   |    |      |            |
|                                 | ential |   |    |      |            |
|                                 | public |   |    |      |            |
|                                 | health |   |    |      |            |
|                                 | se     |   |    |      |            |
|                                 | rvices |   |    |      |            |
|                                 | for    |   |    |      |            |
|                                 | their  |   |    |      |            |
|                                 | empl   |   |    |      |            |
|                                 | oyees. |   |    |      |            |
+---------------------------------+--------+---+----+------+------------+
| **DATA SOURCE(S) AND ISSUES**   | These  |   |    |      |            |
|                                 | data   |   |    |      |            |
|                                 | are    |   |    |      |            |
|                                 | col    |   |    |      |            |
|                                 | lected |   |    |      |            |
|                                 | from   |   |    |      |            |
|                                 | an     |   |    |      |            |
|                                 | annual |   |    |      |            |
|                                 | survey |   |    |      |            |
|                                 | of     |   |    |      |            |
|                                 | tr     |   |    |      |            |
|                                 | ainees |   |    |      |            |
|                                 | who    |   |    |      |            |
|                                 | com    |   |    |      |            |
|                                 | pleted |   |    |      |            |
|                                 | a      |   |    |      |            |
|                                 | nut    |   |    |      |            |
|                                 | rition |   |    |      |            |
|                                 | tr     |   |    |      |            |
|                                 | aining |   |    |      |            |
|                                 | pr     |   |    |      |            |
|                                 | ogram. |   |    |      |            |
|                                 | This   |   |    |      |            |
|                                 | survey |   |    |      |            |
|                                 | could  |   |    |      |            |
|                                 | be     |   |    |      |            |
|                                 | mailed |   |    |      |            |
|                                 | by     |   |    |      |            |
|                                 | each   |   |    |      |            |
|                                 | grant  |   |    |      |            |
|                                 | p      |   |    |      |            |
|                                 | rogram |   |    |      |            |
|                                 | or     |   |    |      |            |
|                                 | done   |   |    |      |            |
|                                 | ele    |   |    |      |            |
|                                 | ctroni |   |    |      |            |
|                                 | cally. |   |    |      |            |
+---------------------------------+--------+---+----+------+------------+
| **SIGNIFICANCE**                | -      |   |    |      |            |
|                                 |   Good |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    nut |   |    |      |            |
|                                 | rition |   |    |      |            |
|                                 |     is |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    ess |   |    |      |            |
|                                 | ential |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    for |   |    |      |            |
|                                 |     g  |   |    |      |            |
|                                 | rowth, |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 | develo |   |    |      |            |
|                                 | pment, |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    and |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |   well |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 | being. |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |   Four |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    out |   |    |      |            |
|                                 |     of |   |    |      |            |
|                                 |     10 |   |    |      |            |
|                                 |     l  |   |    |      |            |
|                                 | eading |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 | causes |   |    |      |            |
|                                 |     of |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |  death |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    are |   |    |      |            |
|                                 |     r  |   |    |      |            |
|                                 | elated |   |    |      |            |
|                                 |     to |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |   poor |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |  nutri |   |    |      |            |
|                                 | tional |   |    |      |            |
|                                 |     h  |   |    |      |            |
|                                 | abits. |   |    |      |            |
|                                 |     In |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |  order |   |    |      |            |
|                                 |     to |   |    |      |            |
|                                 |     i  |   |    |      |            |
|                                 | mprove |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 | health |   |    |      |            |
|                                 |     ou |   |    |      |            |
|                                 | tcomes |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |  among |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |  women |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    and |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    chi |   |    |      |            |
|                                 | ldren, |   |    |      |            |
|                                 |     it |   |    |      |            |
|                                 |     is |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |  vital |   |    |      |            |
|                                 |     to |   |    |      |            |
|                                 |     i  |   |    |      |            |
|                                 | mprove |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |  nutri |   |    |      |            |
|                                 | tional |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 | habits |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 | within |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    the |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    MCH |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |  popul |   |    |      |            |
|                                 | ation. |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 | -   It |   |    |      |            |
|                                 |     is |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    ess |   |    |      |            |
|                                 | ential |   |    |      |            |
|                                 |     to |   |    |      |            |
|                                 |     ma |   |    |      |            |
|                                 | intain |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    and |   |    |      |            |
|                                 |     e  |   |    |      |            |
|                                 | nhance |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    the |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    nut |   |    |      |            |
|                                 | rition |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    wor |   |    |      |            |
|                                 | kforce |   |    |      |            |
|                                 |     in |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |  order |   |    |      |            |
|                                 |     to |   |    |      |            |
|                                 |     i  |   |    |      |            |
|                                 | mprove |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    the |   |    |      |            |
|                                 |     q  |   |    |      |            |
|                                 | uality |   |    |      |            |
|                                 |     of |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |   care |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    and |   |    |      |            |
|                                 |     p  |   |    |      |            |
|                                 | rovide |   |    |      |            |
|                                 |     ad |   |    |      |            |
|                                 | equate |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    nut |   |    |      |            |
|                                 | rition |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |   coun |   |    |      |            |
|                                 | seling |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    ser |   |    |      |            |
|                                 | vices. |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |  These |   |    |      |            |
|                                 |     w  |   |    |      |            |
|                                 | orkers |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    are |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |  vital |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 | partic |   |    |      |            |
|                                 | ipants |   |    |      |            |
|                                 |     in |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    the |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 | system |   |    |      |            |
|                                 |     of |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |   care |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    and |   |    |      |            |
|                                 |     e  |   |    |      |            |
|                                 | nhance |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    the |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |   prev |   |    |      |            |
|                                 | entive |   |    |      |            |
|                                 |     se |   |    |      |            |
|                                 | rvices |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    inf |   |    |      |            |
|                                 | rastru |   |    |      |            |
|                                 | cture. |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 | -      |   |    |      |            |
|                                 | Having |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |   data |   |    |      |            |
|                                 |     on |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    the |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 | number |   |    |      |            |
|                                 |     of |   |    |      |            |
|                                 |     tr |   |    |      |            |
|                                 | ainees |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |   cont |   |    |      |            |
|                                 | inuing |   |    |      |            |
|                                 |     to |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |   work |   |    |      |            |
|                                 |     in |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    the |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    MCH |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |  field |   |    |      |            |
|                                 |     e  |   |    |      |            |
|                                 | nables |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |   MCHB |   |    |      |            |
|                                 |     to |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 | assess |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    the |   |    |      |            |
|                                 |     ad |   |    |      |            |
|                                 | equacy |   |    |      |            |
|                                 |     of |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    the |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |    nut |   |    |      |            |
|                                 | rition |   |    |      |            |
|                                 |     se |   |    |      |            |
|                                 | rvices |   |    |      |            |
|                                 |        |   |    |      |            |
|                                 |   infr |   |    |      |            |
|                                 | astruc |   |    |      |            |
|                                 | tures. |   |    |      |            |
+---------------------------------+--------+---+----+------+------------+

PPM-SPH 1 is a negotiated performance measure in development. Reporting
protocol will be developed as the tool is refined.

