MATERNAL AND CHILD HEALTH 

SERVICES

TITLE V BLOCK GRANT PROGRAM

GUIDANCE AND FORMS

FOR THE

TITLE V APPLICATION/ANNUAL REPORT

OMB NO: 0915-0172

EXPIRES: March 31, 2012

U.S. Department of Health and Human Services

Health Resources and Services Administration

Maternal and Child Health Bureau

Division of State and Community Health

Room 18-31

5600 Fishers Lane, Rockville, MD 20857

(Phone 301-443-2204 FAX 301-443-9354)
2

An agency may not conduct or sponsor, and a person is not required to respond to, a 

collection of information unless it displays a currently valid OMB control number. The 

OMB control number for this project is 0915-0172. Public reporting for this collection of 

information is estimated to average 322 hours per response, including time for reviewing 

instructions, searching existing data sources, gathering and maintaining the data needed, 

and completing and reviewing the collection of information. Send comments regarding 

this burden estimate or any other aspect of this collection of information, including 

suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers 

Lane, Room 14-33, Rockville, Maryland, 20857.
3

MATERNAL AND CHILD HEALTH SERVICES

TITLE V BLOCK GRANT TO STATES PROGRAM

APPLICATION/ANNUAL REPORT/GUIDANCE

FIFTH EDITION

As one of the largest Federal block grant programs, Title V is the key source of support 

for promoting and improving the health of all the Nation‘s mothers and children. When 

Congress passed the Social Security Act in 1935, it contained the initial key landmark 

legislation which established Title V. This legislation is the origin of the Federal 

Government‘s pledge of support to States and their efforts to extend and improve health 

and welfare services for mothers and children throughout the Nation. To date, the Title 

V Federal-State partnership continues to provide a dynamic program to improve the 

health of all mothers and children, including children with special health care needs. 

Each year, all States are required to submit an Application and Annual Report for 

Federal funds for their Maternal and Child Health (MCH) Services Title V Block Grant to 

States Program to the Maternal and Child Health Bureau (MCHB) in the Health 

Resources and Services Administration (HRSA). All the information and instructions for 

the preparation and submission are contained in this Maternal and Child Health 

Services Title V Block Grant to States Program Guidance and Forms for the Title V 

Application and Annual Report (Guidance) document. The Guidance has undergone 

changes and revisions with each published edition. Over time, the previous editions of 

the Guidance represent the legislative changes and requirements passed by Congress. 

Each edition of the Guidance was developed in consultation with State Maternal and 

Child Health (MCH) Directors and Children with Special Health Care Needs (CSHCN) 

Directors. Further, each edition of the Guidance has served to provide the experience 

upon which changes are made and improvements in each subsequent edition. 

Following this tradition, this fifth edition involved a committee of State MCH and CSHCN 

Directors, public health scholars, along with parent representation, working with the 

Division of State and Community Health (DSCH) staff to create the new Guidance. As 

with previous editions, this fifth edition reflects several significant changes designed to 

both improve and facilitate the preparation and the submission of the Application and 

Annual Report by the 50 States and 9 Jurisdictions.

The major changes in this edition are revisions to PART TWO, Section II—NEEDS 

ASSESSMENT. The purpose of these revisions are: (1) To provide more complete 

information on the Background and Conceptual Framework for the Needs Assessment 

Process (Part A); (2) To clarify what State grantees are to include in the Five Year 

Needs Assessment Document (Part B); (3) To better explain the information to include 

in the Annual Needs Assessment Summary/Update, both in the year when the five year 

Needs Assessment is conducted and in interim years (Part C); and (4) To update Figure 

2, the Needs Assessment diagram, to reflect all aspects of the Needs Assessment 

process. In addition, other minor changes and clarifications are included throughout the 

document to provide more complete information and enhance instructions.
4

This is the third edition of the Guidance issued since the Title V Block Grant Application 

and Annual Report became a Web-based application. For the six consecutive years 

(2003-2008) preceding this edition, States have submitted the application via a secure 

Web-based server as authorized by HRSA. The use of this online method for 

completing and submitting the Application and Annual Reports continues to be required 

of all States. This latest edition of the Guidance will continue to enhance the quality of 

submissions and the resultant availability of data output.

Any questions and comments regarding this edition of the Guidance may be addressed 

to:

Cassie B. Lauver, ACSW, Director

Division of State and Community Health

Maternal and Child Health Bureau

Health Resources and Services Administration

Room 18-31, Parklawn Building

5600 Fishers Lane

Rockville, Maryland 20857

Telephone: (301) 443-2204

Fax: (301) 443-9354

CLauver@hrsa.gov
5

CORE PUBLIC HEALTH SERVICES

DELIVERED BY MCH AGENCIES

 MCHB/DSCH 10/20/97

Figure 1

POPULATION-BASED SERVICES:

Examples:

Newborn Screening, Lead Screening, Immunization,

Sudden Infant Death Syndrome Counseling, Oral Health,

Injury Prevention, Nutrition,

and Outreach/Public Education

INFRASTRUCTURE BUILDING SERVICES:

Examples:

Needs Assessment, Evaluation, Planning, Policy Development,

Coordination, Quality Assurance, Standards Development, Monitoring,

Training, Applied Research, Systems of Care, and Information Systems

DIRECT 

HEALTH CARE 

SERVICES: 

(GAP FILLING) 

Examples: 

Basic Health Services, 

and Health Services for CSHCN 

ENABLING SERVICES:

Examples:

Transportation, Translation, Outreach,

Respite Care, Health Education, Family

Support Services, Purchase of Health Insurance, 

Case Management, Coordination with Medicaid,

WIC, and Education
6

THE MCH PYRAMID

The conceptual framework for the services of the Maternal and Child Health Title 

V Block Grant to States is envisioned as a pyramid, as depicted on the previous 

page, with four tiers of services and levels of funding that provide comprehensive 

services for mothers and children, including children with special health care 

needs in the Nation. This model displays the uniqueness of the MCH Title V 

Block Grant to States, which is the only Federal program that provides services 

at all levels. These services are direct health care services (gap filling), enabling 

services, population-based services, and infrastructure building. Since 1997, the 

MCH Pyramid has, over time, been the graphic representation of the MCH Title V 

Block Grant to States program.
7

TITLE V MATERNAL AND CHILD HEALTH

BLOCK GRANT TO STATES PROGRAM

APPLICATION AND ANNUAL REPORT GUIDANCE

TABLE OF CONTENTS

PART ONE

BACKGROUND AND ADMINISTRATIVE INFORMATION

Page

I. HISTORY AND PURPOSE................................................................................. 11

A. The Maternal and Child Health Bureau.................................................... 11

B. Maternal and Child Health Services Block Grant (Title V)........................ 11

II. LEGISLATIVE REQUIREMENTS....................................................................... 14

A. Who Can Apply for Funds [Section 505(a)].............................................. 14

B. Use of Allotment Funds [Section 504]...................................................... 14

C. Application for Block Grant Funds [Section 505]...................................... 15

D. Annual Report [Section 506].................................................................... 16

E. Administration of Federal and State Programs [Section 509] .................. 17

III. BLOCK GRANT APPLICATION AND ANNUAL REPORT PREPARATION 

AND SUBMISSION ............................................................................................ 18

A. Deadline for Application and Annual Report ............................................ 18

B. Electronic Submission.............................................................................. 18

C. General Information on Preparation and Submission .............................. 18

IV. APPLICATION REVIEW PROCESS .................................................................. 21

PART TWO

INSTRUCTIONS FOR COMPLETING THE APPLICATION/ANNUAL REPORT

I. GENERAL REQUIREMENTS............................................................................. 24

A. Letter of Transmittal................................................................................. 24

B. Face Sheet .............................................................................................. 24

C. Assurances and Certifications ................................................................. 24

D. Table of Contents .................................................................................... 24

E. Public Input [Section 505(a)].................................................................... 24

II. NEEDS ASSESSMENT

A. Needs Assessment Process—Background and Conceptual Framework. 26

B. Five Year Needs Assessment Document ................................................ 29

C. Annual Needs Assessment Summary or Update..................................... 36

III. STATE OVERVIEW............................................................................................ 39

A. Overview of the State............................................................................... 39

B. Agency Capacity...................................................................................... 39
8

C. Organizational Structure .......................................................................... 40

D. Other (MCH) Capacity ............................................................................. 41

E. State Agency Coordination ...................................................................... 41

F. Health Systems Capacity Indicators ........................................................ 41

IV. PRIORITIES, PERFORMANCE, AND PROGRAM ACTIVITIES

ANNUAL REPORT/ANNUAL PLAN ................................................................... 44

A. Background and Overview....................................................................... 44

B. State Priorities ......................................................................................... 46

C. National Performance Measures ............................................................. 46

D. State Performance Measures .................................................................. 50

E. Health Status Indicators........................................................................... 50

F. Other Program Activities .......................................................................... 52

G. Technical Assistance Needs.................................................................... 52

V. BUDGET NARRATIVE....................................................................................... 54

A. Expenditures............................................................................................ 54

B. Budget ..................................................................................................... 54

VI. REPORTING FORMS - GENERAL INFORMATION.......................................... 55

FORMS 1 - 11 .................................................................................................... 59

Form 1 - Application for Federal Assistance ..................................................... 61

Form 2 - MCH Budget Details for FY__ ............................................................ 65

Form 3 - State MCH Funding Profile................................................................. 67

Form 4 - Budget Details by Types of Individuals Served (I) and 

Sources of Other Federal Funds (II)................................................... 71

Form 5 - State Title V Program Budget and Expenditures by 

Types of Service................................................................................. 75

Form 6 - Number and Percentage of Newborn and Others Screened, 

Cases Confirmed, and Treated .......................................................... 79

Form 7 - Number of Individuals Served (Unduplicated) Under Title V .............. 81

Form 8 - Deliveries and Infants Served by Title V and Entitled to 

Benefits Under Title XIX ..................................................................... 83

Form 9 - State MCH Toll-Free Telephone Line Data ........................................ 85

Form 10 - Title V Maternal & Child Health Services Block Grant State 

Profile for FY__ .................................................................................. 87

Form 11 - Tracking Performance Measures ....................................................... 90

VII. PERFORMANCE AND OUTCOME MEASURE DETAIL SHEETS and FORMS 

12 – 21..............................................................................................99

[States will add their State PM/OM Detail Sheets after the National ones]

A. National Performance Measures Detail Sheets ..................................... 101

Form 12 - Tracking Health Outcome Measures ................................................ 120

B. National Outcome Measures Detail Sheets ........................................... 125

C. State Outcome Measures Detail Sheets................................................ 133

Form 13 - Characteristics Documenting Family Participation in 
9

CSHCN Programs ............................................................................ 135

Form 14 - List of MCH Priority Needs ............................................................... 137

Form 15 - Technical Assistance (TA) Request.................................................. 138

Form 16 -State Performance/Outcome Measure Detail Sheet......................... 143

Form 17 - Health Systems Capacity Indicators – Forms for HSCI 01 through 04,

07A, 07B & 08 – Multi-Year Data ..................................................... 145

Form 18 - Health Systems Capacity Indicator Reporting Form – 

HSCI 05 & 06 ................................................................................... 149

Form 19 - Health Systems Capacity Indicator – Reporting and Tracking Form –

HSCI 09A & 09B............................................................................... 120

D. Health Systems Capacity Indicators Detail Sheets ................................ 155

Form 20 - Health Status Indicators #01-#05 – Multi-Year Data ........................ 169

Form 21 - Health Status Indicators Demographic Data - #06-#12.................... 175

E. Health Status Indicators Detail Sheets .................................................. 185

VIII. GLOSSARY...................................................................................................... 207

IX. TECHNICAL NOTE: GUIDELINES FOR CALCULATING PERFORMANCE 

MEASURES USING SMALL SAMPLES .......................................................... 217

X. APPENDICES AND STATE SUPPORTING DOCUMENTS............................. 221

A. The Needs Assessment......................................................................... 221

B. The Reporting Forms............................................................................. 221

C. Organizational Charts and All Other State Supporting Documents........ 221
10
11

PART ONE

BACKGROUND AND ADMINISTRATIVE INFORMATION

I. HISTORY AND PURPOSE

A. The Maternal and Child Health Bureau

The Maternal and Child Health Bureau (MCHB) is the principal focus within 

Health Resources and Services Administration (HRSA) for all Maternal and Child 

Health (MCH) activities within the Department of Health and Human Services 

(DHHS). MCHB‘s mission is to provide national leadership through working in 

partnership with States, communities, public/private partners, and families, to 

strengthen the MCH infrastructure, and to build knowledge and human 

resources. Its mission also includes ensuring continued improvement in the 

health, safety, and well-being of the MCH population. To achieve its mission, 

MCHB directs resources towards a combination of direct health care services, 

enabling services, population-based services, and infrastructure or resourcebuilding activities. Within MCHB the Division of State and Community Health 

(DSCH) has the administrative responsibility for the Title V Block Grant to States 

Program. DSCH is committed to being the Bureau‘s main line of communication 

with States and communities, in order to consult and work closely with both of 

these groups and others interested in providing a wide range of MCH programs 

and developing community-based service systems.

B. Maternal and Child Health Services Block Grant (Title V)

Since its original authorization in 1935, Title V of the Social Security Act has 

been amended several times to reflect the increasing national interest in 

maternal and child health and well-being. One of the first changes occurred 

when Title V converted to a block grant program as part of the Omnibus Budget 

Reconciliation Act (OBRA) of 1981. This change resulted in the consolidation of 

seven categorical programs into a single block grant. These programs included: 

Maternal and Child Health and services for Children with Special Health Care 

Needs (Title V of the Social Security Act); supplemental security income for 

children with disabilities (sec. 1651(c) of the Social Security Act); lead-based 

paint poisoning prevention programs (sec. 316 of the Public Health Service 

(PHS) Act); genetic disease programs (sec. 101 of the PHS Act); sudden infant 

death syndrome programs (sec. 1121 of the PHS Act); hemophilia treatment 

centers (sec. 1131 of the PHS Act); and adolescent pregnancy grants (Public 

Law PL 95-626).

Another significant change was contained in the Omnibus Budget Reconciliation 

Act (OBRA) of 1989 which specified new requirements for accountability. These 

amendments enacted under OBRA introduced stricter requirements for the use 
12

of Federal funds and for State planning and reporting. Congress sought to 

balance the flexibility of the block grant with greater accountability, by requiring 

State Title V programs to report progress on key MCH indicators and other 

program information. Thus, the block grant legislation emphasizes accountability 

while providing States with appropriate flexibility to respond to MCH needs and to 

develop solutions. This theme of assisting States in the design and 

implementation of MCH programs to meet local needs, while at the same time 

asking them to account for the use of Federal/State funds, was embodied in the 

requirements contained in guidance documents for block grant applications and 

annual reports. In 1996, the MCHB began a process of programmatic 

assessments and planning activities aimed at improving those guidance 

documents.

In 1993 the Government Performance and Results Act (GPRA), Public Law 103-

62, required Federal agencies to establish measurable goals that could be 

reported as part of the budgetary process. For the first time, funding decisions 

were linked directly with performance. Among its purposes, GPRA is intended to 

―...improve Federal program effectiveness and public accountability by promoting 

a new focus on results, service quality, and customer satisfaction.‖ GPRA 

requires each Federal agency to develop comprehensive strategic plans, annual 

performance plans with measurable goals and objectives, and annual reports on 

actual performance compared to performance goals. The MCHB effort to 

respond to GPRA requirements coincided with other planned improvements to 

the block grant guidance. As a result, the block grant application annual report 

and forms contained in the 1997 edition of the Maternal and Child Health 

Services Title V Block Grant Program - Guidance and Forms for the Title V 

Application/Annual Report served two purposes: they ensured that the States 

and jurisdictions could clearly, concisely, and accurately tell their MCH ―stories;‖ 

and, they became the basis by which MCHB met its GPRA Block Grant to States 

program reporting requirements.

Another significant milestone was the development in 1996 of an information 

system. The block grant application and annual report, submitted annually by all 

States, contains a wealth of information concerning various State MCH initiatives, 

State-supported programs, and other State-based responses designed to 

address their MCH needs. In order to better utilize the data contained in the 

application/annual report, MCHB developed an electronic information system, the 

Title V Information System (TVIS), designed to capture data contained in the 

application/annual report. The system designed initially to capture the qualitative 

programmatic information collected by the States, was modified according to 

MCHB‘s performance measurement model to collect quantitative data as well. 

This joint development of the Guidance and the database enabled the TVIS to 

become a powerful and useful tool for a number of audiences. The TVIS is 

available to the public on the World Wide Web at: 

https://perfdata.hrsa.gov/mchb/mchreports/Search/search.asp. 
13

As the chief financial foundation and the primary legislative authorization for the 

MCHB, Title V provides 80% of the funding sources for all Bureau programs. 

Under Title V, MCHB administers Formula Grants and competitive Discretionary 

Grants. The purpose of the Title V MCH Services Block Grant Program is to 

create Federal/State partnerships in all 50 States and 9 Jurisdictions to develop 

service systems to meet MCH challenges which include the following:

Significantly reducing infant mortality;

Providing comprehensive care for women before, during, and after 

pregnancy and childbirth;

Providing preventive and primary care services for infants, children, 

and adolescents;

Providing comprehensive care for children and adolescents with 

special health care needs;

Immunizing all children;

Reducing adolescent pregnancy;

Preventing injury and violence;

Putting into community practice national standards and guidelines 

for prenatal care, for healthy and safe child care, and for the health 

supervision of infants, children, and adolescents;

Assuring access to care for all mothers and children; and

Meeting the nutritional and developmental needs of mothers, 

children and families.

Under Title V, MCHB also administers two types of Federal Discretionary Grants, 

Community Integrated Service Systems (CISS) grants and Special Projects of 

Regional and National Significance (SPRANS). The CISS set-aside designates 

appropriations for programs to reduce infant mortality and improve the health of 

mothers, pregnant women, and children through the development and expansion 

of community integrated service systems. These systems are public-private 

partnerships of health-related and other relevant organizations and individuals 

collaborating to use community resources to address community-identified health 

problems.

The Community Integrated Service System (CISS) program seeks to improve the 

health of mothers and children through discretionary grant support for the 

development and expansion of community integrated service systems. These 

systems are public/private partnerships of health-related and other relevant

organizations and individuals working collaboratively to use community resources 

to address the health of children in the context of their family in a comprehensive 

way. This program aims to support the health of children in all aspects of their 

physical, social, and emotional development.

A percentage of Title V funds are also set aside for a variety of SPRANS grants. 

SPRANS activities include:
14

MCH research;

MCH training;

Genetic disease testing, counseling, and information dissemination;

Hemophilia diagnostic and treatment centers; and

MCH improvement projects that support a broad range of 

innovative strategies.

MCHB also administers the following categorical programs:

Emergency Medical Services for Children;

Traumatic Brain Injury;

Healthy Start Initiative;

Universal Newborn Hearing Screening; and

Autism.

Throughout its illustrious 74 year history, the Maternal and Child Health Services 

Block Grant Program has sought to fulfill its intent of improving the health of all 

mothers and children consistent with the applicable health status goals and 

national health objectives. This brief history has provided a few highlights of that 

legacy under Title V.

II. LEGISLATIVE REQUIREMENTS

A. Who Can Apply for Funds [Section 505(a)]

The application and annual report shall be developed by, or in consultation with, 

the State maternal and child health agency and shall be made public within the 

State in such manner as to facilitate comment from any person (including any 

Federal or other public agency) during its development and after its transmittal.

B. Use of Allotment Funds [Section 504]

The State may use funds paid to it for the provision of health services and related 

activities (including planning, administration, education, and evaluation) 

consistent with its application. It may also purchase technical assistance if the 

assistance is required in implementing programs funded by Title V. Related to 

technical assistance, the State should plan for and allot funds for two meetings 

each year for the MCH and Children with Special Health Care Needs (CSHCN)

Directors. One of these meetings is the required Block Grant Application/Annual 

Report review that will be held at a site designated annually by DSCH. The 

second is the Partnership Meeting held each year in Washington, D.C., to update 

State MCH and CSHCN Directors on current legislation, implementation of recent 

legislation, and MCHB initiatives.
15

Funds may not be used for cash payments to intended recipients of health 

services or for purchase of land, buildings, or major medical equipment. Other 

restrictions apply.

C. Application for Block Grant Funds [Section 505]

Each State is required to conduct a statewide needs assessment every 5 years. 

The result of that needs assessment and any updates are submitted in the 

interim years in the annual application. The application will contain information 

(consistent with the health status goals and national health objectives) regarding 

the need for:

preventive and primary care services for pregnant women, mothers, 

and infants up to age one;

preventive and primary care services for children;

services for CSHCN [as specified in section 501(a)(1)(D) "familycentered, community-based, coordinated care (including care 

coordination services) for children with special health care needs 

(CSHCN) and to facilitate the development of community-based 

systems of services for such children and their families"];

and includes for each fiscal year:

a plan for meeting the needs identified by the statewide 

assessment; and

a description of how the funds allotted to the State will be used for 

the provision and coordination of services to carry out the MCH 

program.

At least thirty percent (30%) of Federal Title V funds must be used for preventive 

and primary care services for children and at least thirty percent (30%) for 

services for CSHCN as specified in Section 501 (a)(1)(D). Such services include 

providing and promoting family-centered, community-based, coordinated care 

(including care coordination services) for CSHCN and facilitating the 

development of community-based systems of services for such children and their 

families. The thirty percent (30%) requirement may be waived as specified in 

Section 505(b)(1-2). A request for waiver must be included in the application 

transmittal letter. In addition, of the amount paid to a State under Section 503 

from an allotment for a fiscal year under Section 502(c), not more than ten 

percent (10%) may be used for administering the funds paid under this section.

The State must maintain the level of funds being provided solely by such State 

for MCH programs at the level provided in fiscal year 1989. [Section 505(a)(4)].

Other requirements for allocating funds, charging for services, a toll-free hotline, 

and coordination of services with other programs are found in Section 505.
16

D. Annual Report [Section 506]

An Annual Report must be submitted to the MCHB each year in order to evaluate 

and compare the performance of different States assisted under this title and to 

assure the proper expenditure of funds. The Annual Report will include a 

description of program activities, a complete record of the purposes for which 

funds were spent, the extent to which the State has met the goals and objectives 

it set forth, as well as the national health objectives, and the extent to which 

funds were expended consistent with the State's application. The standardized 

format of the Annual Report allows for consistency in reporting and facilitates the 

preparation of the report to congress, as required in [Section 506(a)(3)].

As required in Section 509(a)(5), the MCHB has made a substantial effort not to 

duplicate other Federal data collection efforts. In partnership with the States, 

only MCH data necessary to fulfill the requirements of Title V which are not 

available at the national level or may be more timely from the State or required 

for tracking performance measures, are requested as part of the Annual Report. 

Data are not available from the National Center for Health Statistics (NCHS) or 

other Federal sources for the Marshall Islands, Federated States of Micronesia, 

Republic of Palau, Commonwealth of the Northern Mariana Islands, and 

American Samoa. These jurisdictions must report their own vital statistics and 

health data using general instructions from the NCHS.

All elements that comprise the Annual Report are located in PART TWO

(Sections I, III, IV, V, VI) as described below. To assure that this document 

contains all of the statutorily required elements for an Annual Report, it is critical 

that the elements appear in the exact prescribed format as specified below:

SECTION I - GENERAL REQUIREMENTS

A Transmittal letter

B Face Sheet

C Assurances and Certifications

D Table of Contents

E Public Input

SECTION III - STATE OVERVIEW

A Overview of the State

B Agency Capacity

C Organizational Structure

D Other (MCH) Capacity

E State Agency Coordination

F Health Systems Capacity Indicators

Additional elements only for the Annual Report include:
17

SECTION IV – PRIORITIES, PERFORMANCE, AND PROGRAM ACTIVITIES

Narrative description of activities in C 1a – 18a for each of the National 

Performance Measures and D 1a – 7a to 10a for each State Performance 

Measure.

SECTION V – BUDGET NARRATIVE

Narrative discussion of budget expenditures is located in Section V A.

SECTION VI – REPORTING FORMS

Annual number of individuals served under this title (by class of 

individuals) as reported on Forms 6, 7, 8, 9, and the State Summary 

Profile as reported on Form 10;

Progress made on the National and State Performance Measures from the 

previous reporting year as reported on the appropriate fiscal year annual 

performance indicators row on Form 11 – Tracking Performance 

Measures for each of the National and State Performance Measures; and

Annual Expenditures as reported on Form 3 – State MCH Funding Profile; 

and the appropriate expended columns on Form 4 – Budget Details by 

Types of Individuals Served; and Form 5, State Title V Programs Budget 

and Expenditures by Types of Service, organized hierarchically from direct 

health care services through infrastructure building.

E. Administration of Federal and State Programs [Section 509]

MCHB in HRSA is the organizational unit responsible for the administration of 

Title V. Within the Bureau, DSCH has responsibility for the day-to-day operation 

of the MCH Title V Block Grant to States Program. Applicants may obtain 

additional information regarding administrative, technical and program issues 

concerning the Block Grant application by contacting:

Division of State and Community Health

Maternal and Child Health Bureau

Health Resources and Services Administration

5600 Fishers Lane, Room 18-31

Rockville, Maryland 20857

Telephone: (301) 443-2204

Fax: (301) 443-9354

Within each State and Jurisdiction, the State Health Agency is responsible for the 

administration (or supervision of the administration) of programs carried out with 

Title V allotments.
18

III. BLOCK GRANT APPLICATION AND ANNUAL REPORT PREPARATION AND 

SUBMISSION

A. Deadline for Application and Annual Report

The application is due by close of business on July 15 of each year unless States 

are otherwise notified.

B. Electronic Submission

The Title V Application/Annual Report is completed electronically, using a 

computer that is connected to the Internet. The annual application that is 

available to the States via the Web includes a copy of this Guidance, a copy of 

the Title V law, narrative outlines with required tables, forms, and diagrams. It 

also includes tools to assist the States in assessing the completeness of their 

applications as they are being prepared and alerts to help reduce data entry 

errors and to help ensure data validity.

States identify those individuals that will have access to the electronic 

applications. These users access the system through use of a user name and 

password. This identification system allows access to the Web-based application 

and serves as an authentication of the Block Grant Applicant. States and 

Jurisdictions will receive detailed information from MCHB about these 

registration, log-on and submission procedures prior to the opening of the system 

for access. When technical assistance is needed with the preparation and 

submission of the Application/Annual Report, the HRSA Call Center is available. 

The Call Center can be contacted at 1-877-Go4-HRSA (877-464-4772) or at 

CallCenter@hrsa.gov.

C. General Information on Preparation and Submission

The Application/Annual Report format for the Block Grant described 

in this document enables data on each State‘s needs, priorities, 

program activities, and performance and outcomes measures to be 

compiled and compared with information from other States. The 

Title V Information System (TVIS) has been developed to capture 

information from States‘ Block Grant Applications/Annual Reports. 

This relational database system is open to the public and allows 

easier and more accurate access to information such as State 

performance measures, budget figures, etc. It is important, 

therefore, that States be as accurate as possible with their data and 

follow carefully the organization and formatting instructions in the 

online system.

States complete electronic versions of the forms in this guidance in 

the Web-based Title V Application.
19

A Glossary of Terms is presented in Part Two, Section VIII. 

Definitions for most of the significant words, terms, and phrases 

used on the various forms in the Application/Annual Report may be 

found there. Differences in the State‘s definitions for programs, 

services, or other elements as compared to those presented in the 

glossary should be clarified in the narrative of the 

Application/Annual Report.

The Application/Annual Report must be concise, accurate, and 

complete in addressing the minimum requirements of both Title V 

and this Guidance. All necessary formatting in the electronic Title V 

Application has been determined by MCHB and will be included in 

the annual Application/Annual Report Guidance that is provided.

The sections of the narrative portion of the Application/Annual 

Report have character length limitations enforced by the electronic 

system. These length limits are identified at the top of each section 

in the online system. States should keep these length limitations in 

mind as they compose the narrative in the word processing 

package of their choice. The State user should then cut and paste 

each section from the document into the appropriate section in the 

online system. These length limitations do not apply to a State‘s 

needs assessment, which is a stand-alone document.

The narrative is to be composed of text only, using standard 

characters. Embedding charts, tables or graphs in the narrative is 

not possible. Use of special characters, such as bullets, is not 

permitted.

 For every year after the first in a five year cycle, leave all of the 

previous year‘s narrative in place. Where changes of any kind 

(additions, corrections, updates, and revisions) are needed, begin 

at the left margin of each paragraph or section where the change 

applies and begin the corrected narrative with the following symbol: 

/Application Year/ and conclude with //Application Year//. For 

example, the first reporting year of this guidance will use /2010/ and 

conclude with //2010//. This will allow this text between these 

symbols to be displayed as bolded italics (NOTE: The bold and 

italics will be added automatically by the system in the readable 

version of the report). In this manner, entire sections will not have 

to be rewritten and all changes will be easy for all readers of the 

application to find.

For example, to quickly locate each section updated for 2009, use 

the FIND function (found under the Edit menu of the browser or 

word processing package) to search for the associated tags
20

(/2009/). The following is a short illustration of how this will appear 

(on the View version of the online application):

[From the 2008 Application]: The Program Director of the State Maternal 

and Child Health Program is Dr. Jane Doe. Dr. Doe reports to the 

Director of the State Department of Health.

/2009/ Dr. Doe moved to a new program in December. The new 

Director of the State Maternal and Child Health Program is Dr. John 

Smith. New organizational lines of authority have Dr. Smith 

reporting directly to the Governor.//2009//

If further changes are required in subsequent years, use the same 

procedure. Leave the previous years‘ narrative changes in place, 

remove the italics and begin the new changes with the appropriate 

year within backslashes. (Once the entries are saved, the system 

will automatically place text between the brackets in bold and 

italics.) To continue the illustration, it would look as follows:

[From the 2008 Application]: The Program Director of the State Maternal 

and Child Health Program is Dr. Jane Doe. Dr. Doe reports to the 

Director of the State Department of Health. 

/2009/ Dr. Doe moved to a new program in December. The new Director 

of the State Maternal and Child Health Program is Dr. John Smith. New 

organizational lines of authority have Dr. Smith reporting directly to the 

Governor.//2009//

/2010/ Dr. Smith remains the Director of the MCH program but that 

position once again reports to the Director of the State Department

of Health.//2010//

This procedure allows for rapid determination of differences from 

year to year without the need to find previous years‘ applications 

and compare narratives in order to discover exactly what changes 

have been made.

Since the text of the performance measures changes each year 

and does not retain the previous year‘s narrative, the use of the 

―/Application Year/‖ update is not necessary in narrative sections 

addressing performance measures.

States may attach one document per section to further explain the 

discussion in that section. This allows a State to provide charts, 

graphs, and tables that cannot be included in the narrative. This 

attachment is not to be a continuation of the narrative for that 

section.

All letters of support and other documents may be formulated into a 

single list which is included in the application with a statement that 

the actual items are available upon request in the State MCH office.
21

As required in Section 509(a)(5), the MCHB has made a substantial 

effort not to duplicate other Federal data collection efforts. In 

partnership with the States, only maternal and child health data 

necessary to fulfill the requirements of Title V which are not 

available at the national level or may be more timely from the State 

or required for tracking performance measures, will be gathered for

the annual report. Data are not available from National Center for 

Health Statistics or other Federal sources for the Marshall Islands, 

Federated States of Micronesia, Republic of Palau, Commonwealth 

of the Northern Mariana Islands, and American Samoa. These 

jurisdictions must report their own vital statistics and health data 

using general instructions from the National Center for Health 

Statistics.

Since the MCHB production of Annual Reports will be an extraction 

process it is critical for their development that States carefully follow 

the general instructions for completing the forms and the specific 

instructions included with each form.

IV. APPLICATION REVIEW PROCESS

Each State is required to submit its Annual Application/Annual Report. Once 

submitted, each application is examined by computer software for completeness 

of data. Any application that is incomplete may be returned to the State to 

procure the missing data. All complete applications are submitted to a 

standardized review process by MCHB staff and other experts in MCH, families,

and consumers of the MCH population. Present at the review are the State MCH 

leadership and representation from the Central Office MCHB staff for an in-depth 

discussion of the Application/Annual Report and the State‘s plan for the coming 

year. These reviews are conducted in a face to face format. In some cases, the 

reviews may be conducted via audio/video conference call format. In all cases, 

the focus of the review is on the progress being made by each State in meeting 

its performance goals in the State specific as well as the National Performance 

Measures, and what type(s) of technical assistance may be needed in order for 

the State to move towards achieving these goals. In addition, the face to face 

review includes a detailed discussion on the major financial, policy, and 

legislative actions that will affect the State‘s program in the coming year.
22
23

PART TWO

INSTRUCTIONS FOR COMPLETING THE APPLICATION/ANNUAL REPORT

There are several major changes in this new edition of the Guidance. The major 

changes are as follows:

PART TWO, Section II, Part A. Needs Assessment Process--Background and 

Conceptual Framework: Revisions provide more complete information on the 

Background and Conceptual Framework for the Needs Assessment Process.

PART TWO, Section II, Part B. Five Year Needs Assessment Document: 

Revisions to this section clarify what State grantees are to include in the Five 

Year Needs Assessment Document.

PART TWO, Section II, Part C. Annual Needs Assessment Summary or Update: 

Revisions to this section better explain the information to include in the Annual 

Needs Assessment Summary/Update, both in the year when the five year Needs 

Assessment is conducted and in the interim years.

PART TWO, Section II, Figure 2: Updates to Figure 2 serve to more 

comprehensively reflect all aspects of the Needs Assessment process.

PART TWO, Section III, Part B. Agency Capacity: The second paragraph 

clarifies that States should discuss the system of services for both the MCH and 

CSHCN programs.

Standard Form (SF) 424: The requirement to print, sign, and mail in the 

Application Face Sheet (SF 424) has been deleted. SF 424 is now submitted 

electronically along with the rest of the application and annual report.

Tables 4a and 4b: The headings and instructions have been clarified to indicate 

that States are to report information from the Annual Report year in these tables.

PART TWO, Section IV, Part E. Health Status Indicators (HSIs): Revisions 

clarify the type of information that States are to report annually for the HSIs.

PART TWO Section IV, Part F. Other Program Activities: Revisions clarify the 

types of information that States may want to include in this section.

Form 11, Performance Measure Tracking: Instructions clarify that States are to 

provide a footnote that identifies the data source for each measure.

The application kit that is provided annually to the States via the Web includes a copy of 

the Guidance, a copy of the Title V law, and all required tables, forms, and diagrams.
24

I – GENERAL REQUIREMENTS

A. Letter of Transmittal

An electronic letter of transmittal from the responsible State health agency official 

must be the first page of the Application/Annual Report. The letter must also 

contain the documentation for waiver of a 30 percent allotment if the State is so 

requesting. The letter of transmittal is attached in the Title V Application to 

Section IA.

