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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 communitybased clinics that include State and local health departments, hospitals, university health 

centers, independent clinics, and public and nonprofit agencies.2 OPA’s 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). 
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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 OPA’s 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. 
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• 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 OPA’s 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 OPA’s 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 office’s understanding of grantee requirements regarding reporting of 

suspected child abuse and sexual abuse, 
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• 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 
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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 
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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. 

• OPA’s 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 tool’s 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. 
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• 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 
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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