+-----------------------------------+-----------------------------------+
| **Program Performance Measure     | #### The number of active comm    |
| SPH1**                            | unity partnerships maintained by  |
|                                   | MCHB long-term training programs. |
| # PPM-SPH 1 (SPH)                 |                                   |
+-----------------------------------+-----------------------------------+
| **GOAL**                          | To increase the number of active  |
|                                   | community partnerships maintained |
|                                   | by MCH-PH training programs.      |
+-----------------------------------+-----------------------------------+
| **MEASURE**                       | ThThe number of active community  |
|                                   | partnerships maintained by MCHB   |
|                                   | long-term training programs in    |
|                                   | each of four functional areas:    |
|                                   |                                   |
|                                   | 1\) Training: Field placements in |
|                                   | community sites (state or smaller |
|                                   | entity), collaborative workshops  |
|                                   | or symposia targeting students    |
|                                   |                                   |
|                                   | 2\) Service (continuing           |
|                                   | education, technical assistance,  |
|                                   | and professional consultation):   |
|                                   | Collaborative continuing          |
|                                   | education workshops; expert       |
|                                   | assistance to community           |
|                                   | organizations by training program |
|                                   | faculty, staff, students, and     |
|                                   | alumni.                           |
|                                   |                                   |
|                                   | 3\) Research (development and     |
|                                   | dissemination of new              |
|                                   | information): Community-based     |
|                                   | research projects that involve    |
|                                   | community groups in study         |
|                                   | planning and design, data         |
|                                   | collection, presentation of       |
|                                   | research results and/or           |
|                                   | publication of results.           |
|                                   |                                   |
|                                   | 4\) Advocacy: Joint efforts with  |
|                                   | the community to advocate for     |
|                                   | families and children on specific |
|                                   | topics, such preparing a policy   |
|                                   | paper on children's access to     |
|                                   | health care that merges research  |
|                                   | findings with case examples from  |
|                                   | community organizations.          |
|                                   | Consultation to the federal       |
|                                   | government focusing on            |
|                                   | communities. Efforts to effect    |
|                                   | policy change at the local,       |
|                                   | state, federal government level.  |
|                                   | Letters to the Editor,            |
|                                   | Commentary.                       |
+-----------------------------------+-----------------------------------+
| **DEFINITION**                    | ## Community partnerships---C     |
|                                   | ollaborative relationships betwee |
|                                   | n MCH-PH training programs and co |
|                                   | mmunity-based organizations/agenc |
|                                   | ies and research institutions sha |
|                                   | ring efforts toward common goals. |
|                                   |                                   |
|                                   | ## Active---Mutual                |
|                                   |  commitment to projects or object |
|                                   | ives. within the past 12 months.  |
+-----------------------------------+-----------------------------------+
| **HEALTHY PEOPLE 2010 OBJECTIVE** | ## Goal                           |
|                                   | 23: Public Health Infrastructure  |
|                                   |                                   |
|                                   | "Ensure that Federal, tribal,     |
|                                   | State, and local health agencies  |
|                                   | have the infrastructure to        |
|                                   | provide essential public health   |
|                                   | services effectively."            |
|                                   |                                   |
|                                   | **HP 2010 #23-9**: Increase the   |
|                                   | proportion of schools for public  |
|                                   | health workers that integrate     |
|                                   | into their curricula specific     |
|                                   | content to develop competency in  |
|                                   | the essential public health       |
|                                   | services.                         |
|                                   |                                   |
|                                   | **HP 2010 #23-10**                |
|                                   | "(Developmental) Increase the     |
|                                   | proportion of Federal, Tribal,    |
|                                   | State, and local public health    |
|                                   | agencies that provide continuing  |
|                                   | education to develop competency   |
|                                   | in essential public health        |
|                                   | services for their employees.     |
|                                   |                                   |
|                                   | **HP2010 #23-17**                 |
|                                   | "(Developmental) Increase the     |
|                                   | proportion of Federal, Tribal,    |
|                                   | State, and local public health    |
|                                   | agencies that conduct or          |
|                                   | collaborate on population-based   |
|                                   | prevention research.              |
+-----------------------------------+-----------------------------------+
| **DATA SOURCE(S) AND ISSUES**     | Data will be collected from       |
|                                   | MCH-PH as part of the competitive |
|                                   | and continuation grant            |
|                                   | application process. Training     |
|                                   | programs will be required to      |
|                                   | report specific partnership       |
|                                   | objectives and outcome measures,  |
|                                   | as part of the competitive        |
|                                   | application process.              |
+-----------------------------------+-----------------------------------+
| **SIGNIFICANCE**                  | Active partnerships maximize the  |
|                                   | impact of training programs and   |
|                                   | community organizations on        |
|                                   | health, educational, and other    |
|                                   | outcomes through sharing of       |
|                                   | expertise and resources. Ideally, |
|                                   | partnerships are synergistic,     |
|                                   | allowing each partner to increase |
|                                   | the quality and quantity of their |
|                                   | services and products and         |
|                                   | providing a climate for           |
|                                   | collaborative ventures that would |
|                                   | not otherwise exist.              |
+-----------------------------------+-----------------------------------+

PART 2

Financial and Demographic Data Elements

**FORM 1**

**MCHB PROJECT BUDGET DETAILS FOR FY \_\_\_\_\_\_\_**

**1. MCHB GRANT AWARD AMOUNT** \$\_\_\_\_\_\_\_\_\_**\_**

**2. UNOBLIGATED BALANCE** \$\_\_\_\_\_\_\_\_\_**\_**

**3. MATCHING FUNDS** (Required: Yes \[ \] No \[ \] If yes, amount)
\$\_\_\_\_\_\_\_\_\_\_

> A. Local funds \$\_\_\_\_\_\_\_

B.  State funds \$\_\_\_\_\_\_\_

C.  Program Income \$\_\_\_\_\_\_\_

D.  Applicant/Grantee Funds \$\_\_\_\_\_\_\_

> E. Other funds \$\_\_\_\_\_\_\_

**4. OTHER PROJECT FUNDS** (Not included in 3 above)
\$\_\_\_\_\_\_\_\_\_\_

> A. Local funds \$\_\_\_\_\_\_\_

B.  State funds \$\_\_\_\_\_\_\_

C.  Program Income (Clinical or Other) \$\_\_\_\_\_\_\_

D.  Applicant/Grantee Funds (includes in-kind) \$\_\_\_\_\_\_\_

> E. Other funds (including private sector, e.g., \$\_\_\_\_\_\_\_
>
> Foundations)

**5**. **TOTAL PROJECT FUNDS** (Total lines 1 through 4)
\$\_\_\_\_\_\_\_\_\_\_

**6. FEDERAL COLLABORATIVE FUNDS**

(Source(s) of additional Federal funds contributing to the project)

> Other MCHB Funds (Do not repeat grant funds from Line 1)
>
> 1\) SPRANS \$\_\_\_\_\_\_\_\_
>
> 2\) CISS \$\_\_\_\_\_\_\_\_
>
> 3\) SSDI \$\_\_\_\_\_\_\_\_
>
> 4\) Abstinence Education \$\_\_\_\_\_\_\_\_
>
> 5\) Healthy Start \$\_\_\_\_\_\_\_\_

6)  EMSC \$\_\_\_\_\_\_\_\_

7)  Bioterrorism \$\_\_\_\_\_\_\_\_

8)  Traumatic Brain Injury \$\_\_\_\_\_\_\_\_

9)  State Title V Block Grant \$\_\_\_\_\_\_\_\_

10) Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \$\_\_\_\_\_\_\_\_

> Other HRSA Funds
>
> 1\) HIV/AIDS \$\_\_\_\_\_\_\_\_

Primary Care \$\_\_\_\_\_\_\_\_

Health Professions \$\_\_\_\_\_\_\_\_

Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \$\_\_\_\_\_\_\_\_

> Other Federal Funds

1\) CMS \$\_\_\_\_\_\_\_\_

SSI \$\_\_\_\_\_\_\_\_

Agriculture (WIC/other) \$\_\_\_\_\_\_\_\_

ACF \$\_\_\_\_\_\_\_\_

CDC \$\_\_\_\_\_\_\_\_

SAMHSA \$\_\_\_\_\_\_\_\_

NIH \$\_\_\_\_\_\_\_\_

Education \$\_\_\_\_\_\_\_\_

Other: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \$\_\_\_\_\_\_\_\_

> \$\_\_\_\_\_\_\_\_
>
> \$\_\_\_\_\_\_\_\_

**7. TOTAL COLLABORATIVE FEDERAL FUNDS**
\$[\_\_\_\_\_\_\_\_]{.underline}

**INSTRUCTIONS FOR COMPLETION OF FORM 1**

**MCH BUDGET DETAILS FOR FY \_\_\_\_**

Line 1. Enter the amount of the Federal MCHB grant award for this
project.

