DRAFT SEMIANNUAL PERFORMANCE MEASURES FOR THE ACL TRAUMATIC BRAIN INJURY STATE IMPLEMENTATION PARTNERSHIP GRANT PROGRAM

**INSTRUCTIONS:**  This electronic form has numerous fields that are pre-populated and auto-calculated to generate sums and percentages. This will save grantees time, and reduces the chance of arithmetical errors. Grantees will enter relevant information for the first reporting period of the grant; in subsequent reporting periods, grantees will only have to enter necessary edits rather than enter data from previous reporting periods. The data from past reporting periods will be saved and displayed for each grant year. This electronic form will be submitted with grantees’ semi-annual project narratives and financial reports. 

1. Does your project use any research-based practices?   			YES ___     NO ___ 

    If YES, please enter the name(s) of the research-based or evidence-based practices used under the most appropriate program activity. Add additional practices as needed:

a. Outreach

i. __________________________________________________________________

ii. __________________________________________________________________

iii. __________________________________________________________________

b. Awareness

i. __________________________________________________________________

ii. __________________________________________________________________

iii. __________________________________________________________________

c. Screening

i. __________________________________________________________________

ii. __________________________________________________________________

iii. __________________________________________________________________                                                                                                          

d. Assessment     

i. __________________________________________________________________

ii. __________________________________________________________________

iii. __________________________________________________________________                                                                                                       

e. Services and Supports

i. __________________________________________________________________

ii. __________________________________________________________________

iii. __________________________________________________________________                                                                                                          

f. Training      

i. __________________________________________________________________

ii. __________________________________________________________________

iii. __________________________________________________________________ 

g. Other  

i. __________________________________________________________________

ii. __________________________________________________________________

iii. __________________________________________________________________                                                                                                          

2. For each category of your program's activities, please provide:                 

a. Dollars, rounded to closest $100, spent this reporting period per category. 

i. Outreach             		$______         ____%  *                                                                                                                                                                                                                                                                                     

ii. Awareness           		$______         ____%  *                                                                                                                                                                                                                                                                                     

iii. Screening              		$______         ____%  *                                                                                                                                                                                                                                                                                    

iv. Assessment           		$______         ____%  *                                                                                                                                                                                                                                                                                   

v. Training	   		$______         ____%  *                                                                                                                                                                                   

vi. Services and Supports    	$______         ____%  *                                                                                                                                                                                                                                                                                     

vii. Other (describe)              	$______         ____%  *     

viii. Total project spending:  		$______ **    

* [% is auto calculated based on category total divided by sum of categories] ** [auto calculated by summing categories above]                                                                         

            b. Total dollars spent this reporting period divided by total number of people served.

i. Total spent:   		$_________      [Auto populated from 2a]  

ii. Number served: 		#_________

iii. Spending per person: 	$_________       [Auto calculated based on 2bi/2bii]                  

           c. Total dollars spent this reporting period per category divided by the number of people served within each category. (Total Spent/Number Served = Spending per person by category)

i. Outreach             		$______* / #______ =  $______**                                                                                                      

ii. Awareness           		$______* / #______ =  $______**                                                                                                      

iii. Screening              		$______* / #______ =  $______**                                                                                                      

iv. Assessment           		$______* / #______ =  $______**                                                                                                                                                                                                                                                                                                                    

v. Training	   		$______* / #______ =  $______**                                                                                                                                                                                                           

vi. Services and Supports       	$______* / #______ =  $______**                                                                                                                                                                                                                                                                                                                      

vii. Other (describe)                	$______* / #______ =  $______**                                                                                                                                                                                                                                                                                                                      

 		 * [auto filled from 2a] 		

  ** [% is auto calculated based on category total divided by sum of categories]                                                                                                       

3. Please provide ACL grant fund dollars spent this reporting period by category [ACL: Goal 5 Obj. 5.2].

a. Outreach             			$______             ____% *                                                                                              

b. Awareness           			$______             ____% *                                                                                                 

c. Screening              			$______             ____% *                                                                                                  

d. Assessment           			$______             ____% *                                                                                                

e. Training	   			$______             ____% *    

f. Services and Supports    		$______             ____% *                                                                                                    

g. Other (describe)             		$______             ____% *

h. Total ACL funds spent:   			$______ **          

* [% is auto calculated based on category total divided by sum of categories]                                                                                         ** [auto calculated by summing categories above]     

4. List the funding sources and their relative amounts of this reporting period’s project spending. 

a. Private Payers    			$______            ____% *

b. Medicaid                           		$______            ____% *

c. Medicaidt fund  are being soughts are consistent with ACL'es.tivities and impacts of ext group of granteess with similar prograedicare                          		$______             ____% *                                   

d. SSI					$______             ____% *                                                                                              

e. SSDI					$______             ____% *                                                                                              

f. CMS grants				$______             ____% *                                                                                              

g. Matching funds			$______             ____% *                                                                                              

h. In-kind donations			$______             ____% *                                                                                              

i. ACL grant				$______ **        ____% *   

j. Others					$______             ____% *                                                                                              

* [% is auto calculated based on category total divided by sum of categories]

