Input, Activity, Output, or Outcome Measure/ Indicator Data Source Measurement Interval Data Collection Method Person Responsible What is the operational definition of the variable? How will it be systematically measured (percent of recommended home visits received, number of in the home, etc.)? What tool or method will be used to collect the data on a given measure (e.g., attendance logs, client self-report, etc.)? How frequently will the data be collected (e.g., every 6 months, at intake and 1 year etc.)? What format or method will you use (e.g., electronic data system, hard copy, etc.)? Who will record the data (e.g., home visitor, evaluator, etc.)? 1. 2. 3. 4. 5. 6. Analysis plan Describe your analysis plan for answering each of your research questions/hypotheses. If using quantitative analysis, include information on your selected statistical method for each planned comparison (i.e., descriptive and inferential statistics), and how each of the variables in 2.g above will be analyzed. If primarily qualitative data analysis, include discussion of plans for data reduction (i.e., coding, defining themes and patterns), testing validity (i.e., triangulation, validation procedures), and qualitative data analysis software to be utilized. If you will be utilizing a consultant for your data analysis, please describe your plan for the data analysis consultation process. Tribal Oversight and Institutional Review Board Requirements and Plan Documentation of Office of Subjects Protection approved Federal-wide Assurance (see ).The Federal-wide Assurance (FWA) is an assurance of post-
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 Total Sum of Column C (all rows) Table 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 Total (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 Other 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 Staff Number of FTE MIECHV Vacancies (A+B+C) (Auto-Calculate)
All Continuing Adult Participants (Auto Calculate) All Adult Participants (Auto Calculate) Index Children Has access to IHS, CHS, or UIHP facility Does not have access to IHS, CHS, or UIHP facility Total Not Insured (Auto Calculate) Medicaid or CHIP TriCare Private Insurance not Report Insured (Auto Calculate) Total Newly Enrolled Female Index Children Enrolled Male Index Children All Newly Enrolled Index Children (Auto Calculate) Continuing Female Index Children Continuing Male Children All Continuing Index Children (Auto Calculate) All Index Children (Auto Calculate) A.1 NOTES:
A.2: Participant Demographics during Reporting Period (Newly Enrolled Only) Table 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) Table 10. Participants by Ethnicity (Newly Enrolled) Participants Hispanic or Latino Not Hispanic or Latino Unknown/Did not Report Pregnant Women Female Caregivers Male Caregivers All Adults (Auto Calculate) Female Index Children Male Index Children All Index Children (Auto Calculate) 34
SECTION B: PROGRAM STAFF DEMOGRAPHICS 20. Program Staff by Age Program Staff ≤29 30-39 40-49 50-64 ≥65 Unknown/ Did not Report Home Visitors Project Directors/ Managers/Coordinators All Staff (Auto Calculate) 21. Program Staff by Gender Program Staff Female Male Unknown/Did not Report Total Home Visitors Project Directors/ Managers/Coordinators All Staff (Auto Calculate) Table 22. Program Staff by Ethnicity Program Staff Hispanic or Latino Not Hispanic or Latino Unknown/Did not Report Total Home Visitors Project Directors/ Managers/Coordinators All Staff (Auto Calculate) Table 23. Program Staff by Race Program American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White More than one race including AI/AN More than one race not including AI/AN not Report Home Visitors Project Directors/ Managers/ Coordinators All Staff (Auto Calculate)