Line 2. Enter the amount of carryover from the previous year's award, if
any (the unobligated balance).

Line 3. Indicate if matching funds are required by checking the
appropriate choice. If matching funds are required, enter the total
amount of the matching funds received or committed to the project. List
the amounts by source on lines 3A through 3D as appropriate. Do not
include "overmatch" funds. Any additional funds over and above the
amount required for matching purposes should be reported in Line 4.
Where appropriate, include the dollar value of in-kind contributions.

Line 4. Enter the amount of other funds received for the project, by
source on Lines 4A through 4E, specifying amounts from each source. Do
not include those amounts included in Line 3 above. Also include the
dollar value of in-kind contributions.

Line 5. Enter the sum of lines 1 through 4

Line 6. Line 6. Enter the amount of other Federal funds received on the
appropriate lines (A.1 through C.9) **other** than the MCHB grant award
for the project. Such funds would include those from other Departments,
other components of the Department of Health and Human Services, or
other MCHB grants or contracts.

Line 6C.1. Enter only project funds from the Center for Medicare and
Medicaid Services. Exclude Medicaid reimbursement, which is considered
Program Income and should be included on Line 3C or 4C.

If lines 6A.10, 6B.4, or 6C.9 are utilized, specify the source(s) of the
funds in the order of the amount provided, starting with the source of
the most funds. If more space is required, add a footnote at the bottom
of the page showing additional sources and amounts.

Line 7. Enter the sum of Lines 6A.1 through 6C.9.

NOTE: MCHB Training Grants must fill out Section "V. Detailed Budget" of
the currently approved HRSA-6025 in addition to this form.

**FORM 2**

**PROJECT FUNDING PROFILE**

[FY]{.underline} [FY]{.underline} [FY]{.underline} [FY]{.underline}
[FY]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_ [Budgeted Expended]{.underline}
[Budgeted Expended]{.underline} [Budgeted Expended]{.underline}
[Budgeted Expended]{.underline} [Budgeted Expended]{.underline}

1.  [MCHB Grant]{.underline}

    [Award]{.underline}

[Amount]{.underline} \$ \$ \$ \$ \$ \$ \$ \$ \$ \$\_\_\_\_\_\_\_\_\_

(*Line 1, Form 2)*

2\. [Unobligated]{.underline}

[Balance]{.underline} \$ \$ \$ \$ \$ \$ \$ \$ \$ \$\_\_\_\_\_\_\_\_\_

*(Line 2, Form 2)*

3\. [Matching]{.underline}

[Funds]{.underline}

[(If required)]{.underline} \$ \$ \$ \$ \$ \$ \$ \$ \$
\$\_\_\_\_\_\_\_\_\_

(*Line 3, Form 2)*

4*.* [Other Project]{.underline}

[Funds]{.underline} \$ \$ \$ \$ \$ \$ \$ \$ \$ \$\_\_\_\_\_\_\_\_\_

(*Line 4, Form 2)*

5\. [Total Project]{.underline}

[Funds]{.underline} \$ \$ \$ \$ \$ \$ \$ \$ \$ \$\_\_\_\_\_\_\_\_\_
(*Line 5, Form 2)*

6\. [Total Federal]{.underline}

[Collaborative]{.underline}

[Funds]{.underline} \$ \$ \$ \$ \$ \$ \$ \$ \$ \$\_\_\_\_\_\_\_\_\_

*(Line 7, Form 2)*

**INSTRUCTIONS FOR THE COMPLETION OF FORM 2**

**PROJECT FUNDING PROFILE**

**Instructions:**

Complete all required data cells. If an actual number is not available,
use an estimate. Explain all estimates in a footnote.

The form is intended to provide at a glance funding data on the
estimated budgeted amounts and actual expended amounts of an MCH
project.

> For each fiscal year, the data in the columns labeled Budgeted on this
> form are to contain the same figures that appear on the Application
> Face Sheet and Lines 1 through 7 of Form 1. The lines under the
> columns labeled Expended are to contain the actual amounts expended
> for each grant year that has been completed.

####### FORM 3

**BUDGET DETAILS BY TYPES OF INDIVIDUALS SERVED**

**For Projects Providing Direct Health Care, Enabling, or
Population-based Services**

+-------------------+-----------+-----------+------------+-----------+
|                   | # FY      | **\_\_\_\ | **FY**     | **\_\     |
|                   |           | _\_\_\_** |            | _\_\_\_** |
+-------------------+-----------+-----------+------------+-----------+
| ###### Tar        | **\$      | **\$      | **\$       | **\$      |
| get Population(s) | B         | E         | Budgeted** | E         |
|                   | udgeted** | xpended** |            | xpended** |
+-------------------+-----------+-----------+------------+-----------+
| Pregnant Women    |           |           |            |           |
|                   |           |           |            |           |
| (All Ages)        |           |           |            |           |
+-------------------+-----------+-----------+------------+-----------+
| Infants           |           |           |            |           |
|                   |           |           |            |           |
| (Age 0 to 1)      |           |           |            |           |
+-------------------+-----------+-----------+------------+-----------+
| Children          |           |           |            |           |
|                   |           |           |            |           |
| (Age 1 to 24)     |           |           |            |           |
+-------------------+-----------+-----------+------------+-----------+
| CSHCN Infants     |           |           |            |           |
|                   |           |           |            |           |
| (Age 0 to 1)      |           |           |            |           |
+-------------------+-----------+-----------+------------+-----------+
| CSHCN Children    |           |           |            |           |
|                   |           |           |            |           |
| (Age 1 to 24)     |           |           |            |           |
+-------------------+-----------+-----------+------------+-----------+
| Non-pregnant      |           |           |            |           |
| Women             |           |           |            |           |
|                   |           |           |            |           |
| (Age 22 and over) |           |           |            |           |
+-------------------+-----------+-----------+------------+-----------+
| ###### Other      |           |           |            |           |
+-------------------+-----------+-----------+------------+-----------+
| ### TOTAL         |           |           |            |           |
+-------------------+-----------+-----------+------------+-----------+

> **INSTRUCTIONS FOR COMPLETION OF FORM 3**
>
> **BUDGET DETAILS BY TYPES OF INDIVIDUALS SERVED**

######## For Projects Providing Direct Health Care, Enabling, or Population-based Services

> If the project provides direct health care services, complete all
> required data cells. If an actual number is not available make an
> estimate. Please explain all estimates in a footnote.
>
> All ages are to be read from x [to]{.underline} y, [not]{.underline}
> including y. For example, infants are those from birth
> [to]{.underline} 1, and children are from age 1 [to]{.underline} 22.
>
> Enter the budgeted and expended amounts for the appropriate fiscal
> year, for each targeted population group. Note that the Total for each
> column is to be the same as that appearing in Line 5, Form 1, and in
> Line 5, Form 2.
>
> Enter the expended amounts for the appropriate fiscal year that has
> been completed for each target population group. Note that these
> figures are to be the actual amounts expended; new projects will not
> have data in "Expended" columns.

#### FORM 4

**PROJECT BUDGET AND EXPENDITURES**

**By Types Of Services**

**FY \_\_\_\_\_ FY \_\_\_\_\_**

**[TYPES OF SERVICES]{.underline} [Budgeted]{.underline}
[Expended]{.underline} [Budgeted]{.underline} [Expended]{.underline}**

**I. [Direct Health Care Services]{.underline}** \$ \$ \$ \$
[\_\_\_\_\_\_\_\_\_]{.underline}

> (Basic Health Services and Health
>
> Services for CSHCN.)

