Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 635 - FAMILY PLANNING SERVICES CODE › Appendix D - Instruction Manual For the BCHS Common Reporting Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
FORM APPROVED
OMB NO. 0915-0004
EXPIRES 12/31/82
U.S. DEPARTMENT OF HEALTH AND HUMAN
						  SERVICES
PUBLIC HEALTH SERVICE
Bureau of Community Health
						  Services
Division of Monitoring and
						  Analysis
5600 Fishers Lane
Rockville, Maryland 20857
(301)443-2376
BUREAU OF COMMUNITY HEALTH
						  SERVICES
COMMON REPORTING REQUIREMENTS FACE
						  SHEET
1) BCRR Reporting No.
2) Check one:
Initial Submission
Revision
3) REPORT FOR PERIOD (Check One & Complete
						  Date)
January 198__ through June 198___
January 198__ through December 198___
_____ 198___ through _____ 198___
4) Sponsor/Grantee Name
5) Project Name and Address
6) Project Name/Address Change since last
						  report?YesNo
7) Program(s)*
Grant Number
(a)
(b)
(c)
(d)
8) Name of Person Preparing Report
(e)
(f)
(g)
9) Area Code and Business Telephone Number of Person
						  Preparing Report
10) Director (name)
Signature & Date
11)
Check those tables not submitted with this report
						  because they are totally inapplicable for the reason listed: (do not submit
						  blank tables)
2-A
Only applies to projects serving migratory and seasonal
						  agricultural workers.
4
Only applies to primary care projects/grantees.
2-B
Only applies to CH, FP, MH and other projects designed
						  by the Regional Office.
5
Only applies to projects affected by the Primary Care
						  Effectiveness activity.
*Grantees receiving support from one or more BCHS
						  program will report the identifying code for each program included and the
						  grant number relating to each program (except in free-standing NHSC sites). The
						  codes are as follows:
CH
- Community Health Center (includes RHI,
HC
- National Health Service Corps (BHPDS)
- UHI & Hospital-Affiliated).
MH
- Migrant Health
FP
- Title X Family Planning
1.
Submit:
a.
3 copies to:
the Data Manager
REGIONAL OFFICE
(unless the Regional Office specifies
						  otherwise)
NOTE:
Grantees are in violation of Public Health Service
						  policy if they fail to submit reports that are complete, timely, accurate and
						  valid. Grantees are
ineligible to receive continuation support
if they have failed to comply with the submission requirements of the BCRR as
						  established by the Regional Office.
2.
Direct questions to the Regional Data
						  Manager.
3.
Check the appropriate reporting period and enter the
						  terminal digit for the year in space 3 on the FACE SHEET and the upper right
						  corner of each table.
4.
Attach an explanation to any table for
						  which:
a. sampling is used or estimates have been made;
						  and/or
b. the data is entered inconsistent with the
						  definitions/instructions used in the BCRR Instruction Manual. Contact the
						  Regional Data Manager if non-standard definitions are used.
5.
When submitting revisions of tables that have already
						  been sent to the Regional Office or submitting for the first time a table which
						  was omitted from a previous submission:
a. Submit only those tables which are being revised
						  (changed) or being submitted for the first time.
b. Indicate the reporting period for the revised
						  information on both the FACE SHEET and the table(s).
NOTE: The reporting period for the revised
						  information should match the reporting period indicated on the FACE SHEET. Do
						  not include tables with different due dates under one FACE SHEET;
c. Check the appropriate box (Initial Submission or
						  Revision) on the FACE SHEET and each table revised;
d. Where a small number of cells are being revised they
						  should be circled to avoid a re-keying of the entire table;
e. Follow the distribution schedule in 1
						  above.
(REV. 1/82)
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TABLE 1: NUMBER OF USERS BY TYPE OF
				PROVIDER, AGE AND SEX FOR THIS REPORTING PERIOD
AGE AND SEX
USERS* BY TYPE OF PROVIDER
MEDICAL
(a)
DENTAL
(b)
Female:
1)
0-4
2)
5-9
3)
10-14
4)
15-19
5)
20-34
6)
35-44
7)
45-64
8)
65 and over
9)
SUBTOTAL
(LINES 1 through 8)
Male:
10)
0-4
11)
5-9
12)
10-14
13)
15-19
14)
20-34
15)
35-44
16)
45-64
17)
65 and over
18)
SUBTOTAL
(LINES 10 through 17)
19)
TOTAL
(LINES 9 + 18)
*A user is an individual who has had one or more encounters
				during the reporting period covered by this table (January - June or January -
				December).
