Muscatine $55,986.00 $10,904.00 Osceola $4,838.00 Page $11,268.00 Palo Alto $5,199.00 Plymouth $18,270.00 Polk $415,029.00 Pottawattamie $90,716.00 Poweshiek $23,239.00 Ringgold $4,342.00 Scott $194,963.00 Sioux $29,116.00 Story $107,721.00 Tama $20,996.00 Taylor $5,982.00 Union $14,293.00 Warren $34,500.00 Washington $21,009.00 Webster $41,183.00 Woodbury $133,651.00 Wright $12,615.00 Exhibit 3 FAMILY PLANNING COUNCIL OF IOWA 2014 FEDERAL POVERTY GUIDELINES FOR TITLE X – SLIDING FEE SCALE Poverty Levels 0 - 100% 101 - 150% 151 - 200% 201 - 250% 250+ Family Size Income 1 Person Weekly $0 – 224 $225 – 337 $338 – 449 $450 – 561 $562 and up Monthly $0 – 973 $974 - 1,459 $1,460 - 1,945 $1,946 - 2,431 $2,432 and up Annual $0 – 11,670 $11,671 - 17,505 $17,506 - 23,340 $23,341 - 29,175 $29,176 and up 2 Persons Weekly $0 – 303 $304 – 454 $455 – 605 $606 – 756 $757 and up Monthly $0 – 1,311 $1,312 - 1,966 $1,967 - 2,622 $2,623 - 3,277 $3,278 and up Annual $0 - 15,730 $15,731 - 23,595 $23,596 - 31,460 $31,461 - 39,325 $39,326 and up 3 Persons Weekly $0 – 381 $382 – 571 $572 -761 $762 – 951 $952 and up
Clinic Site Male Services Adolescent Services HIV Services Basic Infertility Services GYN Conditions Health Promotion/Disease Prevention Preconception Health Services Legend 1 = Provided on-site 3 = Referral outside clinic, but paid for by Title X 2 = Reserved for Grantee Use Only 4 = Not provided at clinic site Attachment H Agency Name: SERVICES PROVIDED within the Title X Project (page 3) Clinic Site FERTILITY REGULATION IUD/IUS 3 Month Hormonal Injection Oral Contraceptives Hormonal/ Contraceptive Patch Vaginal Ring Cervical Cap/ Diaphragm Emergency Contraception
Select material for Community Education Presentations which are current, relevant, and medically accurate Community Education Staff 7/1/15-6/30/16 Presentations reflect identified and use current, relevant, medically accurate material Document sources of material used in Community Education Presentations Community Education Staff 7/1/15-6/30/16 Written documentation of sources used Sample K1 SAMPLE FAMILY PLANNING COUNCIL OF IOWA County Specific Workplan – Clinical Agency Name:__Good Guys Inc.__________ County:___Polk_______________ TYPE OF OBJECTIVE – CLINICAL Will agency have a clinic site in this county: yes no. If yes, please complete the following objectives for this county only. OBJECTIVE ACTIVITY PERSON(S) RESPONSIBLE TIME FRAME EVALUATION MECHANISM 1,000 females will receive family planning services. Provide a of family planning clinical services to females a broad range of contraceptives Establish clinic that include non-traditional hours for working family planning clients. Staffing: Clinical Program Director Program Director 7/1/15-6/30/16 7/1/15-6/30/16 7/1/15-6/30/16 Data report identifies # of females received services Pharmaceutical inventory shows a broad range of contraceptives Clinic schedules expanded hours
staff on how to counsel minors on family involvement Goal 3: By June 30, 2016, utilize Health Information Technology (HIT) in Title X service sites OBJECTIVE ACTIVITY PERSON(S) RESPONSIBLE TIME FRAME EVALUATION MECHANISM Electronic billing system in use Electronic Health Records in use Other HIT systems in use Receive funding for meaningful use TYPE OF OBJECTIVE – CLINICAL Goal 1: By June 30, 2016 ensure the availability of clinical family planning services for low income Iowans