B. Face Sheet

Each section of the Application Face Sheet (Standard Form 424) must be 

completed and submitted electronically along with the rest of the application and 

annual report. Procedures for authentication of the Block Grant applicant will be 

sent to each State and Jurisdiction.

C. Assurances and Certifications

The appropriate Assurances and Certifications--non-construction program, 

debarment and suspension, drug free work place, lobbying, program fraud, and 

tobacco smoke--that accompany this guidance are to be maintained on file in the 

State‘s MCH program‘s central office. They may be attached to this section but 

this is not required. Instead, provide either the URL to access these assurances 

or provide information as to where and how the assurances and certifications can 

be made available.

D. Table of Contents

The Table of Contents is automatically generated by the system, and conforms to 

the headings in Parts One and Two on pages seven to nine of the Guidance.

E. Public Input [Section 505(a)]

Describe the process by which the State will make this application public to 

facilitate comment from any person during its development and after its 

transmittal. This includes not only illustrating how it facilitated or provided 

opportunities for the public to provide ideas, comments, or concerns about needs 

or programs, as well as how it facilitated or provided the opportunity for the public 

to comment on the application.

Some activities are linked specifically to the application process. Such activities 

may include:

Public Hearings

Advisory Council Review
25

Web Posting

Public Notices

Other Use of Media

Outreach to Specific Stakeholders

States also have regular mechanisms in place to obtain input and feedback on 

their programs. Such methods include advisory groups and task forces 

addressing specific programs or issues. Many, if not most states, have 

mechanisms in place to obtain regular and ongoing input from parents, especially 

parents of CSHCN. Some states engage youth directly in planning programs 

and developing materials in areas such as suicide prevention. If applicable, 

these mechanisms should also be described.

Further information regarding public input can be found under the Resource 

Page link on the MCHB/DSCH technical assistance (TA) website, 

http://www.mchtaproject.com.
26

II – NEEDS ASSESSMENT

A. Needs Assessment Process—Background and Conceptual Framework

Title V legislation requires that the State prepare a statewide needs assessment 

every five (5) years that shall identify (consistent with health status goals and 

national health objectives) the need for:

preventive and primary care services for pregnant women, mothers 

and infants up to age one;

preventive and primary care services for children; and 

services for CSHCN. [Section 505 (a)(1)].

The next five year Needs Assessment will be submitted in calendar year 2010 as 

an attachment in the electronic application system. It is intended to function for 

the State as a stand-alone document.

An overview of the MCH needs assessment process and its relationship with 

planning and monitoring functions is presented in Figure 2 on page 38. The 

following is a conceptual framework for this process.

Improved Outcomes and Strengthened Partnerships: Figure 2 reflects the 

expectation that following the ten identified steps of the Needs Assessment 

process, as described below, will result in two ultimate goals: (1) Improved 

Outcomes for MCH populations and (2) Strengthened Partnerships. The 

strengthened partnerships should include, but are not limited to, collaboration 

efforts with the Federal MCHB, State Department of Health, other agencies and 

organizations within each State and jurisdiction that have an interest in the 

wellbeing of the MCH population, families, practitioners, and the community. 

The following is a brief description of the steps involved in the Needs 

Assessment process.

1. Engage Stakeholders

As depicted in Figure 2, the starting point is to engage stakeholders. 

Engaging stakeholders and strengthening partnerships is a continuous 

and on-going activity. The State needs strong partnerships with its 

stakeholders throughout the Needs Assessment process. Effective 

coalitions can help the State realistically assess needs and identify 

desired outcomes and mandates, assess strengths and examine capacity, 

select priorities, seek resources, set performance objectives, develop an 

action plan, allocate resources, and monitor progress for impact on 

outcomes.

2. Assess Needs and Identify Desired Outcomes and Mandates
27

The second stage in the process is to assess needs of the MCH 

population groups using Title V indicators, performance measures and 

other quantitative and qualitative data available in the State. The MCH 

population groups identified in Section 505(a)(1) of the statute are: 

pregnant women, mothers, and infants; children; and children with special 

health care needs. The anticipated outcome is to identify the 

community/system needs and desired outcomes by specific MCH 

population group. In addition, the State will need to identify legislative, 

political, community-driven, financial, or other internal and external 

mandates that they will be required to implement, regardless of what the 

Needs Assessment reveals.

3. Examine Strengths and Capacity

The third stage in the process is examining strengths and capacity. 

This stage involves examining the State‘s capacity to engage in various 

activities, including conducting the 5-year Needs Assessment and 

collecting annual performance data, and to provide services by each 

pyramid level. The pyramid appears on page 5. This stage involves 

describing and assessing the State‘s current resources, activities, and 

services as well as the State‘s ability to continue to provide quality 

services by each of the pyramid levels. These levels include direct health 

care services, enabling services, population-based services, and 

infrastructure-building services. The anticipated outcome is a better 

understanding of the relationship of existing program/system capacity to 

identified strengths and needs for each State and Jurisdiction. This 

examination may reveal strengths and weaknesses in capacity not 

previously identified.

4. Select Priorities

In the select priorities stage, each State examines the needs identified 

and matches those needs to desired outcomes, required mandates, and 

level of existing capacity. Based on the results of this process, the State 

then selects its most important, or highest priority, MCH strengths and 

needs to receive targeted efforts for improvement and/or continuation of 

progress. The inputs include: the needs assessment, the opinions of 

stakeholders, the examination of capacity, and the political priorities within 

the State. The anticipated outcome is development of a set of priority 

needs unique to each individual State based on Needs Assessment 

findings. Mandated activities are understood as continuing. Priority needs

should include those areas in which the State believes it has a reasonable 

opportunity to maintain, modify, or enhance existing interventions, 

initiatives, or systems that have been successful, or begin new 
28

interventions, initiatives, or systems that are expected to result in needed 

improvements.

5. Seek Resources

Depending upon the priorities selected and existing resources identified, 

the State may need to seek additional resources, funds, or authority from 

the State legislature or funding agencies in order to address priority areas.

6. Set Performance Objectives

Setting performance objectives consists of two phases. First, each 

State will select seven to ten State-negotiated Performance Measures to 

assess progress on State priorities not already monitored through National 

Performance and Outcome Measures. Next, each State will set Outcome 

Measure targets and State and National Performance Measure targets. 

The anticipated outcome is the identification of State-negotiated 

Performance Measures and Performance Measure targets.

7. Develop an Action Plan

The next stage is to develop an action plan, which includes identifying 

activities to address priority strengths and needs. This stage involves 

describing the activities that have been identified by the four pyramid 

levels: direct health care services, enabling services, population-based 

services, and infrastructure building services.

8. Allocate Resources

Following the identification of activities is the allocation of resources 

stage. In this stage, the focus is on the funding of planned activities to 

address State priorities. The inputs include the action plan, current 

budgets, political priorities, and partnerships. The anticipated outcome is

the development of a budget that directs available resources towards 

activities that have been identified in Stage Seven as most important for 

addressing the State‘s priorities.

9. Monitor Progress for Impact on Outcomes

In monitoring progress for impact on outcomes, the States examine

the results of their efforts to see if there has been improvement. The 

inputs include the State Performance Measures, National Performance 

Measures, Outcome Measures, Health Status Indicators, Health System 

Capacity Indicators, performance objectives, and other quantitative and 

qualitative information. Potential outcomes may include altered activities 

and shifting of resource allocations to address current levels of 
29

performance and the availability of resources. Feedback loops between 

various stages of the process allow for continuous input and re-evaluation 

of the outputs.

10. Report Back to Stakeholders

This final step assures accountability to the stakeholders and partners 

who have worked with the MCH staff throughout the Needs Assessment 

process. It also assures the continued involvement of all stakeholders and 

partners in the ongoing Needs Assessment process.

B. Five Year Needs Assessment Document

States should structure the five year needs assessment document to include six

sections, with each section addressing the items described below.

1. Process for Conducting Needs Assessment

Describe the process used by the State to conduct the Title V 

comprehensive needs assessment for each of the three defined 

population groups. At a minimum, the State should address the following:

Goals and Vision: Describe the goals and the framework that 

guided the Needs Assessment process and how the State arrived 

at them. Include the State‘s vision and purpose for the Needs 

Assessment. Indicate what this document means to the State and 

how it will be used to guide the State‘s MCH activities, such as 

allocation of resources.

Leadership: Define the roles and responsibilities of the Needs 

Assessment leadership team.

Methodology: Describe the State‘s overall needs assessment 

methodology, what actions are taken to insure the ongoing nature 

of the process, and how needs assessment results and activities 

interface with other portions of the Title V grant application and 

annual report (e.g., how performance measures, health status, and 

capacity indicators are used in the needs assessment; how 

resources are allocated based on the State‘s priorities, etc.) 

Describe how the State cycles from the analysis phase to 

examining capacity to identifying priority needs, establishing Statenegotiated performance measures, setting annual targets for 

National and State Performance Measures, identifying activities to 

address priorities, allocating resources, and monitoring progress. 

Describe stakeholder involvement in the Needs Assessment.
30

Methods for Assessing Three MCH Populations: Describe the 

quantitative and qualitative methods used to assess the strengths 

and needs of each of the MCH populations: (1) pregnant women, 

mothers, and infants, (2) children, and (3) children with special 

health care needs.

Methods for Assessing State Capacity: Describe the methods 

used to assess the State‘s capacity to provide direct health care, 

enabling, population-based, and infrastructure building services.

Data Sources: Describe all data sources used. Note any specific 

limitations of the data not commonly understood from the literature 

(e.g., limitations of vital records do not need to be presented).

Linkages between Assessment, Capacity, and Priorities: 

Describe linkages between the assessment of strengths and needs, 

the examination of capacity, and the selection of priorities.

Dissemination: Describe and explain the rationale for the State‘s 

strategies, audiences, and formats for disseminating the Needs 

Assessment document to stakeholders and the public.

Strengths and Weaknesses of Process: Describe the strengths 

and the weaknesses of current methods and procedures for the 

comprehensive needs assessment.

2. Partnership Building and Collaboration Efforts

Reference formal and informal collaboration processes and partnerships 

with the public and private sector and State and local levels of 

government. Describe the methods used to build and enhance 

partnerships with:

State and local MCH programs (e.g., CSHCN, teen pregnancy 

prevention, Healthy Start, Maternal and Infant Program, family 

planning, etc.);

Other HRSA programs (e.g., Primary Health Care, HIV/AIDS);

Other programs within the State Department of Health (e.g., 

chronic disease prevention and health promotion, immunization, 

vital records and health statistics, injury prevention and control, 

disabilities, etc.);

Other governmental agencies (e.g., Medicaid, Education, Social 

Services, etc.). States are encouraged to attach a copy of the 

Inter-Agency Agreement (IAA) between Medicaid and the State 

Title V agency; and

Other State and local public and private organizations.
31

Describe stakeholder involvement, including what stakeholders are 

involved, their purpose, when they contribute to the process, how they 

participate, and why they are important. This should include a discussion 

of public and family members‘ involvement in the needs assessment. 

Describe collaboration efforts related to analyzing the strengths and needs 

of the MCH population, assessing capacity, selecting priority needs, and 

identifying and implementing activities to help meet priority needs. 

Describe the results, strengths, and weaknesses of these efforts. 

3. Strengths and Needs of the Maternal and Child Health Population 

Groups and Desired Outcomes

Using both quantitative and qualitative methods, describe the health status

of each State MCH population group:

Pregnant women, mothers, and infants

Children

Children with special health care needs

Discuss cross-cutting strengths and needs across all population groups.

Describe major morbidity, mortality, risk reduction or maintenance of 

health/wellness successes, problems, gaps, and disparities of the State 

MCH population groups. At a minimum, include major health issue areas 

(e.g., rates of pregnancies, fetal losses, births, age-specific deaths, 

prevalence of preventable disease and chronic diseases) within the MCH 

population as a whole and for significant sub-populations (e.g., racial, 

ethnic, age, income, geographic, frontier/rural/urban, or other relevant 

characteristics).

Use Performance Measures, Outcome Measures, Health Status 

Indicators, Health System Capacity Indicators, and progress towards 

meeting the Healthy People 2010 objectives, as appropriate, to describe 

the health status of the State MCH population groups. Analyze selected 

MCH measures and indicators by finer stratifications (e.g., county/region, 

race/ethnicity, age group, etc.) than reported in interim years, as 

appropriate for the State‘s Needs Assessment and as small number 

limitations allow. Include other indicators selected by the State to present 

a complete picture of each MCH population group‘s strengths and needs.

Report the results of qualitative strengths and needs analysis methods for 

each population group and describe how these results confirm, conflict 

with, or enhance the results of the State‘s quantitative analysis of 

strengths and needs.
32

Describe what is working well and should be continued, as well as areas 

that need to be enhanced or strengthened.

4. MCH Program Capacity by Pyramid Levels. 

Describe and assess the State‘s capacity to meet the needs of the State‘s 

MCH population by level of the pyramid. 

a. Direct Health Care Services

Describe the State‘s capacity to provide or to assure the availability 

of direct health care services for the MCH population, including 

both strengths and unmet needs. Specify the priority State 

concerns regarding availability of health care and health-related 

services, including prevention and primary care services and 

specialty care services when needed.

Assess and describe the availability of care. Enumerate, as 

appropriate, any shortages of specific types of health care 

providers such as primary care physicians, nutritionists, registered 

dietitians (including specialty registered dietitians), public health or 

visiting nurses, nurses certified for obstetric and pediatric primary 

care, medical social workers, dentists, sub-specialty physicians 

who serve CSHCN, audiologists, occupational therapists, physical 

therapists, and speech and language therapists. Illustrate 

underserved geographical areas (by map).

b. Enabling Services

Describe the State‘s capacity to provide or to assure enabling 

services for the MCH population, including both strengths and 

unmet needs. Specify the priority State concerns regarding 

enabling services, including financial access and cultural 

acceptability. Assess and describe barriers and the extent to 

which they impact accessibility of primary/preventive care, 

specialty/sub-specialty care, and habilitation and rehabilitation 

services for each population group.

Describe the impact of ―emerging issues‖ (e.g., accessibility of 

oral health care for low-income populations, any relevant changes 

in the State‘s Child Health Insurance Program, etc.) on the State‘s 

ability to provide or to assure enabling services to MCH population 

groups.

Describe the linkages that exist to promote provision of services 

and referrals between primary level care, specialized secondary 
33

level care and highly specialized tertiary level care. Assess and 

describe existing resources for providing community-based care, 

specialty care through pediatric centers, community-based 

specialty clinics, and multi-disciplinary centers, etc.

c. Population-Based Services

Assess and describe the State‘s capacity related to this level of the 

pyramid. Assess and describe the State‘s involvement in the direct 

management of these services and programs; the State‘s 

coordination with other agencies and organizations (universities, 

managed care organizations, physician groups) in the provision of 

these services; geographic availability/distribution of these services; 

and funding mechanisms for these services. Describe other 

population-based programs provided by the State for each of the 

Title V population groups.

d. Infrastructure-Building Services

Assess and describe the State‘s capacity to promote 

comprehensive systems of services. Assess from the State 

perspective how local delivery systems (include regional areas as 

appropriate) meet the population's health needs. Assess existing 

systems and collaborative mechanisms for the population groups: 

preventive and primary care services for pregnant women, mothers, 

and infants; preventive and primary care services for children, and 

services for CSHCN.

Assess and describe the State‘s planning, evaluation, research, 

and workforce development efforts.

Discuss coordination efforts, which address the following 

programs, organizations and groups:

Medicaid, Supplemental Security Income Program (SSI), 

Ryan White and Title IV AIDS programs, social services 

programs, special education programs, early intervention 

programs including Part C of the Individuals with Disabilities 

Act (IDEA), vocational rehabilitation programs, mental health 

programs including the Child and Adolescent Services 

System Program (CASSP), State interagency transition 

programs, developmental disabilities programs, SSDI, 

school health programs and the Special Supplemental 

Nutrition Program for Women, Infants and Children (WIC).
34

Other groups of major providers of health and health-related 

services, as appropriate for the State. Examples include 

children's hospitals and tertiary medical centers, State 

chapter of the American Academy of Pediatrics, the 

American Academy of Family Practice, the American 

College of Obstetrics and Gynecology, and family and parent 

advocacy organizations.

Assess and describe the State's specific efforts related to the 

development and implementation of standards of care, guidelines, 

monitoring of program effectiveness, and approaches to evaluation 

of care. Discuss efforts to monitor continuous quality improvement 

for each MCH population group. Discuss the State's effort to 

monitor the development of community-based service systems.

For CSHCN, discuss the following four constructs of a service 

system: (1) State program collaboration with other State agencies 

and private organizations, (2) State support for communities, (3) 

coordination of health components of community-based systems, 

and (4) coordination of health services with other services at the 

community level (see glossary). Specify the groups and individuals 

involved in the assessment process. In order to determine a 

measure of the degree to which characteristics documenting family 

participation in CSHCN programs are demonstrated within the 

States, complete Form 13.

5. Selection of State Priority Needs

The narrative addressing the determination of State MCH priorities and 

the summary list of priority needs (and instructions to complete Form 14)

should include the following:

List of Potential Priorities: Provide a list of all items considered 

for inclusion as State priority needs, including pertinent discussion 

of each need, why it was considered for inclusion, and why it was 

or was not included. For example, an item may be considered but 

not chosen as a priority because (1) it is already being measured 

by a National Performance Measure; (2) it falls outside the area of 

responsibility of the MCH or CSHCN Director; (3) a system has 

already been put in place to address the need; or (4) the issue is 

too broadly focused.

Methodologies for Ranking/Selecting Priorities: Describe the 

methodologies used for ranking the priorities identified and for 

selecting the final State priorities to include on Form 14 from all the 

priorities identified. Provide an explanation of why and how the 

State chose its priorities. 
35

Priorities Compared with Prior Needs Assessment: Discuss 

any factors that brought changes in the priorities in the four interim 

years between State MCH needs assessments, with identification 

of: (1) Priorities continued from the previous Needs Assessment; 

(2) Priorities replaced; and (3) Priorities added. For each priority, 

discuss why it was continued, replaced, or added. 

Priority Needs and Capacity: Discuss the State priorities as they 

relate to the four service levels of the pyramid. Discuss the 

relationship between the priority needs and MCH program capacity, 

including a description of the MCH program capacity that is 

available to address the priority needs and any areas where there 

may be inadequate capacity to impact the priority needs in a 

meaningful way. For example, if there is a high need but no 

capacity to address that need, the State may consider this area to 

be an emerging need for possible inclusion as a priority in the 

future, when the State has improved capacity for addressing it.

MCH Population Groups: Provide assurances that there are 

priorities that cover the three major MCH population groups 

(preventive and primary care services for pregnant women, 

mothers and infants; preventive and primary care for services for 

children; and, services for CSHCN).

Priority Needs and State Performance Measures: Describe how 

the State will measure success in meeting each priority need, 

including how it has linked the Priority Needs with the State 

Performance Measures. Examples of how a State may measure its 

success in meeting a priority need include using (1) multiple 

National or State Performance Measures; (2) one National or State 

Performance measure that serves as a proxy for meeting the 

priority need; or (3) one National or State Performance Measure 

that is worded in a manner that is identical to the priority need. 

Discuss each of the State Performance Measures in terms of why 

each measure was chosen and the relationship of each measure to 

the State priority needs. Include the rationale for any State 

Performance Measure that is not linked to priority needs. The State 

may want to include a chart or table that lists each priority need and 

the National and/or State Performance Measure(s) that support that 

need.

When formulating the priority needs statements, use clearly and plainly 

stated phrases such as ―the infant mortality rate for minorities should be 

reduced‖ or ―reduce the barriers to the delivery of care for pregnant 

women.‖ Each priority should have measurable indicators that the State 

can use to track progress related to health status and program or system 

capacity. Copy the 7 to 10 Priority Needs statements to Form 14, List of 

MCH Priority Needs. The Title V information system will record up to 10 

priority needs, but the State may list and describe more if desired.
36

6. Outcome Measures - Federal and State

The MCH Outcome Measures enumerate the final desired result of 

program activities and interventions undertaken to achieve MCH 

objectives. Outcome measures should ultimately answer the question: 

―Why does the State undertake its chosen MCH program activities?‖ It is 

recognized that there are numerous and varied factors that influence 

outcome measures. Therefore, in this section, rather than attempting an 

enumeration of the myriad of factors that may impact outcomes, include a 

brief discussion on the relationship between State program activities, the 

National and State Performance Measures, and the Outcome Measures. 

Include in the discussion changes in existing program activities as well as 

new activities for the coming years that are being planned in an effort to 

positively influence specific outcomes. The State has the option of 

creating one or more State Outcome Measures. If the State has 

developed one or more State Outcome Measures, complete the Tracking 

Health Outcomes Measure form at the end of Form 12. Insert a 

completed detail sheet for each State Outcome Measure at the end of the 

National Outcome Measures Detail Sheets.

In general, briefly describe the relationship between State MCH program 

activities and the National and State Performance Measures and their 

collective contributory positive impact on the outcome measures for the 

Title V population. If the performance measure was not met, discuss 

those factors both within and outside the control of the Title V program 

that may have affected the achievement of this performance measure. 

C. Annual Needs Assessment Summary or Update

1. Year that Needs Assessment is Due—Needs Assessment Summary

During any year when a 5-year Needs Assessment is due, the State must

summarize the results of the State‘s Needs Assessment in this section of 

the application, with a focus on the 7-10 priority needs. The Needs 

Assessment summary should be approximately 2 pages in length and 

should include a discussion of the following:

a. Any changes in the population strengths and needs in the State 

priorities since the last 5-year Needs Assessment.

b. Any changes in the State MCH program or system capacity in 

those State priorities since the last 5-year Needs Assessment.

2. Interim Years—Needs Assessment Update
37

During any interim year when a 5-year Needs Assessment is not due, the 

State must provide a Needs Assessment update in this section of the 

application. The Needs Assessment update should be approximately 2 

pages in length and should include a discussion of the following:

a. Any changes in the population strengths and needs in the State 

priorities since the last Block Grant application.

b. Any changes in the State MCH program or system capacity in 

those State priorities since the last Block Grant application.

c. A brief description of ongoing needs assessment activities, such as 

data collection and analysis, evaluations, focus groups, surveys, 

that enable the State to continue to monitor and assess, on an 

ongoing basis, its priority needs and its capacity to meet those 

needs.

d. A brief description of any activities undertaken to operationalize the 

5-year Needs Assessment, such as establishing an advisory group 

to monitor State progress in addressing the findings and 

recommendations resulting from the Needs Assessment.
38

Figure 2. State Title V MCH Program

Needs Assessment, Planning, Implementation 

& Monitoring Process
39

III - STATE OVERVIEW

A. Overview of the State

This section should put into context the Title V program within the State‘s health 

care delivery environment. Discuss the principal characteristics important to 

understanding the health needs of the entire State's population. Describe the 

State health agency's current priorities or initiatives and the resulting Title V

program's roles and responsibilities.

This overview should include a description of the process used by the Title V

administrator to determine the importance, magnitude, value, and priority of 

competing factors impacting health services delivery in the State including the 

current and emerging issues and how these are taken into consideration as well.

Include in this description the extent to which poverty, racial and ethnic 

disparities in health status, geography, urbanization, and the private sector 

create unique challenges for the delivery of Title V services.

B. Agency Capacity

Describe in this section the State Title V agency's capacity to promote and 

protect the health of all mothers and children, including CSHCN.

The State MCH and CSHCN Programs have the opportunity to indicate some of 

the steps taken to ensure a statewide system of services that reflect the 

principles of comprehensive, community-based, coordinated, family-centered 

care which are essential for effectively fostering and facilitating activities. 

Describe the extent to which the following occur:

State program collaboration with other State agencies and private 

organizations;

State support for communities;

Coordination with health components of community-based systems; 

and

Coordination of health services with other services at the 

community level.

Describe State statutes relevant to Title V program authority and how they impact 

upon the Title V program.

Provide a description of the State‘s Title V capacity to provide:

1. preventive and primary care services for pregnant women, mothers 

and infants;

2. preventive and primary care services for children;
40

3. services for CSHCN [Section 505(a)(1)], including the capacity:

a. to provide rehabilitation services for blind and disabled 

individuals under the age of 16 receiving benefits under Title 

XVI (the Supplemental Security Income Program), to the 

extent medical assistance for such services is not provided 

under Title XIX (Medicaid);

b. to provide and promote family-centered, community-based, 

coordinated care including care coordination services, for 

CSHCN and facilitate the development of community based 

systems of services for such children and their families; and,

4. culturally competent care that is appropriate to the State‘s MCH 

populations.

Provide examples of the mechanisms that have been developed to have 

culturally competent approaches to service delivery. Examples of such activities 

can include:

Collect and analyze data according to different cultural groups (e.g. 

race, ethnicity, language) and use the data to inform program 

development and service delivery.

Ensure the provision of training, both in orientation and ongoing 

professional development, for staff, family leaders, volunteers, 

contractors and subcontractors in the area of cultural and linguistic 

competence.

Collaborate with informal community leaders/groups (e.g. natural 

networks, informal leaders, spiritual leaders, ethnic media, family 

advocacy groups) and families of culturally diverse groups in

needs/assets assessments, program planning, service delivery and 

evaluation/monitoring/quality improvement activities.

Have in place allocation of resources that adequately meet the 

unique access, informational and service needs of culturally diverse 

groups.

Performance standards for staff and contractors which incorporate 

cultural competence practices/policies.

Provide policies and guidelines that support the above items.

C. Organizational Structure

Describe the organizational structure and placement of the Governor, State 

health agency, the MCH and CSHCN programs in the State government. Official 

and dated organizational charts that include all program elements of the Title V 
41

program, clearly depicted, should be on file in the State office and available upon 

request at the time of the Block Grant review. Describe concisely how the State 

health agency is "responsible for the administration (or supervision of the 

administration) of programs carried out with allotments under Title V" [Section 

509(b)]. All programs funded by the Federal-State Block Grant Partnership 

budget total (Form 2, Line 8) should be included.

D. Other (MCH) Capacity

Describe the number and location (central and out-stationed) of staff that work on 

Title V programs. Include staff that provides planning, evaluation, and data 

analysis capabilities. Include the qualifications, in the form of a brief biography, 

of senior level management employees in lead positions. Also include the 

number and role of parents of special needs children on staff. In addition, States 

are encouraged to provide other MCH workforce information that may be 

available, such as full time equivalents (FTEs) at the State and local levels, 

tenure of the State MCH workforce, and projected changes to the MCH 

workforce in the coming year.

E. State Agency Coordination

Describe the relevant organizational relationships among the State Human 

Services agencies (e.g., public health, mental health, social services/child 

welfare, education, corrections, Medicaid, SCHIP, Social Security Administration, 

Vocational Rehabilitation, disability determination unit, alcohol and substance 

abuse, rehabilitation services); the relationship of State and local public health 

agencies (including city MCH programs) and federally qualified health centers; 

primary care associations; tertiary care facilities; and available technical 

resources such as public health and health professional educational programs 

and universities, all of which may enhance the capacity of the Title V program.

In this section also describe the plan for coordination of the Title V program with 

(1) the Early and Periodic Screening, Diagnosis, and Treatment Program 

(EPSDT), (2) other federal grant programs (including WIC, related education 

programs, and other health, developmental disability, and family planning 

programs), and (3) providers of services to identify pregnant women and infants 

who are eligible for Title XIX and to assist them in applying for services [Section 

505(a)(5)(F)]. Also discuss coordination with the Social Security Administration, 

State Disabilities Determination Services unit, Vocational Rehabilitation, and 

family leadership and support programs.

F. Health Systems Capacity Indicators

The nine Health Systems Capacity Indicators (HSCI) are reported annually on 

Forms 17, 18, and 19. These indicators are meant to be used as a selfassessment tool.
42

Besides describing data sources and current findings, the State should utilize this 

section to illustrate such things as:

What has influenced the program‘s ability to maintain and/or 

improve the HSCIs;

What efforts are being made by the program in developing new 

strategies for meeting the HSCIs;

Any interpretation of what the data indicates; and

If a State Systems Development Initiative is in place, what is 

notable regarding it and HSCI 9A (The ability of States to assure 

Maternal and Child Health (MCH) program access to policy and 

program relevant information).

SUMMARY OF HEALTH SYSTEMS CAPACITY INDICATORS

Reported Annually

#01 HEALTH SYSTEMS CAPACITY INDICATOR

The rate of children hospitalized for asthma (ICD-9 Codes: 493.0 – 493.9) per 10,000 children less than 

five years of age.

#02 HEALTH SYSTEMS CAPACITY INDICATOR

The percent of Medicaid enrollees whose age is less than one year who received at least one initial 

periodic screen.

#03 HEALTH SYSTEMS CAPACITY INDICATOR

The percent of State Children’s Health Insurance Program (SCHIP) enrollees whose age is less than 

one year who received at least one periodic screen.

#04 HEALTH SYSTEMS CAPACITY INDICATOR

The percent of women (15 through 44) with a live birth during the reporting year whose observed to 

expected prenatal visits are greater than or equal to 80 percent on the Kotelchuck Index.

#05 HEALTH SYSTEMS CAPACITY INDICATOR

Comparison of health system capacity indicators for Medicaid, non-Medicaid, and all MCH populations 

in the State

#06 HEALTH SYSTEMS CAPACITY INDICATOR

The percent of poverty level for eligibility in the State’s Medicaid and SCHIP programs for infants (0 to 

1), children, and pregnant women.

#07A HEALTH SYSTEMS CAPACITY INDICATOR

The percent of potentially Medicaid eligible children who have received a service paid by the Medicaid 

Program.

(Formerly National Performance Measure #14)

#07B HEALTH SYSTEMS CAPACITY INDICATOR

The percent of EPSDT eligible children aged 6 through 9 years who have received any dental services 

during the year.

#08 HEALTH SYSTEMS CAPACITY INDICATOR

The percent of State SSI beneficiaries less than 16 years old receiving rehabilitative services from the 

State Children with Special Health Care Needs Program.”
43

#09(A) HEALTH SYSTEMS CAPACITY INDICATOR

The ability of States to assure that the Maternal and Child Health program and Title V agency have 

access to policy and program relevant information and data.

#09(B) HEALTH SYSTEMS CAPACITY INDICATOR

The ability of States to determine the percent of adolescents in grades 9 through 12 who report using 

tobacco products in the past month.
44

IV - PRIORITIES, PERFORMANCE AND PROGRAM ACTIVITIES

ANNUAL REPORT/ANNUAL PLAN

A. Background and Overview

The Government Performance and Results Act (GPRA – Public Law 103-62) 

requires that each Federal agency establish performance measures that can be 

reported as part of the budgetary process that links funding decisions with 

performance and related outcome measures to see if there were improved 

outcomes for target populations.

Since 1999 MCHB has included performance plans and performance information 

in its budget submission. MCHB must submit annual reports to Congress on the 

actual performance achieved compared to that proposed in the performance

plan. This section of the guidance describes how the Federal – State partnership 

will implement these performance reporting requirements. Figure 3, page 45, 

―Title V Block Grant Performance Measurement System‖ presents a schematic of 

a system approach that begins with the needs assessment and identification of 

priorities and culminates in improved outcomes for the Title V population. After 

each State establishes a set of priority needs from the five year Statewide needs 

assessment, programs are designed, assigned resources, and implemented to 

specifically address these priorities. Specific program activities are described 

and categorized by the four service levels found in the MCH ―pyramid‖ — direct 

health care, enabling, population-based, and infrastructure building services. 

Because of the flexibility inherent in the Block Grant, the program activities or the 

role that Title V plays in the implementation of each performance measure may 

vary among States (i.e., monitor, advocate, provide, supplement, assure). 

Program activities, as measured by 18 National performance measures and from 

7 to 10 State performance measures should have a collective contributory effect 

to positively impact a set of 6 National outcome measures for the Title V 

population.

Accountability is determined in 3 ways: (1) by measuring the progress towards 

successful achievement of each individual performance measure; (2) by having 

budgeted and expended dollars spread over all four of the recognized MCH 

services; direct health care, enabling services, population-based services, and 

infrastructure building services, and (3) by having a positive impact on the 

outcome measures

While improvement in outcome measures is the long term goal, more immediate 

success may be realized by positive impact on the performance measures which 

are shorter term, intermediate, and precursors for the outcome measures. This 

is particularly important since there may be other significant factors outside of 

Title V control affecting the outcomes.
45

Figure 3

TITLE V BLOCK GRANT

PERFORMANCE MEASUREMENT SYSTEM

DIRECT

HEALTH

ENABLING

SERVICES

POPULATION

BASED 

INFRASTRUCTURE

SERVICES 

PROGRAM AND RESOURCE

ALLOCATION

PERFORMANCE

MEASURES *

OUTCOME

MEASURES

PRENATAL

CARE

MEDICAL

HOME

NEWBORN

SCREENING

CHILDREN

WITH NO

INSURANCE

NEEDS ASSESSMENT PRIORITIES *

HEALTH STATUS/

HEALTH SYSTEMS 

CAPACITY INDICATORS

*

LOWER INFANT

DEATH

DECREASE TEEN

PREGNANCY

INCREASE ACCESS

FOR CSHCN

ASTHMA

HOSPITAL

DISCHARGES

BIRTHS LESS

THAN 2500

GRAMS

ACCESS TO MCH

DATA SETS

MEDICAID

INFANT DEATH

RATES

PERINATAL

MORTALITY

INFANT

MORTALITY

NEONATAL

MORTALITY

POSTNEONATAL

MORTALITY

CHILD

MORTALITY

INFANT

DEATH

DISPARITY
46

B. State Priorities

Describe the relationship of the priority needs, the National and/or State 

performance measures, and the capacity and resource capability of the State 

Title V program. In this discussion, mention where appropriate, the specific 

number of the National and State performance that relate to those activities. 

Details of the development of performance measures and the relationships 

between priorities and performance measures are discussed in parts C and D of 

this section, below.

C. National Performance Measures

Table 4a, page 47, lists the 18 National Performance Measures. Each measure 

is described in the Detail Sheets beginning on page 100 and includes the 

following 5 major components — goal, definition, Healthy People 2010 objective, 

data sources/issues, and significance. A review of the Detail Sheets assists in 

assuring a consistent understanding and reporting of the measures among 

States and in the aggregation of National performance results.

In this section of the narrative discuss, in numerical order, each of the 18 

National Performance Measures. The discussion should focus on MCH 

populations served and activities by level of the pyramid. The discussion should 

be organized by: (a) a report of last year‘s (annual report) accomplishments, (b) 

current activities, and (c) plan for the coming (application) year. 

