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pdfTITLE V MATERNAL AND
CHILD HEALTH SERVICES
BLOCK GRANT TO STATES
PROGRAM
GUIDANCE AND FORMS
FOR THE
TITLE V APPLICATION/ANNUAL REPORT
OMB NO: _________
EXPIRES: __________
U.S. Department of Health and Human Services
Health Resources and Services Administration
Maternal and Child Health Bureau
Division of State and Community Health
5600 Fishers Lane, Room 18N33
Rockville, MD 20857
(Phone 301-443-2204 FAX 301-443-9354)
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completing and reviewing the collection of information. Send comments regarding this
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Lane, Room 14N39, Rockville, Maryland, 20857.
i
TITLE V MATERNAL AND CHILD HEALTH (MCH) SERVICES
BLOCK GRANT TO STATES PROGRAM APPLICATION/ANNUAL
REPORT GUIDANCE
EIGHTH EDITION
The Title V Maternal and Child Health (MCH) Services Block Grant to States Program (hereafter
referred to as the MCH Block Grant) is a formula grant under which funds are awarded to 59
states and jurisdictions upon their submission of an acceptable plan that addresses the health
services needs within a state for the target population of mothers, infants and children, which
includes children with special health care needs (CSHCN), and their families. For purposes of
the MCH Block Grant program, children are defined as ages 1 through 21 years. As referenced
in this Guidance, the population of CSHCN is inclusive of children and youth. Through the MCH
Block Grant, each state and jurisdiction supports and promotes the development and
coordination of systems of care for the MCH population, which are family-centered,
community-based and culturally appropriate.
The Application/Annual Report is used by the 50 states and nine jurisdictions in applying for
their MCH Block Grants under Title V of the Social Security Act and in preparing the required
Annual Report. States/jurisdictions report annually on national and state
outcome/performance measures, which document their progress towards the achievement of
established performance targets, ensure accountability for the ongoing monitoring of health
status in women and children and lend support to the delivery of an effective public health
system for the nation’s MCH population. Complementary to the reporting of outcome and
performance measure data is the narrative description of the state/jurisdiction’s Title V
program activities.
The eighth edition of the Title V MCH Services Block Grant to States Program Guidance consists
of two documents: 1) Instructions to the states on completing the required Application/Annual
Report and Reporting Forms; and 2) Appendix of Supporting Documents, which includes
background program information and other technical resources. As with previous editions, this
Guidance adheres to the specific statutory requirements outlined in Sections 501-509 of the
Title V legislation and honors the rights of states to determine their individual MCH program
priorities, to develop tailored strategies for addressing their unique MCH population needs and
to assume accountability in achieving measurable progress towards stated program goals.
This edition of the Title V MCH Services Block Grant to States Program Application/Annual
Report Guidance provides continued emphasis on the use of evidence-based or -informed
strategies and measures in the MCH Block Grant and retains the performance measure
framework that was introduced in 2015. In recognition that each state and jurisdiction is
unique, the updates to this edition of the Guidance allow states greater flexibility in selecting
national and state performance measures that align with their identified MCH needs. Given
that the MCH priorities largely shape Title V programming within an individual state, the
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proposed updates bring renewed focus to the role and use of State Performance Measures in
addressing state-specific needs and working to improve MCH outcomes.
The updates to this edition also reflect a continued commitment to improving health care
systems for the MCH population, particularly for CSHCN, and the leadership of families in being
active partners engaged in Title V program planning and decision-making. Furthermore, the
updates aim to reduce reporting burden and to streamline the Application/Annual Report
narrative reporting. The updated instructions provided in this Guidance will assist states in
preparing and submitting an Application/Annual Report for the remaining two interim years of
the 2015 Needs Assessment reporting cycle. States will report on the findings of the 2020
Five-Year Needs Assessment in the third and final Application/Annual Report that will be
submitted under this three-year Guidance. The submission of the 2020 Five-Year Needs
Assessment will begin a new five-year reporting cycle.
This edition of the Title V MCH Services Block Grant to States Program Guidance is the sixth to
be released since the introduction of a Web-based Application/Annual Report. The use of this
online method for completing and submitting a yearly Application/Annual Report continues to
be a requirement for the receipt of Federal MCH Block Grant funds. Since its development in
2002, the Title V Information System (TVIS) has contributed to numerous efficiencies in the
Application/Annual Report submission process. Examples include the automatic calculations of
ratios, rates, and percentages; capturing of past years’ narrative and data reporting; and
assurance that the data presented in multiple tables are entered only once by the state.
Administered by the Health Resources and Services Administration’s (HRSA) Maternal and Child
Health Bureau (MCHB), the TVIS consists of two components: 1) MCH Block Grant
Application/Annual Report Data Entry (used by state/jurisdictional MCH Block Grantees to
submit their financial, program, and performance data); and 2) TVIS Reports (a Web-based
interface that allows public users to generate reports from Title V data).
Questions and comments regarding this edition of the Application/Annual Report Guidance
may be addressed to:
Michele H. Lawler, M.S., R.D.
Director, Division of State and Community Health
Maternal and Child Health Bureau
Health Resources and Services Administration
5600 Fishers Lane, Room 18N33
Rockville, Maryland 20857
Telephone: (301) 443-2204
Fax: (301) 443-9354
mlawler@hrsa.gov
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TABLE of CONTENTS
PART ONE: BACKGROUND AND ADMINISTRATIVE INFORMATION
I. Purpose of the Maternal and Child Health (MCH) Block Grant
1
II. Background and Brief History
2
III. Guiding Principles for the Development of the MCH Block Grant
Application/Annual Report Guidance
2
A. Public Health Services Systems Model for MCH Populations
3
B. Data Driven Programming and Performance Accountability
(National Performance Measure Framework)
4
C. Family Partnership
8
IV. Legislative Requirements
9
A. Who Can Apply for Funds
9
B. Use of Allotment Funds
9
C. Application for Block Grant Funds
10
D. Annual Report
11
E. Administration of Federal and State Programs
11
PART TWO: APPLICATION/ANNUAL REPORT INSTRUCTIONS
I. General Requirements
13
13
A. Letter of Transmittal
13
B. Face Sheet
13
C. Assurances and Certifications
13
D. Table of Contents
13
II. Logic Model
13
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III. Components of the Application/Annual Report
15
A. Executive Summary
16
B. Overview of the State
17
C. Needs Assessment
17
1. Needs Assessment Update
18
2. Five-Year Needs Assessment Summary
19
a. Process Description
19
b. Findings
20
i. MCH Population Health Status
21
ii. Title V Program Capacity
21
iii. Title V Program Partnerships, Collaboration,
and Coordination
23
c. Identifying Priority Needs and Linking to Performance
Measures
24
D. Financial Narrative
25
1. Expenditures
26
2. Budget
27
E. Five-Year State Action Plan
28
1. Five-Year State Action Plan Table
28
2. State Action Plan Narrative Overview
30
a. State Title V Program Purpose and Design
30
b. Supportive Administrative Systems and Processes
31
i. MCH Workforce Development
31
ii. Family Partnership
31
v
iii. States Systems Development Initiative and Other
MCH Data Capacity Efforts
32
iv. Health Care Delivery System
33
c. State Action Plan Narrative by Domain
F.
Public Input
34
36
G. Technical Assistance
36
PART THREE: REPORTING FORMS
37
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PART ONE: BACKGROUND AND ADMINISTRATIVE INFORMATION
I.
Purpose of the Maternal and Child Health (MCH) Block Grant
As defined in section 501(a)(1) of the Title V legislation, the purpose of the MCH Block
Grant is to enable each state:
A. To provide and to assure mothers and children (in particular those with low income or
with limited availability of health services) access to quality MCH services;
B. To reduce infant mortality and the incidence of preventable diseases and handicapping
conditions among children, to reduce the need for inpatient and long-term care
services, to increase the number of children (especially preschool children) appropriately
immunized against disease and the number of low income children receiving health
assessments and follow-up diagnostic and treatment services, and otherwise to
promote the health of mothers and infants by providing prenatal, delivery, and
postpartum care for low income, at-risk pregnant women, and to promote the health of
children by providing preventive and primary care services for low income children;
C. To provide rehabilitation services for blind and disabled individuals under the age of 16
receiving benefits under title XVI, to the extent medical assistance for such services is
not provided under title XIX; and
D. To provide and to promote family-centered, community-based, coordinated care
(including care coordination services, as defined in subsection (b)(3)) for children with
special health care needs (CSHCN) and to facilitate the development of communitybased systems of services for such children and their families.
This legislative purpose is further affirmed through the Title V Vision and Mission
statements, as shown below.
Vision of Title V
Title V envisions a nation where all mothers, infants, children aged 1 through 21 years,
including CSHCN, and their families are healthy and thriving.
Mission of Title V
The Mission of Title V is to improve the health and well-being of the nation’s mothers,
infants, children and youth, including children and youth with special health care needs,
and their families.
II. Background and Brief History
Since its original authorization in 1935, Title V of the Social Security Act has been amended
several times to reflect an ongoing commitment to improving the health and well-being of
our Nation's mothers, children and their families. Block-granted in 1981, with new
accountability requirements added in 1989, Title V has remained a vitally important public
health program for serving the MCH population. In 2015, an updated performance
measure framework was introduced to reflect more clearly the contributions of Title V in
improving health outcomes among the MCH population. A more complete history of
Title V can be found in Appendix A of the Supporting Documents to the Title V MCH Block
Grant Application/Annual Report Guidance.
The MCH Block Grant is a formula grant under which funds are awarded to 59 states and
jurisdictions upon the submission of an acceptable plan that addresses the health services
needs within a state for the target population of mothers, infants and children, including
CSHCN. Through this process, each state and jurisdiction supports and promotes the
development and coordination of systems of care for the MCH population.
Annual submission of an Application is required by law to entitle a state to receive MCH
Block Grant funds (Section 505 of Title V of the Social Security Act). Per Section 506, a
state is further required to submit an Annual Report on the expenditure of the previous
year’s funds. In addition, Section 505(a) requires a state to conduct a comprehensive and
statewide needs assessment every five years. The information and instructions for the
preparation and submission of the Application/Annual Report and Five-Year Needs
Assessment are contained in the Title V Maternal and Child Health Services Block Grant to
States Program: Guidance and Forms for the Title V Application/Annual Report (hereafter
referred to as the Application/Annual Report Guidance).
III. Guiding Principles for the Development of the MCH Block Grant
Application/Annual Report Guidance
The development of the application/reporting structure for this edition of the
Application/Annual Report Guidance incorporates key principles that are common to all
state Title V programs. These principles are: 1) delivery of Title V services within a public
health service model; 2) data-driven programming and performance accountability; and 3)
partnerships with individuals/families/family-led organizations (hereafter referred to as
family partnership). These principles have contributed to the MCH Block Grants’ success in
operationalizing the legislative requirements and in delivering public health services and
systems of care that address the needs of the MCH population.
2
A. Public Health Services Systems Model for MCH Populations
1
A 1988 Institute of Medicine (IOM) Report defined the core functions of public health
as assessment, policy development and assurance. In operationalizing the core public
health functions and in ensuring that the unique needs of mothers and children were
addressed, the MCH community worked with the Public Health Service and the IOM to
identify ten (10) “Essential Public Health Services” 2 in 1994. Since that time, the 10
Essential Public Health Services have provided a framework for the delivery of MCH
services, as reflected in Figure 1 below.
Figure 1.
Institute of Medicine. (1988). The Future of Public Health. Washington, D.C.: National Academy Press..
Public Health in America. (1994), Washington, DC: US Public Health Service. Essential Public Health
Services Working Group of the Core Public Health Functions Steering Committee.
1
2
3
A crosswalk of the 10 Essential Public Health Services with the purpose of the State
MCH Block Grants, as defined in Section 501(a)(1) of Title V of the Social Security Act,
yielded the following strategies for states to use in their program planning.
(1) Mobilize partners, including families and individuals, at the federal, state and
community levels in promoting shared vision for leveraging resources, integrating
and improving MCH systems of care, promoting quality public health services and
developing supportive policies;
(2) Integrate systems of public health, health care and related community services to
ensure access and coordination to assure maximum impact;
(3) Conduct ongoing assessment of the changing health needs of the MCH population
to drive priorities for achieving equity in access and positive health outcomes;
(4) Educate the MCH workforce to build the capacity to ensure innovative, effective
programs and services and efficient use of resources;
(5) Inform and educate the public and families about the unique needs of the MCH
population;
(6) Promote applied research resulting in evidence-based policies and programs;
(7) Promote rapid innovation and dissemination of effective practices through quality
improvement and other emerging methods; and
(8) Provide services to address unmet needs in healthcare and public health systems
for the MCH population (i.e., gap-filling services for individuals).
B. Data Driven Programming and Performance Accountability (National Performance
Measurement Framework)
The MCH Block Grant utilizes a three-tiered national performance measurement
framework (Figure 2), which includes National Outcome Measures (NOMs), National
Performance Measures (NPMs) and state-initiated
Evidence-based or -informed Strategy
Measures (ESMs). The framework provides
Figure 2. Performance Measure Framework
flexibility to a state in identifying the best
combination of measures to address the
National Outcome Measures
MCH priority needs that were identified based
on the findings of the Five-Year Needs
Assessment. This edition of the
Application/Annual Report Guidance reduces
National Performance Measures
the required minimum number of NPM
selections by a state to five (5). It also allows
increased flexibility for a state to select as
Evidence-based/Informed Strategy
many NPMs and State Performance Measures
Measures
(SPMs) as necessary to address each of its
priority needs. See Appendices B and C for detailed information about the NPM
Framework, NOMs and NPMs.
4
The NPMs are a set of short-term and medium-term performance measures that utilize
population-based, state-level data derived from national data sources and for which a
state Title V program tracks prevalence rates and works towards demonstrated impact.
They are intended to drive improved outcomes relative to one or more medium and
long-term indicators of health status or access to quality health care (i.e., NOMs) for
the MCH population. Thus, a state tracks the NOMs to monitor the impact of the
NPMs.
ESMs are the final tier of the national performance measurement framework, and they
are the structural or process measures through which a state can achieve intended
impact on the NPMs. State-specific and actionable, the ESMs seek to track a state
Title V program’s strategies/activities and to measure evidence-based or -informed
practices that will impact individual, population-based NPMs. The ESMs are developed
by the state, and they provide accountability for improving quality and performance
related to the NPMs and to the MCH public health issues that they are designed to
address. While not part of the NPM framework, a state will also develop SPMs to
address its identified priority needs to the extent that they have not been fully
addressed through the selected NPMs and ESMs.
Title V is responsible for promoting the health of all mothers and children, including
CSHCN and their families. There are 15 NPMs, which address key MCH priority areas
within five MCH population domains. These domains are: 1) Women/Maternal Health;
2) Perinatal/Infant Health; 3) Child Health; 4) CSHCN; and 5) Adolescent Health. The
NPM framework also applies the life course theory, which identifies critical stages
(i.e., beginning before a child is born and continuing throughout life) that can influence
lifelong health and wellbeing.
A sixth domain addresses Cross-cutting and Systems Building needs. While there are
currently no NPMs included in this last domain, a state may choose to develop one or
more SPMs to address a priority need that is related to program capacity and/or
systems-building (e.g., applies to all MCH population domains). A state is not required
to identify a measure for this domain. If a SPM is developed, the state should define
strategies for determining success. Examples of topics addressed by SPMs in this
domain are:
(1)
(2)
(3)
(4)
Partnerships with individuals, families, and family-led organizations ;
Social determinants of health;
Workforce development; and
Enhanced data infrastructure
An overview of the NPMs, by MCH population health domain, is displayed in Table 1.
It should be noted that the five MCH population health domains reflected in the NPM
framework are contained within the three legislatively-defined MCH populations
[Section 505(a)(1)]. For example, the first two domains are included under “preventive
5
and primary care services for pregnant women, mothers and infants up to age one,”
which is the first of the three defined MCH populations. Child and adolescent health
are included in the second defined MCH population, specifically “preventive and
primary care services for children.” CSHCN is the third legislatively defined MCH
population. This latter population is inclusive of children and youth with special health
care needs.
