TNGP PIMS Instructions

0915-XXXX XX/XX/20XX

	Yes	No
Were telemedicine interactions used for the purpose of overseeing students or trainees involved in formal education programs? These sessions are used to fulfill formal education, licensure or certification requirements.
Were telemedicine interactions used for supervision of clinicians that is NOT REQUIRED to meet formal educational requirements? This includes sessions required to meet regulatory practice requirements, as well as supervision/advice requested by remote practitioners.

Input Form

Did you provide services to patients in any of the following categories during this reporting period?
	Yes	No
Oral Health
Obesity Reduction and Prevention
Asthma
Diabetes
Behavioral Health

Form 1: Originating and Distant Sites

Number of Each Type of Site in this Reporting Period
Originating/Spoke/Patient Sites	[#]
Distant/Hub/Specialist Sites	[#]

Site Name	City/Town	State	Originating or Distant Site (O/D)	Rural or Urban Site (R/U)	Setting
[grantee generated list]					[choose from menu]

Note: For the purposes of this grant program, rural is defined as all counties that are not designated as parts of metropolitan areas (Mas) by the Office of Management and Budget (OMB). In addition, we use Rural Urban Commuting Area Codes (RUCAs) to designate rural areas within Mas. This rural definition can be accessed at https://datawarehouse.hrsa.gov/tools/analyzers/geo/Rural.aspx. If the county is not entirely rural or urban, follow the link for “Check Rural Health Grants Eligibility by Address” to determine if a specific site qualifies as rural based on its specific census tract within an otherwise urban county.

Public Burden Statement:  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0915-XXXX.  Public reporting burden for this collection of information is estimated to average XX hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857

Form 2: Specialties and Services, by Site

Note: Only remote sites and specialty services that are eligible for and receiving OAT funding should be included.

Originating Site		City/Town	State
[grantee generated site]
Specialty	Available through a local practitioner?	Specialty is actively available at this site?	Distance (in road miles) to the nearest health care facility providing the service in-person?
[grantee generated specialty]	[yes/no radio button]	[yes/no radio button]	[#]
[grantee generated specialty]	[yes/no radio button]	[yes/no radio button]	[#]
Originating Site		City/Town	State
[grantee generated site]
Specialty	Available through a local practitioner?	Specialty is actively available at this site?	Distance (in road miles) to the nearest health care facility providing the service in-person?
[grantee generated specialty]	[yes/no radio button]	[yes/no radio button]	[#]
[grantee generated specialty]	[yes/no radio button]	[yes/no radio button]	[#]

Form 3: Volume of Services, by Setting

Setting	Unique Patients	Total Encounters	Number of Interactive/Real-Time Encounters (IN)	Number of Store-an-Forward Encounters (SF)
[grantee generated list]
[grantee generated list]
[grantee generated list]

Total Number of Unique Patients Served because of HRSA funding

[#]

Form 4: Patient Travel Miles Saved

Total Miles Roundtrip	[#]
Total Number of Patient Encounters	[#}
Total Miles Saved	[#]

Form 5: Other Uses of the Telehealth Network

Categories	Number of Sessions
Administrative Meetings	[#]
Distant Learning	[#]
Other	[#]

	Total Number of Sessions	Total Number of People
Formal Education (sessions are used to fulfill formal education, licensure or certification requirements)	[#]	[#]
Informal Education (sessions used to meet regulatory practice requirements, as well as supervision/advice requested by remote practitioners)	[#]	[#]

Form 6: Diabetes

Number of unduplicated patients with diabetes served for at least three months during the reporting period	[grantee reported #]
Number of patients with diabetes (who received services for at least three months during the reporting period) whose most recent Hemoglobin A1c (HbA1c) level is 7.0% or less.	[grantee reported #]
Number of patients with diabetes (who received services for at least three months during the reporting period) whose most recent Hemoglobin A1c (HbA1c) level is between 7.1% and 9.0%.	[grantee reported #]
Number of patients with diabetes (who received services for at least three months during the reporting period) whose most recent Hemoglobin A1c (HbA1c) level during the measurement year was greater than 9.0% (poor control), or if an HbA1c test was not done during the reporting period.	[grantee reported #]

Form 7: Mental Health

Number of sites that have access to mental health services where access did not exist prior to the TNGP grant	[#]
Number of sites that have access to mental health services for pediatric and adolescent populations where access not exist prior to the TNGP grant	[#]
Number of sites that have access to mental health services for adult populations where access did not exist prior to the TNGP grant	[#]

Menu for Form 1

• School Based Health Center

• Community Health Center (including FQHCs)

• Health Care Provider in Private Practice

• Clinic (including RHC)

• Local Health Department

• Hospital (including CAH)

• Long Term Care Provider

• Home Health Service Provider

• Outpatient Mental Health Service Provider/Facility

• Local or Regional Emergency Health Care Provider

• Higher Education Institution

• Oral Health Provider

• Other Publically Funded Health or Social Service Agency

• Other