FREQUENCY OF REPORTING: Semi-annually unless otherwise
				instructed by the Regional Office. Data are reported on a calendar year-to-date
				basis from January first through the ending month of the reporting period (June
				30 or December 31).
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TABLE 2-A: UTILIZATION OF SPECIAL
				POPULATION GROUPS FOR THIS REPORTING PERIOD
NOTE: This table applies to any grantee servicing migratory
				and/or seasonal agricultural workers and their family members.
TYPE OF USER
MEDICAL USERS*
(a)
DENTAL USERS*
(b)
1) Migratory Agricultural Workers and Family
						  Members
2) Seasonal Agricultural Workers and Family
						  Members
*A user is an individual who has had one or more encounters
				during the reporting period covered by this table (January - June or January -
				December).
FREQUENCY OF REPORTING: Semi-annually unless otherwise
				instructed by the Regional Office. Data are reported on a calendar year-to-date
				basis from January first through the ending month of the reporting period (June
				30 or December 31).
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TABLE 2-B: NUMBER OF FAMILY PLANNING USERS
				BY TYPE OF USER AND AGE FOR THIS REPORTING PERIOD
NOTE: This table applies only to CH, FP, MH, and all other
				projects required by the Regional Office to report this table. Grantees which
				are required to submit this table but do no receive Title X funding should
				report all female Family Planning Users, regardless of income, on LINE
				1.
TYPE OF FAMILY PLANNING USER
FAMILY PLANNING USERS*
(a)
1) Women at or below 150% of Poverty
						  Level
2) Women above 150% of Poverty Level
3) Men
4) TOTAL (LINES 1+2)
Female Adolescent Users of Family Planning Services
						  (Subset of LINE 4)
5) Under 20 years old
6) 15-19 Year Olds
*A Family Planning user is an individual who has had one or
				more Family Planning Encounters (Medical or Other Health) during the reporting
				period covered by this table (January - June or January - December).
FREQUENCY OF REPORTING: Semi-annually unless otherwise
				instructed by the Regional Office. Data are reported on a calendar year-to-date
				basis from January first through the ending month of the reporting period (June
				30 or December 31).
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TABLE 3: PERSONNEL BY FUNCTIONAL COST
				CENTER AND ENCOUNTERS BY TYPE OF PROVIDER FOR THIS REPORTING
				PERIOD
PERSONNEL BY FUNCTIONAL COST CENTER*
STAFF* PERSONNEL EQUIVALENTS
ENCOUNTERS
Onsiite With Staff Providers
All Other (Including Offsite and Nonstaff)
(a)**
(b)***
(c)
(d)
MEDICAL SERVICES
(A)
1) Primary Care Physicians
2) Psychiatrists
3) Other Medical/Surgical Specialists
4) Midlevel Practitioners
5) Nurses -- Medical
6) Medical Support
ANCIL- LARY SERVICES
(B)
7) Laboratory-Medical
(C)
8) X-Ray-Medical
(D)
9) Pharmacy-Medical & Dental
DENTAL SERVICES
10) Dentists
(E)
11) Dental Hygienists/
Oral Therapists
12) Dental Support
OTHER HEALTH SERVICES
(G)
13) Education/Social Service
14) Other Health
15)
16) Other Health Support
SUPPORT SERVICES
(H)
17) Community Service
(I)
18) Environmental Health
(J)
19) Patient Transportation
20) Patient Records
CLINIC OVER- HEAD
(K)
21) Administration
(L)
22) Facility
23) TOTAL (LINES 1 through 22)
* Assign staff time by function performed, not title.
						  See instructions for this table.
** Include only NHSC personnel in Column (a).
*** Include salaried personnel, as well as the
						  personnel equivalents of any non-salaried personnel (contractual or donated)
						  who work for the grantee on a scheduled time basis. (See definition of
						  "Staff.") Include WIC, VISTA and volunteer staff, where
						  appropriate.