Table 1: NPMs and Domains
NPM #
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Well-woman visit
Low-risk
cesarean
delivery
Risk-appropriate
perinatal care
Breastfeeding++
Safe sleep
Developmental
screening
Injury
hospitalization*
Physical activity *
Bullying
Adolescent wellvisit
Medical home*
Transition*
Preventive dental
visit *++
Smoking *++
Adequate
insurance *
MCH Population Domains
Women/
Maternal
Health
Perinatal/
Infant
Health
Child
Health
Adolescent
Health
Children with
Special Health
Care Needs
Cross-cutting/ Systems
Building Domain
Optional
States have the option to
develop a state performance
measure (SPM) that is
Cross-cutting/Systems
Building. Examples of
measure topic areas include
but are not limited to:
• Family partnership
activities that cross all
population health
domains;
• Social determinants of
health;
• Workforce
development; and
• Enhanced data
infrastructure
* NPM with multiple domains (Note: States may choose to target children and adolescents without special
health care needs, in addition to children and adolescents with special health care needs for NPM #11 and
NPM #12.)
++ NPMs that are compound measures (i.e. have an “A” and “B” component to the measure)
The 15 NPMs remain the same as in the seventh edition of the MCH Block Grant
Application/Annual Report Guidance, but they are now distributed within the five
population health domains. As noted above, a state must choose a minimum of five (5)
NPMs. At least one NPM must be selected for each of the five (5) MCH population
domains, but a state may opt to select additional NPMs based on its identified priority
needs. There is no maximum for the number of NPMs that a state can select. Thus, a
state may continue to implement its current State Action Plan for the five-year
reporting cycle with the eight (8) NPMs previously selected.
6
Given the redistribution of the NPMs, states should note that the same measure
selected in multiple domains (NPM #7, NPM #8, NPM #11, NPM #12, NPM #13,
NPM #14 and NPM #15) will only count once toward the minimum of five (5) NPMs.
For example, if a state selects NPM #14 in both the Women/Maternal Health Domain
and the Child Health Domain, this measure would only count once towards the
required minimum of five NPMs. The state would need to select another measure in
either the Women/Maternal Health Domain or the Child Health Domain to satisfy the
requirement of one NPM per population domain. If NPM #11 and/or NPM #12 are
selected, the state must address children with special health care needs (i.e., CSHCN
domain). States may choose to also reflect these measures in either the Child Health
Domain or the Adolescent Health Domain. The four scenarios presented in Figure 3
provide further explanation regarding the available options to a state in the selection of
NPMs to meet the minimum requirements.
Figure 3. Scenarios for Assuring Selection of NPMs Across Domains
Scenario 1:
A state selects NPM #7 for both the Child Health Domain and the
Adolescent Health Domain. In selecting a NPM for each of the five
population domains, as required, the state can choose to count
NPM #7 as the selected measure in either of the two domains. The
state must then select a second NPM for the other domain.
Scenario 2:
A state selects NPM #11 for the Child Health Domain, which is an
optional target population. In selecting this measure, the state must
also address the CSHCN Domain. The state may choose to count this
measure in either the CSHCN Domain or the Child Health Domain. If
selected as the NPM for the Child Health Domain, the state must
select a second NPM from the CSHCN Domain.
Scenario 3:
A state selects NPM #13.1 for the Women/Maternal Health Domain
and NPM #13.2 for the Child Health Domain. While the measure
targets different population groups, NPM #13 counts as only one
measure. The state can choose to select this measure for either of
the two domains. The state will need to select a different NPM for
the second domain. A state can select NPM #13.1 without selecting
NPM #13.2, or vice versa.
Scenario 4:
A state selects NPM #15 for the Adolescent Health Domain and the
CSHCN Domain. While the measure targets different population
groups, NPM #15 counts as only one measure. The state may choose
to count this measure as the selected NPM in either the Adolescent
Health Domain or the CSHCN Domain. The state must choose a
different NPM for the second domain.
7
C. Family Partnership
Building the capacity of women and children, including CSHCN, and their families to
partner in decision-making with Title V programs at federal, state and community levels
is a critical strategy in helping states to achieve the identified MCH priorities. Title V’s
commitment to these partnerships are strong, as states expand and strengthen family
engagement activities in all MCH population domains.
Traditionally, state Title V programs have engaged families in a variety of program
activities. Specific examples include:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Contracting with Family-Led Organizations;
Paid Program Staff;
Advisory Committees/Task Forces;
Agency Decision-Making and Policy Development;
Program Outreach;
Training; and
Peer Support.
For purposes of the MCH Block Grant, family partnership is defined as, “patients,
families, their representatives, and health professionals working in active partnership
at various levels across the health care system – direct care, organizational design and
governance, and policy making—to improve health and health care.3 This partnership
is accomplished through the intentional practice of working with families for the
ultimate goal of positive outcomes in all areas through the life course.” 4 Relevant
resources include, but are not limited to, the National Consensus Standards for Systems
of Care for Children and Youth with Special Health Care Needs, authored by the
Association of Maternal and Child Health Programs (AMCHP, 2014); a series of reports
and case studies entitled, Sustaining and Diversifying Family Engagement in Title V
MCH and CYSHCN Programs (AMCHP, 2016); and other resources that are available
through Family Voices.
This edition of the Application/Annual Report Guidance provides added emphasis on
the need for a state to demonstrate the value of family partnerships in improving
health outcomes across all sectors of the MCH population. In addition, a state should:
(1) Assure families and individuals are key partners in health care decision-making at all
levels in the system of services, especially those who are vulnerable and medically
underserved;
3
Carman K., Dardess, P., Maurer, M., Sofaer, S., Adams, K., Bechtcl, C., Sweeney, J. “Patient and Family
Engagement: A framework for understanding the elements and developing interventions and policies.” Health
Affairs. 2013; 32:223-231.
4
Ibid
8
(2) Ensure the provision of training, both in orientation and ongoing professional
development, for staff, family leaders, volunteers, contractors and subcontractors
in the area of cultural and linguistic competence; and
(3) Collaborate with community leaders/groups and families of every background in
needs/assets assessments, program planning, service delivery and
valuation/monitoring/quality improvement activities.
Appendix D includes additional information to assist a state in strengthening the family
partnership and leadership within its Title V program.
IV. Legislative Requirements
The MCH Block Grant is authorized under Title V of the Social Security Act, which is the
longest-standing public health legislation in American history. More than 80 years later,
the law continues to support efforts to improve the health of the nation’s women and
children. The law can be viewed at: http://www.ssa.gov/OPHome/ssact/title05/0500.htm.
A general overview of the legislative requirements and the way in which these
requirements are implemented by MCHB is set out below.
A. Who Can Apply for Funds [Section 505(a)]
The Application/Annual Report shall be developed by, or in consultation with, the state
MCH agency and shall be made public within the state in such manner as to facilitate
comment from any person (including any federal or other public agency) during its
development and after its transmittal.
B. Use of Allotment Funds [Section 504]
The state may use its MCH Block Grant funds for the provision of health services and
related activities (including planning, administration, education, and evaluation)
consistent with its Application. In addition, the state may request supplemental funds
from the MCHB to support identified technical assistance needs. Related to technical
assistance, the state should plan for and allot funds for the MCH and CSHCN Directors
to attend two required meetings each year in person. One of these meetings is the
required MCH Block Grant Application/Annual Report review, which is held at a site
designated annually by the Division of State and Community Health (DSCH) in HRSA’s
MCHB. The other meeting is a MCH Technical Assistance Partners Meeting, which aims
to: 1) update State MCH and CSHCN Directors on relevant legislation and MCHB
initiatives; 2) convene leaders, disseminate best practices and share innovations in the
field of MCH; and 3) provide opportunities for information exchange, networking, and
collaboration among states and with MCHB. States should plan for this meeting to be
held in Washington, DC.
9
The MCH Block Grant funds may not be used for cash payments to intended recipients
of health services or for purchase of land, buildings, or major medical equipment.
Other restrictions apply, as specified in Section 504(b).
C. Application for MCH Block Grant Funds [Section 505]
Each state is required to conduct a statewide Needs Assessment once every five years.
A detailed overview of the MCH Five-Year comprehensive statewide Needs Assessment
process is presented in Appendix E. The Needs Assessment findings will be integrated
into that year’s Application/Annual Report as a Needs Assessment Summary. During
the four interim years of the five-year reporting period, a state will submit an annual
update of its ongoing needs assessment activities and findings in the appropriate
section of the state Application/Annual Report. By law, the Application/Annual Report
will contain information that is consistent with the health status goals and national
health objectives regarding the need for:
(1) Preventive and primary care services for all pregnant women, mothers, and infants
up to age one;
(2) Preventive and primary care services for children; and
(3) Services for CSHCN [as specified in section 501(a)(1)(D) "family-centered,
community-based, coordinated care (including care coordination services) for
children with special health care needs (CSHCN) and to facilitate the development
of community-based systems of services for such children and their families"].
The state will organize its reporting on the three legislatively defined MCH populations
in the context of five population health domains: 1) Women/Maternal Health;
2) Perinatal/Infant Health; 3) Child Health; 4) Adolescent Health; and 5) CSHCN.
Although the Application/Annual Report Guidance defines children as ages 1 year
through 21 years, a separate Adolescent Health domain is included in the NPM
framework due to their unique health needs. Adolescents often require different
strategies than the strategies used to address the needs of the broader child health
population.
Each year, at least thirty percent (30%) of federal Title V funds must be used for
preventive and primary care services for children and at least thirty percent (30%) for
services for CSHCN, as specified in Section 501(a)(1)(D). Such services include providing
and promoting family-centered, community-based, coordinated care (including care
coordination services) for CSHCN and facilitating the development of community-based
systems of services for such children and their families. The thirty percent (30%)
requirement may be waived as specified in Section 505(b)(1-2). A request for waiver
must be included in the Application letter of transmittal. In addition, of the amount
paid to a state under Section 503 from an allotment for a fiscal year under
Section 502(c), not more than ten percent (10%) may be used for administering the
funds paid under this section.
10
The state must maintain the level of funds being provided solely by such state’s MCH
programs at the level provided in fiscal year 1989. [Section 505(a)(4)].
Other requirements for allocation of funds, charging for services, maintenance of a
toll-free hotline (and other appropriate methods) and coordination of services with
other programs are found in Section 505.
D. Annual Report [Section 506]
An Annual Report must be submitted to the MCHB each year in order to evaluate and
compare the performance of different states assisted under Title V and to assure the
proper expenditure of funds. The Annual Report will include a description of program
activities, a complete record of the purposes for which funds were spent, the extent to
which the state has met its goals and performance objectives, as well as the national
health objectives, and the extent to which funds were expended consistent with the
state's Application. The Action Plan includes the Annual Report narrative on the state’s
Title V program strategies and activities. States will utilize the Action Plan section of
the Application/Annual Report to provide narrative discussion on the progress (by
population health domain) achieved during the reporting year relative to the
implementation of planned activities and gains in meeting the established performance
measure targets. The standardized format of the Annual Report, as described, will
allow for consistency in reporting and will facilitate the preparation of a report to
Congress [Section 506(a)(3)].
As required in Section 509(a)(5), the MCHB has made a substantial effort to not
duplicate other federal data collection efforts. The MCHB will collect and provide
national outcome and performance measure data, as well as Other State Data (OSD),
for the individual states, as available. Limited data are available from the National
Center for Health Statistics (NCHS) and other federal sources for Puerto Rico, Guam,
the Republic of the Marshall Islands, Federated States of Micronesia, Republic of Palau,
Commonwealth of the Northern Mariana Islands, American Samoa and Virgin Islands.
In the absence of federally available performance measure data, states and these
jurisdictions must report their own data.
E. Administration of Federal and State Programs [Section 509]
The MCHB in HRSA is the organizational unit responsible for the administration of
Title V. Within the Bureau, DSCH has responsibility for the day-to-day operation of the
State MCH Block Grants. Applicants may obtain additional information regarding
11
administrative, technical and program issues concerning the Block Grant
Application/Annual Report by contacting:
Division of State and Community Health
Maternal and Child Health Bureau
Health Resources and Services Administration
5600 Fishers Lane, Room 18N33
Rockville, Maryland 20857
Telephone: (301) 443-2204; Fax: (301) 443-9354
Within each state, the state health agency is responsible for the administration (or
supervision of the administration) of programs carried out with Title V allotments.
12
PART TWO: APPLICATION/ANNUAL REPORT INSTRUCTIONS
I.
General Requirements
A. Letter of Transmittal
An electronic letter of transmittal from the responsible state health agency official
must be the first page of the MCH Block Grant Application/Annual Report. The letter
must also contain the documentation for waiver of a 30 percent allotment, if the state
is so requesting. The letter of transmittal is uploaded in TVIS as an image to Section I.A.
of the Application/Annual Report.
B. Face Sheet
Each section of the Application Face Sheet (Standard Form 424) must be completed
and submitted electronically along with the rest of the Application/Annual Report.
C. Assurances and Certifications
The appropriate Assurances and Certifications for the State MCH Block Grants, which
include Application Form Standard Form (SF)-424B, Assurances for Non-Construction
Programs and Certifications for debarment and suspension, drug free work place,
lobbying, program fraud and tobacco smoke, are included in Appendix F. The state
does not have to submit these forms as part of the Application/Annual Report, but
they must be maintained on file in the state’s MCH program’s central office. TVIS
provides capability for the state to certify that the required assurances/certifications
are maintained on file and the state can provide them at HRSA’s request.
D. Table of Contents
The Table of Contents is automatically generated by TVIS, and conforms to the
headings in the different Parts/Sections of this Guidance.
II. Logic Model
In follow-up to a legislatively required comprehensive Five-Year Needs Assessment, the
state develops a five-year Title V program plan. Consistent with the block grant concept,
the state has flexibility in the types of programs and activities that it implements to
address the unique needs of their individual MCH populations. As depicted by the process
flow diagram in Figure 4, a state’s priority needs should “drive” the development of a
five-year program plan that is responsive to the needs identified and is performance
driven.
13
Figure 4. MCH Block Grant Logic Model
STEP 2
STEP 3
STEP 4
STEP 5
Conduct a
comprehensive
Title V MCH
program Fiveyear Needs
Assessment
Review and
summarize MCH
Population
Needs, Program
Capacity, and
Partnerships/
Collaborations
Identify (7-10)
State Title V
Program priority
needs, which will
guide the
development of
the state’s fiveyear Title V
Action Plan
Develop program
strategies to
address the
identified priority
needs during the
five-year
reporting period
Identify areas of
alignment
between the
state priorities/
strategies and the
NOMs
STEP 6
STEP 7
STEP 8
Based on
priorities and
strategies, select
five of the 15
NPMs (one per
each of the five
population
domains) for
programmatic
focus
Establish SPMs to
address each
priority need that
is not being
addressed by one
of the five
selected NPMs
Review the
selected NPMs
and SPMs to
ensure that every
identified priority
need is being
addressed
through one or
more of the
NPMS or SPMs
Develop one or
more ESMs for
each of the five
selected NPMS
STEP 13
STEP 14
Analyze annual
and multi-year
performance
trends
In interim year,
Annual Reports/
Applications,
reassess and
update strategies
and objectives for
selected NPMs,
SPMS, & SOMs, if
applicable, to
achieve desired
outcomes
STEP
1
SSTEP
STEP 11
Establish fiveyear performance
objectives for
each selected
NPM, SPM, and,
SOM, if
applicable
STEP 12
Report
performance
indicators for
NPMs, ESMs,
SPMs and SOMs
in Annual Report/
Application
STEP 9
STEP 10
At the state’s
discretion,
consider the need
to develop one or
more SOMs
STEP 15
Conduct
comprehensive
Title V MCH
program Fiveyear Needs
Assessment
The state begins each five-year cycle by conducting a comprehensive Title V Five-Year
Needs Assessment. This Needs Assessment includes a comprehensive review of MCH
population needs, program capacity, and partnerships/collaborations that are critical
14
components of a state’s system of care for addressing the needs of its MCH population.
Based on the findings of the Five-Year Needs Assessment, the state identifies 7-10 Title V
MCH priority needs. Using the State Action Plan Table as a working tool, the state
develops strategies and overarching five-year objectives to address the identified priority
needs. The state examines areas of potential alignment between its MCH priority needs
and the Title V NOMs and NPMs, which informs the selection of at least one NPM in each
of the five population health domains for programmatic focus over the five-year cycle.
