OHIC Profiles-Data Collection Form

Office of Healthcare Information and 

Counseling (OHIC)

OHIC Profiles

Data Collection Form

Instructions

Thank you for taking time to enter your program information into this data collection form. 

The form includes questions from ACL about your SHIP, SMP, and/or MIPPA grants and 

requires you to prepare some information ahead of time. 

Sections and questions appear based on your responses to previous questions. The form will 

appear short when you first open it, but this is not adequate representation of the length of the 

form. Please refer to the supplemental instructions attached to your invitation email for more 

information. 

We understand your time constraints and want to be cognizant of your multiple obligations. 

Depending on how many programs you manage, this form is expected to take 20 minutes to 

complete, with 30 minutes of preparation time. The form must be completed in one sitting. You 

will not be able to save your progress and return to the form later. 

Grant Manager Information

1. First Name * 

Please print your first name.

2. Last Name * 

Please print your last name.

3. Email Address * 

Please print your email address.

Agency/Organization Information 

1. What is the name of your agency/organization? * 
OHIC Profiles-Data Collection Form

Your agency/organization is the direct recipient of SHIP, SMP, and/or MIPPA funding. If your 

agency/organization receives more than one of these grants, please complete this survey with all 

in mind. 

Please enter the name of your agency/organization. 

2. How would you describe your agency/organization? *

Please select the most appropriate response.

Please add additional explanation after you make your selection.

  State Department of Aging (Health and Human Services)

  State Department of Insuranc

  Non-Profit Organization

  Other (Please Specify

2a. [If selected] Please print the name of the State Department of Aging (Health and Human 

Services)* 

2b. [If selected] Please print the name of the State Department of Insurance.* 

2c. [If selected] Please print the name of the Non-Profit Organization. * 

2d. [If selected] What is the "other" agency/organization that supports these grants?*

Please print the name of the “other” agency/organization.

3. Does your agency/organization receive SHIP, SMP, and/or MIPPA program funding?*

Select all that apply.

  SHI

  SM

  MIPPA Priority 1 (SHIP)

  MIPPA Priority 2 (AAA)

  MIPPA Priority 3 (ADRC)

4. Which OHIC programs do you currently manage?*

Select all that apply.

  SHI

  SM

  MIPPA Priority 1 (SHIP)

  MIPPA Priority 2 (AAA)

  MIPPA Priority 3 (ADRC)
OHIC Profiles-Data Collection Form

5. Which model best describes your agency/organization?*

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

out of central office(s)" and Decentralized is defined as a "federally funded grantee 

agency/organization regranting or subcontracting to do program work." 

Select the most appropriate category. 

  Centralize

  Decentralize

  Other (Please Specify

5a. [If Other] Please specify the "other" model that best describes your 

agency/organization.* 

6. Does your agency/organization receive federal funding from any of the following?*

Select all that apply, unless selecting "Not Applicable".

  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

  Other (Please Specify)

  Not Applicabl

6a. [If Other] Please specify the other federal funding source.*

7. Does your agency/organization receive non-federal from any of the following?* 

Select all that apply, unless selecting "Not Applicable".

  Stat

  Loca

  Other (Please Specify

  Not applicable

7a. [If Other] Please specify the “other” non-federal funding source.* 
OHIC Profiles-Data Collection Form

SHIP Program 

Questions for this section will populate if you indicate that your agency/organization receives 

SHIP program funding. 

 1. Is this your agency/organization's first SHIP grant from ACL?* 

  Ye

  N

1a. [If No] What year did your agency/organization first receive the SHIP grant from 

ACL?* 

Please enter the year in YYYY format (e.g., 2010). 

2. Does your agency/organization have any partnerships for the SHIP program?*

These may be paid or unpaid partnerships. 

  Ye

  N

2a. [If Yes] Which type(s) of agencies/organizations do you partner with?*

Please select all that apply.

  Local Community-based Organization

  Federally Qualified Health Centers (FQHC)/Community Health Center

  Pharmacie

  Providers

  State Medicaid Offic

  Other State Agencie

  Local or Regional Social Security Administration (SSA

  Local or Regional Centers for Medicare & Medicaid Services (CMS

  Local or Regional Federal Bureau of Investigation (FBI)

  Local or Regional Office of Inspector General (OIG)

  Area Agencies on Aging

  Navigators

  U.S. Department of Housing and Urban Development (HUD)

  Aging and Disability Resource Center/No Wrong Door (ADRC/NWD)

  Center for Independent Living (CIL)

  Older American Act (OAA) Programs

  State or Local AAR

  Other (Please Specify

2b. [If Other] Please specify the "other" agency/organization you partner with.*
OHIC Profiles-Data Collection Form

3. What population(s) does your SHIP program serve?*

Select all that apply.