**II. [Enabling Services]{.underline}** \$ \$ \$ \$
[\_\_\_\_\_\_\_\_\_\_]{.underline}

> (Transportation, Translation,

Outreach, Respite Care, Health

> Education, Family Support Services,

Purchase of Health Insurance,

> Case Management, and Coordination
>
> with Medicaid, WIC, and Education.)

**III.** **[Population-Based Services]{.underline}** \$ \$ \$
\$\_\_\_\_\_\_\_\_\_\_\_

> (Newborn Screening, Lead Screening,
>
> Immunization, Sudden Infant Death
>
> Syndrome Counseling, Oral Health,
>
> Injury Prevention, Nutrition, and

Outreach/Public Education.)

**IV.** **[Infrastructure Building Services]{.underline}** \$ \$ \$ \$
[\_\_\_\_\_\_\_\_\_\_\_]{.underline}

> (Needs Assessment, Evaluation, Planning,
>
> Policy Development, Coordination,
>
> Quality Assurance, Standards Development,
>
> Monitoring, Training, Applied Research,

Systems of Care, and Information Systems.)

## V. TOTAL \$ \$ \$ \$ [\_\_\_\_\_\_\_\_\_\_\_]{.underline} 

**INSTRUCTIONS FOR THE COMPLETION OF FORM 4**

**PROJECT BUDGET AND EXPENDITURES BY TYPES OF SERVICE**S

Complete all required data cells. If an actual number is not available,
make an estimate. Please explain all estimates in a footnote.
Administrative dollars should be allocated to the appropriate level(s)
of the pyramid on lines I, II, II or IV. If an estimate of
administrative funds use is necessary, one method would be to allocate
those dollars to Lines I, II, III and IV at the same percentage as
program dollars are allocated to Lines I through IV.

Note: Lines I, II and II are for projects providing services. If grant
funds are used to build the infrastructure for direct care delivery,
enabling or population-based services, these amounts should be reported
in Line IV (i.e., building data collection capacity for newborn hearing
screening).

Line I [Direct Health Care Services]{.underline} - enter the budgeted
and expended amounts for the appropriate fiscal year completed and
budget estimates only for all other years.

> **Direct Health Care Services** are those services generally delivered
> one-on-one between a health professional and a patient in an office,
> clinic or emergency room which may include primary care physicians,
> registered dietitians, public health or visiting nurses, nurses
> certified for obstetric and pediatric primary care, medical social
> workers, nutritionists, dentists, sub-specialty physicians who serve
> children with special health care needs, audiologists, occupational
> therapists, physical therapists, speech and language therapists,
> specialty registered dietitians. Basic services include what most
> consider ordinary medical care, inpatient and outpatient medical
> services, allied health services, drugs, laboratory testing, x-ray
> services, dental care, and pharmaceutical products and services. State
> Title V programs support - by directly operating programs or by
> funding local providers - services such as prenatal care, child health
> including immunizations and treatment or referrals, school health and
> family planning. For CSHCN, these services include specialty and
> sub-specialty care for those with HIV/AIDS, hemophilia, birth defects,
> chronic illness, and other conditions requiring sophisticated
> technology, access to highly trained specialists, or an array of
> services not generally available in most communities.

Line II [Enabling Services]{.underline} - enter the budgeted and
expended amounts for the appropriate fiscal year completed and budget
estimates only for all other years.

> **Enabling Services** allow or provide for access to and the
> derivation of benefits from, the array of basic health care services
> and include such things as transportation, translation services,
> outreach, respite care, health education, family support services,
> purchase of health insurance, case management, coordination of with
> Medicaid, WIC and educations. These services are especially required
> for the low income, disadvantaged, geographically or culturally
> isolated, and those with special and complicated health needs. For
> many of these individuals, the enabling services are essential - for
> without them access is not possible. Enabling services most commonly
> provided by agencies for CSHCN include transportation, care
> coordination, translation services, home visiting, and family
> outreach. Family support activities include parent support groups,
> family training workshops, advocacy, nutrition and social work.

Line III [Population-Based Services]{.underline} - enter the budgeted
and expended amounts for the appropriate fiscal year completed and
budget estimates only for all other years.

> **Population Based Services** are preventive interventions and
> personal health services, developed and available for the entire MCH
> population of the State rather than for individuals in a one-on-one
> situation. Disease prevention, health promotion, and statewide
> outreach are major components. Common among these services are newborn
> screening, lead screening, immunization, Sudden Infant Death Syndrome
> counseling, oral health, injury prevention, nutrition and
> outreach/public education. These services are generally available
> whether the mother or child receives care in the private or public
> system, in a rural clinic or an HMO, and whether insured or not.

Line IV [Infrastructure Building Services]{.underline} - enter the
budgeted and expended amounts for the appropriate fiscal year completed
and budget estimates only for all other years.

> **Infrastructure Building Services** are the base of the MCH pyramid
> of health services and form its foundation. They are activities
> directed at improving and maintaining the health status of all women
> and children by providing support for development and maintenance of
> comprehensive health services systems and resources including
> development and maintenance of health services standards/guidelines,
> training, data and planning systems. Examples include needs
> assessment, evaluation, planning, policy development, coordination,
> quality assurance, standards development, monitoring, training,
> applied research, information systems and systems of care. In the
> development of systems of care it should be assured that the systems
> are family centered, community based and culturally competent.

Line V [Total]{.underline} -- enter the total amounts for each column,
budgeted for each year and expended for each year completed.

**FORM 5**

**NUMBER OF INDIVIDUALS SERVED (UNDUPLICATED)**

**By Type of Individual and Source of Primary Insurance Coverage**

######## For Projects Providing Direct Health Care, Enabling or Population-based Services

**Reporting Year**\_\_\_\_\_\_\_\_\_\_

######### Table 1 **(a) (b) (c) (d) (e) (f)**

+-----------+--------+--------+---------+---------+---------+-------+
| *         | **     | **T    | **Title | **Title | **Pri   | **N   |
| *Pregnant | Number | otal** | XIX %** | XXI %** | vate/** | one** |
| Women     | Se     |        |         |         |         |       |
| Served**  | rved** | **Se   |         |         | **Other | **%** |
|           |        | rved** |         |         | %**     |       |
+-----------+--------+--------+---------+---------+---------+-------+
| Pregnant  |        |        |         |         |         |       |
| Women     |        |        |         |         |         |       |
|           |        |        |         |         |         |       |
| (All      |        |        |         |         |         |       |
| Ages)     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 10-14     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 15-19     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 20-24     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 25-34     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 35-44     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 45 +      |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+

> **Table 2** (a) (b) (c) (d) (e) (f)

+-----------+--------+--------+---------+---------+---------+-------+
| **C       | **     | *      | **Title | **Title | **Pri   | **N   |
| hildren** | Number | *Total | XIX %** | XXI %** | vate/** | one** |
|           | Se     | Se     |         |         |         |       |
| *         | rved** | rved** |         |         | **Other | **%** |
| *Served** |        |        |         |         | %**     |       |
+-----------+--------+--------+---------+---------+---------+-------+
| Infants   |        |        |         |         |         |       |
| \<1       |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| Children  |        |        |         |         |         |       |
|           |        |        |         |         |         |       |
| 1 to 22   |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 1-4       |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 5-9       |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 10-14     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 15-19     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 20-24     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+