Priority needs not addressed by the selected NPMs will require the development of a
targeted SPM. The state can chose to develop as many SPMs as needed to ensure that
each priority need is addressed either by a SPM or by a NPM. While not required, the
state may choose to also develop a SOM to complement the NOMs. For each NPM
selected, the state is required to develop at least one ESM that further defines how the
state plans to monitor and assess its annual progress in addressing the selected NPMs. In
the four interim year Application/Annual Reports, the state reports on its ongoing needs
assessment efforts, its success in implementing the five-year Title V program plan and its
progress in achieving the established performance objectives for each selected NPM,
SPM and ESM.
III. COMPONENTS OF THE APPLICATION/ANNUAL REPORT
By July 15 of each year, states and jurisdictions are required to submit an
Application/Annual Report for the federal funds they receive through the MCH Block
Grant. In addition, the state is required to conduct and report on a comprehensive,
statewide Needs Assessment every five years. See Appendix G for Application/Annual
Report Timeline. The findings of this Needs Assessment and the priority needs identified
as a result of this process provide the basis for the development of a five-year Action Plan
for the state Title V program. As new findings become available through the state’s
ongoing/updating needs assessment efforts and the analyses of annual performance
data, the state may refine its Action Plan in interim years (e.g., performance objectives)
related to the state and national MCH priority areas. These changes may include the
substitution of new or revised strategies, ESMs and/or SPMs for existing strategies and
measures. States are encouraged not to change the selected NPMs during the five-year
reporting cycle. If a state determines that a NPM needs to be changed, clear justification
must be provided to the MCHB Project Officer.
The state’s narrative Application/Annual Report includes the following sections:
A.
B.
C.
D.
E.
F.
G.
Executive Summary;
Descriptive Overview of the State;
Five-Year Needs Assessment Summary and Annual Needs Assessment Updates;
Financial Narrative;
State Action Plan Table and Narrative Discussion;
Public Input Process; and
Potential Areas of Needed Technical Assistance.
15
States should structure the narrative discussion of the Application/Annual Report to
include the sections cited above. A detailed explanation of the specific discussion points
that the state should include in each section is provided below.
A. Executive Summary
The Executive Summary describes the contents of the Application/Annual Report and
gives the reader a concise, yet substantive, description of the state’s MCH program.
Limited to no more than five pages in length or 15,000 characters, the Executive
Summary should highlight the state’s Title V program efforts to address its identified
MCH priority needs. The Executive Summary should also reflect on the state’s
progress in improving its performance relative to the selected state and national
performance measures. The points to be discussed are as follows:
(1) A brief description of the state’s MCH population needs and the identified Title V
priorities;
(2) A high level overview of the working framework used by the state or jurisdiction
in carrying out needs assessment, program planning and performance reporting;
(3) The role of the state Title V program in supporting and assuring comprehensive,
coordinated and family-centered services, including services for CSHCN; and
(4) A description of the Title V program’s established partnerships and how federal
and non-federal funds are being leveraged to deliver MCH services in the state.
The goal of the Executive Summary is to convey key descriptors about the state’s
Title V program (i.e., needs assessment/priorities, goals, strategies, action plan and
performance monitoring) to enable a reader to become acquainted with its MCH
program without having to read the entire Application/Annual Report.
The Executive Summary also serves as the narrative portion of the TVIS State
Snapshot. Publicly available, the document serves as a quick point of reference for
policy makers, national MCH leadership associations and programs, local and state
MCH stakeholders, state Title V programs, families, academia and other interested
individuals. The State Snapshot incorporates information submitted in the MCH Block
Grant Application/Annual Report into a format that the state can use in its Title V
program outreach and health promotion efforts.
In addition, the Executive Summary concludes with two brief narrative sections that
demonstrate the impact and value of the MCH Block Grant program in the state. In
the first of the two sections, states should provide a description of how federal MCH
Block Grant funds complement the overall MCH efforts supported by the state. The
second section should highlight what the state considers a MCH success story, which
illustrates the federal-state Title V partnership in action.
16
The Executive Summary is intended to be a standalone document. States can update
the Executive Summary annually, but its overall content should reflect the five-year
Title V program plan.
B. Overview of the State
The intended purpose of this overview is to introduce a reader to the applicant state.
Principal characteristics of the state, such as its demographics, geography, economy
and health care environment, should be succinctly summarized to provide the reader
with needed context for understanding the Title V program structure and approaches
described in the Application/Annual Report.
Specifically, the State Overview should include a description of:
(1) The state’s demographics, geography, economy and urbanization;
(2) The state’s unique strengths and challenges that impact the health status of its
MCH population (e.g., availability and access to health care services);
(3) The defined roles, responsibilities and targeted interests of the state health
agency and how they influence the delivery of Title V services;
(4) Components of the state’s systems of care for meeting the needs of underserved
and vulnerable populations, including CSHCN. This discussion may include, but is
not limited to, the following descriptors:
(a) Population served;
(b) Health services infrastructure (e.g., number of children’s hospitals, pediatric
specialists, accountable care organizational structure, etc.);
(c) Integration of services, such as physical, social and behavioral services; and
(d) Financing of services (e.g., managed care arrangements and Medicaid
eligibility).
(5) Specific state statutes and other regulations that have relevance to the MCH Block
Grant authority and impact the state’s MCH and CSHCN programs.
An organizational chart should be included as an attachment.
C. Needs Assessment
The Title V legislation (Section 505(a)(1)) requires the state, as part of the Application,
to prepare and transmit a comprehensive statewide Needs Assessment every five
years that identifies (consistent with the health status goals and national health
objectives) the need for:
(1) Preventive and primary care services for pregnant women, mothers and infants up
to age one;
(2) Preventive and primary care services for children; and
17
(3) Services for children with special health care needs.
Findings from the Five-Year Needs Assessment serve as the cornerstone for the
development of a five-year Action Plan for the State MCH Block Grant. Figure 5
illustrates the three-year period covered by this Guidance (FY 2019 - FY 2021). As
noted below, states will report on their next Five-Year Needs Assessment on July 15,
2020.
Figure 5. Schedule for Needs Assessment Narrative
2015 Five-Year Needs Assessment – Submitted July 15, 2015
FY 2019 Application: Interim Application Year Three — Provide Needs Assessment Update
FY 2020 Application: Interim Application Year Four — Provide Needs Assessment Update
2020 Five-Year Needs Assessment – Due July 15, 2020
FY 2021 Application: Application Year One — Provide Five-Year Needs Assessment Summary
1. Needs Assessment Update
The changing MCH population demographics, emerging health trends and shifting
program capacity require that states routinely engage in selected steps of the
Needs Assessment process. During any interim year when a state is not reporting
on its Five-Year Needs Assessment, a state should reference and summarize the
findings from its ongoing needs assessment activities in the Needs Assessment
Update section of the Application/Annual Report. This update should include a
discussion of the following items:
a.
b.
c.
d.
A brief description of the state’s ongoing needs assessment activities
(e.g., MCH data collection and analyses, program evaluation, key informant
interviews, customer satisfaction surveys, advisory councils, and other
approaches for soliciting individual feedback and conducting ongoing
performance monitoring and assessment) and the extent to which families,
individuals and other stakeholders were engaged in the process;
Noted changes in the health status and needs of the state’s MCH population,
as compared to the identified priority needs for the MCH Block Grant;
Noted changes in the state’s Title V program capacity or its MCH systems of
care, particularly for CSHCN, and the impact of these changes on MCH
services delivery;
The breadth of the state’s Title V partnerships and collaborations with other
federal, tribal, state and local entities that serve the MCH population;
18
e.
f.
Efforts undertaken by the state to operationalize its Five-Year Needs
Assessment process and findings; and
Changes in organizational structure and leadership.
The needs assessment update should include a dedicated section that describes
emerging public health issues and the state’s capacity and resources to address
them.
2. Five-Year Needs Assessment Summary
The mechanism for states to report on the legislatively required, comprehensive
and statewide Five-Year Needs Assessment is the Needs Assessment Summary,
which is submitted as part of the first year Application/Annual Report of a new
five-year cycle. The state should present a concise summary of the Five-Year
Needs Assessment process, methodology and findings, as described below.
Given that the findings inform the development of the state MCH Block Grant’s
five-year State Action Plan, the Needs Assessment Summary is retained in its
original form as part of the four subsequent interim year Applications/Annual
Reports. As it reflects a point-in-time, the state does not update the Five-Year
Needs Assessment Summary in the interim years. Such updates are presented in
the Needs Assessment Update section of the interim year Applications/Annual
Reports. Each annual update, along with the original Five-Year Needs
Assessment Summary, is prepopulated in each year’s Application/Annual Report
across the five-year reporting cycle.
The Needs Assessment Summary is intended to emphasize only the key findings of
the state’s Five-Year Needs Assessment. Given the scope and comprehensive
nature of the Five-Year Needs Assessment, a state’s findings may exceed the
required content for the Needs Assessment Summary. States may opt to develop
a more detailed and complete Five-Year Needs Assessment document, which is
tailored to meet their individual MCH program needs. If such a document is
created by the state and made accessible on a public website, the state is
encouraged to cite the URL for the website as part of its Application/Annual
Report discussion. States may also choose to submit more detailed
documentation on their Five-Year Needs Assessment findings as an attachment to
this section.
a.
Process Description
This description of the overall process/methodologies used by the state in
conducting its Title V Five-Year Needs Assessment provides context for the
interpretation of the reported findings and the priority needs subsequently
19
identified. A report 5 prepared for MCHB on the needs assessment process
cited four characteristics for states to consider in moving from a solely datadriven needs assessment effort to conducting a comprehensive assessment
of its priority issues and stakeholder needs. These characteristics are:
(i) A clear leadership structure for assembling data from both public and
private sources;
(ii) Engagement of stakeholders for soliciting meaningful programmatic
input;
(iii) A structured and inclusive priority-setting process; and
(iv) Collaborative program planning.
In describing the Five-Year Needs assessment process, states should provide
a high-level summary that includes:
(i) Goals, framework and methodology that guided the Needs Assessment
process;
(ii) Level and extent of stakeholder involvement, including families,
individuals and family-led organizations;
(iii) Quantitative and qualitative methods that were used to assess the
strengths and needs of the MCH population in each of the five identified
population health domains, MCH program capacity and supportive
partnerships/collaborations ;
(iv) Data sources utilized to inform the Needs Assessment process; and
(v) Interface between the collection of Needs Assessment data, the
finalization of the state’s Title V priority needs and the development of
the state’s Action Plan.
b.
Findings
Findings derived from the comprehensive Five-Year Needs Assessment serve
to inform the Title V program’s strategic planning, decision-making and
resource allocation efforts. These findings also provide a benchmark against
which states can compare and assess the progress that they have achieved
during the five-year reporting period.
The Needs Assessment Summary should highlight the state’s noted MCH
strengths/needs in three main areas:
(i) MCH Population Health Status
5
Gabor, V., Noonan, G., Anthony, J. and Gordon, E. “Review of the Title V 5-Year Needs Assessment Process in the
States and Jurisdictions.” Final Report, Health Systems Research, Inc. (Altarum), December 15, 2006.
20
(ii) Title V Program Capacity
(iii) Title V Program Partnerships, Collaboration and Coordination
i. MCH Population Health Status
The state should clearly describe the health status of the MCH population
within each of the five population health domains (i.e., Women/ Maternal
Health, Perinatal/Infant Health, Child Health, Adolescent Health, and
CSHCN), based on the quantitative and qualitative analyses conducted.
Specific discussion points should include:
(a) A summary of the noted strengths and needs in the overall MCH
population and in specific MCH sub-population groups;
(b) A concise description of the state’s successes, challenges and gaps
related to major morbidity, mortality, health risks or wellness for
each of the five population health domains. At a minimum, the
discussion should include the major health issues reflected in the
state’s priority needs relative to the MCH population as a whole or
specific sub-populations when stratified by age, income, geography,
frontier/rural/urban status, or other relevant characteristics.
(c) An analysis of current MCH Block Grant efforts in addressing the
needs of its MCH population to determine areas of success and areas
in which new or enhanced strategies/activities are needed.
ii. Title V Program Capacity
A state’s assessment of its Title V program capacity should examine
current resources, staffing and organizational structure, state agency
coordination and family partnerships. States should summarize the
findings from their Five-Year Needs Assessment relative to each of these
categories in the following sections.
(a) Organizational Structure
In reporting on the organizational structure of the Title V program,
the state should:
(i) Describe the organizational structure and placement of the
Governor, state health agency and the Title V MCH and CSHCN
programs in the state government.
(ii) Clarify how the state health agency is "responsible for the
administration (or supervision of the administration) of
programs carried out with allotments” under Title V
[Section 509(b)]. This description should include all of the
21
programs that are funded by the federal-state MCH Block
Grant.
(b) Agency Capacity
In summarizing the state Title V program capacity, the state should
describe the state Title V agency's capacity to promote and protect the
health of all mothers and children, including CSHCN. Included in this
description should be a discussion of the steps taken by the MCH and
CSHCN programs to ensure a statewide system of services that reflect
the components of comprehensive, community-based and familycentered care. The state should also describe the extent to which the
Title V program collaborates with other state agencies, health services
entities and private organizations to support health services delivery at
the community level.
Specifically, the state’s summary on Title V program capacity should
include the following:
(i) A description of the state’s Title V capacity to provide and assure
services within each of the five population health domains.
(ii) An expanded discussion on the state’s capacity for serving CSHCN,
which includes the Title V program’s ability to provide
rehabilitation services for blind and disabled individuals under the
age of 16 receiving benefits under Title XVI (the Supplemental
Security Income Program), to the extent that medical assistance
for such services is not provided under Title XIX (Medicaid). If
applicable, states may describe their capacity to serve CSHCN and
their families by referencing the National Consensus Standards for
Systems of Care for Children and Youth with Special Health Care
Needs as a guiding framework (AMCHP, 2014) 6.
(c) MCH Workforce Capacity
State Title V program efforts to implement the core public health
functions (assessment, policy development and assurance) and to
achieve increased accountability through ongoing performance
measurement and monitoring require an adequately sized and
skilled workforce. In reporting on their Title V program capacity,
states should describe the strengths and needs of their MCH and
CSHCN workforce. Specifically, states should include in their MCH
workforce summary the following information:
6
http://www.amchp.org/AboutTitleV/Resources/Documents/Standards%20Charts%20FINAL.pdf
22
(i) Number, location and full-time equivalents of state and local
staff who work on behalf of the state Title V programs;
(ii) Names and qualifications (briefly described) of senior level
management employees who serve in lead MCH-related
positions and program staff who contribute to the state’s
planning, evaluation, and data analysis capabilities;
(iii) Number of parent and family members, including CSHCN and
their families, who are on the state’s Title V program staff and a
brief description of their roles (e.g., paid consultant or
volunteer); and
(iv) Additional MCH workforce information, such as the tenure of
the state MCH workforce and projected shifts in the MCH and
CSHCN workforce over the five-year reporting period, that aligns
workforce capacity with the achievement of Title V program
goals.
iii.
Title V Program Partnerships, Collaboration, and Coordination
Title V programs partner with a range of federal, state and local entities to
further supplement state agency capacity in meeting the needs of its MCH
population. In summarizing these partnerships as well as the engagement
of stakeholders in programmatic decisions, the state should describe
relevant organizational relationships that serve to expand the capacity and
reach of a state Title V program in meeting the needs of its MCH
population, including CSHCN. The state should reference formal and
informal collaboration processes and partnerships with the public and
private sector and with state and local levels of government. In addition,
the state should describe the process for involving stakeholders and their
contributions to the Title V program.