There may be multiple activities for each performance measure. Throughout this 

section of the narrative label each National Performance Measure with a "NPM#" 

to differentiate it from the State Performance Measures. Discuss activities as 

they relate to the population groups, etc., and discuss how each activity relates to 

the level of the pyramid. Major activities conducted during the annual report year 

should be listed on Table 4a. Specific activities may reflect different levels of 

the pyramid than the corresponding performance measure. An example of 

some activities has been provided for the first Performance Measure in Table 4a. 

Each State should provide their listing of major activities for each corresponding 

performance measure. Up to ten major activities per each performance measure 

may be listed.
47

TABLE 4a

NATIONAL PERFORMANCE MEASURES SUMMARY FROM THE ANNUAL REPORT YEAR

NATIONAL PERFORMANCE MEASURES

Pyramid Level of Service

E

S

P

B

S

I

B

1) The percent of screen positive newborns who received timely follow up to 

definitive diagnosis and clinical management for condition(s) mandated by their 

State-sponsored newborn screening programs.

*List all major ongoing activities, such as: 

1. Purchase of PKU formula and food products for individuals

2. Contracts providing statewide coverage for consultation related with 

related metabolic conditions.

3. Development of a data system linking newborn screening records with 

birth certificates.

4. Arranging transportation, as needed, to access follow up services.

x

x

X

x

x

2) The percent of children with special health care needs age 0 to 18 whose 

families partner in decision-making at all levels and are satisfied with the services 

they receive. (CSHCN Survey)

*List all ongoing major activities.

1.

2.

3.

4.

X

3) The percent of children with special health care needs age 0 to 18 who receive 

coordinated, ongoing, comprehensive care within a medical home. (CSHCN 

Survey)

*List all ongoing major activities.

1.

2.

3.

4.

X

4) 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 the services 

they need. (CSHCN Survey)

*List all ongoing major activities.

1.

2.

3.

4.

X

5) The percent of children with special health care needs age 0 to 18 whose 

families report the community-based service system are organized so they can 

use them easily. (CSHCN Survey)

*List all ongoing major activities.

1.

2.

3.

4.

X

6) The percentage of youth with special health care needs who received the 

services necessary to make transitions to all aspects of adult life, including adult 

health care, work, and independence. (CSHCN Survey)

*List all major ongoing activities.

1.

2.

3.

4.

X

DHC ES PBS IB

X

X

X

X

X

X

X

X

X
48

7) Percent of 19 to 35 month olds who have received full schedule of age 

appropriate immunizations against Measles, Mumps, Rubella, Polio, Diphtheria, 

Tetanus, Pertussis, Haemophilus Influenza, Hepatitis B.

*List all major ongoing activities.

1.

2.

3.

4.

X

8) The rate of birth (per 1,000) for teenagers aged 15 through 17 years.

*List all major ongoing activities.

1.

2.

3.

4.

X

9) Percent of third grade children who have received protective sealants on at 

least one permanent molar tooth.

*List all major ongoing activities.

1.

2.

3.

4.

X

10) The rate of deaths to children aged 14 years and younger caused by motor 

vehicle crashes per 100,000 children.

*List all major ongoing activities.

1.

2.

3.

4.

X

11) The percent of mothers who breastfeed their infants at 6 months of age.

*List all major ongoing activities.

1.

2.

3.

4.

X X

12) Percentage of newborns who have been screened for hearing before hospital 

discharge.

*List all major ongoing activities.

1.

2.

3.

4.

X

13) Percent of children without health insurance.

*List all major ongoing activities.

1.

2.

3.

4.

X

14) Percentage of children, ages 2 to 5 years, receiving WIC services that have a 

Body Mass Index (BMI) at or above the 85th percentile.

*List all major ongoing activities.

1.

2.

3.

3.

X

15) Percentage of women who smoke in the last three months of pregnancy

*List all major ongoing activities.

1.

2.

3.

4.

X

X

X

X

X

X

X

X

X

X
49

16) The rate (per 100,000) of suicide deaths among youths 15-19.

*List all major ongoing activities.

1.

2.

3.

4.

X

17) Percent of very low birth weight infants delivered at facilities for high-risk 

deliveries and neonates.

*List all major ongoing activities.

1.

2.

3.

4.

X

18) Percent of infants born to pregnant women receiving prenatal care beginning 

in the first trimester.

*List all major ongoing activities.

1.

2.

3.

4.

X

NOTE: DHC = Direct Health Care ES = Enabling Services PBS = Population Based Services IB = 

Infrastructure Building. *List all major ongoing activities in space provided. If there are more than four major 

activities on-going, please include these.

TABLE 4b

STATE PERFORMANCE MEASURES SUMMARY FROM THE ANNUAL REPORT YEAR 

STATE PERFORMANCE MEASURES Pyramid Level of Service

D

H

C

E

S

P

B

S

I

B

1).

2.)

3.)

4.)

5.)

6.)

7.)

8.)

9.)

10).

NOTE: DHC=Direct Health Care ES=Enabling Services PBS=Population Based Services 

IB=Infrastructure Building. List all major ongoing activities in space provided for each State Performance 

Measure.

X

X

X

DHC ES PBS IB
50

D. State Performance Measures

In order to promote State flexibility, while assuring accountability in responding to 

the specific priority needs determined through the needs assessment, each State 

shall develop at least 7, but not more than 10, additional performance measures 

based on their identified priorities that best describes their own unique needs and 

may not otherwise be captured by the National Performance Measures. For 

each State Performance Measure, complete a Performance Outcome Measure 

Detail Sheet (Form 16). Throughout the narrative of the Application/Annual 

Report label each State Performance Measure with a "SPM#" to differentiate it 

from the National Performance Measures.

In this section of the narrative, if there have been changes to any of the SPMs 

since the last application, discuss each new SPM in terms of why it was chosen, 

and its relationship to one or more of the priority needs.

For all SPMs, the discussion should include populations served and activities by 

level of the pyramid. The discussion should be organized by: (a) a report of last 

year‘s (annual report) accomplishments, (b) current activities, and (c) plan for the 

upcoming (application) year. It is understood that there may be more than one 

activity for each performance level. These activities may relate to different levels 

of the pyramid and more than one population group.

Lastly, in order to provide a performance measurement summary, list all major

activities that occurred during the annual report year under each performance

measure in Table 4b, page 49. While there are four lines provided to list the 

major activities, up to ten major activities can be included.

SPMs are reviewed relative to the priorities established in the Needs 

Assessment; their representation of important State Title V program activities; 

and to ensure that they are generally measurable and practical. The review 

process also provides an opportunity to increase consistency among similar 

measures submitted by other States by encouraging uniform definitions of 

numerators and denominators that may lead to National data aggregation of 

corresponding measures.

Since it is likely that priority needs and program activities change and evolve over 

time, the SPMs may need to be discontinued when new ones are added. In any 

given year, when a State measure is discontinued, reporting on that measure is 

no longer required and a State may  ̳deactivate‘ the measure in the system. In 

this case, the State should provide an explanation of the reason for deactivating 

the measure. In the first interim reporting year after a Needs Assessment year 

any State measures that were dropped at any time in the previous 5 year 

reporting cycle are to be removed from Table 4b and Forms 11, 12, and 16 

(Detail Sheets).
51

E. Health Status Indicators

The Health Status Indicators (HSI) are to be reported annually. The HSIs

contribute to the State Title V agency‘s ability to:

Provide information on the State‘s residents;

Assist in directing public health efforts;

Serve as a surveillance or monitoring tool; and 

Function as an evaluative measure.

Besides describing data sources and current findings, the State should utilize this 

section to illustrate such things as:

What has influenced the program‘s ability to maintain and/or 

improve the HSIs;

What efforts are being made by the program in developing new 

strategies for meeting the HSIs; and

Any interpretation of what the data indicates.

SUMMARY OF HEALTH “STATUS” INDICATORS

Reported Annually

#01A. The percent of live births weighing less than 2,500 grams

#01B. The percent of live singleton births weighing less than 2,500 grams

#02A. The percent of live births weighing less than 1,500 grams

#02B. The percent of live singleton births weighing less than 1,500 grams.

#03A. The death rate per 100,000 due to unintentional injuries among children aged 14 years and 

younger.

#03B. The death rate per 100,000 from unintentional injuries due to motor vehicle crashes among 

children aged 14 years and younger.

#03C. The death rate per 100,000 from unintentional injuries due to motor vehicle crashes among 

youth aged 15 through 24 years.

#04A. The rate per100,000 of all non-fatal injuries among children aged 14 years and younger.

#04B. The rate per 100,000 of non-fatal injuries due to motor vehicle crashes among children aged 14 

years and younger.

#04C. The rate per 100,000 of non-fatal injuries due to motor vehicle crashes among youth aged 15 

through 24 years.

#05A. The rate per 1,000 women aged 15 through 19 years with a reported case of chlamydia. 

#05B. The rate per 1,000 women aged 20 through 44 years with a reported case of chlamydia.
52

#06A & B. Infants and children aged 0 through 24 years enumerated by sub-populations of age group, 

race, and ethnicity.

#07A & B. Live births to women (of all ages) enumerated by maternal age, race and ethnicity.

#08A & B. Deaths to infants and children aged 0 through 24 years enumerated by age subgroup, race 

and ethnicity.

#09A & B. Infants and children aged 0 through 19 years in miscellaneous situations or enrolled in 

various State programs enumerated by race and ethnicity

#10. Geographic living area for all resident children aged 0 through 19 years

#11. Percent of the State population at various levels of the federal poverty level 

#12. Percent of the State population aged 0 through 19 years at various levels of the federal poverty 

level

F. Other Program Activities

State MCH program activities have considerable breadth. In order to adequately 

describe those activities which fall outside the parameters of priority needs and 

National and State performance measures outlined above, separate descriptions 

may be necessary. Any activity not discussed within the priority needs and the 

performance measurement sections should be described here. These program 

activities often make significant contributions to the health and well-being of 

mothers and infants, children, and CSHCN within each State. Without these ongoing program activities, the MCH population groups would not benefit from the 

full array of services available to them in some States. Each State has the 

opportunity to present these other activities in this section of the 

Application/Annual Report. Examples of other important issues for discussion 

here may include the following: (1) characteristics documenting family/consumer 

participation in MCH and CSHCN programs; (2) special efforts made to address 

health disparities; (3) evaluations that have been recently completed, are 

ongoing, or are planned relative to State MCH and CSHCN activities; (4) cultural 

competency; or (5) any other specific changes or challenges in the upcoming 

year not covered elsewhere in the application.

Include a discussion of the toll-free hotline [Section 505(a)(5)(E)].

G. Technical Assistance Needs

The purpose of Form 15 is to obtain a preliminary idea of the major issues that 

the State has identified to receive special attention and effort during the coming 

next year. The technical assistance (TA) items listed on this form will be 

regarded as a starting point for the State and MCHB for planning an efficient and 

effective strategy for obtaining the most appropriate technical assistance to meet 

the State's unique needs. Priority will be given to providing technical assistance 

in those areas where the State desires to increase its progress in realizing one or 
53

more performance objectives for its State or national performance measures. In 

some cases, the State may want to obtain technical assistance from another 

State who has achieved a high level of performance. States may also be 

interested in obtaining TA from other experts at universities, public health 

agencies, consulting firms, etc. As the State‘s TA needs clarify or change over 

the course of the year, it is expected that it will submit new and/or more detailed 

TA requests. 
54

V - BUDGET NARRATIVE

A. Expenditures

The State should maintain budget documentation for Block Grant 

funding/expenditures for reporting, consistent with Section 505(a), and consistent 

with Section 506(a)(1) for audit. Describe any significant year to year 

expenditure variations that appear on Forms 3, 4, or 5. 

B. Budget

The budget narrative is to reflect how Federal support complements the State‘s 

total effort and what amounts will be utilized in compliance with the 30% - 30% 

requirements. It should further describe how other spending categories 

(administration and maintenance of effort) of Title V funds as shown on Form 2 

are maintained. Describe how satisfaction of the required match is achieved. 

Adequate discussion is included for significant year to year variations in budget 

or expenditures.

In this section describe briefly the maintenance of effort from 1989 [Sec. 

505(a)(4)]; any continuation funding for special projects [Sec. 505(a)(5)(C)(i)]; or 

special consolidated projects noted in Sec. 501(b)(1) [Sec. 505(a)(5)(B)].

The budget justification should further describe sources of other Federal MCH 

dollars, State matching funds, including non-federal dollars that meet at least the 

legislatively-required minimum match for Title V, and other State funds used by 

the agency to provide the Title V program. Describe any significant year to year 

budget variations that appear on Forms 3, 4, or 5.

Remember that any amount payable to a State under this title from allotments for 

a fiscal year which remains unobligated at the end of such year shall remain 

available to such State for obligation during the next fiscal year. No payment 

may be made to a State under this title from allotments for a fiscal year for 

expenditures made after the following fiscal year [Section 503(b)].
55

VI - REPORTING FORMS - GENERAL INFORMATION

Form 1 - Application for Federal Assistance - This is the ―official‖ application form 

requiring electronic signature by the appropriate State official.

Form 1 is formally titled The Application Face Sheet (SF424) and it is a standard Office 

of Management and Budget (OMB) form. The form should be filled out in accordance 

with the standard instructions that accompany it. However, in order to have it serve 

MCHB purposes some definitions in its sub-sections have been assigned new 

meanings. These are spelled out in the detailed instructions that follow the form.

Form 2 - MCH Budget Details for FY __ - Is the premier annual planning form. It 

presents, at a glance all the funding by the Federal - State Block Grant Partnership and 

other MCH related funding sources. It also stipulates what amounts will be utilized in 

compliance with the various spending requirements such as the 30%-30% 

requirements, administration and maintenance of effort.

Form 2 is also the ―drive‖ form for the budget figures that appear on the other financial 

forms....Forms 3, 4, and 5. The figures entered for the application year will 

automatically be entered in the appropriate ―budgeted‖ columns in those forms. Care 

should be taken to complete this form accurately.

Form 3 - State MCH Funding Profile - This form is used for both reporting and 

planning purposes. For Annual Report purposes complete the ―Expended‖ column for 

the appropriate Fiscal Year. For Annual Plan purposes complete the ―Budgeted‖ 

column for the appropriate Fiscal Year.

Form 4 - Budget Details by Types of Individuals Served (I) and Sources of Other 

Federal Funds (II) - This form is used for both reporting and planning purposes. For 

Annual Report purposes complete the ―Expended‖ column for the appropriate Fiscal 

Year. For Annual Plan purposes complete the ―Budgeted‖ column for the appropriate 

Fiscal Year.

Form 5 - State Title V Program Budget and Expenditures by Types of Service -

Form 5, ―State Title V Programs Budget and Expenditures by Types of Service‖ 

parallels the pyramid shown in Figure 1, page 5, which organizes Maternal and Child 

Health Services hierarchically from direct health care services through infrastructure 

building. Because the narrative description and the implementation of performance 

measures are integrally related to this pyramid, special care should be used in 

completing the appropriate fiscal year Expended fund column on this form.

Form 6 - Number and Percentage of Newborn and Others Screened, Cases 

Confirmed, and Treated - Annual Report form.

Form 7 - Number of Individuals Served (Unduplicated) Under Title V - Annual 

Report form.
56

Form 8 - Deliveries and Infants Served by Title V and Entitled to Benefits Under 

Title XIX - Annual Report form.

Form 9 - State MCH Toll-Free Telephone Line Data - Part of the Annual Report.

Form 10 - Title V Maternal & Child Health Services Block Grant State Profile for FY 

__. - The information in this profile will be used as a stand alone document to quickly 

summarize a State‘s accomplishments during the last fiscal year. Follow the 

instructions carefully.

Form 11 - Tracking Performance Measures - lists the 18 National Performance 

Measures and, up to 10 State Outcome Measures and the objectives (targets) and the 

indicators (actual progress) for each, by fiscal year.

For National Measures: For Annual Report purposes complete the appropriate fiscal 

year annual performance indicators by entering data into the ―Numerator‖ and 

―Denominator‖ rows for each of the National and State Performance Measures. Using 

this data, the indicator will be automatically calculated and entered in the appropriate 

row for the measure. For Annual Plan purposes complete the annual performance 

objective row for the State‘s five year targets for each measure.

For the State Measures: Complete Form 11 by adding each State Performance 

Measure after the National measures.

For both National and State Measures: Since it is likely that priority needs and program 

activities will evolve over time it is also likely the performance objective values may 

need to be changed. These values may be changed in either the National or State 

measures if necessary. When changed, add a note in the Add Notes For This Measure

section of Form 11 explaining the reasons for the change.

Form 12 - Tracking Health Outcome Measures - lists the 6 National Outcome 

Measures and, if developed, optional State Outcome Measures and the objectives 

(targets) and the indicators (actual progress) for each, by year.

For the State Measures: Complete Form 12 by adding the State‘s (optional) Outcome 

Measure after the National measures.

For Annual Report purposes: Complete the appropriate fiscal year annual outcome 

indicators by entering data into the ―Numerator‖ and ―Denominator‖ rows for each of the 

National and State Outcome Measures. Using this data, the indicator will be 

automatically calculated and entered in the appropriate row for the measure.

For Annual Plan purposes: Complete the annual outcome objective row for the State‘s 

five year targets for each measure.

Form 13 – Characteristics Documenting Family Participation in Children With 
57

Special Health Care Needs - This form will provide an idea of the characteristics 

documenting family participation in the care of children with potential or actual chronic 

and disabling conditions and their families.

Form 14 - List of MCH Priority Needs - Basically, this form will provide a summary of 

the 5 year Statewide needs assessment. Use information about the health status of the 

MCH population gathered as a result of the 5 year needs assessment. Condense this 

data into a summary of the State's top 7 to 10 needs and place them on this form. Use 

a simple phrase, such as: "The infant mortality rate for minorities should be reduced," 

or, "To reduce the barriers to the delivery of care for pregnant women.‖ Each of the 

three population groups should be covered by the State‘s selected priorities. The Title 

V information system will record up to 10 priority needs, but the State may list and 

describe more if desired in a form note.

Form 15 - Technical Assistance (TA) Request Form - A preliminary listing of the 

State‘s technical assistance needs for the next fiscal year. This form‘s purpose is 

mainly to develop discussion areas that reviewers and State staff may use to determine 

ongoing TA needs. 

Form 16 - State Performance/Outcome Measure Detail Sheet - Contains the details 

of all the data elements that make up the State Performance and Outcome Measures. 

These data elements are: title, service level category (direct health services, enabling 

services, population-based services, or capacity/infrastructure), goal, measure, 

definition, Healthy People 2010 objective, data source and data issues, and a 

description of the measure‘s significance.

For State Performance Measures: These Detail Sheet forms are identical in format to 

the National Performance Measures Detail Sheets. They should be completed in that 

format and with terminology similar to that found in the National Measures Detail 

Sheets. For these State Performance Measure Detail Sheets it is important to include 

as much detail as can be determined for all of the data elements. When a Form 16 

Detail Sheet is completed for each of the State Performance Measures, the title of that 

measure will be automatically added to Table 4b, and Form 11. It is recognized that the 

assignment of service level (of the MCH pyramid) is a matter of judgment and should be 

chosen by the primary category of program activities planned to meet the measure 

during the next 5 years.

For the State Outcome Measure: Each State may also develop one additional State 

Outcome Measure. Use Form 16 to enumerate the details of the measure in the same 

manner as described for the State Performance Measures above.

For both National and State measures: Footnotes containing additional explanatory 

material may be added to the Detail Sheets to enhance understanding or highlight 

special conditions or concerns within the State. This is important since all of the 

National Performance and Outcome Measures have been and will continue to be, a 

"work in progress" and, taken together, the conditions and concerns represent various 
58

developmental stages from the recommendations on data collection methods, to the 

collection of baseline information that may lead to the development of more 

sophisticated performance measurements.

Form 17 – Health System Capacity Indicators – Reporting/Tracking Forms for 

HSCIs 01, 02, 03, 04, 07 & 08 –

Form 18 – Health Systems Capacity Indicators –Reporting/Tracking Forms for 

HSCIs 05 and 06 –

Form 19 – Health Systems Capacity Indicators – Reporting/Tracking Forms for 

HSCIs 09A and B -

Form 20 – Health Status Indicators #01 - #05

Form 21—Health Status Indicators #06 - #12
59

FORMS
60
61

APPLICATION FOR

FEDERAL ASSISTANCE OMB Approval No. 0348-0043

2. DATE SUBMITTED Applicant Identifier

1. TYPE OF SUBMISSION:

Application

Construction

Non-Construction

 Pre-application

 Construction

 Non-Construction

3. DATE RECEIVED BY STATE State Application Identifier

4. DATE RECEIVED BY FEDERAL AGENCY FEDERAL IDENTIFIER

5. APPLICANT INFORMATION

Legal Name: Organizational Unit:

Address (give city, county, state, and zip code) Name and telephone number of the person to be contacted on matters 

involving this application (give area code)

6. EMPLOYER IDENTIFICATION NUMBER (EIN):

 ─ 

 

7. TYPE OF APPLICANT: (Enter appropriate letter in box)

 A. State H. Independent School District

 B. County I. State Controlled Institution of Higher Learning

 C. Municipal J. Private University

 D. Township K. Indian Tribe

 E. Interstate L. Individual

 F. Intermunicipal M. Profit Organization

 G. Special District N. Other (Specify)________________________

8. TYPE OF APPLICATION:

 New Continuation Revision

If Revision, enter appropriate letter(s) in box (es)  

 A. Increase Award B. Decrease Award C. Increase Duration

Decrease Duration Other (specify):

________________________________________________ 

9. NAME OF FEDERAL AGENCY:

10. CATALOG OF FEDERAL DOMESTIC _ 

ASSISTANCE NUMBER: 

TITLE:

11. DESCRIPTIVE TITLE OF APPLICANT’S PROJECT:

12. AREAS AFFECTED BY PROJECT (cities, counties, states, etc.)

13. PROPOSED PROJECT: 14. CONGRESSIONAL DISTRICTS OF:

Start Date Ending Date a. Applicant b. Project

15. ESTIMATED FUNDING: 16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER 12372 

PROCESS?

a. YES, THIS PREAPPLICATION/APPLICATION WAS MADE AVAILABLE TO 

 THE STATE EXECUTIVE ORDER 12373 PROCESS FOR REVIEW ON 

 DATE _______________________________________________

b. NO  PROGRAM IS NOT COVERED BY E.O. 12372

  OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR REVIEW

a. Federal $ .00

b. Applicant $ .00

c. State $ .00

d. Local $ .00

e. Other $ .00

f. Program Income $ .00 17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT

  Yes If ―Yes‖, attach an explanation  No g. TOTAL $ .00

18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PREAPPLICATION ARE TRUE AND CORRECT, THE DOCUMENT HAS 

BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE ATTACHED ASSURANCES IF THE 

ASSISTANCE IS AWARDED.

a. Typed Name of Authorized Representative b. Title c. Telephone number

d. Signature of Authorized Representative e. Date Signed

Previous Editions Not Usable Standard Form 424 (REV. 4-88)

 Prescribed by OMB A-102 
62

INSTRUCTIONS FOR THE SF 424

This is a standard form used by applicants as a required facesheet for the pre-applications and applications submitted for

Federal Assistance. It will be used by Federal agencies to obtain applicant certification that States which have established a 

review and government procedure in response to Executive Order 12372 and have selected the program to be included in 

their process, have been given an opportunity to review the applicant’s submission.

Item: Entry: Item: Entry:

 1. Self-explanatory 12. List only the largest political entities affected (e.g., State, 

counties

 2. Date application 13. Self-explanatory

3. State use only (if applicable). 14. List the applicant’s Congressional District and Districts 

affected by the program or project.

4.

5.

If this application is to continue or revise an existing 

award, enter present Federal identifier number. If for 

a new project, leave blank.

Legal of applicant, name of primary organizational 

unit which will undertake the assistance activity, 

complete address of the applicant, and name and 

telephone number of the person to contract on matters 

related to this application.

15. Amount requested or to be contributed during the first 

funding/budget period by each contributor. Value of in-kind 

contributions should be included on appropriate lines as 

applicable. If the action will result in a dollar change to an 

existing award, indicate only the amount of the change. For 

decreases, enclose the amounts in parenthesis. If both basic 

and supplemental amounts are included, show breakdown on 

an attached sheet. For multiple program funding, use totals 

and show breakdown using same categories as in Item 15.

 6.

7.

Enter Employer Identification Number (EIN) as 

assigned by the Internal Revenue Service.

Enter the appropriate letter in the space provided.

16. Applicants should contact the State Single Point of Contact 

(SPOC) for Federal Executive Order 12372 to determine 

whether the application is subject to the State 

intergovernmental review process.

8. Check the appropriate box and enter appropriate 

letter(s) in the space(s) provided:

- “New” means a new assistance award

- “Continuation” means an extension for an 

additional funding/budget period for a project 

with a projected completion date.

- “Revision” means any change in the Federal 

Government’s financial obligation or contingent 

liability from an existing obligation.

17. This question applies to the applicant organization, not the 

person who signs as the authorized representative. 

Categories of debt include delinquent audit disallowances, 

loans and taxes.

9. Name of Federal agency from which assistance is 

being requested with this application.

18. To be signed by the authorized representative of the 

applicant. A copy of the governing body’s authorization for 

you to sign this application as official representative must be 

on file in the applicant’s office. (Certain Federal agencies 

may require that this authorization be submitted as part of 

the application.)

10. Use the Catalog of Federal Domestic Assistance 

number and title of the program under which 

assistance is requested.

11. Enter a brief descriptive title of the project, if more 

than one program is involved, you should append an 

explanation on a separate sheet. If appropriate (e.g., 

construction or real property projects), attach a map 

showing project location. For pre-applications, use a 

separate sheet to provide a summary description of 

this project.

SF 424 (REV 4-88) Back
63

INSTRUCTIONS FOR THE COMPLETION OF FORM 1

APPLICATION FACE SHEET (STANDARD FORM 424)

The Application Face Sheet (SF424) is not subject to revision; it is an OMB standard form that 

can be revised by OMB only. The Form should be filled out in accordance with the standard 

instructions that accompany it. However, in order for the SF424 to serve MCHB purposes, the 

sub-groupings of funding categories under Section 15 will be defined as follows:

15. Estimated Funding:

a. Federal - The Title V MCH Block grant allocation only.

b. Applicant - The unobligated balance from previous year’s MCH Block Grant 

allocation.

c. State - Total State funds. The State’s total matching funds plus overmatch 

for the Title V Allocation.

d. Local - Total of MCH dedicated funds from local jurisdictions within the 

State.

e. Other - Foundation and other public and private and non-profit monies, 

used for Title V programs.

f. Program Income - Funds collected by State MCH agencies from insurance payments, 

Medicaid, HMOs, etc.

g. TOTAL - ALL the MCH funds administered by the State MCH program.
64
65

FORM 2

MCH BUDGET DETAILS FOR FY ____

[Secs.504(d) and 505(a)(3)(4)]

1. FEDERAL ALLOCATION $__________

 (Item 15a of the Application Face Sheet [SF 424]

 Of the Federal Allocation (1 above), the amount earmarked for:

 A. Preventive and primary care for children:

 $________________ (_____%)

 B. Children with special health care needs:

 $________________ (_____%)

 (If either A or B is less than 30%, a waiver request must

 accompany the application) [Sec. 505(a)(3)]

 C. Title V administrative costs:

 $_________________(_____%)

 (The above figure cannot be more than 10% [Sec. 504(d)]

2. UNOBLIGATED BALANCE (Item 15b of SF 424) $__________

3. STATE MCH FUNDS 

 (Item 15c of SF 424) $__________

4. LOCAL MCH FUNDS (Item 15d of SF424) $__________

5. OTHER FUNDS (Item 15e of the SF 424) $__________

6. PROGRAM INCOME (Item 15f of SF 424) $__________

7. TOTAL STATE MATCH (Lines 3 through 6)

 (Enter below your State=s FY1989 Maintenance of Effort Amount) $_____________

 $______________________

8. FEDERAL-STATE TITLE V BLOCK GRANT PARTNERSHIP (SUBTOTAL) $____________ 

(Total lines 1 through 6. Same as line 15g of SF 424)

 

9. OTHER FEDERAL FUNDS

 (Funds under the control of the person responsible for the

 administration of the Title V program)

a. SPRANS: $________

b. SSDI: $________

c. CISS: $________

d. Abstinence Education $________

e. Healthy Start: $________

f. EMSC: $________

g. WIC: $________

h. AIDS: $________

i. CDC: $________

j. Education: $________

k. Other: $________

 $________

 $________

 $________

10. OTHER FEDERAL FUNDS (SUBTOTAL of all funds under item 9) $__________

11. STATE MCH BUDGET GRAND TOTAL $__________

 (Partnership subtotal + Other Federal MCH Funds subtotal)
66

INSTRUCTIONS FOR COMPLETION OF FORM 2

MCH BUDGET DETAILS FOR FY ____

Title V Citation: Section 504(d) states: “Of the amounts paid to a State...not more than 10 percent may be used for administering the fund paid...@ In order to be entitled 

to payments for allotments under Title V, Section 505(a)(3) provides that the State will use: “(A) at least 30 percent of such payment amounts for preventive and primary 

care services for children, and (B) at least 30 percent of such payment amounts for services to children with special health care needs.@ Section 505(a)(4) provides that “a 

State receiving funds for maternal and child health services...shall maintain the level of funds being provided solely by such State for maternal and child health programs 

at a level at least equal to the level that such State provided for such programs in fiscal year 1989...@

Instructions: A glossary of terms is presented in Part Two, Section VIII of this document.

This form provides details of the State=s MCH budget and the fulfillment of certain spending requirements under Title V for a given year.

Line 1. Enter the amount of the Federal Title V allocation. This is to be the same figure that appears in line 15a of the AFS (SF 424) and in the “Budgeted” column of line 1 

of Form 3 (for the appropriate year).

Line 1A. Enter the amount of the Federal allotment your State is budgeting for preventive and primary care for children and enter the percentage of the total (Line 1) this 

amount represents.

Line 1B. Enter the amount of the Federal allotment your State is budgeting for children with special health care needs and enter the percentage of the total (Line 1) this amount 

represents.

Line 1C. Enter the amount of the Federal allotment your State is budgeting for the administration of the allotment and enter the percentage of the total (Line 1) this amount 

represents.

Line 2. Enter the amount of carryover from the previous year=s MCH Block Grant Allocation (the unobligated balance). This is to be the same figure that appears in line 15b 

of the AFS (SF 424) and in the “Budgeted“ column of line 2 of Form 3 (for the appropriate year).

Line 3. Enter the amount of your State total funds for the Title V allocation (match). This is to be the same figure that appears in line 15c of the AFS (SF 424) and in the 

“Budgeted” column of line 3 of Form 3 (for the appropriate year).

Line 4. Enter the amount of total MCH dedicated funds garnered from local jurisdictions within your State. This is to be the same figure that appears in line 15d of the AFS 

(SF 424) and in the “Budgeted” column of line 4 of Form 3 (for the appropriate year).

Line 5. Enter the total of MCH funds available from other sources such as foundations. This is to be the same figure that appears in line 15e of the AFS (SF 424) and in the 

“Budgeted” column of line 5 of Form 3 (for the appropriate year).

Line 6. Enter the amount of MCH program income funds collected by your State=s MCH agencies from insurance payments, MEDICAID, HMO=s, etc. This is to be the same 

figure that appears in line 15f of the AFS (SF 424) and in the “Budgeted” column of line 6 of Form 3 (for the appropriate year).

Line 7. Enter the sum total of Lines 3, 4, 5, and 6 for the total of your State match and overmatch.

Line 7A. Enter your State=s FY 1989 Maintenance of Effort amount.

Line 8. Enter the amount of the total of lines 1, 2, and 7. This is the “Federal-State Title V Block Grant “Partnership” and is to be the same figure that appears in line 15g of 

SF 424 and in the “Budgeted” column of line 7 of Form 3.

Line 9. On the appropriate lines (a through k) enter Federal funds other than the Title V Block Grant that are under the control of the person responsible for the administration 

of the Title V program. If line 8k is 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 

than two lines are required, add a footnote at the bottom of the page showing additional sources and amounts. 

Line 10. Enter the sum of all Lines in item 9. This is to be the same figure that appears in the “Budgeted” column of line 8 of Form 3 (for the appropriate year).

Line 11. Enter the sum of lines 7 and 10. This is the total of all MCH funds administered by your State=s MCH program and is to be the same figure that appears in the 

“Budgeted” column of line 9 of Form 3 (for the appropriate year)
67

FORM 3

STATE MCH FUNDING PROFILE

[Secs. 505(a) and 506((a)(I-3)]

 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008

 Budgeted Expended Budgeted Expended Budgeted Expended Budgeted Expended Budgeted Expended

1. Federal

 Allocation

 (Line 1, Form 2) $________ $_________ $________ $________ $_________ $________ $________ $_________ $________ $__________

2. Unobligated

 Balance

 (Line 2, Form 2) $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________

3. State

 Funds

 (Line 3, Form 2) $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________

4. Local MCH

 Funds

 (Line 4, Form 2) $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________

5. Other Funds

 (Line 5, Form 2) $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________

 6. Program

 Income

 (Line 6, Form 2) $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________

 7. SUBTOTAL

 (Line 8, Form 2)

$__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________

(THE FEDERAL-STATE TITLE BLOCK GRANT PARTNERSHIP)

8. Other

 Federal

 Funds

(Line 10, Form 2 $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________

9. TOTAL

 (Line 11, Form 2) $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________

(STATE MCH BUDGET TOTAL)
68

 FORM 3

STATE MCH FUNDING PROFILE

[Secs. 505(a) and 506((a)(I-3)]

 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013

 Budgeted Expended Budgeted Expended Budgeted Expended Budgeted Expended Budgeted Expended

1. Federal

 Allocation

(Line 1, Form 2) $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________

2. Unobligated

 Balance

(Line 2, Form 2) $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________

3. State

 Funds

(Line 3, Form 2) $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________

4. Local MCH

 Funds

(Line 4, Form 2) $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________

5. Other Funds

(Line 5, Form 2) $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________

6. Program

 Income

(Line 6, Form 2) $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________

7. SUBTOTAL

(Line 8, Form 2) $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________

(THE FEDERAL-STATE TITLE BLOCK GRANT PARTNERSHIP)

8. Other

 Federal

 Funds

(Line 10, Form 2 $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________

9. TOTAL

(Line 11, Form 2) $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________

(STATE MCH BUDGET TOTAL)
69

INSTRUCTIONS FOR THE COMPLETION OF FORM 3

STATE MCH FUNDING PROFILE

Title V Citation: Section 505(a) states, in part: “In order to be entitled to payments for allotments...a State 

must prepare and transmit to the Secretary an application (in a standard form specified by the Secretary)...”. 

The columns labeled “Budgeted” on this form are intended to partially fulfill the Secretary’s application 

requirements.

Section 506(a)(1-3) describe the annual reporting requirements that A...each State shall prepare and submit 

to the Secretary annual reports on its activities under this title.”

