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Title X was funded at $280 million in fiscal year (FY) 2004.  Title X supports 
approximately 4,600 clinics and provides reproductive health services to roughly  
5 million persons a year.  The program provides for grants and contracts in the areas of 
service, training, research, and information/education.  The service and training grants, 
which are most relevant to our review, are described below. 
Service Grants  Title X funded service delivery grants to 86 public and private 
organizations in FY 2004. These grantees may directly provide services or contract with 
subgrantees, known as delegates, or both.  Services are delivered through community-
based clinics that include State and local health departments, hospitals, university health 
centers, independent clinics, and public and nonprofit agencies.2 OPAs 10 regional 
offices award service grants and monitor program performance.  Each grantee is 
responsible for monitoring its delegates performance.   
Training Grants  Title X training grants support 10 regional training centers and 2 clinical 
specialty training grantees.  These organizations train personnel of Title X service 
grantees and delegates to carry out family planning programs, with the clinical specialty 
training grantees focusing primarily on clinical skills needed to provide family planning 
care. 
State Reporting Laws and Title X 
Title X does not establish a requirement for program grantees to report instances of child 
abuse, child molestation, sexual abuse, rape, or incest as such. Rather, State law 
determines reporting requirements regarding these offenses.  The FY 1999 Omnibus 
Appropriations bill (P.L. 105-277 Section 219) first addressed State reporting laws and 
their relevance to Title X.  Specifically, it stated that Title X grantees were not exempt 
from State reporting requirements: 
Notwithstanding any other provision of law, no provider of services under title X 
of the Public Health Service Act shall be exempt from any State law requiring 
notification, or the reporting of child abuse, child molestation, sexual abuse, rape, 
or incest. 
The same language has been included in appropriations laws every year since 1999.  
Most recently, this language is in Section 212 of Public Law 108-447, which includes the 
appropriations for the Departments of Labor, Health and Human Services, Education, and 
related agencies for FY 2005. 
All States have laws mandating reporting of child abuse, but these State laws vary 
considerably in their definitions, scope, and procedures.3   Under the Federal Child Abuse  
2 http://opa.osophs.dhhs.gov/titlex/ofp.html, accessed 8/4/04. 
3 Abigail English and Catherine Teare, Statutory Rape Enforcement and Child Abuse Reporting:  Effects on Health 
Care Access for Adolescents, 50 DePaul L. Rev., 827, 838-840 (2001).   Page 3 - Alma L. Golden 
Prevention and Treatment Act (CAPTA), each State must have a State law or a statewide 
program that provides for the reporting of child abuse and neglect.4 The CAPTA 
provides minimum guidelines that States must incorporate in their statutory definitions of 
child abuse and neglect.5 
Based on CAPTA guidelines, each State provides its own definition of child abuse and 
neglect. States generally provide separate definitions for physical abuse, neglect, sexual 
abuse, sexual exploitation, and emotional maltreatment.  Some definitions are detailed, 
while others are general.6 
All States include sexual abuse as a form of child abuse, although the definition of sexual 
abuse varies.  For example, some States include statutory rape in their definitions of 
sexual abuse, while others do not. The definition of statutory rape and the requirements 
for reporting it also vary among States.7 
Each State designates certain individuals, typically by professional group, who are 
mandated by law to report child abuse and neglect.  These individuals include health care 
workers, school personnel, social workers, childcare providers, and law enforcement 
officers. All States have enacted statutes specifying procedures that a mandatory reporter 
must follow when making a report of child abuse or neglect.  Generally, the initial report 
may be made orally to either the child protective services agency or to a law enforcement 
agency.8 
Methodology 
The information presented in this memorandum is based on our review of relevant 
documents issued by OPA and its training grantees; a written survey of OPA regional 
office representatives; and structured interviews with representatives from OPAs central 
office, regional offices, and training grantees. 
Document Review We reviewed the following documents related to Title X program 
requirements: 
 	 January 12, 1999, memorandum from the Deputy Assistant Secretary for 
Population Affairs to the Regional Health Administrators with the subject line,  
OPA Program Instructions Series, OPA 99-1:  Compliance With State Reporting 
Laws; 
4 42 U.S.C.  5106a(b)(1)(A)(Supp. 2003); 42 U.S.C.  5106a(b)(2)(A)(i)(Supp.2003).  