In summarizing the strengths and weaknesses of its partnership building and
collaboration efforts, the state should describe its partnerships and
relationships with such programs as:
(a) Other MCHB investments (e.g., State System Development
Initiative (SSDI) Grants, Family-to-Family Health Information
Centers; MCHB investments related to newborn and early
childhood screenings, epilepsy, genetics, and blood disorders,
Maternal, Infant, and Early Childhood Home Visiting (MIECHV)
Grants, Healthy Start Grants, Early Childhood Systems of Care
(ECCS) Grants, MCH Training programs and other MCHB efforts
relating to injury prevention, autism, developmental disabilities,
23
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
adolescent health, workforce development, oral health, bullying
and emergency medical services for children);
Other Federal investments (e.g., ACF, CDC and USDA-funded
programs, such as immunizations, infant and child death reviews
and WIC);
Other HRSA programs (e.g., community health centers and
HIV/AIDS/AIDS programs and Area Health Education Centers);
State and local MCH programs (e.g., local health departments and
urban MCH programs );
Other programs within the State Department of Health (e.g.,
chronic disease, prevention and health promotion, immunization,
vital records and health statistics, injury prevention, behavioral and
mental health and substance abuse);
Other governmental agencies (e.g., Medicaid, CHIP, Education,
Social Services/Child Welfare, Social Security Administration,
Corrections and Vocational Rehabilitation Services);
Tribes, Tribal Organizations and Urban Indian Organizations;
Public health and health professional educational programs and
universities; and
Other state and local public and private organizations that serve
the state’s MCH population.
c. Identifying Priority Needs and Linking to Performance Measures
Consistent with Figure 4 on page 14, findings from the Five-Year Needs
Assessment should drive the state’s identification of its seven to ten highest
MCH priority needs for the five-year reporting cycle. The selected priorities
may address the defined MCH population groups and/or cross-cutting/
systems building areas, and they should reflect the unique needs of the state.
In addition, the identified priority needs should address areas in which a state
believes that targeted interventions can result in needed improvements to its
health care delivery systems. Once identified, the priority needs inform the
selection of a minimum of five NPMs, one in each of the MCH population
health domains, and the development of SPMs. Collectively, the NPMs and
SPMs should address the state’s identified priority needs.
States list their seven to ten priority needs on Form 9 of the
Application/Annual Report. The TVIS will record up to 10 priority needs, but a
state can include additional priorities in a field note, if desired. For each of the
listed priority needs on Form 9, states should indicate if the need is new for
this reporting cycle or if it is being revised or continued from the previous
reporting cycle.
24
The narrative discussion supplements the listing of the final priority needs by
providing a rationale for how the priority needs were determined and how
they link with the selected national and state performance measures.
Specifically, this discussion should include:
(i)
Methodologies used to rank the broad set of identified needs and the
state’s process for selecting its final seven to ten priorities;
(ii) Emerging issues or other frequently cited needs that were not included in
the final list of priority needs and a rationale for why they were not
selected;
(iii) Factors that contributed to changes in the state’s priority needs since the
previous five-year reporting cycle; and
(iv) Relationship between the priority need and the selected national and/or
state performance measures in driving improvement.
D. Financial Narrative
The development and implementation of a workable State Action Plan requires careful
analysis and utilization of available funding and resources. Building on the assessment
of state MCH population needs and Title V program needs, the state should present a
budget plan for the Application year that aligns its proposed Title V program activities
with the identified MCH needs. In addition, the state should report and reflect on its
MCH Block Grant expenditures for the Annual Report year. This reflection should
include a comparison of planned, budgeted activities with actual expenditures for that
fiscal year and link the allocation of financial resources with outcomes achieved relative
to the State’s Title V program plan. Together, the budget and expenditure narrative
reporting demonstrate how federal MCH Block Grant funds complement non-federal
Title V funds in enabling a state to address its unique MCH priority needs. The state
should also describe the contribution of federal MCH Block Grant funds towards
supporting essential MCH programs/services and the capacity of the state to
adequately address its MCH population needs in the absence of this federal funding.
The combined Expenditure and Budget narrative sections should demonstrate
accountability in the state’s use of its federal and state MCH Block Grant funds to meet
the program’s legislative intent, i.e., “to improve the health of all mothers and
children” (Section 501(a)). States should reflect on whether the Title V program efforts
and outcomes discussed in the State Action Plan and other sections of the
Application/Annual Report could have been achieved without federal MCH Block Grant
funding support.
States should maintain expenditure and budget documentation for the MCH Block
Grant, consistent with the requirements in Section 505(a) and Section 506(a). Per
Section 506(b)(1), each state is required to conduct an audit of its expenditures every
two years.
25
1. Expenditures
In describing its MCH Block Grant expenditures, states should reflect on the federal
and non-federal monies that have been obligated and spent. This discussion is
intended to provide the reader with an understanding of how the supported
programs and services link with the state’s MCH priority needs and meet the
requirements of Title V legislation.
The expenditure narrative should demonstrate the Federal/State partnership and
how federal support complements the state’s total MCH investment, as reflected
on Form 2, Lines 3-6 (i.e., reported State, Local, Other, and Program Income
expenditures). States should monitor expenditures regularly to ensure compliance
with legislative financial requirements. The state should document and explain
how the reported expenditures comply with the 30%-30%-10% requirements, as
specified in Section 504(d) and Section 505(a)(3). Significant variations of more
than 10% in the expenditure data reported on Form 2 and Form 3, as compared to
the state’s planned budget for that same fiscal year, should be explained in the
narrative discussion. In addition, states should reflect on the number/percent of
the MCH population who are served by Title V, as reported on Form 5, and provide
a description of the state’s efforts to expand its reach. Challenges faced by the
state should be noted and addressed.
It is recognized that funds for the reporting year may be not be fully expended at
the time of submission. Given that the state is required to submit a Federal
Financial Report (FFR) with the final financial data within 3 months of the expiration
of funds, the most recent expenditure data should be reported at the time of
submission. The state may wish to utilize the form or field notes on Forms 2 and
Form 3 to explain any discrepancies in its submitted financial data and work with its
MCHB Project Officers in reporting final expenditures.
States report the federal and non-federal MCH Block Grant expenditures separately
on the budget/expenditure forms. This breakdown should be further examined as
part of the narrative discussion.
With respect to Medicaid, Title V should be the payer of last resort and MCH Block
Grant funds cannot be used to reimburse a claim for a service that is otherwise
covered under Medicaid. Additionally, service providers receiving MCH Block Grant
funds are strongly encouraged to seek payment from other public and private
insurance providers when applicable. The state should describe how services
supported by the MCH Block Grant reflect services that were not covered or
reimbursed through the Medicaid program or another provider.
26
2. Budget
In its budget narrative, a state should present a plan that describes how federal and
non-federal Title V funds will be used to address the state’s priority needs, improve
performance related to the targeted MCH outcomes and expand its systems of care
for both the MCH and CSHCN populations. The budget narrative should also
demonstrate and assure the state’s commitment to complying with the legislative
financial requirements (e.g., 30%-30%-10% requirements) and program regulations.
Similar to the narrative description that the state provided for its expenditures, the
budget narrative should demonstrate the federal-state partnership and how federal
MCH Block Grant support will be utilized to complement the state’s planned total
match (i.e., State, Local, Other, and Program Income funds) for the Application
year. The budget narrative should highlight the State’s MCH/CSHCN program and
align with the identified MCH/CSHCN priorities. This discussion should clearly
articulate how federal and non-federal MCH Block Grant funds will support the
activities that are described in the State Action Plan for the upcoming budget
period.
While the final federal MCH Block Grant allocation is not yet known, states should
use the allocation for the current fiscal year as a basis for determining budget
estimates for federal and non-federal MCH Block Grant funds in the Application
year. In the budget narrative discussion, the state should describe sources of other
federal MCH dollars (as noted on Form 2, Line 9), state matching funds and other
state funds used by the agency in its Title V programming. This discussion should
include how MCH Block Grant funds support essential services, as defined by the
Title V MCH Services Block Grant Pyramid (Figure 1), for the three legislatively
defined populations. The narrative discussion should provide an explanation of
how the planned funding will support the budget estimates for individuals served
and types of services provided, as reported on Form 3a and Form 3b.
Significant variations in the budgeted amounts reported by a state on Form 2 and
Form 3, as compared to previous years’ reporting, should be explained. Any budget
notes provided on Form 2, Form 3a, and Form 3b should be further clarified in the
narrative discussion.
The state should describe how the it plans to meet and monitor the required match
requirements, which includes a $3 match in non-federal funds for every $4 of
federal MCH Block Grant funds expended [Section 503(a)] and the maintenance of
effort from 1989 [Section 505(a)(4)]. Any continuation funding for special projects
[Section 505(a)(5)(C)(i)]; or special consolidated projects as defined in Section
501(b)(1) and the nondiscrimination provisions in Section 505(a)(5)(B) should also
be briefly described.
27
States are reminded that “any amount payable to a state under this title from
allotments for a fiscal year, which remains unobligated at the end of such year, shall
remain available to such state for obligation during the next fiscal year. No
payment may be made to a state under this title from allotments for a fiscal year
for expenditures made after the following fiscal year” [Section 503(b)]. While
states apply annually for MCH Block Grant funding, a state has two years in which
to expend the federal MCH Block Grant allocation awarded in any fiscal year.
E.
Five-Year State Action Plan
States shall develop a five-year State Action Plan in follow-up to the Five-year Needs
Assessment. This Action Plan serves as the Application/Annual Report narrative
discussion for the state on their planned activities for the Application year and the
activities that were implemented in the Annual Report year. Activities should be
discussed relative to the pertinent domain, state priority need, Title V program goal,
evidence-based or -informed strategies and national and state-specific performance
and outcome measures. Building on its needs assessment, financial planning and
performance reporting, the state’s five-year action planning begins with the
completion of the State Action Plan Table.
1. Five-Year State Action Plan Table
Based on the logic model presented in Figure 4, the State Action Plan Table
(Figure 6) is intended to serve as a planning tool for states to use in identifying key
strategies, objectives and relevant performance measures to align with the selected
priority needs. Organized by the five MCH population health domains
(i.e., women/maternal health, perinatal/infant health, child health, CSHCN and
adolescent health) and the sixth cross-cutting and systems building domain, the
State Action Plan Table should include the following components.
a. Priority Needs – Title V legislation directs states to conduct a state-wide MCH
Needs Assessment every 5 years to identify the need for preventive and primary
care services for pregnant women, mothers, infants, children, and CSHCN.
From this assessment, states select seven to ten priorities for focused
programmatic efforts over the five-year reporting cycle.
b. Strategies – Strategies are the general approaches taken to achieve the
objectives; activities are specific actions to implement the strategies. Program
activities for implementing the identified strategies will be discussed and
updated annually as part of the State Action Plan narrative.
c. Objectives – An objective is a statement of intention with which actual
achievement and results can be measured and compared. SMART objectives
are Specific, Measurable, Achievable, Relevant and Time-phased.
28
d. Performance Measures – For purposes of the MCH Block Grant, performance
measures include both national and state-specific measures (i.e., NPMs, ESMs,
SOMs, and SPMs). States select performance measures that align with their
identified strategies, and to the NOMs and SOMs.
States should update the Five-year State Action Plan Table as needed for each
year’s Application/Annual Report.
Figure 6. Five-Year State Action Plan Table
Priority
Needs
Strategies
Objectives
National and
State
Performance
Measures
Women’s/Maternal
Health
Perinatal/Infant Health
Child Health
CSHCN
Adolescent Health
Cross-cutting/Systems
Building
29
Evidence–
Based or
–Informed
Strategy
Measures
National and
State Outcome
Measures
2. State Action Plan Narrative Overview
a. State Title V Program Purpose and Design
Each state Title V program is unique in its organizational and fiscal structure;
operating statutes and regulations; available resources; targeted MCH needs;
established performance goals; and portfolio of supported programs and
services. States should provide a “big picture” overview of their Title V program
to give context to the activities and approaches that are described in the State
Action Plan. Noted discussion points should include:
(i) The Title V program’s partnership and leadership roles in accomplishing the
MCH Block Grant’s goals and mission;
(ii) The Title V program’s framework (e.g., life course model) and strategic
approach to addressing the identified MCH priorities while considering
program successes, ongoing challenges and emerging issues;
(iii) The purpose and commitment of the Title V program in providing a
foundation for family and community health across the state and in assuring
access to the delivery of quality health care services for mothers, infants and
children, including CSHCN.
Given the uniqueness of each state, the Title V program has flexibility in writing
a narrative description that best conveys the elements it considers to be the
most critical in giving context to the Title V program. This description should
respond to the question, “What does a reader need to know about the Title V
program to understand the activities and approaches that are described in the
State Action Plan?” Most relevant to this discussion is the Title V program’s
demonstrated leadership in such areas as:
(i) Serving as a convener, collaborator and partner in addressing MCH issues;
(ii) Supporting coordinated, comprehensive and family-centered systems of
care at state and local levels, which may include the implementation of
AMCHPs’ National Consensus Standards for Systems of Care for Children and
Youth with Special Health Care Needs;
(iii) Developing and utilizing innovative and evidence-based or -informed
approaches to address cross-cutting issues that impact the health status of
specific MCH populations and sub-populations, such as social determinants
of health; and
(iv) Implementing the core public health functions of assessment, assurance and
policy development through program efforts that are supported by the MCH
Block Grant.
30
b. Supportive Administrative Systems and Processes
In developing the Action Plan, the state should describe other administrative
factors (e.g., personnel, family partnerships, MCH program capacity and
integrated health care delivery partnerships) that influence the Title V
program’s ability to meet its planning goals and objectives.
(i) MCH Workforce Development
Successful implementation of the five-year State Action Plan requires a
workforce that is adequate in size, effectively trained and properly
supported. The state should describe its Title V program workforce plan and
the strategies in place for advancing a common agenda and future MCH
workforce vision (e.g., types of personnel and skill sets needed). Specific
activities to meet the following three workforce goals, along with other
state-identified goals, should be discussed.
(a) Recruitment and retention of a qualified Title V program staff;
(b) Training and growth opportunities for Title V program staff and family
leaders; and
(c) Innovations in staffing structures and workforce financing.
(ii) Family Partnership
As discussed on page 8 family partnership is defined in the MCH Block Grant
as: “the intentional practice of working with families for the ultimate goal of
positive outcomes in all areas through the life course. Family engagement
reflects a belief in the value of the family leadership at all levels from an
individual, community and policy level.”
The state should provide an overarching discussion of its organizational
capacity and vision for partnering with families and individuals in all aspects
of their Title V Action Plan development and implementation in all
population domains. Descriptions of partnership activities may include, but
are not limited to, the following areas:
(a)
(b)
(c)
(d)
(e)
(f)
(g)
Advisory Committees;
Strategic and Program Planning;
Quality Improvement;
Workforce Development and Training;
Block Grant Development and Review;
Materials Development; and
Program Outreach and Awareness
31
Training activities that serve to strengthen and advance family partnership
in the Title V program, both in orientation and ongoing professional
development, which are conducted for staff, family leaders, volunteers,
contractors and subcontractors should be discussed. In addition, the state
should describe the contributions of family and community leaders to such
Title V program processes as assessment of needs/assets, program planning,
MCH and CSHCN services delivery and evaluation/monitoring/quality
improvement activities. Participating members should reflect the MCH
community that is being served.
Specific details on the roles and responsibilities of families, individuals and
family-led organizations at the direct care, organizational and governance,
and policymaking levels, should be presented in each of the MCH
domain-specific discussions in the State Action Plan. The state should
highlight the outcomes and impacts of their family partnerships on Title V
program policies and activities in the overarching discussion. Specific
impacts of family partnership on each of the five MCH populations and on
the Title V program’s cross-cutting and systems building activities should be
included in the appropriate MCH domain narrative discussion.
(iii) States Systems Development Initiative and Other MCH Data Capacity
Efforts
States who receive SSDI funding should discuss how this grant funding
supports MCH data collection and reporting in the MCH Block Grant. In
addition, each state should discuss its progress in achieving direct, annual
access to timely, electronic MCH health data and how these data have
served to inform and support Title V programming, assessment and
monitoring.
States should also highlight other MCH epidemiological and data
enhancement activities that support Title V needs assessment and
performance measure reporting.
Launched in 1993, the purpose of the State Systems Development Initiative
(SSDI) is to develop, enhance, and expand state and jurisdictional Title V
MCH data capacity for responding to the needs assessment activities and
performance measure reporting requirements in the MCH Block Grant.
Such enhanced MCH data capacity is intended to enable states and
jurisdictional Title V programs to engage in informed decision-making and
resource allocation that supports effective, efficient and quality
programming for women, infants, children, including CSHCN, and their
families. SSDI complements the MCH Block Grant by improving the
availability, timeliness, and quality of MCH data in the 59 states and
32
jurisdictions. Utilization of these data is central to state and jurisdictional
reporting on their Title V program assessment, planning, implementation,
and evaluation efforts, along with related investments, in the yearly MCH
Block Grant Application/Annual Report.
