**U.S. Department of Health and Human Services**

**Health Resources and Services Administration**

Maternal and Child Health Bureau (MCHB)

Division of Services for Children with Special Health Care Needs
(DSCSHN)

Integrated Services Branch (ISB)

**Integrated Services for Children with Special Health Care Needs: the
President's New Freedom Initiative**

Announcement Type: New

Announcement Numbers:

**Initiative #1 Cooperative Agreement for Adolescent Transition: Healthy
and Ready to Work: HRSA-06-098**

**Initiative #2: Cooperative Agreement for Inclusive Community
Integrated Services for Children and Youth with Special Health Care
Needs: HRSA-06-097**

**Initiative #3: Family-to-Family Health Information and Education
Centers:**

**HRSA-06-096**

**Initiative #4: State Implementation Grants for Integrated Community
Systems for Children and Youth with Special Healthcare Needs:
HRSA-06-099**

**Catalog of Federal Domestic Assistance (CFDA) No. 93.110**

**PROGRAM GUIDANCE**

**Fiscal Year 2006**

**Letter of Intent Due Date: September 9, 2005**

**Application Due Date: November 2, 2005**

**(for all Initiatives)**

**Release Date: July 29, 2005**

**Date of Issuance: July 29, 2005**

**Authority: Title V of the Social Security Act**

**Contacts:**

**Initiative \# 1:** Cooperative Agreement, Adolescent Transition:
Healthy and Ready to Work

Contact Name: Monique Fountain

Program Officer, Integrated Services Branch

Division of Services for Children with Special Health Needs

Telephone: 301-443- 9775/2370

Fax: 301-443-0832

<Mfountain@hrsa.gov>

**Initiative \# 2:** Cooperative Agreement for Inclusive Community
Integrated Services for Children and Youth with Special Health Care
Needs

Contact Name: Diana Denboba

Program Officer, Integrated Services Branch

Division of Services for Children with Special Health Needs

Telephone: 301-443-9332/2370

Fax: 301-443-0832

<DDenboba@hrsa.gov>

**Initiative \# 3:** Family- to-Family Health Information and Education
Centers

Contact Name: Diana Denboba

Program Officer, Integrated Services Branch

Division of Services for Children with Special Health Needs

Telephone: 301-443-9332/2370

Fax: 301-443-0832

<DDenboba@hrsa.gov>

**Initiative \# 4:** The President's New Freedom Initiative: State
Implementation Grants for Integrated Community Systems for Children and
Youth with Special Healthcare Needs

Lynda Honberg

Program Officer, Integrated Services Branch

Division of Services for Children with Special Health Needs

Telephone: 301-443-6314/2370

Fax: 301-443-0832

<LHonberg@hrsa.gov>

**Guidance Table of Contents**

[I. Funding Opportunity Description 5](#__RefHeading___Toc47265096)

[Purpose](#__RefHeading___Toc47265097) 5

[Background 7](#__RefHeading___Toc47265098)

[II. Award Information 10](#__RefHeading___Toc47265100)

Type of Award 10

[Summary of Funding 11](#__RefHeading___Toc47265102)

[III. Eligibility Information 11](#__RefHeading___Toc47265103)

[1. Eligible Applicants 11](#__RefHeading___Toc47265104)

[2. Cost Sharing/Matching](#__RefHeading___Toc47265106) 11

[IV. Application and Submission Information
12](#__RefHeading___Toc47265110)

[1. Address to Request Application Package
12](#__RefHeading___Toc47265113)

[*Application Materials*](#__RefHeading___Toc47265114) 12

[2. Content and Form of Application
Submission](#__RefHeading___Toc47265115) 12

> [*Application Format Requirements*](#__RefHeading___Toc47265116) 12
>
> [*Application Format 13*](#__RefHeading___Toc47265117)

[**i.** ***Application Face Page*** 13](#__RefHeading___Toc47265118)

[**ii.** ***Table of Contents*** 14](#__RefHeading___Toc47265119)

[**iii.** ***Application Checklist*** 14](#__RefHeading___Toc47265120)

[**iv.** ***Budget*** 14](#__RefHeading___Toc47265121)

[**v.** ***Budget Justification*** 14](#__RefHeading___Toc47265122)

[**vi.** ***Staffing Plan and Personnel Requirements***
16](#__RefHeading___Toc47265123)

[**vii.** ***Assurances*** 16](#__RefHeading___Toc47265124)

[**viii.** ***Certifications*** 16](#__RefHeading___Toc47265125)

[**ix.** ***Project Abstract*** 16](#__RefHeading___Toc47265126)

[**x.** ***Program Narrative*** 16](#__RefHeading___Toc47265128)

[**xi.** ***Program Specific Forms*,** 18](#__RefHeading___Toc47265129)

[**xii.** ***Appendices*** 18](#__RefHeading___Toc47265130)

[3. Submission Dates and Times 19](#__RefHeading___Toc47265131)

[4. Intergovernmental Review 20](#__RefHeading___Toc47265137)

[5. Funding Restrictions 20](#__RefHeading___Toc47265139)

[6. Other Submission Requirements 21](#__RefHeading___Toc47265140)

[V. Application Review Information 23](#__RefHeading___Toc47265142)

[1. Review Criteria 23](#__RefHeading___Toc47265143)

[2. Review and Selection Process](#__RefHeading___Toc47265144) 31

[3. Anticipated Announcement and Award Dates
31](#__RefHeading___Toc47265150)

[VI. Award Administration Information 31](#__RefHeading___Toc47265153)

[1. Award Notices 31](#__RefHeading___Toc47265154)

[2. Administrative and National Policy Requirements
32](#__RefHeading___Toc47265156)

[3. Reporting](#__RefHeading___Toc47265158) 33

[VII. Agency Contacts 33](#__RefHeading___Toc47265160)

[VIII. Other Information/Resources for
Applicants](#__RefHeading___Toc47265164) ***35***

[ix. Tips for Writing a Strong Application
33](#__RefHeading___Toc47265165)

***ATTACHMENTS:** 40*

Attachment #1: MCHB Discretionary Grant Performance Measures 41
Attachment #2: Financial and Demographic Data Elements 68 Attachment #3:
Additional Data Elements 83 Attachment #4: Key Personnel 86

Attachment #5: Project Activities Allocation Table 87

Attachment #6: Biographical Sketch *88*

[]{#__RefHeading___Toc47265096 .anchor}**I. Funding Opportunity
Description**

**Purpose**

The MCHB discretionary grant program for children and youth with special
health care needs is authorized by Title V of the Social Security Act.
This announcement solicits applications for "Integrated Services for
Children with Special Health Care Needs: The President's New Freedom
Initiative". The purpose of these initiatives is to implement the
*President's New Freedom Initiative* by improving access to quality,
comprehensive, coordinated Community-Based Systems of Services for
children and youth with special health care needs (CYSHCN) and their
families that are family-centered, community-based and culturally
competent. These initiatives support national centers and
state-implementation grants to assist State Title V Children with
Special Health Care Needs Programs (CSHCN), family advocates and other
partners to implement the six core components of a system of services
for children and youth with special health care needs (CYSHCN): 1)
families partner in decision making and are satisfied with the services
they receive; 2) CYSHCN receive coordinated ongoing comprehensive care
within a medical home; 3) families of CYSHCN have adequate private
and/or public insurance to pay for the services they need; 4) children
are screened early and continuously for special health care needs; 5)
community-based service systems are organized so families can use them
easily; and 6) youth with special health care needs receive the services
necessary to make transitions to adult life, including adult health
care, work, and independence. A description of each Initiative is as
follows:

**[Initiative \# 1 (HRSA 06-098): Cooperative Agreement for Adolescent
Transition: Healthy and Ready to Work (HRTW)]{.underline}**

One Cooperative Agreement to Support Adolescent Transition, Healthy and
Ready to Work (HRTW) through a HRTW National Resource Center. This
national center will provide national leadership to the Division of
Services for Children and Youth with Special Health Care Needs (DSCSHN)
and its constituents on achieving full implementation of the
*President's New Freedom Initiative* (NFI), which charges HRSA/MCHB with
"developing and implementing a plan to achieve appropriate
community-based service systems for children and youth with special
health care needs and their families". The HRTW National Resource Center
is specifically responsible for the component of that plan that assures
that all youth with special health care needs receive the services
necessary to transition to adult health care, work, and independence. To
fulfill this responsibility the National Resource Center will: (1)
assist States in increasing the percentage of youth with special health
care needs who have received services necessary to make transitions to
all aspects of adult life, including adult health care, work, and
independence, (2) monitor, analyze, and publish papers, issue briefs,
and other materials on trends, issues, and strategies related to youth
transition, (3) convene and participate in expert workgroup meetings,
selected conferences and other meetings relevant to youth transition,
(4) develop and maintain a Healthy and Ready to Work website, (5)
identify and work with major national public and private initiatives to
integrate youth with special health care needs, and (6) develop and
disseminate resources and materials.

**[Type/Amount/Project Period:]{.underline}** 1 Cooperative Agreement.
Approximately \$400,000 per year for 4 years, subject to availability of
funds. Project period May 1, 2006 -- April 30, 2010.

**[Initiative #2 (HRSA 06-097): Cooperative Agreement for Inclusive
Community Integrated Services for Children and Youth with Special Health
Care Needs]{.underline}**

The purpose of the National Resource Center for Inclusive Community
Integrated Services is to provide national leadership to the Division of
Services for Children and Youth with Special Health Care Needs (DSCSHN)
and its constituents on achieving full implementation of the
*President's New Freedom Initiative* (NFI). In order to reduce barriers
to community living for people with disabilities, the NFI charges
HRSA/MCHB with "developing and implementing a plan to achieve
appropriate community-based service systems for children and youth with
special health care needs and their families". The National Resource
Center for Community Integrated Services is specifically responsible for
the component of the plan that assures that services provided at the
community level are inclusive and easy to use. To fulfill this
responsibility the National Resource Center will: (1) identify and work
with major national public and private community development initiatives
to integrate children and youth with special health care needs (CYSHCN),
(2) facilitate linkages between inclusive community development
initiatives and State Title V Programs and other public and private
constituents, (3) develop and maintain a website linked to relevant
community development initiatives, (4) develop and disseminate materials
on inclusion of CYSHCN, (5) develop and implement a community
recognition program that focuses on successful community integration
models, and (6) collect, analyze, and expand the current body of
evidence-based data on the process and outcomes of integrating community
systems.

**[Type/Amount/Project Period:]{.underline}** 1 Cooperative Agreement.
Approximately \$400,000 per year for 4 years, subject to availability of
funds. Project period: May 1, 2006 -- April 30, 2010.

**[Initiative \# 3 (HRSA-06-096): Family- to-Family Health Information
and Education Centers]{.underline}**

The purpose of this initiative for "Family To Family Health Care
Information and Education Centers for Families of Children with Special
Health Care Needs" is to address the *President's New Freedom
Initiative* to reduce barriers to community living for people with
disabilities by implementing a core component of a system of services
for children and youth with special health care needs (CYSHCN) and their
families: "Families of children with special health care needs will
partner in decision-making at all levels. Grants will fund, state-wide,
family-run centers that will: (1) develop and disseminate needed health
care and related information to families and providers-including
responding to information gaps identified by families; (2) provide
education and training opportunities for families and providers; (3)
collect and analyze data related to project activities, family and
system impact and the Healthy People 2010 agenda for CYSHCN; (4) become
a community of learners by linking with community and state partners,
other MCHB and/or Centers for Medicare and Medicaid Family-to-Family
Health Information (F2F) Centers, and Family Voices; (5) encourage
additional funding, including in-kind contributions from partners with a
plan for sustainability after grant funding; and (6) integrate and
promote the philosophy and practices of family-centered care,
family/professional partnerships and cultural competence.

**[Type/Amount/Project Period:]{.underline}** 6 grants. Approximately
\$100,000 each per year for 4 years, subject to availability of funds.
Project period: May 1, 2006 -- April 30, 2010.

**[Initiative #4 (HRSA-06-099):]{.underline} [The President's New
Freedom Initiative: State Implementation Grants for Integrated Community
Systems for Children and Youth with Special Healthcare
Needs]{.underline}**

The purpose of this initiative is to support statewide implementation of
the HRSA component of the *President's New Freedom Initiative* to create
inclusive community-based systems of care for children and youth with
special health care needs.  Under this initiative, HRSA's Maternal and
Child Health Bureau has the lead in developing and implementing a plan
to achieve appropriate community-based service systems, as defined by
the following components:  (1) family/ professional partnership; (2)
comprehensive health care through a medical home; (3) access to adequate
health insurance; (4) early and continuous screening; (5) organization
of community services for easy use by families; and (6) transition to
adult health care, work, and independence.  This program replaces
previous initiatives which addressed each of these systems components
separately.  Applicants must: (1) be, or work closely with, the State
Title V Program for Children with Special Health Care Needs, (2) have a
complete and current statewide needs assessment that addresses the
State's status in each of the 6 systems components, (3) implement a
specific plan to incorporate each of  these components, (4) integrate
the plan into the Title V Block Grant and other public/private programs
serving CSHCN and their families, (5) define a comprehensive evaluation
plan using national, state, and community data. and 6**)** provide
assurances that data and evaluation results are shared with the State
Title V Program for Childen with Special Health Care Needs.** **

**[Type/Amount/Project Period:]{.underline}** 6 grants. Approximately
\$300,000 per year for 3 years, subject to availability of funds.
Project period May 1, 2006 -- April 30, 2009.

[]{#__RefHeading___Toc47265098 .anchor}**Background**

**The Maternal & Child Health Bureau**

The Maternal and Child Health Bureau (MCHB) is a component of the Health
Resources and Services Administration (HRSA) within the Department of
Health and Human Services (DHHS). Since its inception, Maternal and
Child Health (MCH) Services Grants through Title V of the Social
Security Act have provided a foundation for ensuring the health of our
Nation's mothers and children. The mission of the MCHB is to provide
national leadership in partnership with key stakeholders, to reduce
disparities, assure the availability of quality care, and strengthen the
nation's Maternal and Child Health (MCH) infrastructure in order to
improve the physical and mental health, safety, and well-being of the
MCH population -- *all* women, infants, children, adolescents and their
families, including fathers and Children with Special Health Care Needs
(CSHCN).

**Division of Services for Children with Special Health Needs**

With the Omnibus Budget Reconciliation Act (OBRA) of 1989, Public Law
101-239 amended Title V of the Social Security Act to extend the
authority and responsibility of MCHB to address core elements of
community-based systems of services for children with special health
care needs and their families. With this amendment, State Title V
Programs for Children with Special Health Care Needs (CSHCN) under the
Maternal and Child Health Services Block Grant were given the
responsibility to "provide and promote family-centered, community-based,
coordinated care for children with special health care needs, and
facilitate the development of community-based systems of services for
such children and their families. Children and youth with special health
care needs are defined as "those children and youth who have or are at
increased risk for a chronic physical, developmental, behavioral, or
emotional condition and who also require health and related services of
a type or amount beyond that required by children generally" (American
Academy of Pediatrics, 1998).

The Division's mission to assure access to care through systems
improvement is reflected in both the *Healthy People 2010 Objectives*,
and the *President's New Freedom Initiative*. Through these national
initiatives, MCHB is specifically charged with developing and
implementing a plan to achieve appropriate community-based systems of
services for children and youth with special health care needs and their
families.

Components of the plan include:

1\. Family/professional partnership at all levels of decision-making.

2\. Access to comprehensive health and related services through the
medical home.

3\. Early and continuous screening, evaluation and diagnosis.

4\. Adequate public and/or private financing of needed services.

5\. Organization of community services so that families can use them
easily.

6\. Successful transition to all aspects of adult health care, work, and
independence.

**The Integrated Services Branch**

The Integrated Services Branch within the DSCSHN has been given the lead
for implementing these systems components, and has dedicated all program
resources to the achievement of this agenda as it works to assure that
all children with special health care needs receive appropriate health
care through a comprehensive community-based system of services. Each of
the 6 program areas correspond with one of the 6 core outcomes mentioned
previously. The program areas are:

[Family Professional Partnerships/Cultural Competence:]{.underline} The
purpose of this program is to promote the integration of family-centered
care, family/professional partnerships and cultural and linguistic
competence into existing service systems to address issues related to
quality of health care, access to services, disparities in heath care
and health outcomes and the quality of life for CYSHCN and their
families. Values, principles and practices supporting this effort should
be the standard of practice for providers and the expectation of
families with CYSHCN. This program area is accomplished through
respectful partnerships between families with CYSHCN, health
professionals, policy makers, programs and agencies at local, state and
national levels and should be inclusive of these same entities who are
and/ have expertise in, working with culturally and linguistically
diverse populations.

[Medical Home]{.underline}: This program improves (1) access to quality
sources of ongoing primary health care, (2) appropriate referral to
specialty care, and (3) integration of medical services with the
community services required by CSHCN and their families. The medical
home defines care for CSHCN as accessible, continuous, comprehensive,
family-centered, coordinated, compassionate, and culturally effective.
The Branch's program is a collaborative effort among child health
professionals, CYSHCN, and their families to assure universal access to
medical homes, as well as support systems for the providers who serve
these children. Partnerships with families, State Title V programs and
other national and State constituents have been established for the
planning, development, and oversight of the medical home.

[Health Insurance and Financing]{.underline}: This program works to
improve access to adequate, affordable health insurance of CSHCN by
employing 3 strategies: (1) expand insurance to include uninsured CSHCN,
(2) assure that currently insured CSHCN have access to the full array of
benefits and services they need, and (3) improve the financing and
reimbursement of services. Grant activities are focused on promoting
state and regional partnerships to develop strategies focused on
improving access to health insurance for CSHCN and cooperative
agreements and contracts are awarded to provide support and assistance
on special issues impacting health insurance.

[Community Integrated Services]{.underline}: The purpose of this program
is to: (1) identify barriers to coordinating, integrating and financing
multiple and fragmented health and related services in community-based
service systems, (2) implement community driven model solutions
addressing barriers facing families in accessing community health and
related services that are coordinated and easy to use, and (3) implement
successful models state-wide with support from Title V programs and key
partners and stakeholders. Strategies include developing private/public
partnerships to implement community-based service integration
initiatives; coordinating community and State/territory plans and
activities with partners around the six core measures for CYSHCN in
accordance with the *President's New Freedom Initiative*; and developing
measurement and monitoring strategies to more accurately demonstrate
community and states' progress on the six core measures.

[Early and Continuous Screening]{.underline}: This program supports
periodic developmental screening for all children in conjunction with
the medical home. To achieve this goal, the program works through
"Bright Futures Guidelines for Health Supervision of Infants, Children
and Adolescents." In addition, the Branch supports a national program to
implement universal newborn hearing screening prior to hospital
discharge and intervention by six months of age by linking all
identified infants to a medical home, family-to-family support and early
intervention.

[Healthy and Ready to Work]{.underline}: The purpose of this program is
to provide the necessary support systems to ensure that youth with
special health care needs and their families make a successful
transition to adulthood, including: (1) moving from the pediatric to the
adult health care system; (2) from secondary to post-secondary
education; and (3) to employment and self-sufficiency. The program
implements the "Consensus Statement on Health Care Transition for Young
Adults with Special Health Care Needs" developed by the American Academy
of Pediatrics, American Academy of Family Physicians, and American
College of Physicians-American Society of Internal Medicine (December
2002).

All grants, cooperative agreements, and other activities supported by
these programs work collaboratively to implement each systems component,
as well as the broader system. Initiative #4, "The President's New
Freedom Initiative: State Implementation Grants for Integrated Community
Systems for Children and Youth with Special Healthcare Needs," provides
states with an opportunity to integrate all of the lessons learned about
the six systems components into a comprehensive community-based system
that is inclusive of CYSHCN.

According to the National Survey of Children with Special Health Care
Needs (2002), the estimated number of CYSHCN is 12.8% of the population
or 9.4 million children, with 20% of households with children under 18
years of age having at least one child with special health care needs.
The prevalence of special health care needs is highest among Native
American/Alaska Native, multiracial and non-Hispanic White and Black
children. Data from the recent survey demonstrate that there is still
much to accomplish in creating community-based systems of services that
address the 6 core outcomes and DSCSHN program areas. Families report
that approximately:

-   57.4% of families with CYSHCN participate in decision making and are
    satisfied with the services they receive;

-   52% of the nation's children with special health care needs receive
    comprehensive, coordinated care within the context of a medical
    home;

-   59.8% CYSHCN are adequately insured for the services they need;

-   51.8% of CYSHCN are screened early and continuously for special
    health care needs;

-   74.2% of services for CYSHCN are organized so families can use them
    easily; and

-   6.3% of youth with special needs receive services needed to support
    the transition to adulthood.

In addition, children who are poor, minorities or have complex
conditions and/or significant limitation on their activities of daily
living are more significantly impacted in terms of lack of coordinated
services; 18 % have at least one unmet need and 5% have at least one
unmet family support need. The priorities for funding in this guidance
will contribute to: greater implementation and monitoring of the 6 core
program areas at the local, state and national levels; ensuring that
MCHB programs have access to assistance on issues related to the 6 core
components of a system; and ensuring that data are gathered regarding
the effectiveness of activities.

