OHIC Profiles Data Collection

OHIC Profiles Data Collection Form Instructions

The data collection form includes questions from ACL about your organization/agency’s SHIP, SMP, and/or 

MIPPA programs and requires you to prepare information ahead of time. This document is intended to serve as 

a quick guide to help you prepare that information. 

ACL will use the information gathered from this form to create an updated set of grantee profiles that are 

accessible, visually appealing, and consistent across the SHIP, SMP, and MIPPA programs. As you recall, ACL 

developed profiles for SHIP programs in 2016. 

Please make sure to submit the most current data in this data collection. 

General Instructions: 

• The form should be completed in one sitting. You will not be able to save your progress and return to 

the form later.

• Please note that additional sections and questions will populate throughout the form based on your 

responses to previous questions. For this reason, the form may appear shorter when you first open it, but 

this is not an adequate representation of the length of the form.

• Depending on the number of programs your agency/organization manages, the form will take you 

approximately 20 minutes to complete, with 30 minutes of preparation time. 

The table below lists the questions in the order they appear on the form and information you may need to have 

handy before completing the form:

All Respondents

What we will ask about What we need from you 

Agency/Organization 

Name

The official name of your agency/organization as it appears on your grant application. 

Agency/Organization Type Select the type of agency/organization and explain your selection. Selection options include 

State Department of Aging (Health and Human Services), State Department of Insurance, 

Non-Profit Organization, or Other. 

You will be asked to add an explanation to your selection in an open-ended response. If you 

select “Other”, you will be asked to describe the agency/organization type in an open-ended 

response.

Program Funding Type Identify all types of OHIC program funding (e.g., SHIP, SMP, MIPPA Priority 1 (SHIP), 

MIPPA Priority 2 (AAA), MIPPA Priority 3 (ADRC)). 

OHIC Program 

Management

Identify all types of OHIC programs that you currently manage (e.g., SHIP, SMP, MIPPA 

Priority 1 (SHIP), MIPPA Priority 2 (AAA), MIPPA Priority 3 (ADRC)).
OHIC Profiles Data Collection

All Respondents

What we will ask about What we need from you 

Operational Model 

(Centralized/Decentralized)

Identify if your agency/organization is centralized, decentralized, or another model of 

operation. 

Centralized is defined as a "federally funded grantee agency/organization doing all program 

work out of central office(s)".

Decentralized is defined as a "federally funded grantee agency/organization primarily 

regranting or subcontracting to do program work."

If you select “Other”, you will be asked to describe the operational model in an open-ended 

response.

Funding Sources (Federal 

and Non-Federal)

Identify all funding from federal and non-federal sources from the provided list. 

Federal funding sources include Aging and Disability Resource Center/No Wrong Door 

(ADRC/NWD), Older Americans Act (OAA), Center for Independent Living (CIL), 

University Centers for Excellence in Developmental Disabilities (UCEDD), or Other. 

Non-federal funding sources include State, Local, or Other. 

If you select “Other” for either question, you will be asked to enter the source in an openended response. 

For each SHIP, SMP, or MIPPA Grant Award

What we will ask about What we need from you

Year Grant Received If this is not your first SHIP/SMP/MIPPA grant award, provide the year your 

agency/organization first received the grant award in the YYYY format. 

Partnerships Does your agency/organization have any partnerships for the SHIP/SMP/MIPPA grant? 

If you work with partners, you will be asked to identify the types of partners such as 

pharmacies, providers, community health centers, Area Agencies on Aging, local or regional 

CMS, etc. 

Partners may be provided funding to participate in shared work or may work in-kind.

If you select “Other”, you will be asked to print the partner organization’s name in an openended response.

Populations Served Identify all populations served by this OHIC grant such as low-income (150% FPL), rural, 

under 65, Hispanic or Latino, etc.
OHIC Profiles Data Collection

For each SHIP, SMP, or MIPPA Grant Award

What we will ask about What we need from you

Subrecipients (SMP and 

MIPPA only)

If you share SMP or MIPPA grant money with subrecipients, please prepare in 

advance then upload an Excel file with subrecipients’ names and contact information. 

Use the Annual SMP/MIPPA Sub-Recipients Report Template included in your invitation 

email. This template includes the following fields:

• Grantee Name

• State

• Report Period

• Total # of Sub-Recipients

• Total Annual Sub-Recipient Amount (Federal SMP/MIPPA Dollars Only)

• Subrecipient Name, Address, City, State, ZIP Code, and Annual Federal 

SMP/MIPPA Amount

• If you have both SMP and MIPPA subrecipients, you will need to prepare and 

upload two separate files, one for SMP and one for MIPPA.

Goals for Grant Have ready the goals your agency/organization listed in your grant application. If you 

do not have access to your grant application, please contact your ACL Project Officer. 

If your goals have not changed since the original application, you can copy and paste your 

response into the form. If your goals have changed since the original application, please 

enter updated goals in the same format utilized in the application. 

Best Practices Select best practices learned from the SHIP/SMP/MIPPA program(s) from the following 

list of categories: 

• Team Member Training

• Open Enrollment Practices

• Volunteers and/or Team Member Management

• Use of Technology

• Outreach Practices

• Intake Process

• Team Member Certification Process

• Counseling Practices

• Grant Management

• Data Collection and/or Management

• Program Management

• Casework (SMP Only)

Describe what your agency/organization has learned on the topic. 

If you need guidance, review Best Practices responses from the most recent semi-annual 

report. 
OHIC Profiles Data Collection

For each SHIP, SMP, or MIPPA Grant Award

What we will ask about What we need from you

Lessons Learned from 

Challenges

Select lessons learned from challenges from the SHIP/SMP/MIPPA program(s), using the

following list of categories: 

• Team Member Training

• Open Enrollment Practices

• Volunteers and/or Team Member Management

• Use of Technology

• Outreach Practices

• Intake Process

• Team Member Certification Process

• Counseling Practices

• Grant Management

• Data Collection and/or Management

• Program Management

• Casework (SMP Only)

Describe what your agency/organization has learned on the topic. 

If you need guidance, review Lessons Learned responses from the most recent semi-annual 

report.