Collection and reporting of timely and comprehensive MCH Block Grant
data is determined in part by the state’s ability to link data from multiple
sources (e.g., vital records, child health surveys, newborn screening,
Medicaid claims, immunization and birth defects registries, hospital
discharges and the Special Supplemental Nutrition Program for Women,
Infants and Children (WIC)) and across programs.
(iv) Health Care Delivery System
Organizational relationships and the leveraging of federal and state program
resources contribute to the services delivery capacity of a state Title V
program. States should provide a description of their collaborative work
with other federal, state and non-governmental partners, and how this work
complements Title V program efforts to provide a system’s approach to
ensure access to quality health care and needed services for the MCH
population.
Within a state, the Title V program and Title XIX Medicaid program share a
common goal in working to improve the overall health of the MCH
population through affordable health care delivery systems and expanded
coverage. Partnership and collaboration between these two programs allow
for the effective leveraging of federal and state resources, which yields
administrative efficiencies to help ensure that women and children are
provided needed preventive services, health examinations, treatments and
follow-up care. Section 509(a)(2) of Title V of the Social Security Act cites
the need to promote “coordination at the Federal level of activities
authorized under this title [Title V] and under title XIX….” Also,
Section 1902(a)(11) of Title XIX requires State Medicaid agencies to enter
into Inter-Agency Agreements (IAAs) with state Title V agencies. This
provision further clarifies that Medicaid funds are to be used to reimburse
expenditures made by the Title V agency for Medicaid-covered services to
Medicaid recipients, as appropriate, (i.e., that Medicaid should be the first
payer.)
The state should provide a detailed description of the existing relationship
between the Title V program and the Medicaid program, which builds on
the noted areas of coordination and collaboration in the IAA/Memorandum
of Understanding (MOU). A copy of the most recently signed IAA/MOU is a
required attachment for this Application/Annual Report.
33
The state’s narrative discussion should address areas of defined
coordination between the two programs and the benefits that have been
realized. At a minimum, the discussion should address Title V program
impacts in the following areas:
a. Program outreach and enrollment;
b. Health care financing (e.g., the percent of services delivered by managed
care organizations (MCO), primary care case management (PCCM) and
fee for service, if applicable);
c. Waivers or state plan amendments that influence health care delivery
for the MCH population, particularly CSHCN; and
d. Joint policy level decision making on issues related to MCH services
delivery and coverage, particularly for CSHCN.
In working to strengthen their Title V – Title XIX IAAs, states may wish to
consider the strategies developed by the National Academy of State Health
Policy (NASHP) under funding support provided by the HRSA/MCHB. 7
c.
State Action Plan Narrative by Domain
Supplemental to the overarching State Action Plan narrative discussion is the
state’s detailed reporting, by MCH domain, on its specific Title V program
activities for the Annual Report year and for the Application year. The order
of the narrative reporting is organized to allow states to discuss their
strategies, achievements and performance trends, relevant to the specific
MCH domain, in the Annual Report year prior to presenting the planned
activities and performance objectives for the Application year. The six MCH
domains are:
Five MCH Population Domains
1. Women/Maternal Health
2. Perinatal/Infant Health
3. Child Health
4. Adolescent Health
5. CSHCN
Optional Domain
6. Cross-cutting/Systems Building
The state should include a discussion of the selected NPM and related ESM(s),
along with any SPMs and/or SOMs, in each of the five MCH population
7
Wirth, B. and Van Landeghem, K. “Strengthening the Title V-Medicaid Partnership: Strategies to Support the
Development of Robust Interagency Agreements between Title V and Medicaid.” April 2017.
http://nashp.org/wp-content/uploads/2017/04/Strengthening-the-Title-V-Updated.pdf.
34
domains. While there is not an associated NPM in the Cross-cutting/Systems
Building domain, the state should report on any state-initiated activities or
established SPMs/SOMs that fall within this domain. This discussion will likely
build on the high-level presentation in the State Action Plan Narrative
Overview and include more detailed descriptions of such Title V program
efforts as strengthening family partnerships, addressing social determinants
of health, expanding MCH data capacity and enhancing public health
surveillance/reporting systems.
The domain-specific State Action Plan narrative discussion should focus on the
alignment of the strategies, objectives and performance measures for a
corresponding priority need, as outlined in the State Action Plan Table. This
discussion should primarily include strategies and activities for which the
Title V program has a leadership role in administering the activity. Critical
partnerships with other MCHB-supported programs (e.g., MIECHV, MCH
Training Programs, Healthy Start programs and Collaborative Improvement
and Innovation Networks (CoIINs)) should be highlighted, along with family
partnerships, in the relevant MCH domain narrative discussions.
For the Annual Report year, the state should:
1. Provide an analysis that gives context to the state of this population
domain;
2. Summarize programmatic efforts and the use of evidence-based or
-informed approaches to address each of the identified priority needs;
3. Re-assess the alignment of the selected NPMs, ESMs, SPMs and SOMs, if
applicable, with its related priority need:,
4. Analyze the state’s progress in achieving its established performance
measure targets along with other programmatic impacts;
5. Note challenges and emerging issues that have resulted in changes to the
State Action Plan; and
6. Assess the overall effectiveness of the implemented program strategies
and approaches in addressing the identified MCH population needs and in
promoting continuous quality program improvement.
For the Application year, the state should:
1. Describe the planned activities for the Application year, with ongoing
emphasis on their relevance to the identified priority needs;
2. Align planned activities with the priority needs that were identified based
on the Five-Year Needs Assessment and the annual needs assessment
updates;
3. Assess if new priorities have emerged that take precedence over the
established priority needs;
35
4. Assess the relevance of the current ESM(s) for a selected NPM and
determine if a new ESM needs to be established;
5. Assess if changes are needed in the established SPMs and SOMs, if
applicable; and
6. Discuss updates to the Five-year Action Plan Table that reflect new or
revised priority needs, evidence-based or -informed strategies or
performance measures for driving improved performance.
MCH strategies and activities that reflect ongoing efforts and support the
overall system of care for the MCH population but do not directly align with a
State’s identified priority needs should be discussed in the relevant MCH
domain. For example, state Title V program support for newborn screening
should be described in the perinatal/infant health section regardless if there is
an identified priority need.
F. Public Input [Section 505a]
In its Application/Annual Report, the state should describe its process for making the
Application/Annual Report available to the public for comment during its development
and after its transmittal. This discussion should include efforts by the state to solicit
public comments during the development of the Application/Annual Report. The
number and nature of the comments received and how they were addressed in the
final Application/Annual Report should be noted for each year. The state should clearly
identify specific activities for engaging families and other stakeholders prior to, during
and after the Application process. Such activities may include:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Public Hearings;
Advisory Council Review;
Web Posting;
Social Media;
Public Notices;
Other Use of Media; and
Outreach to Specific Stakeholders (e.g., MCH Training Grantees)
G. Technical Assistance
States should consider potential areas of needed technical assistance as they work to
implement their five-year Action Plan. In accordance with the responsibilities specified
in Section 509 of the Title V legislation, the MCHB makes available to states and
jurisdictions needed technical support and resources, as determined by a state. To
receive MCHB-supported technical assistance, the state may complete and submit a
Technical Assistance Request Form. This form is available upon request from the MCHB
Project Officer.
36
PART THREE: REPORTING FORMS
Form 1
Application for Federal Assistance (Standard Form - 424)
Form 2
MCH Budget/Expenditure Details
Form 3a
Budget and Expenditure Details by Types of Individuals Served (IA and IB)
Form 3b
Budget and Expenditure Details by Types of Services (IIA and IIB)
Form 4
Number and Percentage of Newborns and Others Screened, Cases
Confirmed and Treated
Form 5a
Count of Individuals Served By Title V
Form 5b
Total Percentage of Populations Served by Title V
Form 6
Deliveries and Infants Served by Title V and Entitled to Benefits Under
Title XIX
Form 7
State MCH Toll-Free Telephone Line and Other Appropriate Methods Data
Form 8
State MCH and CSHCN Directors Contact Information
Form 9
List of MCH Priority Needs
Form 10
Tracking Measures (NPMs, ESMs, SPMs and SOMs)
Form 11
Other State Data (OSD) – #01 - #03
37
38
39
40
Instructions for Application for Federal Assistance (SF-424)
This is a standard form required for use as a cover sheet for submission of pre-applications and applications and related
information under discretionary programs. Some of the items are required and some are optional at the discretion of
the applicant or the federal agency (agency). Required fields on the form are identified with an asterisk (*) and are also
specified as "Required" in the instructions below. In addition to these instructions, applicants must consult agency
instructions to determine other specific requirements.
Item
Field Name
1.
Type of Submission:
Information
(Required) Select one type of submission in accordance with agency
instructions.
Pre-application
Application
Changed/Corrected Application - Check if this submission is to
change or correct a previously submitted application. Unless
requested by the agency, applicants may not use this form to
submit changes after the closing date.
(Required) Select one type of application in accordance with agency
instructions.
•
•
•
2.
Type of Application:
New - An application that is being submitted to an agency for the
first time.
• Continuation - An extension for an additional funding/budget
period for a project with a projected completion date. This can
include renewals.
• Revision - Any change in the federal government's financial
obligation or contingent liability from an existing obligation. If a
revision, enter the appropriate letter(s). More than one may be
selected. If "Other" is selected, please specify in text box provided.
A. Increase Award
B. Decrease Award
C. Increase Duration
D. Decrease Duration
E. Other (specify)
Leave this field blank. This date will be assigned by the Federal agency.
Enter the entity identifier assigned by the Federal agency, if any, or the
applicant's control number if applicable.
Enter the number assigned to your organization by the federal agency, if
any.
For new applications leave blank. For a continuation or revision to an
existing award, enter the previously assigned federal award identifier
number. If a changed/corrected application, enter the federal identifier in
accordance with agency instructions.
Leave this field blank. This date will be assigned by the state, if applicable.
Leave this field blank. This identifier will be assigned by the state, if
applicable.
Enter the following in accordance with agency instructions:
(Required) Enter the legal name of applicant that will undertake the
assistance activity. This is the organization that has registered with the
•
3.
4.
Date Received:
Applicant Identifier:
5a.
Federal Entity Identifier:
5b.
Federal Award Identifier:
6.
7.
Date Received by State:
State Application Identifier:
8.
Applicant Information:
a. Legal Name:
41
b. Employer/Taxpayer Number
(EIN/TIN):
c. Organizational DUNS:
d. Address:
e. Organizational Unit:
9.
f. Name and contact
information of person to be
contacted on matters involving
this application:
Type of Applicant: (Required)
Select up to three applicant
type(s) in accordance with
agency instructions.
10.
Name Of Federal Agency:
11.
Catalog Of Federal Domestic
Assistance Number/Title:
12.
Funding Opportunity
Number/Title:
Central Contractor Registry (CCR). Information on registering with CCR may
be obtained by visiting www.Grants.gov.
(Required) Enter the employer or taxpayer identification number (EIN or
TIN) as assigned by the Internal Revenue Service. If your organization is not
in the US, enter 44-4444444.
(Required) Enter the organization's DUNS or DUNS+4 number received from
Dun and Bradstreet. Information on obtaining a DUNS number may be
obtained by visiting www.Grants.gov.
Enter address: Street 1 (Required); city (Required); County/Parish, State
(Required if country is US), Province, Country (Required), 9-digit zip/postal
code (Required if country US).
Enter the name of the primary organizational unit, department or division
that will undertake the assistance activity.
Enter the first and last name (Required); prefix, middle name, suffix, title.
Enter organizational affiliation if affiliated with an organization other than
that in 7.a. Telephone number and email (Required); fax number.
A. State Government
B. County Government
C. City or Township Government
D. Special District Government
E. Regional Organization
F. U.S. Territory or Possession
G. Independent School District
H. Public/State Controlled Institution of Higher Education
I. Indian/Native American Tribal Government (Federally Recognized)
J. Indian/Native American Tribal Government (Other than Federally
Recognized)
K. Indian/Native American Tribally Designated Organization
L. Public/Indian Housing
M. Nonprofit
N. Private Institution of Higher Education
O. Individual
P. For-Profit Organization (Other than Small Business)
Q. Small Business
R. Hispanic-serving Institution
S. Historically Black Colleges and Universities (HBCUs)
T. Tribally Controlled Colleges and Universities (TCCUs)
U. Alaska Native and Native Hawaiian Serving Institutions
V. Non-US Entity
W. Other (specify)
(Required) Enter the name of the federal agency from which assistance is
being requested with this application.
Enter the Catalog of Federal Domestic Assistance number and title of the
program under which assistance is requested, as found in the program
announcement, if applicable.
(Required) Enter the Funding Opportunity Number and title of the
opportunity under which assistance is requested, as found in the program
announcement.
42
13.
14.
Competition Identification
Number/Title:
Areas Affected By Project:
15.
Descriptive Title of Applicant's
Project:
16.
Congressional Districts Of:
17.
Proposed Project Start and End
Dates:
Estimated Funding:
18.
19.
Is Application Subject to Review
by State Under Executive Order
12372 Process?
20.
Is the Applicant Delinquent on
any Federal Debt?
21.
Authorized Representative:
Enter the competition identification number and title of the competition
under which assistance is requested, if applicable.
This data element is intended for use only by programs for which the
area(s) affected are likely to be different than the place(s) of performance
reported on the SF-424 Project/Performance Site Location(s) Form. Add
attachment to enter additional areas, if needed.
(Required) Enter a brief descriptive title of the project. If appropriate,
attach a map showing project location (e.g., construction or real property
projects). For pre-applications, attach a summary description of the project.
15a. (Required) Enter the applicant's congressional district. 15b. Enter all
district(s) affected by the program or project. Enter in the format: 2
characters state abbreviation - 3 characters district number, e.g., CA-005 for
California 5th district, CA-012 for California 12 district, NC-103 for North
Carolina's 103 district. If all congressional districts in a state are affected,
enter "all" for the district number, e.g., MD-all for all congressional districts
in Maryland. If nationwide, i.e. all districts within all states are affected,
enter US-all. If the program/project is outside the US, enter 00-000. This
optional data element is intended for use only by programs for which the
area(s) affected are likely to be different than place(s) of performance
reported on the SF-424 Project/Performance Site Location(s) Form. Attach
an additional list of program/project congressional districts, if needed.
(Required) Enter the proposed start date and end date of the project.
(Required) Enter the amount requested, or to be contributed during the
first funding/budget period by each contributor. Value of in-kind
contributions should be included on appropriate lines, as applicable. If the
action will result in a dollar change to an existing award, indicate only the
amount of the change. For decreases, enclose the amounts in parentheses.
(Required) Applicants should contact the State Single Point of Contact
(SPOC) for Federal Executive Order 12372 to determine whether the
application is subject to the State intergovernmental review process. Select
the appropriate box. If "a." is selected, enter the date the application was
submitted to the State.
(Required) Select the appropriate box. This question applies to the
applicant organization, not the person who signs as the authorized
representative. Categories of federal debt include; but, may not be limited
to: delinquent audit disallowances, loans and taxes. If yes, include an
explanation in an attachment.
To be signed and dated by the authorized representative of the applicant
organization. Enter the first and last name (Required); prefix, middle name,
suffix. Enter title, telephone number, email (Required); and fax number. A
copy of the governing body's authorization for you to sign this application
as the official representative must be on file in the applicant's office.
(Certain federal agencies may require that this authorization be submitted
as part of the application.)
43
FORM 2
MCH BUDGET/EXPENDITURE DETAILS
[SECTIONS 503(a), 504(d) AND 505(a)(3),(4)]
FY__ Application
Budgeted
FY__ Annual Report
Expended
$___________
$___________
A. Preventive and Primary Care for Children:
$___________ (__%)
$___________ (__%)
B. Children with Special Health Care Needs:
$___________ (__%)
$___________ (__%)
C. Title V Administrative Costs:
$___________ (__%)
$___________ (__%)
2. SUBTOTAL OF LINES 1A-C (This subtotal does not include)
Pregnant Women and All Others)
$___________
$___________
3. STATE MCH FUNDS (Item 18c of SF-424)
$___________
$___________
4. LOCAL MCH FUNDS (Item 18d of SF-424)
$___________
$___________
5. OTHER FUNDS (Item 18e of the SF-424)
$___________
$___________
6. PROGRAM INCOME (Item 18f of SF-424)
$___________
$___________
7. TOTAL STATE MATCH (Lines 3 through 6)
$___________
A. Enter your State's FY 1989
Maintenance of Effort Amount $____________________
$___________
1. FEDERAL ALLOCATION
(Referenced items on the Application Face
Sheet [SF-424] apply only to the Application Year)
Of the Federal Allocation, the amount earmarked for:
8. FEDERAL-STATE TITLE V BLOCK GRANT PARTNERSHIP SUBTOTAL
(Total lines 1 and 7)
$___________
$___________
9. OTHER FEDERAL FUNDS [Select Appropriate Funding Sources from the Drop-Down Box]
(Report only funds under the control of the Title V Program Administrator)
Select the Appropriate Federal Department
Select the Appropriate Federal Agency.