Instructions: A glossary of terms applicable to this form is presented in Part Two, Section VIII of this 

document.

Complete all required data cells. If an actual number is not available, make an estimate. Please 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 a State’s MCH program. For each fiscal year, the lines under the columns labeled 

“Budgeted” are to contain the same figures (for that year) that appear in section 15 of Application Face 

Sheet (SF 424) for that year. Lines 1 through 7 are also to contain the same figures (for the applicable 

year) as lines 1 through 6 and 8 of Form 2, and Line 8 is to contain the same figure as Line 10 of Form 2, 

and Line 9 is to contain the same figure as Line 11 of Form 2. The lines under the columns labeled 

“Expended” are to contain the actual amounts expended for the applicable year.
70
71

FORM 4

BUDGET DETAILS BY TYPES OF INDIVIDUALS SERVED (1) AND

SOURCES OF OTHER FEDERAL FUNDS (II)

[Secs 506(2)(2)(iv)

FY 2006 FY 2007

I. Federal-State MCH

Block Grant Partnership

a. Pregnant Women

Budgeted

$__________

Expended

$________

Budgeted

$__________

Expended

$________

b. Infants < 1 year old $__________ $________ $__________ $________

c. Children 1 to 22 years old $__________ $________ $__________ $________

d. CSHCN $__________ $________ $__________ $________

e. All Others $__________ $________ $__________ $________

f. Administration $__________ $________ $__________ $________

g. SUBTOTAL $__________

(Line 8 and Line 

7, Form 3)

$________

(Line 7, Form 3)

$__________

(Line 8 and Line 

7, Form 3)

$________

(Line 7, Form 3)

II. Other Federal Funds (under the control of the person responsible for administration of the Title V 

program).

a. SPRANS $__________ $__________

b. SSDI $__________ $__________

c. CISS $__________ $__________

d. Abstinence 

Education

$__________ $__________

e. Healthy Start $__________ $__________

f. EMSC $__________ $__________

g. WIC $__________ $__________

h. AIDS $__________ $__________

i. CDC $__________ $__________

j. Education $__________ $__________

k. Other: 

____________

 (Specify)

$__________

$__________

____________

 (Specify)

$__________ $__________

____________

 (Specify)

$__________ $__________

 _____________

 (Specify)

$__________ $__________

III. SUBTOTAL $__________ $__________

(Line 10, Form 2

 and

Line 8, Form 3)

(Line 10, Form 2

 and

Line 8, Form 3
72

FORM 4 (Continuation Page)

BUDGET DETAILS BY TYPES OF INDIVIDUALS SERVED (1) AND

SOURCES OF OTHER FEDERAL FUNDS (II)

[Secs 506(2)(2)(iv)

FY 2008 FY 2009 FY 2010

Budgeted Expended Budgeted Expended Budgeted Expended

$________ $________ $________ $________ $________ $________

$________ $________ $________ $________ $________ $________

$________ $________ $________ $________ $________ $________

$________ $________ $________ $________ $________ $________

$________ $________ $________ $________ $________ $________

$________ $________ $________ $________ $________ $________

(Line 7 & Line 8, Form 3) (Line 7, Form 3) (Line 7 & Line 8, Form 3) (Line 7, Form 3) (Line 7 & Line 8, Form 3) (Line 7, Form 3)

$___________ $___________ $___________

$___________ $___________ $___________

$___________ $___________ $___________

$___________ $___________ $___________

$___________ $___________ $___________

$___________ $___________ $___________

$___________ $___________ $___________

$___________ $___________ $___________

$___________ $___________ $___________

$___________ $___________ $___________

$___________ $___________ $___________

$________ $________ $_______

$________ $________ $________

$________ $________ $________

$__________ $_________ $__________

(Line 10, Form 2 (Line 9, Form 2 (Line 10, Form 2

and and and

Line8, Form 3) Line 8, Form 3) Line 8, Form 3)
73

FORM 4 (Continuation Page)

BUDGET DETAILS BY TYPES OF INDIVIDUALS SERVED (1) AND

SOURCES OF OTHER FEDERAL FUNDS (II)

[Secs 506(2)(2)(iv)

FY 2011 FY 2012 FY 2013

Budgeted Expended Budgeted Expended Budgeted Expended

$________ $________ $________ $________ $________ $________

$________ $________ $________ $________ $________ $________

$________ $________ $________ $________ $________ $________

$________ $________ $________ $________ $________ $________

$________ $________ $________ $________ $________ $________

$________ $________ $________ $________ $________ $________

 (Line 8 and Line 7, Form 3) (Line 7, Form 3) (Line 8 and Line 7, Form 3) (Line 7, Form 3) (Line 8 and Line 7, Form 3) (Line 7, Form 3)

$________ $________ $________

$________ $________ $________

$________ $________ $________

$________ $________ $________

$________ $________ $________

$________ $________ $________

$________ $________ $________

$________ $________ $________

$________ $________ $________

$________ $________ $________

$________ $________ $________

$________ $________ $________

$________ $________ $________

$________ $________ $________

$________ $________ $________

(Line 10, Form 2 (Line 9, Form 2 (Line 10, Form 2

 and and and

Line8, Form 3) Line 8, Form 3) Line 8, Form 3)
74

INSTRUCTIONS FOR COMPLETION OF FORM 4

BUDGET DETAILS BY TYPES OF INDIVIDUALS SERVED (I) AND

SOURCES OF OTHER FEDERAL FUNDS (II)

Title V Citation: Section 506(a)(2)(iv) requires that each State submit an annual report of its activities under its 

Title V program. Among the items required to be reported are, “...the amount spent under this title...by class of 

individuals served.”

Instructions: A glossary of terms applicable to the terms used in this form is provided in Part Two, Section VIII of 

this document.

Complete all required data cells. If an actual number is not available make an estimate. Please explain all estimates 

in a footnote.

Lines I(a) through I(f) - enter the budgeted and expended amounts for the appropriate fiscal year.

Line I(g) - enter the sum of the figures of lines I(a) through (f). Note that for the “Budgeted” columns this figure is 

to be the same figure that appears in the “Budgeted” column of Line 8, Form 2, and in Line 7, Form 3, and for the 

“Expended” column this is the same figure that appears in the “Expended” columns of Line 7, Form 3.

Lines II(a) through II(k) - enter the budgeted amounts for the appropriate fiscal year. Note that these figures are to 

be the same figures that appear in the “Budgeted” columns of lines 9(a) through (k) of Form 2.

Line III - enter the sum of the figures of lines II(a) through (k). Note that this figure is to be the same figure that 

appears in Line 10, Form 2, and in the “Budgeted” column of Line 8, Form 3.
75

FORM 5

STATE TITLE V PROGRAM BUDGET AND EXPENDITURES

BY TYPES OF SERVICES

[Secs. 505(a)(2)(A-B) and 506(a)(1)(A-D)]

 

 FY 2006 FY 2007

TYPES OF SERVICES Budgeted Expended Budgeted Expended

I. Direct Health Care Services $ $ $ $__________ 

(Basic Health Services and Health 

Services for CSHCN.)

II. Enabling Services $ $ $ $__________ 

(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 $ $ $ $__________ 

(Newborn Screening, Lead Screening,

Immunization, Sudden Infant Death 

Syndrome Counseling, Oral Health,

Injury Prevention, Nutrition, and

Outreach/Public Education.)

IV. Infrastructure Building Services $ $ $ $___________ 

(Needs Assessment, Evaluation, Planning,

Policy Development, Coordination,

Quality Assurance, Standards Development,

Monitoring, Training, Applied Research,

Systems of Care, and Information Systems.)

V. FEDERAL-STATE TITLE V BLOCK

GRANT PARTNERSHIP

TOTAL $ $ $ $____________ 

(Federal-State Partnership only.

Item 15g of SF 424. For the “Budget”

columns this is the same figure that

appears in Line 8, Form 2, and in

the “Budgeted” columns of Line 7 Form 3.

For the “Expended” columns this is

the same figure that appears in the

 “Expended” columns of Line 7, Form 3.)
76

FORM 5 (Continuation Page)

STATE TITLE V PROGRAM BUDGET AND EXPENDITURES

BY TYPES OF SERVICES

[Secs. 505(a)(2)(A-B) and 506(a)(1)(A-D)]

 FY 2008 FY 2009 FY 2010

Budgeted Expended Budgeted Expended Budgeted Expended

$ $ $ $ $ $___________ 

$ $ $ $ $ $___________ 

$ $ $ $ $ $___________ 

$ $ $ $ $ $___________ 

$ $ $ $ $ $___________ 
77

FORM 5 (Continuation Page)

STATE TITLE V PROGRAM BUDGET AND EXPENDITURES

BY TYPES OF SERVICES

[Secs. 505(a)(2)(A-B) and 506(a)(1)(A-D)]

 FY 2011 FY 2012 FY 2013

Budgeted Expended Budgeted Expended Budgeted Expended

$ $ $ $ $ $__________ 

$ $ $ $ $ $__________ 

$ $ $ $ $ $__________ 

$ $ $ $ $ $__________ 

$ $ $ $ $ $__________
78

INSTRUCTIONS FOR THE COMPLETION OF FORM 5

STATE TITLE V PROGRAM BUDGET AND EXPENDITURES BY TYPES OF SERVICES

Title V Citation: Section 505(a)(2)(A)(B) and (B)(iii) states, in part, “In order to be entitled to payments for 

allotments...a State must prepare and transmit to the Secretary an application...that - includes for each fiscal year (A) 

a plan for meeting the needs identified by the state-wide needs assessment...and (B) a description of how funds 

allotted to the State...will be used for the provision and coordination of services to carry out such a plan that shall 

include - [(B)(iii)] an identification of the types of services to be provided...” Section 506(a)(1)(A-D) states, “Each 

State shall prepare and submit to the Secretary annual reports on its activities under this title. Each such report shall 

be prepared by, or in consultation with, the State maternal and child health agency. In order to properly evaluate and 

to compare the performance of different States assisted under this title and to assure the proper expenditure of funds 

under this title, such reports shall be in such standardized form and contain such information...as the Secretary 

determines...to be necessary (A) to secure an accurate description of those activities, (B) to secure a complete record 

of the purposes for which funds were spent, of the recipients of such funds, (C) to describe the extent to which the 

State has met the goals and objectives it set forth...and the national health objectives...and (D) to determine the 

extent to which funds were expended consistent with the State’s application...”

Instructions: A Glossary of terms applicable to the terms used in this form contained in Part Two, Section VIII of 

this document.

For reference see Figure 1, “Core Public Health Services Delivered by MCH Agencies.”

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 the lines 

below. If an estimate is necessary, one method would be to allocate those dollars at the same percentage as program 

dollars.

Line I. Direct Health Care Services - enter the budgeted and expended amounts for the appropriate fiscal year. 

Line II. Enabling Services - enter the budgeted and expended amounts for the appropriate fiscal year. 

Line III. Population-Based Services - enter the budgeted and expended amounts for the appropriate fiscal year. 

Line IV. Infrastructure Building Services - enter the budgeted and expended amounts for the appropriate fiscal year. 

Line V. Total Federal-State Partnership Budget and Expenditures - enter the totals of the budgeted and expended 

figures shown in lines I through IV for the appropriate fiscal year. Federal-State Partnership only; item 15g 

of the SF 424. For the “Budgeted” columns this is the same figure that appears in Line 8, Form 2, and in 

the “Budgeted” columns of Line 7, Form 3. For the “Expended” columns this is the same figure that 

appears in the “Expended” columns of Line 7, Form 3.
79

FORM 6

NUMBER AND PERCENTAGE OF NEWBORNS AND OTHERS SCREENED,

CASES CONFIRMED, AND TREATED

Sect. 506(a)(2)(B)(iii)

Total Births by Occurrence:_____________________ Reporting Year: 

Type of Screening 

Tests

(A)

Receiving at

least one 

Screen(1)

No. %

(B)

No. 

Presumptive

Positive 

Screens

(C)

No. 

Confirmed

Cases(2)

(D)

Needing Treatment

that Received 

Treatment(3)

No. %

Phenylketonuria

(Classical)

Congenital 

Hypothyroidism

(Primary)

Galactosemia

(Classical)

Sickle Cell Disease

Other Screening 

(Specify)

1)

2)

3)

4)

5)

6)

Screening Programs 

for Older Children & 

Women (Specify Tests 

by name)

(1) Use occurrent births as denominator.

(2) Report only those from resident births.

(3) Use number of confirmed cases as denominator.
80

INSTRUCTIONS FOR THE COMPLETION OF FORM 6

NUMBER AND PERCENTAGE OF NEWBORNS AND OTHERS SCREENED,

CASES CONFIRMED, AND TREATED

Title V citation: Section 506(a)(2)(B)(iii) requires each State to submit an annual report on its activities under Title 

V. Included in this requirement is the following (iii) “... information on such other indicators of maternal, infant, 

and child health care status as the Secretary may specify.”

Instructions: A glossary of terms applicable to this form is presented in Part Two, Section VIII of this document.

Complete all required data cells. If an actual number is not available, make an estimate. Please explain all estimates 

in a footnote.

1. At the top of the form, on the lines “Total Births by Occurrence” and “Reporting Year” enter the total number 

of occurrent births for your State and the year for which the data applies. Total births by occurrence is to be 

defined as all births that occur in the State regardless of residency. Use the umber submitted by vital records to 

the National Center for Health Statistics. The reporting year is to be defined as calendar year, Jan. 1 – Dec. 31. 

Please note that the “Total Births...” figure is related to the “Total infants < 1 year of age” row in Form 7, and 

the “TOTAL INFANTS IN STATE” row in section I of Form 8. While these figures are not expected to match, 

they should show a fairly close relationship to each other.

2. In column A, for all screening tests listed, enter the number and percentage of occurrent births that received one 

of the tests indicated. Percentage is to be based on occurrent births receiving one test out of the total listed at 

the top of the form.

3. In column B, enter the number of presumptive positive screens.

4. In column C, enter the number of confirmed cases discovered. Use only those from resident births.

5. In column D, enter the number and percent of those confirmed cases needing and receiving treatment. Use 

confirmed cases as the denominator.

6. Under “Other Screening” enter the specific names of any other screens not listed and then complete columns A 

through D. Other tests may include, but are not limited to: homocystinuria, biotinidase deficiency, and maple 

syrup urine disease. 

7. Under “Screening Programs for Older Children and Women,” enter the specific names of any screening tests 

specific to those populations and then complete columns A through D. Note that the % (percentage) portion of 

column A is not to be completed since the denominator of Total Births by Occurrence does not apply.

All States now require screening for at least 2 disorders, and the four most common tests are specifically noted on 

the form, with room to write in other tests. All tests which are done during the reporting year should be listed along 

with the numbers screened and followed.

Follow-up is based on State activity; therefore, use resident live births for confirmed cases. For those needing 

treatment use confirmed cases as the denominator. If the program continues to monitor older children or adults for 

any of these conditions, these should be reported in the row labeled Screening Programs for Older Children and 

Women.
81

FORM 7

NUMBER OF INDIVIDUALS SERVED (UNDUPLICATED) UNDER TITLE V

(By class of Individuals and Percent of Health Coverage)

[Sec. 506(a)(2)(A)(i-ii)]

Reporting Year__________

(A) (B) (C) (D) (E) (F)

TITLE V PRIMARY SOURCE OF COVERAGE

Title XIX Title XXI Private/Other None Unknown

Type of Individuals Served

Total 

Served % % % % %

 Pregnant Women

 Infants < 1 year of age

 Children 1 to 22 years of age

 Children with Special Health Care

 Needs

 Others

 Total
82

INSTRUCTIONS FOR THE COMPLETION OF FORM 7

NUMBER OF INDIVIDUALS SERVED (UNDUPLICATED) UNDER TITLE V

[Sec. 506(a)(2)(A)(i-ii)]

Title V citation: [Sec. 506(a)(2)(A)(i-ii)] requires each State to submit an annual report on its activities under Title 

V. Included in this requirement is the following: “(2) Each annual report...shall include the following information: 

(A)(i) The number of individuals served by the State under the title (by class of individuals). (ii) The proportion of 

each class of such individuals which has health coverage.”

Instructions: A glossary of terms applicable to this form is presented in Part Two, Section VIII of this document.

Complete all required data cells. If an actual number is not available, make an estimate. Please explain all estimates 

in a footnote.

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

2. In column (A) enter the unduplicated count of individuals who received a service (in person, by phone) from the 

Title V program that is included in the top three levels of the MCH pyramid, regardless of the primary source of 

coverage. The fourth, or base level, of the MCH pyramid would generally not contain services and thus would 

not be included. These services would include all individuals served by total dollars reported on line 8 of Form 

2, and may include individuals served by dollars reported on Line 9 of Form 2.

Please note that the figure in the “Title V Total Served” column of the “Infants < 1 year of age” row is related to 

the “Total Births by Occurrence” line in Form 6, and the “TOTAL INFANTS IN STATE” row in section I of 

Form 8. While these figures are not expected to match, they should show a fairly close relationship to each 

other.

3. In the following columns report by the class of individuals served by the Title V program the percentage of 

those who have as their primary source of coverage either:

Column B: Title XIX (includes Medicaid expansion under Title XXI)

Column C: Title XXI

Column D: Other (public or private) coverage

Column E: None

Column F: Unknown

These may be estimates. If individuals are covered by more than one source, they should be listed under the 

column of their primary source.
83

FORM 8

DELIVERIES AND INFANTS SERVED BY TITLE V

AND ENTITLED TO BENEFITS UNDER TITLE XIX

(By Race and Ethnicity)

[Sec. 506(a)(2)(C-D])

 

Reporting Year:________

I. UNDUPLICATED COUNT BY RACE

(A)

TOTAL ALL 

RACES

(B)

White

(C)

Black or 

African 

American

(D)

American 

Indian or 

Native 

Alaskan

(E)

Asian

(F)

Native 

Hawaiian 

or Other 

Pacific 

Islander

(G)

More 

Than One 

Race 

Reported

(H)

Other & 

Unknown

TOTAL 

DELIVERIES

IN STATE

TITLE V SERVED

ELIGIBLE FOR 

TITLE XIX

TOTAL INFANTS 

IN STATE

TITLE V SERVED

ELIGIBLE FOR 

TITLE XIX

II. UNDUPLICATED COUNT BY ETHNICITY

(A)

TOTAL

NOT

Hispanic 

or Latino

(B)

TOTAL

Hispanic or 

Latino

(C)

Ethnicity

Not

Reported

HISPANIC OR LATINO (Sub-categories by country or area of origin)

(B.1)

Mexican

(B.2)

Cuban

(B.3)

Puerto

Rican

(B.4)

Central and 

South 

American

(B.5)

Other and 

Unknown

TOTAL DELIVERIES IN 

STATE

TITLE V SERVED

ELIGIBLE FOR TITLE 

XIX

TOTAL INFANTS IN 

STATE

TITLE V SERVED

ELIGIBLE FOR TITLE 

XIX
84

INSTRUCTIONS FOR THE COMPLETION OF FORM 8

DELIVERIES AND INFANTS SERVED BY TITLE V

AND ENTITLED TO BENEFITS UNDER TITLE XIX

Title V Citation: Section 506 (a)(2)(C-D) requires each State to submit an annual report on its activities 

under Title V. Included in this requirement is the following:

(C) “Information (by racial and ethnic group) on--

(i) the number of deliveries in the State in the year, and

(ii) the number of such deliveries to pregnant women who were provided prenatal, delivery, 

or postpartum care under this title or were entitled to benefits with respect to such 

deliveries under the State plan under title XIX in the year.

(D) Information (by racial and ethnic group) on--

(i) the number of infants under one year of age who were in the State in the year, and

(ii) the number of such infants who were provided services under this title or were entitled to 

benefits under the State plan under title XIX at any time during the year.”

Instructions: A glossary of terms applicable to this form is presented in Part Two, Section VIII of this 

document.

At the top of the form, on the line “Reporting Year,” enter the year for which the data applies. The same 

“Reporting Year” is to be used for both parts I and II of this form.

Complete all required data cells. If an actual number is not available, make an estimate. Please explain all 

estimates in a footnote.

Section I: 

“Total Deliveries in State” - In column A enter the number for the population-based total of all deliveries in 

the State for the reporting year eligible for Title XIX who were provided delivery of services in the 

reporting year. For columns B-H enter the number of individuals who were eligible by race. In column A, 

for “Total infants in State,” enter the number of infants who were eligible for Title XIX during the 

reporting year. (Please note that this figure is related to the “Total Births by Occurrence” line in Form 6, 

and the “Total infants < 1 year of age” row in Form 7. While these figures are not expected to match, they 

should show a fairly close relationship to each other). For columns B-H enter the number of infants who 

were eligible by race.

Section II

States without a significant Hispanic or Latino population should report only Hispanic or Latino, Not 

Hispanic or Latino, or Ethnicity Not Reported categories in columns A through C. States with a significant 

Hispanic or Latino population are encouraged to report subcategories by country or area of origin in 

columns B.1 through B.5. If these columns are used, the total of the populations reported in those columns 

must equal the population figure in column B. 

There will be overlap between the figures listed for “Title V Served” and “Eligible for Title XIX,” because 

this form asks for all individuals served by Title V and an estimate of all those in the State eligible for Title 

XIX. The form does not ask for a report on those served by Title V who are also eligible for Title XIX.
85

FORM 9

STATE MCH TOLL-FREE TELEPHONE LINE DATA FORM

[Secs. 505(a)(5)(E) and 509(a)(8)]

STATE: __________________________

FY____ FY ____ FY ____ FY ____ FY ____

1. State MCH Toll-Free 

“Hotline” Telephone Number ___________ ___________ ___________ ___________ ___________

2. State MCH Toll-Free

“Hotline” Name ___________ ___________ ___________ ___________ ___________

3. Name of Contact Person for

State MCH “Hotline” ___________ ___________ ___________ ___________ ___________

4. Contact Person’s 

Telephone Number ___________ ___________ ___________ ___________ ___________

5. Number of calls received

On the State MCH “Hotline”

This reporting period ___________ ___________ ___________ ___________ ___________
86

INSTRUCTIONS FOR THE COMPLETION OF FORM 9

STATE MCH TOLL-FREE TELEPHONE LINE DATA FORM

Title V citations: Section 505(a)(5)(E) and 509(a)(8) state, in part, “the State agency (or agencies) administering the State’s program under this title 

will provide for a toll-free number (and other appropriate methods) for the use of parents to access information about health care providers and 

practitioners who provide health care services under this title and Title XIX and about other relevant health and health-related providers and 

practitioners...”

The Maternal and Child Health Bureau is the designee of the Secretary of the Department of Health and Human Services to carry out the mandate of 

Section 509(a)(8) of Title V, which requires that a national directory of toll-free numbers be made available to State agencies that administer the State’s 

Title V programs. 

Instructions: Complete all required data cells. If an actual number is not available for line 5, make an estimate. Please explain the estimate in a 

footnote.

1. On the line labeled “State” enter the name of your State.

2. At the top of the first column labeled “FY___” enter the appropriate reporting year and then, in each succeeding column to the right, enter the next 

year in chronological order.

For each year:

3. On line 1, enter your State’s toll-free MCH information line telephone number.

4. On line 2, enter the name of your State’s toll-free information line.

5. On line 3, enter the name of the person who should be contacted with any concerns about the toll-free line.

6. On line 4, enter the telephone number of the contact person listed on line 3. 

7. On line 5, for the reporting year only, enter the number of calls your State’s toll-free MCH information number received for the reporting period.

If your State has an additional toll-free telephone number administered by Title V that you wish to report, use an additional copy of this form. The first 

Form 9 should be for the primary MCH toll-free number for your State.
87

FORM 10

TITLE V MATERNAL & CHILD HEALTH SERVICES BLOCK GRANT

STATE PROFILE FOR FY____

[Sec. 506(a)(1)]

STATE: __________________________________________

1. State MCH Administration:

 Block Grant Funds

2. Federal Allocation (Line 1, Form 2) $_______________________

3. Unobligated balance (Line 2, Form 2) $_______________________

4. State Funds (Line 3, Form 2) $_______________________

5. Local MCH Funds (Line 4, Form 2) $_______________________

6. Other Funds (Line 5, Form 2) $_______________________

7. Program Income (Line 6, Form 2) $_______________________

8. Total Federal-State Partnership (Line 8, Form 2) $_______________________

9. Most significant providers receiving MCH funds: ____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

10. Individuals served by the Title V Program (Col. A, Form 7)

a. Pregnant Women ___________________

b. Infants < 1 year old ___________________

c. Children 1 to 22 years old ___________________

d. CSHCN ___________________

e. Others ___________________
88

FORM 10 (Continued)

TITLE V MATERNAL & CHILD HEALTH SERVICES BLOCK GRANT

STATE PROFILE

11. Statewide Initiatives and Partnerships:

a. Direct Medical Care and Enabling Services:

b. Population-Based Services:

c. Infrastructure Building Services:

12. The primary Title V Program contact person:

13. The children with special health care needs (CSHCN) contact person:
89

INSTRUCTIONS FOR THE COMPLETION OF FORM 10

TITLE V MATERNAL & CHILD HEALTH SERVICES BLOCK GRANT

STATE PROFILE

Title V Citation: Section 506(a)(1) states, in part, “Each State shall prepare and submit to the Secretary annual 

reports on its activities under this title. Each such report...shall be in such standardized form and contain such 

information...as the Secretary determines...”

(This summary information is extremely useful as a stand-alone document for those who don’t have the time or 

desire to read the entire Block Grant Application/Annual Report). 

Instructions: A glossary with definitions of terms used in this form is presented in Part Two, Section VIII of this 

document.

(While this is a “reporting” form certain future year(s) data, as specified in the instructions, will be required for its 

completion)

Fill in the appropriate fiscal year in the title of the form. Enter the name of your State on the line indicated.

Item 1. State which agency administers the Title V program and provide a brief summary of services included 

within Title V’s administrative control.

Items 2-8. Complete the items for Block Grant Funds. These figures should correspond with figures that are 

shown on lines 1 through 6 and line 8 on Form 2.

Item 9. List a few of the most significant providers to the community and State receiving MCH funds for the 

provision of key MCH services.

Item 10. (Items a through e) - Enter the figures for the populations served by the Title V program. These figures 

should be the same as shown in Column A of Form 7.

Item 11. Complete 2 to 4 short (3 or 4 sentences) examples of statewide initiatives, public health activities, or 

community-based efforts for each level of the pyramid (6 to 12 examples total). These descriptions 

should include particularly successful programs or activities that were either provided directly, or 

coordinated by Title V. Begin each example with a brief title of the program activity followed by the 

description.

Item 12. Enter the name of the primary Title V program contact. Include title, address, telephone number, FAX 

number, e-mail address, and Title V program Web site address, if available. 

Item 13. Enter the name of the primary CSHCN program contact. Include title, address, telephone number, FAX 

number, e-mail address, and CSHCN program Web site address, if available.
90

FORM 11

TRACKING PERFORMANCE MEASURES

[Secs. 505(a)(2)(B)(iii) and 506(a)(2)(A)(iii)]

Annual Objective and Performance Data

PERFORMANCE MEASURE #1

The percent of screen positive newborns who received timely 

follow up to definitive diagnosis and clinical management for 

condition(s) mandated by their State-sponsored newborn 

screening programs.

FY__ FY__ FY__ FY__ FY__

Annual Performance Objective ______ ______ _____ _____ _____

Annual Performance Indicator ______ ______ _____ _____ _____

Numerator ______ ______ _____ _____ _____

Denominator ______ ______ _____ _____ _____

PERFORMANCE MEASURE #2

The percent of children with special health care needs age 0 to 

18 whose families partner in decision-making at all levels and 

are satisfied with the services they receive (CSHCN Survey)

Annual Performance Objective ______ ______ _____ _____ _____

Annual Performance Indicator ______ ______ _____ _____ _____

Numerator ______ ______ _____ _____ _____

Denominator ______ ______ _____ _____ _____

PERFORMANCE MEASURE #3

The percent of children with special health care needs age 0 to 

18 who receive coordinated, ongoing, comprehensive care 

within a medical home. (CSHCN Survey)

______ ______ _____ _____ _____

Annual Performance Objective ______ ______ _____ _____ _____

Annual Performance Indicator ______ ______ _____ _____ _____

Numerator ______ ______ _____ _____ _____

Denominator ______ ______ _____ _____ _____
91

FORM 11 (Continuation Page)

TRACKING PERFORMANCE MEASURES

[Secs. 505(a)(2)(B)(iii) and 506(a)(2)(A)(iii)]

Annual Objective and Performance Data

PERFORMANCE MEASURE #4

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 the services they need. (CSHCN Survey)

FY__ FY__ FY__ FY__ FY__

Annual Performance Objective ______ ______ _____ _____ _____

Annual Performance Indicator ______ ______ _____ _____ _____

Numerator ______ ______ _____ _____ _____

Denominator ______ ______ _____ _____ _____

PERFORMANCE MEASURE #5

The percent of children with special health care needs age 0 to 

18 whose families report the community-based service systems 

are organized so they can use them easily. (CSHCN Survey)

Annual Performance Objective ______ ______ _____ _____ _____

Annual Performance Indicator ______ ______ _____ _____ _____

Numerator ______ ______ _____ _____ _____

Denominator ______ ______ _____ _____ _____

PERFORMANCE MEASURE #6 (Please refer to the 

instructions for this Performance Measure)

The percentage of youth with special health care needs who 

received the services necessary to make transitions to all 

aspects of adult life, including adult health care, work, and 

independence. (CSHCN Survey)

Annual Performance Objective ______ ______ _____ _____ _____

Annual Performance Indicator ______ ______ _____ _____ _____

Numerator ______ ______ _____ _____ _____

Denominator ______ ______ _____ _____ _____
92

FORM 11 (Continuation Page)

TRACKING PERFORMANCE MEASURES

[Secs. 505(a)(2)(B)(iii) and 506(a)(2)(A)(iii)]

Annual Objective and Performance Data

PERFORMANCE MEASURE #7

Percent of 19 to 35 month olds who have received full schedule 

of age appropriate immunizations against Measles, Mumps, 

Rubella, Polio, Diphtheria, Tetanus, Pertussis, Haemophilis 

Influenza, Hepatitis B.

FY__ FY__ FY__ FY__ FY__

Annual Performance Objective ______ ______ _____ _____ _____

Annual Performance Indicator ______ ______ _____ _____ _____

Numerator ______ ______ _____ _____ _____

Denominator ______ ______ _____ _____ _____

PERFORMANCE MEASURE #8

The birth rate (per 1,000) for teenagers aged 15 through 17 

years.

Annual Performance Objective ______ ______ _____ _____ _____

Annual Performance Indicator ______ ______ _____ _____ _____

Numerator ______ ______ _____ _____ _____

Denominator ______ ______ _____ _____ _____

PERFORMANCE MEASURE #9

Percent of third grade children who have received protective 

sealants on at least one permanent molar tooth.

Annual Performance Objective ______ ______ _____ _____ _____

Annual Performance Indicator ______ ______ _____ _____ _____

Numerator ______ ______ _____ _____ _____

Denominator ______ ______ _____ _____ _____
93

FORM 11 (Continuation Page)

TRACKING PERFORMANCE MEASURES

[Secs. 505(a)(2)(B)(iii) and 506(a)(2)(A)(iii)]

Annual Objective and Performance Data

PERFORMANCE MEASURE #10

The rate of deaths to children aged 14 years and younger caused 

by motor vehicle crashes per 100,000 children.

FY__ FY__ FY__ FY__ FY__

Annual Performance Objective ______ ______ _____ _____ _____

Annual Performance Indicator ______ ______ _____ _____ _____

Numerator ______ ______ _____ _____ _____

Denominator ______ ______ _____ _____ _____

PERFORMANCE MEASURE # 11

The percent of mothers who breastfeed their infants at 6 months 

of age.

Annual Performance Objective ______ ______ _____ _____ _____

Annual Performance Indicator ______ ______ _____ _____ _____

Numerator ______ ______ _____ _____ _____

Denominator ______ ______ _____ _____ _____

PERFORMANCE MEASURE #12

Percentage of newborns who have been screened for hearing 

before hospital discharge.

Annual Performance Objective ______ ______ _____ _____ _____

Annual Performance Indicator ______ ______ _____ _____ _____

Numerator ______ ______ _____ _____ _____

Denominator ______ ______ _____ _____ _____
94

FORM 11 (Continuation Page)

TRACKING PERFORMANCE MEASURES

[Secs. 505(a)(2)(B)(iii) and 506(a)(2)(A)(iii)]

Annual Objective and Performance Data

PERFORMANCE MEASURE #13

Percent of children without health insurance.

FY__ FY__ FY__ FY__ FY__

Annual Performance Objective ______ ______ _____ _____ _____

Annual Performance Indicator ______ ______ _____ _____ _____

Numerator ______ ______ _____ _____ _____

Denominator ______ ______ _____ _____ _____

PERFORMANCE MEASURE #14

Percentage of children, ages 2 to 5 years, receiving WIC services 

with a Body Mass Index (BMI) at or above the 85th percentile.

Annual Performance Objective ______ ______ _____ _____ _____

Annual Performance Indicator ______ ______ _____ _____ _____

Numerator ______ ______ _____ _____ _____

Denominator ______ ______ _____ _____ _____

PERFORMANCE MEASURE #15

Percentage of women who smoke in the last three months of 

pregnancy.

Annual Performance Objective ______ ______ _____ _____ _____

Annual Performance Indicator ______ ______ _____ _____ _____

Numerator ______ ______ _____ _____ _____

Denominator ______ ______ _____ _____ _____
95

FORM 11 (Continuation Page)

TRACKING PERFORMANCE MEASURES

[Secs. 505(a)(2)(B)(iii) and 506(a)(2)(A)(iii)]

Annual Objective and Performance Data

PERFORMANCE MEASURE #16

The rate (per 100,000) of suicide deaths among youths aged 15-

19.

FY__ FY__ FY__ FY__ FY__

Annual Performance Objective ______ ______ _____ _____ _____

Annual Performance Indicator ______ ______ _____ _____ _____

Numerator ______ ______ _____ _____ _____

Denominator ______ ______ _____ _____ _____

PERFORMANCE MEASURE #17

Percent of very low birth weight infants delivered at facilities for 

high-risk deliveries and neonates.

Annual Performance Objective ______ ______ _____ _____ _____

Annual Performance Indicator ______ ______ _____ _____ _____

Numerator ______ ______ _____ _____ _____

Denominator ______ ______ _____ _____ _____

PERFORMANCE MEASURE #18

Percent of infants born to pregnant women receiving prenatal 

care beginning in the first trimester.