FREQUENCY OF REPORTING: Semi-annually unless otherwise
				instructed by the Regional Office. Data are reported on a calendar year-to-date
				basis from January first through the ending month of the reporting period (June
				30 or December 31).
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TABLE 4: HOSPITAL INPATIENT CARE BY TYPE
				OF ENCOUNTER FOR THIS REPORTING PERIOD
NOTE: To be completed by all primary care grantees/projects.
				Primary care grantees/projects include: CH, HC, and MH.
TYPE OF SERVICE
PATIENT ADMISSIONS BY PROJECT
						  STAFF
(a)
HOSPITAL INPATIENT ENCOUNTERS BY PROJECT
						  STAFF*
(b)
1) Pediatrics
2) Internal Medicine
3) Obstetrics
4) Other (Specify)
_____________
_____________
*Project staff include salaried, contracted or donated medical
				personnel, i.e., physicians and midlevel practitioners.
FREQUENCY OF REPORTING: Semi-annually unless otherwise
				instructed by the Regional Office. Data are reported on a calendar year-to-date
				basis from January first through the ending month of the reporting period (June
				30 or December 31).
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TABLE 5: SELECTED CLINICAL SERVICES FOR
				THIS REPORTING PERIOD
NOTE: Only applies to projects affected by Primary Care
				Effectiveness activity, as follows: CH, FP, HC and MH.
Clinical
User Category
Records Sampled
(a)
Records in Compliance
(b)
1)
Immunization
24-27 months
2)
Immunization
6 year olds
3)
Adolescent Family Planning
Counseling (under 20 years)
4)
Pap Smear Follow-up
5)
Hypertension Follow-up
(10 years and over)
6)
Anemia Screening
24-27 months
FREQUENCY OF REPORTING: Semi-annually (January 1 - June 30,
				July 1 - December 31)
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TABLE 6: COSTS BEFORE AND AFTER
				DISTRIBUTION BY FUNCTIONAL COST CENTER FOR THIS REPORTING PERIOD
NOTE: Grantees should complete this table as follows:
Annual: The entire table (LINES 1 through 13, COLS.
				a through g).
First six months (unless instructed by the Regional
				Office to report quarterly for the first three quarters): Complete all of LINE
				13, and the applicable cells of COLS. (f) and (g).
FUNCTIONAL COST CENTER
SALARIED PERSONNEL* (WORKSHEET A, COL. h)
OTHER (INCLUDING CONSULTANT AND CONTRACT
						  SERVICES)
VALUE OF DONATED MATERIAL & SERVICE**
TOTAL BEFORE DISTRIBUTION (COLS.
a + b + c + d)
TOTAL AFTER DISTRIBUTION OF FACILITY COSTS ***
						  (WORKSHEET B, COL. e)
TOTAL AFTER FINAL DIST. OF CLINIC OVERHEAD COSTS
						  (WORKSHEET B, COL. h)
(a)
(c)
(d)
(e)
(f)
(g)
HEALTH CARE FUNCTIONS
1)
Medical (A)
2)
Laboratory-Medical (B)
3)
X-Ray Medical (C)
4)
Pharmacy-Medical & Dental (D)
5)
Dental (inc. Lab & X-Ray) (E)
6)
Inpatient (F)
7)
Other Health (G)
8)
Community Service (H)
9)
Environment (I)
10)
Patient Transportation (J)
CLINIC OVERHEAD FUNCTIONS
11)
Administration (K)
- 0 -
12)
Facility (L)
- 0 -
- 0 -
13)
TOTAL (LINES 1 though 12)
*Include the costs of salaried personnel, including the costs
				of fringe benefits paid to employees (see TABLE 6 Worksheet A).
**Include the costs associated with donated personnel,
				including NHSC assignees. For NHSC personnel, include the reimbursable cost of
				the assignee(s), not the amount actually reimbursed to the Corps.
***Only the cells not shaded should be completed with the data
				transferred from Worksheet B.
