Form Approved OMB No.0990-XXX Exp. Date xx/xx/2017
PAPERWORK REDUCTION ACT (PRA) PUBLIC BURDEN STATEMENT
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-XXXX. The time required to complete this information collection is estimated to average XX hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OIRM/PRA, 200 Independence Ave., S.W., Suite 336–E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.
Performance Measure |
Performance Question |
All Grantees |
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0.01 Number and percentage distribution of eligible participants enrolled in the program, by participant category |
How many eligible participants received at least one activity? Indicate the total number in each category below.
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0.02 Number and percentage distribution of non-participant extended family members |
How many non-participant extended family members received at least one activity? Indicate the number served in each category.
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0.03 Number and percentage distribution of expectant and parenting participants, by age group |
What is the age of expectant and parenting participants? Indicate the total number in each category below.
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Performance Measure |
Performance Question |
0.04 Number and percentage distribution of expectant and parenting participants, by Hispanic or Latino ethnicity |
What is the ethnicity of expectant and parenting participants? Indicate the total number in each category below.
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0.05 Number and percentage distribution of expectant and parenting participants, by race |
What is the race of expectant and parenting participants? Indicate the total number in each category below.
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0.06 Number and percentage distribution of expectant and parenting participants that is limited English proficient (report speaking English not well or not at all) |
How well do expectant or parenting participants speak English? Indicate the total number in each category below.
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0.07 Number and percentage distribution of expectant and parenting participants, by their current relationship status
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What is the current relationship status of expectant and parenting participants?
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Performance Measure |
Performance Question |
0.08 Number of expectant and parenting participants, by their current living arrangement at program entry |
What is the current living arrangement of expectant and parenting participant? Indicate the total number in each category.
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0.09 Number of expectant and parenting female participants that receives (in the last 4 weeks) financial or social support for themselves or their (youngest) child from the child’s father
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How many expectant or parenting female participants received any financial or social support for themselves or their (youngest) child from the child’s father in the last 4 weeks? Indicate the total number in each category:
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0.10 Number of expectant and parenting male participants that provides (in the last 4 weeks) financial or social support for their (youngest) child or the child’s mother
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How many expectant and parenting male participants provided financial or social support for their (youngest) child or the child’s mother in the last 4 weeks? Indicate the total number in each category:
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Performance Measure |
Performance Question |
0.11 Number of expectant and parenting participants and their dependent children that received services directly from program staff, by type of services received
(NOTE: Category 3 grantees should enter any services for Violence Against Women in question 3.1) |
How many expectant and parenting participants received any of the following services directly from program staff? Indicate the number in each category below.
|
Performance Measure |
Performance Question |
0.12 Number of expectant and parenting participants and non-participant extended family members that were referred for service(s) by program staff, by type of service referrals offered (NOTE: Category 3 grantees should enter any services for Violence Against Women in question 3.1) |
How many expectant and parenting participants and non-participant extended family members were referred by program staff at least once for any of the following services? Indicate the number referred in each category below.
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0.13 .Number of extended family members of expectant and parenting participants that were referred for service(s) by program staff 1) |
How many extended family members of the expectant and parenting participants were referred by program staff at least once for any services? Indicate the total number referred. (Extended family members may include any family member who is not eligible for services, such as the participants’ parents, legal guardians, grandparents)
|
Performance Measure |
Performance Question |
0.14 Number of new staff that receive initial training from the grantee or project partners |
How many new staff (including teachers, facilitators, and human service professionals) has received initial training from the grantee or project partners? Please include only training provided to new staff.
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0.15 Number of existing staff that receive supplemental or follow-up training from the grantee or project partners |
How many existing staff (including teachers, facilitators, and human service professionals) has received supplemental or follow-up training from the grantee or project partners? Please include only training provided to existing staff.
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0.16 Number of implementation partners with which the grantee has a formal or informal agreement to plan, coordinate, or implement project activities |
How many formal and informal implementation partners currently involved in project planning, coordination, or implementation? Indicate the number in each category below.
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0.17 Number of formal and informal implementation partners that remains engaged for the entire program year
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Of the formal and informal implementation partners that were engaged at the beginning of the program year, how many were still engaged at the end of the program year?
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Category 1 Grantee Programs Only: (Grantees Working with Institutions of Higher Education (IHEs)): Programs will need to measure IHE enrollment at the beginning of each quarter/semester so that they can track IHE graduation and continuation rates
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Performance Measure |
Performance Question |
1.1 Number and percentage distribution of expectant and parenting IHE student participants, by type of Institution of Higher Education (IHE) where they are enrolled
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How many expectant and parenting IHE student participants does the program serve?? Indicate the number for each category below.