** [auto populated from 3h]                                                                                                                                                                                    

5. Please list the types of referral sources to your TBI system and numbers of referrals from each.

a. Acute hospitals  							# _______

b. Acute hospitals rehabilitation units  					# _______

c. Residential rehabilitation centers  					# _______

d. Nursing homes  							# _______

e. Outpatient treatment programs  					# _______

f. Universities, colleges, or schools  					# _______

g. Assisted-living settings  						# _______

h. Homeless services organizations					# _______

i. Veterans & Military organizations					# _______

j. Other:______________________					# _______

6. Please list the types and numbers of service and support providers participating in grant activities [ACL: Goal 4 Obj. 4.2].

a. Hospitals	 							# _______

b. Residential rehabilitation centers 					# _______

c. Nursing homes 							# _______

d. Outpatient treatment programs 					# _______

e. Assisted-living settings 						# _______

f. TBI Model System Centers 						# _______

g. Brain injury support groups 						# _______

h. Protection and Advocacy System and Client Assistance Programs 	# _______ 

i. Vocational rehabilitation organizations   				# _______

j. Homeless services organizations					# _______

k. Veterans & Military organizations					# _______

l. Other:____________________					# _______	

7. Regarding your project’s screening and referral tools and procedures, please describe:

a. Screening methods/protocols used

i. Widely offering a brief TBI screen followed by a confirmatory evaluation if indicated			

YES___	 NO___

ii. Self-report of injury and/or symptoms triggers a screening, followed by a confirmatory evaluation if indicated 				

YES___	 NO___

iii. Offering a screening to specific populations at higher risk of TBI (homeless, incarcerated, athletes, crime victims, etc.), followed by a confirmatory evaluation if indicated 	  

YES___ 	NO___

iv. Other methods: ________________________________	

YES___	 NO___

b. Standardized instruments used for screening

i. The Ohio State University Traumatic Brain Injury Identification Method (OSU TBI-ID) 							

YES___	 NO___

ii. The Brain Injury Screening Questionnaire (BISQ) 					YES___	 NO___

iii. Defense and Veterans Brain Injury Center TBI Screening Tool (DVBIC TBI), also called The Brief Traumatic Brain Injury Screen (BTBIS) 		

YES___	 NO___

iv. The Traumatic Brain Injury Screening Instrument (TBISI) 	

	YES___	 NO___

v. HELPS

YES___	 NO___

vi. Military Acute Concussion Evaluation (MACE) 	

YES___	 NO___

vii. Automated Neuropsychological Assessment Metrics (ANAM)

YES___	 NO___

viii. Others:_____________________________ YES___	 NO___

c. Technological tools used for screening 

i. Computed Tomography (CT)  		YES___	 NO___

ii. Magnetic Resonance Imaging (MRI) 		YES___	 NO___

iii. Diffuse Tensor Imaging (DTI) 		YES___	 NO___

iv. Fluid-Attenuated Inversion Recovery (FLAIR)    YES___	  NO___

v. Electroencephalogram (EEG) 		YES___	 NO___

vi. Magnetic Resonance Angiography (MRA) 	YES___	 NO___

vii. Positron Emission Tomography (Pet Scan) 	YES___	 NO___

viii. Magnetic Resonance Spectroscopy (MRS) 	YES___	 NO___

ix. Otic Resonance Spectroscopy (MRSs at higher risk of TBI (homeless people, thers: ____________________________ 	YES___	 NO___

d. Screening events this reporting period: 	#______

e. People screened this reporting period:	#______	 

f. People whose screens this reporting period suggested a potential TBI: 	#______

g. Types of referrals and numbers referred following positive screening results:

i. Hospital-based Neurologist	 		#______

ii. Specialized Neurology clinic	 		#______

iii. Veteran’s hospital or clinic			#______

iv. Publicly-funded clinic				#______

v. Other: ____________________ 		#______

h. People with TBI receiving coordinated, long-term services: 	#______

8. Please list the total number of individuals with TBI who are in the categories listed:              

a. Need home and community-based services            		#______

b. Have requested home and community-based services            	#______            _____% *                                                                                                                        

c. Receive home and community-based services        		#______            _____% *                                                                                                                        

d. Do you have a waitlist for services?	YES___	 NO___

e. If YES, how many people are on this waitlist?	#______           _____% *   

* [% is auto calculated based on category total divided by sum of categories]                                                                                                       