5 42 U.S.C.  5106g. 

6  http://nccanch.acf.gov/general/legal/statutes/sag/define.cfm, accessed 4/21/04. 

7 English and Teare. 

8 http://nccanch.acf.gov/general/legal/statutes/sag/define.cfm, accessed 4/21/04. 
 Page 4 - Alma L. Golden 
 	 Federal Register, Vol. 69, No. 129, Wednesday, July 7, 2004, which contains the 
announcement of anticipated availability of funds for family planning service 
grants for FY 2005; 
 	 Notice of Grant Award, which is the official document notifying a grant 
applicant of funding approval and outlining the terms and conditions of the grant; 
the notice is issued to grantees every year they receive funding; 
 	 Program Guidelines for Project Grants for Family Planning Service, developed 
by OPA in January 2001 for current and future grantees; it explains project 
management and administration, client services, and clinic management;  
 	 Office of Family Planning Regional Work Plan Guidance, Fiscal Year 2004, 
which instructs the regional offices on how to develop their work plans;   
 	 Fiscal Year 2004 Regional Memorandum of Agreement, which describes the 
agreement between OPA and the regional offices on the use of Title X funds and 
program monitoring; 
 	 Title X Program Review, January 2003, which is the assessment tool used by 
all but one region in their comprehensive program reviews; 
 	 Site Visit Protocols for Conducting Program Reviews of Title X Family 
Planning Projects, Reviewers Manual, June 2003, which is the assessment tool 
used by the remaining region in its comprehensive program reviews; 
 	 Presentation materials from OPAs national conferences, September 2002 and 
July 2003; and 
 	 Training materials and meeting agendas from all 10 regional training centers and 
the 2 clinical specialty training grantees. 
Survey of Regional Offices  We conducted a written survey of the regional program 
consultants in each of the 10 regional offices. This survey included the following topics: 
 	 The number of comprehensive program reviews conducted, 
 	 The chart reviews conducted as part of the comprehensive program reviews, and 
 	 The protocols followed during chart reviews. 
Structured Interviews  We conducted structured interviews in person and by telephone 
with OPA central office representatives, the 10 OPA regional program consultants, and 
representatives from each of the 10 regional training centers and the 2 clinical specialty 
training grantees. 
Central Office  The structured interviews with representatives from OPAs central office 
included the following topics:  
 	 The purpose of Title X grants, 
 	 The roles of central office and regional offices in administering the Title X 
program, 
 	 The central offices understanding of grantee requirements regarding reporting of 
suspected child abuse and sexual abuse,  Page 5 - Alma L. Golden 
 	 The methods the central office uses to inform and monitor regional offices and 
grantees regarding State reporting requirements, and 
 	 The role of the training grantees. 
Regional Offices  The regional program consultant administers the Title X program in his 
or her region and participates in the program reviews of the grantees. The structured 
interviews with the regional program consultants included the following topics: 
 	 The content and frequency of communication between the regional office and 
grantees regarding State reporting requirements, 
 	 The extent to which the region has received guidance from the central office to 
address the reporting issue, 
 	 The role of the training grantees and the types of training the grantees have 
received, and 
 	 The extent to which the regional office monitors grantee activities and uses 
assessment tools that include State reporting requirements. 
Training Grantees  The structured interviews with the representatives from the 10 
regional training centers and the 2 clinical specialty training grantees included the 
following topics: 
 	 Training conducted about State reporting requirements, 
 	 Specific topics addressed by the training, and 
 	 Training materials and agendas related to State reporting requirements. 
Mechanisms for Informing Title X Grantees About Reporting Requirements  
OPA informs its Title X service grantees about State reporting requirements for child 
abuse and sexual abuse through a variety of methods that include written 
communications, training, and discussions: 
 	 In a memorandum dated January 12, 1999, OPA informed its regional offices 
about State reporting laws.  This memorandum explained the language that had 
been added to the appropriations bill in 1999 concerning State reporting 
requirements.  The memorandum stated that reporting and notification 
requirements referenced in the appropriations bill concern State laws; the 
authority to enforce compliance with such laws lies with the States.  It urged 
Title X grantees to consult with their own attorneys for guidance, noting that 
States laws vary. OPA instructed the regional offices to share this memorandum 
with all Title X grantees. 