[]{#__RefHeading___Toc47265100 .anchor}**II. Award Information**

**Type of Award**

Funding for Initiatives #1 and #2 will be provided in the form of
cooperative agreements. Funding for Initiative #3 and #4 will be
provided in the form of grants.

**[The Federal Role in Cooperative Agreements]{.underline}**

In addition to the usual monitoring and technical assistance provided
under grants, the Federal Role for cooperative agreements will include
the following:

a.  Participation in meetings conducted during the period of the
    cooperative agreement;

b.  Ongoing review of activities and procedures to be established and
    implemented for accomplishing the proposed project;

c.  Review of project information prior to dissemination;

d.  Review of information/data on project activities;

e.  Assistance with the establishment of contacts with Federal and State
    agencies, Maternal and Child Health Bureau (MCHB) grant projects,
    and other contacts that may be relevant to the project's mission and
    referrals to these agencies; and

f.  Assistance in the establishment of State and Federal interagency
    partnerships, collaboration, and cooperation that may be necessary
    for carrying out the project.

**[Cooperative Agreement -- The Grantee Role]{.underline}**

Under the terms of this cooperative agreement, grantee responsibilities
will include:

a.  Completion of activities proposed in response to application review
    criteria listed in Section V of this application.

b.  National Centers will maintain a website; provide technical
    assistance and training opportunities; and produce and disseminate
    materials including publishing articles.

c.  Providing leadership, in collaboration with the Federal Office in
    data collection and analysis of State/grantee HP 2010 and the
    *President's New Freedom Initiative* implementation activities.

d.  Participation in face-to-face meetings and conference calls with the
    Federal Office conducted during the period of the cooperative
    agreement.

e.  Collaboration with the Federal Office on ongoing review of
    activities, procedures and budget items, information/publication
    prior to dissemination, contracts and interagency agreements.

    []{#__RefHeading___Toc47265102 .anchor}**Summary of Funding**

[]{.mark}

HRSA will provide funding for up to 4 years, beginning in May, 2006,
subject to availability of funds for Initiatives #1, #2, and #3; and for
three years, beginning in May, 2006 for Initiative #4. Approximately \$
400,000 is expected to be available to fund 1 cooperative agreement for
Initiative #1; \$400,000 is expected to be available to fund 1
cooperative agreement for Initiative #2; \$600,000 is expected to be
available to fund 6 grants for Initiative #3; and \$1,773,000 is
expected to be available to fund approximately 6 grants for Initiative
#4. Funding beyond the first year is dependent on the availability of
appropriated funds in subsequent years, grantee satisfactory
performance, and a decision that funding is in the best interest of the
Federal government. Please refer to Section I for more specific
information.

[]{#__RefHeading___Toc47265103 .anchor}

**III. Eligibility Information**

[]{#__RefHeading___Toc47265104 .anchor}**1. Eligible Applicants**

As cited in 42 CFR Part 51a.3 (a), any public or private entity,
including an Indian tribe or tribal organization (as those terms are
defined at 25 U.S.C. 450b), faith based and community based organization
is eligible to apply for this federal funding opportunity. Applicants
must have significant experience with implementing systems of services
for children with special healthcare needs and their families.
Applicants that fail to show such experience will not be considered.

For Initiative #3, states that currently have a MCHB or Centers for
Medicare and Medicaid Services (CMS) Family-to-Family Health Information
and Education Center grant that will continue beyond May 2006 are not
eligible to apply.

For Initiative #4, states/territories that were awarded a statewide
implementation grant under HRSA Announcement Number-05-014 (Integrated
Services for Children with Special Health Care Needs) are not eligible
to apply.

**2. Cost Sharing/Matching**

There are no cost sharing/matching requirements for these Initiatives.
However, for Initiative #4, successful projects are expected to
demonstrate existing state and local commitment to this initiative, have
established partnerships, and leverage other sources of support which
will maximize resources and initiate a sustainability plan, post grant
funding. Applicants for Initiative #4 are encouraged to have
approximately 25% of the grant award as direct or in-kind contributions
from state and local agencies and organizations and/or foundations, and
to indicate these as line items in the budget. See "Application Review
Criteria" which reflect the need for applicants in Initiative #4 to
document meaningful partnerships.

[]{#__RefHeading___Toc47265110 .anchor}**IV. Application and Submission
Information**[]{#__RefHeading___Toc47265113 .anchor}

**1. Address to Request Application Package**

**Application Materials**

Applicants must submit proposals using appropriate form(s), e.g. Public
Health

Service (PHS) Application Form 5161-1. These forms contain additional
general

information and instructions for grant applications, proposal
narratives, and budgets.

These forms may be obtained from the following sites by:

> []{.mark}

(1) Download from http://www.hrsa.gov/grants/forms.htm

> ***Or***

\(2\) Contacting the HRSA Grants Application Center at:

> The Legin Group, Inc.
>
> 901 Russell Avenue, Suite 450
>
> Gaithersburg, MD 20879
>
> Telephone: 877-477-2123
>
> <HRSAGAC@hrsa.gov>.
>
> []{.mark}
>
> Instructions for preparing portions of the application that must
> accompany Application Form 5161-1 appear in the "Application Format"
> section below.
>
> Applicants may be eligible for more than one Initiative. However, a
> separate application must be submitted for each Initiative.

**2. Content and Form of Application Submission**

**Application Format Requirements**

> If applying on-line, the total size of all uploaded files **may not
> exceed the equivalent of 80 pages when printed by HRSA, approximately
> 10 MB. This 80 page limit includes the abstract, project and budget
> narratives, attachments, any appendices, and letters of commitment and
> support. However, it does not include program specific forms required
> by funding programs (found in Program Specific Information Section,
> i.e., financial, program and performance measures forms) --
> Attachments #1, #2, and #3.**
>
> If applying on paper, **the entire application may not exceed 80 pages
> in length**, including the abstract, project and budget narratives,
> attachments, any appendices and letters of commitment and support.
> Pages must be numbered consecutively.
>
> **Applications, whether submitted on paper or electronically, that
> exceed the specified limits (80 pages or approximately 10 MB, or that
> exceed 80 pages when printed by HRSA) will be deemed non-compliant.
> All non-compliant applications will be returned to the applicant
> without further consideration.**

a.  Number of Copies (Paper Applications only)

> Please submit one (1) original and two (2) unbound copies of the
> application.
>
> Please do not bind or staple the application. Application must be
> single sided.

b.  Font

> Please use an easily readable serif typeface, such as Times Roman,
> Courier, or CG Times. The text and table portions of the application
> must be submitted in not less than 12 point and 1.0 line spacing.
> Applications not adhering to 12 point font requirements may be
> returned.
>
> []{.mark}

c.  Paper Size and Margins

> For scanning purposes, please submit the application on 8 ½" x 11"
> white paper. Margins must be at least one (1) inch at the top, bottom,
> left and right of the paper. Please left-align text.

[]{.mark}

d.  Numbering

> Please number the pages of the application sequentially from page 1
> (face page) to the end of the application, including charts, figures,
> tables, and appendices.

[]{.mark}

e.  Names

> Please include the name of the applicant on each page.

[]{.mark}

f.  Section Headings

> Please put all section headings flush left in bold type.

[]{#__RefHeading___Toc47265117 .anchor}**Application Format**

Applications for funding must consist of the following documents in the
following order:

i.  []{#__RefHeading___Toc47265118 .anchor}***Application Face Page***

> Public Health Service (PHS) Application Form 5161-1 is provided with
> the application
>
> package. Prepare this page according to instructions provided in the
> form itself. For information pertaining to the Catalog of Federal
> Domestic Assistance, the Catalog of Federal Domestic Assistance Number
> is 93.110.
>
> **DUNS Number**
>
> All applicant organizations are required to have a Data Universal
> Numbering System (DUNS) number in order to apply for a grant from the
> Federal Government. The DUNS number is a unique nine-character
> identification number provided by the commercial company, Dun and
> Bradstreet. There is no charge to obtain a DUNS number. Information
> about obtaining a DUNS number can be found at
> [http://www.hrsa.gov/grants/preview/dunsccr.htm](http://www.hrsa.gov/grants/preview/dunsccr.htm )
> or call 1-866-705-5711. Please include the DUNS number next to the OMB
> Approval Number on the application face page. Applications ***will
> not*** be reviewed without a DUNS number.
>
> Additionally, the applicant organization will be required to register
> with the Federal Government's Central Contractor Registry (CCR) in
> order to do electronic business with the Federal Government.
> Information about registering with the CCR can be found at
> [http://www.hrsa.gov/grants/preview/dunsccr.htm](http://www.hrsa.gov/grants/preview/dunsccr.htm ).

ii. []{#__RefHeading___Toc47265119 .anchor}***Table of Contents***

> Provide a Table of Contents for the remainder of the application
> (including appendices), with page numbers.

iii. []{#__RefHeading___Toc47265120 .anchor}***Application Checklist***

> Please use Application Form 5161-1 provided with the application
> package.

iv. []{#__RefHeading___Toc47265121 .anchor}***Budget***

> Please use Application Form 5161-1 provided with the application
> package. Financial data are also collected in the Program Specific
> Information, Forms 1-4 (Attachment #2). As the financial information
> for the PHS 5161 is completed in the online application, certain
> budget data are automatically duplicated on these program financial
> forms to ensure data accuracy. These forms collect financial data that
> show how federal funds leverage other sources of income to support the
> project, and also provide greater detail on budget expenditures by
> population served, and if required, types of services.

v.  []{#__RefHeading___Toc47265122 .anchor}***Budget Justification***

> Provide a narrative that explains the amounts requested for each line
> in the budget. The budget justification should specifically describe
> how each item will support the achievement of proposed objectives. The
> budget period is for ONE year. However, the applicant must submit
> one-year budgets for each of the subsequent project period years
> (usually one to three years or more) at the time of application. Line
> item information must be provided to explain the costs entered in
> appropriate form, Application Form 5161-1. The budget justification
> must clearly describe each cost element and explain how each cost
> contributes to meeting the project's objectives/goals. Be very careful
> about showing how each item in the "other" category is justified. The
> budget justification MUST be concise. Do NOT use the justification to
> expand the project narrative.
>
> **Budget for Multi-Year Grant Award-Required, if applicable**
>
> This announcement is inviting applications for project periods up to 4
> years for Initiatives #1, #2, and #3, and up to 3 years for Initiative
> #4. Awards, on a competitive basis, will be for a one‑year budget
> period, although project periods may be for 4 or 3 years respectively.
> Applications for continuation grants funded under these awards beyond
> the one-year budget period but within the 4 or 3 year project period
> will be entertained in subsequent years on a noncompetitive basis,
> subject to availability of funds, satisfactory progress of the grantee
> and a determination that continued funding would be in the best
> interest of the Government.
>
> Include the following in the Budget Justification narrative:
>
> **Personnel Costs:** Personnel costs should be explained by listing
> each staff member who will be supported from funds, name (if
> possible), position title, percent full time equivalency, annual
> salary, and the exact amount requested for each project year which
> mainly covers indirect cost.
>
> []{.mark}
>
> **Indirect Costs:** Indirect costs are those costs incurred for common
> or joint objectives which cannot be readily identified but are
> necessary to the operations of the organization, e.g., the cost of
> operating and maintaining facilities, depreciation, and administrative
> salaries. For institutions subject to OMB Circular A-21, the term
> "facilities and administration" is used to denote indirect costs. If
> the applicant does not have an indirect cost rate, you may obtain one
> by visiting the Division of Cost Allocation website:
> http://rates.psc.gov/.

[]{.mark}

> **Fringe Benefits:** List the components that comprise the fringe
> benefit rate, for example health insurance, taxes, unemployment
> insurance, life insurance, retirement plan, tuition reimbursement. The
> fringe benefits should be directly proportional to that portion of
> personnel costs that are allocated for the project.
>
> **Travel:** List travel costs according to local and long distance
> travel. For local travel, the mileage rate, number of miles, reason
> for travel and staff member/consumers completing the travel should be
> outlined. The budget should also reflect the travel expenses
> associated with participating in meetings and other proposed trainings
> or workshops, including expenses for 1-2 individuals to travel to
> Washington, D.C. to meet with program officials.
>
> **Equipment:** List equipment costs and provide justification for the
> need of the equipment to carry out the program's goals. Extensive
> justification and a detailed status of current equipment must be
> provided when requesting funds for the purchase of computers and
> furniture items.
>
> **Supplies:** List the items that the project will use. In this
> category, separate office supplies from medical and educational
> purchases. Office supplies could include paper, pencils, and the like;
> medical supplies are syringes, blood tubes, plastic gloves, etc., and
> educational supplies may be pamphlets and educational videotapes.
> Remember, they must be listed separately.

[]{.mark}

> **Subcontracts:** To the extent possible, all subcontract budgets and
> justifications should be standardized, and contract budgets should be
> presented by using the same object class categories contained in the
> Standard Form 424A. Provide a clear explanation as to the purpose of
> each contract, how the costs were estimated, and the specific contract
> deliverables.
>
> **Other:** Put all costs that do not fit into any other category into
> this category and provide an explanation of each cost in this
> category. This category might also include costs associated with
> supporting family partnerships, complying with the Americans with
> Disabilities Act (ADA), and providing culturally competent services.
> In some cases, grantee rent, utilities and insurance fall under this
> category if they are not included in an approved indirect cost rate.

vi. []{#__RefHeading___Toc47265123 .anchor}***Staffing Plan and
    Personnel Requirements***

    Applicants must present a staffing plan and provide a justification
    for the plan that includes education and experience qualifications
    and rationale for the amount of time being requested for each staff
    position. Position descriptions that include the roles,
    responsibilities, and qualifications of proposed project staff must
    be included in Appendix B Copies of biographical sketches for any
    key employed personnel that will be assigned to work on the proposed
    project must be included in Appendix C.

vii. []{#__RefHeading___Toc47265124 .anchor}***Assurances***

Use Application Form 5161-1 provided with the application package.

viii. []{#__RefHeading___Toc47265125 .anchor}***Certifications***

> Use Application Form 5161-1 provided with the application package.

ix. []{#__RefHeading___Toc47265126 .anchor}***Project Abstract***

> Provide a summary of the application. Because the abstract is often
> distributed to provide information to the public and Congress, please
> prepare this so that it is clear, accurate, concise, and without
> reference to other parts of the application. It must include a brief
> description of the proposed grant project including the needs to be
> addressed, the proposed services, and the population group(s) to be
> served. [The project abstract must be single-spaced and limited to one
> page in length]{.underline}.

Please place the following at the top of the abstract:

-   Project Title

-   Applicant Name

-   Address

-   Contact Phone Numbers (Voice, Fax)

-   E-Mail Address

-   Web Site Address, if applicable

> In addition to completing the abstract as a standalone document that
> is attached in the online application, the abstract must also be
> entered on Form 6 in the Program Specific Information section. To do
> this, copy from the application abstract and paste the text in the
> appropriate data fields on Form 6. Information is extracted from each
> of these documents for differing purposes, including HRSA publications
> and Web reports.

x.  []{#__RefHeading___Toc47265128 .anchor}***Program Narrative***

> This section provides a comprehensive framework and description of all
> aspects of the proposed program. It should be succinct,
> self-explanatory and well organized so that reviewers can understand
> the proposed project.

Use the following section headers for the Narrative:

-   **Introduction**

> This section should briefly describe the purpose of the proposed
> project. The applicant should clearly describe the problem, the
> proposed interventions, and the anticipated benefit of the project.

[]{.mark}

-   **NEEDS ASSESSMENT**

> This section outlines the specific needs, and strengths, upon which
> your application is based (national, state, community) relative to the
> six core components of a system of services for children and youth
> with special health care needs. The target population and its unmet
> health needs must be described and documented in this section.
> Relevant data from the National Survey of Children with Special Health
> Care Needs, Title V CSHCN Block Grant activities, (including the most
> recent Title V Block Grant Needs Assessment), performance measures;
> and discretionary grant activities should be described. If not already
> completed, needs assessments must be completed within the first 6
> months of the project. Discuss relevant barriers in the state(s) that
> the project hopes to overcome. Demographic data that includes ethnic,
> cultural, racial, socioeconomic and geographic factors and disparities
> should be used and cited whenever possible to support the information
> provided. This section should help reviewers understand the state(s),
> communities, and/or organization(s) that will be served by the
> proposed project.

[]{.mark}

-   **Methodology**

> Propose methods that will be used to meet each of the
> previously-described program requirements and expectations in this
> grant announcement. Clearly describe the goals and objectives using an
> approach that is specific, time-oriented, measurable, and responsive
> to the identified challenges facing the proposed project. Describe the
> activities used to achieve each goal and objective, including the
> specific expected outcomes and how they will be measured. Identify all
> partners, including the State Title V Children with Special Health
> Care Needs Program and provide evidence of substantive involvement in
> the project planning, implementation, and evaluation, as well as
> commitment to sustaining the program after project completion. Include
> strategies that reflect integration of family-centered care,
> family/professional partnerships, and cultural competence.

-   **Work Plan**

> Describe the activities or steps that will be used to achieve each of
> the activities proposed in the methodology section. Use a time line
> that includes each activity and identifies responsible staff.
>
> []{.mark}

-   **Resolution of Challenges**

> Discuss challenges that are likely to be encountered in designing and
> implementing the activities described in the Work Plan, and approaches
> that will be used to resolve such challenges.
>
> []{.mark}

-   **Evaluation and Technical Support Capacity**

> Describe current experience, skills, and knowledge, including
> individuals on staff, materials published, and previous work of a
> similar nature. Demonstrate evidence of organizational experience and
> capability to coordinate and support planning, implementation, and
> evaluation of a comprehensive plan to meet the objectives of this
> initiative. Describe an evaluation plan that will: (1) measure the
> impact of strategies used and of the project objectives/activities;
> and (2) monitor the efficiency of the proposed project activities,
> including family-centered care. Project level evaluation methodology
> should be specific and related to the stated goals, objectives, and
> priorities of the project. Applications lacking a complete and
> well-conceived evaluation protocol may not be funded.

-   **Organizational Information**

> Provide information on the applicant agency's current mission and
> structure, scope of current activities, and an organizational chart,
> and describe how these all contribute to the ability of the
> organization to conduct the program requirements and meet program
> expectations. Describe the organization's proven leadership role in
> activities undertaken related to the priority area, proposed
> activities and review criteria. Include a description of the available
> resources (staff, funds, related projects, in-kind contributions) to
> carry out the project.

xi. []{#__RefHeading___Toc47265129 .anchor}***Program Specific Forms, if
    applicable.***

xii. []{#__RefHeading___Toc47265130 .anchor}***Appendices***

> Please provide the following items to complete the content of the
> application. Please note that these are supplementary in nature, and
> are not intended to be a continuation of the project narrative. Be
> sure each appendix is clearly labeled.

1)  Appendix A: Tables, Charts, etc.

> To give further details about the proposal.

2)  Appendix B: Job Descriptions for Key Personnel

> Keep each to one page in length as much as is possible. Item 6 in the
> Program Narrative section of the PHS 5161-1 Form provides some
> guidance on items to include in a job description.

3)  Appendix C: Biographical Sketches of Key Personnel

> Include biographical sketches for persons occupying the key positions
> described in Appendix B, not to exceed two pages in length. In the
> event that a biographical sketch is included for an identified
> individual who is not yet hired, please include a letter of commitment
> from that person with the biographical sketch.

4)  Appendix D: Letters of Agreement and/or Description(s) of
    Proposed/Existing Contracts (project specific) Provide any documents
    that describe working relationships between the applicant agency and
    other agencies and programs cited in the proposal. Documents that
    confirm actual or pending contractual agreements should clearly
    describe the roles of the subcontractors and any deliverable.
    Letters of agreements must be dated.

5)  Appendix E: Project Organizational Chart

> Provide a one-page figure that depicts the organizational structure of
> the project, including subcontractors and other significant
> collaborators.

6)  Appendix F: Other Relevant Documents

> Include here any other documents that are relevant to the application,
> including letters of support. Letters of support must be dated.
> **Include only letters of support which specifically indicate a
> commitment to the project/program (in-kind services, dollars, staff,
> space, equipment, etc.) Letters of agreements and support must be
> dated. List all other support letters on one page.**

[]{#__RefHeading___Toc47265131 .anchor}**3. Submission Dates and Times**

**Notification of Intent to Apply**

> In order to plan more effectively for the objective review process,
> this announcement requests that potential applicants submit a Letter
> of Intent. An applicant is eligible to apply even if no letter of
> intent is submitted. Receipt of Letters of Intent will NOT be
> acknowledged. The letter should identify the applicant organization
> and its intent to apply, and briefly describe the proposal to be
> submitted. This letter should be sent by September 9, 2005 or by mail
> or fax to:

Division of Independent Review

Director

HRSA Grants Application Center (GAC)

The Legin Group, Inc.