NOTE: The distribution of PERSONNEL COSTS across from the
				functional areas should correspond to the distribution of STAFF PERSONNEL
				EQUIVALENTS shown in TABLE 3. For any individual whose time is split among two
				or more functions in TABLE 3, the same percentage split should be applied to
				personnel and consultant costs in this table.
All amounts should be rounded off to the nearest dollar.
CONSISTENCY CHECK:
LINE 13, COL. (e) = LINE 13, COL. (g)
FREQUENCY OF REPORTING: Semi-annually unless otherwise
				instructed by the Regional Office. Data are reported on a calendar year-to-date
				basis from January first through the ending month of the reporting period (June
				30 or December 31).
TABLE 6 WORKSHEET A: DISTRIBUTION OF
				PATIENT RECORDS COSTS AND FRINGE BENEFITS ACROSS FUNCTIONAL COST
				CENTERS
NOTE: If this Worksheet is used, it must be retained by the
				grantee.
It should not be submitted with TABLE 6.
DISTRIBUTION OF PATIENT RECORDS COSTS
DISTRIBUTION OF FRINGE
BENEFITS COSTS
Other Costs
Value of Donated Mat. & Svcs.
Total Before Distribution
FUNCTIONAL COST CENTERS
Number of Encounters
% of Total Encounters
Amount of Personnel Distrb. to Functions
Amount of Other Distrb. to Functions
Salaried Personnel Costs (inc. Col. C)
% of Total Salaries
Amount of Fringe Benefits Distrb. to Functions
Total Salaried Personnel Costs
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
(j)
(k)
HEALTH CARE FUNCTIONS
1) Medical (A)
2) Laboratory-Medical (B)
3) X-Ray - Medical (C)
4) Pharmacy-Medical & Dental (D)
5) Dental (Lab & X-Ray) (E)
6) Inpatient (F)
7) Other Health (G)
8) Community Service (H)
9) Environmental (I)
10) Patient Transportation (J)
11) Patient Records
( )
( )
CLINIC OVERHEAD FUNCTIONS:
12) Administration (K)
13) Facility (L)
14) Fringe Benefits
( )
15) TOTAL (LINES 1 though 14)
100%
-0-
-0-
100%
-0-
TABLE 6 WORKSHEET B:
DISTRIBUTION OF CLINIC OVERHEAD COSTS
				ACROSS HEALTH CARE COST CENTERS
NOTE: If this Worksheet is used, it must be retained by the
				grantee. It should not be submitted with TABLE 6.
FUNCTIONAL COST CENTERS
Total before Distribution
Worksheet A, Col (k)
DISTRIBUTION OF FACILITY COSTS
Total after Distrb. of Facility Costs
(a + d)
DISTRIBUTION OF ADMINISTRATION COSTS
Total after Final Distrb.
of Clinic Overhead Costs
(e + g)
Square Feet
of Space Used
% of Square
Footage
Amount of Facility Distrb. to Functions
% of Health Care Cost Subtotal
Amount of Admin. Distrb. to Functions
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
HEALTH CARE FUNCTIONS
1) Medical (A)
2) Laboratory -- Medical (B)
3) X-Ray -- Medical (C)
4) Pharmacy-Medical & Dental (D)
5) Dental (Lab & X-Ray) (E)
6) Inpatient (F)
7) Other Health (G)
8) Community Service (H)
9) Environmental (I)
10) Patient Transportation (J)
11) SUBTOTAL (LINES 1 through 10)
100%
CLINIC OVERHEAD FUNCTIONS:
12) Administration (K)
( )
-0-
13) Facility (L)
( )
-0-
-0-
14) SUBTOTAL (LINES 12 + 13)
15) GRAND TOTAL
100%
-0-
-0-
CONSISTENCY CHECKS:
1. COL. (a) equals TABLE 6: COL. (e)
2. COL. (e) equals TABLE 6: COL. (f)
3. COL. (h) equals TABLE 6: COL. (g)
4. LINE 15, COL. (a), COL. (e), COL. (h) should all be
						  equal.