Annual Performance Objective ______ ______ _____ _____ _____

Annual Performance Indicator ______ ______ _____ _____ _____

Numerator ______ ______ _____ _____ _____

Denominator ______ ______ _____ _____ _____
96

FORM 11 (Continuation Page)

TRACKING PERFORMANCE MEASURES

[Secs. 505(a)(2)(B)(iii) and 506(a)(2)(A)(iii)]

Annual Objective and Performance Data

PERFORMANCE MEASURE # FY__ FY__ FY__ FY__ FY__

Annual Performance Objective ______ ______ ______ ______ ______

Annual Performance Indicator ______ ______ ______ ______ ______

Numerator ______ ______ ______ ______ ______

Denominator ______ ______ ______ ______ ______
97

INSTRUCTIONS FOR THE COMPLETION OF FORM 11

PERFORMANCE MEASURE TRACKING

Title V Citation: Section 505(a)(2)(B)(i & iii) requires the States to submit an application that includes, A...a statement of the goals and objectives consistent with the health 

status goals and national health objectives...for meeting the needs specified in the State plan...[and]...an identification of the types of services to be provided... “Section 

506(a)(2)(A)(iii) requires the States to report annually on the A...type (as defined by the Secretary) of services provided under this title...”

General Instructions: A glossary of terms applicable to this form is presented in Part Two, Section VIII of this document.

Complete all required data cells. If an actual number is not available, make an estimate. Please explain all estimates in a footnote. If neither actual data nor an estimate can be

provided, the State must provide a footnote that describes a time framed plan for providing the required data. In such cases the “Annual Performance Objective” and “Annual 

Performance Indicator,” lines are to be left blank.

This form serves two purposes: to show performance measures with 5-year planned performance objective targets for the application, and performance “Annual Performance 

Indicator,” values actually achieved each year for the annual report for each national and State “negotiated” performance measure.

Under the applicable “FY” heading, each State will complete the Annual Performance Objectives, the Annual Performance Indicators, and numerator and denominator data for 

each measure as described below under Specific Instructions. For State “negotiated” measures, enter these data on the form beginning with the first blank Performance Measure 

area under the national measure(s).

Specific Instructions: 

Note: Because the CSHCN SLAITS Survey did not yield reliable State Estimates for NPM number 6, (except for Maine) the numbers shown on Form 11 for this NPM reflect 

only the National estimate. As a result, States are not required to set Performance Objectives for this Performance Measure. However, a State may set an objective if the State is

using another data source. States are encouraged to discuss any activities related to this Performance Measure in the narrative for IV, D.

 In the first available space under “Performance Measure” on the appropriate form, enter the brief title of the State performance measure that has been selected. The titles are to be 

numbered consecutively with notations of "SP 1, SP 2,” etc. Titles are to be written exactly as they appear on Form 16, "State Performance/Outcome Measure Detail Sheet." 

For both national and State measures, in the lines labeled “Annual Performance Objective” enter a numerical value for the target the State plans to meet for the next 5 years. These 

values may be expressed as a number, a rate, a percentage, or “yes - no.”

For both national and State measures, in the lines labeled “Annual Performance Indicator,” enter the numerical value that expresses the progress the State has made toward the 

accomplishment of the performance objective for the appropriate reporting year. Note that the indicator data are to go in the years column from which they were actually derived 

even if the data are a year behind the "reporting" year. This value is to be expressed in the same units as the performance objective: a number, a rate, a percentage, or a “yes - no.”

If there are numerator and denominator data for the performance measures, enter those data on the appropriate lines for the appropriate fiscal year. If there are no numerator and 

denominator data leave these lines empty. 

For each national and State measure, provide a footnote that identifies the data source for the measure.

Repeat this process for each performance measure. A continuation page is included. If the continuation page is used, be sure to enter the number for each listed performance 

measure.

99

VIIA - National Performance Measures Detail Sheets
100
101

01

PERFORMANCE MEASURE The percent of screen positive newborns who 

received timely1follow up to definitive 

diagnosis and clinical management for 

condition(s) mandated by their Statesponsored newborn screening programs. 

GOAL To assure all screen positive newborns receive timely 

follow up to definitive diagnosis and clinical management 

for condition(s) mandated by their State-sponsored 

newborn screening programs.

DEFINITION Numerator: The number of newborns screened and 

confirmed with condition(s) mandated by the State 

sponsored newborn screening program that received 

timely follow-up to definitive diagnosis and clinical 

management.

Denominator: The number of newborns screened 

and confirmed with condition(s) mandated by the 

State sponsored newborn screening program.

Units: 100 Text: Percent

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.

DATA SOURCES and

DATA ISSUES

Data supplied annually by each State to the National 

Newborn Screening and Genetic Resource Center.

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.

 

1

 Timely is defined by each State based on established National guidelines for the individual conditions.
102

02

PERFORMANCE MEASURE The percent of children with special 

health care needs age 0 to 18 years whose 

families partner in decision making at all 

levels and are satisfied with the services 

they receive. (CSHCN survey)

GOAL To increase the number of families with CSHCN who 

partner in decision making and are satisfied with the 

services they receive.

DEFINITION Numerator: The number of children with special 

health care needs in the State age 0 to 18 whose 

families report participating in decision making and 

being satisfied with the services they received during 

the reporting period.

Denominator: The number of children with special 

health care needs in the State age 0 to 18 during the 

reporting period.

Units: 100 Text: Percent

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 SOURCES and

DATA ISSUES

The National CSHCN Survey provides State level 

data on the extent to which families perceive that their 

doctors make the family feel like a partner and the 

family is very satisfied with the overall care 

experience. If State uses another data source, please 

cite source.

SIGNIFICANCE Family/professional partnerships have been: 

incorporated into the MCHB Block Grant 

Application, the MCHB strategic plan. The Omnibus 

Budget Reconciliation Act of 1989 (OBRA ’89)

mandated that the States provide and promote family 

centered, community-based, coordinated care. Family 

satisfaction is also a crucial measure of system 

effectiveness.
103

03

PERFORMANCE MEASURE The percent of children with special health 

care needs age 0 to 18 who receive 

coordinated, ongoing, comprehensive care 

within a medical home. (CSHCN Survey)

GOAL To increase the number of children with special health 

care needs who have a medical home.

DEFINITION Numerator: The percent of children with special 

health care needs in the State age 0 to 18 who have a 

medical home during the reporting period.

Denominator: The number of children with special 

health care needs in the State age 0 to 18 during the 

reporting period.

Units: 100 Text: Percent

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 SOURCES and

DATA ISSUES

The National CSHCN Survey will provide State and 

national level data on the extent to which families 

perceive that their child with a special health care 

need has access to a medical home. Indicators include 

having a regular doctor for routine and sick care: 

access to care that is coordinated with specialty care 

and community services; ease in obtaining referrals: 

and receipt of respectful and culturally competent 

care.

The National CSHCN Survey, conducted every four 

years, provides national and State estimates. If State 

uses another data source, please cite source.

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. The 

MCHB uses the AAP definition of “medical home.” 

(AAP Medical Home Policy Statement, presented in 

Pediatrics, Vol. 110 No. 1, July, 2002)
104

04

PERFORMANCE MEASURE 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 the services they need. (CSHCN 

Survey)

GOAL To increase the percent of children with special health 

care needs, age 0 to 18, with adequate insurance 

coverage for all the services they need.

DEFINITION Numerator: Number of children with special health 

care needs in the State age 0 to 18 whose families 

perceive that they have adequate insurance coverage.

Denominator: Number of children with special 

health care needs in the State age 0 to 18 during the 

reporting period.

Units: 100 Text: Percent

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 1.1: Increase the proportion of 

persons with health insurance to 100 percent.

DATA SOURCES and

DATA ISSUES

The National CSHCN Survey provides State level 

data on the percent of parents of children with special 

health care needs reporting private or public health 

insurance coverage, no gaps in coverage, coverage 

that meets their child’s needs, reasonable out-ofpocket costs, access to needed providers, and lack of 

unmet needs due to health plan coverage. 

The National CSHCN Survey, conducted every four 

years, provides national and State estimates.
105

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. Adequacy of 

insurance ensures comprehensive care, which in turn 

reduces emergency room visits, hospitalizations, and time 

lost from school/work.
106

05

PERFORMANCE MEASURE Percent of children with special health care 

needs age 0 to 18 whose families report the 

community-based service systems are 

organized so they can use them easily. 

(CSHCN Survey)

GOAL To increase the number of families with CSHCN who 

have access to easy-to-use community-based service 

systems.

DEFINITION Numerator:

The number of children with special health care needs 

in the State age 0 to 18 whose families report that 

community-based service systems are organized so 

they can use them easily.

Denominator:

The number of children with special health care needs 

in the Sate age 0 to 18 whose families report that 

community-based service systems are organized so 

they can use them easily.

Units: 100 Text: Percent

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 SOURCES and

DATA ISSUES

The National CSHCN Survey provides State and 

national level data on the extent to which families 

perceive that services are organized for easy use. 

The National CSHCN Survey, conducted every four 

years, provides national and State estimates. 

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. 

Addressing these issues will lead to more efficient use of 

public funds and reduced family stress.
107

06

PERFORMANCE MEASURE The percentage of youth with special health 

care needs who received the services 

necessary to make transitions to all aspects 

of adult life, including adult health care, 

work, and independence. (CSHCN Survey)

GOAL To increase the percent of youth with special health 

care needs who have received the services necessary 

to make transitions to all aspects of adult life, 

including adult health care, work, and independence.

DEFINITION Numerator: Number of youth with special health 

care needs in the Sate 18 years of age and younger 

whose families perceive that they have received the 

services necessary to transition to adult health care, 

work, and independence.

Denominator: Number of youth with special health 

care needs in the State 18 years of age and younger 

during the reporting period.

Units: 100 Text: Percent

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 SOURCES and

DATA ISSUES

The National CSHCN Survey provides State and level 

data on the percent of parents of children with special 

health care needs reporting that their child receives 

support in the transition to adult health care and 

vocational and career training. This survey, 

conducted every four years, provides National and 

State estimates.

SIGNIFICANCE The transition of youth to adulthood has become a 

priority issue nationwide 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.
108

07

PERFORMANCE MEASURE Percent of 19 to 35 month olds who have 

received full schedule of age appropriate 

immunizations against Measles, Mumps, 

Rubella, Polio, Diphtheria, Tetanus, 

Pertussis, Haemophilis Influenza, and 

Hepatitis B.

GOAL To avert all cases of vaccine-preventable morbidity 

and mortality in children.

DEFINITION Numerator: Number of resident children who have 

received the complete immunization schedule for 

DTP/DTAP, OPV, measles, mumps, rubella (MMR), 

H. influenza, and hepatitis B before their second 

birthday. Complete immunization status is generally 

considered to be:

3 Hepatitis B

4 DtaP

3 Polio

1 MMR

3 Hib

Denominator: Number of resident children aged 2 

years.

Units: 100 Text: Percent

HEALTHY PEOPLE 2010

OBJECTIVE

Objective 14-24: Increase the proportion of young 

children who receive all vaccines that have been 

recommended for universal administration for at least 

5 years. Increase the proportion of children aged 19 

through 35 months who received all recommended 

vaccines to 80 percent. (Baseline: 73 percent in 

1998).

DATA SOURCES and

DATA ISSUES

State Immunization Registry, CDC National 

Immunization Survey, State Vital Records, and Bureau of 

Census population estimates.

SIGNIFICANCE Infectious diseases remain important causes of 

preventable illness in the United States despite 

significant reductions in incidence in the past 100 

years. Vaccines are among the safest and most 

effective preventive measures.
109

08

PERFORMANCE MEASURE The rate of birth (per 1,000) for teenagers 

aged 15 through 17 years.

GOAL To lower the birth rate among teenagers, especially 

those age 15 through 17 years.

DEFINITION Numerator: Number of live births to teenagers aged 

15-17 years in the calendar year.

Denominator: Number of females aged 15 through 

17 years in the calendar year.

Units: 1,000 Text: Rate per 1,000

HEALTHY PEOPLE 2010

OBJECTIVE

Objective 9-7. Reduce pregnancies among females 

aged 15-17 to no more than 46 per 1,000 females aged 

15-17 years. (Baseline: 72 pregnancies per 1,000 

females aged 15-17 years in 1995).

DATA SOURCES and

DATA ISSUES

Vital records are the source of data on mother’s age 

and births. Population records are available from the 

Census.

SIGNIFICANCE DHHS is making lowering the rate of teen pregnancies (a 

major threat to healthy and productive lives) a priority 

goal in its strategic plan. Teen parenting is associated 

with the lack of high school completion and initiating a 

cycle of poverty for mothers.
110

09

PERFORMANCE MEASURE Percent of third grade children who have 

received protective sealants on at least one 

permanent molar tooth.

GOAL To prevent pit and fissure tooth decay (dental caries).

DEFINITION Numerator: Number of third grade children who 

have a protective sealant on at least one permanent 

molar tooth.

Denominator: Number of third grade children in the 

State during the year.

Units: 100 Text: Percent

HEALTHY PEOPLE 2010

OBJECTIVE

Objective 21.8: Increase the proportion of children 

who have received dental sealants on their molar teeth 

to 50 percent. (Baseline: 23 percent of children aged 

8 years received sealants on their molars in the years 

1988-94.)

DATA SOURCES and

DATA ISSUES

This requires primary data collection, such as 

examination or screening of a representative sample 

of school children.

SIGNIFICANCE Dental caries affects two-thirds of children by the 

time they are 15 years of age. Developmental 

irregularities, called pits and fissures, are the sites of 

80-90% of childhood caries. Sealants selectively 

protect these vulnerable sites, which are found mostly 

in permanent molar teeth. Targeting sealants to those 

at greatest risk for caries has been shown to increase 

their cost-effectiveness. Although sealants have the 

potential to combine with fluorides to prevent almost 

all childhood tooth decay, they have been 

underutilized.

In addition to being an excellent service in preventing 

tooth decay, sealants may also be a surrogate indicator of 

dental access, oral health promotion and preventive 

activities, and a suitable means to assess the linkages that 

exist between the public and private services delivery 

system. Public managed sealant programs are usually 

school-based or school-linked and target under served 

children, thus providing entry to other services. It has 

been stated on several occasions that dental sealants are 

the oral health equivalent of immunization.
111

10

PERFORMANCE MEASURE The rate of deaths to children aged 14 years 

and younger caused by motor vehicle crashes 

per 100,000 children.

GOAL To reduce the number of deaths to children aged 14 

years old and younger caused by motor vehicle 

crashes.

DEFINITION Numerator: Number of deaths to children aged 14 

years and younger caused by motor vehicle crashes. 

This includes all occupant, pedestrian, motorcycle, 

bicycle, etc. deaths caused by motor vehicles.

Denominator: All children in the State aged 14 years 

and younger.

Units: 100,000 Text: Rate per 100,000

HEALTHY PEOPLE 2010

OBJECTIVE

Objective 15-15: Reduce deaths caused by motor 

vehicle crashes to 9.0 deaths per 100,000 population. 

(Baseline: 15 deaths per 100,000 population by motor 

vehicle crashes in 1998. Baseline for children aged 

14 years and under, 4.2 deaths per 100,000 in 1998).

DATA SOURCES and

DATA ISSUES

Fatal Accident Reporting System (FARS), U.S. 

Department of Transportation, and Vital Statistics 

Systems are sources of the data.

SIGNIFICANCE About 50% of all deaths to children aged 14 years and 

younger are due to injuries, and around 80% of these are 

from motor vehicle crashes. Injuries are the leading 

cause of mortality in this age group and they are the most 

significant health problems affecting the Nation’s 

children.
112

11

PERFORMANCE MEASURE The percent of mothers who breastfeed their 

infants at 6 months of age.

GOAL To increase the percent of mothers who breastfeed 

their infants at 6 months of age.

DEFINITION Numerator:

Number of mothers who indicate that breastmilk is at 

least one of the types of food their infant is fed at 6 

months of age.

Denominator:

Number of mothers with infants at 6 months of age.

Units: 100 Text: Percent

HEALTHY PEOPLE 2010

OBJECTIVE

Objective 16-19b: Increase the proportion of mothers 

who breastfeed their infants at 6 months of age to 50 

percent. (Baseline: 29 percent in 1998).

DATA SOURCES and

DATA ISSUES

CDC’s National Immunization Survey (NIS), Ross 

Laboratories Mothers Survey, State WIC data, CDC’s 

Pediatric Nutrition Surveillance System (PedNSS), 

and HRSA’s National Survey of Children’s Health 

(NSCH).

SIGNIFICANCE Human milk is the preferred feeding for all infants, 

including premature and sick newborns. Exclusive 

breastfeeding is ideal nutrition and sufficient to support 

optimal growth and development for approximately the

first 6 months after birth. The advantages of 

breastfeeding are indisputable and include nutritional, 

immunological and psychological benefits to both mother 

and infant, as well as economic benefits.

Breastfeeding is defined as including any amount of breast milk in the infant’s diet, regardless of additional 

food substances consumed by an infant.

Exclusive breastfeeding is defined as being fed breast milk or water only. Introduction of other substances 

to an infant such as formula, cow’s milk, juice and solid foods in addition to breast milk does not qualify as 

“exclusive” breastfeeding.
113

12

PERFORMANCE MEASURE Percentage of newborns that have been 

screened for hearing before hospital 

discharge.

GOAL To reduce the morbidity associated with hearing 

impairment through early detection.

DEFINITION Numerator: The number of infants in the State 

whose hearing has been screened before hospital 

discharge by tests of either otoacoustic emissions or 

auditory brainstem responses.

Denominator: Number of births in the State in the 

calendar year.

Units: 100 Text: Percent

HEALTHY PEOPLE 2010

OBJECTIVE

Objective 28-11: Increase the proportion of newborns 

that 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.

DATA SOURCES and

DATA ISSUES

State birth certificates, newborn hearing registries, 

tests of otoacoustic emissions and auditory brainstem 

responses. Potential data source – State based Early 

Hearing Detection and Intervention (EDHI) Program 

Network, CDC.

SIGNIFICANCE The advantages of early detection of hearing impairments 

are indisputable and include necessary follow-up of free 

and appropriate enrollment in habilitation and education 

programs.
114

13

PERFORMANCE MEASURE Percent of children without health insurance.

GOAL To ensure access to needed and continuous health care 

services for children.

DEFINITION Numerator: Number of children under 18 in the 

State who are not covered by any private or public 

health insurance (Including Medicaid or risk pools) at 

some time during the reporting year.

Denominator: Number of children in the State under 

18 (estimated by Census in March).

Units: 100 Text: Percent

HEALTHY PEOPLE 2010

OBJECTIVE

Related to Objectives 1-1: Increase the proportion of 

persons with health insurance to 100 percent. 

(Baseline: 86 percent of the population was covered 

by health insurance in 1997).

DATA SOURCES and

DATA ISSUES

There is no current uniform source of data at the State 

level, but data may be available by State estimate 

beginning in 1997 from the March CPS, U.S. Bureau 

of the Census. States need to choose among existing 

estimating techniques and use one consistently.

SIGNIFICANCE There is a well-documented association between 

insurance status and utilization of health care services 

among adults. Less is known about the utilization of 

services in children. A 1996 study by the Harvard School 

of Public Health, The Henry J. Kaiser Foundation and the 

National Opinion Research Center found the uninsured 

are four more times likely to have an episode of needing 

and not getting medical care. As noted in the 1997 

“Families USA Report,” children without health 

insurance have an average of 1 less visit per year and 

receive less treatment than insured children with similar 

problems.
115

14

PERFORMANCE MEASURE Percentage of children, ages 2 to 5 years, 

receiving WIC services with a Body Mass 

Index1(BMI) at or above the 85

th percentile.

GOAL To reduce the proportion of children, ages 2 to 5 

years, who are at risk of overweight or obese.2

DEFINITION Numerator: The number of children, ages 2 to 5 

years, receiving WIC services with a BMI at or above 

the 85

th percentile. 

Denominator: Number of children, ages 2 to 5 years 

that receive WIC services during the reporting period.

Units: 100 Text: Percent

HEALTHY PEOPLE 2010

OBJECTIVE

Related to Objective 19.3: Reduce the proportion of 

children and adolescents who are overweight or 

obese. (1988-1994 Baseline for children aged 6 to 11 

years of age: 11 %)

DATA SOURCES and

DATA ISSUES

State WIC Data, CDC’s Pediatric Nutrition 

Surveillance System (PedNSS), and HRSA’s National 

Survey of Children’s Health (NSCH).

SIGNIFICANCE Childhood overweight is a serious health problem in the 

United States, and the prevalence of overweight among 

preschool children has doubled since the 1970s. There 

have been significant increases in the prevalence of 

overweight in children younger than 5 years of age across 

all ethnic groups. Onset of overweight in childhood 

accounts for 25 percent of adult obesity; but overweight 

that begins before age 8 and persists into adulthood is 

associated with an even greater degree of adult obesity. 

Childhood overweight is associated with a variety of 

adverse consequences, including an increased risk of 

cardiovascular disease, type 2 diabetes mellitus, asthma, 

social stigmatization, and low self-esteem.

 

1 Body Mass Index is defined as the ratio of weight in kilograms to the square of the height in meters.

2 Childhood overweight is defined as a BMI at or above the 95th percentile for children of the same age 

and sex, based on the reference values included in the National Center for Health Statistics 2000 growth 

charts. The term “at risk for overweight” is applied to children whose BMI is between the 85th and 95th 

percentiles.
116

15

PERFORMANCE MEASURE Percentage of women who smoke in the 

last three months of pregnancy.

GOAL Decrease smoking during pregnancy.

DEFINITION Numerator: The number of women reporting 

smoking in the last three months of pregnancy during 

the calendar year.

Denominator: The number of women delivering 

babies during the calendar year.

Units: 100 Text: Percent

HEALTHY PEOPLE 2010

OBJECTIVE

Objective 27-6. Increase smoking cessation during 

pregnancy.

DATA SOURCES and

DATA ISSUES

Birth certificate. States are encouraged to use US 

Standard Certificate of Live Birth (revised 11/2003); 

Pregnancy Risk Assessment Monitoring System 

(PRAMS).

SIGNIFICANCE Birth weight is the single most important determinant of a 

newborn’s survival during the first year. Maternal 

smoking during pregnancy has been directly related to 

low birth weight.
117

16

PERFORMANCE MEASURE The rate (per 100,000) of suicide deaths 

among youths aged 15 through 19.

GOAL To eliminate self-induced, preventable morbidity and 

mortality.

DEFINITION Numerator: Number of deaths attributed to suicide 

among youths aged 15 through 19.

Denominator: Number of youths aged 15 through 

19.

Units: 100,000 Text: Rate per 100,000

HEALTHY PEOPLE 2010

OBJECTIVE

Related to Objectives 18-1: Reduce the suicide rate to 

6.0 deaths per 100,000 population. (Baseline: 10.8 

suicide deaths per 100,000 in 1997). Related to 

Objective 18-2: Reduce the rate of suicide attempts 

by adolescents in grades 9 through 12 to a 12 month 

average of 1 percent. (Baseline: 12 month average of 

2.6 percent among adolescents in grades 9 through 12 

in 1997).

DATA SOURCES and

DATA ISSUES

State vital records are the source.

SIGNIFICANCE Suicide is the third leading cause of death in the United 

States among youths aged 15 through 19, and in many 

States it ranks as the second leading cause of death in this 

population.
118

17

PERFORMANCE MEASURE Percent of very low birth weight infants 

delivered at facilities for high-risk deliveries 

and neonates.

GOAL To ensure that higher risk mothers and newborns deliver 

at appropriate level hospitals.

DEFINITION Numerator: Number of infants with a birth weight 

less than 1,500 grams born at sub-specialty facilities 

(Level III facility).

Denominator: Total number of infants born with a 

birth weight of less than 1,500 grams.

Units: 100 Text: Percent

HEALTHY PEOPLE 2010

OBJECTIVE

Objective 16-9: Increase the proportion of very low 

birth weight (VLBW) infants born at Level III 

hospitals or sub-specialty perinatal centers to 90 

percent. (Baseline: 73 percent of VLBW born at 

level III hospitals or sub-specialty perinatal centers in 

the years 1996-97).

DATA SOURCES and

DATA ISSUES

There is no national data source for this at present. Vital 

records and hospital discharge records would be sources.

SIGNIFICANCE Very low birth weight infants are more likely to survive 

and thrive if they are born/cared for in an appropriately 

staffed and equipped facility with a high volume of highrisk admissions.
119

18

PERFORMANCE MEASURE Percent of infants born to pregnant women 

receiving prenatal care beginning in the first 

trimester.

GOAL To ensure early entrance into prenatal care to enhance 

pregnancy outcomes.

DEFINITION Numerator: Number of live births with reported first 

prenatal visit during the first trimester (before 13 

weeks’ gestation) in the calendar year.

Denominator: Number of live births in the State in 

the calendar year.

Units: 100 Text: Percent 

HEALTHY PEOPLE 2010

OBJECTIVE

Objective 16-16a: Increase the proportion of pregnant 

women who receive early and adequate perinatal care 

beginning in the first trimester of pregnancy to 90 

percent. (Baseline: 83 percent in 1998.)

DATA SOURCES and

DATA ISSUES

Birth certificate data in the State vital records are 

available for over 99% of births.

SIGNIFICANCE Early identification of maternal disease and risks for 

complications of pregnancy or birth are the primary 

reason for first trimester entry into prenatal care. This 

can help ensure that women with complex problems and 

women with chronic illness or other risks are seen by 

specialists. Early high-quality prenatal care is critical to 

improving pregnancy outcomes.
120

FORM 12

TRACKING HEALTH OUTCOME MEASURES

[Secs. 505(a)(2)(B)(iii) and 506(a)(2)(A)(iii)]

 Annual Objective and Performance Data

OUTCOME MEASURE 1 CY__ CY__ CY__ CY__ CY__

The infant mortality rate per 1,000 live births.

Annual Outcome Objective ______ ______ ______ ______ ______

Annual Outcome Indicator ______ ______ ______ ______ ______

Numerator ______ ______ ______ ______ ______

Denominator ______ ______ ______ ______ ______

OUTCOME MEASURE 2

The ratio of the black infant mortality rate to the white

infant mortality rate.

Annual Outcome Objective ______ ______ ______ ______ ______

Annual Outcome Indicator ______ ______ ______ ______ ______

Numerator ______ ______ ______ ______ ______

Denominator ______ ______ ______ ______ ______

OUTCOME MEASURE 3

The neonatal mortality rate per 1,000 live births.

Annual Outcome Objective ______ ______ ______ ______ ______

Annual Outcome Indicator ______ ______ ______ ______ ______

Numerator ______ ______ ______ ______ ______

Denominator ______ ______ ______ ______ ______
121

FORM 12 (Continuation Page)

TRACKING HEALTH OUTCOME MEASURES

[Secs. 505(a)(2)(B)(iii) and 506(a)(2)(A)(iii)]

 Annual Objective and Performance Data

OUTCOME MEASURE 4 CY__ CY__ CY__ CY__ CY__

The post-neonatal mortality rate per 1,000 live births.

Annual Outcome Objective ______ ______ ______ ______ ______

Annual Outcome Indicator ______ ______ ______ ______ ______

Numerator ______ ______ ______ ______ ______

Denominator ______ ______ ______ ______ ______

OUTCOME MEASURE 5

The perinatal mortality rate per 1,000 live births plus fetal deaths.

Annual Outcome Objective ______ ______ ______ ______ ______

 Annual Outcome Indicator ______ ______ ______ ______ ______

Numerator ______ ______ ______ ______ ______

Denominator ______ ______ ______ ______ ______

OUTCOME MEASURE 6

The child death rate per 100,000 children aged 1 through14.

Annual Outcome Objective ______ ______ ______ ______ ______

Annual Outcome Indicator ______ ______ ______ ______ ______

Numerator ______ ______ ______ ______ ______

Denominator ______ ______ ______ ______ ______
122

FORM 12

TRACKING HEALTH OUTCOME MEASURES

[Secs. 505(a)(2)(B)(iii) and 506(a)(2)(A)(iii)]

 Annual Objective and Performance Data

STATE OUTCOME MEASURE # CY__ CY__ CY__ CY__ CY__

Annual Outcome Objective ______ ______ ______ ______ ______

Annual Outcome Indicator ______ ______ ______ ______ ______

Numerator ______ ______ ______ ______ ______

Denominator ______ ______ ______ ______ ______
123

INSTRUCTIONS FOR THE COMPLETION OF FORM 12

TRACKING HEALTH OUTCOME MEASURES

Title V Citation: Section 505(a)(2)(B)(i & iii) requires the States to submit an application that “...a statement of the goals and objectives consistent with the 

health status goals and national health objectives...for meeting the needs of specified in the State plan...[and]...an identification of the types of services to be 

provided...” Section 506(a)(2)(A)(iii) requires the States to report annually on the “...type (as defined by the Secretary) of services provided under this title...”

Instructions: A glossary of terms applicable to this form is presented in Part Two, Section VIII of this document.

Complete all required data cells. If an actual number is not available, make an estimate. Please explain all estimates in a footnote.

This form serves two purposes: (1) to show health outcome measures with planned outcome objective targets for the application, and, (2) outcome indicator 

values actually achieved each year for the annual report.

The “Outcome Measure” titles will already be completed for National Outcome Measures.

On each “Annual Outcome Objective” line, enter a value for the targets the State plans to meet. This value may be expressed as a number, a rate, a percentage, 

or a “yes – no.”

On each “Annual Outcome Indicator” line, enter the value that expresses the progress the State has made toward the accomplishment of the outcome objective 

for the appropriate reporting year. This value is to be expressed in the same units as the outcome objective: a number, a rate, a percentage, or a “yes – no.”

Repeat this process for each health outcome measure.

States have the option of adding one State Outcome Measure of their choice. For this purpose a blank continuation page has been added. To add a State 

Outcome Measure, enter “ASO 1” in the blank provided on the line STATE OUTCOME MEASURE. Under that line enter the title of the State Outcome 

Measure exactly as it appears on Form 12. Complete the remaining columns in the same manner as described above for National Outcome Measures.
124
125

VIIB - National Outcome Measures Detail Sheets
126
127

01

OUTCOME MEASURE The infant mortality rate per 1,000 live 

births.

GOAL To reduce the number of infant deaths.

DEFINITION Numerator: Number of deaths to infants from birth 

through 364 days of age.

Denominator: Number of live births.

Units: 1,000 Text: Rate per 1,000 

HEALTHY PEOPLE 2010

OBJECTIVE

Objective 16-1c: Reduction of infant deaths (within 1 

year) to 4.5 per 1,000 live births. (Baseline: 7.2 in 

1998)

DATA SOURCES and

DATA ISSUES

Vital records collected by the State.

SIGNIFICANCE All countries of the world measure the infant mortality 

rate as an indicator of general health status. The U.S. has 

made progress in reducing this rate, but the rate of decline 

has slowed in the last 10 years. There is still significant 

racial disparity, as noted in the Healthy People 2000 Midcourse Review. Rates are much higher in the lower social 

class and in the lowest income groups across all 

populations.
128

02

OUTCOME MEASURE The ratio of the black infant mortality rate to 

the white infant mortality rate.

GOAL To reduce the disparity (ratio) between the black and 

white infant mortality rates.

DEFINITION Numerator: The black infant mortality rate per 1,000 

live births.

Denominator: The white infant mortality rate per 

1,000 live births.

Units: 1 Text: Ratio

HEALTHY PEOPLE 2010

OBJECTIVE

Objective 16-1c: Reduce all infant deaths (within 1 

year) to 4.5 per 1,000 live births. Objective 16-1d: 

Reduce all neonatal deaths (within the first 28 days of 

life) to 2.9 per 1,000 live births. Objective 16-1e: 

Reduce all post-neonatal deaths (between 28 days and 

1 year) to 1.5 per 1,000 live births. (Baselines [all 

1997] – Infant deaths: White = 6.0 and Black = 13.7; 

Neonatal deaths: White = 4.0 and Black = 9.2; Postneonatal deaths: White = 2.1 and Black = 4.5)

DATA SOURCES and

DATA ISSUES

Vital records collected by the State.

SIGNIFICANCE All countries of the world measure the infant mortality 

rate as an indicator of general health status. The U.S. has 

made progress in reducing this rate, but the rate of decline 

has slowed in the last 10 years. There is still significant 

racial disparity, as noted in the Healthy People 2000 Midcourse Review. Rates are much higher in the lower social 

class and in the lowest income groups across all 

populations. The disparity (ratio) for black infant 

mortality is over twice the white rate. Black women are 

twice as likely as white women to experience 

prematurity, low birth weight, and fetal death.
129

03

OUTCOME MEASURE The neonatal mortality rate per 1,000 live 

births.

GOAL To reduce the number of neonatal deaths

DEFINITION Numerator: Number of deaths to infants under 28 

days.

Denominator: Number of live.

Units: 1,000 Text: Rate per 1,000

HEALTHY PEOPLE 2010

OBJECTIVE

Objective 16-1d: Reduce all neonatal deaths (within 

the first 28 days of life) to 2.9 per 1,000 live births. 

(Baseline: 4.8 in 1998)

DATA SOURCES and

DATA ISSUES

Vital records collected by the State.

SIGNIFICANCE Neonatal mortality is a reflection of the health of the 

newborn and reflects health status and treatment of the 

pregnant mother and of the baby after birth.
130

04

OUTCOME MEASURE The post-neonatal mortality rate per 1,000 

live births.

GOAL To reduce the number of post-neonatal deaths.

DEFINITION Numerator: Number of deaths to infants 28 through 

364 days of age.

Denominator: Number of live births.

Units: 1,000 Text: Rate per 1,000 

HEALTHY PEOPLE 2010

OBJECTIVE

Objective 16-1e: Reduce all post-neonatal deaths 

(between 28 days and 1 year) to 1.5 per 1,000 live 

births. (Baseline: 2.4 in 1998)

DATA SOURCES and

DATA ISSUES

Vital records collected by the State.

SIGNIFICANCE This period of mortality reflects the environment and the 

care infants receive. SIDS deaths occur during this 

period and have been recently reduced due to new infant 

positioning in the U.S. Poverty and a lack of access to 

timely care are also related to late infant deaths.
131

05

OUTCOME MEASURE The perinatal mortality rate per 1,000 live 

births plus fetal deaths.

GOAL To reduce the number of perinatal deaths.

DEFINITION Numerator: Number of fetal deaths 28 weeks or 

more gestation plus early neonatal deaths occurring 

under 7 days.

Denominator: Live births + fetal deaths.

Units: 1,000 Text: Rate per 1,000

HEALTHY PEOPLE 2010

OBJECTIVE

Objective 16-1b: Reduce the death rate during the 

perinatal period (28 weeks of gestation or more to 7 

days or less after birth) to 4.5 per 1,000 live births 

plus fetal deaths. (Baseline: 7.5 in 1997)

DATA SOURCES and

DATA ISSUES

Vital records collected by the State.

SIGNIFICANCE Perinatal mortality is a reflection of the health of the 

pregnant woman and newborn and reflects the pregnancy 

environment and early newborn care.
132

06

OUTCOME MEASURE The child death rate per 100,000 children 

aged 1 through 14.