901 Russell Ave., Suite 450

Gaithersburg, MD 20879

*Fax: 877/477-2345*

> Program Contacts will respond to questions and provide technical
> assistance to prospective applicants via conference call on: September
> 27 from 1:30 -3:00 PM ET. More information regarding accessing the
> conference call can be obtained by contacting Beverly Jones, staff
> assistant at 301-443-2370 or <Bjones2@hrsa.gov>.

**Application Due Date**

The due date for all applications under this grant announcement is
November 2, 2005 at 5:00 P.M. ET.

Applications will be considered as meeting the deadline if they are
either:

\(1\) Received on or before the due date; or

> \(2\) Post marked or E marked on or before the due date, and received
> in time for the Independent Review Committee review.
>
> The Chief Grants Management Officer (CGMO) or a higher level designee
> may authorize an extension of published deadlines when justified by
> circumstances such as acts of God (e.g. floods or hurricanes),
> widespread disruptions of mail service, or other disruptions of
> services, such as a prolonged blackout. The authorizing official will
> determine the affected geographical area(s).
>
> **Electronic Submission:**
>
> Applications must be submitted by 5:00 P.M. ET. To ensure that you
> have adequate time to follow procedures and successfully submit the
> application, we recommend you start submission no later than noon on
> the due date. Applications submitted electronically will be time/date
> stamped electronically, which will serve as receipt of submission.
>
> **Paper Submission:**
>
> Upon receipt of a paper application, the Grants Application Center
> will mail an acknowledgement of receipt to the applicant
> organization's Program Director.
>
> In the event that questions arise about meeting the application due
> date, applicants must have a legibly dated receipt from a commercial
> carrier or the U.S. Postal Service. Private metered postmarks will not
> be accepted as proof of timely mailing.

**Late applications:**

> Applications which do not meet the criteria above are considered late
> applications. Health Resources and Services Administration (HRSA)
> shall notify each late applicant that its application will not be
> considered in the current competition.
>
> []{#__RefHeading___Toc47265137 .anchor}**4. Intergovernmental Review**
>
> This program is not subject to the provisions of Executive Order
> 12372, as implemented by 45 CFR 100.

[]{#__RefHeading___Toc47265139 .anchor}**5. Funding Restrictions**

Applicants responding to this announcement may request funding for a
project period of up to 4 years, up to \$400,000 per year for Initiative
#1 and Initiative #2; and up to \$100,000 per year for Initiative #3.
For Initiative #4, applicants may request funding for a project period
of up to 3 years for up to \$300,000. Awards to support projects beyond
the first budget year will be contingent upon Congressional
appropriation, satisfactory progress in meeting the project's
objectives, and a determination that continued funding would be in the
best interest of the government.

> Under current OMB regulations, funds under this announcement may not
> be used for the following purposes:

-   Supplantation: Funds may only be used to supplement, and NOT to
    supplant other Federal or non-Federal funds that would otherwise be
    made available to the project.

-   Shared Staffing: Applicants proposing to utilize the same director
    or contractual staff across multiple grants should assure that the
    combined funding for each position does not exceed 100% FTE. If such
    an irregularity is found, funding will be reduced accordingly.

-   Shared Equipment: Applicant proposing to purchase equipment which
    will be used across multiple grants/programs should pro-rate the
    costs of the equipment across programs and show the calculation for
    this pro-ration in their justification. If an irregularity is found
    where program equipment is being used by other programs without
    reimbursement, funding will be reduced accordingly.

-   Cash Stipends/Incentives: Funds cannot be utilized for cash
    stipends/monetary incentives given to clients to enroll in project
    services. However, funds can be used to facilitate participation in
    project activities (e.g. transportation costs/tokens), as well as
    for services rendered to the project.

-   Purchase of Vehicles: Projects should not allocate funds to buy
    vehicles for the transportation of clients, but rather lease
    vehicles or contract for these services.

-   No Lobbying: Funds cannot be used to lobby the Executive or
    Legislative branches of the Federal government in connection with
    this initiative. All applicants should review and sign page 19 of
    PHS 5161-1 (Rev.7/00) certifying that project funds are not being
    used for lobbying activities. Pursuant to Section 1352 of Title 31,
    United States Code, all grantees must now disclose any lobbying
    undertaken with non-Federal (non-appropriated funds). If non-Federal
    funds are being used for lobbying activities, grantees must disclose
    this information by completing Standard Form LLL "Disclosure of
    Lobbying Activities," page 27 of PHS 5161-1 (Rev.7/00).

    []{#__RefHeading___Toc47265140 .anchor}**6. Other Submission
    Requirements**

> **Electronic Submission**
>
> You may submit your application to us either in electronic or paper
> format. To submit an application electronically, please use the
> [http://www.Grants.gov](http://www.Grants.gov/) apply site. If you use
> Grants.Gov you will be able to download a copy of the application
> package, complete it off-line, and then upload and submit the
> application via the Grants.gov site. You may not e-mail an electronic
> copy of a grant application to us.
>
> Please note the following if you plan to submit your application
> electronically via Grants.Gov:
>
> • Electronic submission is voluntary
>
> • When you enter the Grants.Gov site, you will find information about
> submitting an application electronically through the site, as well as
> the hours of operation. We strongly recommend that you do not wait
> until the application deadline date to begin the application process
> through Grants.Gov. The registration process is a separate process
> from submitting an application. **Applicants are, therefore,
> encouraged to register early**. The registration process can take
> approximately two weeks to be completed. Therefore, registration
> should be done in sufficient time to ensure it does not impact your
> ability to meet required submission deadlines. You will be able to
> submit your application online anytime after you receive your
> e-authentication credentials.
>
> • To use Grants.gov, you, as the applicant, must have a DUNS Number
> and register in the Central Contractor Registry (CCR). You should
> allow a minimum of five days to complete the CCR registration.
>
> • You will not receive additional point value because you submit a
> grant application in paper format, nor will we penalize you if you
> submit an application in paper format.
>
> • You may submit all documents electronically, including all
> information typically included on the SF424 and all necessary
> assurances and certifications.
>
> • Your application must comply with any page limitation requirements
> described in this program announcement.
>
> • After you electronically submit your application, you will receive
> an automatic acknowledgement from Grants.Gov that contains a
> Grants.Gov tracking number. The Health Resources and Services
> Administration will retrieve your application from Grants. Gov.
>
> • You may access the electronic application for this program on
> [http://www.Grants.gov](http://www.Grants.gov/).
>
> • You must search for the downloadable application package by the CFDA
> number.
>
> • The grants.gov website provides customer support via (800)
> 518-GRANTS (this is a toll-free number) or through e-mail at
> [**support@grants.gov**](mailto:support@grants.gov). The customer
> support center is open from 7:00 a.m. to 9:00 p.m. Eastern time,
> Monday through Friday, except federal holidays, to address grants.gov
> technology issues. For technical assistance to program related
> questions, contact the number listed in the Program Section of the
> program you are applying for.
>
> Online applications are required to submit ONLY one form in signed
> hard copy: the SF-424/5161 Face Sheet, since all other elements of the
> application have been captured and transmitted electronically. 
>
> **Formal submission of the electronic application:** Applications
> completed online are considered formally submitted when the
> Authorizing Official electronically submits the application to HRSA.
> However, to complete the submission requirements, a hard-copy of the
> SF-424/ SF-5161/SF-6025 Face Sheet must be printed, signed, and
> submitted to the HRSA Grants Application Center. The SF-5161 Face
> Sheet can be printed from the online application.
>
> For an online application, the signed SF-5161 must be sent to the HRSA
> GRANTS APPLICATION CENTER at the below address, and received by HRSA
> by no later than five days after the November 2, 2005 due date:
>
> Grants Management Officer, CFDA# 93.110
>
> Government & Special Focus Branch
>
> Division of Grants Management Operations
>
> Attn: *(Refer to the first page of this Guidance for the Initiative
> Number, Initiative*
>
> *Name and the Announcement Number (Ex. HRSA-06-XXX)*
>
> HRSA Grants Application Center

901 Russell Avenue

Suite 450

Gaithersburg, MD 20879

> Telephone: 1-877-477-2123

[]{.mark}

> Applications will be considered as having met the deadline if: (1) the
> application has been submitted electronically by your organization's
> Authorizing Official to grants.gov on or before the deadline date and
> time, and (2) the signed SF-5161 Face Sheet is received by HRSA no
> later than five days after the deadline date.
>
> **REMINDER:** Only applicants who apply online are permitted to forego
> hard-copy submission of all application forms EXCEPT the signed
> SF-5161 Face Sheet.
>
> If the application is submitted as a hard-copy, the rules of
> submission as described elsewhere in this guidance must be followed.

**Paper Submission**

> If you choose to submit paper copy, please send the original and 2
> copies of the application to:
>
> The HRSA Grants Application Center
>
> The Legin Group, Inc.
>
> Attn: Integrated Services for Children with Special Health Care Needs:
> The President's New Freedom Initiative
>
> Program Announcement No. (Use the Announcement \# for the Initiative
> for which you are applying)
>
> CFDA No. 93.110
>
> 901 Russell Avenue, Suite 450
>
> Gaithersburg, MD 20879
>
> Telephone: 877-477-2123
>
> In the event that questions arise about meeting the application due
> date, applicants must have a legibly dated receipt from a commercial
> carrier or the U.S. Postal Service. Private metered postmarks will not
> be accepted as proof of timely mailing.
>
> Whether you submit electronically or via paper, please understand that
> we will not consider additional information and/or materials submitted
> after your initial application. You must therefore ensure that all
> materials are submitted together, whether electronically or on paper.

[]{#__RefHeading___Toc47265142 .anchor}

**V. Application Review Information**

**1.** []{#__RefHeading___Toc47265143 .anchor}**Review Criteria**

> Procedures for assessing the technical merit of grant applications
> have been instituted to provide for an objective review of
> applications and to assist the applicant in understanding the
> standards against which each application will be judged. Critical
> indicators have been developed for each review criterion to assist the
> applicant in presenting pertinent information related to that
> criterion and to provide the reviewer with a standard for evaluation.
> Review criteria are outlined below with specific detail and scoring
> points.
>
> Review Criteria are used to review and rank applications. All
> initiatives under the Integrated Services for Children with Special
> Health Care Needs: President's New Freedom Initiative have 6 generic
> review criteria. These 6 generic criteria are further delineated for
> each Initiative below. Applicants should pay strict attention to
> addressing these criteria, as they are the basis upon which the
> reviewers will evaluate the application.
>
> **CRITERION 1: [NEED]{.underline} (15 points)** **- Refer to Narrative
> Sections, "Introduction" and "Needs Assessment"**
>
> **All Initiatives**: The extent to which the application describes the
> problem and associated contributing factors to the problem. The needs
> assessment process should include: families, members of the targeted
> community or population group and other key stakeholders, including
> diverse ethnic, cultural, racial and linguistic groups; natural,
> informal, support and helping networks within communities;
> neighborhood, civic and advocacy associations and, ethnic, social,
> religious and faith-based organizations. Other factors to be
> considered should be social, political and economic factors impacting
> the population, the impact of health disparities on the target
> population or community and urban, suburban, rural or frontier
> settings. In addition:

**Initiative \# 1:**

The extent to which the application:

-   Reflects a clear understanding of the concept of transition to
    adulthood for YSHCN, with supporting evidence that clearly
    illustrates the magnitude of the problem,

-   Identifies any previous or existing activities related to transition
    to adulthood for YSHCN and the impact of those activities,

-   Describes the anticipated improvements to the health of YSHCN as a
    result of the project,

-   Discusses relevant unmet needs, barriers, and special problems to be
    overcome. Relevant data from the National Survey of Children with
    Special Health Care Needs, Title V CSHCN Block Grant
    activities/needs assessments, performance measures and/or
    discretionary grant activities and needs assessments should be
    described. Demographic data should be used and cited whenever
    possible to support the information provided, and

-   Identifies existing resources that will be utilized to implement the
    proposed project.

**Initiative \# 2:**

> The extent to which the application:

-   Reflects the rationale and summary of existing evidence for the
    DSCSHN core component that services provided at the community level
    to be inclusive of CYSHCN and easy to use by families; and, how it
    relates to the other five core outcomes,

-   Provides an analysis of national and state data that helps
    describe (1) issues faced by CYSHCN and their families in accessing
    and paying for integrated services at the community level; (2)issues
    and status of Title V CYSHCN programs, partners and communities in
    efforts to assure an integrated service system at the community
    level; (3) any unmet needs; and (4) challenges and barriers,

-   The role of and need for a wide range of private/public partnerships
    and stakeholders, in assuring inclusive and integrated and easy to
    use services for children with special health care needs, and

-   The status of other major national public and private community
    development initiatives in terms of inclusion of CYSHCN**.**

**Initiative \# 3:**

> The extent to which the application:

-   Reflects the rationale for the DSCSHN core component that, "families
    of children with special health care needs will partner in decision
    making at all levels and will be satisfied with the services they
    receive; and, how it relates to the other five core outcomes, and

-   Provides an analysis of national (if possible), state and local data
    that helps describe (1) the issues faced by CYSHCN and their
    families in having the necessary information needed to partner in
    decision making and be satisfied with services; (2) any unmet
    needs; (3) challenges and barriers; and (4) the status of Title V
    CSHCN programs, partners and communities in efforts to address this
    core outcome.

**Initiative \# 4**

> The extent to which the application:

-   Reflects the state's current status in each of the 6 systems
    components (based upon a complete statewide needs assessment and
    state specific data from the results of the National Survey for
    CSHCN),

-   Clearly describes the strengths, areas of growth, opportunities and
    challenges in implementing the six core components, and

-   Links the results of analyzed data to a plan of action to achieve
    community-based systems of services, incorporating each of the six
    components of a system, and provides a rationale for two or more
    areas of emphasis.

> **CRITERION 2: [RESPONSE]{.underline}** **(30 points**) **Refer to
> Narrative Sections, "Methodology", "Work Plan" and "Resolution of
> Challenges"**
>
> **All Initiatives:** The extent to which the proposed project responds
> to the "Purpose" included in the program description, the clarity of
> the proposed goals and objectives and their relationship to the
> identified project. The extent to which the activities (scientific or
> other) described in the application are capable of addressing the
> problem and attaining the project objectives. The extent to which
> policies and practices of family-centered care, meaningful
> family/professional partnerships and cultural and linguistic
> competence are integrated throughout project activities. In addition:

**Initiative \# 1**:

The extent to which the application:

-   Describes how it will assist States to increase the percentage of
    youth with special health needs (YSHN) making transitions to adult
    health care, work, and independence,

-   Addresses the development of a comprehensive system of care for
    youth with special health care needs that includes, but is not
    limited to: long-term health and disability management; access to
    independent living and personal assistance services (when not paid
    by Medicaid); pre-vocational counseling and training; youth as self
    advocates; preparation for families for a changing role as YSHN
    transition; and capacity building and training of the health care
    system, both pediatric and adult, to transfer and receive
    transitioning YSHN,

-   Reflects a clear understanding of the "Consensus Statement on Health
    Care Transitions for Young Adults with Special Health Care Needs" by
    the American Academy of Pediatrics, American Academy of Family
    Physicians, and American College of Physicians-American Society of
    Internal Medicine ([Pediatrics]{.underline}, Vol. 110, No. 6,
    December 2002, pp. 1304-1306) and describes how it will attempt to
    integrate it into State health policy,

-   Describes how it will attempt to increase the number of State CYSHCN
    programs that have a youth advisory council in place to provide
    input on transition issues, and

-   Describes how it will resolve any challenges that it might encounter
    while implementing the proposed activities.

> **Initiative #2**
>
> The extent to which the application:

-   Identifies and works with major national public and private
    community development initiatives to integrate CYSHCN into their
    activities,

-   Identifies inclusive community development initiatives that have
    partnerships with families, community leaders and programs and
    facilitate linkages between these communities, State Title V
    Programs and other public and private constituents,

-   Facilitates technical assistance to communities that enhances their
    partnership development, planning, implementation, monitoring and
    measurement of activities to develop inclusive, integrated systems
    of services,

-   Assists state Title V programs and partners to identify strategies
    in which they can assist with and enhance community-based service
    integration activities that are actually reflected at the community
    and family levels and to take these activities state-wide,

-   Facilitates the involvement of other major national public and
    private community development activities,

####### Presents and discusses the challenges likely to be encountered in designing and implementing the activities, as well as approaches that would be used to address such challenges, and

-   Implements the criteria for a National Center as described in the
    "Purpose" section of this guidance.

> **[Initiative \# 3]{.underline}**

The extent to which the application reflects plans to:

-   Develop effective collaborative partnerships with advocates,
    community based organizations, Title V CSHCN programs, etc. in order
    to provide health care information and education to families of
    children with special health care needs, and their providers, to
    assist them in accessing information and services related to the six
    core outcomes,

-   Develop effective tools and strategies for ongoing partnerships,
    communication, information sharing and mentoring opportunities to
    all families, with necessary efforts to include families of
    culturally, linguistically, socio-economically and geographically
    diverse backgrounds,

-   Develop effective collaborative partnerships with advocates,
    community based organizations, Title V CSHCN programs, etc. to
    provide current, accurate and culturally and linguistically
    appropriate information and education to families that also accounts
    for their health literacy levels,

-   Develop effective collaborative partnerships with families,
    advocates, community based organizations, Title V CSHCN programs,
    etc. in order to educate local and state providers and policy makers
    on the needs of CYSHCN,

-   Provide data on information disseminated and impact data on families
    and systems, with an emphasis on data related to the six core
    outcome measures in partnership with the State Title V CSHCN
    program,

-   Document the processes that will be used to implement efforts
    state-wide and sustain promising practices post grant funding with
    in-kind and actual funding from partner agencies/ programs, and

-   Participate in technical assistance and training opportunities
    offered by the Family Voices Cooperative Agreement and Centers for
    Medicare and Medicaid F2F Centers.

**Initiative \# 4:**

The extent to which the application:

-   Demonstrates a clear understanding of the inter-dependence of the
    six systems components in achieving a statewide system of services,
    and how the two or more selected areas of emphasis inter-relate with
    achieving all six components of a system,

```{=html}
<!-- -->
```
-   Reflects an implementation plan that engages multiple public and
    private agencies and families in the design and implementation of
    the plan,

-   Develops and maintains partnerships with families and youth with
    special health care needs that enhance collaborative decision
    making,

-   Reflects a strategy for systematic state-wide implementation of the
    plan, incorporating each of the core systems components,

-   Integrates grant activities into the Title V Block Grant where they
    can be tracked and sustained over a period of time, and

-   Addresses criteria specific to the systems components addressed in
    the application as follow:

> [Family/Professional Partnerships:]{.underline} The extent to which
> activities:

-   Implement, practice and promote the principles of family-centered
    care, family/professional partnerships, and culturally-competent
    care,

-   Ensure that partnerships between families and professionals are a
    key element of the medical home,

-   Support family/professional collaboration in efforts to improve
    systems of services at the state and community levels,

-   Support the participation of traditionally under-represented
    families in all decision making, educational and technical
    assistance activities, and

-   Develop and promote measures for determining family satisfaction.

> [Medical Home]{.underline}. The extent to which activities:

-   Reflect a clear understanding of the medical home concept as
    outlined in the 2002 American Academy of Pediatrics Medical Home
    Policy Statement (Pediatrics,2002),

-   Reflect a well-defined strategy to incorporate Continuous Quality
    Improvement(CQI) activities with primary care practices, Title V and
    families around medical home in the state, and

-   Provide well defined coordination strategies that link medical homes
    to other community-based services and other health related needs
    (e.g. education, specialty care, early intervention, etc.).

> [Health Insurance]{.underline}: The extent to which activities focus
> on at least one of the following:

-   Decrease the number of CYSHCN who are uninsured or do not

> have continuous health insurance,

-   Increase the number of CYSHCN who have adequate health insurance
    that meets their needs and/or,

```{=html}
<!-- -->
```
-   Improve the financing and reimbursement of services and benefits
    needed by CYSHCN.

> [Early and Continuous Screening:]{.underline} The extent to which
> activities:

-   Improves access to, and availability of screening services,

-   Improves access to, and availability of intervention services in a
    timely and coordinated manner,

-   Monitors, tracks and periodically screens identified children,

-   Supports data capacity for integrating screening results across
    relevant programs, and

-   Links screening to medical homes, family to family support and
    intervention.

> [Easy to Use Community Systems:]{.underline} The extent to which
> activities:

-   Reflect partnership with communities and other state agencies to
    implement coordinated enrollment and/or eligibility criteria,
    coordinated financing of services, shared data and information
    systems, and/or coordination of services with the medical home,

-   Assist and build the capacities of key community stakeholders to
    develop integrated service systems inclusive of CYSHCN that are
    family-centered and culturally competent, and

-   Promote family/professional partnerships and community
    planning/governance and leadership as strategies in systems
    building.

