HRSA Patient Navigator Demonstration Program
Quarterly Report Form (DRAFT)
Introduction to the Quarterly Report
These are draft instructions. Do not train staff with this document until drafts have been finalized. Revisions may be made to improve form/data entry screen layout and the clarity of instructions. A final version of this document will be released no later than May 2011. Suggestions for improvements are welcome. |
The Quarterly Report allows for the recording of data that need to be collected and reported to HRSA on a quarterly basis. Submissions will be due on the 5th of the month in the month following the end of the quarter. The first required submission will cover the first year of the grant, and will be due on October 5, 2011. Information for each of the quarters after the first year must be updated by 5th of the month following the end of the quarter. If the 5th falls on a weekend or holiday, the quarterly report submission will be due the next regular business day.
Grantees may choose to record these data at the end of the reporting period, or may choose to update them throughout the reporting period (e.g., updating the Outreach Activity table after each event occurs). Data may be cut-and-pasted from completed Quarterly Report electronic documents, or may be key-entered directly into the online database.
Using the Quarterly Report document. You are welcome to customize and otherwise modify the formatting of the Quarterly Report document. For example, you may choose to highlight options under required elements (categories) applicable to your site, or to delete those that are not applicable. However, you are responsible for the information on the form, so take care to avoid deleting required data elements. Since the data entry screen on the online database will mirror this data entry form, major changes are likely to cause increased data entry effort. If there is doubt about whether a specific modification may cause problems, please contact NOVA.
Please email any questions or concerns regarding these instructions or the form to Debra Stark dstark@novaresearch.com and Caroline McLeod cmcleod@novaresearch.com.
Quarterly Report Form: Staffing (DRAFT)
Site |
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Year: |
2011 2012 2013 2014 |
Quarter: |
Q1 (Jan-Mar) Q2 (Apr-Jun) Q3 (Jul-Sep) Q4 (Oct-Dec) |
Number of Patient Navigator FTEs
Number of Full-Time Navigators (30+ hours/week)
Number of Part-Time Navigators (<30 hours/week)
Number of Navigators joing the program (new hires)
Number of Navigators leaving the program (resigned/fired)
Quarterly Report Form: Navigation Trainings and Meetings (DRAFT)
Site |
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Year: |
2011 2012 2013 2014 |
Quarter: |
Q1 (Jan-Mar) Q2 (Apr-Jun) Q3 (Jul-Sep) Q4 (Oct-Dec) |
Date |
Type |
Length (hrs) |
Description |
# Attendees |
# PNs Attended |
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Quarterly Report Form: Outreach Activities (DRAFT)
Site |
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Year: |
2011 2012 2013 2014 |
Quarter: |
Q1 (Jan-Mar) Q2 (Apr-Jun) Q3 (Jul-Sep) Q4 (Oct-Dec) |
Date |
Type |
Disease Focus |
Location |
Population |
# receiving outreach |
if applicable, # screening positive |
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Quarterly Report Form: Lessons Learned (DRAFT)
Site |
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Year: |
2011 2012 2013 2014 |
Quarter: |
Q1 (Jan-Mar) Q2 (Apr-Jun) Q3 (Jul-Sep) Q4 (Oct-Dec) |
Date |
Challenge |
Action Taken |
Lesson Learned |
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Quarterly Report Form: Notable Cases (DRAFT)
Site |
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Year: |
2011 2012 2013 2014 |
Quarter: |
Q1 (Jan-Mar) Q2 (Apr-Jun) Q3 (Jul-Sep) Q4 (Oct-Dec) |
Date |
Description of Notable Case |
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Quarterly Report Form: Media Coverage (DRAFT)
Site |
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Year: |
2011 2012 2013 2014 |
Quarter: |
Q1 (Jan-Mar) Q2 (Apr-Jun) Q3 (Jul-Sep) Q4 (Oct-Dec) |
Date |
Description of Coverage |
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Quarterly Report Form: Technical Assistance (DRAFT)
Site |
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Year: |
2011 2012 2013 2014 |
Quarter: |
Q1 (Jan-Mar) Q2 (Apr-Jun) Q3 (Jul-Sep) Q4 (Oct-Dec) |
Date |
Description of Issue Requiring Technical Assistance |
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Instructions for Completing the Quarterly Report Form (DRAFT)
These are draft instructions. Do not train staff with this document until drafts have been finalized. Revisions may be made to improve form/data entry screen layout and the clarity of instructions. A final version of this document will be released no later than May 2011. Suggestions for improvements are welcome. |
The data included on the Quarterly Report document must be completed and submitted quarterly.