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Performance Measure |
Performance Question |
1.2 Number and percentage of expectant and parenting IHE student participants that graduates from the IHE
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How many expectant and parenting IHE student participants graduated from the IHE? Indicate the number for each category below.
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1.3 Number and percentage of expectant and parenting IHE student participants that enrolls in the next semester or quarter of classes
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How many expectant and parenting IHE student participants are enrolled in the next semester or quarter of classes? Indicate the number for each category below.
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1.4 Number of parenting IHE student participants 19 years and younger that reports a new pregnancy during the program year |
How many parenting IHE student participants 19 years and younger reported a new pregnancy during the program year? |
Category 2 Grantee Programs Only (Grantees Working with High Schools or Community Service Centers) Programs will need to measure HS enrollment at the beginning of the school year so that they can track HS drop out and graduation rates For GED students program will need to track GED program enrollment and completion throughout program year because of the flexible nature of GED programs and testing |
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Performance Measure |
Performance Question |
2.1 Number and percentage distribution of expectant and parenting participants, by high school enrollment status and grade level |
What is the number of expectant and parenting participants by their high school enrollment status? Indicate the number for each category below.
|
Performance Measure |
Performance Question |
2.2 Number and percentage of expectant and parenting high school students served that drops out during the school year |
How many expectant and parenting high school students served dropped out of high school during the school year? |
2.3 Number and percentage of expectant and parenting high school seniors served that graduates at the end of the school year |
How many expectant and parenting students served who were high school seniors at enrollment or at the beginning of the program year that graduated from high school at the end of the school year? |
2.4 Number and percentage of expectant and parenting participants that passes the GED exam during the program year |
How many expectant and parenting participants passed the GED exam during the program year?
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2.5 Number and percentage of expectant and parenting participants who either graduate from high school or obtain a GED that is accepted into an IHE during the program year |
How many expectant and parenting participants who either graduated from high school or obtained a GED that are accepted into an IHE? |
2.6 Number of parenting participants 19 years and younger that reports a new pregnancy during the program year |
How many parenting participants 19 years and younger reported a new pregnancy during the program year?
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Category 3 Grantee Programs Only (Grantees who are Working with Women who have Experienced Stalking, Sexual Assault, or Intimate Partner Violence.) The target population is defined by legislation as expectant and parenting females who are victims of stalking, sexual assault, or Intimate Partner Violence |
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Performance Measure |
Performance Question |
3.1 Number of individuals from government, private nonprofit, and other agencies serving victims of stalking, sexual assault, and intimate partner violence (IPV) that receives training related to violence against expectant and parenting teens and women
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How many individuals from government, private nonprofit, and other agencies serving victims of stalking, sexual assault, and IPV received training on violence against expectant and parenting teens and women? |
3.2 Number of expectant and parenting female participants who are victims of IPV, sexual violence, sexual assault, or stalking that receives any intervention or supportive social services (such as shelter referral, individual, or group counseling, etc.) through the program |
How many expectant and parenting female participants who are victims of IPV, sexual violence, sexual assault, or stalking received any of the following services directly through the program? Indicate the number in each category below.
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Category 4 Grantee Programs Only (Grantees who are Increasing Public Awareness and Education)
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Performance Measure |
Performance Question |
4.1 Number and type of public awareness campaigns or education strategies that are implemented by the program, by type
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How many public awareness or education strategies were implemented by the program during the reporting period? Indicate the number in each category below.
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Optional Measures for Grantees: The measures in Section 5 are included for consideration by those grantees whose programs focus specifically on providing any of these services. Grantees may select any of these measures to monitor program performance or create additional measures that are specific to their programs. Grantees are not required to collect or report any of these measures to the Office of Adolescent Health. |
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Performance Measure |
Performance Question |
5.1 Access to Prenatal Care for Expectant Teens or Women Participating in the Program |
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5.11 Number and percentage of expectant female participants who enroll in the program during their first trimester that receives at least one prenatal visit during the first trimester |
How many expectant female participants who enrolled in the program during their first trimester received at least one prenatal visit during the first trimester of the pregnancy?