> [Healthy and Ready to Work]{.underline}: The extent to which
> activities:

-   Reflect a clear understanding of the Consensus Statement on Health
    Care Transitions for Young Adults With Special Health Care Needs\",
    (Pediatrics, November 2002),

-   Prepare youth and adolescents; families; medical home/pediatric and
    adult healthcare providers; and service systems for the
    transitioning of CYSHN from pediatric to adult health care and
    related services, employment and independence,

-   Address the development of a comprehensive system of care for youth
    with special health care needs that includes, but is not limited to:
    long-term health and disability management; access to independent
    living and personal assistance services (when not paid by Medicaid);
    pre-vocational counseling and training; youth as self advocates;
    preparation for families for a changing role as CSHN transition; and
    capacity building and training of the health care system, both
    pediatric and adult, to transfer and receive transitioning CYSHN,
    and

-   Include documentation of a compensated, diverse Youth Advisory
    Committee (YAC) which actively participates in all aspects of
    project planning, implementation, and evaluation giving the YAC
    members the opportunity to act as self advocates and future
    leaders.[]{#__RefHeading___Toc47265144 .anchor}

> **CRITERION 3: [EVALUATIVE MEASURES]{.underline} (20 points) -- Refer
> to Narrative Sections, "Methodology" and "Evaluation and Technical
> Assistance Support Capacity"**
>
> **All Initiatives:** The effectiveness of the method proposed to
> monitor and evaluate the project results. Evaluative measures must be
> able to assess: (1) to what extent the program objectives have been
> met, and (2) to what extent these can be attributed to the project.
> The application must reflect a plan of action to track and provide
> program data that incorporates a carefully designed and well-planned
> evaluation protocol capable of demonstrating and documenting
> measurable progress toward achieving the project's stated goal and a
> comprehensive evaluation plan using national, state, and local data,
> and Title V Block grant performance measures are described. In
> addition:
>
> **Initiative #2:** The extent to which the application:

-   Reflects data collection activities that indicate the degree to
    which communities and State Title V CSHCN programs involved with the
    project have progressed in the "systems" outcome of community based
    systems of services that are inclusive of CYSHCN, integrated and
    easy to use.

> **Initiative \# 3**: The extent to which the application:

-   Describes how internal management mechanisms enable the applicant to
    provide baseline data, and annually reporting of data using the
    Family Voices Solutions database system. Such data would include,
    but not be limited to the numbers (totals)of families and
    professionals served, information;
    meetings/presentations/conferences and topics presented; the number
    of issues reported by families reflecting 6 core outcomes, etc.,

-   Describes any systems changes/enhancements made as a result of the
    above mentioned data and project activities that indicate progress
    is being made in the core outcome," Families of children with
    special health care needs will partner in decision making at all
    levels and will be satisfied with the services they receive," and

-   Reflects any outcomes for families and CYSHCN because of project
    activities.

> Initiative \# 4: The extent to which the application:

-   Demonstrates an ability to and provides assurances that data and
    evaluation will be developed in collaboration with, and shared with
    State Title V Program for Children with Special Health Care Needs

 

> **CRITERION 4: [IMPACT]{.underline} (15 points) -- Refer to Narrative
> Sections, "Work Plan", Methodology" and "Evaluation and Technical
> Support Capacity"**
>
> **For All Initiatives:** The extent and effectiveness of plans for
> dissemination of project results and/or the extent to which project
> results may be national in scope and/or degree to which the project
> activities are replicable, and/or the sustainability of the program
> beyond the Federal Funding. In addition:
>
> **Initiative \# 1**: The extent to which the application:

-   Utilizes innovative strategies for dissemination and sustained use
    of data at the national, state, and community level including
    ongoing coordination with MCHB supported national centers to
    disseminate results; collaboration with other public and private
    entities; and publication of evidence-base in professional journals,
    and

-   Presents a well-designed, creative and coherent plan that describes
    how project results will be effectively disseminated to key
    stakeholders audiences, including families, providers, health plans,
    federal and state legislators, employers and policy makers.

**Initiative \# 2**: The extent to which the application:

-   Utilizes innovative strategies for dissemination and sustained use
    of data at the national, state, and community levels including
    ongoing coordination with MCHB supported national centers to
    disseminate results,

-   Reflects meaningful support and collaboration with key stakeholders,
    including families, national public and private community
    development initiatives and other entities,

-   Describes strategies for publication and dissemination of
    evidence-base and best practices materials, and

-   Plans for working with States to ensure that successful
    community/state activities will be included and sustained in Title V
    CSHCN Block grant and other state and local activities, where they
    can be tracked over a period of time.

> **Initiative \# 3:** The extent to which the application:

-   Utilizes innovative strategies for disseminating and sustaining use
    of data at the national, state, and community levels including:

    -   Materials developed and data analyzed in conjunction with
        "Family Stories" that are disseminated by Family Voices, other
        MCHB National Centers, Title V partners and advocates and media
        coverage, and

    -   Plans for working with the State to ensure that successful
        community/state activities will be included and sustained in
        Title V CSHCN Block grant and other state and local activities,
        where they can be tracked over a period of time.

**Initiative \# 4:** The extent to which the application:

-   Describes a specific process and mechanism for how progress will be
    sustained and maintained through the Title V CSHCN Block grant and
    other state and local activities after the project ends.

> **CRITERION 5: [RESOURCES/CAPABILITIES]{.underline} (10 points) --
> Refer to Narrative Sections, "Evaluation and Technical Support
> Capacity" and "Organizational Information"**
>
> **For All Initiatives:** The extent to which project personnel are
> qualified by training and/or experience to implement and carry out the
> projects. The capabilities of the applicant organization, and quality
> and availability of facilities and personnel to fulfill the needs and
> requirements of the proposed project. The applicant should also
> describe experience in family-centered care, family/professional
> partnerships (working closely with families, family led
> organizations/networks) and in integrating cultural and linguistic
> competence principles and practices. In addition:

**Initiative \# 1**:

> The extent to which the application:

-   Describes the administrative structure within which the project will
    function, including partnerships with other community, State,
    regional or national entities, institutions or agencies relevant to
    the program. Charts outlining these relationships may be included.
    Copies of any formal agreements defining these relationships should
    be included in the Appendices,

-   Describes its current mission and structure, scope of current
    activities, and an organizational chart, and describe how these will
    all contribute to the ability of the applicant to meet program
    expectations, and

-   Reflects documented success in working collaboratively across
    public/private agencies and programs to address issues related to
    establishing the evidence base for community-based systems of
    services for CYSHCN and the six performance measures targeted for
    this project.

**Initiative \# 2**: The extent to which the application:

-   Reflects documented success in working collaboratively with states,
    and communities; across public/private agencies and programs; and
    with national public and private community development initiatives
    to address issues related national to establishing the evidence base
    for community-based systems of services for CYSHCN targeted for this
    project.

**Initiative \# 3**: The extent to which the application:

-   Reflects documented success in working collaboratively with
    families, advocates, state and community programs and agencies,
    including Title V, and

-   Describes the infrastructure necessary to achieve the purpose of
    this initiative.

**Initiative \# 4:** The extent to which the application:

-   Demonstrates close working relationships with the State Title V
    Program for Children with Special Health Care Needs,

-   Describes experience in working across state and local level
    agencies, organizations and families on implementing the core
    components of a system of care, and

-   Describes experience working with other stakeholders, including
    employers, providers, health insurance companies, and other
    community agencies.

> **CRITERION 6: [SUPPORT REQUESTED]{.underline} (10 points) -- Refer to
> "Budget" sections**
>
> **For All Initiatives:** The reasonableness of the proposed budget in
> relation to the objectives, the complexity of the activities, and the
> anticipated results. For all initiatives, funding should be included
> to support family partnership (stipends, salaries), ADA requirements
> if needed, sign language interpreters, and cultural and linguistic
> competence modifications such as interpretation services, cultural
> brokers, and modifications due to health literacy levels. All in-kind
> and additional funding should be reported. In addition:

**Initiative \# 4:** The extent to which the application:

-   Describes and itemizes at least twenty-five percent of the
    anticipated annual grant award that will be from direct (blending of
    other funding, e.g., state or foundation funding) or in-kind
    contributions (e.g., personnel time, rental space, etc) from
    non-grant sources.

> **2. Review and Selection Process**
>
> The Division of Independent Review is responsible for managing
> objective reviews within HRSA. Applications competing for federal
> funds receive an objective and independent review performed by a
> committee of experts qualified by training and experience in
> particular fields or disciplines related to the program being
> reviewed. In selecting review committee members, other factors in
> addition to training and experience may be considered to improve the
> balance of the committee, e.g., geographic distribution,
> race/ethnicity, and gender. Each reviewer is screened to avoid
> conflicts of interest and is responsible for providing an objective,
> unbiased evaluation based on the review criteria noted above. The
> committee provides expert advice on the merits of each application to
> program officials responsible for final selections for award.

[]{.mark}

[]{#__RefHeading___Toc47265150 .anchor}**3. Anticipated Announcement and
Award Dates**

Funding decisions for FY 2006 are expected to be announced on or about
April 1, 2006.

[]{#__RefHeading___Toc47265153 .anchor}**VI. Award Administration
Information**

[]{#__RefHeading___Toc47265154 .anchor}**1. Award Notices**

> Each applicant will receive written notification of the outcome of the
> objective review process, including a summary of the expert
> committee's assessment of the application's merits and weaknesses, and
> whether the application was selected for funding. Applicants who are
> selected for funding may be required to respond in a satisfactory
> manner to Conditions placed on their application before funding can
> proceed. Letters of notification do not provide authorization to begin
> performance. The Notice of Grant Award, which is signed by the Grants
> Management Officer and is sent to the applicant agency's Authorized
> Representative, is the authorizing document. It will be sent prior to
> the start date of May 1, 2006.[]{#__RefHeading___Toc47265156 .anchor}
>
> **Administrative and National Policy Requirements**

Successful applicants must comply with the administrative requirements
outlined in 45 CFR Part 74 or 45 CFR Part 92, as appropriate.

**PUBLIC POLICY ISSUANCE**

[]{.mark}

**HEALTHY PEOPLE 2010**

> **Healthy People 2010** is a national initiative led by HHS that sets
> priorities for all HRSA programs. The initiative has two major goals:
> (1) To increase the quality and years of a healthy life; and (2)
> Eliminate our country's health disparities. The program consists of 28
> focus areas and 467 objectives. HRSA has actively participated in the
> work groups of all the focus areas, and is committed to the
> achievement of the Healthy People 2010 goals.
>
> Applicants must summarize the relationship of their projects and
> identify which of their programs objectives and/or sub-objectives
> relate to the goals of the Healthy People 2010 initiative.
>
> Copies of the Healthy People 2010 may be obtained from the
> Superintendent of Documents or downloaded at the Healthy People 2010
> website: [http://www.health.gov/healthypeople/document]{.underline}/.

[]{.mark}

> The Public Health Service strongly encourages all award recipients to
> provide a smoke-free workplace and to promote the non-use of all
> tobacco products. Further, Public Law 103-227, the Pro-Children Act of
> 1994, prohibits smoking in certain facilities (or in some cases, any
>
> portion of a facility) in which regular or routine education, library,
> day care, health care or early childhood development services are
> provided to children.[]{#__RefHeading___Toc47265158 .anchor}
>
> **Public Health System Reporting Requirements**
>
> Applications for all Initiatives may be subject to the Public Health
> System Reporting Requirements (approved under OMB No. 0937-0195).
> Under these requirements, the subject applicants must prepare and
> submit a Public Health System Impact Statement (PHSIS). The PHSIS is
> intended to provide information to State and local health officials to
> keep them apprised of proposed health services grant applications
> submitted by community-based non-governmental organizations within
> their jurisdictions.

[]{.mark}

Subject applicants are required to submit the following information to
the head of the appropriate State and local health agencies in the
area(s) to be impacted no later than the application receipt due date:

1\. A copy of the face page of the application (HRSA 5161-1) and

2\. A summary of the project (PHSIS), not to exceed one page, which
provides:

a\) A description of the population to be served,

b\) A summary of the services to be provided, and

c\) A description of the coordination planned with the appropriate state
and local health agencies.

**[The Abstract may be used in lieu of the one-page Public Health System
Impact Statement (PHSIS).]{.underline}**

[]{.mark}

[]{.mark}

**Copyrighted Material**

With respect to copyrightable material that might be developed as a part
of the grant activity, please note the following grants policy
statement:

If any copyrightable material (e.g., audiovisuals, software,
publications, curricula and training materials, etc.) is developed under
this grant (by the grantee, sub grantee, or contractor) the Department
of Health and Human Services (HHS) shall have a royalty---free,
nonexclusive and irrevocable right to produce, publish, or otherwise
use, and authorize others to use the work, for purposes which further
the objectives of the Maternal and Child Health (MCH) program. All
contracts or other arrangements entered into by the grantee for the
purpose of developing or procuring such material shall specifically
reference and reserve the rights of HHS with respect to the material.
The grantee shall provide three copies of all such copyrightable
material upon the request of the MCH Bureau.

**3. Reporting**

The successful applicant under this guidance must:

a.  Comply with audit requirements of Office of Management and Budget
    (OMB) Circular A-133. Information on the scope, frequency, and other
    aspects of the audits can be found on the Internet at
    [www.whitehouse.gov/omb/circulars](http://www.whitehouse.gov/omb/circulars);

b.  Submit a Payment Management System Quarterly Report. The reports
    identify cash expenditures against the authorized funds for the
    grant. Failure to submit the report may result in the inability to
    access grant funds. Submit report to the:

> Division of Payment Management
>
> DPM/FMS/PSC/ASAM/HHS
>
> PO Box 6021
>
> Rockville, MD 20852
>
> Telephone: (301) 443-1660;

c.  Submit a Financial Status Report. A financial status report is
    required within 90 days of the end of each grant year. The report is
    an accounting of expenditures under the project that year;

d.  Submit a Progress Report(s),

e.  OMB Approved Performance Measures and Administrative Data Reporting.

> The Health Resources and Services Administration (HRSA) has modified
> its reporting requirements for SPRANS projects, CISS projects, and
> other grant programs administered by the Maternal and Child Health
> Bureau (MCHB) to include national performance measures which have been
> developed in accordance with the requirements of the Government
> Performance and Results Act (GPRA) of 1993 (Public Law 103-62). This
> Act requires the establishment of measurable goals for Federal
> programs that can be reported as part of the budgetary process, thus
> linking funding decisions with performance.
>
> Performance measures for MCHB-funded grant programs have been approved
> by the Office of Management and Budget. Measures are based primarily
> on existing data. A new electronic system for reporting these data is
> available. All MCH grantees will now report annual data into this
> electronic system. Applications funded under this grant program will
> be required to report on selected measures included in Attachment 1.

f\. Post-Award Reporting

Successful applicants receiving grant funds will be required, within 120
days of the Notice of Grant Award (NGA), to register in HRSA's
Electronic Handbooks (EHBs) and electronically complete the program
specific data forms that appear in Part I Appendix I of this
guidance.** ** This requires the provision of budget breakdowns in the
financial forms based on the grant award amount, the project abstract
and other grant summary data, and objectives for the performance
measures.

[]{#__RefHeading___Toc47265160 .anchor}**VII. Agency Contacts**

> Applicants may obtain additional information regarding business,
> administrative, or fiscal issues related to the awarding of grants
> under this program by contacting the following:

**Initiative \# 1:** Cooperative Agreement for Adolescent Transition:
Healthy and Ready to Work

Grants Management Team Leader: Theda Duvall

Telephone: 301-443-3414

Fax: 301-443-6686

<Tduvall@hrsa.gov>

**Initiative \# 2:** Cooperative Agreement for Inclusive Community
Integrated Services for Children and Youth with Special Health Care
Needs

Grants Management Team Leader: Theda Duvall

Telephone: 301-443-3414

Fax: 301-443-6686

<Tduvall@hrsa.gov>

**Initiative \# 3:** Family- to-Family Health Information and Education
Centers

Grants Management Team Leader: Jackie Whitaker

Telephone: 301-443-1440

Fax: 301-443-6686

<Jwhitaker@hrsa.gov>

**Initiative \# 4:** The President's New Freedom Initiative: State
Implementation Grants for Integrated Community Systems for Children and
Youth with Special Healthcare Needs

Grants Management Team Leader: Neal Meyerson

Telephone: 301-443-5906

Fax: 301-443-6686

<Nmeyerson@hrsa.gov>

Applicants may obtain additional information relating to program issues
concerning these applications by contacting:

**Initiative \# 1:** Cooperative Agreement for Adolescent Transition:
Healthy and Ready to Work

Monique Fountain

Public Health Analyst, Integrated Services Branch

Division of Services for Children with Special Health Needs

Telephone: 301-443-9775/2370

Fax: 301-443-0832

<Mfountain@hrsa.gov>

**Initiative \# 2:** Cooperative Agreement for Inclusive Community
Integrated Services for Children and Youth with Special Health Care
Needs

Diana Denboba

Public Health Analyst, Integrated Services Branch

Division of Services for Children with Special Health Needs

Telephone: 301-443-9332/2370

Fax: 301-443-0832

<Ddenboba@hrsa.gov>

**Initiative \# 3:** Family- to-Family Health Information and Education
Centers

Diana Denboba

Public Health Analyst, Integrated Services Branch

Division of Services for Children with Special Health Needs

Telephone: 301-443-9332/2370

Fax: 301-443-0832

<Ddenboba@hrsa.gov>

**Initiative \# 4:** The President's New Freedom Initiative: State
Implementation Grants for Integrated Community Systems for Children and
Youth with Special Healthcare Needs

Lynda Honberg

Public Health Analyst, Integrated Services Branch

Division of Services for Children with Special Health Needs

Telephone: 301-443-6314/2370

Fax: 301-443-0832

<LHonberg@hrsa.gov>

**VIII. Resources for Applicants**

[www.hrsa.gov](http://www.hrsa.gov/) and
[www.mchb.hrsa.gov](http://www.mchb.hrsa.gov/)

Health Resources and Services Administration's Maternal and Child Health
Bureau

is the federal agency responsible for assuring the availability of
quality health care to low-income, uninsured, vulnerable and special
needs populations. Its web site contains fact sheets and links to all
HRSA programs, including the Maternal and Child Health Bureau, which
administers the Title V Block Grant.

[www.mchlibrary.info](http://www.mchlibrary.info/)

This timely, easy-to-use virtual library for the MCH community holds
resource guides, searchable databases of publications, programs and
organizations within the MCH Bureau, an A-Z search function and
frequently asked questions.

**National Center Websites:**

[www.championsforprogress.org]()

The Champions for Progress Center, housed at the Early Intervention
Research Institute (EIRI) at Utah State University, is a cooperative
agreement funded by the Maternal and Child Health Bureau to assist state
and territorial CSHCN programs in providing leadership to accelerate the
process of systems building at the state and community levels. Access
presentations and outcomes of multi-state meetings, summaries of states'
activities in the six core outcomes, including results or incentive
awards. The CSHCN Data Resource Center is a sub-contract of "Champions"
and can also be accessed through their web site.

[www.cshcndata.org](http://www.cshcndata.org/)

The Data Resource Center on CYSHCN, developed by the Child and
Adolescent Health Measurement Initiative (CAHMI), features easy to use,
hands-on access to each states' data from the National Survey of CSHCN.
Also available are resources, tools and templates to assist users in
communicating current data to stimulate improvements and create
Community-Based Systems of services for CYSHCN and the 2001 National
Survey Chartbook.

[http://www.familyvoices.org](http://www.familyvoices.org/)

Family Voices, provides a website for a national grassroots network of
families and friends, advocates for health care services that are
family-centered, community-based, comprehensive, coordinated and
culturally competent for all children and youth with special health care
needs; and provides information promoting the inclusion of all families
as decision makers at all levels of health care; how to support
essential partnerships between families and professionals and on
Family-To-Family Health Information Centers. 

[www.georgetown.edu/research/gucdc/nccc](http://www.georgetown.edu/research/gucdc/nccc)

The National Center for Cultural Competence maintains a website on
information related to families, systems and program perspectives and
implementation of cultural and linguistic competence. Tools, resources,
consultants and materials can be accessed, and there is a Spanish Portal
to health information in Spanish and family stories. See: the conceptual
framework and definitions for cultural and linguistic competence,
checklists for "getting started", self assessment and cultural broker
tools and materials and archives from topical conference calls around
the six core outcomes.

 

[http://www.hdwg.org](http://www.hdwg.org/)

The Catalyst Center seeks to promote adequate financing for
comprehensive, family-centered care of children and youth with special
health care needs. The Center works with a broad range of stakeholders
in financing and coverage issues including government agencies, parent
groups, health and social service agencies, employers, payers and other
stakeholders to determine family and community needs, identify gaps in
current funding to meet those needs, and develop creative funding
strategies. Goals of the Center are: to promote health coverage of all
CYSHCN, to eliminate underinsurance among CYSHCN, to disseminate
innovative financing methods for services to CYSHCN, and to enhance
knowledge and collaboration among stakeholder groups around financing
issues. 