  Low-Income (150% FPL)

  Rural

  English as a Second Language

  Under 65

  American Indian or Alaskan Nativ

  Black or African America

  Hispanic or Latin

  Asian or Asian America

  Native Hawaiian or other Pacific Islande

  Other (Please Specify

3a. [If Other] Please specify the "other" population(s) your SHIP program serves if not 

listed above.* 

4. What are your agency/organization's goals for this grant?*

Refer to the goals in your grant application (If you do not have access to your grant application, 

please contact your Project Officer).

If your goals have changed since the original application, please enter updated goals. Please 

make sure your goals are in the same format as your grant application. 

5. What best practices has your agency/organization learned in these program areas?*

Select all that apply. 

Please add an explanation to your selection(s) below. 

  Team Member Trainin

  Open Enrollment Practice

  Volunteers and/or Team Member Managemen

  Use of Technology

  Outreach Practice

  Intake Process

  Team Member Certification Proces

  Counseling Practice

  Grant Managemen

  Data Collection and/or Managemen

  Program Management
OHIC Profiles-Data Collection Form

5a. [If selected] Please describe the best practices for Team Member Training.*

5b. [If selected] Please describe the best practices for Open Enrollment Practices.* 

5c. [If selected] Please describe the best practices for Volunteers and/or Team Member 

Management.* 

5d. [If selected] Please describe the best practices for Use of Technology.* 

5e. [If selected] Please describe the best practices for Outreach Practices.* 

5f. [If selected] Please describe the best practices for Intake Process.* 
OHIC Profiles-Data Collection Form

5g. [If selected] Please describe the best practices for Team Member Certification Process.* 

5h. [If selected] Please describe the best practices for Counseling Practices.* 

5i. [If selected] Please describe the best practices for Grant Management.* 

5j.[If selected] Please describe the best practices for Data Collection and/or Management.* 

5k. [If selected] Please describe the best practices for Program Management.* 
OHIC Profiles-Data Collection Form

6. What lessons has your agency/organization learned from challenges in these program 

areas?*

Select all that apply.

Please add an explanation to your selection(s) below. 

  Team Member Trainin

  Open Enrollment Practice

  Volunteers and/or Team Member Managemen

  Use of Technology

  Outreach Practice

  Intake Process

  Team Member Certification Proces

  Counseling Practice

  Grant Managemen

  Data Collection and/or Managemen

  Program Management

6a. [If selected] Please describe the lessons learned from Team Member Training.*

6b. [If selected] Please describe the lessons learned from Open Enrollment Practices.* 

6c. [If selected] Please describe the lessons learned from Volunteers and/or Team Member 

Management.* 
OHIC Profiles-Data Collection Form

6d. [If selected] Please describe the lessons learned from Use of Technology.* 

6e. [If selected] Please describe the lessons learned from Outreach Practices.* 

6f. [If selected] Please describe the lessons learned from Intake Process.* 

6g. If selected] Please describe the lessons learned from Team Member Certification 

Process.* 

6h. [If selected] Please describe the lessons learned from Counseling Practices.* 

6i. [If selected] Please describe the lessons learned from Grant Management.* 
OHIC Profiles-Data Collection Form

6j. [If selected] Please describe the lessons learned from Data Collection and/or 

Management.* 

6k. [If selected] Please describe the lessons learned from Program Management.* 

Thank you!

Thank you for taking the time to complete the SHIP program section. If you manage another 

OHIC program, please fill out all applicable sections of this form. 

Once you complete all applicable sections, please hit "Submit". 

SMP Program 

Questions for this section will populate if you indicate that your agency/organization receives 

SMP program funding. 

 1. Is this your agency/organization's first SMP grant from ACL?* 

  Ye

  N

1a. [If No] What year did your agency/organization first receive the SMP grant from 

ACL?* 

Please enter the year in YYYY format (e.g., 2010). 

2. Does your agency/organization have any partnerships for the SMP program?*

These may be paid or unpaid partnerships. 

  Ye

  N
OHIC Profiles-Data Collection Form

2a. [If Yes] Which type(s) of agencies/organizations do you partner with?*

Please select all that apply.

  Local Community-based Organization

  Federally Qualified Health Centers (FQHC)/Community Health Center

  Pharmacie

  Providers

  State Medicaid Offic

  Other State Agencie

  Local or Regional Social Security Administration (SSA

  Local or Regional Centers for Medicare & Medicaid Services (CMS

  Local or Regional Federal Bureau of Investigation (FBI)

  Local or Regional Office of Inspector General (OIG)

  Area Agencies on Aging

  Navigators

  U.S. Department of Housing and Urban Development (HUD)

  Aging and Disability Resource Center/No Wrong Door (ADRC/NWD)

  Center for Independent Living (CIL)

  Older American Act (OAA) Programs

  State or Local AAR

  Other (Please Specify

2b. [If Other] Please specify the "other" agency/organization you partner with.*

3. What population(s) does your SMP program serve?*

Select all that apply.