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5.2 Reproductive Health |
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5.2.1
Number and percentage of female participants who gave birth during the program year and are at risk of unintended pregnancy (i.e., sexually active and not seeking pregnancy) that reports postpartum use of a long-acting reversible contraceptive (i.e., implant or IUD) |
What kind of birth control methods are parenting female participants who gave birth during the program year and are at risk of unintended pregnancy or their husbands/partners currently using to keep from getting pregnant? If a participant uses more than one type, choose the most effective method. Methods are listed from most effective (sterilization) to least effective (no method).
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5.2.2: Number of parenting female participants 19 years and younger that receives any reproductive health service directly from program staff (grantee or partner)
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How many parenting female participants 19 years and younger received any reproductive health service directly from program staff (grantee or partner)? |
Performance Measure |
Performance Question |
5.2.3: Number of parenting male participants 19 years and younger that receives any reproductive health service directly from program staff (grantee or partner) |
How many parenting male participants 19 years and younger received any reproductive health service directly from program staff (grantee or partner)? |
5.2.4: Number of parenting female participants 20 years and older that receives any reproductive health service directly from program staff (grantee or partner) |
How many parenting female participants ages 20 and older received any reproductive health service directly from program staff (grantee or partner)? |
5.2.5: Number of parenting male participants20 years and older that receives any reproductive health service directly from program staff (grantee or partner) |
How many parenting male participants ages 20 and older received any reproductive health service directly from program staff (grantee or partner)? |
5.3 Birth Outcomes for Expectant Teens and Women Participating in the Program Grantee may wish to consider these optional outcome measures if they are implementing activities aimed at preventing adverse birth outcomes, specifically low birth weight and prematurity |
|
Performance Measure |
Performance Question |
5.3.1 Number and percentage of female participants that reports the birth of an infant that is low birth weight (less than 5 lbs., 8 oz.) while participating in the program |
How many female participants report the birth of an infant that is low birth weight (less than 5 lbs., 8 oz.) while participating in the program? |
5.3.2 Number and percentage of female participants that reports the birth of an infant that is very low birth weight (less than 3lbs., 4oz.) while participating in the program |
How many female participants report the birth of an infant that is very low birth weight (less than 3 lbs., 4 oz.) while participating in the program? |
5.3.3 Number and percentage of female participants that reports the birth of an infant that is premature (less than 37 weeks gestation) while participating in the program |
How many female participants report a premature birth (less than 37 weeks gestation) while participating in the program? |
5.3.4 Number and percentage of female participants that reports the birth of an infant that is very premature birth (less than 32 weeks of gestation) while participating in the program
|
How many female participants report a very premature birth (less than 32 weeks gestation) while participating in the program? |
5.4 Parenting Outcomes Grantee may wish to consider these optional outcome measures if they are implementing activities specifically aimed at improving these specific parenting outcomes |
|
Performance Measure |
Performance Question |
5.4.1 Number and percentage of expectant female participants that receives information on the benefits of breastfeeding |
How many expectant female participants received information on the benefits of breastfeeding? |
5.4.2 Number of postpartum and parenting female participants who give birth during the program year that reports ever breastfeeding their new baby |
How many postpartum and parenting female participants who give birth during the program year reported ever breastfeeding their new baby? |
5.4.3 Number of expectant and parenting female participants who have a child or children 0 to 5 years of age that reports that they or someone in the family reads to the child or children every day
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How many expectant and parenting female participants who have a child or children 0 to 5 years of age reported that they or someone in their family reads to the child or children every day? |
Performance Measure |
Performance Question |
5.5 Child Outcomes These measures are optional and are included for consideration for grantees that are implementing activities aimed at improving health outcomes, developmental outcomes or access to child care for children |
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5.5.1 Number of children (of parenting participants) 9 years and younger that is enrolled in licensed child care during the program year |
How many children (of parenting participants) 9 years and younger are enrolled in a licensed child care program during the program year? |
5.5.2 Number of children (of parenting participants) 4 years and younger that is enrolled in a preschool program during the program year |
How many children (of parenting participants) 4 years and younger are enrolled in a preschool program (such as Head Start, private pre-Kindergarten program) during the program year? |
5.5.3 Number of children (of parenting participants) that receives at least one well-child visit during the program year |
How many children (of parenting participants) received at least one well-child visit while in the program by self-report during the program year? |
5.5.4 Number and percentage of children (of parenting participants) that has at least one emergency care, urgent care, or hospital visit for an injury or ingestion during the program year |
How many children (of parenting participants) had at least one emergency care, urgent care, or hospital visit for an injury or ingestion during the program year? |
5.5.5 Number of parenting participants with children 0 to 12 months of age that reports using rear-facing child safety seats |
How many parenting participants with children 0 to 12 months of age report using a rear-facing child safety seat?