######### Table 3 **(a) (b) (c) (d) (e) (f)**

+-----------+--------+--------+---------+---------+---------+-------+
| **CSHCN** | **     | **T    | **Title | **Title | **Pri   | **N   |
|           | Number | otal** | XIX %** | XXI %** | vate/** | one** |
| *         | Se     |        |         |         |         |       |
| *Served** | rved** | **Se   |         |         | **Other | **%** |
|           |        | rved** |         |         | %**     |       |
+-----------+--------+--------+---------+---------+---------+-------+
| Infants   |        |        |         |         |         |       |
| \<1       |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| Children  |        |        |         |         |         |       |
|           |        |        |         |         |         |       |
| 1 to 22   |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 1-4       |        | []{    | []      | []      | []      | []{.  |
|           |        | .mark} | {.mark} | {.mark} | {.mark} | mark} |
+-----------+--------+--------+---------+---------+---------+-------+
| 5-9       |        | []{    | []      | []      | []      | []{.  |
|           |        | .mark} | {.mark} | {.mark} | {.mark} | mark} |
+-----------+--------+--------+---------+---------+---------+-------+
| 10-14     |        | []{    | []      | []      | []      | []{.  |
|           |        | .mark} | {.mark} | {.mark} | {.mark} | mark} |
+-----------+--------+--------+---------+---------+---------+-------+
| 15-21     |        | []{    | []      | []      | []      | []{.  |
|           |        | .mark} | {.mark} | {.mark} | {.mark} | mark} |
+-----------+--------+--------+---------+---------+---------+-------+

######## FORM 5 Continued

**NUMBER OF INDIVIDUALS SERVED (UNDUPLICATED)**

**By Type of Individual and Source of Primary Insurance Coverage**

######## For Projects Providing Direct Health Care, Enabling or Population-based Services

**Reporting Year**\_\_\_\_\_\_\_\_\_\_

> **Table 4** (a) (b) (c) (d) (e) (f)

+-----------+--------+--------+---------+---------+---------+-------+
| **Women** | **     | **T    | **Title | **Title | **Pri   | **N   |
|           | Number | otal** | XIX %** | XXI %** | vate/** | one** |
| *         | Se     |        |         |         |         |       |
| *Served** | rved** | **Se   |         |         | **Other | **%** |
|           |        | rved** |         |         | %**     |       |
+-----------+--------+--------+---------+---------+---------+-------+
| Women 22  |        |        |         |         |         |       |
| +         |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 22-24     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 25-29     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 30-34     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 35-44     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 45-54     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 55-64     |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+
| 65 +      |        |        |         |         |         |       |
+-----------+--------+--------+---------+---------+---------+-------+

> **Table 5** (a) (b) (c) (d) (e) (f)

+-----------+--------+--------+----------+---------+---------+-------+
| **Other** | **Nu   | **T    | **Title  | **Title | **Pri   | **N   |
|           | mber** | otal** | XIX**    | XXI**   | vate/** | one** |
|           |        |        |          |         |         |       |
|           | **Se   | **Se   | **%**    | **%**   | **Other | **%** |
|           | rved** | rved** |          |         | %**     |       |
+-----------+--------+--------+----------+---------+---------+-------+
|           |        |        |          |         |         |       |
+-----------+--------+--------+----------+---------+---------+-------+

###### Table 6 (a) (b) (c) (d) (e) (f)

+-----------+--------+--------+----------+--------+---------+-------+
| #####     | **Nu   | **T    | **Title  | *      | **Pri   | **N   |
| ## TOTALS | mber** | otal** | XIX**    | *Title | vate/** | one** |
|           |        |        |          | XXI**  |         |       |
|           | **Se   | **Se   | **%**    |        | **Other | **%** |
|           | rved** | rved** |          | **%**  | %**     |       |
+-----------+--------+--------+----------+--------+---------+-------+
|           |        |        |          |        |         |       |
+-----------+--------+--------+----------+--------+---------+-------+

> **INSTRUCTIONS FOR THE COMPLETION OF FORM 5**

**NUMBER OF INDIVIDUALS SERVED (UNDUPLICATED)**

**By Type of Individual and Source of Primary Insurance Coverage**

######## For Projects Providing Direct Health Care, Enabling or Population-based Services

**Instructions:**

Enter data into all required (unshaded) data cells. If an actual number
is not available, make an estimate. Please explain all estimates in a
footnote. Do not enter data into shaded cells.

**[Note]{.underline}** that ages are expressed as either x to y,
[not]{.underline} through y (i.e., 1 to 22, meaning from age 1 [up
to]{.underline} age 22, but not including 22), or x -- y (i.e., 1- 4)
meaning age 1 [through]{.underline} age 4. Also, symbols are used to
indicate directions. For example \<1 means less than 1, or from birth up
to, but not including age 1. On the other hand, 45+ means age 45 and
over.

1\. At the top of the Form, on the Line Reporting Year, enter the year
for which the data applies.

2.  In Column (a) for all tables, enter the unduplicated count of
    individuals who received a direct service from the project
    regardless of the primary source of insurance coverage. These
    services would generally be included in the top three levels of the
    MCH pyramid (the fourth, or base level, would generally not contain
    direct services) and would include individuals served by total
    dollars reported on Line 5 of Form 3.

3\. In Column (b), enter the total number of the individuals summed from
Column (a).

4.  In the remaining columns report, for all tables, the percentage of
    those individuals receiving direct health care, enabling or
    population-based services, the percentage who have as their primary
    source of coverage:

> Column (c): Title XIX (includes Medicaid expansion under Title XXI)

Column (d): Title XXI

Column (e): Private or other coverage

Column (f) None

> These may be estimates. If individuals are covered by more than one
> source of insurance, they should be listed under the column of their
> [primary]{.underline} source.
>
> **FORM 6**

**MATERNAL & CHILD HEALTH DISCRETIONARY GRANT**

**PROJECT ABSTRACT**

**FOR FY\_\_\_\_**

**PROJECT:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**I. PROJECT IDENTIFIER INFORMATION**

1\. Project Title:

2\. Project Number:

3\. E-mail address:

**II. BUDGET**

1\. MCHB Grant Award \$\_\_\_\_\_\_\_\_\_\_\_\_\_

(Line 1, Form 2)

2\. Unobligated Balance \$\_\_\_\_\_\_\_\_\_\_\_\_\_

(Line 2, Form 2)

3\. Matching Funds (if applicable) \$\_\_\_\_\_\_\_\_\_\_\_\_\_

> (Line 3, Form 2)

4\. Other Project Funds \$\_\_\_\_\_\_\_\_\_\_\_\_\_

> (Line 4, Form 2)

5\. Total Project Funds \$\_\_\_\_\_\_\_\_\_\_\_\_\_

> (Line 5, Form 2)

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

\[ \] Direct Health Care Services

> \[ \] Enabling Services
>
> \[ \] Population-Based Services
>
> \[ \] Infrastructure Building Services

##### PROJECT DESCRIPTION OR EXPERIENCE TO DATE

> A. Project Description

1.  Problem (in 50 words, maximum):

2.  Goals and Objectives: (List up to 5 major goals and time-framed
    objectives per goal for the project)

> Goal 1:

Objective 1:

Objective 2:

Goal 2:

Objective 1:

Objective 2:

Goal 3:

Objective 1:

Objective 2:

Goal 4:

Objective 1:

Objective 2:

Goal 5:

Objective 1:

Objective 2:

3.  Activities undertaken to meet project goals

4.  Specify the primary *Healthy People 2010* objectives(s) (up to
    three) which this project addresses:

> a\.
>
> b\.
>
> c\.

5\. Coordination (List the State, local health agencies or other
organizations involved in the project and their roles)

6\. Evaluation (briefly describe the methods which will be used to
determine whether process and outcome objectives are met)

##### Continuing Grants ONLY

##### Experience to Date (For continuing projects ONLY):

2\. Website URL and annual number of hits

##### KEY WORDS

#### VI. ANNOTATION 

> **INSTRUCTIONS FOR THE COMPLETION OF FORM 6**

###  PROJECT ABSTRACT

**NOTE:** All information provided should fit into the space provided in
the form. The completed form should be no more than 3 pages in length.
Where information has previously been entered in forms 1 through 5, the
information will automatically be transferred electronically to the
appropriate place on this form.