  Low-Income (150% FPL)

  Native America

  Non-English Speaking

  People with Disabilitie

  Racial/Ethnic Minorit

  Rural

  Other (Please Specify

3a. [If Other] Please specify the "other" population(s) your SMP program serves if not 

listed above.* 

4. Do you share grant money with any subrecipients?* 

  Ye

  N
OHIC Profiles-Data Collection Form

4a. [If Yes] How many subrecipients do you share grant money with?*

Please enter a number.

Please upload an Excel file that lists your SMP subrecipients in Question 4b in the MIPPA Grant section 

of this form.

5. What are your agency/organization's goals for this program?*

Refer to the goals in your grant application (If you do not have access to your grant application, 

please contact your Project Officer).

If your goals have changed since the original application, please enter updated goals. Please 

make sure your goals are in the same format as your grant application. 

6. What best practices has your agency/organization learned in these program areas?*

Select all that apply. 

Please add an explanation to your selection(s) below. 

  Team Member Trainin

  Open Enrollment Practice

  Volunteers and/or Team Member Managemen

  Use of Technology

  Outreach Practice

  Intake Process

  Team Member Certification Proces

  Counseling Practice

  Grant Managemen

  Data Collection and/or Managemen

  Program Management

  Casework

6a. [If selected] Please describe the best practices for Team Member Training.*
OHIC Profiles-Data Collection Form

6b. [If selected] Please describe the best practices for Open Enrollment Practices.* 

6c. [If selected] Please describe the best practices for Volunteers and/or Team Member 

Management.* 

6d. [If selected] Please describe the best practices for Use of Technology.* 

6e. [If selected] Please describe the best practices for Outreach Practices.* 

6f. [If selected] Please describe the best practices for Intake Process.* 

6g. [If selected] Please describe the best practices for Team Member Certification Process.* 
OHIC Profiles-Data Collection Form

6h. [If selected] Please describe the best practices for Counseling Practices.* 

6i. [If selected] Please describe the best practices for Grant Management.* 

6j.[If selected] Please describe the best practices for Data Collection and/or Management.* 

6k. [If selected] Please describe the best practices for Program Management.* 

6l. Please describe the best practices for Casework.* 
OHIC Profiles-Data Collection Form

7. What lessons has your agency/organization learned from challenges in these program 

areas?*

Select all that apply, unless selecting "None".

Please add an explanation to your selection(s) below. 

  Team Member Trainin

  Open Enrollment Practice

  Volunteers and/or Team Member Managemen

  Use of Technology

  Outreach Practice

  Intake Process

  Team Member Certification Proces

  Counseling Practice

  Grant Managemen

  Data Collection and/or Managemen

  Program Management

  Casework

7a. [If selected] Please describe the lessons learned from Team Member Training.*

7b. [If selected] Please describe the lessons learned from Open Enrollment Practices.* 

7c. [If selected] Please describe the lessons learned from Volunteers and/or Team Member 

Management.* 
OHIC Profiles-Data Collection Form

7d. [If selected] Please describe the lessons learned from Use of Technology.* 

7e. [If selected] Please describe the lessons learned from Outreach Practices.* 

7f. [If selected] Please describe the lessons learned from Intake Process.* 

7g. If selected] Please describe the lessons learned from Team Member Certification 

Process.* 

7h. [If selected] Please describe the lessons learned from Counseling Practices.* 

7i. [If selected] Please describe the lessons learned from Grant Management.* 
OHIC Profiles-Data Collection Form

7j. [If selected] Please describe the lessons learned from Data Collection and/or 

Management.* 

7k. [If selected] Please describe the lessons learned from Program Management.* 

7l. [If selected] Please describe the lessons learned from Casework.* 

Thank you!

Thank you for taking the time to complete the SMP program section. If you manage another 

OHIC program, please fill out all applicable sections of this form.

Once you complete all applicable sections, please hit "Submit". 

MIPPA Program 

Questions for this section will populate if you indicate that your agency/organization receives 

MIPPA program funding. 

1. Is this your agency/organization's first MIPPA grant from ACL?* 

  Ye

  N
OHIC Profiles-Data Collection Form

1a. [If No] What year did your agency/organization first receive the MIPPA grant from 

ACL?* 

Please enter the year in YYYY format (e.g., 2010). 

2. Does your agency/organization have any partnerships for the MIPPA program?*

These may be paid or unpaid partnerships. 

  Ye

  N

2a. [If Yes] Which type(s) of agencies/organizations do you partner with?*

Please select all that apply.