 [www.infanthearing.org](http://www.infanthearing.org/)

The goal of the National Center for Hearing Assessment and Management at
Utah State University is to ensure that all infants (newborns) and
toddlers with hearing loss are identified as early as possible and
provided with timely and appropriate audiological, educational, and
medical intervention.

[www.hrtw.org](http://www.hrtw.org/)

The mission of the Health and Ready to Work (HRTW) National Center is to
create changes in policy, programs and practices that will help youth
with special health care needs transition to adult health care. Its
website has resources for agencies, providers, families and youth
related to transition, including state-specific SSI Information. See "A
Consensus Statement on Health Care Transitions for Young Adults With
Special Health Care Needs", PEDIATRICS Vol. 110 No. 6 December 2002 on
this web site.

[http://www.medicalhomeinfo.org](http://www.medicalhomeinfo.org/)

The National Center of Medical Home Initiatives for Children with
Special Needs provides support to physicians, families, and other
medical and non-medical providers who care for children with special
needs so that they have access to a medical home

See the American Academy of Pediatrics' "Policy Statement on the Medical
Home - Organizational Principles to Guide and Define the Child Health
Care System and/or Improve the Health of All Children" on this web site.

**Other Helpful Web sites**

[www.cshcn.org](http://www.cshcn.org/)

The Center for Children with Special Needs in Seattle offers information
and resources for parents and professionals who advocate and care for
children with special health care needs. The web site highlights news &
events, resources, programs and special projects, and includes many of
the Center's publications and presentations.

[www.ichp.edu](http://www.ichp.edu/)

The Institute for Child Health Policy, located in Gainesville, Florida,
maintains a comprehensive web site that is dedicated to "creative vision
in research and science." The goal of the Institute is to research,
evaluate, formulate and advance health policies, programs and systems
that promote the health and well being of children and youth.

[www.mchpolicy.org](http://www.mchpolicy.org/)

The MCH Policy Research Center is a health policy group that provides
federal and state policymakers, public health officials, provider and
family organizations with analysis of financing and service delivery
issues affecting children and adolescents. The Center focuses on public
and private insurance, public programs and special populations,
epidemiology of childhood illnesses and pediatric provider issues.

[www.mgh.harvard.edu/children/ccahp](http://www.mgh.harvard.edu/children/ccahp)

Created in 1999, the Center for Child and Adolescent Health Policy at
Boston\'s Massachusetts General Hospital brought together a dedicated
group of researchers interested in improving the lives of children - in
particular those who are poor, minority or chronically ill - and their
families through identifying, developing and supporting effective health
care policies and interventions. Recent research activities can be found
on this web site.

[www.neserve.org](http://www.neserve.org/)

Established in 1983, New England SERVE is a health policy, research and
planning organization working to promote quality systems of care for
children with special health care needs and their families. Its "Shared
Responsibilities Toolkit" contains tools for health plans to use to
improve care for children with special health care needs. It elaborates
on who children with special health care needs are, why health plans
should identify this population, and where the opportunities for
improvement at health plans are.

[http://genes-r-us.uthscsa.edu](http://genes-r-us.uthscsa.edu/)

The National Newborn Screening and Genetics Resource Center serves as a
national resource center for information and education regarding newborn
screening and genetics programs and policies.\
  

[www.geneticalliance.org](http://www.geneticalliance.org/)

Genetic Alliance i**s** an international coalition of families, health
professionals and genetic organizations, representing more than 300 lay
advocacy organizations. The Alliance works to foster the integration of
genetic advances into quality healthcare, public awareness and
consumer-informed public policy.[]{#__RefHeading___Toc47265165 .anchor}

**ix. Tips for Writing a Strong Application**

[]{.mark}

**Include DUNS Number.** You must include a DUNS Number to have your
application reviewed. Applications ***will not*** be reviewed without a
DUNS number. To obtain a DUNS number, access
[www.dunandbradstreet.com](http://www.dunandbradstreet.com/) or call
1-866-705-5711. Please include the DUNS number next to the OMB Approval
Number on the application face page.

**Keep your audience in mind.** Reviewers will use only the information
contained in the application to assess the application. Be sure the
application and responses to the program requirements and expectations
are complete and clearly written. Do not assume that reviewers are
familiar with the applicant organization. Keep the review criteria in
mind when writing the application.

**Start preparing the application early.** Allow plenty of time to
gather required information from various sources.

**Follow the instructions in this guidance carefully.** Place all
information in the order requested in the guidance. If the information
is not placed in the requested order, you may receive a lower score.

**Be brief, concise, and clear.** Make your points understandable.
Provide accurate and honest information, including candid accounts of
problems and realistic plans to address them. If any required
information or data is omitted, explain why. Make sure the information
provided in each table, chart, attachment, etc., is consistent with the
proposal narrative and information in other tables.

**Be organized and logical.** Many applications fail to receive a high
score because the reviewers cannot follow the thought process of the
applicant or because parts of the application do not fit together.

**Be careful in the use of appendices.** Do not use the appendices for
information that is required in the body of the application. Be sure to
cross-reference all tables and attachments located in the appendices to
the appropriate text in the application.

**Carefully proofread the application.** Misspellings and grammatical
errors will impede reviewers in understanding the application. Be sure
pages are numbered (including appendices) and that page limits are
followed. Limit the use of abbreviations and acronyms, and define each
one at its first use and periodically throughout application.

**Print out and carefully review an electronic application**. If
submitting electronically, print out the application before submitting
it to ensure appropriate formatting and adherence to page limit
requirements.

**PART 1**

**MCHB Discretionary Grant Performance Measures**

**[ATTACHMENT "1"]{.underline}**

**PART 1: MCHB Discretionary Grant Performance Measures**

**[Measures for ALL Initiatives]{.underline}**

Performance Measure \# 7 The degree to which MCHB supported programs
ensure family participation in program and policy activities.

Performance Measure \# 10 The degree to which MCHB supported programs
have incorporated cultural competence elements into their policies,
guidelines, contracts, and training.

Performance Measure \# 31 The degree to which grantees have assisted
States in organizing community-based service systems so that families of
children with special health care needs can use them easily.

**[Additional Measures for Initiative #1]{.underline}**

Performance Measure \# 3 The percent of completed MCHB supported
projects publishing findings in peer-reviewed journals.

Performance Measure #37 The degree to which grantees have assisted
States in increasing the percentage of youth with special health care
needs who have received services necessary to make **transitions** to
all aspects of adult life, including adult health care, work, and
independence.

**[Additional Measures for Initiative #2]{.underline}**

Performance Measure \# 3 The percent of completed MCHB supported
projects publishing findings in peer-reviewed journals.

Performance Measure \# 31 The degree to which grantees have assisted
States in organizing community-based service systems so that families of
children with special health care needs can use them easily.

**[Additional Measures for Initiative #3]{.underline}**

Performance Measure #5 The percent of MCHB supported projects that are
sustained in the community after the federal grant project is completed.

Performance Measure #6 The degree to which grantees assist families of
children with special health needs to partner in decision making and be
satisfied with services they receive.

**[Additional Measures for Initiative #4]{.underline}**

Performance Measure #5 The percent of MCHB supported projects that are
sustained in the community after the federal grant project period is
completed.

Performance Measure \# 16 The degree to which grantees have assisted
States in increasing 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.

Performance Measure \# 19 The degree to which grantees have assisted
States in increasing the percent of children with special health care
needs age 0 to 18 who receive coordinated, ongoing, comprehensive care
within a medical home.

Performance Measure \# 23 The degree to which grantees have assisted
States in increasing the percentage of children who are screened early
and continuously for special health care needs and linked to medical
homes, appropriate follow-up, and early intervention.

Performance Measure \# 31 The degree to which grantees have assisted
States in organizing community-based service systems so that families of
children with special health care needs can use them easily.

Performance Measure #37 The degree to which grantees have assisted
States in increasing the percentage of youth with special health care
needs who have received services necessary to make transitions to all
aspects of adult life, including adult health care, work, and
independence.

**[Detail Sheets and Data Collection Forms (where available) for each of
these Performance Measures are included on the following
pages]{.underline}**

+-----------------------------------+-----------------+-----------------+
| **[03 PERFORMANCE                 | The percent of  |                 |
| MEASURE]{.underline}**            | completed MCHB  |                 |
|                                   | supported       |                 |
| **Goal 1: Provide National        | projects        |                 |
| Leadership for MCHB**             | publishing      |                 |
|                                   | findings in     |                 |
| **(Strengthen the MCH knowledge   | peer-reviewed   |                 |
| base and support scholarship      | journals.       |                 |
| within the MCH community)**       |                 |                 |
|                                   |                 |                 |
| **Level: Grantee**                |                 |                 |
|                                   |                 |                 |
| **Category: Information           |                 |                 |
| Dissemination**                   |                 |                 |
+-----------------------------------+-----------------+-----------------+
| **GOAL**                          | To increase the |                 |
|                                   | number of study |                 |
|                                   | findings from   |                 |
|                                   | research        |                 |
|                                   | projects that   |                 |
|                                   | are published   |                 |
|                                   | in              |                 |
|                                   | peer-reviewed   |                 |
|                                   | journals.       |                 |
+-----------------------------------+-----------------+-----------------+
|                                   |                 |                 |
+-----------------------------------+-----------------+-----------------+
| **MEASURE**                       | The percent of  |                 |
|                                   | completed MCHB  |                 |
|                                   | supported       |                 |
|                                   | projects        |                 |
|                                   | publishing      |                 |
|                                   | findings in     |                 |
|                                   | peer-reviewed   |                 |
|                                   | journals.       |                 |
+-----------------------------------+-----------------+-----------------+
|                                   |                 |                 |
+-----------------------------------+-----------------+-----------------+
| **DEFINITION**                    | **Numerator:**  |                 |
+-----------------------------------+-----------------+-----------------+
|                                   | Number of       |                 |
|                                   | completed       |                 |
|                                   | projects        |                 |
|                                   | publishing main |                 |
|                                   | study findings  |                 |
|                                   | in              |                 |
|                                   | peer-reviewed   |                 |
|                                   | journals no     |                 |
|                                   | later than 3    |                 |
|                                   | years following |                 |
|                                   | completion in a |                 |
|                                   | cohort year.    |                 |
+-----------------------------------+-----------------+-----------------+
|                                   | *               |                 |
|                                   | *Denominator:** |                 |
+-----------------------------------+-----------------+-----------------+
|                                   | Total number of |                 |
|                                   | completed       |                 |
|                                   | projects in a   |                 |
|                                   | cohort year.    |                 |
+-----------------------------------+-----------------+-----------------+
|                                   | **Units:** 100  | **Text:**       |
|                                   |                 | Percent         |
+-----------------------------------+-----------------+-----------------+
|                                   | A completed     |                 |
|                                   | project means   |                 |
|                                   | that the        |                 |
|                                   | funding period  |                 |
|                                   | has ended and   |                 |
|                                   | the final       |                 |
|                                   | report has been |                 |
|                                   | submitted by    |                 |
|                                   | the grantee.    |                 |
|                                   |                 |                 |
|                                   | Cohort year is  |                 |
|                                   | defined as      |                 |
|                                   | projects        |                 |
|                                   | completed in a  |                 |
|                                   | given fiscal    |                 |
|                                   | year. Each      |                 |
|                                   | cohort year     |                 |
|                                   | will be         |                 |
|                                   | collected for   |                 |
|                                   | three years.    |                 |
+-----------------------------------+-----------------+-----------------+
|                                   |                 |                 |
+-----------------------------------+-----------------+-----------------+
| **HEALTHY PEOPLE 2010 OBJECTIVE** | Related to Goal |                 |
|                                   | 1: Improve      |                 |
|                                   | access to       |                 |
|                                   | comprehensive,  |                 |
|                                   | high-quality    |                 |
|                                   | health care     |                 |
|                                   | services        |                 |
|                                   | (Objectives     |                 |
|                                   | 1.1- 1.16).     |                 |
+-----------------------------------+-----------------+-----------------+
|                                   |                 |                 |
+-----------------------------------+-----------------+-----------------+
| **DATA SOURCE(S) AND ISSUES**     | -   Attached    |                 |
|                                   |     data        |                 |
|                                   |     collection  |                 |
|                                   |     form will   |                 |
|                                   |     be sent     |                 |
|                                   |     annually to |                 |
|                                   |     grantees    |                 |
|                                   |     after the   |                 |
|                                   |     funding     |                 |
|                                   |     period for  |                 |
|                                   |     3 years.    |                 |
|                                   |                 |                 |
|                                   | -   Some        |                 |
|                                   |     preliminary |                 |
|                                   |     information |                 |
|                                   |     may be      |                 |
|                                   |     gathered    |                 |
|                                   |     from        |                 |
|                                   |     mandated    |                 |
|                                   |     project     |                 |
|                                   |     final       |                 |
|                                   |     reports.    |                 |
+-----------------------------------+-----------------+-----------------+
|                                   |                 |                 |
+-----------------------------------+-----------------+-----------------+
| **SIGNIFICANCE**                  | To be           |                 |
|                                   | successful, MCH |                 |
|                                   | information     |                 |
|                                   | must reach      |                 |
|                                   | professionals   |                 |
|                                   | who are         |                 |
|                                   | delivering      |                 |
|                                   | services,       |                 |
|                                   | developing      |                 |
|                                   | programs and    |                 |
|                                   | making policy   |                 |
|                                   | in order to     |                 |
|                                   | ensure that the |                 |
|                                   | latest          |                 |
|                                   | evidence-based, |                 |
|                                   | scientific      |                 |
|                                   | knowledge is    |                 |
|                                   | applied in      |                 |
|                                   | practice and    |                 |
|                                   | policy          |                 |
|                                   | development.    |                 |
|                                   | Peer reviewed   |                 |
|                                   | journals are    |                 |
|                                   | considered one  |                 |
|                                   | of the best     |                 |
|                                   | methods for     |                 |
|                                   | distributing    |                 |
|                                   | new knowledge   |                 |
|                                   | because of      |                 |
|                                   | their wide      |                 |
|                                   | circulation and |                 |
|                                   | rigorous        |                 |
|                                   | standard of     |                 |
|                                   | review.         |                 |
+-----------------------------------+-----------------+-----------------+

> OMB #0915-0272
>
> Exp. 1-31-2006

**DATA COLLECTION FORM FOR DETAIL SHEET #03**

**LIST OF PUBLICATIONS RELATED TO THE RESEARCH PROJECT FUNDED OR**

**CO-FUNDED BY MCHB**

FUNDED PROJECT
#:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

PRINCIPAL INVESTIGATOR:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

GRANTEE/INSTITUTION:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(At the time the research was conducted)

######## 

######## **TYPE OF PROJECT: Research \_\_\_\_ Training \_\_\_\_\_\_ Programmatic \_\_\_\_\_\_\_**

**LIST OF PUBLICATIONS**

**Produced by or for the Funded Project**

Please attach a reprint of listed article(s) to this form

TITLE OF THE ARTICLE:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

JOURNAL:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

VOLUME:\_\_\_\_\_\_ NUMBER:\_\_\_\_\_\_\_\_
SUPPLEMENT:\_\_\_\_\_\_\_YEAR:\_\_\_\_\_\_PAGE:\_\_\_\_\_\_

> OMB #0915-0272
>
> Exp. 1-31-2006

+-----------------------------------+----------------+----------------+
| #### [05                          | The percent of |                |
|  PERFORMANCE MEASURE]{.underline} | MCHB supported |                |
|                                   | projects that  |                |
| **Goal 1: Provide National        | are sustained  |                |
| Leadership for MCHB**             | in the         |                |
|                                   | community      |                |
| **(Forge strong collaborative,    | after the      |                |
| sustainable MCH partnerships both | federal grant  |                |
| within and beyond the health      | project period |                |
| sector)**                         | is completed.  |                |
|                                   |                |                |
| **Level: Grantee**                |                |                |
|                                   |                |                |
| **Category: Sustainability**      |                |                |
+-----------------------------------+----------------+----------------+
| **GOAL**                          | To increase    |                |
|                                   | the            |                |
|                                   | sustainability |                |
|                                   | of MCHB funded |                |
|                                   | projects after |                |
|                                   | their federal  |                |
|                                   | grant project  |                |
|                                   | period is      |                |
|                                   | completed.     |                |
+-----------------------------------+----------------+----------------+
|                                   |                |                |
+-----------------------------------+----------------+----------------+
| **MEASURE**                       | The percent of |                |
|                                   | MCHB funded    |                |
|                                   | projects that  |                |
|                                   | are sustained  |                |
|                                   | in the         |                |
|                                   | community      |                |
|                                   | after the      |                |
|                                   | federal grant  |                |
|                                   | project period |                |
|                                   | is completed.  |                |
+-----------------------------------+----------------+----------------+
|                                   |                |                |
+-----------------------------------+----------------+----------------+
| **DEFINITION**                    | **Numerator:** |                |
+-----------------------------------+----------------+----------------+
|                                   | Number of      |                |
|                                   | designated     |                |
|                                   | MCHB funded    |                |
|                                   | projects that  |                |
|                                   | are sustained  |                |
|                                   | after the      |                |
|                                   | federal MCHB   |                |
|                                   | project        |                |
|                                   | period.        |                |
+-----------------------------------+----------------+----------------+
|                                   | **             |                |
|                                   | Denominator:** |                |
+-----------------------------------+----------------+----------------+
|                                   | Total number   |                |
|                                   | of designated  |                |
|                                   | MCHB funded    |                |
|                                   | projects that  |                |
|                                   | have completed |                |
|                                   | the federal    |                |
|                                   | MCHB project   |                |
|                                   | period during  |                |
|                                   | the reporting  |                |
|                                   | year.          |                |
+-----------------------------------+----------------+----------------+
|                                   | **Units:** 100 | **Text:**      |
|                                   |                | Percent        |
+-----------------------------------+----------------+----------------+
|                                   | The relevant   |                |
|                                   | MCHB supported |                |
|                                   | projects are   |                |
|                                   | defined as     |                |
|                                   | projects that  |                |
|                                   | attempt to     |                |
|                                   | foster         |                |
|                                   | community      |                |
|                                   | partnerships   |                |
|                                   | and build      |                |
|                                   | capacity       |                |
|                                   | and/or program |                |
|                                   | resources that |                |
|                                   | continue as    |                |
|                                   | needed in that |                |
|                                   | community      |                |
|                                   | after federal  |                |
|                                   | funds          |                |
|                                   | discontinue.   |                |
|                                   | These projects |                |
|                                   | include but    |                |
|                                   | are not        |                |
|                                   | limited to     |                |
|                                   | Healthy        |                |
|                                   | Tomorrows,     |                |
|                                   | Healthy Child  |                |
|                                   | Care America   |                |
|                                   | Campaign,      |                |
|                                   | CISS,          |                |
|                                   | Integrated     |                |
|                                   | Services       |                |
|                                   | projects, etc. |                |
|                                   | A "sustained"  |                |
|                                   | project refers |                |
|                                   | to a project   |                |
|                                   | that           |                |
|                                   | demonstrates   |                |
|                                   | the            |                |
|                                   | continuation   |                |
|                                   | of key         |                |
|                                   | elements of    |                |
|                                   | p              |                |
|                                   | rogram/service |                |
|                                   | components     |                |
|                                   | started under  |                |
|                                   | the MCHB       |                |
|                                   | supported      |                |
|                                   | project.       |                |
+-----------------------------------+----------------+----------------+
|                                   |                |                |
+-----------------------------------+----------------+----------------+
| **HEALTHY PEOPLE 2010 OBJECTIVE** | No related     |                |
|                                   | Healthy People |                |
|                                   | 2010           |                |
|                                   | Objective.     |                |
+-----------------------------------+----------------+----------------+
|                                   |                |                |
+-----------------------------------+----------------+----------------+
| **DATA SOURCE(S) AND ISSUES**     | -   The final  |                |
|                                   |     project    |                |
|                                   |     report     |                |
|                                   |     (submitted |                |
|                                   |     after the  |                |
|                                   |     grant      |                |
|                                   |     period     |                |
|                                   |     ends) for  |                |
|                                   |     each MCHB  |                |
|                                   |     supported  |                |
|                                   |     project    |                |
|                                   |     will       |                |
|                                   |     provide    |                |
|                                   |     the        |                |
|                                   |     necessary  |                |
|                                   |     data.      |                |
|                                   |                |                |
|                                   | -   One        |                |
|                                   |     potential  |                |
|                                   |     source of  |                |
|                                   |     difficulty |                |
|                                   |     is the     |                |
|                                   |     variable   |                |
|                                   |     submission |                |
|                                   |     rate of    |                |
|                                   |     required   |                |
|                                   |     final      |                |
|                                   |     project    |                |
|                                   |     reports by |                |
|                                   |     grantees   |                |
|                                   |     and the    |                |
|                                   |     narrative  |                |
|                                   |     nature of  |                |
|                                   |     final      |                |
|                                   |     project    |                |
|                                   |     reports.   |                |
+-----------------------------------+----------------+----------------+
|                                   |                |                |
+-----------------------------------+----------------+----------------+
| **SIGNIFICANCE**                  | A major        |                |
|                                   | strategy of    |                |
|                                   | MCHB is to     |                |
|                                   | strengthen     |                |
|                                   | public health  |                |
|                                   | infrastructure |                |
|                                   | at the state   |                |
|                                   | and local      |                |
|                                   | level by       |                |
|                                   | providing      |                |
|                                   | small "start   |                |
|                                   | up" grants     |                |
|                                   | which          |                |
|                                   | communities    |                |
|                                   | are encouraged |                |
|                                   | to use to      |                |
|                                   | leverage other |                |
|                                   | community      |                |
|                                   | resources.     |                |
|                                   | These grants   |                |
|                                   | are meant to   |                |
|                                   | foster         |                |
|                                   | community      |                |
|                                   | partnerships,  |                |
|                                   | and build      |                |
|                                   | capacity and   |                |
|                                   | program        |                |
|                                   | services that  |                |
|                                   | continue in    |                |
|                                   | the community  |                |
|                                   | after the      |                |
|                                   | federal grant  |                |
|                                   | period ends.   |                |
|                                   | Measuring      |                |
|                                   | sustainability |                |
|                                   | gauges the     |                |
|                                   | effectiveness  |                |
|                                   | of Bureau      |                |
|                                   | resources in   |                |
|                                   | generating     |                |
|                                   | longer-term    |                |
|                                   | community      |                |
|                                   | investments    |                |
|                                   | through its    |                |
|                                   | initial        |                |
|                                   | funding.       |                |
+-----------------------------------+----------------+----------------+