$___________
Select the Appropriate Federal Grant Program.
$___________
10. OTHER FEDERAL FUNDS (SUBTOTAL of all funds under item 9)
$___________
$___________
11. STATE MCH BUDGET/EXPENDITURE GRAND TOTAL
(Partnership Subtotal + Other Federal MCH Funds Subtotal)
$__________
$___________
44
INSTRUCTIONS FOR COMPLETION OF FORM 2
MCH BUDGET/EXPENDITURE DETAILS
Title V Citation: Section 504(d) states: “Of the amounts paid to a State...not more than 10 percent may be
used for administering the funds paid....” In order to be entitled to payments for allotments under Title V,
Section 505(a)(3) provides that the State will use: “(A) at least 30 percent of such payment amounts for
preventive and primary care services for children, and (B) at least 30 percent of such payment amounts for
services to children with special health care needs.” Section 505(a)(4) provides that a State receiving funds for
maternal and child health services “...shall maintain the level of funds being provided solely by such State for
maternal and child health programs at a level at least equal to the level that such State provided for such
programs in fiscal year 1989....”
Instructions: This form provides details of the State’s MCH budget and expenditures for the Application year
and Annual Report year, respectively, and the fulfillment of certain spending requirements under Title V for a
given year. A Glossary that contains terms applicable to this form is provided in Appendix H of the Supporting
Documents, which accompany the Application/Annual Report Guidance. Note: It is recognized that States
may not have final expenditure data at the time of submission of the application/annual report. States will
report final expenditure data at grant closeout.
LINE NUMBER
1
INSTRUCTIONS FOR APPLICATION BUDGETED
The Title V Information System (TVIS) will prepopulate the Federal Title V allocation from the
SF 424 (Item 18a).
1A
Enter the amount of the Federal allotment for preventive and primary care for children. The
percentage of the total (Line 1) that this amount represents will be calculated by TVIS.
1B
Enter the amount of the Federal allotment for children with special health care needs. The
percentage of the total (Line 1) that this amount represents will be calculated by TVIS.
1C
Enter the amount of the Federal allotment for the administration of the allotment. The
percentage of the total (Line 1) that this amount represents will be calculated by TVIS.
2
The TVIS will calculate the subtotal of Lines 1A, 1B and 1C. Please note that Pregnant Women
and All Others will not be included in this amount.
3
The TVIS will prepopulate the amount of your State total funds for the Title V allocation
(match) from the SF 424 (Item 18c).
4
The TVIS will prepopulate the amount of total MCH dedicated matching funds garnered from
local jurisdictions within your State from the SF 424 (Item 18d).
5
The TVIS will prepopulate the total of MCH funds available from other sources such as
foundations from the SF 424 (Item 18e).
6
The TVIS will prepopulate the amount of MCH program income funds collected by your
State’s MCH agencies from insurance payments, MEDICAID, HMO’s, etc. from the SF 424
(Item 18f).
7
The TVIS will calculate the sum total of Lines 3, 4, 5, and 6 for the total of your State match
and overmatch.
7A
The TVIS will prepopulate your State’s FY 1989 Maintenance of Effort amount.
8
The TVIS will calculate the total for Lines 1 and 7. This amount is the “Federal-State Title V
Block Grant “Partnership.”
9
Use the respective drop-down menus in TVIS to select all Federal funding award programs
planned to be received by the State MCH program other than the Title V Block Grant that are
directly under the control of the Title V Program Administrator and enter planned amounts.
45
10
The TVIS will calculate the sum of all lines in item 9.
11
The TVIS will calculate the sum of Lines 8 and 10. This amount is the total of all MCH funds
administered by your State’s MCH program.
INSTRUCTIONS FOR ANNUAL R EPORT EXPENDED
Enter the Federal Title V allocation received. Note: TVIS will display the original budgeted
amounts for reference.
LINE NUMBER
1
1A
Enter the amount of the Federal allotment for preventive and primary care for children. The
percentage of the total (Line 1) that this amount represents will be calculated by TVIS.
1B
Enter the amount of the Federal allotment for children with special health care needs. The
percentage of the total (Line 1) that this amount represents will be calculated by TVIS.
1C
Enter the amount of the Federal allotment for the administration of the allotment. The
percentage of the total (Line 1) that this amount represents will be calculated by TVIS.
2
The TVIS will calculate the subtotal of Lines 1A, 1B and 1C. Please note that Pregnant Women
and All Others will not be included in this amount.
3
Enter the amount of your State total funds for the Title V allocation (match).
4
Enter the amount of total MCH dedicated matching funds garnered from local jurisdictions
within your State.
5
Enter the total of MCH funds available from other sources such as foundations.
6
Enter the amount of MCH program income funds collected by your State’s MCH agencies
from insurance payments, MEDICAID, HMO’s, etc..
7
The TVIS will calculate the sum total of Lines 3, 4, 5, and 6 for the total of your State match
and overmatch.
7A
The TVIS will prepopulate your State’s FY 1989 Maintenance of Effort amount.
8
The TVIS will calculate the total for Lines 1 and 7. This amount is the “Federal-State Title V
Block Grant “Partnership.”
9
TVIS will prepopulate programs and amounts. Adjust the amounts to reflect actuals
expended during the budget period. Use field and form notes for any major changes to
awards from what had been projected to be received. For Federal awards budgeted or
received that are not included in the menu in TVIS, select “Other” and enter the appropriate
information.
10
The TVIS will calculate the sum of all lines in item 9.
11
The TVIS will calculate the sum of Lines 8 and 10. This amount is the total of all MCH funds
administered by your State’s MCH program.
46
FORM 3a
BUDGET AND EXPENDITURE DETAILS BY TYPES OF INDIVIDUALS SERVED (IA and IB)
[Section 506(a)(2)(A)(iv), Section 505(a)(2)(A-B) and Section 506(a)(1)(A-D)]
I. TYPES OF INDIVIDUALS SERVED
FY ____ Application
IA. Federal MCH
Block Grant
FY ____ Annual Report
Budgeted
Expended
1.
Pregnant Women
$_______
$_______
2.
Infants < 1 year
$_______
$_______
3.
Children 1 through 21 years
$_______
$_______
4.
CSHCN
$_______
$_______
5.
All Others
$_______
$_______
Federal TOTAL
$_______
$_______
FY ____ Application
IB. Non-Federal MCH
Block Grant
FY ____ Annual Report
Budgeted
Expended
1.
Pregnant Women
$_______
$_______
2.
Infants < 1 year
$_______
$_______
3.
Children 1 through21 years
$_______
$_______
4.
CSHCN
$_______
$_______
5.
All Others
$_______
$_______
Non-Federal TOTAL
$_______
$_______
FY ____ Application
Budgeted
FEDERAL-STATE MCH BLOCK GRANT
PARTNERSHIP TOTAL
$_______
47
FY ____ Annual Report
Expended
$_______
INSTRUCTIONS FOR COMPLETION OF FORM 3a
BUDGET/EXPENDITURE DETAILS BY TYPES OF INDIVIDUALS SERVED
Title V Citation: Section 506(a)(2)(A)(iv) requires that each State submit an annual report of its activities under
its Title V program. Among the items required to be reported are, “...the amount spent under this title...by
class of individuals served.”
Instructions: Complete all required data cells. If an actual number is not available, the State should provide an
estimate. All estimates should be explained in a form or field note. A Glossary that contains terms applicable
to this form is provided in Appendix H of the Supporting Documents, which accompany the Application/Annual
Report Guidance.
LINE NUMBER
I.A.1 – I.A.5
INSTRUCTIONS
Enter the budgeted (Application year) and expended (Annual Report year) amounts for the
Federal MCH allocation. Any discrepancies should be addressed with a field or form note in
TVIS.
**Note: The amounts for Children 1 through 21 years and CSHCN should match the amounts reported on
Form 2, Lines 1a and 1b for budgeted (Application year) and expended (Annual Report year), respectively.
**Note: Line 2 on Form 2 should not equal 100% if amounts are reported for Pregnant Women.
I.A.1
Federal TOTAL
I.B.1 - I.B.5
The TVIS will calculate the sum of the amounts entered for Lines I.A.1 through I.A.5.
**Note: The Federal TOTAL should equal the Federal Allocation total minus the Title V Administrative Costs.
Enter the budgeted (Application year) and expended (Annual Report year) amounts for the
non-Federal Title V program funds.
I.B.1
Non-Federal
TOTAL
The TVIS will calculate the sum of the amounts entered for Lines I.B.1 through I.B.5.
Federal-State
MCH Block
Grant
Partnership
TOTAL
The TVIS will calculate the sum of the amounts entered for the I.A.1 TOTAL and I.B.1 TOTAL.
Use form or field notes to explain any discrepancies or unexpected variations.
48
FORM 3b
BUDGET AND EXPENDITURE DETAILS BY TYPES OF SERVICES (IIA and IIB)
[Section 506(a)(2)(A)(iv), Section 505(a)(2)(A-B) and Section 506(a)(1)(A-D)]
II. TYPES OF SERVICES
FY ____ Application
IIA. Federal MCH Block Grant
FY ____ Annual Report
Budgeted
Expended
Direct Services
$_______
$_______
a. Preventive and primary care
services for all pregnant
women, mothers, and infants
up to age one
$_______
$_______
b. Preventive and primary care
services for children
$_______
$_______
c. Services for CSHCN
$_______
$_______
2.
Enabling Services
$_______
$_______
3.
Public Health Services and
Systems
$_______
$_______
1.
4. Review below the specific types of Federally-supported “Direct Services”, as reported in II.A.1. Provide the
total amount of Federal MCH Block Grant funds expended for each type of reported service.
1.
2.
3.
4.
5.
6.
7.
Pharmacy
Physician/Office Charges
Hospital Charges (Includes Inpatient and Outpatient Services)
Dental Care (Does Not Include Orthodontic Services)
Durable Medical Equipment and Supplies
Laboratory Services
Other _____________________
FY ____ Application
Budgeted
FEDERAL TOTAL
$_______
49
($)_____
($)_____
($) _____
($)_____
($)_____
($)_____
($)_____
FY ____ Annual Report
Expended
$_______
FORM 3b
BUDGET AND EXPENDITURE DETAILS BY TYPES OF SERVICES (IIA and IIB)
[Section 506(a)(2)(A)(iv), Section 505(a)(2)(A-B) and Section 506(a)(1)(A-D)]
II. TYPES OF SERVICES (Continued)
FY ____ Application
IIB. Non-Federal
MCH Block Grant
FY ____ Annual Report
Budgeted
Expended
Direct Services
$_______
$_______
a. Preventive and primary care
services for all pregnant
women, mothers, and infants
up to age one
$_______
$_______
b. Preventive and primary care
services for children
$_______
$_______
c. Services for CSHCN
$_______
$_______
2.
Enabling Services
$_______
$_______
3.
Public Health Services and
Systems
$_______
$_______
1.
4. Review below the specific types of non-Federally-supported “Direct Services”, as reported in II.A.1.
Provide the total amount of Federal MCH Block Grant funds expended for each type of reported service.
1.
2.
3.
4.
5.
6.
7.
Pharmacy
Physician Office Services
Hospital Charges (Includes Inpatient and Outpatient Services)
Dental Care (Does Not Include Orthodontic Services)
Durable Medical Equipment and Supplies
Laboratory Services
Other _____________________
FY ____ Application
Budgeted
NON-FEDERAL TOTAL
$_______
50
($) _____
($) _____
($) _____
($) _____
($) _____
($) _____
($) _____
FY ____ Annual Report
Expended
$_______
INSTRUCTIONS FOR THE COMPLETION OF FORM 3b
STATE TITLE V PROGRAM BUDGET AND EXPENDITURES BY TYPES OF SERVICES
Title V Citation: Section 505(a)(2) states, in part, “In order to be entitled to payments for allotments...a State
must prepare and transmit to the Secretary an application...that includes for each fiscal year (A) a plan for
meeting the needs identified by the statewide needs assessment...and (B) a description of how funds allotted to
the State...will be used for the provision and coordination of services to carry out such a plan that shall include (iii) an identification of the types of services to be provided....”
Section 506(a)(1) states, “Each State shall prepare and submit to the Secretary annual reports on its activities
under this title.” Among the items required to be reported (Section 506(a)(2)(A)(i-iv)) are, “...the number of
individuals served by the State under this title (by class of individuals), the proportion of each class of such
individuals which has health coverage, the types (as defined by the Secretary) of services provided under this
title to individuals within each such class, and the amounts spent under this title on each type of services, by
class of individuals served.”
Instructions: Complete all required data cells. If an actual number is not available, the State should make an
estimate. All estimates should be explained in a form or field note in TVIS. A Glossary that contains terms
applicable to this form is provided in Appendix H of the Supporting Documents, which accompany the
Application/Annual Report Guidance.
LINE NUMBER
II.A.1
II.A.1.a –
II.A.1c
INSTRUCTIONS
Of the Federal MCH allocation, enter the Total budgeted (Application year) and expended
(Annual Report year) amounts for Direct Services.
Of the Federal MCH allocation, enter the Total budgeted (Application year) and expended
(Annual Report year) amounts for Direct Services by types of services and MCH population
group.
II.A.2
Of the Federal MCH allocation, enter the Total budgeted (Application year) and expended
(Annual Report year) amounts for Enabling Services.
II.A.3
Of the Federal MCH allocation, enter the Total budgeted (Application year) and expended
(Annual Report year) amounts for Public Health Services and Systems.
II.A.4
Enter the amount of Federal Title V funds expended for services that are closely related to
each type of direct service listed. If a service cannot be related to one of the provided
choices, the state can choose “Other” and enter the type of service that is supported and
amount.
Federal
TOTAL
The TVIS will calculate the sum of the Federal amounts entered for Line II.A.1, Line II.A.2 and
Line II.A.3.
51
INSTRUCTIONS FOR THE COMPLETION OF FORM 3b (Continued)
STATE TITLE V PROGRAM BUDGET AND EXPENDITURES BY TYPES OF SERVICES
LINE NUMBER
II.B.1
II.B.1.a –
II.B.1c
INSTRUCTIONS
Of the non-Federal MCH allocation, enter the Total budgeted (Application year) and
expended (Annual Report year) amounts for Direct Services.
Of the non-Federal MCH allocation, enter the Total budgeted (Application year) and
expended (Annual Report year) amounts for Direct Services by types of services and MCH
population group.
II.B.2
Of the non-Federal MCH allocation, enter the Total budgeted (Application year) and
expended (Annual Report year) amounts for Enabling Services.
II.B.3
Of the non-Federal MCH allocation, enter the Total budgeted (Application year) and
expended (Annual Report year) amounts for Public Health Services and Systems.
II.B.4
Enter the amount of non-Federal Title V funds expended for services that are closely related
to each type of direct service listed. If a service cannot be related to one of the provided
choices, the state can choose “Other” and enter the type of service that is supported and
amount.
Non-Federal
TOTAL
The TVIS will calculate the sum of the non-Federal amounts entered for Line II.B.1, Line II.B.2
and Line II.B.3.
52
FORM 4
NUMBER AND PERCENTAGE OF NEWBORNS AND OTHERS SCREENED,
CASES CONFIRMED AND TREATED
[SECTION 506(a)(2)(B)(iii)]
Annual Report Year: _____
Total Births by Occurrence: ____________
Type of Screening Tests
Data Source Year: _______
(A)
Aggregate Total
Number
Receiving at
Least One
Screen(1)
No.