GOAL To reduce the death rate of children aged 1 through 

14.

DEFINITION Numerator: Number of deaths among children aged 

1 through 14 years.

Denominator: Number of children aged 1 through 

14.

Units: 100,000 Text: Rate per 100,000

HEALTHY PEOPLE 2010

OBJECTIVE

Combination of Objectives 16-2a: Reduce deaths in 

children aged 1 to 4 years to 25.0 per 100,000 in that 

age group. (Baseline: 34.2 in 1998) Objectives 16-

2b: Reduce deaths in children aged 5 to 9 years to 

14.3 per 100,000 in that age group. (Baseline: 17.6 

in 1998) Objectives 16-3a: Reduce deaths in 

adolescents aged 10 to 14 years to 16.8 per 100,000 in 

that age group. (Baseline: 21.8 in 1998)

DATA SOURCES and

DATA ISSUES

Child death certificates are collected by State vital 

records. Data on total number of children comes from 

the Census.

SIGNIFICANCE While children’s likelihood of survival increases 

dramatically after the first year of life, the child death rate 

remains certain. The child death rate has decreased in the 

last decade, falling from 33.8 in 1985 to 28.8 in 1992. 

The DHH’s strategic plan identifies improvements in the 

rates of preventable death as part of priority goals for 

children and youth.
133

VIIC - State Outcome Measures Detail Sheets

[If the State has developed Outcome Measures, insert the completed Detail Sheet in 

this Section.]
134
135

FORM 13

CHARACTERISTICS DOCUMENTING FAMILY PARTICIPATION IN CSHCN PROGRAMS

 0 1 2 3*

1. GGGG

Family members participate on advisory committee or task forces and are offering training, mentoring, and 

reimbursement, when appropriate.

 0 1 2 3

2. GGGG

Financial support (financial grants, technical assistance, travel, and child care) is offered for parent 

activities or parent groups.

 0 1 2 3

3. GGGG

Family members are involved in the Children with Special Health Care Needs elements of the MCH Block 

Grant Application process.

 0 1 2 3

4. GGGG

Family members are involved in service training of CSHCN staff and providers.

 0 1 2 3

5. GGGG

Family members are hired as paid staff or consultants to the State CSHCN program (a family member is 

hired for his or her expertise as a family member.

 0 1 2 3

6. GGGG

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
136

INSTRUCTIONS FOR THE COMPLETION OF FORM 13

FAMILY PARTICIPATION IN CHILDREN WITH SPECIAL 

HEALTH CARE NEEDS PROGRAMS

Title V Citation: Section 501(a)(1)(D) states in part: That a portion of Title V funds shall be appropriated 

for the purpose of enabling each State “...to provide and to promote family-centered, community-based, 

coordinated care (including care coordination services...for children with special health care needs and to 

facilitate the development of community-based systems of services for such children and their families.)”

The goal of this form is to determine the degree to which family participation exists for the care of children 

with special health care needs. These are defined as (For planning and systems development) – Those 

children 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. The establishment of systems of services that reflect the principles of comprehensive, 

community-based, coordinated, family-centered care is essential for effectively fostering and facilitating 

activities to:

Strengthen the ability of families to care for children with actual or potential chronic and 

disabling conditions; and

Enable children with special health care needs to remain in the home and community-based 

living arrangements, rather than in institutional settings.

The completion of the form will assist the Maternal and Child Health Bureau in determining the degree to 

which families participate in children with special health care needs programs as required by Public Law 

101-239. Check the degree to which each describes the State CSHCN program.

Instructions: For each item, on lines 1 through 6, please check the box that best relates the degree which 

indicates the characteristic that describes the State CSHCN program. The numbers of the boxes represent 

the degree to which participation have been met. States should seek family input when filling out this 

form.
137

FORM 14

LIST OF MCH PRIORITY NEEDS

[Sec. 505(a)(1)]

STATE__________________________________ FY_________

Your State’s 5-year Needs Assessment should identify the need for 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. With each year’s Block Grant application provide a list, 

(whether or not the priority needs change) of the top maternal and child health needs in your State. Using a 

simple sentence or phrase, list below your State’s needs. Examples of such statements are: “To reduce the 

barriers to the delivery of care for pregnant women,” and “The infant mortality rate for minorities should be 

reduced.”

MCHB will capture annually every State’s top 7 to 10 priority needs in an information system for 

comparison, tracking, and reporting purposes; you must list at least 7 and no more than 10. Note that the 

numbers list below is for computer tracking only and is not meant to indicate a priority order.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.
138

FORM 15

TECHNICAL ASSISTANCE (TA) REQUEST

This form should contain a PRELIMINARY statement of the TA that you anticipate requesting for the application year. All 

TA requested on your Block Grant Application may be changed or revised AT ANY TIME during the year. When updating 

the information on this form during the year, you may photocopy or download the form from the Block Grant Guidance. The 

form should then be submitted to your MCHB Project Officer, with a copy to the MCHB TA coordinator. Revised forms can 

be transmitted via mail, fax or as an email attachment. Please attach a detailed explanation of any item not fully described in 

the Table. A glossary of terms applicable to this form is included in Part Two, Section VIII of this document.

STATE _____________________ DATE _____________________

Category of

Technical Assistance Requested Reason(s) Why Assistance Is 

Needed

What State, Organization or

Individual Would You Suggest

Provide the TA (if known)

I. GENERAL SYSTEMS CAPACITY ISSUES

A.

B.

C.
139

FORM 15 (Continuation Page)

TECHNICAL ASSISTANCE (TA) REQUEST

II. STATE PERFORMANCE MEASURE ISSUES

Measure # __.

Measure # __.

Measure # __.

III. NATIONAL PERFORMANCE MEASURE 

ISSUES

Measure # __.

Measure # __.

Measure # __.
140

FORM 15 (Continuation Page)

TECHNICAL ASSISTANCE (TA) REQUEST

IV. DATA-RELATED ISSUES

A. Data System Development

B. Needs Assessment

C. Performance Indicators
141

INSTRUCTIONS FOR COMPLETION OF FORM 15

TECHNICAL ASSISTANCE (TA)

Instructions:

Identify your State and date of initial request on page 1. Subsequent requests (made later in the year) can be entered 

on a Technical Assistance Support Form available from the Division of State and Community Health (MCHB).

Enter all assistance requested in the appropriate category:

1. General Systems Capacity – Assistance needed to improve State’s ability to support services to MCH 

populations, i.e., workforce training, distance learning, hotlines, etc.

2. State Performance Measures – Assistance needed to increase State’s ability to meet its objectives for one or 

more State Performance Measures where performance has not been as strong as desired/expected.

3. National Performance Measures – Assistance needed to increase State’s ability to meet its objectives for 

one or more National Performance Measures where performance has not been as strong as 

desired/expected.

4. Data Related Issues – Assistance needed to improve State’s ability to increase its capacity to collect, 

tabulate, and report data accurately and reliably.

Complete all data cells for each item requested, providing a detailed explanation of why each of item of assistance is 

needed, and what person or persons State would like to have provide TA, if known. (Include the performance 

measure number if appropriate.)
142
143

FORM 16

STATE PERFORMANCE/OUTCOME MEASURE DETAIL SHEET

SP# ___________ (Or SO#)

PERFORMANCE MEASURE:

GOAL

DEFINITION Numerator:

Denominator:

Units: ________ _________

(Number) (Text)

HEALTHY PEOPLE 2010

OBJECTIVE

DATA SOURCES and

DATA ISSUES

SIGNIFICANCE
144

INSTRUCTIONS FOR THE COMPLETION OF FORM 16

STATE PERFORMANCE/OUTCOME MEASURE DETAIL SHEET

Title V Citation: Section 505(a)(2)(B)(i & iii) requires the States to submit an application that includes: “...a 

statement of the goals and objectives consistent with the health status goals and national health objectives...for 

meeting the needs specified in the State plan...[and]...an identification of the types of services to be provided...” 

Section 506(a)(2)(A)(iii) requires the States to report annually on the “...type (as defined by the Secretary) of 

services provided under this title...”

Instructions: A glossary of terms applicable to this form is presented in Part Two, Section VIII of this document. 

This form is to be used for both State Performance Measures and the additional State Outcome Measure if the State 

chooses to add one. Complete each section as appropriate for the measure being described.

SP# (or SO): Enter the number of the State Performance or Outcome Measure

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

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

Definition: Describe how the value of the measure is determined from the data. If the value of the measure is

“yes/no” or some other narrative indicator such as “stage 1/stage 2/stage 3," a clear description of what those values 

mean and how they are determined should be provided.

Numerator: If the measure is a percentage, rate, or ratio, provide a clear description of the numerator.

Denominator: If the measure is a percentage, rate, or ratio, provide a clear description of the denominator.

Units: If the measure is a percentage, rate, ratio, or scale, indicate the units in which the measure is to be expressed 

(e.g., 1,000, 100) on the "Number" line and type of measure (e.g., percentage, rate, ratio or scale) on "Text" line. 

If the measure is a narrative, indicate “yes/no” or “stage 1, stage 2", etc. on the "Text" line and make no entry on 

the "Number" line.

Healthy People 2010 Objective: If the measure is related to a Healthy People 2010 objective describe the 

objective and corresponding number.

Data Source &Data Issues: Enter the source(s) of the data used in determining the value of the measure and any 

issues concerning the methods of data collection or limitations of the data used.

Significance: Briefly describe why this measure is significant, especially as it relates to the Goal.

Note that the Performance or Outcome measure title and numerator and denominator data are to appear on Form 11 

exactly as they appear on this Form.
145

FORM 17

HEALTH SYSTEMS CAPACITY INDICATORS

FORMS FOR HSCI 01 THROUGH 04, 07A, 07B & 08 – MULTI-YEAR DATA

Annual Indicator Data

FY __ FY __ FY __ FY __ FY __

HEALTH SYSTEMS CAPACITY INDICATOR #01

The rate of children hospitalized for asthma (ICD-9 

Codes: 493.0 – 493.9) per 10,000 children less than five 

years of age.

Annual Indicator __________ __________ __________ __________ __________

Numerator __________ __________ __________ __________ __________

Denominator __________ __________ __________ __________ __________

HEALTH SYSTEMS CAPACITY INDICATOR #02

The percent of Medicaid enrollees whose age is less than 

one year who received at least one initial or periodic 

screen.

Annual Indicator __________ __________ __________ __________ __________

Numerator __________ __________ __________ __________ __________

Denominator __________ __________ __________ __________ __________

HEALTH SYSTEMS CAPACITY INDICATOR #03

The percent of SCHIP enrollees whose age is less than 

one year who received at least one periodic screen.

Annual Indicator __________ __________ __________ __________ __________

Numerator __________ __________ __________ __________ __________

Denominator __________ __________ __________ __________ __________
146

FORM 17 (Continuation Page)

HEALTH SYSTEMS CAPACITY INDICATORS

FORMS FOR HSCI 01 THROUGH 04, 07A, 07B, & 08 – MULTI-YEAR DATA

Annual Indicator Data

FY __ FY __ FY __ FY __ FY __

HEALTH SYSTEMS CAPACITY INDICATOR #04

The percent of women (15 through 44) with a live birth 

during the reporting year whose observed to expected 

prenatal visits are greater than or equal to 80 percent on 

the Kotelchuck Index.

Annual Indicator __________ __________ __________ __________ __________

Numerator __________ __________ __________ __________ __________

Denominator __________ __________ __________ __________ __________

HEALTH SYSTEMS CAPACITY INDICATOR #07A

The percent of potentially Medicaid-eligible children, 

aged 1 to 21 years, who have received a service paid by 

the Medicaid Program.

Annual Indicator __________ __________ __________ __________ __________

Numerator __________ __________ __________ __________ __________

Denominator __________ __________ __________ __________ __________

HEALTH SYSTEMS CAPACITY INDICATOR #07B

The percent of EPSDT eligible children Medicaid aged 6 

through 9 years who have received any dental services 

during the year.

Annual Indicator __________ __________ __________ __________ __________

Numerator __________ __________ __________ __________ __________

Denominator __________ __________ __________ __________ __________
147

FORM 17 (Continuation Page)

HEALTH SYSTEMS CAPACITY INDICATORS

FORMS FOR HSCI 01 THROUGH 04, 07A, 07B, & 08 – MULTI-YEAR DATA

Annual Indicator Data

FY __ FY __ FY __ FY __ FY __

HEALTH SYSTEMS CAPACITY INDICATOR #08

The percent of State SSI beneficiaries less than 16 years 

old receiving rehabilitation services from the State 

Children with Special Health Care Needs (CSHCN 

Program.

Annual Indicator __________ __________ __________ __________ __________

Numerator __________ __________ __________ __________ __________

Denominator __________ __________ __________ __________ __________
148

INSTRUCTIONS FOR TRACKING HEALTH SYSTEMS CAPACITY

INDICATORS 01 THROUGH 04, 07A, 07B, AND 08

General Instructions:

A glossary of terms applicable to this form is presented in Part Two, Section VIII of this document.

Complete all required data cells. If an actual number is not available make an estimate. Please explain all estimates 

in a footnote.

The purpose of this form is to show, annually, selected measurements (indicators) of MCH Health Systems Capacity 

status in the State and to track those indicators over a five year period.

For each of the Health Systems Capacity Indicators, on the lines labeled “Annual Indicator,” enter the numerical 

value that shows the status for the indicator for the appropriate reporting year. Note that the indicator data is to go in 

the years column from which it was actually derived even if the data is a year behind the “reporting” year. This 

value is to be expressed in the units that are described on the health status indicator detail sheets which, for these 

indicators, are either a rate or a percentage.

If there are numerator and denominator data for the indicator value, enter those data on the appropriate lines for the 

appropriate fiscal year. If actual data is not available for the reporting year, use provisional or estimated numbers 

for numerator and denominator to generate the indicator value.

Specific Instructions:

Systems Capacity Indicator #01 (Ambulatory Sensitive Condition) There is one part to this indicator. The value 

is to be expressed as the hospitalization rate per 10,000 children less than 5 years of age.

Systems Capacity Indicator #02 and #03 (Adequacy of Primary Care) The values are to be expressed as percents 

of Medicaid or SCHIP enrollees who received at least one initial or periodic screen in the age ranges indicated.

Systems Capacity Indicator #04 (Prenatal Care Participation) There is one part to this indicator. The value is to 

be expressed as a percent of women (15 through 44) with a live birth whose observed to expected prenatal visits 

were greater than or equal to 80 percent on the Kotelchuck Index.

Systems Capacity Indicator #07A (Medicaid Services) There is one part to this indicator. The values are to be 

expressed as the percent of children who have received any service in the age range indicated.

Systems Capacity Indicator #07B (Medicaid [EPSDT] Dental Health Services) There is one part to this 

indicator. The values are to be expressed as the percent of children who have received any dental services in the age 

range indicated.

Systems Capacity Indicator #08 (Direct Health Service) There is one part to this indicator. The values are to be 

expressed as the percent of State SSI beneficiaries less than 16 years old who are receiving rehabilitative services 

from the State CSHCN program.
149

FORM 18

HEALTH SYSTEMS CAPACITY INDICATOR REPORTING FORM

HEALTH SYSTEMS CAPACITY INDICATOR #05 (Medicaid and Non-Medicaid Comparison)

INDICATOR #05

Comparison of health system capacity indicators 

for Medicaid, non-Medicaid, and all MCH 

populations in the State YEAR

POPULATION

MEDICAID* NON-MEDICAID ALL

a) Percent of low birth weight (<2,500 grams)

  payment source from birth certificate

  matching data files

b) Infant deaths per 1,000 live births

  payment source from birth certificate

  matching data files

c) Percent of infants born to pregnant women 

receiving prenatal care beginning in the first 

trimester

  payment source from birth certificate

  matching data files

d) Percent of pregnant women with adequate 

prenatal care (observed to expected prenatal visits 

is greater than or equal to 80% [Kotelchuck 

Index])

  payment source from birth certificate

  matching data files

*Please indicate your data source by checking the appropriate box

HEALTH SYSTEMS CAPACITY INDICATOR #06 (Medicaid and SCHIP Eligibility Levels)

INDICATOR #06

The percent of poverty level for eligibility in the 

State’s Medicaid and SCHIP programs for 

infants (0 to 1), children, Medicaid and pregnant 

women. YEAR

PERCENT OF POVERTY LEVEL

MEDICAID SCHIP

a) Infants (0 - 1)

b) Medicaid Children (Age range _____ to _____ )

 SCHIP Children (Age range _____ to _____ )

c) Pregnant Women
150

INSTRUCTIONS FOR THE COMPLETION OF

HEALTH SYSTEMS CAPACITY INDICATOR FORM 18

HEALTH SYSTEMS CAPACITY INDICATORS #05 AND #06

General Instructions: 

A glossary of terms applicable to this form is presented in Part Two, Section VIII of this document.

Complete all required data cells. If an actual number is not available make an estimate. Please explain all estimates 

in a footnote.

The purpose of this form is to show, annually, selected Medicaid and SCHIP indicators in the State. These health 

system capacity indicators deals with data that is to be shown every year. Indicator #05 has four parts and indicator 

#06 has three parts. Specific instructions are:

Specific Instructions:

Health Systems Capacity Indicator #05 (Medicaid and Non-Medicaid Comparison)

In the first column, under the health systems capacity indicator title, check the appropriate box that shows the data 

source. In the next column enter the specific year for the figures reported. Then:

For #05a, in the appropriate cells, enter the percentage of Medicaid infants, Non-Medicaid infants and all infants 

born at a low birth weight (<2,500 grams) in the reporting year.

For #05b, in the appropriate cells, enter the rate (per 1,000 infants) of Medicaid infant deaths, Non-Medicaid infant 

deaths, and all infant deaths in the reporting year.

For #05c, in the appropriate cells, enter the percentage of Medicaid covered infants, Non-Medicaid covered infants

and all infants born to pregnant women who entered prenatal care in the first trimester in the reporting year.

For #05d, in the appropriate cells, enter the percentage of Medicaid covered pregnant women, Non-Medicaid 

covered pregnant women and all pregnant women with adequate prenatal care in the reporting year.

Health Systems Capacity Indicator #06

In the second column enter the specific year for the figures reported. Then:

For #06a, enter the percentages of poverty level required for Medicaid and SCHIP program eligibility for all infants 

0-1 in the State.

For #06b, enter the percentages of the poverty level required for Medicaid and SCHIP program eligibility for all 

Medicaid and SCHIP children in the State. In the first column, under the health systems capacity indicator titles 

enter the age range used for the reported figures. Note that there can be multiple age ranges.

For #06c, enter the percentages of poverty level required for Medicaid and SCHIP program eligibility for pregnant 

women in the State.
151

FORM 19

HEALTH SYSTEMS CAPACITY INDICATOR – REPORTING AND TRACKING FORM

General Instructions:

The purpose of this form is to show the State MCH data capacity and whether the MCH program has the ability to obtain 

timely analyses of certain data for programmatic and policy issues. A glossary of terms applicable to this form is 

presented in Part Two, Section VIII of this document.

HEALTH SYSTEMS CAPACITY INDICATOR #09A (General MCH Data Capacity)

The Ability of the State to Assure MCH Program Access to Policy and Program Relevant Information

DATABASES OR SURVEYS

Does your MCH program have the 

ability to obtain data for program 

planning or policy purpose in a timely 

manner?

(Enter 1-3)*

Does your MCH program have

direct access to the electronic

database for analysis?

(Enter Y/N)

ANNUAL DATA LINKAGES

Annual linkage of infant birth and 

infant death certificates.

 

Annual linkage of birth certificates 

and Medicaid eligibility or paid 

claims files.  

Annual linkage of birth records and 

WIC eligibility files.  

Annual linkage of birth records and 

newborn screening files.  

REGISTRIES AND SURVEYS

Hospital discharge survey for at 

least 90% of in-State discharges.

 

Annual birth defects surveillance 

system.  

Survey of recent mothers at least 

every two years (like PRAMS).  

*Where:

1 = No, the MCH agency does not have this ability.

2 = Yes, the MCH agency sometimes has this ability, but not on a consistent basis.

3 = Yes, the MCH agency always has this ability.
152

FORM 19

HEALTH SYSTEMS CAPACITY INDICATOR – REPORTING AND TRACKING FORM

(Continuation Page)

HEALTH SYSTEMS CAPACITY INDICATOR #09B

The ability of States to monitor tobacco use by children and youth. 

(Data Capacity – Adolescent Tobacco Use)

The Percent of Adolescents in Grades 9 through 12

Who Reported Using Tobacco Products in the Past Month

DATA SOURCES

Does your State participate in 

the YRBS survey?

(Enter 1-3)*

Does your MCH program have direct 

access to the State YRBS database for 

analysis?

(Enter Y/N)

Youth Risk Behavior System (YRBSS)  

Other:

*Where:

1 = No.

2 = Yes, the State participates but the sample size is not large enough for valid statewide estimates for this age group.

3 = Yes, the State participates and the sample size is large enough for valid statewide estimates for this age group.
153

INSTRUCTIONS FOR COMPLETION FORM 19

HEALTH SYSTEMS CAPACITY INDICATOR – REPORTING AND TRACKING FORM

Instructions:

The purpose of Part A of this form is to show, annually, the State MCH data capacity in terms of access to policy 

and program relevant data in a timely manner and whether the MCH program has direct access to the electronic 

database for analysis. 

1. = No, the State MCH program the does NOT have the ability to obtain data for program planning or 

policy purposes in a timely manner.

2. = Yes, the State MCH program SOMETIMES has the ability to obtain data for program planning or 

policy purposes in a timely manner.

3. = Yes, the State MCH program ALWAYS has the ability to obtain data for program planning or policy 

purposes in a timely manner.

The purpose of Part B of this form is to determine the State’s capacity to monitor Adolescent Tobacco Use by 

participating in the YRBSS or some other similar survey.

1. = No, the State does NOT participate in the YRBSS or a similar survey.

2. = Yes, the State participates but the sample size is not large enough for valid statewide 

3. = Yes, the State participates and the sample size is large enough for valid statewide estimates.
154
155

VIID - Health Systems Capacity Indicators Detail Sheets
156
157

01

HEALTH SYSTEMS CAPACITY 

INDICATOR

The rate of children hospitalized for asthma 

(ICD-9 Codes: 493.0 – 493.9) per 10,000 

children less than five years of age.

GOAL To reduce asthma hospitalization for children less 

than five years old.

DEFINITION Numerator: Number of resident asthma (ICD-9 

codes: 493.0 – 493.9) hospital discharges for children 

less than five years old.

Denominator: Estimate of all children less than five 

years old in the State.

Units: 10,000 Text: Rate per 10,000

HEALTHY PEOPLE 2010

OBJECTIVE

Objective 24-2a: Reduce hospitalization for asthma in 

children 0-5 to no more than 25 per 10,000. 

(Baseline: 1997, 60.9 per 10,000)

DATA SOURCES and

DATA ISSUES

Numerator: State hospital discharge data.

Denominator: State population estimates, Bureau of 

Census data.

SIGNIFICANCE Asthma is one of the few medical problems that may be 

used to measure the extent to which children are 

receiving quality disease preventive care and health 

promotion education. Access to and utilization of 

appropriate medical care can often prevent severe 

episodes of asthma. Increased asthma hospitalization

rates may be a consequence of inadequate outpatient 

management and diminished access to a medical home.
158

02

HEALTH SYSTEMS CAPACITY 

INDICATOR

The percent Medicaid enrollees whose age is 

less than one year who received at least one 

initial or periodic screening.

GOAL To increase the adequacy of primary care for 

Medicaid enrollees.

DEFINITION Numerator: Number of Medicaid enrollees whose 

age is less than one year during the reporting year 

who received at least one initial or periodic screen.

Denominator: Number of Medicaid enrollees whose 

age is less than one year.

Units: 100 Text: Percent

HEALTHY PEOPLE 2010

OBJECTIVE

No specific Healthy People 2010 Objective

DATA SOURCES and

DATA ISSUES

Numerator: State Medicaid claims files or EPSDT 

visits for the reporting period.

Denominator: State Medicaid program enrollees for 

the reporting period. The assumption is that all 

Medicaid enrollees whose age is less than one year 

should have at least one initial well child or EPSDT 

visit.

SIGNIFICANCE The EPSDT program is a national initiative to provide 

quality comprehensive services to all Medicaid eligible 

children. Increasing access to comprehensive, familycentered, community-based, culturally competent care for 

the medically under served populations of the State is the 

first step toward establishing a medical home and a 

regular source of care.
159

03

HEALTH SYSTEMS CAPACITY 

INDICATOR

The percent State Children’s Health 

Insurance Program (SCHIP) enrollees whose 

age is less than one year who received at least 

one periodic screen.

GOAL To increase the adequacy of primary care for SCHIP 

enrollees.

DEFINITION Numerator: Number of SCHIP enrollees whose age 

is less than one year during the reporting year who 

received at least one initial or periodic screen.

Denominator: Number of SCHIP enrollees whose 

age is less than one year.

Units: 100 Text: Percent

HEALTHY PEOPLE 2010

OBJECTIVE

No specific Healthy People 2010 Objective.

DATA SOURCES and

DATA ISSUES

Numerator: SCHIP program claims files for well 

child visits, or Early and Periodic Screening, 

Diagnosis and Treatment (EPSDT) visits for the 

reporting period.

Denominator: SCHIP program enrollees for the 

reporting period. The assumption is that all SCHIP 

enrollees whose age is less than one year should have 

at least one initial well child or EPSDT visit.

SIGNIFICANCE The EPSDT program is a national initiative to provide 

quality comprehensive services to all Medicaid eligible 

children. Some states include the EPSDT program as part 

of the SCHIP coverage With the help of public/private 

partners, increasing access to comprehensive, familycentered, community-based, culturally competent care for 

the medically under served populations of the State is the 

first step toward establishing a medical home.
160

04

HEALTH SYSTEMS CAPACITY 

INDICATOR

The percent of women (15 through 44) with a 

live birth during the reporting year whose 

observed to expected prenatal visits are 

greater than or equal to 80 percent on the 

Kotelchuck Index.

GOAL To increase the adequacy of prenatal care utilization.

DEFINITION Numerator: Number of women (15 through 44) 

during the reporting year whose observed to expected 

prenatal visits are greater than or equal to 80 percent 

on the Kotelchuck Index.

Denominator: All women (15 through 44) with a 

live birth during the reporting year.

Units: 100 Text: Percent

HEALTHY PEOPLE 2010

OBJECTIVE

Objective 16-16b: Increase to at least 90 percent the 

proportion of all live born infants whose mothers 

receive prenatal care that is adequate or more than 

adequate according to the Adequacy of Prenatal Care 

Utilization (Kotelchuck) Index. (Baseline: 74 percent 

of live births in 1995)

DATA SOURCES and

DATA ISSUES

State vital statistic records are sources of this data.

SIGNIFICANCE Adequate prenatal care is an effective intervention that 

improves pregnancy outcomes, including reducing infant 

mortality. The two-part (Kotelchuck) Adequacy of 

Prenatal Care Utilization Index combines independent 

assessment of the timing of prenatal care initiation and 

the frequency of visits received after initiation.
161

05

HEALTH SYSTEMS CAPACITY 

INDICATOR

Comparison of health system capacity 

indicators for Medicaid, Non-Medicaid, and 

all MCH populations in the State.

GOAL To eliminate disparities in pregnancy health outcomes 

in Medicaid, non-Medicaid, and all populations in the 

State.

DEFINITION The table for Health Systems Capacity Indicator 05 is 

on Form 18 (Medicaid and SCHIP data). The table 

compares low birth weight (<2,500 grams), infant 

deaths per 1,000 live births, initiation of prenatal care 

during first trimester of pregnancy, and adequacy of 

prenatal care (Kotelchuck Index) by the population 

groups; maternal Medicaid recipient, maternal nonMedicaid recipient, and total maternal population. 

The table is completed with the appropriate number in 

the Medicaid, non-Medicaid, and total State 

population cells for the specified reporting year.

HEALTHY PEOPLE 2010

OBJECTIVE

No specific HP 2010 objective.

DATA SOURCES and

DATA ISSUES

Birth certificates with payment source, linked 

Medicaid files.

SIGNIFICANCE Adverse health outcomes disproportionately affect the 

poor. Enrollment and participation in the State Medicaid, 

SCHIP, or other programs (food stamps, WIC, 

AFDC/TANF) may not eliminate the disparity in 

pregnancy outcomes by socioeconomic status, race and/or 

ethnicity. The quality of services provided to pregnant 

women and their newborns should be evaluated to 

identify barriers to comprehensive, family-centered, 

community-based, culturally competent care.
162

06

HEALTH SYSTEMS CAPACITY 

INDICATOR

The percent of poverty level for eligibility in 

the State’s Medicaid and SCHIP programs 

for infants (0 to 1), children, Medicaid and 

pregnant women.

GOAL To increase State Medicaid and SCHIP enrollment for 

infants (0 to 1), children, and pregnant women.

DEFINITION The table for Health Systems Capacity Indicator 06 is 

on Form 18 (Medicaid and SCHIP data). This table 

has cells for infants (0 to 1), children (specify age 

range), and pregnant women, by year and percent of 

poverty level required for program eligibility. 

Complete the cells with the appropriate percentage of 

poverty level for each of the three groups, and specify 

the reporting year.

Units: 100 Text: Percent

HEALTHY PEOPLE 2010

OBJECTIVE

No specific Healthy People 2010 objective. Related 

Objective 1-1: Increase the proportion of persons 

with health insurance to 100 percent. (Baseline: 86 

percent in 1997) Related Objective 1-4: Increase the 

proportion of children and youth aged 17 years and 

under who have a specific source of ongoing care to 

96 percent. (Baseline 93 percent in 1997)

DATA SOURCES and

DATA ISSUES

State Medicaid and SCHIP programs.

SIGNIFICANCE Adverse health outcomes disproportionately affect the 

poor. Infants (0 to 1), children, and pregnant women 

without private health insurance may not have access to 

medical care. Participation in the State Medicaid or 

SCHIP programs may positively impact health outcomes. 

Important features of Maternal and Child Health (MCH) 

State program evaluations should include eligibility 

thresholds, enrollment volume, program retention, 

transitions in coverage, and access to care.
163

07A

HEALTH SYSTEMS CAPACITY 

INDICATOR

Percent of potentially Medicaid-eligible 

children who have received a service paid by 

the Medicaid Program.

GOAL To enroll all Medicaid-eligible children in Medicaid 

ensuring better access to health care services.

DEFINITION Numerator: Number of children 1 to 21 years of age 

who have received a service paid by Medicaid during 

the Federal fiscal year.

Denominator: The estimated number of children 1 to 

21 years of age who are potentially eligible, by State 

definition, for Medicaid at the end of the Federal 

fiscal year.

Units: 100 Text: Percent

HEALTHY PEOPLE 2010

OBJECTIVE

Related to Objective 1-4b: Increase the proportion of 

children and youth aged 17 years and under who have 

a specific source of ongoing care to 96 percent. 

(Baseline: 93 percent in 1997). Related to Objective 

1-6: Reduce the proportion of families that 

experience difficulties or delays in obtaining health 

care or do not receive needed care for one or more 

family members to 7 percent. (Baseline: 12 percent 

in 1996).

DATA SOURCES and

DATA ISSUES

Numerator: The State Medicaid program counts 

participation monthly and estimates caseload. There 

are peaks and valleys in participation throughout the 

year. Most systems do not link the income of the 

family on the program records, but only the eligibility 

category (e.g., AFDC, expansion, etc.).

Denominator: States may not have these data readily 

available, and therefore estimates are made by using a 

variety of data from CPS, State programs, Census, 

and experience.

SIGNIFICANCE Financial access to health care does not guarantee that all 

children will enroll and access care, but insured children 

are more likely to get care. Currently 3 million children 

are estimated to be eligible non-participants in Medicaid.
164

07B

HEALTH SYSTEMS CAPACITY 

INDICATOR

The percent of EPSDT eligible children 

Medicaid aged 6 through 9 years who have 

received any dental services during the year.

GOAL To increase dental health services to EPSDT eligible 

children aged 6 through 9 years.

DEFINITION Numerator: Total EPSDT eligible children aged 6 

through 9 receiving any dental services in the 

reporting period.

Denominator: Total children aged 6 through 9 

eligible for EPSDT in the State in the reporting 

period.

Units: 100 Text: Percent

HEALTHY PEOPLE 2010

OBJECTIVE

No specific Healthy People 2010 objective. Related 

objective 21-1b: Reduce the proportion of children 

with dental caries experience either in their primary or 

permanent teeth to 42 percent. (Baseline: 52 percent 

of children aged 6 to 8 years had dental caries 

experience in 1988-94) Related Objective 21-2b: 

Reduce the proportion of children with untreated 

dental decay in primary and permanent teeth to 21 

percent. (Baseline: 29 percent of children aged 6 to 8 

years had untreated dental decay in1988-94)

DATA SOURCES and

DATA ISSUES

Revised HCFA-416. Form element numbers 1 and 

12a.

SIGNIFICANCE Dental caries is perhaps the most prevalent disease 

known. Except in its early stages, it is irreversible and

cumulative. Children aged 6 through 8 are at an 

important stage of dental development. The importance 

of optimal oral health for these children is not only to 

their current oral functioning, but also for long-term 

health. Community water fluoridation, use of preventive 

services (sealants and topical fluoride treatments) and 

appropriate oral health behaviors decrease the chance that 

children will develop caries. Many children, particularly 

those in high-risk groups, do not receive adequate 

fluoride exposure or adhesive sealants, regular 

professional care, or oral hygiene instruction. For 

children from low-income families, a significant hurdle is 

paying for services.
165

08

HEALTH SYSTEMS CAPACITY 

INDICATOR

The percent of State SSI beneficiaries less 

than 16 years old receiving rehabilitation 

services from the State Children with Special 

Health Care Needs (CSHCN) Program.

GOAL For the State CSHCN program to provide 

rehabilitative services for blind and disabled children 

less than 16 years old receiving benefits under Title 

SVI, to the extent medical assistance for such services 

is not provided by Medicaid.

DEFINITION Numerator: The number of State SSI beneficiaries 

less that 16 years old receiving rehabilitative services 

from the State’s CSHCN program during the Federal 

fiscal year.

Denominator: The number of SSI beneficiaries less 

than 16 years old in the State.

Units: 100 Text: Percent

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. (Baseline: 15.7 percent of Territories and 

States met Title V for service systems for CSHCN in 

FY 1997)

DATA SOURCES and

DATA ISSUES

State CSHCN and Medicaid programs and Federal 

Supplemental Security Income (SSI) program.