Staffing
This table should be used to record current staffing at the site and to describe any changes during the current reporting period.
Site Enter the name of the site.
Year Circle the year component of the current reporting period.
Quarter Circle the quarter component of the current reporting period.
Patient Navigator FTEs Enter the number of Full-Time Equivalent Navigators currently assigned to the Navigation Program. This should represent the staffing at the end of the current reporting period.
Full-Time Navigators Enter the number of Navigators who are currently working at least 30 hours/week on this project. For example, a Navigator who is a full-time employee at the organization, but only works 10 hours/week on this project would not be counted here.
Part-Time Navigators Enter the number of Navigators who are currently working less than 30 hours/week on this project. For example, a Navigator who is a full-time employee at the organization, but only works 10 hours/week on this project would be counted here.
Joining the program Enter the number of navigators who were new to the project during the current reporting period. A navigator who has been working at the organization for the past year, but was assigned to this project during the current reporting period would be counted here.
Leaving the program Enter the number of navigators who left the project during the current reporting period. Navigators who are still employed by the organization but are no longer associated with the project would be counted here.
Navigation Training and Meetings
This table should be used to record all trainings and meetings that occurred at the site during the current reporting period. Meetings repeated weekly or monthly should be entered once on the date of the first meeting, with a description indicating that the meeting was repeated for the particular time interval.
Site Enter the name of the site.
Year Circle the year component of the current reporting period.
Quarter Circle the quarter component of the current reporting period.
Date Enter the date the training or meeting occurred. For multi-day events, enter the first day. If the meeting or training spans the end of one reporting period and the beginning of the next, record it for the reporting period in which the event started.
Type Enter a description of the type of training or meeting.
Length (hrs) Record the total number of hours associated with this event.
Description Enter a description of the content of the training or meeting.
Attendees Record the total number of attendees.
PNs Attended Record the total number of project navigators who attended—only navigators assigned to this project should be counted here.
Outreach Activities
This table should be used to record all outreach activities that occurred at the site during the current reporting period.
Site Enter the name of the site.
Year Circle the year component of the current reporting period.
Quarter Circle the quarter component of the current reporting period.
Date Enter the date of the activity. For multi-day events, enter the first day. If the meeting or training spans the end of one reporting period and the beginning of the next, record it for the reporting period in which the event started.
Type Record the Type of activity. If Other is selected, please specify the other type of activity. Please indicate the type of activity rather than the name of a specific event.
Disease Focus Record the disease focus of the activity; multiple foci may be entered.
Location Record the location of the activity. If Other is select, please specify the other location type. Please indicate the type of location rather than the name of a specific location.
Population Describe the target population for the activity
# receiving outreach Record the number of individuals who received outreach
# screening positive If applicable, record the number of individuals who screened positive for services.
Lessons Learned
This table should be used to record any noteworthy lessons learned or challenges faced at the site during the current report period. These include any changes in staffing, resources, or procedures made to address specific issues impacting patient care. For example, program staff may have created a new link to a community organization to obtain needed services, or may have negotiated new clinic procedures that are more patient-friendly.
Site Enter the name of the site.
Year Circle the year component of the current reporting period.
Quarter Circle the quarter component of the current reporting period.
Challenge Describe the challenge.
Action Taken Describe the action taken to address the challenge. If no action has been taken yet, indicate this.
Lesson Learned Describe the lesson learned, if any.
Notable Cases
This table should be used to record one or two notable cases encountered at the site during the current report period. Ideally, cases should exemplify how the impact of the program is related to the most common or difficult barriers encountered by patients in your area.
Site Enter the name of the site.
Year Circle the year component of the current reporting period.
Quarter Circle the quarter component of the current reporting period.
Description Describe the case including what was noteworthy about the case and what, if any, effects this case had on procedures at the site.
Media Coverage
This table should be used to record any media coverage of the program during the current reporting period.
Site Enter the name of the site.
Year Circle the year component of the current reporting period.
Quarter Circle the quarter component of the current reporting period.
Date Date of coverage.
Description Describe the coverage, including type and content.
Technical Assistance
This table should be used to record any issues requiring technical assistance. Please indicate whether the issues were addressed, or whether additional assistance is needed.
Site Enter the name of the site.
Year Circle the year component of the current reporting period.
Quarter Circle the quarter component of the current reporting period.
Date Date issue identified.
Description Describe the issue requiring technical assistance. If the issue has been resolved, please include a brief description of the
| File Type | application/msword |
| Author | Debra Stark |
| Last Modified By | HRSA |
| File Modified | 2011-06-14 |
| File Created | 2011-06-14 |