**Section I -- Project Identifier Information**

Project Title: List the appropriate shortened title for the project.

Project Number: This is the number assigned to the project when funded,
and will, for new projects, be filled in later.

E-mail address: Include electronic mail addresses

#### Section II -- Budget - These figures will be transferred from Form 1, Lines 1 through 5. 

#### Section III - Types of Services

#### Indicate which type(s) of services your project provides, checking all that apply (consistent with Form 5)

#### Section IV -- Program Description OR Current Status (DO NOT EXCEED THE SPACE PROVIDED)

A. New Projects only are to complete the following items:

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.  Up to 5 goals of the project, in priority order. Examples are: To
    reduce the barriers to the delivery of care for pregnant women, to
    reduce the infant mortality rate for minorities and "services or
    system development for children with special healthcare needs." MCHB
    will capture annually every project's top goals in an information
    system for comparison, tracking, and reporting purposes; you must
    list at least 1 and no more than 5 goals. For each goal, list the
    two most important objectives. The objective must be specific (I.e.,
    decrease incidence by 10%) and time limited (by 2005).

3.  List the primary Healthy people 2010 goal(s) that the project
    addresses.

4.  Describe the programs and activities used to attain the goals and
    objectives, and comment on innovation, cost, and other
    characteristics of the methodology, proposed or are being
    implemented. Lists with numbered items can be used in this section.

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

6.  Briefly describe the evaluation methods that will be used to assess
    the success of the project in attaining its goals and objectives.

    B.  For continuing projects ONLY:

    ```{=html}
    <!-- -->
    ```
    1.  Provide a brief description of the major activities and
        accomplishments over the past year (not to exceed 200 words).

    2.  Provide website and number of hits annually, if applicable.

**Section V - -Key Words**

Key words describe the project, including populations served. Choose key
words from the included list.

**Section VI -- Annotation**

> Provide a three- to five-sentence description of your project that
> identifies the project's purpose, the needs and problems, which are
> addressed, the goals and objectives of the project, the activities,
> which will be used to attain the goals, and the materials, which will
> be developed.

**FORM 7**

DISCRETIONARY GRANT PROJECT

SUMMARY DATA

1.  **Project Service Focus**

> \[ \] Urban/Central City \[ \] Suburban \[ \] Metropolitan Area (city
> & suburbs)
>
> \[ \] Rural \[ \] Frontier \[ \] Border (US-Mexico)

2.  **Project Scope**

> \[ \] Local \[ \] Multi-county \[ \] State-wide
>
> \[ \] Regional \[ \] National

3.  **Grantee Organization Type**

> \[ \] State Agency

\[ \] Community Government Agency

\[ \] School District

\[ \] University/Institution Of Higher Learning (Non-Hospital Based)

\[ \] Academic Medical Center

\[ \] Community-Based Non-Governmental Organization (Health Care)

\[ \] Community-Based Non-Governmental Organization (Non-Health Care)

\[ \] Professional Membership Organization (Individuals Constitute Its
Membership)

\[ \] National Organization (Other Organizations Constitute Its
Membership)

\[ \] National Organization (Non-Membership Based)

\[ \] Independent Research/Planning/Policy Organization

\[ \] Other
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

4.  **Project Infrastructure Focus** (from MCH Pyramid) if applicable

\[ \] Guidelines/Standards Development And Maintenance

\[ \] Policies And Programs Study And Analysis

\[ \] Synthesis Of Data And Information

\[ \] Translation Of Data And Information For Different Audiences

\[ \] Dissemination Of Information And Resources

\[ \] Quality Assurance

\[ \] Technical Assistance

\[ \] Training

\[ \] Systems Development

\[ \] Other

**5. Products and Dissemination**

+--------------------------------------------------------+-------------+
| # PRODUCTS                                             | #  NUMBER   |
+--------------------------------------------------------+-------------+
| Peer reviewed Journal Article                          |             |
+--------------------------------------------------------+-------------+
| Book/Chapter                                           |             |
+--------------------------------------------------------+-------------+
| Report/Monograph                                       |             |
+--------------------------------------------------------+-------------+
| Presentation                                           |             |
+--------------------------------------------------------+-------------+
| Doctoral Dissertation                                  |             |
+--------------------------------------------------------+-------------+
| Other:                                                 |             |
+--------------------------------------------------------+-------------+

**6. Demographic Characteristics of Project Participants for Clinical
Services Projects**

+-----------+--------+------+--------+--------+-------+-------+-----+---+
|           | **RACE |      |        |        |       | **E   |     |   |
|           | (In    |      |        |        |       | THNIC |     |   |
|           | dicate |      |        |        |       | ITY** |     |   |
|           | all    |      |        |        |       |       |     |   |
|           | that   |      |        |        |       |       |     |   |
|           | ap     |      |        |        |       |       |     |   |
|           | ply)** |      |        |        |       |       |     |   |
+===========+========+======+========+========+=======+=======+=====+===+
|           | Am     | A    | Black  | Native | White | His   | Not |   |
|           | erican | sian | or     | Ha     |       | panic | Hi  |   |
|           | Indian |      | A      | waiian |       | or    | spa |   |
|           | or     |      | frican | or     |       | L     | nic |   |
|           | Alaska |      | Am     | Other  |       | atino |     |   |
|           | Native |      | erican | P      |       |       | or  |   |
|           |        |      |        | acific |       |       | Lat |   |
|           |        |      |        | Is     |       |       | ino |   |
|           |        |      |        | lander |       |       |     |   |
+-----------+--------+------+--------+--------+-------+-------+-----+---+
| # Pregn   |        |      |        |        |       |       |     |   |
| ant Women |        |      |        |        |       |       |     |   |
+-----------+--------+------+--------+--------+-------+-------+-----+---+
| ##        |        |      |        |        |       |       |     |   |
|  Children |        |      |        |        |       |       |     |   |
+-----------+--------+------+--------+--------+-------+-------+-----+---+
| Children  |        |      |        |        |       |       |     |   |
| with      |        |      |        |        |       |       |     |   |
| Special   |        |      |        |        |       |       |     |   |
| Health    |        |      |        |        |       |       |     |   |
| Care      |        |      |        |        |       |       |     |   |
| Needs     |        |      |        |        |       |       |     |   |
+-----------+--------+------+--------+--------+-------+-------+-----+---+
| Women     |        |      |        |        |       |       |     |   |
|           |        |      |        |        |       |       |     |   |
| (Not      |        |      |        |        |       |       |     |   |
| Pregnant) |        |      |        |        |       |       |     |   |
+-----------+--------+------+--------+--------+-------+-------+-----+---+
| ## Other  |        |      |        |        |       |       |     |   |
+-----------+--------+------+--------+--------+-------+-------+-----+---+
| ##        |        |      |        |        |       |       |     |   |
|           |        |      |        |        |       |       |     |   |
| ## TOTALS |        |      |        |        |       |       |     |   |
+-----------+--------+------+--------+--------+-------+-------+-----+---+

######### Clients' Primary Language(s)

######### \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

######### 

######### Resource/TA and Training Centers ONLY

######### **Answer all that apply.**

a.  Characteristics of Primary Intended Audience(s)

> \[ \] Policy Makers/Public Servants
>
> \[ \] Consumers

\[ \] Providers/Professionals

b\. Number of Requests Received/Answered: \_\_\_/\_\_\_\_

c.  Number of Continuing Education credits provided: \_\_\_\_\_\_\_

d.  Number of Individuals/Participants Reached: \_\_\_\_\_\_\_

e.  Number of Organizations Assisted: \_\_\_\_\_\_\_

f.  Major Type of TA or Training Provided:

> \[ \] continuing education courses,

\[ \] workshops,

\[ \] on-site assistance,

\[ \] distance learning classes

\[ \] other

> **INSTRUCTIONS FOR THE COMPLETION OF FORM 7**

###  PROJECT SUMMARY

**NOTE:** All information provided should fit into the space provided in
the form. Where information has previously been entered in forms 2
through 9, the information will automatically be transferred
electronically to the appropriate place on this form.