SIGNIFICANCE Title V legislative requirements mandate the provision of 

rehabilitative services for blind and disable individuals 

under the age of 16 receiving benefits under the SSI 

Program to the extent medical assistance for such services 

is not provided by promoting family-centered, 

community-based care. This requirement serves as the

basis for States to establish a policy whereby all SSI 

disabled children are eligible to participate in or benefit 

from the State Title V CSHCN Program.
166

09A

HEALTH SYSTEMS CAPACITY 

INDICATOR

The ability of States to assure Maternal and 

Child Health (MCH) program access to 

policy and program relevant information.

GOAL To assure MCH program and Title V agency access to 

essential policy and program relevant information 

from key public health data sets relating to women, 

children, and families. To demonstrate core MCH 

data capacity.

DEFINITION Form 19 for this Health Systems Capacity Indicator is 

a table with two questions about important databases 

that document the MCH programs’ ability to obtain 

essential program and policy relevant information. 

Following the instructions, enter the degree to which 

these functions are implemented (1-3) and whether the 

State MCH program has direct access to the databases 

(Y/N).

HEALTHY PEOPLE 2010

OBJECTIVE

No specific Healthy People 2010 Objective. Related 

Objective 23-5: Increase the proportion of Leading 

Health Indicators, Health Status Indicators, and

Priority Data Needs for which data – especially for 

select populations – are available at the Tribal, State 

and local levels.

DATA SOURCES and

DATA ISSUES

The State Title V Agency.

SIGNIFICANCE To carry out the 10 essential public health services, MCH 

programs need access to relevant program and policy 

information. This requires basic data capacity on the part 

of the Title V agency including the ability to monitor 

health status, to investigate health problems, and to 

evaluate programs and policies. One measure of this 

capacity is the availability and use by State MCH 

programs of key public health data sets related to women, 

children, and families.
167

09B

HEALTH SYSTEMS CAPACITY 

INDICATOR

The ability of States to monitor tobacco use 

by children and youth.

GOAL To assure MCH program and Title V agency access to 

essential policy and program relevant information 

from key public health data sets relating to women, 

children, and families. To demonstrate core MCH 

data capacity.

DEFINITION Form 19 for this Health Systems Capacity Indicator is 

a table with two questions about important databases 

that document the MCH programs’ ability to obtain 

essential program and policy relevant information. 

Following the instructions, enter the degree to which 

the State participating in the surveys (1-3) and 

whether the State has direct access to the databases 

(Y/N). 

HEALTHY PEOPLE 2010

OBJECTIVE

No specific Healthy People 2010 Objective. Related 

Objective 23-5: Increase the proportion of Leading 

Health Indicators, Health Status Indicators, and 

Priority Data Needs for which data – especially for 

select populations – are available at the Tribal, State 

and local levels.

DATA SOURCES and

DATA ISSUES

Youth Risk Behavior Surveillance System or State 

survey data.

SIGNIFICANCE To carry out the 10 essential public health services, MCH 

programs need access to relevant program and policy 

information. This requires basic data capacity on the part 

of the Title V agency including the ability to monitor 

health status, to investigate health problems, and to 

evaluate programs and policies. One measure of this 

capacity is the availability and use by State MCH 

programs of key public health data sets related to women, 

children, and families.
168
169

FORM 20

HEALTH STATUS INDICATORS #01 - 05

MULTI-YEAR DATA

Annual Indicator Data

FY _____ FY _____ FY _____ FY _____ FY _____

HEALTH STATUS INDICATOR #01A (Low Birth Weight)

The percent of live births weighing less than 2,500 grams. (Risk)

Annual Indicator

_________ _________ _________ _________ _________

Numerator

_________ _________ _________ _________ _________

Denominator

_________ _________ _________ _________ _________

HEALTH STATUS INDICATOR #01A (Low Birth Weight - Singleton Births)

The percent of live singleton births weighing less than 2,500 grams. (Risk)

Annual Indicator

_________ _________ _________ _________ _________

Numerator

_________ _________ _________ _________ _________

Denominator

_________ _________ _________ _________ _________
170

FORM 20

HEALTH STATUS INDICATORS #01 - 05

MULTI-YEAR DATA (Continuation Page)

Annual Indicator Data

FY _____ FY _____ FY _____ FY _____ FY _____

HEALTH STATUS INDICATOR #02A (Low Birth Weight)

The percent of live births weighing less than 1,500 grams. (Risk)

Annual Indicator

_________ _________ _________ _________ _________

Numerator

_________ _________ _________ _________ _________

Denominator

_________ _________ _________ _________ _________

HEALTH STATUS INDICATOR #01A (Low Birth Weight - Singleton Births)

The percent of live singleton births weighing less than 1,500 grams. (Risk)

Annual Indicator

_________ _________ _________ _________ _________

Numerator

_________ _________ _________ _________ _________

Denominator

_________ _________ _________ _________ _________
171

FORM 20

HEALTH STATUS INDICATORS #01 - 05

MULTI-YEAR DATA (Continuation Page)

Annual Indicator Data

FY _____ FY _____ FY _____ FY _____ FY _____

HEALTH STATUS INDICATOR #03A (Fatal Unintentional Injuries)

The death rate per 100,000 due to unintentional injuries

among children aged 14years and younger. (Injuries)

Annual Indicator

_________ _________ _________ _________ _________

Numerator

_________ _________ _________ _________ _________

Denominator

_________ _________ _________ _________ _________

HEALTH STATUS INDICATOR #03B (Fatal Unintentional Injuries)

The death rate per 100,000 for unintentional injuries among children

aged 14 years and younger due to motor vehicle crashes. (Injuries)

Annual Indicator

_________ _________ _________ _________ _________

Numerator

_________ _________ _________ _________ _________

Denominator

_________ _________ _________ _________ _________

HEALTH STATUS INDICATOR #03C (Fatal Unintentional Injuries)

The death rate per 100,000 for unintentional injuries for youth aged

15 through 24 years old due to motor vehicle crashes. (Injuries)

Annual Indicator

_________ _________ _________ _________ _________

Numerator

_________ _________ _________ _________ _________

Denominator

_________ _________ _________ _________ _________
172

FORM 20

HEALTH STATUS INDICATORS #01 - 05

MULTI-YEAR DATA (Continuation Page)

Annual Indicator Data

FY _____ FY _____ FY _____ FY _____ FY _____

HEALTH STATUS INDICATOR #04A (Nonfatal Unintentional Injuries)

The rate per 100,000 of all nonfatal injuries among children

aged 14 years and younger. (Injuries)

Annual Indicator

_________ _________ _________ _________ _________

Numerator

_________ _________ _________ _________ _________

Denominator

_________ _________ _________ _________ _________

HEALTH STATUS INDICATOR #04B (Nonfatal Unintentional Injuries)

The rate per 100,000 of all nonfatal injuries due to motor vehicle

crashes among children aged 14 years and younger (Injuries)

Annual Indicator

_________ _________ _________ _________ _________

Numerator

_________ _________ _________ _________ _________

Denominator

_________ _________ _________ _________ _________

HEALTH STATUS INDICATOR #04C (Nonfatal Unintentional Injuries)

The rate per 100,000 of all nonfatal injuries due to motor vehicle crashes

among youth aged 15 years through 24 years. (Injuries)

Annual Indicator

_________ _________ _________ _________ _________

Numerator

_________ _________ _________ _________ _________

Denominator

_________ _________ _________ _________ _________
173

FORM 20

HEALTH STATUS INDICATORS #01 - 05

MULTI-YEAR DATA (Continuation Page)

Annual Indicator Data

FY _____ FY _____ FY _____ FY _____ FY _____

HEALTH STATUS INDICATOR #05A 

(Sexually Transmitted Disease – Chlamydia)

The rate per 1,000 women aged 15 through 19 years with

a reported case of chlamydia. (Prevention)

Annual Indicator

_________ _________ _________ _________ _________

Numerator

_________ _________ _________ _________ _________

Denominator

_________ _________ _________ _________ _________

HEALTH STATUS INDICATOR #05B

(Sexually Transmitted Disease – Chlamydia)

The rate per 1,000 women aged 20 through 44 years with

a reported case of chlamydia. (Prevention)

Annual Indicator

_________ _________ _________ _________ _________

Numerator

_________ _________ _________ _________ _________

Denominator

_________ _________ _________ _________ _________
174

INSTRUCTIONS FOR THE COMPLETION OF HEALTH STATUS INDICATOR FORM 20

TRACKING HEALTH STATUS INDICATORS #01 THROUGH #05

General Instructions:

A glossary of terms applicable to this form is presented in Part Two, Section VIII of this document.

Complete all required data cells. If an actual number is not available make an estimate. Please explain all estimates in a footnote. 

The purpose of this form is to show, annually, selected measurements (indicators) of MCH health status in the State and to track those indicators over a five year 

period. The first five health status indicators deal with data that is to be tracked and displayed over five years. Some of these set of indicators have two or three 

parts resulting in a total of twelve data elements that are to be completed. Specific instructions, by Health Status Indicator number, are provided below.

For each of the Health Status Indicators, on the lines labeled “Annual Indicator,” enter the numerical value that shows the status for the indicator for the 

appropriate reporting year. Note that the indicator data is to go in the years column from which it was actually derived even if the data is a year behind the 

“reporting” year. This value is to be expressed in the units that are described on the health status indicator detail sheets which, for these indicators, are either a 

rate or a percentage.

If there are numerator and denominator data for the indicator value, enter those data on the appropriate lines for the appropriate fiscal year. If there are no 

numerator and denominator data, leave these lines empty.

Specific Instructions:

Indicator #01 (Low Birth Weight) There are two parts to this indicator (A and B). The values are to be expressed as percents of total or singleton live births 

weighing less than 2,500 grams.

Indicator #02 (Very Low Birth Weight) There are two parts to this indicator (A and B). The values are to be expressed as percents of total or singleton live 

births weighing less than 1,500 grams.

Indicator #03 (Fatal Unintentional Injuries) There are three parts to this indicator (A-C). The value is to be expressed as a death rate per 100,000 in the age 

ranges indicated.

Indicator #04 (Nonfatal Unintentional Injuries) There are three parts to this indicator (A-C). The values are to be expressed as an injury rate per 100,000 in 

the age ranges indicated.

Indicator #05 (Sexually Transmitted Disease [Chlamydia]) There are two parts to this indicator (A and B). The values are to be expressed as Chlamydia case 

rates per 1,000 women in the age ranges indicated.
175

FORM 21

HEALTH STATUS INDICATORS DEMOGRAPHIC DATA

HSI #06A – Demographics (Total Population) Infants and children aged 0 through 24 years enumerated by sub-populations of age group and race. 

(Demographics)

 For both parts A and B: Reporting Year _________ Is this data from a State Projection?  YES  NO

CATEGORY

TOTAL POPULATION

BY RACE

TOTAL

ALL

RACES

WHITE BLACK 

OR 

AFRICAN

AMERICAN

AMERICAN

INDIAN

OR 

NATIVE

ALASKAN

ASIAN NATIVE

HAWAIIAN

OR OTHER 

PAC. IS.

MORE THAN 

ONE RACE

REPORTED

OTHER 

AND

UNKNOWN

Infants 0 to 1

Children 1 through 4

Children 5 through 9

Children 10 through 14

Children 15 through 19

Children 20 through 24

Children 0 through 24

 HSI #06B – Demographics (Total Population) Infants and children aged 0 through 24 years enumerated by 

 sub-populations of age group and ethnicity. (Demographics)

CATEGORY

TOTAL POPULATION BY

HISPANIC ETHNICITY

TOTAL NOT 

HISPANIC OR 

LATINO

TOTAL HISPANIC 

OR LATINO

EHTNICITY NOT 

REPORTED

Infants 0 to 1

Children 1 through 4

Children 5 through 9

Children 10 through 14

Children 15 through 19

Children 20 through 24

Children 0 through 24
176

FORM 21

HEALTH STATUS INDICATORS DEMOGRAPHIC DATA (Continuation page)

 HSI #07A – Demographics (Total live births) Live births to women (of all ages) enumerated by maternal age and race. (Demographics)

 For both parts A and B: Reporting Year _________ Is this data from a State Projection?  YES  NO

CATEGORY

TOTAL LIVE BIRTHS

BY RACE

TOTAL

ALL

RACES

WHITE BLACK 

OR 

AFRICAN

AMERICAN

AMERICAN

INDIAN

OR 

NATIVE

ALASKAN

ASIAN NATIVE

HAWAIIAN

OR OTHER 

PAC. IS.

MORE THAN 

ONE RACE

REPORTED

OTHER 

AND

UNKNOWN

Women <15

Women 15 through 17

Women 18 through 19

Women 20 through 34

Women 35 or older

Women of all ages

 HSI #07B – Demographics (Total live births Live births to women (of all ages) enumerated by maternal age 

 and ethnicity. (Demographics)

CATEGORY

TOTAL POPULATION BY

HISPANIC ETHNICITY

TOTAL NOT 

HISPANIC OR 

LATINO

TOTAL HISPANIC 

OR LATINO

EHTNICITY NOT 

REPORTED

Women <15

Women 15 through 17

Women 18 through 19

Women 20 through 34

Women 35 or older

Women of all ages
177

FORM 21

HEALTH STATUS INDICATORS DEMOGRAPHIC DATA (Continuation page)

 HSI #08A – Demographics (Total deaths) Deaths of infants and children aged 0 through 24 years enumerated by age subgroup and race. (Demographics)

 For both parts A and B: Reporting Year _________ Is this data from a State Projection?  YES  NO

CATEGORY

TOTAL DEATHS

BY RACE

TOTAL

ALL

RACES

WHITE BLACK 

OR AFRICAN

AMERICAN

AMERICAN

INDIAN

OR 

NATIVE

ALASKAN

ASIAN NATIVE

HAWAIIAN

OR OTHER 

PAC. IS.

MORE THAN 

ONE RACE

REPORTED

OTHER 

AND

UNKNOWN

Infants 0 to 1

Children 1 through 4

Children 5 through 9

Children 10 through 14

Children 15 through 19

Children 20 through 24

Infants and children 0 through 24

 

 HSI #08B – Demographics (Total deaths) Deaths of infants and children aged 0 through 24 years enumerated by 

 age subgroup and ethnicity. (Demographics)

CATEGORY

TOTAL DEATHS BY

HISPANIC ETHNICITY

TOTAL NOT 

HISPANIC OR 

LATINO

TOTAL HISPANIC 

OR LATINO

EHTNICITY NOT 

REPORTED

Infants 0 to 1

Children 1 through 4

Children 5 through 9

Children 10 through 14

Children 15 through 19

Children 20 through 24

Infants and Children 0 - 24
178

FORM 21

HEALTH STATUS INDICATORS DEMOGRAPHIC DATA (Continuation page)

HSI #09A – Demographics (Miscellaneous Data) Infants and children aged 0 through 19 years in miscellaneous situations or enrolled in various State programs 

enumerated by race. (Demographics) 

CATEGORY

MISCELLANEOUS DATA

BY RACE

TOTAL

ALL

RACES

WHITE BLACK 

OR AFRICAN

AMERICAN

AMERICAN

INDIAN

OR 

NATIVE

ALASKAN

ASIAN NATIVE

HAWAIIAN

OR OTHER 

PACIFIC

ISLANDER

MORE THAN 

ONE RACE

REPORTED

OTHER 

AND

UNKNOWN

SPECIFIC

REPORTING 

YEAR

All children 0 through 19

Percent in household 

headed by single parent

Percent in TANF (Grant) 

families

Number enrolled in 

Medicaid

Number enrolled in SCHIP

Number living in foster 

home care

Number enrolled in food 

stamp program

Number enrolled in WIC

Rate (per 100,000) of 

juvenile crime arrests

Percentage of high school 

drop-outs (grade 9 through 

12)
179

FORM 21

HEALTH STATUS INDICATORS DEMOGRAPHIC DATA (Continuation page)

HSI #09B – Demographics (Miscellaneous Data) Infants and children aged 0 through 19 years in miscellaneous situations 

or enrolled in various State programs enumerated by ethnicity. (Demographics) 

CATEGORY

MISCELLANEOUS 

DATA BY HISPANIC

ETHNICITY

TOTAL NOT 

HISPANIC OR 

LATINO

TOTAL

HISPANIC OR LATINO

ETHNICITY NOT 

REPORTED

SPECIFIC 

REPORTING 

YEAR

All children 0 through 19

Percent in household 

headed by single parent

Percent in TANF (Grant) 

families

Number enrolled in 

Medicaid

Number living in foster 

home care

Number enrolled in 

SCHIP

Number enrolled in food 

stamp program

Number enrolled in 

WIC

Rate (per 100,000) of 

juvenile crime arrests

Percentage of high school 

drop-outs (grade 9 

through 12)
180

FORM 21

HEALTH STATUS INDICATORS

DEMOGRAPHIC DATA (Continuation page)

HSI #10 – Demographics (Geographic Living Area) Geographic living 

area for all resident children aged 0 through 19 years old. (Demographics)

Reporting Year _________ Is this data from a State Projection?  YES  NO

GEOGRAPHIC LIVING AREAS TOTAL

Living in metropolitan areas

Living in urban areas

Living in rural areas

Living in frontier areas

Total – all children 0 through 19

HSI #11 – Demographics (Poverty Levels) Poverty levels for the total State Population.(Demographics)

Reporting Year _________ Is this data from a State Projection?  YES  NO

POVERTY LEVELS TOTAL

Total Population

Percent Below: 50% of poverty

100% of poverty

200% of poverty

HSI #12 – Demographics (Poverty Levels) Poverty levels for all children aged 0 

through 19 years.(Demographics)

Reporting Year _________ Is this data from a State Projection?  YES  NO

POVERTY LEVELS TOTAL

Children 0 through 19 years old

Percent Below: 50% of poverty

100% of poverty

200% of poverty
181

INSTRUCTIONS FOR THE COMPLETION OF HEALTH STATUS INDICATOR FORM 21

HEALTH STATUS INDICATORS #06 THROUGH #12

General Instructions:

A glossary of terms applicable to this form is presented in Part Two, Section VIII of this document.

The purpose of this form, which contains 11 tables for 6 indicators, is to provide, annually, selected demographic data in the State. Indicators 13, 14, 15, and 16 

each have two parts (A and B) and indicators 17, 18, and 19 each have one part. The racial and ethnic population categories included in these tables are from the 

most current Office of Management and Budget guidelines.

At the top of each table [EXCEPT FOR THE TABLES FOR HIS 16A AND 16B] enter the year for which the data is being reported and check the appropriate 

box to indicate if the data is from a State projection. For Health Status Indicators 13 through 15 the Reporting Year will be the same for parts A and B of each 

form. See specific instructions below for dating the data on tables HIS 16A and 16B.

Specific Instructions:

Health Status Indicators 13-20 (Demographics)

For Table #06A (Total Population): In the column labeled “TOTAL ALL RACES” enter the total population of the State in the age groups specified. In the 

next seven columns enter the population of the State in the racial categories indicated at the head of each column and in the age groups specified. In the column 

headed “MORE THAN ONE RACE REPORTED” enter the population figure for instances where more than one race is reported. In the column headed 

“OTHER AND UNKNOWN” enter the population figure for other racial categories not shown and/or population figures where the racial category is not known. 

The population figures in the columns for the racial categories must equal the figures in the “TOTAL ALL RACES” column.

For Table #06B: In the column headed “TOTAL NOT HISPANIC OR LATINO” enter the total of the population of the State, in the age groups specified, that

are not of Hispanic or Latino ethnicity. In the column headed “TOTAL HISPANIC OR LATINO” enter the total population figures for those that are of Hispanic 

or Latino ethnicity. IN the column headed “EHTNICITY NOT REPORTED” enter the total of the population whose ethnicity is not reported. The sum of these 

three figures must equal the figures in the “TOTAL ALL RACES’ column of Table 06A.
182

INSTRUCTIONS FOR THE COMPLETION OF HEALTH STATUS INDICATOR FORM 21

HEALTH STATUS INDICATORS #06 THROUGH #12 (Continued)

For Table #07A (Total live births): In the column labeled “TOTAL ALL RACES” enter the number of live births in the Sate for the age groups specified. IN 

the next seven columns enter the number of live births in the racial categories indicated at the head of each column and in the age groups specified. In the 

column headed “MORE THAN ONE RACE REPORTED” enter the number of live births for instances where more than one race is reported. In the column 

headed “OTHER AND UNKNOWN” enter the number of live births for other racial categories not shown and/or live birth figures where the racial category is 

not known. The live birth figures in the columns for the racial must equal the figures in the “TOTAL ALL RACES” column.

For Table #07B: In the column headed “TOTAL NOT HISPANIC OR LATINO” enter the number of live births in the State, in the age groups specified, that 

are not of Hispanic or Latino ethnicity. In the column headed “TOTAL HISPANIC OR LATINO” enter the number of live births for the population that are of 

Hispanic or Latino ethnicity. In the column headed “ETHNICITY NOT REPORTED” enter live birth figures for the total of the population whose ethnicity is 

not reported. The sum of these three figures must equal the figures in the “TOTAL ALL RACES” column of Table 07A.

For Table #08A (Total deaths): In the column labeled “TOTAL ALL RACES” enter the number of deaths to infants and children in the State for the age 

groups specified. In the next seven columns enter the number of deaths to infants and children in the racial categories indicated at the head of each column and 

in the age groups specified. In the column headed “MORE THAN ONE RACE REPORTED” enter the number of deaths to infants and children for instances 

where more than one race is reported. In the column headed “OTHER AND UNKNOWN” enter the number of deaths to infants and children for other racial 

categories not shown and/or infant/child death figures where the racial category is not known. The infant/child death figures in the columns for the racial 

categories must equal the figures in the “TOTAL ALL RACES’ column.

For Table #08B: In the column headed “TOTAL NOT HISPANIC OR LATINO” enter the number of deaths to infants and children in the State, in the age 

groups specified, that are not of Hispanic ethnicity. In the column headed “TOTAL HISPANIC OR LATINO” enter the infant/child death figures for those that 

are of Hispanic or Latino ethnicity. In the column headed “ETHNICITY NOT REPORTED” enter the population data for those instances where the ethnic 

category is not reported. Enter in the column headed “SPECIFIC REPORTING YEAR” the year for which the data is reported.

For Table #09A (Miscellaneous Data): In the column labeled “ALL RACES” enter the population data requested for the categories listed in the first column. 

IN the next seven columns enter the population data for the categories listed and for the racial categories indicated at the head of each column. In the column 

headed “MORE THAN ONE RACE REPORTED” enter the population data for the categories listed where more than one race is reported. In the column headed 

“OTHER AND UNKNOWN” enter the population data for the categories listed for other racial categories not shown and/or for those instances where the racial 

category is not known. Enter in the column headed “SPECIFIC REPORTING YEAR” the year for which the data is reported. 

For Table #09B: In the column headed “TOTAL NOT HISPANIC OR LATINO” enter the population data for the categories listed in the first column that are 

not of Hispanic or Latino ethnicity. In the column headed “TOTAL HISPANIC OR LATINO” enter the population data for those that are of Hispanic or Latino 

ethnicity. In the column headed “ETHNICITY NOT REPORTED” enter the population data for those instances where the ethnic category is not reported. Enter 

in the column headed “SPECIFIC REPORTING YEAR” the year for which the data is reported.
183

INSTRUCTIONS FOR THE COMPLETION OF HEALTH STATUS INDICATOR FORM 21

HEALTH STATUS INDICATORS #06 THROUGH #12 (Continued)

For Table #10 (Geographic Living Area): 

In the second column of the first four rows enter the number of children aged 0 through 19 residing in the State for each geographic region listed in the first 

column. If the State already has figures for these geographic breakouts they may use those. In such cases specify in a footnote the parameters that are used for 

the geographic locations. For States that do not have these breakouts, the following information is provided:

METROPOLITAN areas are defined by the Office of Management and Budget (OMB) according to published standards that are applied to U.S. Census Bureau 

data. The most current list of Metropolitan Areas is available in PDF downloadable file format

http://www.census.gov/population/www/metroareas/metrodef.html or can be acquired by contacting the Bureau of the Census at 1-866-758-1060.

URBAN areas are defined by the Bureau of the Census and can be found at http://www.census.gov/geo/www/ua/ua_2k.html or can be acquired by contacting the 

Bureau of the Census at ua@geo.census.gov. “Urban” consists of territory, persons and housing units in: 1. Places of 2,500 or more persons incorporated as 

cities, villages, boroughs (except in Alaska and New York), and towns (except in the six New England States, New York, and Wisconsin), but excluding the rural 

portion of “extended cities”; 2. Census designated places of 2,500 or more persons; and , 3. Other territory, incorporated or unincorporated, included in 

urbanized areas.

RURAL areas are defined as territory, population, and housing units not classified as urban.

FRONTIER areas, for the purposes of this table, are defined as counties with population densities of 6 persons or fewer per square mile.

In the second column of the last row enter the total State population of children aged 0 through 19.

For Table #11 (Poverty Levels – Total Population)

In the second cell of the first row enter the total of the State population living at or below the Federal Poverty Level. In the second cell of the remaining rows 

enter the percent of the total population living at or below the percentages indicated in the first column.

For Table #12 (Poverty Levels – Children 0 through 19)

In the second cell of the first row enter the number of the State population aged 0 through 19 living at or below the Federal Poverty Level. In the second cell of 

the remaining rows enter the percent of the State population aged 0 through 19 living at or below the percentages indicated in the first column.
184
185

VIIE - Health Status Indicators Detail Sheets
186
187

01A

HEALTH STATUS INDICATOR The percent of live births weighing less 

than 2,500 grams.

GOAL To reduce proportion of all live deliveries with low 

birth weight.

DEFINITION Numerator: Number of resident live births less than 

2,500 grams.

Denominator: Number resident live births in the 

State in the reporting period.

Units: 100 Text: Percent

HEALTHY PEOPLE 2010

OBJECTIVE

Objective 16-10a: Reduce low birth weights (LBW) 

to no more than 5 percent of all live births. (Baseline: 

7.6 percent 1998)

DATA SOURCES and

DATA ISSUES

State vital records and census data are source.

SIGNIFICANCE The general category of low birth weight infants includes 

pre-term infants and infants with intrauterine growth 

retardation. Many risk factors have been identified for 

low birth weight babies including: both young and old 

maternal age, poverty, late prenatal care, smoking, 

substance abuse, and multiple births.
188

01B

HEALTH STATUS INDICATOR The percent of live singleton births 

weighing less than 2,500 grams.

GOAL To reduce the proportion of all live singleton 

deliveries with low birth weight.

DEFINITION Numerator: Number of resident live singleton births 

weighing less than 2,500 grams.

Denominator: Number resident live singleton births 

in the State in the reporting period.

Units: 100 Text: Percent

HEALTHY PEOPLE 2010

OBJECTIVE

No specific Healthy People 2010 objective. Related 

to Objective 16-10a: Reduce low birth weights 

(LBW) to no more than 5 percent of all live births. 

(Baseline: 7.6 percent in 1998)

DATA SOURCES and

DATA ISSUES

State vital records and census data are source.

SIGNIFICANCE In vitro fertilization has increased the number of multiple 

births. Multiple births often result in shortened gestation 

and low or very low birth weight infants.
189

02A

HEALTH STATUS INDICATOR The percent of live births weighing less than 

1,500 grams.

GOAL To reduce proportion of all live deliveries with low 

birth weight.

DEFINITION Numerator: Number of resident live births weighing 

less than 1,500 grams.

Denominator: Number resident live births in the 

State in the reporting period.

Units: 100 Text: Percent

HEALTHY PEOPLE 2010

OBJECTIVE

Objective 16-10b: Reduce very low birth weight 

births to no more than 0.9 percent of all live births. 

(Baseline: 1.4 percent in 1998)

DATA SOURCES and

DATA ISSUES

State vital records and census data are source.

SIGNIFICANCE Very low birth weight births are usually associated with 

pre-term birth. The primary risk factors for pre-terms 

births are prior preterm birth, prior spontaneous abortion, 

low pre-pregnancy weight, cigarette smoking, and 

multiple births.
190

02B

HEALTH STATUS INDICATOR The percent of live singleton births weighing 

less than 1,500 grams.

GOAL To reduce the proportion of all live singleton

deliveries with very low birth weight.

DEFINITION Numerator: Number of resident singleton births 

weighing less than 1,500 grams.

Denominator: Number resident singleton births in 

the State in the reporting period.

Units: 100 Text: Percent

HEALTHY PEOPLE 2010

OBJECTIVE

No specific Healthy People 2010 objective. Related 

to Objective 16-10b: Reduce very low birth weights 

to no more than 0.9 percent of all live births. 

(Baseline: 1.4 percent in 1998)

DATA SOURCES and

DATA ISSUES

State vital records and census data are source.

SIGNIFICANCE In vitro fertilization has increased the number of multiple 

births. Multiple births may result in shortened gestation 

and low or very low birth weight infants.
191

03A

HEALTH STATUS INDICATOR The death rate per 100,000 due to 

unintentional injuries among children aged 

14 years and younger.

GOAL To reduce the number of deaths among children aged 

14 years and younger due to unintentional injuries.

DEFINITION Numerator: Number of deaths from all unintentional 

injuries for children aged 14 years and younger.

Denominator: Number of children aged 14 years and 

younger in the State for the reporting period.

Units: 100 Text: Rate per 100,000

HEALTHY PEOPLE 2010

OBJECTIVE

No specific Healthy People 2010 objective. Related 

objective 15-13: Reduce deaths caused by 

unintentional injuries to no more than 20.8 per 

100,000 population. (Baseline: 33.3 deaths per 

100,000 in 1998)

DATA SOURCES and

DATA ISSUES

Child death certificates are collected in State vital 

records. Data on total number of children comes from 

the Fatality Analysis Reporting Systems (FARS), the 

U.S. Department of Transportation and Vital Statistics 

Systems are further sources.

SIGNIFICANCE Injuries are the leading cause of death among persons 

aged 1 through 34 years and a significant health problem 

affecting the nation’s children. About 50 percent of all 

deaths of children aged 1-14 years are due to injuries, and 

around 80 percent of these are from motor vehicle 

crashes.
192

03B

HEALTH STATUS INDICATOR The death rate per 100,000 for unintentional 

injuries among children aged 14 years and 

younger due to motor vehicle crashes.

GOAL To reduce the number of deaths to children aged 14 

years and younger due to motor vehicle crashes.

DEFINITION Numerator: Number of unintentional fatalities to 

children aged 14 years and younger from motor 

vehicle crashes in the reporting year.

Denominator: Number of children aged 14 years and 

younger in the State in the reporting year.

Units: 100,000 Text: Rate per 100,000

HEALTHY PEOPLE 2010

OBJECTIVE

Objective 15-15a: Reduce deaths caused by motor 

vehicle crashes. (Target 9.0 deaths per 100,000 

population). (Baseline for children aged 14 years and 

younger, 4.2 in 1998)

DATA SOURCES and

DATA ISSUES

Child death certificates are collected in State vital 

records. Data on total number of children comes from 

the Bureau of the Census. The Fatality Analysis 

Reporting System (FARS), the U.S. Department of 

Transportation and Vital Statistics Systems are further 

sources.

SIGNIFICANCE Injuries are the leading cause of death among persons 

aged 1 through 34 years and a significant health problem 

affecting the Nation’s children. About 50 percent of all 

deaths of children aged 1 through 14 years are due to 

injuries, and around 80 percent of these are from motor 

vehicle crashes.

GOAL To reduce the number of deaths to children aged 14 

years and younger due to motor vehicle crashes.
193

03C

HEALTH STATUS INDICATOR The death rate per 100,000 for unintentional 

injuries for youth aged 15 through 24 years 

old due to motor vehicle crashes.

GOAL To reduce the number of deaths to youth aged 15 

through 24 years due to motor vehicle crashes.

DEFINITION Numerator: Number of unintentional fatalities to 

youth aged 15 through 24 years due to motor vehicle 

crashes in the reporting year.

Denominator: Number of youths aged 15 through 24 

years in the State in the reporting year.

Units: 100,000 Text: Rate per 100,000

HEALTHY PEOPLE 2010

OBJECTIVE

Objective 15-15a: Reduce deaths caused by motor 

vehicle crashes. (Target 9.0 deaths per 100,000 

population). (Baseline for persons aged 15 through 

24 years, 25.4 deaths per 100,000 in 1998)

DATA SOURCES and

DATA ISSUES

Child deaths certificates are collected in State vital 

records. Data on total number of children comes from 

the Bureau of the Census. The Fatality Analysis 

Reporting System (FARS), the U.S. Department of 

Transportation and Vital Statistics Systems are further 

sources.

SIGNIFICANCE Injuries are the leading cause of death among persons 

aged 1 through 34 years and a significant health problem 

affecting the Nation’s children. About 50 percent of all 

deaths of children aged 1 through 14 years are due to 

injuries, and around 80 percent of these are from motor 

vehicle crashes.
194

04A

HEALTH STATUS INDICATOR The rate per 100,000 of all non-fatal injuries 

among children aged 14 years and younger.

GOAL To reduce the number of hospitalizations of children 

aged 14 years and younger due to non-fatal injuries.

DEFINITION Numerator: Number of children aged 14 years and 

younger who have a hospital discharge for non-fatal 

injuries.

Denominator: Number of children aged 14 years and 

younger in the State for the reporting period.

Units: 100,000 Text: Rate per 100,000

HEALTHY PEOPLE 2010

OBJECTIVE

No specific Healthy People 2010 objective. Related 

objective 15-14 (Developmental): Reduce non-fatal 

unintentional injuries.

DATA SOURCES and

DATA ISSUES

Numerator: State E-coded hospital discharge data.

Denominator: Census data, State population 

estimates.

Potential Data Source: National Hospital Discharge 

Survey (NHDS), CDC, HCHS.

SIGNIFICANCE Serious non-fatal unintentional injuries account for 84 

percent of injury-related hospitalizations and result in an 

estimated $108 billion in lifetime medical costs. (A 

lifetime cost is defined as the total cost of an injury from 

onset until either complete cure or death. Twenty-eight 

percent of these lifetime costs due to unintentional injury 

are attributable to motor vehicle crashes.)1

 

1 Rice, DP, MacKenzie EJ, et al. Cost of Injury in the United States: A Report to Congress, 1989. San 

Francisco, CA: Institutes for Health and Aging of the University of California San Francisco and Injury 

Prevention Center, The Johns Hopkins University, 1989.
195

04B

HEALTH STATUS INDICATOR The rate per 100,000 of non-fatal injuries due 

to motor vehicle crashes among children 

aged 14 years and younger.

GOAL To reduce the number of hospitalizations among 

children aged 14 years and younger due to motor 

vehicle crashes.

DEFINITION Numerator: Number of children aged 14 years and 

younger with a hospital discharge for non-fatal 

injuries due to motor vehicle crashes in the reporting 

year.

Denominator: Number of children aged 14 years and 

younger in the State for the reporting year.

Units: 100,000 Text: Rate per 100,000

HEALTHY PEOPLE 2010

OBJECTIVE

No specific Healthy People 2010 objective by age 

group. Related objective 15-17: Reduce non-fatal 

injuries caused by motor vehicle crashes to 1,000 nonfatal injuries per 100,000 population. (Baseline: 

1,270 non-fatal injuries per 100,000 in 1997.