%
(B)
Aggregate
Total Number
Presumptive
Positive
Screens
(A)
Total Number
Receiving at
Least One
Screen(1)
(B)
Total Number
Presumptive
Positive Screens
(C)
Aggregate Total
Number
Confirmed
Cases(2)
(D)
Aggregate
Total Number
Referred for
Treatment (3)
No.
%
1. Newborn Screening Program
Select all applicable screening tests from
the core and secondary conditions in the
Recommended Uniform Screening Panel
(RUSP) using the drop down list.
Type of Screening Tests
No.
%
(B)
Total Number
Confirmed
Cases(2)
(B)
Total Number
Referred for
Treatment(3)
No.
%
2. Other Newborn Screening Tests (Specify
by Name)
1. ______ ______
2. ____ ________
3. ______________
3. Screening Programs for Older Children &
Women
1) ______ ______
2) ____ ________
3) ______ ______
4. Long-term follow-up (follow-up beyond referring an infant for treatment) varies based on State policy and
practice. Briefly describe your State’s practice for monitoring infants with confirmed diagnoses, including what
information is obtained and for how long infants are monitored.
1
TVIS will use occurrent births as denominator.
Report only those from resident births.
3
TVIS will use number of confirmed cases as denominator.
2
53
INSTRUCTIONS FOR THE COMPLETION OF FORM 4
NUMBER AND PERCENTAGE OF NEWBORNS AND OTHERS SCREENED,
CASES CONFIRMED, AND TREATED
Title V Citation: Section 506(a)(1) requires each State to submit an annual report on its activities under Title V.
Included in this requirement is the following: (2)(B)(iii) “... information on such other indicators of maternal,
infant, and child health care status as the Secretary may specify.”
Instructions: Complete all required data cells for the reporting year. If an actual number is not available,
make an estimate. All estimates should be explained in a form or field note in TVIS. A Glossary that contains
terms applicable to this Form is provided in Appendix H of the Supporting Documents, which accompany the
Application/Annual Report Guidance.
LINE NUMBER
Annual Report
Year
INSTRUCTIONS
TVIS will prepopulate the annual report year.
Lines: “Total
Births by
Occurrence” and
“Data Source
Year”
Enter the total number of occurrent births for the State and the year for which the data
apply. Total births by occurrence are to be defined as “all births that occur in the State
regardless of residency.” States should use the number submitted by the Vital Records
program to the National Center for Health Statistics. The data source year is to be defined
as calendar year, January 1 – December 31. Please note that the “Total Births...” figure is
related to the “Total infants < 1 year of age” row in Form 5a and 5b, and the “TOTAL
INFANTS IN STATE” row in section I of Form 6. While these figures are not expected to
match, there should be a fairly close relationship between them.
1. Newborn
Screening
Program
All States now screen for at least 29 out of the 34 core conditions on the Recommended
Uniform Screening Panel (RUSP). Using the drop down box, select the names of all
screening tests specific to your state’s newborn population.
a. In column A, enter the aggregate total number of occurrent births that received one of
the tests indicated. TVIS will calculate the percentage based on occurrent births
receiving one test out of the total listed at the top of the form.
b. In column B, enter the aggregate total number of presumptive positive screens.
c. In column C, enter the aggregate total number of confirmed cases discovered. Use
only those from resident births.
d. In column D, enter the aggregate total number of those confirmed cases that were
referred for treatment. TVIS will calculate the percentage by using the confirmed cases
as the denominator.
2. Other
Newborn
Screening
Tests
Enter additional screening tests specific to your state’s newborn population, such as
screenings for other conditions that are not listed in the RUSP. Complete Columns A
through D for each of the listed screenings. TVIS will calculate the percentages.
3. Screening
Programs for
Older
Children and
Women
Enter any screening tests that are specific to older children and women. Complete
Columns A through D for each of the listed screenings. Note that the % (percentage)
portion of Column A is not to be completed since the denominator of Total Births by
Occurrence does not apply. Enter the specific names of any other screens that are not
listed and complete Columns A through D.
54
FORM 5a
COUNT OF INDIVIDUALS SERVED BY TITLE V
(By Class of Individuals and Percent of Health Coverage)
[Section 506(a)(2)(A)(i-ii)]
Annual Report Year__________
(A)
TITLE V
Total
Served
Type of Individuals Served
1.
Pregnant Women
2.
Infants < 1 year of age
3.
Children 1 through 21 years of
age
(B)
Title XIX
%
(C)
(D)
a. Children with Special Health
Care Needs
4.
Others
TOTAL
FORM 5b
TOTAL PERCENTAGE OF POPULATIONS SERVED BY TITLE V
(By Class of Individuals)
[Section 506(a)(2)(A)(i-ii)]
Annual Report Year ________
Population Served by Title V
Total % Served
1. Pregnant Women
_______
2. Infants < 1 year of age
_______
3. Children 1 through 21 years of age
_______
a. Children with Special Health Care
Needs
_______
_______
4. Others
55
(E)
(F)
PRIMARY SOURCE OF COVERAGE
Title XXI
Private/Other
None
Unknown
%
%
%
%
INSTRUCTIONS FOR THE COMPLETION OF FORM 5a and FORM 5b
COUNT OF INDIVIDUALS SERVED BY TITLE V
AND
TOTAL PERCENTAGE OF POPULATIONS SERVED BY TITLE V
[Section 506(a)(2)(A)(i-ii)]
Title V Citation: Section 506(a)(1) requires each State to submit an annual report on its activities under Title V.
Included in this requirement is the following: “(2) Each annual report...shall include the following information:
(A)(i) The number of individuals served by the State under the title (by class of individuals)…(ii) The proportion
of each class of such individuals which has health coverage.”
Instructions: Complete all required data cells for the reporting year. If an actual number is not available, the
State should make an estimate. In particular, Form 5b and the insurance coverage section in Form 5a may
require estimation. All methods, data sources and included services/programs should be explained in field
notes in TVIS. A Glossary that contains terms applicable to this form and examples of included
services/programs in each participant category is provided in Appendix H of the Supporting Documents, which
accompany the Application/Annual Report Guidance.
The purpose of Form 5a and Form 5b is two-fold.
Form 5a, Count of Individuals Served by Title V, enables the State to track and report on the number who
received an individually-delivered service funded by the Title V program without full reimbursement within the
top two levels of the MCH Pyramid (direct and enabling services).
Form 5b, Total Percentage of Population Served by Title V, enables the State to track and report on the total
percentage who received a Title V-supported service within all levels of the MCH Pyramid (direct services,
enabling services, and public health services and systems).
Since States began to report Title V program participant data in the 1990’s, MCH programs have seen a shift in
the delivery of services from direct primary care MCH services to public health and preventive services within
well-coordinated and comprehensive systems of care that are designed for the MCH population. This shift has
resulted in a need for more complete reporting of individuals served by Title V, which goes beyond an
unduplicated count of individuals served (often derived from reimbursement data or individual client records
for MCH direct and enabling services).
It is recognized that precisely quantifying the number of individuals reached through the administration or
promotion of population-based services and systems (e.g., injury prevention and education, regionalized
systems of perinatal care, newborn screening programs) is difficult, and informed estimates are often required.
Relying only on reimbursement data or individual client program records supported by Title V, however, can
lead to serious underestimates of the number of individuals in a State who actually received and benefitted
from a Title V-supported service. For this reason, Form 5b was developed to better capture the full “reach” of
the State’s Title V program in serving its MCH population.
Unlike Forms 3a and 3b, the totals reported on Forms 5a and 5b reflect both Federal and Non-federal Title V
program dollars.
56
INSTRUCTIONS FOR THE COMPLETION OF FORM 5a and FORM 5b
COUNT OF INDIVIDUALS SERVED BY TITLE V
AND
TOTAL PERCENTAGE OF POPULATIONS SERVED BY TITLE V
[Section 506(a)(2)(A)(i-ii)]
FORM/LINE
NUMBER
Form 5a
Report Year
1 – 5,
Column A
INSTRUCTIONS
States should report the number of individuals who received a direct or enabling service
funded by Title V in each of the listed MCH population groups, along with the percentage of
each group by insurance coverage type.
TVIS will prepopulate the annual report year for which the data apply.
Enter the best possible estimate for the number who received an individually-delivered direct
or enabling service funded by the Title V program without full reimbursement. This number
includes individuals who received a service funded by total Federal and Non-federal dollars as
reported on line 8 of Form 2, and it should align with the combined totals on Form 3a and 3b
for direct and enabling services. Pregnant women may also receive non-pregnancy related
services and be counted in other participant categories (i.e., Children ages 1 through 21 and
Others). All remaining categories are mutually exclusive, with CSHCN reported as a subset of
all children ages 1 through 21. Within each reporting category, the count of individuals served
should be unduplicated to the fullest extent possible. All methods, data sources, and included
services/programs should be explained in field notes in TVIS.
1 -5,
Columns B - F
Enter the percentages of individuals reported in Column A by their primary source of
coverage. If insurance status is unknown, states should report an estimate. Estimates from
population-based data sources will be provided by MCHB to facilitate reporting.
Form 5b
States should report an estimate for the total percentage of populations who received a
Title V-supported service in each of the listed MCH population groups across all levels of the
MCH Pyramid, including public health services and systems.
Report Year
1-5
TVIS will prepopulate the annual report year for which the data apply.
Enter the best possible estimate for a total percentage of each population group served by
the Title V program across all levels of the MCH Pyramid (i.e. direct services, enabling services,
and public health services and systems). This estimate includes all individuals and populations
served by the total Federal and State dollars as reported on line 8 of Form 2 and the
combined totals on Form 3a and 3b for all service levels. Non-Title V programs that provide
direct and enabling services (e.g., WIC, Home Visiting) may be included if Title V funds or staff
time are used to promote or enhance services (individual services that are Title V funded may
also be counted in 5a). To avoid duplication, numerators for the percentage estimate should
focus on the programs and services that have the largest reach for a given population, which
generally involves public health services and systems. Approximate denominators for each
population group will be provided by MCHB to facilitate percentage estimation. Within public
health services and systems, only those populations who are reached by activities that directly
promote access or quality of specific population-based services and systems should be
counted (see examples in Appendix H of the Supporting Documents). All methods, data
sources, and included services/programs should be explained in field notes in TVIS.
57
FORM 6
DELIVERIES AND INFANTS SERVED BY TITLE V
AND ENTITLED TO BENEFITS UNDER TITLE XIX
(By Race and Ethnicity)
[Section 506(a)(2)(C-D)]
I. UNDUPLICATED COUNT BY RACE/ETHNICITY
(A)
TOTAL
(B)
NonHispanic
White
(C)
NonHispanic
Black or
African
American
(D)
Hispanic
1. TOTAL
DELIVERIES
IN STATE
TITLE V
SERVED
ELIGIBLE
FOR
TITLE XIX
2. TOTAL
INFANTS
IN STATE
TITLE V
SERVED
ELIGIBLE
FOR
TITLE XIX
58
(E)
NonHispanic
American
Indian or
Native
Alaskan
Annual Report Year: ________
(F)
(G)
(H)
(I)
NonNonNonOther
Hispanic Hispanic Hispanic & UnAsian
Native
Multiple known
Hawaiian
Race
or Other
Pacific
Islander
INSTRUCTIONS FOR THE COMPLETION OF FORM 6
DELIVERIES AND INFANTS SERVED BY TITLE V
AND ENTITLED TO BENEFITS UNDER TITLE XIX
Title V Citation: Section 506 (a)(1) requires each State to submit an Annual Report on its activities under
Title V. Included in this requirement is the following:
(2)(C) “Information (by racial and ethnic group) on-(i) the number of deliveries in the State in the year, and
(ii) the number of such deliveries to pregnant women who were provided prenatal, delivery, or
postpartum care under this title or were entitled to benefits with respect to such deliveries under
the State plan under title XIX in the year.
(2)(D) Information (by racial and ethnic group) on-(i) the number of infants under one year of age who were in the State in the year, and
(ii) the number of such infants who were provided services under this title or were entitled to
benefits under the State plan under title XIX at any time during the year.”
Instructions: Complete all required data cells for the annual report year. If an actual number is not
available, the State should make an estimate. All estimates should be explained in a form or field note
in TVIS. A Glossary that contains terms applicable to this form is provided in Appendix H of the
Supporting Documents, which accompany the Application/Annual Report Guidance. It is recognized that
there will be overlap between the reported totals for “Title V Served” and “Eligible for Title XIX”, due to
an individual’s changing insurance eligibility status during the course of a year (i.e., “churning”.) Form 6
asks for all individuals who are served by Title V and an estimate of the individuals in the State who are
eligible for Title XIX. The form does not ask for a report on those individuals served by Title V who are
also eligible for Title XIX.
LINE NUMBER
INSTRUCTIONS
Section I: Unduplicated Count by Race/Ethnicity
Annual Report TVIS will prepopulate the annual report year for which the data apply.
Year
In columns A, enter the number for the population-based total of all deliveries in the
Total Deliveries State for the reporting year eligible for Title XIX who were provided delivery of services
in State
in the reporting year. For Columns B-I, enter the number of individuals who were
eligible by race and ethnicity. TVIS will calculate the total in columns A based on the
numbers provided by race/ethnicity.
Total Infants in
State
In column A, enter the number of infants, which is related to the “Total Births by
Occurrence” line in Form 4. The “Total Infants <1 year of age” served by Title V is
related to the count of infants served in Form 5b. While these figures may not match
exactly, they should show a fairly close relationship to each other. For columns B-I,
enter the number of infants who were eligible by race and ethnicity. TVIS will calculate
the total in columns A based on the numbers provided by race/ethnicity.
59
FORM 7
STATE MCH TOLL-FREE TELEPHONE LINE AND OTHER APPROPRIATE METHODS DATA
A. State MCH Toll-Free Telephone Line [Sections 505(a)(5)(E) and 509(a)(8)]:
STATE: _______
Application Year__
Annual Report Year__
1. State MCH Toll-Free
“Hotline” Telephone
Number
________________________________________
2. State MCH Toll-Free
“Hotline” Name
________________________________________
3. Name of Contact Person for
State MCH “Hotline”
________________________________________
4. Contact Person’s Telephone
Number
________________________________________
5. Number of Calls Received
on the State MCH “Hotline”
in this Reporting Period
________________________________________
B. Other Appropriate Methods [Sections 505(a)(5)(E) and 509(a)(8)]:
Application Year__ Annual Report Year__
1. Other Toll-Free “Hotline”
Names (e.g., 2-1-1 Infoline)
________________________________________
2. Number of Calls on the
State 2-1-1 Infoline or Other
Relevant Hotlines in this
Reporting Period
________________________________________
3. State Title V Program
Website Address
________________________________________
4. Number of Hits to Title V
Program Website
________________________________________
5. State Title V Social Media
Websites
________________________________________
6. Number of Hits to Title V
Program Social Media
Websites
________________________________________
60
INSTRUCTIONS FOR THE COMPLETION OF FORM 7
STATE MCH TOLL-FREE TELEPHONE LINE AND OTHER APPROPRIATE METHODS DATA
Title V Citation: Section 505(a)(5)(E) states, in part, “the State agency (or agencies) administering the
State’s program under this title will provide for a toll-free telephone number (and other appropriate
methods) for the use of parents to access information about health care providers and practitioners who
provide health care services under this title and title XIX and about other relevant health and
health-related providers and practitioners...”
The Maternal and Child Health Bureau is the designee of the Secretary of the Department of Health and
Human Services to carry out the mandate of Section 509(a)(8) of Title V, which requires that a national
directory of toll-free numbers be made available to State agencies that administer the State’s Title V
programs.
Instructions: Complete all required data cells for the application and annual report year, as specified. If
an actual total number of calls received or total hits to the website is not available, the State should
make an estimate. All estimates should be explained in a form or field note in TVIS.
LINE NUMBER
State
Year
INSTRUCTIONS
TVIS will prepopulate the name of the State.
TVIS will prepopulate the application and annual report year.
A.1
Enter the State’s primary toll-free MCH information line telephone number.
A.2
Enter the name of the State’s primary toll-free MCH information line.
A.3
Enter the name of the person who should be contacted with any concerns about the State’s
primary toll-free MCH information line.
A.4
Enter the telephone number of the contact person that is listed on Line A.3.
A.5
For the annual report year only, enter the number of calls received on the State’s primary
toll-free MCH information line.