**Section 1 -- Project Service Focus**

Select all that apply

#### 

#### Section 2 -- Project Scope

#### Choose the one that best applies to your project.

#### Section 3 -- Grantee Organization Type

#### Choose the one that best applies to your organization.

### Section 4 -- Project Infrastructure Focus

If applicable, choose all that apply.

**Section 5 -- Products and Dissemination**

Indicate the number of each type of product resulting from the project.

#### Section 6 -- Demographic Characteristics of Project Participants (for Clinical Services Projects)

#### Please fill in each of the cells as appropriate. 

#### Section 7 -- Clients Primary Language(s) (for Clinical Services Projects)

#### Indicate which languages your clients speak as their primary language, other than English. List up to three.

#### Section 8 -- Resource/TA and Training Centers (Only)

Answer all that apply.

**FORM 9**

**TRACKING PROJECT PERFORMANCE MEASURES**

### 

### 

### 

### [Annual Objective and Performance Data]{.underline}

> **FY\_\_\_ FY\_\_\_ FY\_\_\_ FY\_\_\_ FY\_\_\_**

**[PERFORMANCE MEASURE \# 1]{.underline}**

##  Annual Performance Objective \_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_

**Annual Performance Indicator \_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_
\_\_\_\_\_\_ \_\_\_\_\_\_**

Numerator \_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_
\_\_\_\_\_\_

> Denominator \_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_
> \_\_\_\_\_\_

**[PERFORMANCE MEASURE \# 2]{.underline}**

**Annual Performance Objective \_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_
\_\_\_\_\_\_ \_\_\_\_\_\_**

**Annual Performance Indicator \_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_
\_\_\_\_\_\_ \_\_\_\_\_\_**

> Numerator \_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_
> \_\_\_\_\_\_
>
> Denominator \_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_
> \_\_\_\_\_\_

**[PERFORMANCE MEASURE \#]{.underline}**

**Annual Performance Objective \_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_
\_\_\_\_\_\_ \_\_\_\_\_\_**

**Annual Performance Indicator \_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_
\_\_\_\_\_\_ \_\_\_\_\_\_**

> Numerator \_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_
> \_\_\_\_\_\_
>
> Denominator \_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_
> \_\_\_\_\_\_

**INSTRUCTIONS FOR THE COMPLETION OF FORM 9**

**PERFORMANCE MEASURE TRACKING**

**[General Instructions:]{.underline}**

Complete all required data cells. If an actual number is not available,
make an estimate. Please explain all estimates in a footnote. If neither
actual data nor an estimate can be provided, the State must provide a
footnote that describes a time framed plan for providing the required
data. In such cases, the Annual Performance Objective and Annual
Performance Indicator lines are to be left blank.

This form serves two purposes: 1) to show performance measures with
5-year planned performance objective targets for the application, and 2)
the performance Annual Performance Indicator,@ values actually achieved
each year for the annual report for each performance measure.

For each program (i.e., Healthy Start, Research, LEND, etc.) there are
appropriate, required Performance Measures. Under the applicable AFY@
heading, each project will complete the Annual Performance Objectives,
the Annual Performance Indicators, and numerator and denominator data
for each measure as described below under [Specific
Instructions]{.underline}. For project developed additional performance
measures, enter these data on the form beginning with the first blank
Performance Measure area under the national measure(s).

**[Specific Instructions:]{.underline}**

In the first available space under Performance Measure\" on the
appropriate form, enter the brief title of the project performance
measure that has been selected. The titles are to be numbered
consecutively with notations of \"PP 1, PP 2,@ etc. Titles are to be
written [exactly]{.underline} as they appear on Form 16, \"Project
Performance/Outcome Measure Detail Sheet.\"

For both national and project measures, in the lines labeled Annual
Performance Objective enter a numerical value for the target the project
plans to meet for the next 5 years. These values may be expressed as a
number, a rate, a percentage, or yes - no

For both national and project measures, in the lines labeled Annual
Performance Indicator, enter the numerical value that expresses the
progress the project has made toward the accomplishment of the
performance objective for the appropriate reporting year. Note that the
indicator data are to go in the years column from which they were
actually derived even if the data are a year behind the \"reporting\"
year. This value is to be expressed in the same units as the performance
objective: a number, a rate, a percentage, or a yes - no.

If there are numerator and denominator data for the performance
measures, enter those data on the appropriate lines for the appropriate
fiscal year. If there are no numerator and denominator data leave these
lines empty. NOTE: [Do not enter numerator and denominator data for
scale measures.]{.underline}

Repeat this process for each performance measure. A continuation page is
included. If the continuation page is used, be sure to enter the number
for each listed performance measure. If there are more than six
performance measures, make as many copies of the continuation page as
necessary.

**FORM 10**

**PROJECT PERFORMANCE/OUTCOME MEASURE**

# DETAIL SHEET

**PERFORMANCE MEASURE:**

**Type:**

**Category:**

**GOAL**

**MEASURE**

**DEFINITIONS**

**Numerator:**

**Denominator:**

**Units:**

**(Number) (Text)**

**HEALTHY PEOPLE 2010**

**OBJECTIVE**

**DATA SOURCE and DATA ISSUES**

**SIGNIFICANCE**

**FORM 10**

**DETAIL SHEET INSTRUCTIONS**

**PROJECT PERFORMANCE MEASURE**

**[Instructions:]{.underline}**

This form is to be used for both the nationally required Project
Performance Measures and the any Outcome Measure the project chooses to
add. Complete each section as appropriate for the measure being
described.

**Performance**

**Measure:** Enter the narrative description of the performance or
outcome measure**.**

**Level:** Select from National, State, or Grantee the most appropriate
classification for the measure being described.

**Category:** Select from CSHN/Health Insurance, CSHN/Medical Home,
CSHCN/Infrastructure, CSHN/Screening, CSHCN/Youth, Child Health/Medical
Home, Child Health/Infrastructure, Dental, Women's Health, Abstinence,
Nutrition/Infrastructure, Injury/Infrastructure, Cultural Competence,
Family Participation, Training, Information Dissemination,
Sustainability, Data and Evaluation, and Client Satisfaction the most
appropriate classification for the measure being described.

**Goal:** Enter a short statement indicating what the State hopes to
accomplish by tracking this measure.

**Measure:** Enter a brief statement of the measure with information
sufficient to interpret the meaning of a value associated with it (e.g.,
*The percent of children with special health care needs age 0 to 18
whose families have adequate private and/or public insurance to pay for
needed services).* The measure statement [should not]{.underline}
indicate a desired direction (e.g., an increase).

**Definition:** Describe how the value of the measure is determined from
the data. If the value of the measure is Ayes/no@ or some other
narrative indicator such as Astage 1/stage 2/stage 3,\" a clear
description of what those values mean and how they are determined should
be provided.

> **Numerator:** If the measure is a percentage, rate, or ratio, provide
> a clear description of the numerator.
>
> **Denominator:** If the measure is a percentage, rate, or ratio,
> provide a clear description of the denominator.
>
> **Units:** If the measure is a percentage, rate, ratio, or scale,
> indicate the units in which the measure is to be expressed (e.g.,
> 1,000, 100) on the **\"Number\"** line and type of measure (e.g.,
> percentage, rate, ratio or scale) on **\"Text\"** line. If the measure
> is a narrative, indicate yes/no or stage 1, stage 2\", etc. on the
> **\"Text\"** line and make no entry on the **\"Number\"** line.