9. Please list the number of individuals receiving TBI-related home and community-based services this reporting period who are identified as needing but not yet receiving services and the number who are receiving these services: 

a. Persons with disabilities 					#______ *         

i. Need home and community-based services            	#______            _____% **      

ii. Receive home and community-based services           #______            _____% **                                                                                                                        

b. Older adults (age 65 and above) 				#______*          

i. Need home and community-based services            	#______            _____% **      

ii. Receive home and community-based services           #______            _____% **                                                                                                                        

c. Live in underserved geographic areas (rural or urban) 	#______ *         

i. Need home and community-based services            	#______            _____% **      

ii. Receive home and community-based services           #______            _____% **                                                                                                                        

d. Racial and ethnic minority group				#______ *         

i. Need home and community-based services            	#______            _____% **      

ii. Receive home and community-based services           #______            _____% **         

e. Disadvantaged individuals					#______ *        

i. Need home and community-based services            	#______            _____% **      

ii. Receive home and community-based services           #______            _____% **                                                                                                                        

f. Individuals with limited English proficiency			#______ *        

i. Need home and community-based services            	#______            _____% **      

ii. Receive home and community-based services           #______            _____% **                                                                                                                       

g. Others: ____________________________  			#______ *         

i. Need home and community-based services            	#______            _____% **      

ii. Receive home and community-based services           #______            _____% **                                                                                                                                                                                                                              

  * [# is auto calculated based on number needing plus number receiving services within that population]                                                                                                      

**[% is auto calculated based on number needing or number receiving divided by the population group’s total]        

*Since people may be members of multiple populations, total number of people in unserved and underserved populations and percentages of that total would be inaccurate.*

**

10. Number and percent of family members/informal caregivers needing but not yet receiving and the number who are receiving supportive services this reporting period: 

a. Need supportive services				#______            

b. Receive supportive services				#______            _____% *                                                                                                                       

* [% is auto calculated based on number receiving services divided by the two groups’ total number]        

11. Percent of your state’s counties reached through your project’s activities: 

a. Total number of counties				#______

b. Counties reached					#______	_____% *  

* [% is auto calculated based on # of counties reached divided by total number of counties]        

12. Please estimate the number of people with TBI in your state, and then provide the number of individuals currently being treated:  	

c. Estimated number with TBI				#______

d. Receive treatment              				#______	_____% **      

e. Need treatment             				#______ *       _____% **                                                                                                  

* [# is auto calculated based on total number with TBI minus the number receiving services]                                                                                                      

** [% is auto calculated based on number needing or number receiving treatment divided by the two groups’ total number, 12a.]        

13. What number and percent of the total of your state’s TBI staff and advisory board members are individuals living with TBI?   

a. Total number of state TBI staff				#______

i. Staff members living with TBI 			#______             _____% *  

b. Total number of state advisory board members		#______

i. Advisory board members living with TBI	 	#______             _____% *        

* [% is auto calculated based on number living with TBI divided by the group’s total number]                                                                                          

14. Please list the number of project-sponsored trainings that occurred this reporting period, categorized by type/topic and number of attendees.

a. TBI Basics 						#______ 	# attended: _____

b. Diagnosing & Treating TBI				#______ 	# attended: _____

c. Concussions & Mild TBI 				#______ 	# attended: _____

d. Caregiving  						#______ 	# attended: _____

e. Prevention 						#______ 	# attended: _____

f. Employment and Training 				#______ 	# attended: _____

g. Assistive technology 					#______ 	# attended: _____

h. Educational issues 					#______ 	# attended: _____

i. Policy							#______ 	# attended: _____

j. Others: ______________				#______ 	# attended: _____

15. Of the people with TBI receiving treatment during the past reporting period, how many moved from:

a. Institutions to community settings?	 		#______             _____% *  

b. Community settings to institutions? 	 		#______             _____% *  

* [% is auto calculated based on the item number divided by 12b]                                                                                                   

16. Of the people with TBI who transitioned from an institutional setting to a community setting this reporting period, to what type of settings did they move, and percent of the total transitioning?  

c. Previous home						#______             _____% *  

d. Family member’s home				#______             _____% *  

e. Friend’s home						#______             _____% *  

f. Transitional living program				#______             _____% *  

g. Long-term care and supervised living programs	#______             _____% *  

h. Assisted-living settings 				#______             _____% *  

i. Other: ___________________			#______             _____% *  

j. Total transitioning to all community settings         	# ______ **  

* [% is auto calculated based on category total divided by sum of categories]

** [Auto calculates sum – should match the 15a. There may be some difference due to incorrect or unavailable data.]

17. Of the people who are being treated for TBI and are living in community settings, what number and percent of the total are currently employed and/or in school?  

a. Receive home and community-based services    	#______ *           _____%                                                                                                                   

b. Employed 						#______              _____% **       

c. In school or training                  			#______              _____% **                                                        

* [auto populated from 8c]    

** [% is auto calculated based on category total divided by sum of categories]

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