Based on the information in the table above, identify the “at-risk tribal community” or communities that will be served as part of your program. Please note: your at-risk tribal community (or communities) could be the same as the targeted community (or communities) that was assessed. You may define an at-risk tribal community in the following ways: A tribe or tribes within a discrete geographic region (e.g., on a reservation, Tribal Jurisdictional Service Area, Alaska Native village) Subgroups or communities of a or tribes within a discrete geographic region Members of a tribe(s) scattered throughout a larger, non-tribal geographic area interspersed with non-tribal members (e.g., AIAN living in an urban environment) For the identified at-risk tribal community or communities, discuss the needs, strengths, and priorities that stand out and how these are likely to influence your program vision, goals, objectives, and design Organizational Capacity and Readiness Assessment Assess your organization’s capacity to respond to the identified needs of the community through a high quality, culturally appropriate, evidence-based home visiting program. Assess your organization’s readiness and identify any administrative and organizational concerns that must be addressed prior to program implementation. Areas within your organization to consider include (but are not limited to) the following. Leadership and Governance Describe the leadership or governance structure in place in your tribe or organization Describe how home visiting programs would or do fit into the broader structure, including a current organizational chart Describe how this structure receives input from key stakeholders Management Practices Discuss current management practices within your tribe or organization that are or would be applicable to your home visiting program Human Resources Describe organizational hiring practices and the extent to which they would or do support the ability to respond quickly and effectively to home visiting program staffing needs Financial Resources Describe how the organization ensures sound fiscal management practices
Number of New Households Enrolled Number of Continuing Households Current Caseload (A+B) (Auto-Calculate) Maximum Service Capacity Capacity Percentage (C÷D) (Auto-Calculate) Table A.2: Place-Based Services Add a row for each additional community served during the reporting period. Column A Column B Column C Community Zip Codes within Community Number of Households Served Sum of Column C (all rows) A.3: Family Engagement Column A Column B Column C Column D Column E Column F Number of Households Currently Receiving Services Number of Households who Completed Program Number of Households who Stopped Services Before Completion Other (A+B+C+D) Attrition Rate (C÷E) Table A.4.1: Staff Recruitment and Retention Column A Column B Column C Column D Column E Column F Column G Column H Column I of New FTE Number of FTE Number of FTE Home Number of New FTE Number of FTE Number of FTE of New FTE Number of FTE Number of FTE Staff Calculate) Calculate)
Home Visitors Home Visitors Visitors (A+B) (D+E) Other Staff Other Staff (G+H) Table A.4.2: Staff Vacancies Column A Column B Column C Column D Number of Vacant FTE MIECHV Home Visitors Number of Vacant FTE MIECHV Supervisors Number of Vacant FTE MIECHV Other Staff Number of FTE MIECHV Staff Vacancies (A+B+C) (Auto-Calculate)
Continuing Male Caregivers All Continuing Adult Participants (Auto Calculate) All Adult Participants (Auto Calculate) Children Has access to IHS, CHS, or UIHP facility Does not have access to IHS, CHS, or UIHP facility Not Insured (Auto Calculate) Medicaid or CHIP TriCare Private Insurance not Report Total Insured (Auto Calculate) Total Newly Enrolled Female Index Children Newly Enrolled Male Index Children All Enrolled Index Children (Auto Calculate) Continuing Female Index Children Continuing Male Index Children All Continuing Children (Auto Calculate) All Children (Auto Calculate)
A.1 NOTES: A.2: Participant Demographics during Reporting Period (Newly Enrolled Only) 9. Adult Participants by Age (Newly Enrolled) Adult Participants ≤17 18-19 20-21 22-24 25-29 35-44 45-54 55-64 ≥65 not Report Total Pregnant Women Female Caregivers Male Caregivers All Adults (Auto Calculate) 10. Participants by Ethnicity (Newly Enrolled) Participants Hispanic or Latino Not Hispanic or Latino Unknown/Did not Report Total Pregnant Women Female Caregivers Male Caregivers All Adults (Auto Calculate) Female Index Children Male Index Children All Index Children (Auto Calculate) 34
11. Participants by Race (Newly Enrolled) Participants American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White More than one race including AI/AN More than one race not including AI/AN Unknown/Did not Report Total Pregnant Women Female Caregivers Male Caregivers All Adults (Auto Calculate) Female Index Children Male Children All Index Children (Auto Calculate) Table 12. Adult Participants by Marital Status (Newly Enrolled) Adult Participants Single Legally Married Not married but living together with partner Unknown/Did not Report Total Pregnant Female Caregivers Male Caregivers All Adults (Auto Calculate) Table 13. Adult Participants by Educational Attainment (Newly Enrolled) Adult Participants Less than HS diploma HS GED Some college/ training Technical training or certification Associate’s Degree Bachelor’s Degree or higher Other not Report Total Pregnant Female Caregivers Male Caregivers
24. Program Staff by Educational Attainment Program Staff Less than HS Diploma HS Diploma /GED Some college/ training Technical training or certification Associate’s Degree Bachelor’s Degree Master’s Degree or Higher Other Unknown/ Did Not Report Total Home Visitors Project All Staff (Auto Calculate) Table 25. Unduplicated Count of Home Visiting Staff Full Time Equivalents Home Visiting Program Staff Number Number of FTE Home Visitors Number of FTE Project Directors /Managers/Coordinators All Tribal MIECHV Staff FTE (Auto Calculate) SECTION B NOTES:
Tribal MIECHV Form 1 Instructions Data for Tribal MIECHV Form 1: Demographic and Service Utilization Data should be collected at enrollment (as defined by grantee or per model developer guidelines) for newly enrolled participants/households and once during the reporting period (as determined by grantee) for continuing participants/households. Grantees may determine the method of and individuals responsible for data collection based on their own policies and procedures, and as guided by model developers and in consultation with ACF. Technical assistance is available to grantees to determine the method and timing of data collection and to ensure high quality data collection and reporting. The form is organized into two sections. Section A includes Participant Demographics and Service Utilization and contains three sub-sections (A.1: Participant Demographics during Reporting Period (Newly Enrolled and Continuing); A.2: Participant Demographics during Reporting Period (Newly Enrolled Only); and A.3 Participant Service Utilization during Reporting Period (Newly Enrolled and Continuing)) and requests demographic and service utilization data for program participants and households, which will be used to help ACF better understand the population receiving services from Tribal MIECHV grantees and the degree to which they are using services. Section B includes Program Staff Demographics and requests information on demographics of program staff, which will be used by ACF to better understand the Tribal MIECHV workforce. All information is collected to support improved knowledge of Tribal MIECHV grantee programs and guide technical assistance provided through the cooperative agreement. After each sub-section, the form includes a “Notes” field. Grantees should use this field to explain the reasons for missing data if more than 10 percent of data are missing (i.e., Unknown/Did Not Report) for a particular data element, and to provide any other contextual information that may be helpful to ACF in understanding the data reported. For each explanation of missing data, include the Table number for ease of reference.