 	 OPA informs grantees about State reporting requirements in its annual grant 
announcements.  Most recently, the Federal Register, Vol. 69, No. 129, July 7, 
2004, announced the anticipated availability of funds for family planning service   Page 6 - Alma L. Golden 
grants for 2005 and instructed Title X grant applicants to address the relevant 
section of the appropriations bill about State reporting requirements. 
 	 OPA issues an annual Notice of Grant Award to each Title X grantee that includes 
a statement about the State reporting requirements.  The notice restates the 
appropriations bill language and identifies it as a special condition with which the 
grantee must agree.  The notice also identifies the reporting requirements 
regarding child abuse and sexual abuse as a key issue that impacts the delivery 
of family planning services. 
 	 OPA issues a Memorandum of Agreement and Work Plan Guidance that address 
State reporting requirements to its regional offices every year.  These documents 
describe the agreement between central and regional offices on how Title X funds 
are to be used and how the program will be monitored.  They include the 
appropriations bill language and instruct the regional offices to address State 
reporting requirements in their monitoring and training of grantees.  
 	 OPA includes State reporting requirements in the training provided to grantees.  
Based on our review of training agendas and presentation materials and on our 
interviews with training center representatives, all 10 training centers include 
State reporting requirements in their training.  All training centers identify 
mandatory reporters in their training.  They also all present State-specific statutes 
and State-specific definitions of child abuse and sexual abuse in their training.  
Other training topics include identifying clients who may be at risk for sexual 
abuse, ethical issues in working with adolescents, and confidentiality 
requirements.  All 10 regional program consultants report that all their grantees 
have received training on the topic of State reporting requirements in the past 
year. 
 	 Based on our discussions with representatives from the two clinical specialty 
training grantees and a review of their training materials, these grantees also 
include State reporting requirements in their training.  They teach clinicians to 
recognize possible victims of sexual coercion or sexual violence and to follow 
appropriate procedures when dealing with such cases.  They offer training onsite 
and online to service grantees in all 10 regions. 
 	 OPA central office representatives and regional program consultants report that 
they discuss State reporting requirements. Central office representatives say that 
they discuss reporting requirements with regional staff during semiannual 
meetings.  They also hold monthly conference calls with regional staff, often 
discussing the reporting issue. In addition, all regional program consultants say 
that they discuss State reporting requirements with their grantees at least once a 
year. Seven of the ten consultants say they have these discussions 3 or more   Page 7 - Alma L. Golden 
times a year.  Five of the ten mention that they also use e-mail to distribute 
instructions or answer grantees questions and concerns on this issue.   
Reviews and Site Visits of Grantees    
OPA regional offices monitor grantees through comprehensive program reviews and 
annual site visits. Three components of the comprehensive program reviews address 
State reporting requirements: chart reviews, policy reviews, and discussions with 
grantees. Discussions between regional offices and grantees during annual site visits also 
address State reporting requirements. 
 	 OPAs policy is that the regional offices conduct a comprehensive program 
review of a grantee every 3 years to examine financial, administrative, counseling, 
and clinical issues.  The OPA central office does not issue specific guidance for 
conducting the comprehensive program reviews or the chart reviews included in 
them.  The central office approves assessment tools developed by the regional 
offices to use in the reviews. The regional program consultants report that they 
conducted a total of 27 comprehensive program reviews in the past year.     
 	 Based on our review of the assessment tools and on discussions with regional 
program consultants, all regions use an assessment tool in their comprehensive 
program reviews that includes State reporting requirements.  Nine of the ten 
regions use an assessment tool entitled Title X Program Review, which was last 
updated in January 2003.  This assessment tools Clinical Services Section 
includes a part dealing with contraceptive services entitled Adolescent Services. 
It contains an element stating, Grantee/Delegate complies with state 
requirements regarding notification or reporting of child abuse, child molestation, 
sexual abuse, rape, or incest. The assessment tool instructs the reviewer to mark 
a grantee compliant or not compliant with this element.   