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5.6 Outcomes Related to Family Self-sufficiency These measures are optional and are included for consideration for grantees that are implementing activities aimed at increasing family self-sufficiency |
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Performance Measure |
Performance Question |
5.6.1 Number and percentage of expectant and parenting participants that has full-time employment during the program year |
How many expectant and parenting participants have full-time employment? |
5.6.2 Number and percentage of expectant and parenting participants that has part-time employment during the program year
|
How many expectant and parenting participants have part-time employment?
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5.6.3 Number and percentage of expectant and parenting participants that receives cash benefits or other services under the Temporary Aid to Needy Families (TANF) program during the program year |
How many expectant and parenting participants received cash benefits or other services under the Temporary Aid to Needy Families (TANF) program? |
5.6.4 Number and percentage of expectant and parenting female participants that receives benefits from the Women, Infants, and Children (WIC) program during the program year |
How many expectant and parenting female participants received benefits from the Women, Infants, and Children (WIC) program? |
5.6.5 Number and percentage of expectant and parenting participants that receives benefits from the Supplemental Nutrition Assistance Program (SNAP) during the program year
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How many expectant and parenting participants received benefits from the Supplemental Nutrition Assistance Program (SNAP)? |
5.7.0 Access to Health Care These measures are optional and are included for consideration by grantees that are focusing on enrolling participants in health insurance and medical homes. |
|
Performance Measure |
Performance Question |
5.7.1 Number and percentage of expectant and parenting participants that has public (e.g., Medicaid or CHIP) or private health insurance coverage |
How many expectant and parenting participants have health insurance (including Medicaid, Children’s Health Insurance Program, or private health insurance)? |
5.7.2 Number and percentage of expectant and parenting participants who are uninsured at program enrollment that enrolls in a public or private health insurance plan during the program year |
|
5.7.3 Number and percentage of children (of expectant and parenting participants) that has public (e.g., Medicaid or CHIP) or private health insurance coverage at program enrollment |
How many children (of expectant and parenting participants) have health insurance (including Medicaid, Children’s Health Insurance Program, or private health insurance)? |
5.7.4 Number and percentage of children (of expectant and parenting participants) who are uninsured at program enrollment that enrolls in a public or private health insurance plan during the program year
|
How many children (of expectant and parenting participants) have health insurance (including Medicaid, Children’s Health Insurance Program, or private health insurance)? |
Performance Measure |
Performance Question |
5.7.5 Number and percentage of expectant and parenting participants that reports having a medical home |
How many expectant and parenting participants report having a medical home? (A medical home is a comprehensive, coordinated, and accessible source of regular primary care).
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5.7.6 Number and percentage of expectant and parenting participants who have no medical home at program enrollment that reports having a medical home at the end of the program year |
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5.7.7 Number of children (of expectant and parenting participants) that has a medical home |
How many children (of expectant and parenting participants) have a medical home? (A medical home is a comprehensive, coordinated, and accessible source of regular primary care). |
5.7.8 Number and percentage of children (of expectant and parenting participants) who have no medical home at program enrollment that reports having a medical home at the end of the program year |
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5.7.9 Number of expectant and parenting participants that receives application assistance for enrolling in a health insurance exchange during the program year |
How many expectant and parenting participants received application assistance for enrolling in a health insurance exchange during the program year? |
5.8 Tobacco Use These measures are optional for those grantees that are focusing on tobacco cessation. |
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5.8.1: Number and percentage of expectant and parenting participants that currently uses a tobacco product (use of cigarettes, chewing tobacco, or cigars in the 30 days prior to program enrollment)
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How many expectant and parenting participants report current use (1 or more of the last 30 days) of cigarettes, chewing tobacco, or cigars? |
Performance Measure |
Performance Question |
5.8.2: Number and percentage of expectant and parenting participants who are current tobacco users (used a tobacco product [cigarettes, chewing tobacco, or cigars] in the 30 days prior to program enrollment) that attempts smoking cessation during the program year |
How many expectant and parenting participants who are current tobacco users (used a tobacco product [cigarettes, chewing tobacco, or cigars] in the 30 days prior to program enrollment) have attempted tobacco cessation during the program year? |
