Form 12 Financial Performance Measures - clean

OMB No.: 0915-0285. Expiration Date: XX/XX/20XX

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration Financial Performance Measures PERFORMANCE MEASURES		FOR HRSA USE ONLY
		Grant Number	Application Tracking Number
Focus Area: Prepopulated according to chart below
Performance Measure	Prepopulated according to chart below
Target Goal Description
Numerator Description	Prepopulated according to chart below
Denominator Description	Prepopulated according to chart below
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Progress Field (for Service Area Competition and non-competing continuation applications)
Projected Goal (by December 31, 2021)
Data Source & Methodology
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Total Cost Per Total Patient (Costs)
Performance Measure	Ratio of total cost per patient served in the measurement calendar year
Numerator Description	Total accrued cost before donations and after allocation of overhead
Denominator Description	Total number of patients
Focus Area: Medical Cost Per Medical Visit (Costs)
Performance Measure	Ratio of total medical cost per medical visit in the measurement calendar year
Numerator Description	Total accrued medical staff and other medical cost after allocation of overhead, excluding medical lab and x-ray cost
Denominator Description	Medical visits, excluding nurse visits
Focus Area: BPHC Health Center Program Grant Cost Per Total Patient (Grant Costs)
Performance Measure	Ratio of total BPHC section 330 grant funds per patient served in the measurement calendar year
Numerator Description	BPHC section 330 grants drawn-down for the period from January 1 to December 31 of the measurement calendar year
Denominator Description	Total number of patients

Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. The Health Center Program application forms provide essential information to HRSA staff and objective review committee panels for application evaluation; funding recommendation and approval; designation; and monitoring. The OMB control number for this information collection is 0915-0285 and it is valid until XX/XX/XXXX. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of information is estimated to average 1.5 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 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.