Form 1 RHP Program Data Indicators Form

REFUGEE HEALTH PROMOTION

Program Data Indicators

The Program Data Points are reported on an annual basis and are to be submitted on September 14, along with the semi-annual Performance Progress Report (PPR) and Federal Financial Report (FFR).

For more detailed instruction of the below data points, see the Refugee Health Promotion Program Data Indicators User Guide. For more information about general program reporting requirements, please refer to the FOA that aligns with current funding.

Legal Organization Name		DUNS Number			EIN
Federal Grant Number	Project Period			Reporting Period
	Start Date: (MM/DD/YYYY)		End Date: (MM/DD/YYYY)	Start Date: (MM/DD/YYYY)			End Date: (MM/DD/YYYY)
I. DEMOGRAPHICS & LOCALITIES SERVED
Where applicable, provide the number of unduplicated individual clients served for each demographic in the ‘Total’ column. Do not leave any blanks; indicate ‘0’ where applicable.
Data Indicator							Total
1. Total unduplicated number of clients served
2. Number of unduplicated of clients served by immigration status
Refugee
Asylee
SIV
Cuban or Haitian Entrant
Trafficking Victim
3. Number of unduplicated clients served by country of origin List the top 5 countries.
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All other countries (combined)
4. Number of organization(s) funded and location(s) served
Number of organization(s) funded by RHP
Number of location(s) served
II. SERVICES
Provide the total number of recipients for each service in the ‘Total’ column and a description for each service in the space provided. Do not leave any blanks; indicate ‘0’ and ‘N/A’ where applicable. *For Pro Bono Services, provide the number of hours instead of the number of clients.
Data Indicator							Total
1. Case management Includes medical and mental health case management and coordination of community resources for the provision of medically necessary health care services.
Number of clients who received medical case management services
Number of clients who received mental health case management services
Total unduplicated number of clients receiving case management services
2. Adjustment or support groups Includes community adjustment groups, support groups, or other similar activities
Number of clients that attended adjustment or support groups
Number of Groups: Frequency of Groups:
3. Health orientation and education Includes U.S. healthcare orientation workshops and other health education classes.
Number of clients who received initial health orientation services
Number of clients who received additional health education services
Number of clients who received mental health education/training
4. Service provider education Includes education on refugee health, mental health training, and National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care.
Number of service providers that received training
5. Interpretation services
Number of hours of interpretation services provided
6. Translation services
Number of clients who received translated materials
7. Pro Bono Services For each service area, indicate the total number of pro-bono hours contributed by providers and other volunteers during the reporting period.
Interpreters/translators
Medical
Mental health
Social
General volunteer hours
Other
Total hours contributed
8. Please provide a breakdown by percentage of RHP grant activities:
Medical Case Management
Mental Health Case Management
Interpretation/Translation
Health Orientation/Education
Adjustment or Support Groups
Administrative
Other Activities

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)

Public reporting burden for this collection of information is estimated to average 3 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.

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.

OMB Control Number: 0970-0490

Expiration date: 1/31/2020