DATA SOURCES and

DATA ISSUES

Numerator: State E-coded hospital discharge data.

Denominator: Census data, State population 

estimates.

SIGNIFICANCE Serious non-fatal unintentional injuries account for 84 

percent of injury-related hospitalizations and result in an 

estimated $108 billion in lifetime medical costs. (A 

lifetime cost is defined as the total cost of an injury from 

onset until either complete cure or death. Twenty-eight 

percent of these lifetime costs due to unintentional injury 

are attributable to motor vehicle crashes.1

 

1 Rice, DP, MacKenzie EJ et al. Cost of Injury in the United States: A Report to Congress, 1989. San 

Francisco, CA: Institute for Health and Aging of the University of California-San Francisco and Injury 

Prevention Center, The Johns Hopkins University, 1989.
196

04C

HEALTH STATUS INDICATOR The rate per 100,000 of non-fatal injuries due 

to motor vehicle crashes among youth aged 

15 through 24 years.

GOAL To reduce the number of hospitalizations among 

youth aged 15 through 24 years due to motor vehicle 

crashes.

DEFINITION Numerator: Number of youths aged 15 through 24 

years with a hospital discharge for non-fatal injuries 

due to motor vehicle crashes in the reporting year.

Denominator: Number of youths aged 15 through 24 

years in the State for the reporting year.

Units: 100,000 Text: Rate per 100,000

HEALTHY PEOPLE 2010

OBJECTIVE

No specific Healthy People 2010 objective by age 

group. Related objective 15-17: Reduce non-fatal 

injuries caused by motor vehicle crashes to 1,000 nonfatal injuries per 100,000 population. (Baseline: 

3,116 non-fatal injuries per 100,000 persons aged 16 

through 20 and 2,496 non-fatal injuries per 100,000 

persons aged 21 to 24 years in 1997).

DATA SOURCES and

DATA ISSUES

Numerator: State E-coded hospital discharge data.

Denominator: Census data, State population 

estimates.

SIGNIFICANCE Serious non-fatal unintentional injuries account for 84 

percent of injury-related hospitalizations and result in an 

estimated $108 billion in lifetime medical costs. (A 

lifetime cost is defined as the total cost of an injury from

onset until either complete cure or death. Twenty-eight 

percent of these lifetime costs due to unintentional injury 

are attributable to motor vehicle crashes.)1

 

1 Rice DP, MacKenzie EJ, et al. Cost of Injury in the United States: A Report to Congress, 1989. San 

Francisco, CA: Institute for Health and Aging of the University of California-San Francisco and Injury 

Prevention Center, The Johns Hopkins University, 1989.
197

05A

HEALTH STATUS INDICATOR The rate per 1,000 women aged 15 through 

19 years with a reported case of chlamydia.

GOAL To decrease the sexually transmitted disease 

(chlamydia) rates among women aged 15 through 19 

years.

DEFINITION Numerator: Number of women aged 15 through 19 

years with a reported case of chlamydia.

Denominator: Number of women aged 15 through 

19 years in the State in the reporting year.

Units: 1,000 Text: Rate per 1,000

HEALTHY PEOPLE 2010

OBJECTIVE

Objective 25-1: Reduce the proportion of adolescents 

and young adults with Chlamydia Trachomatitis

infections. Objective 25-1a: Reduce the proportion 

of females aged 15 through 24 years attending family 

planning clinics to 3.0 percent. (Baseline: 5.0 percent 

in 1997) Objective 25-1b: Reduce the proportion of 

females aged 15 to 24 years attending STD clinics to 

3.0 percent. (Baseline: 12.0 percent in 1997).

DATA SOURCES and

DATA ISSUES

State STD Program Surveillance, State 

Communicable Disease Registry.

SIGNIFICANCE 1n 1997, chlamydia was the most frequently reported 

communicable disease in the United States. Chlamydia is 

common in sexually active adolescents and young adults. 

The highest annual rates are reported in females aged 15 

through 19 years.
198

05B

HEALTH STATUS INDICATOR The rate per 1,000 women aged 20 through 

44 years with a reported case of chlamydia.

GOAL To decrease the sexually transmitted disease 

(chlamydia) rates among women aged 20 through 44 

years.

DEFINITION Numerator: Number of women aged 20 through 44 

years with a reported case of chlamydia.

Denominator: Number of women aged 20 through 

44 years in the State in the reporting year.

Units: 1,000 Text: Rate per 1,000

HEALTHY PEOPLE 2010

OBJECTIVE

No specific Healthy People 2010 objective for this 

age group or gender. 

Related Objective 25-18: Increase the proportion of 

primary care providers who treat patients with 

sexually transmitted diseases and who manage cases 

according to recognized standards.

Related Objective 25-1a: Reduce the proportion of 

families aged 15 to 24 years attending family planning 

clinics to 3.0 percent. (Baseline: 5.0 percent in 1997) 

Related Objective 25-1b: Reduce the proportion of 

females aged 15 to 24 years attending STD clinics to 

3.0 percent. (Baseline 12.0 percent in 1997)

DATA SOURCES and

DATA ISSUES

State STD Program Surveillance, State 

Communicable Disease Registry.

SIGNIFICANCE In 1997, chlamydia was the most frequently reported 

communicable disease in the United States. Chlamydia is 

common in sexually active adolescents and young adults. 

The highest annual rates are reported in females aged 15 

through 19 years.
199

06 A & B

HEALTH STATUS INDICATOR Infants and children aged 0 through 24 

years enumerated by age subgroup, race, 

and ethnicity.

GOAL To enumerate the total population of children aged 0 

through 24 years by age subgroup, race, and ethnicity.

DEFINITION Tables 06 A & B on Health Status Indicator Form 21 

have cells for populations of subgroups of children 

aged 0 through 24 years aggregated by race and 

ethnicity. In each cell of the two tables enumerate the 

population figures requested.

Unit: Counts of State residents aged 0 through 24 

years old.

Text: Number

HEALTHY PEOPLE 2010

OBJECTIVE

No specific Healthy People 2010 Objective.

DATA SOURCES and

DATA ISSUES

Census data, State projections, Vital Records and 

Health Statistics.

SIGNIFICANCE Demographers predict that, by the end of the year 2000, 

one of every Americans will be African American, 

Asian/Pacific Islander, Middle Eastern, or Hispanic. 

Maternal and Child Health (MCH) professionals and 

policy makers must develop strategies and programs to 

address the needs of this growing segment of the 

population. Data reveals marked variations in morbidity 

and mortality by race and/or ethnicity. Reaching the goal 

of eliminating racial and ethnic disparities in health 

outcomes will necessitate identifying barriers to accessing 

family-centered, community-oriented, culturallycompetent, and comprehensive care for all Americans. 

Improved collection and use of standardized demographic 

data will identify high-risk populations and monitor the 

effectiveness of health promotion and disease prevention 

interventions targeting these groups.
200

07 A & B

HEALTH STATUS INDICATOR Live births to women (of all ages) 

enumerated by maternal age, race, and 

ethnicity.

GOAL To enumerate total live births by maternal age, race, 

and ethnicity.

DEFINITION Tables 07 A & B on Health Status Indicator Form 21 

have cells for population subgroups of women 

aggregated by race and ethnicity. In each cell on the 

two tables enumerate the live births to the groups of 

women indicated.

Units: Count of State live births. Text: Number

HEALTHY PEOPLE 2010

OBJECTIVE

No specific Healthy People 2010 objective.

DATA SOURCES and

DATA ISSUES

Vital Records.

SIGNIFICANCE Younger or older mothers, and mothers belonging to 

racial and/or ethnicity minority groups may be at 

increased risk of adverse maternal outcomes. Identifying 

populations of women and their infants at risk, and 

implementing coordinated systems of preconceptual/perinatal services that assures receipt of riskappropriate health care delivery is essential for healthy 

mothers and babies.
201

08 A & B

HEALTH STATUS INDICATOR Deaths of infants and children aged 0 

through 24 years enumerated by age 

subgroup, race, and ethnicity.

GOAL To enumerate deaths of infants and children aged 0 

through 24 years by age subgroup, race, and ethnicity.

DEFINITION Tables 08 A & B on Health Status Indicator Form 21 

have cells for population subgroups of children aged 

birth through 24 6ears aggregated by race and 

ethnicity. In each cell on the two tables enumerate the 

deaths in each sub-population.

Units: Count of State residents aged 0 through 24 

years.

Text: Number

HEALTHY PEOPLE 2010

OBJECTIVE

No specific Healthy People 2010 objective.

DATA SOURCES and

DATA ISSUES

Vital Records.

SIGNIFICANCE The greatest racial and ethnic disparities are seen in the 

following causes of death in infants: disorders relating to 

pre-term birth and unspecified low birth weight; 

respiratory distress syndrome; infections specific to the 

perinatal period; complications of pregnancy; and sudden 

infant death syndrome (SIDS). In some American 

Indian/Alaskan Native populations, the incidence of SIDS 

is three times that of white populations. African 

American adolescent males have the highest homicide 

rates in the country. Suicide among adolescent males in 

certain American Indian/Alaskan Native tribes has 

reached epidemic proportions. Identifying at-risk 

populations and implementing and monitoring 

prevention/intervention programs will play an integral 

role in eliminating disparities in mortality.
202

09 A & B

HEALTH STATUS INDICATOR Infants and children aged 0 through 19 

years in miscellaneous situations or 

enrolled in various State programs 

enumerated by race and ethnicity.

GOAL To determine number/percentage of infants and 

children aged 0 through 19 years in miscellaneous 

situations or enrolled in various State programs.

DEFINITION Tables 09 A & B on Health Status Indicator Form 21 

have cells for populations of subgroups of infants and 

children aged 0 through 19 years in miscellaneous 

situations and/or State programs by race and ethnicity. 

Complete each of the cells in the tables with a 

percentage or count as appropriate.

Units: 100 or count Text: Percent, number or rate

HEALTHY PEOPLE 2010

OBJECTIVE

No specific Healthy People 2010 objective.

DATA SOURCES and

DATA ISSUES

AFDC/TANF, Medicaid, SCHIP, food stamp, and 

WIC files; State juvenile criminal justice and Board of 

Education files, Linked child health data files, Census 

data.

SIGNIFICANCE Adverse health outcomes disproportionately affect infants 

and children in foster care or in single parent homes. In 

1995, 14 million infants and children aged 0 through 18 

years lived below the Federal poverty level; 59 percent of 

these families were single parent families. Leaving high 

school before graduation can lead to continued poverty 

and a higher incidence of juvenile arrests. Many infants 

and children eligible for Medicaid and other State 

programs are not enrolled. Data linkage of State program 

files with Medicaid may identify factors associated with 

State program eligibility without full participation.
203

10

HEALTH STATUS INDICATOR Geographic living area for all resident 

children aged 0 through 19 years.

GOAL To determine the number of children in the State aged 

0 through 19 years by geographic living area.

DEFINITION Table 10 on Health Status Indicator Form 21 includes 

cells for children in sub-population groups ranging 

from birth through 19 years of age. Complete the 

cells with the number of children in those age ranges 

living in metropolitan, urban, rural, or frontier 

geographic areas.

Units: Count Text: Number

HEALTHY PEOPLE 2010

OBJECTIVE

No specific Healthy People 2010 objective.

DATA SOURCES and

DATA ISSUES

Census data or State population projections.

SIGNIFICANCE Child health outcomes and the patterns of utilization of 

health care services can differ greatly by geographic area 

of living. Poor families living in metropolitan and urban 

areas without a regular source of coordinated health 

services may over utilize emergency services or present 

as frequent walk-ins to community or public health 

clinics. Access to care for the poor and under-served in 

rural and frontier areas is largely dependent on the 

number of providers available and willing to see the 

uninsured or accept Medicaid or CHIP. Barriers to 

quality health care may also include inadequate transport 

to care and ill-equipped health care facilities.
204

11

HEALTH STATUS INDICATOR Poverty levels for the total State 

population.

GOAL To determine the percentage of the State population at 

50 percent, 100 percent, and 200 percent of the federal 

poverty level.

DEFINITION Table 11 on Health Status Indicator Form 21 has cells 

for the population at various poverty levels. Please 

complete the cells with the count of total population 

and the percentages of the population living at the 50 

percent, 100 percent or 200 percent poverty level.

Units: Count for population and 100. 

Text: Number for population and percent.

HEALTHY PEOPLE 2010

OBJECTIVE

No specific Healthy People 2010 Objective.

DATA SOURCES and

DATA ISSUES

Census data or State population projections.

SIGNIFICANCE Eligibility for Medicaid, SCHIP and other State programs 

is in part determined by family income as a percentage of 

federally defined poverty levels. States have some 

discretion in determining which groups their Medicaid 

and SCHIP programs will cover and the financial criteria 

for Medicaid and SCHIP eligibility.
205

12

HEALTH STATUS INDICATOR Poverty levels for all children aged 0 

through 19 years.

GOAL To determine the percentage of all children aged 0 

through 19 years at 50 percent, 100 percent, and 200 

percent of the federal poverty level.

DEFINITION Table 12 on Health Status Indicator Form 21 has cells 

for the State population aged 0 through 19 years and 

percentages of that population at various poverty 

levels. Please complete the cells with the count of the 

population in that age range and the percentages of 

that population living at the 50 percent, 100 percent or 

200 percent poverty level.

Units: Count for population and 100.

Text: Number for population and percent.

HEALTHY PEOPLE 2010

OBJECTIVE

No specific Healthy People 2010 Objective.

DATA SOURCES and

DATA ISSUES

Census data or State population projections.

SIGNIFICANCE Eligibility for Medicaid, SCHIP and other State programs 

is in part determined by family income as a percentage of 

federally defined poverty levels. States have some 

discretion in determining which groups their Medicaid 

and SCHIP programs will cover and the financial criteria 

for Medicaid and SCHIP eligibility.
206
207

VIII - GLOSSARY

Adequate prenatal care - Prenatal care where the observed to expected prenatal visits 

is greater than or equal to 80% (the Kotelchuck Index).

Administration of Title V Funds - The amount of funds the State uses for the 

management of the Title V allocation. It is limited by statute to 10 percent of the Federal 

Title V allotment.

Assessment – (see ―Needs Assessment‖).

Capacity - Program capacity includes delivery systems, workforce, policies, and 

support systems (e.g., training, research, technical assistance, and information 

systems) and other infrastructure needed to maintain service delivery and policy making 

activities. Program capacity results measure the strength of the human and material 

resources necessary to meet public health obligations. As program capacity sets the 

stage for other activities, program capacity results are closely related to the results for 

process, health outcome, and risk factors. Program capacity results should answer the 

question, ―What does the State need to achieve the results we want?‖

Capacity Objectives - Objectives that describe an improvement in the ability of the 

program to deliver services or affect the delivery of services.

Care Coordination Services for Children With Special Health Care Needs (CSHCN, 

see definition below) - those services that promote the effective and efficient 

organization and utilization of resources to assure access to necessary comprehensive 

services for children with special health care needs and their families. [Title V Sec. 

501(b)(3)]

Carryover (as used in Forms 2 and 3) - The unobligated balance from the previous 

years MCH Block Grant Federal Allocation.

Case Management Services - For pregnant women - those services that assure 

access to quality prenatal, delivery and postpartum care. For infants up to age one -

those services that assure access to quality preventive and primary care services. (Title 

V Sec. 501(b)(4)

Children - A child from 1st birthday through the 21st year, who is not otherwise 

included in any other class of individuals.

Children With Special Health Care Needs (CSHCN) - (For budgetary purposes)

Infants or children from birth through the 21st year with special health care needs who 

the State has elected to provide with services funded through Title V. CSHCN are

children who have health problems requiring more than routine and basic care including 

children with or at risk of disabilities, chronic illnesses and conditions and health-related 

education and behavioral problems. (For planning and systems development) -
208

Those children 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.

Children With Special Health Care Needs (CSHCN) - Constructs of a Service 

System

1. State Program Collaboration with Other State Agencies and Private 

Organizations

States establish and maintain ongoing interagency collaborative processes for 

the assessment of needs with respect to the development of community-based 

systems of services 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 and their families.

2. State Support for Communities

State programs 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

A mechanism exists in communities across the State for coordination of health 

services with one another. This includes coordination among providers of 

primary care, habilitative and rehabilitative services, other specialty medical 

treatment services, mental health services, and home health care.

4. Coordination of Health Services with Other Services at the Community Level

A mechanism exists in communities across the State for coordination and service 

integration among programs serving CSHCN, including early intervention and special 

education, social services, and family support services.

Classes of Individuals - authorized persons to be served with Title V funds. See 

individual definitions under ―Pregnant Women,‖ ―Infants,‖ ―Children with Special Health 

Care Needs,‖ ―Children,‖ and ―Others.‖

Community - a group of individuals living as a smaller social unit within the confines of 

a larger one due to common geographic boundaries, cultural identity, a common work 

environment, common interests, etc.
209

Community-based Care - services provided within the context of a defined community.

Community-based Service System - an organized network of services that are 

grounded in a plan developed by a community and that is based upon needs 

assessments.

Coordination - (see Care Coordination Services).

Cultural Competence – a set of values, behaviors, attitudes, and practices within a 

system, organization, program, or among individuals and which enables them to work 

effectively cross culturally. Further, it refers to the ability to honor and respect the 

beliefs, language, inter-personal styles and behaviors of individuals and families 

receiving services, as well as staff who are providing such services. At a systems, 

organizational, or program level, cultural competence requires a comprehensive and 

coordinated plan that includes interventions at all the levels from policy-making to the 

individual, and is a dynamic, ongoing, process that requires a long-term commitment. A 

component of cultural competence is linguistic competence, the capacity of an 

organization and its personnel to communicate effectively, and convey information in a 

manner that is easily understood by diverse audiences including persons of limited 

English proficiency, those who are not literate or have low literacy skills, and individuals 

with disabilities.

Regarding the principles of cultural competence, an organization should value diversity 

in families, staff, providers and communities; have the capacity for cultural selfassessment; be conscious of the dynamics inherent when cultures interact, e.g. families 

and providers; institutionalize cultural knowledge; and develop adaptations to service 

delivery and partnership building reflecting an understanding of cultural diversity. An 

individual should examine one‘s own attitude and values; acquire the values, 

knowledge, and skills for working in cross cultural situations; and remember that every 

one has a culture.

Sources: Maternal and Child Health Bureau (MCHB), Guidance and Performance Measures for 

Discretionary Grants, Health Resources and Services Administration, U.S. Department of Health and 

Human Services, Denboba and Goode, 1999 and 2004. 

Cross, Bazron, Dennis and Isaacs, Towards a Culturally Competent System of Care, 1989.

Goode and Jones, Definition of Linguistic Competence, National Center for Cultural Competence, 

Revised 2004.

Denboba, “Federal Viewpoint,” Special Additions Newsletter for Children with Special Health Care Needs, 

Spring/Summer 2005.

Culturally Sensitive - the recognition and understanding that different cultures may 

have different concepts and practices with regard to health care; the respect of those 

differences and the development of approaches to health care with those differences in 

mind.
210

Deliveries - women who received a medical care procedure (were provided prenatal, 

delivery or postpartum care) associated with the delivery or expulsion of a live birth or 

fetal death.

Direct Health Care Services - 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.

Early Neonatal – Infants less than or equal to 6 days of age.

Enabling Services - Services that 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 education. 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.

EPSDT - Early and Periodic Screening, Diagnosis and Treatment - a program for 

medical assistance recipients under the age of 21, including those who are parents. 

The program has a Medical Protocol and Periodicity Schedule for well-child screening 

that provides for regular health check-ups, vision/hearing/dental screenings, 

immunizations and treatment for health problems.

Family-centered Care – Approach that assures the health and well-being of children 

and their families through a respectful family-professional partnership. It honors the 

strengths, cultures, traditions and expertise that everyone brings to this relationship. 

Family-Centered Care is the standard of practice which results in high quality services.
211

Family/Professional Partnerships – The foundation of family-centered care is the 

partnership between families and professionals. The following key principles to this 

partnership are:

Families and professionals work together in the best interest of the child and the 

family. As the child grows, s/he assumes a partnership role;

Everyone respects the skills and expertise brought to the relationship;

Trust is acknowledged as fundamental;

Communication and information sharing are open and objective;

Participants make decisions together; and 

There is a willingness to negotiate.

Based on this partnership, family-centered care:

Acknowledges the family as the constant in a child‘s life;

Builds on family strengths;

Supports the child in learning about and participating in his/her care and 

decision-making;

Honors cultural diversity and family traditions;

Recognizes the importance of community-based services;

Promotes an individual and developmental approach;

Encourages family-to-family and peer support;

Supports youth as they transition to adulthood;

Develops policies, practices, and systems that are family-friendly and familycentered in all settings; and

Celebrates successes.

Sources: National Center for Family-Centered Care. Family-Centered Care for Children with Special 

Health Care Needs. (1989). Bethesda, MD: Association for the Care of Children’s Health.

Bishop, Woll and Arango (1993). Family/Professional Collaboration for Children with Special Health Care 

Needs and their Families. Burlington, VT: University of Vermont, Department of Social Work.

Family-Centered Care Projects 1 and 2 (2002-2004). Bishop, Woll, Arango. Algodones, NM; Algodones 

Associates.

Federal (Allocation) (as it applies specifically to the Application Face Sheet [SF 424] 

and Forms 2 and 3) -The monies provided to the States under the Federal Title V Block 

Grant in any given year.

Government Performance and Results Act (GPRA) - Federal legislation enacted in 

1993 that requires Federal agencies to develop strategic plans, prepare annual plans 

setting performance goals, and report annually on actual performance.

Health Care System - the entirety of the agencies, services, and providers involved or 

potentially involved in the health care of community members and the interactions 

among those agencies, services and providers.
212

Infants - Children less than one year of age not included in any other class of 

individuals.

Infrastructure Building Services - The services that are the base of the MCH pyramid 

of health services and form its foundation 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 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.

Jurisdictions - As used in the Maternal and Child Health block grant program: the 

District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, 

American Samoa, the Commonwealth of the Northern Mariana Islands, the Republic of 

the Marshal Islands, the Federated States of Micronesia and the Republic of Palau.

Kotelchuck Index - An indicator of the adequacy of prenatal care. See Adequate 

Prenatal Care.

Local Funding (as used in Forms 2 and 3) - Those monies deriving from local 

jurisdictions within the State that are used for MCH program activities.

Low Income - an individual or family with an income determined to be below the 

income official poverty line defined by the Office of Management and Budget and 

revised annually in accordance with section 673(2) of the Omnibus Budget 

Reconciliation Act of 1981. [Title V, Sec. 501 (b)(2)]

MCH Pyramid of Health Services - (see ―Types of Services‖).

Measures - (see ―Performance Measures‖).

National Children with Special Health Care Needs (CSHCN) Survey – National 

survey conducted every four years which serves as the primary data source for 

reporting on National Performance Measures 2-6.

National Survey of Children’s Health – National survey conducted every four years 

which provides a snapshot of the status of children‘s health in each State and in the 

Nation.

Needs Assessment - a study undertaken to determine the service requirements within 

a jurisdiction. For maternal and child health purposes, the study is to aimed at 

determining:1) What is essential in terms of the provision of health services; 2) What is 

available; and, 3) What is missing.
213

Neonatal – Infants less than 28 days of age.

Objectives - The yardsticks by which an agency can measure its efforts to accomplish 

a goal. (See also ―Performance Objectives‖)

Other Federal Funds (Forms 2 and 3) - Federal funds other than the Title V Block 

Grant that are under the control of the person responsible for administration of the Title 

V program. These may include, but are not limited to: WIC, EMSC, Healthy Start, 

SPRANS, HIV/AIDs monies, CISS funds, MCH targeted funds from CDC, and MCH 

Education funds.

Others (as in Forms 4, 7, and 10) - Women of childbearing age, over age 21, and any 

others defined by the State and not otherwise included in any of the other listed classes 

of individuals.

Outcome Objectives - Objectives that describe the eventual result sought, the target 

date, the target population, and the desired level of achievement for the result. 

Outcome objectives are related to health outcome and are usually expressed in terms of 

morbidity and mortality.

Outcome Measure - The ultimate focus and desired result of any set of public health 

program activities and interventions is an improved health outcome. Morbidity and 

mortality statistics are indicators of achievement of health outcome. Health outcomes 

results are usually longer term and tied to the ultimate program goal. Outcome 

measures should answer the question, ―Why does the State do our program?‖

Performance Indicator - The statistical or quantitative value that expresses the result 

of a performance objective.

Performance Measure - a narrative statement that describes a specific maternal and 

child health need, or requirement, that, when successfully addressed, will lead to, or 

will assist in leading to, a specific health outcome within a community or jurisdiction 

and generally within a specified time frame. (Example: ―The rate of women in [State] 

who receive early prenatal care in 19__.‖ This performance measure will assist in 

leading to [the health outcome measure of] reducing the rate of infant mortality in the 

State).

Performance Measurement - The collection of data on, recording of, or tabulation of 

results or achievements, usually for comparing with a benchmark.

Performance Objectives - A statement of intention with which actual achievement and 

results can be measured and compared. Performance objective statements clearly 

describe what is to be achieved, when it is to be achieved, the extent of the 

achievement, and target populations.
214

Perinatal – Period from gestation of 28 weeks or more to 7 days or less after birth.

Population Based Services - 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.

PRAMS - Pregnancy Risk Assessment Monitoring System - a surveillance project of 

the Centers for Disease Control and Prevention (CDC) and State health departments to 

collect State- specific, population-based data on maternal attitudes and experiences 

prior to, during, and immediately following pregnancy.

Pregnant Woman - A female from the time that she conceives to 60 days after birth, 

delivery, or expulsion of fetus.

Preventive Services - activities aimed at reducing the incidence of health problems or 

disease prevalence in the community, or the personal risk factors for such diseases or 

conditions.

Primary Care - the provision of comprehensive personal health services that include 

health maintenance and preventive services, initial assessment of health problems, 

treatment of uncomplicated and diagnosed chronic health problems, and the overall 

management of an individual‘s or family‘s health care services.

Process - Process results are indicators of activities, methods, and interventions that 

support the achievement of outcomes (e.g., improved health status or reduction in risk 

factors). A focus on process results can lead to an understanding of how practices and 

procedures can be improved to reach successful outcomes. Process results are a 

mechanism for review and accountability, and as such, tend to be shorter term than 

results focused on health outcomes or risk factors. The utility of process results often 

depends on the strength of the relationship between the process and the outcome. 

Process results should answer the question, ―Why should this process be undertaken 

and measured (i.e., what is its relationship to achievement of a health outcome or risk 

factor result)?‖

Process Objectives - The objectives for activities and interventions that drive the 

achievement of higher-level objectives.

Program Income (as used in the Application Face Sheet [SF 424] and Forms 2 and 

3) - Funds collected by State MCH agencies from sources generated by the State‘s 

MCH program to include insurance payments, Medicaid reimbursements, HMO 

payments, etc.
215

Risk Factor Objectives - Objectives that describe an improvement in risk factors 

(usually behavioral or physiological) that cause morbidity and mortality.

Risk Factors - Public health activities and programs that focus on reduction of 

scientifically established direct causes of, and contributors to, morbidity and mortality 

(i.e., risk factors) are essential steps toward achieving health outcomes. Changes in 

behavior or physiological conditions are the indicators of achievement of risk factor 

results. Results focused on risk factors tend to be intermediate term. Risk factor results 

should answer the question, ―Why should the State address this risk factor (i.e., what 

health outcome will this result support)?‖

State - as used in this guidance, includes the 50 States and the 9 jurisdictions. (See 

also, Jurisdictions)

State Funds (as used in Forms 2 and 3) - The State‘s required matching funds 

(including overmatch) in any given year.

Systems Development - activities involving the creation or enhancement of 

organizational infrastructures at the community level for the delivery of health services 

and other needed ancillary services to individuals in the community by improving the 

service capacity of health care service providers.

Technical Assistance (TA) - the process of providing recipients with expert assistance 

of specific health related or administrative services that include; systems review 

planning, policy options analysis, coordination coalition building/training, data system 

development, needs assessment, performance indicators, health care reform wrap 

around services, CSHCN program development/evaluation, public health managed care 

quality standards development, public and private interagency integration and, 

identification of core public health issues.

Title V – The authorizing legislation for the Maternal and Child Health Block Grant to 

States program, which is found in Title V of the Social Security Act.

Title V, number of deliveries to pregnant women served under - Unduplicated 

number of deliveries to pregnant women who were provided prenatal, delivery, or postpartum services through the Title V program during the reporting period.

Title V, number of infants enrolled under - The unduplicated count of infants provided 

a direct service by the State‘s Title V program during the reporting period.

Title XIX – The authorizing legislation for the Medicaid program, which is found in Title 

XIX of the Social Security Act.
216

Title XIX, number of infants entitled to - The unduplicated count of infants who were 

eligible for the State‘s Title XIX (Medicaid) program at any time during the reporting 

period.

Title XIX, number of pregnant women entitled to - The number of pregnant women 

who delivered during the reporting period who were eligible for the State‘s Title XIX 

(Medicaid) program.

Total MCH Funding - All the MCH funds administered by a State MCH program which 

is made up of the sum of the Federal Title V Block grant allocation, the Applicant’s

funds (carryover from the previous year‘s MCH Block Grant allocation - the unobligated 

balance), the State funds (the total matching funds for the Title V allocation - match and 

overmatch), Local funds (total of MCH dedicated funds from local jurisdictions within 

the state), Other federal funds (monies other than the Title V Block Grant that are under 

the control of the person responsible for administration of the Title V program), and 

Program Income (those collected by State MCH agencies from insurance payments, 

Medicaid, HMO‘s, etc.)

Types of Services - The major kinds or levels of health care services covered under 

Title V activities. See individual definitions under ―Infrastructure Building,‖ ―Population 

Based Services,‖ ―Enabling Services‖ and ―Direct Medical Services.‖

YRBS - Youth Risk Behavior Survey - A national school-based survey conducted 

annually by CDC and State health departments to assess the prevalence of health risk 

behaviors among high school students.
217

IX - TECHNICAL NOTE:

GUIDELINES FOR CALCULATING PERFORMANCE

MEASURES USING SMALL SAMPLES *

The procedures outlined below are intended to assist States and territories in displaying 

data on required Title V Performance Measures. When the number of events in any 

one year is very small, other approaches are needed to compare results and 

determining statistical significance. The following guidelines are intended to provide a 

consistent approach for those jurisdictions confronting ―the small numbers‖ situation.

GUIDELINES

Number of Events Calculate 

Rate?

Calculate 

Confidence

Interval?

Suggested Approach

A. If at least 20 events 

(numerator)

Yes Yes Use calculated rate

B. If fewer than 20 

events (numerator)

Yes Yes First, calculate a three year 

average rate, then calculate a 

confidence interval

C. If 3 year average is 

fewer than 20 events but 

greater than 4 events

(numerator)

Yes Yes Calculate a standardized ratio

D. If fewer than 5 events

(numerator)

No No Use the low number checkbox 

provided in the electronic 

application and include a note 

that further explains the data.

E. Special Case: Infant 

and Fetal Mortality: If 

fewer than 1000 live births 

(denominator)

No No Apply above alternatives and 

consider using a standardized 

mortality ratio

F. Special Case: 

Childhood Mortality: If 

fewer than 5 events 

(numerator)

No No Apply above alternatives and 

consider using a standardized 

mortality ratio

*Source: Family Health Outcomes Project
218

PROCEDURES

A. Calculate rates (at least 20 events)

Example #1: 25 infant deaths and 860 live births

calculate rate:

25 infant deaths

860 live births

X 1,000 = 29.1 (rate)

calculate 95% confidence interval:

 _______________

= rate 1.96 X √ rate/denominator X 1,000 

 ________

= 29.1 1.96 X √ .029/860 X 1,000 

= 29.1 1.96 X 5.82 = 29.1 11.4

= (17.7, 40.5)

B. Calculate 3 year annual average rates (fewer than 20 events)

To calculate the numerator:

Add up the number of events for the current year and the number of events for the previous 2 

years. 

To calculate the denominator:

Method 1: Add the population denominator for the current year combined with the population 

denominators for the previous 2 years. 

OR

Method 2: Use the population statistic for the middle year only.

For a three year average rate, divide the numerator by the denominator and multiply by 1,000 for a 

rate per 1,000. Calculate XYZ state‘s average annual death rate per 1,000 for 1989-1991 as follows:

Method 1:

(D1 + D2 + D3)

(P1 + P2 + P3)

X 1,000 = Three Year Average Rate

OR

Method 2:

1/3 X (D1 + D2 + D3)

(P1 + P2 + P3)

X 1,000 = Three Year Average Rate
219

Where:

D = the number of deaths in years 1, 2, and 3, respectively

P = the total population in years 1, 2, and 3, respectively

Example #2: 5 infant deaths in 1989, 6 in 1990, 7 in 1991; and 1,520 live births in 1989, 1,530 in 1990, 

and 1,525 in 1991

Calculate three year average using method 1:

(5 + 6 + 7)

(1,520 + 1,530 + 1,525)

X 1,000 = 3.93

OR

Calculate three year average using method 2:

1/3 X (5 + 6 + 7)

1,530

X 1,000 = 3.92

Note: The actual number of events for each year should be documented along with the three year total 

and the calculated annual average rate.

C. Calculate a Standardized Ratio

A standardized ratio is the relationship between the observed number of events versus the expected 

number of events.

To calculate the expected number of events, National rates are applied to the State denominator to 

generate an expected number of events if the State was the same as the national rate.

State Denominator X U.S. Rate

1,000

= Expected Number of Events

Example 3: In 1993, the national infant mortality rate was 6.8 per 1,000 and XYZ State had 500 births.

calculate standardized ratio:

Calculate the expected number of infant deaths by multiplying 500 by 6.8 and dividing by 1,000 

(even though, the actual observed number of deaths was 6):

500 X 6.8

1,000

= Expected Number of Events

Dividing the observed number of events by the expected number and multiplying by 100:

Observed Number of Events

Expected Number of Events

X 100 = Standardized Ratio

_6_

3.3

X 100 = 181.8
220

If the Standardized Ratio is: It means that the State rate is:

Less than 100

Equal to 100

Greater than 100 but ≤ 200

Greater than 200

Lower than the U.S. rate

Same as the U.S. rate

Higher than the U.S. rate

Significantly higher than the U.S. rate

When the standardized ration is greater than 100, further investigation by the State or Territory MCH

office may be indicated. Follow-up analysis can be conducted by examining the characteristics of 

individual cases, or by performing case studies.
221

X - APPENDICES AND STATE SUPPORTING DOCUMENTS

A. The Needs Assessment

B. The Reporting Forms

C. Organizational Charts and all other State supporting documents
222