**Healthy People**

**2010 Objective:** If the measure is related to a *Healthy People 2010*
objective describe the objective and corresponding number.

**Data Source &**

**Data 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.

Note that the Performance Measure title and numerator and denominator
data are to appear on Form 10 [exactly]{.underline} as they appear on
this Form.

**PART 3**

Administrative Data

**MCH Training and Education Programs**

**Data Form**

1\. CFDA Number: 93.110T\_\_\_\_\_

2\. **Faculty and Staff Information\
**List all personnel (faculty, staff, and others) contributing to your
training project, include those not supported by the grant.

  -----------------------------------------------------------------------
  Personnel (Do not list trainees)

  -----------------------------------------------------------------------

+----------------+-----------+-------+------+--------+-------+-------+
| Name           | Race      | Ethn  | Ge   | Disc   | De    | F     |
|                | (indicate | icity | nder | ipline | grees | ormer |
|                | all that  |       |      |        |       |       |
|                | apply     |       |      |        |       | MCHB  |
|                | e.g.,     |       |      |        |       |       |
|                | American  |       |      |        |       | Trai  |
|                | Indian or |       |      |        |       | nee ? |
|                | Alaska    |       |      |        |       |       |
|                | Native,   |       |      |        |       | Y/N   |
|                | Asian,    |       |      |        |       |       |
|                | Black or  |       |      |        |       |       |
|                | African   |       |      |        |       |       |
|                | American, |       |      |        |       |       |
|                | Native    |       |      |        |       |       |
|                | Hawaiian  |       |      |        |       |       |
|                | or Other  |       |      |        |       |       |
|                | Pacific   |       |      |        |       |       |
|                | Islander, |       |      |        |       |       |
|                | White)    |       |      |        |       |       |
+----------------+-----------+-------+------+--------+-------+-------+
| Faculty        |           |       |      |        |       |       |
+----------------+-----------+-------+------+--------+-------+-------+
|                |           |       |      |        |       |       |
+----------------+-----------+-------+------+--------+-------+-------+
|                |           |       |      |        |       |       |
+----------------+-----------+-------+------+--------+-------+-------+
| Staff          |           |       |      |        |       |       |
+----------------+-----------+-------+------+--------+-------+-------+
|                |           |       |      |        |       |       |
+----------------+-----------+-------+------+--------+-------+-------+
| Other          |           |       |      |        |       |       |
+----------------+-----------+-------+------+--------+-------+-------+
|                |           |       |      |        |       |       |
+----------------+-----------+-------+------+--------+-------+-------+

**3. Trainee Information (Long --term Trainees Only)**

> Definition: Long-term trainees (those with greater than or equal to
> 300 contact hours within the training program) benefiting from the
> training grant (both supported and non-supported trainees).

Total Number of long term trainees participating in the training program
\_\_\_\_\_\_\_\_\_\_\*

Name

Race

Ethnicity

Gender

Permanent Address (For supported trainees ONLY)

Discipline(s) upon Entrance to the Program

Degree(s)

Position at Admission (position title and setting)

Degree Program in which enrolled

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

> Type: \[ \] Pre-doctoral \[ \] Post-doctoral
>
> \[ \] Part-time student \[ \] Full-time student

Epidemiology training grants ONLY

> Length of time receiving support: \_\_\_\_\_\_\_\_\_\_\_\_

Research Topic or
Title\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Products completed through the project

\[ \] manuscripts \[ \] Presentations \[ \] monographs \[ \] Other

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

4.  **Former Trainee Information (For Long-term Trainees ONLY)**

**(**Definition of Former Trainee = Grant supported trainees 5 years
post graduation)

Name

Year Graduated

Degree(s) Earned with MCH support

Was the University able to contact the trainee?

> Y/N (If no, proceed to Section 5 below)

Current Position (position title and setting)

City and State of Residence

Remain in MCH Field? Yes/No

5.  **Short-term (Less than 40 contact hours) and Medium-term (40 or
    more and less than 300 contact hours) Training Information**

> Number of Short term Trainees during the past 12-month grant period
> \_\_\_\_\_\_\_
>
> List types/disciplines (i.e., pediatricians, nutrritionists, etc)
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Number of Medium term Trainees during the past 12-month grant period
> \_\_\_\_\_\_\_
>
> List types/disciplines (i.e., residents, interns, etc)
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> 6\. Technical Assistance

**MCH Training and Education Program Data Form, Section 6**

> **Technical Assistance/Collaboration Form**

**OMB #0915-0272, Expiration Date:  January 31, 2006**

DEFINITION: Technical assistance/collaboration: Mutual problem solving
and collaboration on a range of issues, which may include program
development, clinical services, program evaluation, and policy &
guidelines formulation. Collaborative partners might include State or
local health agencies, and education or social service agencies. Faculty
may serve on advisory boards to develop &/or review policies at the
local, State, or national levels.

+------------------+------------------+-----------+-------------------+
| **Topic of       | **Recipient of   | *         | **Geographic      |
| Technical        | TA/              | *Indicate | Description\*\*** |
| Assistance       | Collaborator\*** | Level of  |                   |
| /Collaboration** |                  | Coll      |                   |
|                  |                  | aboration |                   |
|                  |                  | (low,     |                   |
|                  |                  | medium,   |                   |
|                  |                  | high)**   |                   |
+------------------+------------------+-----------+-------------------+
|                  |                  |           |                   |
+------------------+------------------+-----------+-------------------+
|                  |                  |           |                   |
+------------------+------------------+-----------+-------------------+
|                  |                  |           |                   |
+------------------+------------------+-----------+-------------------+
| Total Number     | Total \# and %   | No Totals | Local #\_\_\_     |
| \_\_\_\_\_       | of Recipients    | Here      | ;%\_\_\_          |
|                  |                  |           |                   |
|                  |                  |           | State #\_\_\_     |
|                  |                  |           | ;%\_\_\_          |
|                  |                  |           |                   |
|                  |                  |           | Another State     |
|                  |                  |           | #\_\_\_ ;%\_\_\_  |
|                  |                  |           |                   |
|                  |                  |           | Regional #\_\_\_  |
|                  |                  |           | ;%\_\_\_          |
|                  |                  |           |                   |
|                  |                  |           | National #\_\_\_  |
|                  |                  |           | ;%\_\_\_          |
|                  |                  |           |                   |
|                  |                  |           | International     |
|                  |                  |           | #\_\_\_ ;%\_\_\_  |
+------------------+------------------+-----------+-------------------+

List the 8-10 most significant technical assistance/collaborative
activities in the past year, start with the most significant one.

\*Recipient = Other departments in your university, Title V (MCH
Programs), Medicaid Agency, Health Insurance/Managed Care Organization,
Provider Organization, State Department of Education or Local School
District, Social Service Agency, Developmental Disability Agency, Mental
Health agency, Legal entity, Independent research or policy
organization, foundation, family and/or consumer group, Other (please
specify)

\*\*local, within state, another state, regional, national,
international

**7. Continuing Education**

  -------------------- -------------- ------------- ------------ --------------
  **Topic**            **Method\***   **Number of   **Duration   **Continuing
                                      CE Students** in Hours**   Education
                                                                 Credits
                                                                 Provided?
                                                                 Y/N**

                                                                 

                                                                 

                                                                 
  -------------------- -------------- ------------- ------------ --------------

\*Method: Presentation/Seminar; Workshop/Conference; Web-based Course;
Audioconference; Videoconference, etc.

List the Topics, methods, number of students, duration and whether CE
units were provided for the 5 most significant CE activities in the past
project year, starting with the most significant one. Provide the total
number of CE students reached through your training program last year.

[^1]: After baseline data is established, a more specific target goal
    will be determined.