> OMB #0915-0272
>
> Exp. 1-31-2006

+-----------------------------------+-----------------+-----------------+
| **[06 PERFORMANCE                 | The degree to   |                 |
| MEASURE]{.underline}**            | which grantees  |                 |
|                                   | assist families |                 |
| **Goal 1: Provide National        | of children     |                 |
| Leadership for MCHB**             | with special    |                 |
|                                   | health needs to |                 |
| **(Promote family participation   | partner in      |                 |
| in care)**                        | decision making |                 |
|                                   | and be          |                 |
| **Level: Grantee**                | satisfied with  |                 |
|                                   | services they   |                 |
| **Category: Family                | receive.        |                 |
| Participation**                   |                 |                 |
+-----------------------------------+-----------------+-----------------+
| #### GOAL                         | To increase the |                 |
|                                   | number of       |                 |
|                                   | families with   |                 |
|                                   | CSHCN           |                 |
|                                   |                 |                 |
|                                   | receiving       |                 |
|                                   | needed health   |                 |
|                                   | and related     |                 |
|                                   | information/    |                 |
|                                   |                 |                 |
|                                   | training.       |                 |
+-----------------------------------+-----------------+-----------------+
|                                   |                 |                 |
+-----------------------------------+-----------------+-----------------+
| #### MEASURE                      | The degree to   |                 |
|                                   | which grantees  |                 |
|                                   | have assisted   |                 |
|                                   | States in       |                 |
|                                   | facilitating    |                 |
|                                   | families as     |                 |
|                                   | partners in     |                 |
|                                   | decision making |                 |
|                                   | and increasing  |                 |
|                                   | satisfaction.   |                 |
+-----------------------------------+-----------------+-----------------+
|                                   |                 |                 |
+-----------------------------------+-----------------+-----------------+
| **DEFINITION**                    | **Numerator:**  |                 |
|                                   |                 |                 |
|                                   | The total       |                 |
|                                   | number of       |                 |
|                                   | families in a   |                 |
|                                   | state who have  |                 |
|                                   | been provided   |                 |
|                                   | information,    |                 |
|                                   | education       |                 |
|                                   | and/or training |                 |
|                                   | from            |                 |
|                                   | F               |                 |
|                                   | amily-To-Family |                 |
|                                   | Health          |                 |
|                                   | Information     |                 |
|                                   | Centers.        |                 |
+-----------------------------------+-----------------+-----------------+
|                                   | *               |                 |
|                                   | *Denominator:** |                 |
|                                   |                 |                 |
|                                   | The estimated   |                 |
|                                   | number of       |                 |
|                                   | families having |                 |
|                                   | CSHCN           |                 |
+-----------------------------------+-----------------+-----------------+
|                                   | **Units:        | **Text:**       |
|                                   | Number**        |                 |
+-----------------------------------+-----------------+-----------------+
|                                   |                 |                 |
+-----------------------------------+-----------------+-----------------+
| #                                 | Related to: 1)  |                 |
| ### HEALTHY PEOPLE 2010 OBJECTIVE | Objective       |                 |
|                                   | 16-23: Increase |                 |
|                                   | the proportion  |                 |
|                                   | of States and   |                 |
|                                   | jurisdictions   |                 |
|                                   | that have       |                 |
|                                   | service systems |                 |
|                                   | for children    |                 |
|                                   | with or at risk |                 |
|                                   | of chronic and  |                 |
|                                   | disabling       |                 |
|                                   | conditions, as  |                 |
|                                   | required by     |                 |
|                                   | public law      |                 |
|                                   | 101-239.        |                 |
+-----------------------------------+-----------------+-----------------+
|                                   |                 |                 |
+-----------------------------------+-----------------+-----------------+
| **DATA SOURCE(S) AND ISSUES**     | 1)Progress      |                 |
|                                   | reports from    |                 |
|                                   | F               |                 |
|                                   | amily-To-Family |                 |
|                                   | Health Care     |                 |
|                                   | Information and |                 |
|                                   | Education       |                 |
|                                   | Centers         |                 |
+-----------------------------------+-----------------+-----------------+
|                                   |                 |                 |
+-----------------------------------+-----------------+-----------------+
| **SIGNIFICANCE**                  | The last decade |                 |
|                                   | has emphasized  |                 |
|                                   | the central     |                 |
|                                   | role of         |                 |
|                                   | families as     |                 |
|                                   | informed        |                 |
|                                   | consumers of    |                 |
|                                   | services and    |                 |
|                                   | participants in |                 |
|                                   | policy-making   |                 |
|                                   | activities.     |                 |
|                                   | Research has    |                 |
|                                   | indicated that  |                 |
|                                   | families need   |                 |
|                                   | information     |                 |
|                                   | they can        |                 |
|                                   | understand and  |                 |
|                                   | to get          |                 |
|                                   | information     |                 |
|                                   | from other      |                 |
|                                   | parents who     |                 |
|                                   | have            |                 |
|                                   | experiences     |                 |
|                                   | similar to      |                 |
|                                   | theirs and who  |                 |
|                                   | have navigated  |                 |
|                                   | services        |                 |
|                                   | systems. In     |                 |
|                                   | accordance with |                 |
|                                   | this            |                 |
|                                   | philosophy,     |                 |
|                                   | MCHB is         |                 |
|                                   | facilitating    |                 |
|                                   | such activities |                 |
|                                   | through SPRANS  |                 |
|                                   | funding. To     |                 |
|                                   | better ensure   |                 |
|                                   | access to       |                 |
|                                   | health          |                 |
|                                   | information,    |                 |
|                                   | including       |                 |
|                                   | information on  |                 |
|                                   | systems,        |                 |
|                                   | financing and   |                 |
|                                   | participation   |                 |
|                                   | in decision     |                 |
|                                   | making at the   |                 |
|                                   | individual      |                 |
|                                   | family and      |                 |
|                                   | policy levels.  |                 |
+-----------------------------------+-----------------+-----------------+

> OMB #0915-0272
>
> Exp. 1-31-2006

**DATA COLLECTION FORM FOR DETAIL SHEET #06**

Using the scale below, please circle the one answer that best describes
how frequently your organization performs the following activities.

> 1 2 3 4 5

Never Rarely Sometimes Much of the time All the time

<table>
<colgroup>
<col style="width: 16%" />
<col style="width: 68%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td><h2 id="section-1"> </h2>
<p><strong>Providing</strong></p>
<p><strong>Information</strong></p></td>
<td><p>Our organization provided health care information/education to
families to assist them in accessing information and services related
to:</p>
<p>1. partnering/decision making with providers</p>
<p>2. accessing a medical home</p>
<p>3. financing for needed services</p>
<p>4. early and continuous screening</p>
<p>5. navigating systems</p>
<p>6. adolescent transition issues</p>
<p>Total number of families served/trained: ___________</p></td>
<td>111111</td>
<td>222222</td>
<td colspan="2">333333</td>
<td colspan="2">444444</td>
<td colspan="2">555555</td>
</tr>
<tr class="even">
<td><p><strong>Receiving/</strong></p>
<p><strong>Providing</strong></p>
<p><strong>Technical</strong></p>
<p><strong>Assistance</strong></p></td>
<td><p>Our organization received training/ technical assistance
from:</p>
<p>1. National Family Voices Office</p>
<p>2. State/local Title V</p>
<p>Our organization provided training/ technical assistance to other
Family-To-Family Centers pertaining to:</p>
<p>1. HP 2010 information</p>
<p>2. Infrastructure/Chapter development</p>
<p>3. Family leadership development</p>
<p>4. Data collection and analysis</p>
<p>5. Outreach/cultural competence</p>
<p>6. Collaboration with partners</p></td>
<td><p>1</p>
<p>1</p>
<p>1</p>
<p>1</p>
<p>1</p>
<p>1</p>
<p>1</p>
<p>1</p></td>
<td><p>2</p>
<p>2</p>
<p>2</p>
<p>2</p>
<p>2</p>
<p>2</p>
<p>2</p>
<p>2</p></td>
<td colspan="2"><p>3</p>
<p>3</p>
<p>3</p>
<p>3</p>
<p>3</p>
<p>3</p>
<p>3</p>
<p>3</p></td>
<td colspan="2"><p>4</p>
<p>4</p>
<p>4</p>
<p>4</p>
<p>4</p>
<p>4</p>
<p>4</p>
<p>4</p></td>
<td colspan="2"><p>5</p>
<p>5</p>
<p>5</p>
<p>5</p>
<p>5</p>
<p>5</p>
<p>5</p>
<p>5</p></td>
</tr>
<tr class="odd">
<td><strong>Collaboration</strong></td>
<td><p>Our organization enhanced collaboration between families and:</p>
<p>1. Informal culturally diverse community leaders/groups (e.g. natural
networks, informal leaders, spiritual leaders, ethnic media, cultural
brokers)</p>
<p>2. Other individual families and family groups</p>
<p>3. State/community partners (specify:____________________ )</p>
<p>in the area(s) of:</p>
<p>a. Program planning</p>
<p>b. Service delivery</p>
<p>c. Evaluation/monitoring of services</p>
<p>d. Block grant activities</p>
<p>e. Policy development</p>
<p>4. Individual providers</p></td>
<td><p>1</p>
<p>1</p>
<p>1</p>
<p>1</p>
<p>1</p>
<p>1</p>
<p>11</p>
<p>1</p></td>
<td><p>2</p>
<p>2</p>
<p>2</p>
<p>2</p>
<p>2</p>
<p>2</p>
<p>2</p>
<p>2</p>
<p>2</p></td>
<td colspan="2"><p>3</p>
<p>3</p>
<p>3</p>
<p>3</p>
<p>3</p>
<p>3</p>
<p>3</p>
<p>3</p>
<p>3</p></td>
<td colspan="2"><p>4</p>
<p>4</p>
<p>4</p>
<p>4</p>
<p>4</p>
<p>4</p>
<p>4</p>
<p>4</p>
<p>4</p></td>
<td colspan="2"><p>5</p>
<p>55</p>
<p>5555</p>
<p>55</p></td>
</tr>
<tr class="even">
<td><strong>Satisfaction</strong></td>
<td><p>1. Families were satisfied with our services</p>
<p>2. Families became more satisfied with their children’s services</p>
<p>% of families with increased satisfaction: ________________</p></td>
<td><p>1</p>
<p>1</p></td>
<td colspan="2"><p>2</p>
<p>2</p></td>
<td colspan="2"><p>3</p>
<p>3</p></td>
<td colspan="2"><p>4</p>
<p>4</p></td>
<td><p>5</p>
<p>5</p></td>
</tr>
</tbody>
</table>

> OMB #0915-0272
>
> Exp. 1-31-2006

+-----------------------------------+-----------------------------------+
| #### [07                          | The degree to which MCHB          |
|  PERFORMANCE MEASURE]{.underline} | supported programs ensure family  |
|                                   | participation in program and      |
| **Goal 1: Provide National        | policy activities.                |
| Leadership for MCHB**             |                                   |
|                                   |                                   |
| **(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.                             |
+-----------------------------------+-----------------------------------+

> OMB #0915-0272
>
> Exp. 1-31-2006

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.  Family 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) \_\_\_\_\_\_\_\_\_

> OMB #0915-0272
>
> Exp. 1-31-2006

+-----------------------------------+-----------------------------------+
| # [10                             | The degree to which MCHB          |
|  PERFORMANCE MEASURE]{.underline} | supported programs have           |
|                                   | incorporated cultural competence  |
| **Goal 2: Eliminate Health        | elements into their policies,     |
| Barriers & Disparities**          | guidelines, contracts and         |
|                                   | training.                         |
| **(Develop and promote health     |                                   |
| services and systems of care      |                                   |
| designed to eliminate disparities |                                   |
| and barriers across MCH           |                                   |
| populations)**                    |                                   |
|                                   |                                   |
| **Level: Grantee**                |                                   |
|                                   |                                   |
| **Category: Cultural Competence** |                                   |
+-----------------------------------+-----------------------------------+
| **GOAL**                          | To increase the number of MCHB    |
|                                   | supported programs that have      |
|                                   | integrated cultural competence    |
|                                   | into their policies, guidelines,  |
|                                   | contracts and training.           |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **MEASURE**                       | The degree to which MCHB          |
|                                   | supported programs have           |
|                                   | incorporated cultural competence  |
|                                   | elements into their policies,     |
|                                   | guidelines, contracts and         |
|                                   | training.                         |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **DEFINITION**                    | Attached is a checklist of 23     |
|                                   | elements that demonstrate         |
|                                   | cultural competency. Please check |
|                                   | the degree to which the elements  |
|                                   | have been implemented. The answer |
|                                   | scale is 0-69. Please keep the    |
|                                   | completed checklist attached.     |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **HEALTHY PEOPLE 2010 OBJECTIVE** | Related to Objective 16.23:       |
|                                   | Increase the proportion of States |
|                                   | and jurisdictions that have       |
|                                   | service systems for children with |
|                                   | or at risk for chronic and        |
|                                   | disabling conditions as required  |
|                                   | by Public Law 101-239.            |
|                                   |                                   |
|                                   | Related to Objective 23.11        |
|                                   | (Developmental) Increase the      |
|                                   | proportion of State and local     |
|                                   | public health agencies that meet  |
|                                   | national performance standards    |
|                                   | for essential public health       |
|                                   | services.                         |
|                                   |                                   |
|                                   | Related to Objective 23.15        |
|                                   | (Developmental) Increase the      |
|                                   | proportion of Federal, Tribal,    |
|                                   | State, and local jurisdictions    |
|                                   | that review and evaluate the      |
|                                   | extent to which their statutes,   |
|                                   | ordinances, and bylaws assure the |
|                                   | delivery of essential public      |
|                                   | health services.                  |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **DATA SOURCE(S) AND ISSUES**     | -   Attached data collection form |
|                                   |     to be completed by grantees.  |
|                                   |                                   |
|                                   | -   There is no existing national |
|                                   |     data source to measure the    |
|                                   |     extent to which MCHB          |
|                                   |     supported programs have       |
|                                   |     incorporated cultural         |
|                                   |     competence elements into      |
|                                   |     their policies, guidelines,   |
|                                   |     contracts and training.       |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **SIGNIFICANCE**                  | Over the last decade, researchers |
|                                   | and policymakers have emphasized  |
|                                   | the central influence of cultural |
|                                   | values and cultural/linguistic    |
|                                   | barriers: health seeking          |
|                                   | behavior, access to care, and     |
|                                   | racial and ethnic disparities. In |
|                                   | accordance with these concerns,   |
|                                   | cultural competence objectives    |
|                                   | have been: (1) incorporated into  |
|                                   | the MCHB strategic plan; and (2)  |
|                                   | in guidance materials related to  |
|                                   | the Omnibus Budget Reconciliation |
|                                   | Act of 1989 (OBRA '89), which is  |
|                                   | the legislative mandate that      |
|                                   | health programs supported by MCHB |
|                                   | Children with Special Health Care |
|                                   | Needs (CSHCN) provide and promote |
|                                   | family centered, community‑based, |
|                                   | coordinated care.                 |
+-----------------------------------+-----------------------------------+

> OMB #0915-0272
>
> Exp. 1-31-2006

**DATA COLLECTION FORM FOR DETAIL SHEET #10**

Using a scale of 0-3, please rate the degree to which your grant program
has incorporated the following cultural competence elements into your
policies, guidelines, contracts and training.

+------+------+------+------+------------------------------------------+
| *    | *    | *    | *    | **Element**                              |
| *0** | *1** | *2** | *3** |                                          |
+------+------+------+------+------------------------------------------+
|      |      |      |      | **CORE FUNCTIONS:** Our organization     |
|      |      |      |      | incorporates the following culturally    |
|      |      |      |      | competent core function elements:        |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 1.  Performs needs/assets assessments    |
|      |      |      |      |     with the culturally diverse groups   |
|      |      |      |      |     we serve.                            |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 2.  Collects and analyzes data according |
|      |      |      |      |     to different cultural groups (e.g.   |
|      |      |      |      |     race, ethnicity, language).          |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 3.  Designs services to meet the needs   |
|      |      |      |      |     of culturally diverse groups (e.g.   |
|      |      |      |      |     use of traditional healers, flexible |
|      |      |      |      |     times of services, language          |
|      |      |      |      |     services).                           |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 4.  Uses data on different groups for    |
|      |      |      |      |     program development.                 |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 5.  Considers barriers and the provision |
|      |      |      |      |     of appropriate strategies to address |
|      |      |      |      |     them.                                |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 6.  Evaluates and monitors quality       |
|      |      |      |      |     services (via customer satisfaction  |
|      |      |      |      |     surveys, focus groups, chart         |
|      |      |      |      |     reviews).                            |
+------+------+------+------+------------------------------------------+
|      |      |      |      | Is there a policy to incorporate         |
|      |      |      |      | cultural competence in the core          |
|      |      |      |      | functions? *None\_\_\_ Informal\_\_\_    |
|      |      |      |      | Formal\_\_\_ In process\_\_\_*           |
+------+------+------+------+------------------------------------------+
|      |      |      |      | **TRAINING/HUMAN RESOURCES**: Our        |
|      |      |      |      | organization incorporates the following  |
|      |      |      |      | culturally competent training/human      |
|      |      |      |      | resource elements:                       |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 1.  Employs a culturally diverse and     |
|      |      |      |      |     linguistically and culturally        |
|      |      |      |      |     competent staff.                     |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 2.  Ensures the provision of training,   |
|      |      |      |      |     both in orientation and ongoing      |
|      |      |      |      |     professional development, for staff, |
|      |      |      |      |     volunteers, contractors and          |
|      |      |      |      |     subcontractors in the area of        |
|      |      |      |      |     cultural and linguistic competence.  |
+------+------+------+------+------------------------------------------+
|      |      |      |      | Is there a policy to incorporate         |
|      |      |      |      | cultural competence in training and      |
|      |      |      |      | human resources?                         |
|      |      |      |      |                                          |
|      |      |      |      | *None\_\_\_ Informal\_\_\_ Formal\_\_\_  |
|      |      |      |      | In process\_\_\_*                        |
+------+------+------+------+------------------------------------------+
|      |      |      |      | **COLLABORATION:** Our organization      |
|      |      |      |      | collaborates with informal community     |
|      |      |      |      | leaders/groups (e.g. natural networks,   |
|      |      |      |      | informal leaders, spiritual leaders,     |
|      |      |      |      | ethnic media, family advocacy groups) in |
|      |      |      |      | various aspects of the following         |
|      |      |      |      | categories::                             |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 1.  Program planning                     |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 2.  Service delivery                     |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 3.  Evaluation/monitoring of services    |
+------+------+------+------+------------------------------------------+
|      |      |      |      | **COLLABORATION:** Our organization      |
|      |      |      |      | collaborates with families of culturally |
|      |      |      |      | diverse groups in various aspects of the |
|      |      |      |      | following categories:                    |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 4.  Program planning                     |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 5.  Service delivery                     |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 6.  Evaluation/monitoring of services    |
+------+------+------+------+------------------------------------------+
|      |      |      |      | Is there a policy to support the above   |
|      |      |      |      | mentioned collaborative activities?      |
|      |      |      |      | *None\_\_\_ Informal\_\_\_ Formal\_\_\_  |
|      |      |      |      | In process\_\_\_*                        |
+------+------+------+------+------------------------------------------+