The remaining region uses an assessment tool entitled Site Visit Protocols for 
Conducting Program Reviews of Title X Family Planning Projects, which was 
last updated in June 2003. The section on Adolescent Services in this assessment 
tool contains an element reading, All clinical staff have received training on 
reporting sexual abuse, molestation, etc., based upon state requirements.  The 
assessment tool instructs the reviewer to mark a grantee acceptable or 
unacceptable in this element.   
 	 Based on the comprehensive program reviews in the past year, the 10 regional 
program consultants report that they have not marked any grantees as not 
compliant or unacceptable in the State reporting requirement element in the 
assessment tool in the past year.    Page 8 - Alma L. Golden 
 	 As a part of their comprehensive program reviews, all 10 regional program 
consultants report that their regions conduct chart reviews.  The regional program 
consultants in nine of the regions report that they review the charts to determine 
whether and how the grantees are addressing State reporting requirements.  The 
regional program consultant in the remaining region reports that her region does 
not review charts to specifically determine whether and how the grantee is 
addressing State reporting requirements.  The reviewers in this region evaluate the 
chart for this element only if it is applicable to the particular case.  According to 
the regional program consultants, the 10 regional offices conducted a total of 
1,044 chart reviews in the past year.     
 	 The regional program consultants report that they use different methods for 
reviewing charts. Eight of the regional program consultants say that their 
reviewers examine the medical histories and client responses contained in the 
charts for any indication of abuse or sexual coercion.  Six regional program 
consultants say that the reviewers use the grantees policies and procedures when 
reviewing charts for reporting activity. Six regional program consultants say that 
reviewers examine the chart notes on counseling.  Five regional program 
consultants say that reviewers check if appropriate followup is documented in the 
charts when abuse is indicated. 
 	 Seven of the ten regional program consultants say that the charts are selected 
randomly for review.  The remaining three regions select purposive samples, 
based on a certain time period or on case characteristics such as client age, client 
gender, or services received. All regional program consultants say that nurses or 
nurse practitioners review the charts.  Two regional program consultants also say 
that they use physicians to review charts. 
 	 Based on the chart reviews in the past year, one regional program consultant 
reports finding one chart that documented an identified instance of child abuse, 
child molestation, sexual abuse, rape, or incest.  This region also found an 
indication that the one identified instance of abuse was reported as required by the 
applicable State requirements.  The regional program consultant in another region 
notes that grantees there found that their delegates have identified cases of abuse 
and reported them as required.  A regional program consultant in a third region 
says that reviewers found some indication that one client might have been abused 
in the past, although it was unclear from the chart if the case should have been 
reported. The regional program consultant says the issue was brought to the 
attention of the clinic director, delegate agency staff, and grantee.   
 	 All 10 regional program consultants also report that they conduct policy reviews 
and have discussions with grantees about State reporting activities as part of their 
comprehensive program reviews.  They say that the regional representatives 
determine whether grantees have policies and procedures in place that describe   Page 9 - Alma L. Golden 
when and how to report suspected abuse.  All the regional program consultants 
say that they also speak with grantee directors and staff to gain a better 
understanding of grantees knowledge of their requirements.  These discussions 
sometimes involve regional representatives presenting scenarios to clinic 
personnel to find out how a possible case of sexual abuse would be handled.   
 	 All regional program consultants report that they address Title X grantees 
reporting activities during annual site visits.  They say that they conduct a site 
visit with each grantee every year that the grantee is not undergoing a 
comprehensive program review.  During these annual visits, regional program 
consultants say they hold discussions with grantee directors and staff about their 
knowledge of reporting requirements and what policies and procedures they have 
to meet these requirements.   
Summary 
In summary, we found that OPA has informed and periodically reminds Title X grantees 
of their responsibilities regarding State child-abuse and sexual-abuse reporting 
requirements.  Furthermore, OPA includes State reporting requirements in its reviews and 
site visits of grantees. 
Agency Comments 
OPA provided comments on the draft memorandum.  OPA concurred with our findings 
and included additional information regarding its efforts to inform, train, and monitor 
grantees on this issue.  The full text of its comments is attached. 
Attachment