  Local Community-based Organization

  Federally Qualified Health Centers (FQHC)/Community Health Center

  Pharmacie

  Providers

  State Medicaid Offic

  Other State Agencie

  Local or Regional Social Security Administration (SSA

  Local or Regional Centers for Medicare & Medicaid Services (CMS

  Local or Regional Federal Bureau of Investigation (FBI)

  Local or Regional Office of Inspector General (OIG)

  Area Agencies on Aging

  Navigators

  U.S. Department of Housing and Urban Development (HUD)

  Aging and Disability Resource Center/No Wrong Door (ADRC/NWD)

  Center for Independent Living (CIL)

  Older American Act (OAA) Programs

  State or Local AAR

  Other (Please Specify

2b. [If Other] Please specify the "other" agency/organization you partner with.*

3.What population(s) does your MIPPA program serve?*

Select all that apply.

  Under 65

  Rural

  Native America

  English as a Second Languag

  American Indian or Alaskan Nativ

  Asian or Asian America

  Black or African America

  Hispanic or Latin

  Native Hawaiian or other Pacific Islande

  Other (Please Specify
OHIC Profiles-Data Collection Form

3a. [If Other] Please specify the "other" population(s) your MIPPA program serves if not 

listed above.* 

4. Do you share grant money with any subrecipients?* 

  Ye

  N

4a. [If Yes] How many subrecipients do you share grant money with?*

Please enter a number.

 

4b. [If Yes] Please upload an Excel file that lists your subrecipients for SMP and/or 

MIPPA.*

Please upload an individual Excel file for SMP and MIPPA (if applicable). 

Please follow the format provided in the supplemental instructions.

5. What are your agency/organization's goals for this program?*

Refer to the goals in your grant application (If you do not have access to your grant application, 

please contact your Project Officer).

If your goals have changed since the original application, please enter updated goals. Please 

make sure your goals are in the same format as your grant application. 

6. What best practices has your agency/organization learned in these program areas?*

Select all that apply. 

Please add an explanation to your selection(s) below. 

  Team Member Trainin

  Open Enrollment Practice

  Volunteers and/or Team Member Managemen

  Use of Technology

  Outreach Practice

Drag and drop files here or browse files 
OHIC Profiles-Data Collection Form

  Intake Process

  Team Member Certification Proces

  Counseling Practice

  Grant Managemen

  Data Collection and/or Managemen

  Program Management

6a. [If selected] Please describe the best practices for Team Member Training.*

6b. [If selected] Please describe the best practices for Open Enrollment Practices.* 

6c. [If selected] Please describe the best practices for Volunteers and/or Team Member 

Management.* 

6d. [If selected] Please describe the best practices for Use of Technology.* 

6e. [If selected] Please describe the best practices for Outreach Practices.* 
OHIC Profiles-Data Collection Form

6f. [If selected] Please describe the best practices for Intake Process.* 

6g. [If selected] Please describe the best practices for Team Member Certification Process.* 

6h. [If selected] Please describe the best practices for Counseling Practices.* 

6i. [If selected] Please describe the best practices for Grant Management.* 

6j. [If selected] Please describe the best practices for Data Collection and/or Management.* 

6k. [If selected] Please describe the best practices for Program Management.* 
OHIC Profiles-Data Collection Form

7. What lessons has your agency/organization learned from challenges in these program 

areas?*

Select all that apply.

Please add an explanation to your selection(s) below.

  Team Member Trainin

  Open Enrollment Practice

  Volunteers and/or Team Member Managemen

  Use of Technology

  Outreach Practice

  Intake Process

  Team Member Certification Proces

  Counseling Practice

  Grant Managemen

  Data Collection and/or Managemen

  Program Management

7a. [If selected] Please describe the lessons learned from Team Member Training.*

7b. [If selected] Please describe the lessons learned from Open Enrollment Practices.* 

7c. [If selected] Please describe the lessons learned from Volunteers and/or Team Member 

Management.* 
OHIC Profiles-Data Collection Form

7d. [If selected] Please describe the lessons learned from Use of Technology.* 

7e. [If selected] Please describe the lessons learned from Outreach Practices.* 

7f. [If selected] Please describe the lessons learned from Intake Process.* 

7g. If selected] Please describe the lessons learned from Team Member Certification 

Process.* 

7h. [If selected] Please describe the lessons learned from Counseling Practices.* 

7i. [If selected] Please describe the lessons learned from Grant Management.* 
OHIC Profiles-Data Collection Form

7j. [If selected] Please describe the lessons learned from Data Collection and/or 

Management.* 

7k. [If selected] Please describe the lessons learned from Program Management.* 

Thank you!

Thank you for taking the time to complete the MIPPA program section. If you have completed 

all applicable sections, please hit "Submit".