+------+------+------+------+------------------------------------------+
|      |      |      |      | **RESOURCE ALLOCATION:** Our             |
|      |      |      |      | organization's allocation of resources   |
|      |      |      |      | adequately meets the unique access,      |
|      |      |      |      | information and service needs of         |
|      |      |      |      | culturally diverse groups in the         |
|      |      |      |      | following program areas:                 |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 1.  Planning                             |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 2.  Implementation                       |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 3.  Evaluation/Monitoring (e.g. customer |
|      |      |      |      |     satisfaction surveys, focus groups)  |
+------+------+------+------+------------------------------------------+
|      |      |      |      | Is there a policy to support the         |
|      |      |      |      | allocation of fiscal resources for the   |
|      |      |      |      | needs and services for culturally        |
|      |      |      |      | diverse groups?                          |
|      |      |      |      |                                          |
|      |      |      |      | *None\_\_\_ Informal\_\_\_ Formal\_\_\_  |
|      |      |      |      | In process\_\_\_*                        |
+------+------+------+------+------------------------------------------+
|      |      |      |      | **CONTRACTS:** Our agency puts language  |
|      |      |      |      | in contracts that addresses our goals to |
|      |      |      |      | incorporate cultural competence for      |
|      |      |      |      | culturally and linguistically diverse    |
|      |      |      |      | groups in the following areas**:**       |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 1.  Needs/assets assessments             |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 2.  Outreach                             |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 3.  Specialized services                 |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 4.  Training for                         |
|      |      |      |      |     contractors/subcontractors           |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 5.  Sufficient funds to support 1-4      |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 6.  Reporting requirements 1-4           |
+------+------+------+------+------------------------------------------+
|      |      |      |      | Is there a policy to support monitoring  |
|      |      |      |      | of contractors/ subcontractors?          |
|      |      |      |      |                                          |
|      |      |      |      | *None\_\_\_ Informal\_\_\_ Formal\_\_\_  |
|      |      |      |      | In process\_\_\_*                        |
+------+------+------+------+------------------------------------------+

0=Not Met

1=Partially Met

2=Mostly Met

3=Completely Met

Total the numbers in the boxes (possible 0‑69 score)
\_\_\_\_\_\_\_\_\_\_

> OMB #0915-0272

Exp. 1-31-2006

+-----------------------------------+-----------------------------------+
| **[16 PERFORMANCE                 | The degree to which grantees have |
| MEASURE]{.underline}**            | assisted States                   |
|                                   |                                   |
| **Level: Grantee**                | in increasing the percent of      |
|                                   | children with special health care |
| **Category: CSHN/Health           | needs, age 0 to 18, whose         |
| Insurance**                       | families have adequate private    |
|                                   | and/or public insurance to pay    |
|                                   | for needed services.              |
+-----------------------------------+-----------------------------------+
| #### GOAL                         | To increase the percent of        |
|                                   | children with special health care |
|                                   | needs with adequate insurance     |
|                                   | coverage for primary care,        |
|                                   | specialty care, inpatient, and    |
|                                   | enabling services.                |
+-----------------------------------+-----------------------------------+
| #### MEASURE                      | The degree to which grantees have |
|                                   | assisted States                   |
|                                   |                                   |
|                                   | in improving access to adequate   |
|                                   | health insurance                  |
|                                   |                                   |
|                                   | for children with special health  |
|                                   | care needs in the state and       |
|                                   | nationally.                       |
+-----------------------------------+-----------------------------------+
| **DEFINITION**                    | Attached is a checklist of 4      |
|                                   | elements that demonstrate how a   |
|                                   | grantee has assisted their State  |
|                                   | in improving access to adequate   |
|                                   | health insurance for children     |
|                                   | with special health care needs.   |
|                                   | Please check the degree to which  |
|                                   | the elements have been            |
|                                   | implemented.                      |
+-----------------------------------+-----------------------------------+
| #                                 | Related to Objective 16.23:       |
| ### HEALTHY PEOPLE 2010 OBJECTIVE | Increase the proportion of States |
|                                   | and jurisdictions that have       |
|                                   | service systems for children with |
|                                   | or at risk of chronic and         |
|                                   | disabling conditions as required  |
|                                   | by Public Law 101-239.            |
+-----------------------------------+-----------------------------------+
| **DATA SOURCE(S) AND ISSUES**     | -   Attached data collection form |
|                                   |     to be completed by grantees.  |
|                                   |                                   |
|                                   | -   The data collection form      |
|                                   |     represents a menu of          |
|                                   |     strategies by which grantees  |
|                                   |     may assist States in          |
|                                   |     improving access to adequate  |
|                                   |     health insurance for children |
|                                   |     with special health care      |
|                                   |     needs.                        |
+-----------------------------------+-----------------------------------+
| **SIGNIFICANCE**                  | Children with special health care |
|                                   | needs often require an amount and |
|                                   | type of care beyond that required |
|                                   | by typically developing children, |
|                                   | and are more likely to incur      |
|                                   | catastrophic expenses. This       |
|                                   | population of children and        |
|                                   | families often have               |
|                                   | disproportionately low incomes    |
|                                   | and, therefore, are at higher     |
|                                   | risk of being uninsured. Since    |
|                                   | children are more likely to       |
|                                   | obtain health care if they are    |
|                                   | insured, insurance coverage and   |
|                                   | the content of that coverage is   |
|                                   | an important indicator of access  |
|                                   | to care. Because children with    |
|                                   | special health care needs often   |
|                                   | require more and different        |
|                                   | services than typically           |
|                                   | developing children,              |
|                                   | under-insurance is a major factor |
|                                   | in determining adequacy of        |
|                                   | coverage.                         |
+-----------------------------------+-----------------------------------+

> OMB #0915-0272
>
> Exp. 1-31-2006
>
> DATA COLLECTION FORM FOR DETAIL SHEET #16

Using a scale of 0-3, indicate the degree to which your grant has
assisted the State to improve access to adequate health insurance
coverage for primary care, specialty care, inpatient and enabling
services for children with special health care needs.

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

                                      1\. **Access to adequate health
                                      insurance for children with special
                                      health care needs:** The grantee was
                                      able to assist the State in
                                      improving access to adequate health
                                      insurance coverage by: 1) decreasing
                                      the number of children with special
                                      health care needs without insurance;
                                      and/or 2) increasing the number of
                                      children with special health care
                                      needs with access to insurance that
                                      meets their needs; and/ or
                                      3)improving the financing and
                                      reimbursement of services needed by
                                      children with special health care.

                                      2\. **Statewide:** The grantee was
                                      able to successfully assist the
                                      State in implementing activities on
                                      a statewide basis.

                                      3\. **Collaboration**: The grantee
                                      was able to assist the State in
                                      developing partnerships and
                                      collaborating with key stakeholders
                                      in the state, such as State agencies
                                      (e.g., Medicaid agencies, State
                                      insurance commissioners), health
                                      insurance companies/managed care
                                      organizations, provider
                                      organizations (e.g. hospitals,
                                      physician groups); employers,
                                      unions, and other employee related
                                      organizations; families and consumer
                                      groups.

                                      4\. **Dissemination**: The grantee
                                      participates in activities to
                                      disseminate the project's results,
                                      products, and materials to local,
                                      state and/or national audiences.
  -------- -------- -------- -------- ------------------------------------

0=Not Met

1=Partially Met

2=Mostly Met

3=Completely Met

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

> OMB #0915-0272
>
> Exp. 1-31-2006

+-----------------------------------+-----------------------------------+
| #### [19                          | The degree to which grantees have |
|  PERFORMANCE MEASURE]{.underline} | assisted States in                |
|                                   |                                   |
| **Level: Grantee**                | increasing the percent of         |
|                                   | children with special health care |
| **Category: CSHN/Medical Home**   | needs age 0 to 18 who receive     |
|                                   | coordinated, ongoing,             |
|                                   | comprehensive care within a       |
|                                   | medical home.                     |
+-----------------------------------+-----------------------------------+
| **GOAL**                          | To increase the number of         |
|                                   | children with special health care |
|                                   | needs in the State and nationally |
|                                   | who have a medical home.          |
+-----------------------------------+-----------------------------------+
| **MEASURE**                       | The degree to which grantees have |
|                                   | assisted States in achieving      |
|                                   | access to a medical home for all  |
|                                   | children with special health care |
|                                   | needs in the State and            |
|                                   | nationally.                       |
+-----------------------------------+-----------------------------------+
| **DEFINITION**                    | Attached is a checklist of 5      |
|                                   | elements that demonstrate how a   |
|                                   | grantee has assisted their State  |
|                                   | in achieving access to a medical  |
|                                   | home for children with special    |
|                                   | health care needs. Please check   |
|                                   | the degree to which the elements  |
|                                   | have been implemented.            |
|                                   |                                   |
|                                   | The MCHB uses the AAP definition  |
|                                   | of "medical home." The definition |
|                                   | establishes that the medical care |
|                                   | of infants, children and          |
|                                   | adolescents should be accessible, |
|                                   | continuous, comprehensive, family |
|                                   | centered, coordinated and         |
|                                   | compassionate. It should be       |
|                                   | delivered or directed by          |
|                                   | well‑trained physicians who are   |
|                                   | able to manage or facilitate      |
|                                   | essentially all aspects of        |
|                                   | pediatric care. The physician     |
|                                   | should be known to the child and  |
|                                   | family and should be able to      |
|                                   | develop a relationship of mutual  |
|                                   | responsibility and trust with     |
|                                   | them. (AAP, Volume 90, No. 5,     |
|                                   | 11/92).                           |
+-----------------------------------+-----------------------------------+
| **HEALTHY PEOPLE 2010 OBJECTIVE** | Related to Objective 16.22:       |
|                                   | (Developmental): Increase the     |
|                                   | proportion of children with       |
|                                   | special health care needs who     |
|                                   | have access to a medical home.    |
+-----------------------------------+-----------------------------------+
| **DATA SOURCE(S) AND ISSUES**     | -   Attached data collection form |
|                                   |     to be completed by grantees.  |
|                                   |                                   |
|                                   | ```{=html}                        |
|                                   | <!-- -->                          |
|                                   | ```                               |
|                                   | -   The data collection form      |
|                                   |     represents a menu of          |
|                                   |     strategies by which grantees  |
|                                   |     may assist States in          |
|                                   |     achieving access to a medical |
|                                   |     home for children with        |
|                                   |     special health care needs.    |
+-----------------------------------+-----------------------------------+
| **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     |
|                                   | preventive 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.          |
+-----------------------------------+-----------------------------------+

> OMB #0915-0272
>
> Exp. 1-31-2006
>
> **DATA COLLECTION FORM FOR DETAIL SHEET #19**

Using a scale of 0-3, indicate the degree to which your grant has
assisted the State to develop and implement medical home provision.

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

                                      **1. Establishment of Medical Home
                                      Practice Sites** -- Through
                                      implementation of grantee
                                      activities, the number of medical
                                      home practice sites in the State has
                                      been increased.

                                      **2. Primary Care Providers Receive
                                      Training in the Medical Home
                                      Concept** - The grantee has assisted
                                      the State to provide training in the
                                      medical home concept to primary care
                                      providers throughout the State.

                                      **3. Development of Medical Home
                                      Information Tools** -- The grantee
                                      has assisted the State to develop
                                      communications tools, including
                                      kits, brochures and internet
                                      websites accessible to other states
                                      and promoted the medical home
                                      concept.

                                      **4.Mentoring of Other States** --
                                      The grantee has assisted the State
                                      to provide mentorship activities to
                                      other States in support of fostering
                                      the medical home concept nationally.

                                      **5. Development of Medical Home CQI
                                      Tools --** The grantee has assisted
                                      the State to develop evaluation
                                      tools to continuously monitor the
                                      progress of care coordination in
                                      medical homes in the State, which
                                      may be used on a national basis.
  -------- -------- -------- -------- ------------------------------------

0=Not Met

1=Partially Met

2=Mostly Met

3=Completely Met

Total the numbers in the boxes (possible 0-15
score)\_\_\_\_\_\_\_\_\_\_\_\_\_

> OMB #0915-0272
>
> Exp. 1-31-2006

+-----------------------------------+-----------------------------------+
| **[23 PERFORMANCE                 | The degree to which grantees have |
| MEASURE]{.underline}**            | assisted States in increasing the |
|                                   | percentage of children who are    |
| **Level: Grantee**                | screened early and continuously   |
|                                   | for special health care needs and |
| **Category: CSHN/Screening**      | linked to medical homes,          |
|                                   | appropriate follow-up, and early  |
|                                   | intervention.                     |
+-----------------------------------+-----------------------------------+
| **GOAL**                          | To assure early and continuous    |
|                                   | screening and early intervention  |
|                                   | for all children for special      |
|                                   | health care needs.                |
+-----------------------------------+-----------------------------------+
| **MEASURE**                       | The degree to which grantees have |
|                                   | assisted States in enhancing the  |
|                                   | early and continuous screening,   |
|                                   | followed by early intervention    |
|                                   | for all children with special     |
|                                   | health care needs.                |
+-----------------------------------+-----------------------------------+
| **DEFINITION**                    | Attached is a checklist of 6      |
|                                   | elements that demonstrate         |
|                                   | progress toward implementing a    |
|                                   | coordinated and comprehensive     |
|                                   | State system to assure early and  |
|                                   | continuous screening and early    |
|                                   | intervention for all children for |
|                                   | special health care needs. Please |
|                                   | check the degree to which the     |
|                                   | elements have been implemented.   |
|                                   | The answer scale is 0-18. Please  |
|                                   | keep the completed checklist      |
|                                   | attached.                         |
+-----------------------------------+-----------------------------------+
| **HEALTHY PEOPLE 2010 OBJECTIVE** | Related to Objectives 16.20:      |
|                                   | (Developmental) Ensure            |
|                                   | appropriate newborn bloodspot     |
|                                   | screening, follow-up testing, and |
|                                   | referral to services.             |
|                                   |                                   |
|                                   | Related to Objectives 16.21:      |
|                                   | (Developmental) Reduce            |
|                                   | hospitalization for               |
|                                   | life-threatening sepsis among     |
|                                   | children aged 4 years and under   |
|                                   | with sickling hemoglobinopathies. |
|                                   |                                   |
|                                   | Related to Objectives 28.1-4 :    |
|                                   | (Developmental) Increase the      |
|                                   | proportion of persons who have a  |
|                                   | dilated eye examination at        |
|                                   | appropriate intervals;            |
|                                   | (Developmental) Increase the      |
|                                   | proportion of preschool children  |
|                                   | aged 5 years and under who        |
|                                   | receive vision screening;         |
|                                   | (Developmental) Reduce            |
|                                   | uncorrected visual impairment due |
|                                   | to refractive errors; Reduce      |
|                                   | blindness and visual impairment   |
|                                   | in children and adolescents aged  |
|                                   | 17 years and under.               |
|                                   |                                   |
|                                   | Related to Objectives 28.11-14:   |
|                                   | (Developmental) Increase the      |
|                                   | proportion of newborns who are    |
|                                   | screened for hearing loss by age  |
|                                   | 1 month, have audiologic          |
|                                   | evaluation by age 3 months, and   |
|                                   | are enrolled in appropriate       |
|                                   | intervention services by age 6    |
|                                   | months; Reduce otitis media in    |
|                                   | children and adolescents;         |
|                                   | (Developmental) Increase access   |
|                                   | by persons who have hearing       |
|                                   | impairments to hearing            |
|                                   | rehabilitation services and       |
|                                   | adaptive devices, including       |
|                                   | hearing aids, cochlear implants,  |
|                                   | or tactile or other assistive or  |
|                                   | augmentative devices;             |
|                                   | (Developmental) Increase the      |
|                                   | proportion of persons who have    |
|                                   | had a hearing examination on      |
|                                   | schedule.                         |
+-----------------------------------+-----------------------------------+
| **DATA SOURCE(S) AND ISSUES**     | -   Attached data collection form |
|                                   |     to be completed by grantees.  |
+-----------------------------------+-----------------------------------+
| **SIGNIFICANCE**                  | Screening programs for newborns   |
|                                   | and children have been shown to   |
|                                   | be cost-effective and successful  |
|                                   | and have been shown to prevent    |
|                                   | mortality and morbidity. Their    |
|                                   | success reflects the systems      |
|                                   | approach from early screening to  |
|                                   | appropriate early intervention    |
|                                   | and treatment.                    |
+-----------------------------------+-----------------------------------+

> OMB #0915-0272
>
> Exp. 1-31-2006

**DATA COLLECTION FORM FOR DETAIL SHEET #23**

Using a scale of 0-3, indicate the degree to which your grant program
has assisted States in enhancing early and continuous screening,
followed by early intervention for all children with special health care
needs.

+---+---+---+---+------------------------------------------------------------+
| * | * | * | * | **Element**                                                |
| * | * | * | * |                                                            |
| 0 | 1 | 2 | 3 |                                                            |
| * | * | * | * |                                                            |
| * | * | * | * |                                                            |
+---+---+---+---+------------------------------------------------------------+
|   |   |   |   | 1)  The grantee has assisted the State to expand or        |
|   |   |   |   |     enhance its programs for early and continuous          |
|   |   |   |   |     screening and intervention and treatment to identify   |
|   |   |   |   |     and treat all children with SHCN.                      |
|   |   |   |   |                                                            |
|   |   |   |   |     a.  Number of infants screened for inherited or other  |
|   |   |   |   |         congenital disorders                               |
|   |   |   |   |                                                            |
|   |   |   |   |     b.  Conditions screened (yes/no)                       |
|   |   |   |   |                                                            |
|   |   |   |   |         i.  Hearing loss                                   |
|   |   |   |   |                                                            |
|   |   |   |   |         ii. PKU                                            |
|   |   |   |   |                                                            |
|   |   |   |   |         iii. Hemoglobinopathies                            |
|   |   |   |   |                                                            |
|   |   |   |   |         iv. Hypothyroidism                                 |
|   |   |   |   |                                                            |
|   |   |   |   |         v.  Congenital Adrenal Hyperplasia                 |
|   |   |   |   |                                                            |
|   |   |   |   |         vi. MSUD                                           |
|   |   |   |   |                                                            |
|   |   |   |   |         vii. MCAD                                          |
|   |   |   |   |                                                            |
|   |   |   |   |         viii. Biotinidase                                  |
|   |   |   |   |                                                            |
|   |   |   |   |         ix. Cystic Fibrosis                                |
|   |   |   |   |                                                            |
|   |   |   |   |         x.  Galactosemia                                   |
+---+---+---+---+------------------------------------------------------------+
|   |   |   |   | 1)  The grantee has assisted the State to establish,       |
|   |   |   |   |     maintain and coordinate state based surveillance       |
|   |   |   |   |     systems to identify infants and children with SHCN     |
|   |   |   |   |     (e.g., birth defects, newborn screening, EPSDT,        |
|   |   |   |   |     hearing screening, vision screening).                  |
+---+---+---+---+------------------------------------------------------------+
|   |   |   |   | 2)  The grantee has assisted the State to develop and      |
|   |   |   |   |     promote policies for early and continuous screening    |
|   |   |   |   |     and intervention and treatment for children identified |
|   |   |   |   |     with SHCN.                                             |
|   |   |   |   |                                                            |
|   |   |   |   |     a.  Does the State have a Newborn Screening Advisory   |
|   |   |   |   |         Committee                                          |
|   |   |   |   |                                                            |
|   |   |   |   |     b.  Does the State have procedures for informed        |
|   |   |   |   |         consent                                            |
|   |   |   |   |                                                            |
|   |   |   |   |     c.  Does the state have procedures for genetic         |
|   |   |   |   |         counseling for families with a infant screened     |
|   |   |   |   |         positive in a newborn screening program            |
+---+---+---+---+------------------------------------------------------------+
|   |   |   |   | 3)  The grantee has assisted the State to ensure that all  |
|   |   |   |   |     infants with test results that screen positive will    |
|   |   |   |   |     have confirmatory diagnosis as early as possible.      |
+---+---+---+---+------------------------------------------------------------+
|   |   |   |   | 4)  The grantee has assisted the State to ensure that all  |
|   |   |   |   |     infants who screen positive are linked to a medical    |
|   |   |   |   |     home.                                                  |
+---+---+---+---+------------------------------------------------------------+
|   |   |   |   | 5)  The grantee has assisted the State to ensure that all  |
|   |   |   |   |     infants who are identified to be at risk for           |
|   |   |   |   |     developmental disability will be enrolled in a program |
|   |   |   |   |     of early intervention by 6 months of age               |
+---+---+---+---+------------------------------------------------------------+
|   |   |   |   | 6)  The grantee has assisted the State to leverage         |
|   |   |   |   |     resources to adequately fund public health approaches  |
|   |   |   |   |     to early and continuous screening and intervention and |
|   |   |   |   |     treatment for children identified with SHCN.           |
|   |   |   |   |                                                            |
|   |   |   |   |     a.  Does the state fund medical foods for infants      |
|   |   |   |   |         identified with a metabolic disorder such as PKU   |
+---+---+---+---+------------------------------------------------------------+
|   |   |   |   | 7)  The grantee has assisted the State to ensure that all  |
|   |   |   |   |     infants to be at risk for a special health care need   |
|   |   |   |   |     will be linked to a family to family support network.  |
|   |   |   |   |                                                            |
|   |   |   |   |     a.  Number of diagnosed infants referred to family-to  |
|   |   |   |   |         family support                                     |
+---+---+---+---+------------------------------------------------------------+