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TABLE 7: ACCOUNTS RECEIVABLE, CHARGES AND
				COLLECTIONS BY SOURCE OF FUNDS FOR THIS REPORTING PERIOD
SOURCE OF FUNDS
ACCOUNTS RECEIVABLE AT BEGINNING OF THIS PERIOD
FULL CHARGES AND PREMIUMS DURING THIS PERIOD*
AMOUNT COLLECTED DURING THIS PERIOD
ADJUSTMENTS (identify below)**
ACCOUNTS RECEIVABLE AT END OF THIS PERIOD
(a)
(b)
(c)
(d)
(e)
1) Medicare (Title XVIII)
2) Medicaid (Title XIX)
3) Title XX
4) Other Third Parties
5) Patient Fees/Premiums
6) TOTAL (LINES
1+2+3+4+5)
*Charges or premiums prior to adjustments for
				patients' ability to pay, third party disallowances, etc. If Full
				Charges/Premiums are based upon a negotiated or contractual arrangement with a
				third party payor, and are not generally reflective of the costs of operation,
				footnote and explain below (name of third party, per unit, service, or
				capitation reimbursement rate or dollar limit).
**Breakdown of Adjustments by Type
DESCRIPTION
AMOUNT
7) Disallowances and Reductions (Contractual
						  Allowances)
$
8) Sliding Payment Scale Adjustments
$
9) Bad Debt Write Off
$
10) Other (Specify)
$
CONSISTENCY CHECKS:
1. COL. (e) should equal COL. (a) + COL. (b) - COL.
				(c) - COL. (d)
2. The amount entered in COL. (a) should equal the
				amount entered in COL. (e) of the TABLE 7 for the preceding calendar
				year.
When TABLE 7 is completed for the same reporting
				period as TABLE 8, then:
3. LINE 6, COL. (c) should equal TABLE 8: LINE 16
				COL. (a).
FREQUENCY OF REPORTING: Semi-annually unless otherwise
				instructed by the Regional Office. Data are reported on a calendar year-to-date
				basis from January first through the ending month of the reporting
				period.
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TABLE 8: SUMMARY OF RECEIPTS AND
				EXPENDITURES FOR THIS REPORTING PERIOD
NOTE: This table applies to grantee receipts and expenditures
				associated with services or activities in the approved application for BCHS
				funds, including those associated with delegate agency operations.
Grantees should complete this table as
				follows:
Annual: The entire table (LINES 1 through 23, COL.
				a).
First Six Months (unless instructed by the Regional
				Office to report quarterly for the first three quarters):
LINES 10, 16, 20 and 21 through 23, COL. (a).
Summary of Receipts and
						  Expenditures
Actual for Reporting Period
(a)
Federal Grants
1) Section 329 (Migrant Health)
2) Section 330 (Community Health Center)
3) MCH Block Grants*
4) Title X (Family Planning)**
5) Section 340 (Primary Care R & D)
6) Appalachian Health
7) Black Lung Clinic Program
8) WIC***
9) Other (Specify)****_____________
10) SUBTOTAL (LINES 1 through 9)
Payment for Services
11) Title XVIII (Medicare)
12) Title XIX (Medicaid)
13) Title XX
14) Other Third Parties
15) Patient Collections
16) SUBTOTAL (LINES 11 through 15)
Other Sources
17) State
18) Local
19) Other (Specify)**** _____________
20) SUBTOTAL (LINES 17 through 19)
Expenditures
21) Capital Expenditures
22) Non-Capital Expenditures*****
23) SUBTOTAL (LINES 21 + 22)
* Any form of State assistance through MCH
				Block
** Indicate Title X funds received directly from the
				Federal government or indirectly through a delegate agency type relationship on
				LINE 4. Indicate other Federal grants received directly or indirectly on LINE
				9.
*** Only include monies received for administration
				and operation of the WIC program, not the monies received for food. Do not
				include money spent on food on LINE 22.
**** Enter NHSC loans on LINE 19.
***** Include all actual expenditures by the grantee
				and its delegates on LINE 22. Payments made to the Federal government during
				the reporting period for the cost of NHSC assignees are entered on LINE
				22.
FREQUENCY OF REPORTING: Semi-annually unless otherwise
				instructed by the Regional Office. Data are reported on a calendar year-to-date
				basis from January first through the ending month of the reporting period (June
				30 or December 31).