5.8.3 Number and percentage of expectant and parenting participants who are current tobacco users (used a tobacco product [cigarettes, chewing tobacco, or cigars] in the 30 days prior to program enrollment) that used tobacco for the first time in the 12 months prior to program enrollment |
How many expectant and parenting participants used cigarettes, chewing tobacco, or cigars for the first time in the 12 months prior to program enrollment? |
5.8.4 Number and percentage of expectant and parenting participants who are current tobacco users (used a tobacco product [cigarettes, chewing tobacco, or cigars] in the 30 days prior to program enrollment) that receives tobacco use or exposure-related health education during the program year
|
How many expectant and parenting participants who are current tobacco user were provided tobacco use/exposure health educations? |
Performance Measure |
Performance Question |
5.9 General Education Diploma (GED) preparation These are optional questions for grantees who provide formal GED preparation to expectant and parenting teens and women |
|
5.9.1 Number and percentage of expectant and parenting participants that are enrolled in a GED preparation course during the program year |
How many expectant and parenting participants are enrolled in a GED preparation course? |
5.9.2 Number and percentage of expectant and parenting participants who enrolled in a GED preparation course during the program year that drops out of the GED program by the end of the program year |
Of the expectant and parenting participants enrolled in a GED preparation course during the program year, how many drop out by the end of the program year? |
Appendix – Glossary of Terms
ACCOMPANIMENT- The term ”accompaniment” means assisting, representing, and accompanying a woman in seeking judicial relief for child support, child custody, restraining orders, and restitution for harm to persons and property, and in filing criminal charges, and may include the payment of court costs and reasonable attorney and witness fees associated therewith.
COMMUNITY SERVICE CENTER - The term “community service center” means a non-profit organization that provides social services to residents of a specific geographical area via direct service or by contract with a local governmental agency.
ELIGIBLE INSTITUTION OF HIGHER EDUCATION - The term "eligible institution of higher education” means an institution of higher education (as such term is defined in section 101 of the Higher Education Act of 1965 (20 U.S.C. 1001)) that has established and operates, or agrees to establish and operate upon the receipt of a grant under this part, a pregnant and parenting student services office.
HIGH SCHOOL - The term “high school” means any public or private school that operates grades 10 through 12, inclusive, grades 9 through 12, inclusive or grades 7 through 12, inclusive.
HEALTH INSURANCE-The term health insurance refers to both public health insurance (Medicaid, CHIP, etc.) and private health insurance coverage.
IMPLEMENTATION PARTNER–The term implementation partner refers to any entity (public, nonprofit, private business, etc.) that (1) participates in planning for the PAF program, (2) participates in implementing activities related to the PAF program, or (3) helps to co-sponsor events related to the PAF program. An implementation partner may contribute money, staff time, physical space, or other in-kind donations to the implementation of the PAF program. There are two types of implementation partners: formal and informal:
Formal Implementation Partner–Refers to an implementation partner with whom the grantee has an MOU or written agreement to help implement the program.
Informal Implementation Partner–Refers to an implementation partner with whom the grantee has no formal MOU or written agreement to help implement the program.
INTERVENTION SERVICES - The term “intervention services” means, with respect to domestic violence, sexual violence, sexual assault, or stalking, 24-hour telephone hotline services for police protection and referral to shelters.
LONG-ACTING REVERSIBLE CONTRACEPTIVE – The term “long-acting reversible contraceptive” refers to contraceptive implants (e.g., Implanon, Nexplanon) and intrauterine devices (IUDs).
MEDICAL HOME– The term “medical home” refers to a comprehensive, accessible, and routine source of primary care for children, youth, and adults.
PARTICIPANTS – The term “participants” references target populations among expectant and parenting teens, women, fathers and their dependent children for categories 1 and 2; in category 3 the “participants” are the eligible pregnant women who have experienced intimate partner violence, stalking, or sexual assault either during the pregnancy or who was pregnant up to 12 months prior to the date of experiencing either intimate partner violence, stalking, or sexual assault.
REPRODUCTIVE HEALTH SERVICES - The term “reproductive health services” includes services such as family planning services, sexually transmitted infection testing or counseling, pregnancy testing, or cervical cancer screening.
SUPPORTIVE SOCIAL SERVICES - The term “supportive social services” means transitional and permanent housing, vocational counseling, and individual and group counseling aimed at preventing domestic violence, sexual violence, sexual assault, or stalking.
VIOLENCE – The term “violence” means actual violence and the risk or threat of violence.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Tara Rice |
File Modified | 0000-00-00 |
File Created | 2021-01-28 |