0= Not Met

1=Partially Met

2=Partially Met

3=Completely Met

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

> OMB #0915-0272
>
> Exp. 1-31-2006

+-----------------------------------+-----------------------------------+
| #### [31                          | The degree to which grantees have |
|  PERFORMANCE MEASURE]{.underline} | assisted States in organizing     |
|                                   | community-based service systems   |
| **Goal 4: Improve the Health      | so that families of children with |
| Infrastructure and Systems of     | special health care needs can use |
| Care**                            | them easily.                      |
|                                   |                                   |
| **(Assist states and communities  |                                   |
| to plan and develop               |                                   |
| comprehensive, integrated health  |                                   |
| services systems)**               |                                   |
|                                   |                                   |
| **Level: Grantee**                |                                   |
|                                   |                                   |
| **Category: CSHN/Infrastructure** |                                   |
+-----------------------------------+-----------------------------------+
| **GOAL**                          | To assure access to integrated    |
|                                   | community systems of care for     |
|                                   | children with special health care |
|                                   | needs.                            |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **MEASURE**                       | The degree to which grantees have |
|                                   | assisted states in developing     |
|                                   | integrated systems of care for    |
|                                   | children with special health care |
|                                   | needs.                            |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| #### DEFINITION                   | Attached is a checklist of 4      |
|                                   | elements that demonstrate the     |
|                                   | degree to which grantees have     |
|                                   | assisted States to develop        |
|                                   | integrated systems of care for    |
|                                   | children with special health care |
|                                   | needs. Please check the degree to |
|                                   | which the elements have been      |
|                                   | implemented.                      |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **HEALTHY PEOPLE 2010 OBJECTIVE** | Related to Objective 16.23:       |
|                                   | Increase the proportion of States |
|                                   | and jurisdictions that have       |
|                                   | service systems for children with |
|                                   | or at risk for chronic and        |
|                                   | disabling conditions as required  |
|                                   | by Public Law 101-239.            |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **DATA SOURCE(S) AND ISSUES**     | -   Attached data collection form |
|                                   |     to be completed by grantees.  |
|                                   |                                   |
|                                   | -   The National CSHCN Survey     |
|                                   |     will provide national and     |
|                                   |     state estimates on the extent |
|                                   |     to which families perceive    |
|                                   |     that integrated community     |
|                                   |     systems of care are available |
|                                   |     to their child with a special |
|                                   |     health care need.             |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **SIGNIFICANCE**                  | Families, service agencies and    |
|                                   | the Federal Interagency           |
|                                   | Coordinating Council (FICC) have  |
|                                   | identified major challenges       |
|                                   | confronting families in accessing |
|                                   | coordinated health and related    |
|                                   | services that families need for   |
|                                   | their children with special       |
|                                   | health care needs. Differing      |
|                                   | eligibility criteria, duplication |
|                                   | and gaps in services, inflexible  |
|                                   | funding streams and poor          |
|                                   | coordination among service        |
|                                   | agencies are concerns across most |
|                                   | States. This effort should        |
|                                   | provide model strategies for      |
|                                   | addressing these issues.          |
+-----------------------------------+-----------------------------------+

> OMB #0915-0272
>
> Exp. 1-31-2006

###### DATA COLLECTION FOR FORM FOR DETAIL SHEET #31

Using the scale below, indicate the degree to which your grant has
assisted States to develop and implement an integrated system of care
for children with special health needs.

+------+------+------+------+------------------------------------------+
| **N  | *    | *    | *    | **Element**                              |
| /A** | *1** | *2** | *3** |                                          |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 1.  **State Collaboration with Other     |
|      |      |      |      |     State Agencies and Private           |
|      |      |      |      |     Organizations:** The grantee has     |
|      |      |      |      |     assisted the State to establish and  |
|      |      |      |      |     maintain an ongoing interagency      |
|      |      |      |      |     collaborative process for the        |
|      |      |      |      |     assessment of needs with respect to  |
|      |      |      |      |     the development of community-based   |
|      |      |      |      |     systems of care for CSHCN. State     |
|      |      |      |      |     programs collaborate with other      |
|      |      |      |      |     agencies and organizations in the    |
|      |      |      |      |     formulation of coordinated policies, |
|      |      |      |      |     standards, data collection and       |
|      |      |      |      |     analysis, financing of services, and |
|      |      |      |      |     program monitoring to assure         |
|      |      |      |      |     comprehensive, coordinated services  |
|      |      |      |      |     for CSHCN.                           |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 2.  **State Support for Communities:**   |
|      |      |      |      |     The grantee has assisted the State   |
|      |      |      |      |     to emphasize the development of      |
|      |      |      |      |     community-based programs by          |
|      |      |      |      |     establishing and maintaining a       |
|      |      |      |      |     process for facilitating community   |
|      |      |      |      |     systems building through mechanisms  |
|      |      |      |      |     such as technical assistance and     |
|      |      |      |      |     consultation, education and          |
|      |      |      |      |     training, common data protocols, and |
|      |      |      |      |     financial resources for communities  |
|      |      |      |      |     engaged in systems development to    |
|      |      |      |      |     assure that the unique needs of      |
|      |      |      |      |     CSHCN are met.                       |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 3.  **Coordination of Health Components  |
|      |      |      |      |     of Community-Based Systems:** The    |
|      |      |      |      |     grantee has assisted the State to    |
|      |      |      |      |     develop a mechanism in communities   |
|      |      |      |      |     across the State for coordination of |
|      |      |      |      |     health services with one another.    |
|      |      |      |      |     This includes coordination among     |
|      |      |      |      |     providers of primary care,           |
|      |      |      |      |     habilitative services, other         |
|      |      |      |      |     specialty medical treatment          |
|      |      |      |      |     services, mental health services and |
|      |      |      |      |     home health care.                    |
+------+------+------+------+------------------------------------------+
|      |      |      |      | 4.  **Coordination of Health Services    |
|      |      |      |      |     with Other Services a the Community  |
|      |      |      |      |     Level:** The grantee has assisted    |
|      |      |      |      |     the State to develop a mechanism in  |
|      |      |      |      |     communities across the State for     |
|      |      |      |      |     coordination and services            |
|      |      |      |      |     integration among program serving    |
|      |      |      |      |     CSHCN, including early intervention  |
|      |      |      |      |     and special education, social        |
|      |      |      |      |     services, and family support         |
|      |      |      |      |     services.                            |
+------+------+------+------+------------------------------------------+

N/A=This item is not a planned component of the grant

1=This item is a planned component of the grant: Scheduled activities
have not begun

2=This item is a planned component of the grant: Scheduled activities
have just begun

3=This item is a planned component of the grant: Scheduled activities
are underway and timely

Total the numbers in the boxes (possible 0-12 score)\_\_\_\_\_\_\_\_\_\_

> OMB #0915-0272
>
> Exp. 1-31-2006

+-----------------------------------+-----------------------------------+
| #### [37                          | The degree to which grantees have |
|  PERFORMANCE MEASURE]{.underline} | assisted States in increasing the |
|                                   | percentage of youth with special  |
| **Goal 4: Improve the Health      | health care needs who have        |
| Infrastructure and Systems of     | received services necessary to    |
| Care**                            | make transitions to all aspects   |
|                                   | of adult life, including adult    |
| **(Work with states and           | health care, work, and            |
| communities to assure that        | independence.                     |
| services and systems of care      |                                   |
| reach targeted populations)**     |                                   |
|                                   |                                   |
| **Level: Grantee**                |                                   |
|                                   |                                   |
| **Category: CSHN/Youth**          |                                   |
+-----------------------------------+-----------------------------------+
| **GOAL**                          | To assure that youth with special |
|                                   | health care needs receive the     |
|                                   | services necessary to transition  |
|                                   | to adult health care, work, and   |
|                                   | independence.                     |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **MEASURE**                       | The degree to which grantees have |
|                                   | assisted States in ensuring that  |
|                                   | youth with special health care    |
|                                   | needs receive the services        |
|                                   | necessary to transition to adult  |
|                                   | health care, work, and            |
|                                   | independence.                     |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **DEFINITION**                    | Attached is a checklist of 3      |
|                                   | elements that demonstrate how a   |
|                                   | grantee has assisted their State  |
|                                   | in ensuring appropriate           |
|                                   | transition for adolescents with   |
|                                   | special health care needs. Please |
|                                   | check the degree to which the     |
|                                   | elements have been implemented.   |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **HEALTHY PEOPLE 2010 OBJECTIVE** | Related to Objective 16.23:       |
|                                   | Increase the proportion of States |
|                                   | and jurisdictions that have       |
|                                   | service systems for children with |
|                                   | or at risk for chronic and        |
|                                   | disabling conditions as required  |
|                                   | by Public Law 101-239.            |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **DATA SOURCE(S) AND ISSUES**     | -   Attached data collection form |
|                                   |     to be completed by grantees.  |
|                                   |                                   |
|                                   | ```{=html}                        |
|                                   | <!-- -->                          |
|                                   | ```                               |
|                                   | -   The data collection form      |
|                                   |     represents 3 elements that    |
|                                   |     demonstrate comprehensive     |
|                                   |     transition services for youth |
|                                   |     with special health care      |
|                                   |     needs.                        |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **SIGNIFICANCE**                  | The transition of youth to        |
|                                   | adulthood has become a Initiative |
|                                   | issue nation wide as evidenced by |
|                                   | the President's "New Freedom      |
|                                   | Initiative: Delivering on the     |
|                                   | Promise"(March, 2002). Over 90    |
|                                   | percent of children with special  |
|                                   | health care needs now live to     |
|                                   | adulthood, but are less likely    |
|                                   | than their non‑disabled peers to  |
|                                   | complete high school, attend      |
|                                   | college or to be employed. Health |
|                                   | and health care are cited as two  |
|                                   | of the major barriers to making   |
|                                   | successful transitions. Currently |
|                                   | SPRANS supported health and       |
|                                   | related transition services are   |
|                                   | available in only a few states.   |
|                                   | No other Federal agency is        |
|                                   | addressing these issues.          |
|                                   | Successful preparation for the    |
|                                   | adult work force is important for |
|                                   | all youth and is based on healthy |
|                                   | developmental transitions between |
|                                   |                                   |
|                                   | childhood and adolescence, and    |
|                                   | between adolescence and           |
|                                   | adulthood.                        |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+

> OMB #0915-0272 Exp. 1-31-2006

**DATA COLLECTION FORM FOR DETAIL SHEET #37**

Using the scale below, please indicate for each element the degree to
which your grant has assisted the State to provide comprehensive HRTW
services to adolescents and young adults:

+------+-------+--------+---------+----------------------------------+
| **N  | **1** | **2**  | **3**   | ###### Element                   |
| /A** |       |        |         |                                  |
+------+-------+--------+---------+----------------------------------+
|      |       |        |         | A.  The grantee has assisted the |
|      |       |        |         |     State to improve coordinated |
|      |       |        |         |     transition from pediatric to |
|      |       |        |         |     adult primary care providers |
|      |       |        |         |     for adolescents with special |
|      |       |        |         |     health care needs in the     |
|      |       |        |         |     State.                       |
+------+-------+--------+---------+----------------------------------+
|      |       |        |         | B.  The grantee has assisted the |
|      |       |        |         |     State to provide health      |
|      |       |        |         |     representation at transition |
|      |       |        |         |     planning meetings aimed at   |
|      |       |        |         |     education/ employment/       |
|      |       |        |         |     independence.                |
+------+-------+--------+---------+----------------------------------+
|      |       |        |         | C.  The grantee has assisted the |
|      |       |        |         |     State to provide             |
|      |       |        |         |     self‑advocacy/determination  |
|      |       |        |         |     training in terms of         |
|      |       |        |         |     managing one's own health    |
|      |       |        |         |     care.                        |
+------+-------+--------+---------+----------------------------------+

NA=This item is not a planned component of the grant

1=This item is a planned component of the grant: Scheduled activities
have not begun

2=This item is a planned component of the grant: Scheduled activities
have just begun

3=This item is a planned component of the grant: Scheduled activities
are underway and timely

Total the numbers in the boxes (possible 0-09 score)\_\_\_\_\_\_\_\_\_\_

> OMB #0915-0272
>
> Exp. 1-31-2006

[ATTACHMENT "2"]{.underline}

PART 2

Financial and Demographic Data Elements

FORM 1: MCHB PROJECT BUDGET DETAILS AND INSTRUCTIONS

FORM 2: PROJECT FUNDING PROFILE AND INSTRUCTIONS

#### FORM 4: PROJECT BUDGET AND EXPENDITURES: By Types Of Services 

AND INSTRUCTIONS

FORM 6: MATERNAL & CHILD HEALTH DISCRETIONARY GRANT

PROJECT ABSTRACT AND INSTRUCTIONS

FORM 7: DISCRETIONARY GRANT PROJECT SUMMARY DATA AND INSTRUCTIONS

**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)

> A. 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 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \$\_\_\_\_\_\_\_\_

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

2\) Primary Care \$\_\_\_\_\_\_\_\_

3\) Health Professions \$\_\_\_\_\_\_\_\_

4\) Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \$\_\_\_\_\_\_\_\_

C. Other Federal Funds

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

2\) SSI \$\_\_\_\_\_\_\_\_

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

4\) ACF \$\_\_\_\_\_\_\_\_

5\) CDC \$\_\_\_\_\_\_\_\_

6\) SAMHSA \$\_\_\_\_\_\_\_\_

7\) NIH \$\_\_\_\_\_\_\_\_

8\) Education \$\_\_\_\_\_\_\_\_

9\) Other: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \$\_\_\_\_\_\_\_\_

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

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

OMB #0915-0272**/**Exp. 1-31-2006

**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.

> OMB #0915-0272
>
> Exp. 1-31-2006

**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 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)*

> OMB #0915-0272
>
> Exp. 1-31-2006

**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.
>
> OMB #0915-0272
>
> Exp. 1-31-2006

#### 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}** \$ \$ \$ \$
[\_\_\_\_\_\_\_\_\_]{.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} 

> OMB #0915-0272
>
> Exp. 1-31-2006

**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.

> OMB #0915-0272
>
> Exp. 1-31-2006
>
> **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

#### ANNOTATION

> OMB #0915-0272
>
> Exp. 1-31-2006
>
> **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 Initiative 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.
>
> OMB #0915-0272
>
> Exp. 1-31-2006
>
> **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)**

#########  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ {#section-2}

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

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

######### **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

> OMB #0915-0272
>
> Exp. 1-31-2006
>
> **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-3}

#### 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.

> OMB #0915-0272
>
> Exp. 1-31-2006

[ATTACHMENT "3"]{.underline}

PART 3

Additional Data Elements

**Children with Special Health Needs Data Elements**

**Children with Special Health Needs Data Elements**

1\. Are you involved in a broad statewide process for implementation of
the 10-Year Action Plan to Achieve Community-Based Service Systems for
Children and Youth with Special Health Care Needs and Their Families?

\[ \] Yes \[ \] No

If yes, how are you involved? (Check ALL that apply below)

\[ \] Participate in a state-level task force or work group on
implementation

\[ \] Work with other state agencies on implementation activities

\[ \] Work with other partners (e.g., American Academy of Pediatrics,
March of Dimes) on implementation activities

> \[ \] Provide technical assistance, consultation, education, and or
> training to communities engaged in system development
>
> \[ \] Provide financial resources to communities for systems
> development
>
> \[ \] Other
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\. Are you working with other MCHB grants/grantees that are funded to
assist statewide implementation of the 10-Year Action Plan to Achieve
Community-Based Service Systems for Children and Youth with Special
Health Care Needs and Their Families either in your State or in other
States?

\[ \] Yes \[ \] No

If yes, which ones? (Check ALL that apply below)

\[ \] Family-to-family support

\[ \] Medical home

\[ \]Insurance/financing

\[ \] Newborn genetic screening

\[ \] Newborn hearing screening

\[ \] Integrated systems

\[ \] Healthy and Ready to Work

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

3\. Is there a strategic planning process underway in your State?

\[ \] Yes \[ \] No

> If yes, is statewide implementation of the 10-Year Action Plan to
> Achieve Community-Based Service Systems for Children and Youth with
> Special Health Care Needs and Their Families part of the strategic
> planning process in your State?\
> \[ \] Yes \[ \] No

If yes, is your grant staff involved in that strategic planning process?

\[ \] Yes \[ \] No

4\. Is any mention of the 10-Year Action Plan to Achieve Community-Based
Service Systems for Children and Youth with Special Health Care Needs
and Their Families part of the budget planning process in your State?

\[ \] Yes \[ \] No

If yes, is your grant staff involved in that budget planning process?

\[ \] Yes \[ \] No

> OMB #0915-0272
>
> Exp. 1-31-2006

**Additional Forms**

> **[ATTACHMENT "4"]{.underline}**

**Key Personnel**

**SUPPLEMENT TO SECTION F of FORM 424A**

+--------------------+----------+------------+---------+-------------+
| NAME AND POSITION/ | ANNUAL   | NUMBER OF  | PER     | TOTAL FUNDS |
| TITLE              | SALARY   | MONTHS FOR | CENTAGE | REQUESTED   |
|                    |          | BUDGET     | TIME    |             |
+--------------------+----------+------------+---------+-------------+
|                    | \(1\)    | \(2\)      | \(3\)   | \(4\)       |
+--------------------+----------+------------+---------+-------------+
|                    | \$       |            | \%      | \$          |
+--------------------+----------+------------+---------+-------------+
| FRINGE BENEFIT     | Total    |            |         | \$          |
|                    |          |            |         |             |
| (Rate )            |          |            |         |             |
+--------------------+----------+------------+---------+-------------+

**[ATTACHMENT "5"]{.underline}**

**PROJECT ACTIVITIES TIME ALLOCATION TABLE**

**[Project Title:]{.underline}**

**[Project Director:]{.underline}**

**Budget Period: [\_\_\_\_\_]{.underline} to [\_\_\_\_\_]{.underline}
State:**

+---------------------------------+--------+--------+------------------+
| **Objectives and Approaches**   | **S    | **     | **Tra            |
|                                 | tart** | Comple | cking/Evaluation |
| **(same as Personnel Allocation |        | tion** | Methods**        |
| Chart)**                        | **     |        |                  |
|                                 | Date** | **     |                  |
|                                 |        | Date** |                  |
+---------------------------------+--------+--------+------------------+
|                                 |        |        |                  |
+---------------------------------+--------+--------+------------------+

**ATTACHMENT "6"**

**Page 1 of 2**

> **Biographical Sketch**
>
> **Give the following information for all new professional personnel
> contributing to the project in this budget period.**
>
> **(DO NOT EXCEED 2 PAGES ON ANY INDIVIDUAL)**

+-----------------------------------+--------------+-------+-----------+
| **Name (Last, first, middle       | **Title**    |       | **Birth   |
| initial)**                        |              |       | Date**    |
|                                   |              |       |           |
|                                   |              |       | **(Mo.    |
|                                   |              |       | Day       |
|                                   |              |       | Yr.)**    |
+-----------------------------------+--------------+-------+-----------+
| **Education (begin with           |              |       |           |
| baccalaureate or other initial    |              |       |           |
| professional education and        |              |       |           |
| include postdoctoral training)**  |              |       |           |
+-----------------------------------+--------------+-------+-----------+
| **Institution and Location**      | **Degree**   | **Y   | **Field   |
|                                   |              | ear** | of        |
|                                   |              |       | Study**   |
|                                   |              | **C   |           |
|                                   |              | omple |           |
|                                   |              | ted** |           |
+-----------------------------------+--------------+-------+-----------+
|                                   |              |       |           |
+-----------------------------------+--------------+-------+-----------+
| **HONORS**                        |              |       |           |
+-----------------------------------+--------------+-------+-----------+
| **MAJOR PROFESSIONAL              |              |       |           |
| INTEREST(S)**                     |              |       |           |
+-----------------------------------+--------------+-------+-----------+
| **RESEARCH AND PROFESSIONAL       |              |       |           |
| EXPERIENCE List in reverse        |              |       |           |
| chronological order previous      |              |       |           |
| employment and experience. List   |              |       |           |
| in reverse chronological order    |              |       |           |
| most representative               |              |       |           |
| publications.)**                  |              |       |           |
+-----------------------------------+--------------+-------+-----------+

**Page 2 of 2**

> **Continuation Page for**
>
> **Biographical Sketch**

  ----------------------------------- -----------------------------------
  **Name (Last, first, middle         **Social Security Number**
  initial)**                          

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