Form 1 P4C Implementation Form

Supporting Statement A

Partnerships for Care (P4C) Progress Reports

OMB Control No. 0915-XXXX

APPENDIX A – IMPLEMENTATION REPORT FORM

P4C PROGRESS REPORT # X – IMPLEMENTATION REPORT

INSTRUCTIONS FOR HEALTH CENTERS

Due in EHB XX-XX-201X

Reporting Period XX-XX-201X to XX-XX-201X

INSTRUCTIONS

This progress report requests information on health center progress toward implementing the Partnerships for Care (P4C) project. Data pertaining to P4C outcome measures is not required in this report.

Please use the reporting form beginning on the next page to provide requested information. Do not delete any information contained on the reporting form. Type your responses directly into the reporting form tables.

Submit the completed reporting forms to your BPHC project officer via the Electronic Handbooks (EHB) Submissions task titled xyz title of submission task by XX-XX-201X.Be sure to save a copy for your records.

If you have any questions regarding the content of this report, please contact your P4C project officer, Dr. Rene Sterling at rsterling@hrsa.gov or 301-443-9017.

If you experience any technical challenges submitting this report via EHB, please contact the BPHC Help Desk on-line at http://www.hrsa.gov/about/contact/bphc.aspx or by phone at 877-974-2742 Monday through Friday (except federal holidays) from 8:30 AM to 5:30 PM (ET).

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0906-XXXX. Public reporting burden for this collection of information is estimated to average five hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information.

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10C-03I, Rockville, Maryland, 20857.

P4C PROGRESS REPORT # X – IMPLEMENTATION REPORT

REPORTING FORM FOR HEALTH CENTERS

Due in EHB XX-XX-201X

Reporting Period XX-XX-201X to XX-XX-201X

Use the reporting tables below to provide requested information and data. Type your responses directly into corresponding boxes. Do not delete any information.

CONTACT INFORMATION Please provide contact information for questions regarding this report.
Health center name
H80 number
Point of contact for questions regarding this report	Name and title
	Phone
	Email

WORKPLAN IMPLEMENTATION Please provide a brief summary of health center progress on the P4C project. For each of the five project focus areas, describe successes and challenges experienced during the reporting period. Where applicable, describe any anticipated delays or accelerated progress in meeting established project projections. Identify any specific training and technical assistance (TA) needs you may have. Please be concise and limit each response to no more than 300 words (5,400 words total for this table).
Workforce development
Successes
Challenges
Projections
Training/TA needs
Infrastructure development
Successes
Challenges
Training/TA needs
Infrastructure development
Successes
Challenges
Projections
Training/TA needs
Partnership development
Successes
Challenges
Projections
Training/TA needs
Quality Improvement/ Evaluation
Successes
Challenges
Training/TA needs

BUDGET Please provide a brief summary of any changes made to the budget in each of the major cost categories below. Describe how changes will support P4C project implementation. Please be concise and limit each response to no more than 100 words (400 words total for this table).
Personnel and Fringe
Equipment
Supplies
All Other

[Add tables below to Implementation Report #2 only]

PROJECTIONS Please provide target projections and actuals numbers for each of the focus areas below. Target projections must match numbers provided with the “P4C Future Year Budget” submission for year two of the project.
	Year X Target Projection	Year X Actual
Workforce Development
Number of health center providers who received training in HIV testing, prevention, care, or treatment
Number of other health center staff and board who received training in HIV related topics
Partnership Development
Number of meetings (face to face or remote) with health department staff focused on using surveillance and EHR data to improve HIV service delivery to patients and other clinical issues
Number of meetings (face to face or remote) with health department staff focused on P4C project implementation, coordination, and other operational issues
Service Delivery
Number of HIV-positive medical patients
Percent of medical patients aged 15-65 years who had at least one HIV test in their lifetime
Number of sites in scope where routine HIV testing is underway compared to number of sites required for routine HIV testing implementation

CONTINUITY OF PROJECT Please provide a brief summary of recent efforts to develop a plan to maintain the capacity and activities developed during the project in each of the areas listed below. Please be concise and limit each response to no more than 100 words (300 words total for this table).
Ongoing provision of established HIV services
Retention in care for all health center patients living with HIV
Financial sustainability of health center operations