LINE NUMBER
B.1
B.2
INSTRUCTIONS
Enter the names of other toll-free information lines that are administered by the State.
For the annual report year, enter the number of calls received by the other toll-free MCH
information lines administered by the State.
B.3
Enter the URL for the State Title V Program website.
B.4
For the annual report year only, enter the number of hits to the State Title V Program
website address listed on Line B.3.
B.5
Enter the URLs for the State Title V Social Media Websites
B.6
For the annual report year only, enter the number of hits to the State Title V Program social
media website addresses listed on Line B.5.
61
FORM 8
STATE MCH AND CSHCN DIRECTORS CONTACT INFORMATION
FOR APPLICATION YEAR____
STATE: __________________________
1. Title V Maternal and Child Health (MCH) Director
Name:
__________________________________
Title
__________________________________
Street Address:
__________________________________
Room Number:
__________________________________
City/State/Zip:
__________________________________
Telephone:
__________________________________
Email:
__________________________________
2. Title V Children with Special Health Care Needs (CSHCN) Director
Name:
__________________________________
Title
__________________________________
Street Address:
__________________________________
Room Number:
__________________________________
City/State/Zip:
__________________________________
Telephone:
__________________________________
Email:
__________________________________
3. State Family or Youth Leader (Optional):
Name:
__________________________________
Title
__________________________________
Street Address:
__________________________________
Room Number:
__________________________________
City/State/Zip:
__________________________________
Telephone:
__________________________________
Email:
__________________________________
Instructions: TVIS will prepopulate the name of the State and the application year. Enter the name of
the Title V MCH Director, CSHCN Director and, at the option of the State, the Family and/or Youth
Leader. For each of the listed contacts, provide the title, address, telephone number and e-mail
address.
62
FORM 9
LIST OF MCH PRIORITY NEEDS
[Section 505(a)(1)]
Your state’s Five-Year Statewide Needs Assessment should identify the need for preventive and
primary care services for pregnant women, mothers, and infants; preventive and primary care services
for children; and services for Children with Special Health Care Needs. The established priorities
should guide the activities that are included in the State's Five-year Action Plan. In order to evaluate
success in meeting the goals of the priority needs, the State should determine, at the time of priority
setting, its plan for assessing if priority needs have been addressed. This assessment should include
the development of State Performance Measures (SPMs), which are specifically tailored to a priority
need to the extent that such need is not fully addressed by the National Performance Measures
(NPMs) or the State Evidence-based or –informed Strategy Measures (ESMs).
Instructions: With each year’s Block Grant Application, the State should provide a list, (whether or not
the priority needs change) of its top maternal and child health needs and crosslink the identified
priorities with the existing National Outcome Measures (NOMs), NPMs, SPMs and ESMs. Use a simple
sentence or phrase to list your State’s needs below. Examples of such statements are: “To reduce the
barriers to the delivery of care for pregnant women,” and “The infant mortality rate for minorities
should be reduced.” For each priority, indicate if it a new priority need for this five-year reporting
cycle or if it is being revised or continued from the previous five-year cycle. Please note that TVIS will
prepopulate the priority needs provided in the previous year.
MCHB will capture annually every State’s top 7 to 10 priority needs in TVIS for comparison, tracking,
and reporting purposes. The State must list at least 7 priority needs, and the form will only accept up
to 10. If desired, the State may list and describe additional priority needs in a form note. Note that
the numerical listing below is for computer tracking only and is not meant to indicate a priority order.
STATE__________________________________
APPLICATION YEAR______
NEW (N), REVISED (R) OR CONTINUED
(C) PRIORITY NEED FOR THIS FIVE-YEAR
REPORTING PERIOD
N
R
C
PRIORITY NEEDS
1
2
3
4
5
6
7
8
9
10
63
FORM 10
TRACKING MEASURES
National Performance Measures (NPMs), Evidence-based or –Informed Strategy Measures (ESMs),
State Performance Measures (SPMs) and State Outcome Measures (SOMs)
[Sections 505(a)(2)(B)(i),(iii) and 506(a)(2)(A)(iii)]
10a. NPM Annual Report Year: Objective and Performance Data
Click here to view Federally Available Data ⃝
MEASURE #__
(Measure Title)
Annual Objective
Annual Indicator
Annual
Report Year:
______
______
Numerator
Denominator
Data Source: ________
Click here to view MCHB provided Detail Sheet
⃝
FY__
FY__
FY__
FY__
FY__
______
______
______
______
______
______
______
Data Source Year: _____
Provisional or Final?: ⃝ Provisional
⃝ Final
Click here to provide note: ⃝
10b. ESM Annual Report Year: Objective and Performance Data
Click here to create/view Detail Sheet (10e) ⃝
MEASURE #__
(Measure Title)
Annual Objective
Annual Indicator
Annual
Report Year:
______
______
Numerator
Denominator
Data Source: ________
FY__
FY__
FY__
FY__
FY__
______
______
______
______
______
______
______
Data Source Year: _____
Provisional or Final?: ⃝ Provisional
⃝ Final
Click here to provide note: ⃝
10c. SPM Annual Report Year: Objective and Performance Data
Click here create/view Detail Sheet (10e) ⃝
MEASURE #__
(Measure Title)
Annual Objective
Annual Indicator
Annual
Report Year:
______
______
Numerator
Denominator
Data Source: ________
FY__
FY__
FY__
FY__
FY__
______
______
______
______
______
______
______
Data Source Year: _____
Provisional or Final?: ⃝ Provisional
⃝ Final
Click here to provide note: ⃝
64
10d. SOM Annual Report Year: Objective and Performance Data (Optional)
Click here for Detail Sheet (10e) ⃝
MEASURE #__
(Measure Title)
Annual Objective
Annual Indicator
Annual
Report Year:
______
______
Numerator
Denominator
Data Source: ________
FY__
FY__
FY__
FY__
FY__
______
______
______
______
______
______
______
Data Source Year: _____
Provisional or Final?: ⃝ Provisional
⃝ Final
Click here to provide note: ⃝
10e. ESM/SPM/SOM Detail Sheet
ESM/SPM/SOM # ___________
PERFORMANCE MEASURE TITLE:
For SPMs and SOMs only:
CHOOSE THE POPULATION DOMAIN(S)
TO WHICH THIS MEASURE RELATES:
Select the Domain(s)
For ESMs Only:
CHOOSE THE NPM TO WHICH THIS ESM
IS LINKED: (Choose one)
Select the National Performance Measure
CHOOSE THE ESM SUBGROUP (IF
RELEVANT): (Choose one or more)
Select Subgroup (if relevant)
GOAL
DEFINITION
Numerator:
Denominator:
Units: ________
(Number)
HEALTHY PEOPLE 2020
OBJECTIVE
DATA SOURCES and DATA ISSUES
SIGNIFICANCE
65
_________
(Text)
INSTRUCTIONS FOR THE COMPLETION OF FORM 10
TRACKING MEASURES
National Performance Measures (NPMs), Evidence-based or –Informed Strategy Measures
(ESMs), State Performance Measures (SPMs) and State Outcome Measures (SOMs)
Title V Citation: Section 505(a)(2)(B)(i),(iii) requires the States to submit an Application that includes, ...a
statement of the goals and objectives consistent with the health status goals and national health
objectives...for meeting the needs specified in the State plan...[and]...an identification of the types of
services to be provided... “Section 506(a)(2)(A)(iii) requires the States to report annually on the ...type (as
defined by the Secretary) of services provided under this title...”
Instructions: As the standard form to be used by States in tracking all measurement types (e.g., NOMs,
NPMs, ESMs, SPMs and SOMs) specified in this Guidance, this form serves a dual purpose: 1) Displays 5year planned objectives (targets) for each NPM, ESM, SPM and SOM, as applicable, as part of the
Application, and 2) Reports Annual Indicators, values actually achieved during a reporting year, for each
NPM, SPM, ESM and SOM, as applicable, as part of the Annual Report. States are not required to
establish performance targets for the NOMs. For the NPMs and the NOMs, the Annual Indicator data
will be populated annually by the Maternal and Child Health Bureau, as available, using the referenced
national data source identified on the detail sheet for each specific NPM and NOM. While not
responsible for entering an Annual Indicator, States will be responsible for tracking their annual progress
on the NPMs and their related NOMs. A Glossary that contains terms applicable to this form is provided
in Appendix H of the Supporting Documents, which accompany the Application/Annual Report
Guidance.
For the Application Year, States will establish five-year performance targets for each selected NPM,
ESM, SPM and SOM, as applicable. Within the five-year period, performance targets that were
established by the State in previous years’ Applications will be pre-populated on the form.
For the annual report year, TVIS will prepopulate the federally available indicator data for the NOMs and
the NPMs. If federal indicator data is not available for a measure chosen by the state, the state will be
required to provide state data for their five chosen NPMs. States will complete the required data cells
(i.e., Annual Indicator, Numerator, Denominator, Data Source and Reporting Note) for the ESMs, SPMs
and SOMs, if applicable. If the final data are not available, the State should provide provisional or
estimated data with an explanation in a field note in TVIS.
LINE NUMBER
Measure Number
Annual Report Year
INSTRUCTIONS FOR 10A-10D
The TVIS will prepopulate the measure number.
The TVIS will prepopulate the annual report years.
Annual Objective
Enter the Annual Objective (for the most recently added out-year). The TVIS will
prepopulate objectives provided in previous years.
Annual Indicator
For the current annual report year, enter the Annual Indicator, including the
Numerator and Denominator, for each ESM, SPM and SOM. The TVIS will
prepopulate the Annual Indicator from federal sources, where available for the
NPMs. If federal data is not available, enter the Annual Indicator, including the
Numerator and Denominator for the five chosen NPMs.
66
Data Source
For the current annual report year, enter the Data Source for the reported Annual
Indicator for each ESM, SPM and SOM. The TVIS will prepopulate the Data Source
from federal sources, where available for the NPMs. If federal data is not available,
enter the Data Source for the five chosen NPMs.
Data Source Year
For the current annual reporting year, enter the Data Source Year for the reported
Annual Indicator for each ESM, SPM and SOM. The TVIS will prepopulate the Data
Source Year from federal sources, where available for the NPMs. If federal data is
not available, enter the Data Source Year for the five chosen NPMs.
Provisional/Final?
Check the button in TVIS to indicate if the data is provisional or final.
Note
For the current annual reporting year, enter a data note to clarify any estimated or
provisional data and to describe other limitations which impact the reporting of an
Annual Indicator for each NPM, ESM, SPM and SOM.
Instructions: Section 10e of this form is used for creating an ESM, SPM or SOM. Complete each section as
appropriate for the measure being described. Note that the measure title and numerator and denominator
data will be displayed in TVIS on the respective section (e.g., 10b, 10c and 10d) as they are defined on this
form. A Glossary that contains terms applicable to this form is provided in Appendix H of the Supporting
Documents, which accompany the Application/Annual Report Guidance.
LINE NUMBER
ESM, SPM or SOM #
INSTRUCTIONS FOR 10E
TVIS will prepopulate the measure number.
Performance Measure
Title
Enter a brief, narrative description of the performance or outcome measure.
Choose the Population
Domain(s) to which this
SPM or SOM is linked
Select the related population domain(s) from the displayed pick list, as applicable.
Choose the NPM to
which this ESM is linked
Select the related national performance measure from the displayed pick list in
TVIS.
Choose ESM Subgroup (if
relevant)
If focusing on a subpopulation group, select the subgroup from the displayed pick list
in TVIS. Refer to Table 1 in Appendix E for a list of subgroups.
Goal
Enter a short statement indicating what the State hopes to accomplish by tracking
this measure.
Numerator: If the measure is a percentage, rate, or ratio, provide a clear
description of the numerator.
Denominator: If the measure is a percentage, rate, or ratio, provide a clear
description of the denominator.
Units: If the measure is a percentage, rate, ratio, or scale, indicate the units in
which the measure is to be expressed (e.g., 10,000; 1,000; 100) by selecting a choice
Definition
67
in pick list for the "Number" field. Select the type of measure from the pick list (e.g.,
percentage, rate, ratio, scale, yes/no) on "Text" field.
Healthy People 2020
Objective
If the measure is related to a Healthy People 2020 objective describe the objective
and corresponding number.
Data Source & Data
Issues
Enter the source(s) of the data used in determining the value of the measure and
any issues concerning the methods of data collection or limitations of the data used.
Significance
Briefly describe why this measure is significant, especially as it relates to the Goal.
Describe also how the value of the measure is determined from the data. If the
value of the measure is a scale or a “yes/no,” a clear description of what those
values mean and how they are determined should be provided.
68
FORM 11
OTHER STATE DATA (OSD) – #01- #03
(Prepopulated by MCHB, as available)
OSD #01 – Rates of infant mortality, low birth weight, and preterm birth by race and ethnicity
[SECTION 506 (a)(2)(B)(i)]
Annual Report Year _________
CATEGORY
RATE BY
RACE/ETHNICITY
STATE
RATE
NONHISPANIC
WHITE
NONHISPANIC
BLACK OR
AFRICAN
AMERICAN
HISPANIC
NONHISPANIC
AMERICAN
INDIAN OR
NATIVE
ALASKAN
NONHISPANIC
ASIAN
NONHISPANIC
NATIVE
HAWAIIAN
OR OTHER
PACIFIC
ISLANDER
Infant Mortality
(Rate per 1,000)
Low Birth
Weight (%)
Preterm Birth
(%)
OSD #02 – Rates of infant mortality, low birth weight, and preterm birth by county
[SECTION 506 (a)(2)(B)(i)]
COUNTY
(List each
County)
INFANT
MORTALITY
(Rate per 1,000)
LOW BIRTH
WEIGHT (%)
PRETERM BIRTH
(%)
OSD #03 –State MCH Workforce
[SECTION 506 (a)(2)(E)(i-vi)]
WORKFORCE CATEGORY
OBSTETRICIANS
FAMILY PRACTITIONERS
CERTIFIED FAMILY NURSE PRACTITIONERS
CERTIFIED NURSE MIDWIVES
PEDIATRICIANS
CERTIFIED PEDIATRIC NURSE PRACTITIONERS
69
TOTAL NUMBER
NONHISPANIC
MULTIPLE
RACE
INSTRUCTIONS FOR THE COMPLETION OF FORM 11
OTHER STATE DATA (OSD) – #01 - #03
Title V Citation: See OSD reporting tables above.
Instructions: A glossary of terms applicable to this form is presented in Appendix H of the Supporting
Documents, which accompany the Application/Annual Report Guidance.
States are not required to collect or report on any of the OSD elements. The purpose of this form is to
make available, annually, other State data required by the Title V legislation. Required data elements on
this form will be provided by the Maternal and Child Health Bureau (MCHB) in TVIS, as available, for the
States. States should review and monitor the annual data.
The racial and ethnic population categories included in these tables are based on the Office of
Management and Budget guidelines. More specific instructions are provided below.
TVIS will provide the year for which the data are being reported.
FORM NUMBER
OSD #01:
INSTRUCTIONS
In the column labeled “STATE RATE,” the rate for the State is provided in TVIS in the
category specified. In the next seven columns the rate of the State in the racial/ethnic
categories indicated at the head of each column and in the categories specified is
provided in TVIS. Since these data are reported by rates, these data are not totaled.
OSD #02
Data are provided in TVIS for the rate of infant mortality, low birth weight, and
preterm birth by each county in the State. In the first column of the first row, the
name of the county is provided. In the second cell of the first row, the rate of infant
mortality for that county is provided. In the third cell of the first row, the rate of low
birth weight for that county is provided. In the fourth cell of the first row, the rate of
preterm birth is provided. In subsequent rows, the names of each county and the
rates requested are provided. Depending on the size of the population being reported
for each county, rates may use a three-year moving average. Since these data are
reported by rates, these data are not totaled.
OSD #03
Data are provided in TVIS for the numbers of MCH workforce professionals noted that
are licensed in the State in the reporting year identified. In the second cell of the first
row, the number of obstetricians is provided. In the second cell of the each remaining
rows, the number of family practitioners, certified family nurse practitioners, certified
nurse midwives, pediatricians, and certified pediatric nurse practitioners are provided,
as noted.
70
| File Type | application/pdf |
| Author | Michele Lawler |
| File Modified | 2017-11-07 |
| File Created | 2017-11-07 |