OHIC Profiles Template

OHIC Profiles-Data Collection Form

Office of Healthcare Information and
Counseling (OHIC)
OHIC Profiles
Data Collection Form

Instructions

Thank you for taking time to enter your program information into this data collection form.
The form includes questions from ACL about your SHIP, SMP, and/or MIPPA grants and
requires you to prepare some information ahead of time.
Sections and questions appear based on your responses to previous questions. The form will
appear short when you first open it, but this is not adequate representation of the length of the
form. Please refer to the supplemental instructions attached to your invitation email for more
information.
We understand your time constraints and want to be cognizant of your multiple obligations.
Depending on how many programs you manage, this form is expected to take 20 minutes to
complete, with 30 minutes of preparation time. The form must be completed in one sitting. You
will not be able to save your progress and return to the form later.

Grant Manager Information
1. First Name *
Please print your first name.

2. Last Name *
Please print your last name.

3. Email Address *
Please print your email address.

Agency/Organization Information
1. What is the name of your agency/organization? *

OHIC Profiles-Data Collection Form
Your agency/organization is the direct recipient of SHIP, SMP, and/or MIPPA funding. If your
agency/organization receives more than one of these grants, please complete this survey with all
in mind.
Please enter the name of your agency/organization.
2. How would you describe your agency/organization? *
Please select the most appropriate response.
Please add additional explanation after you make your selection.
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State Department of Aging (Health and Human Services)
State Department of Insurance
Non-Profit Organization
Other (Please Specify)

2a. [If selected] Please print the name of the State Department of Aging (Health and Human
Services)*
2b. [If selected] Please print the name of the State Department of Insurance.*
2c. [If selected] Please print the name of the Non-Profit Organization. *
2d. [If selected] What is the "other" agency/organization that supports these grants?*
Please print the name of the “other” agency/organization.

3. Does your agency/organization receive SHIP, SMP, and/or MIPPA program funding?*
Select all that apply.
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SHIP
SMP
MIPPA Priority 1 (SHIP)
MIPPA Priority 2 (AAA)
MIPPA Priority 3 (ADRC)

4. Which OHIC programs do you currently manage?*
Select all that apply.
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SHIP
SMP
MIPPA Priority 1 (SHIP)
MIPPA Priority 2 (AAA)
MIPPA Priority 3 (ADRC)

OHIC Profiles-Data Collection Form
5. Which model best describes your agency/organization?*
Centralized is defined as a "federally funded grantee agency/organization doing program work
out of central office(s)" and Decentralized is defined as a "federally funded grantee
agency/organization regranting or subcontracting to do program work."
Select the most appropriate category.
 Centralized
 Decentralized
 Other (Please Specify)
5a. [If Other] Please specify the "other" model that best describes your
agency/organization.*

6. Does your agency/organization receive federal funding from any of the following?*
Select all that apply, unless selecting "Not Applicable".
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Aging and Disability Resource Center/No Wrong Door (ADRC/NWD)
Older Americans Act (OAA)
Center for Independent Living (CIL)
University Centers for Excellence in Developmental Disabilities (UCEDD)
Other (Please Specify)
Not Applicable

6a. [If Other] Please specify the other federal funding source.*

7. Does your agency/organization receive non-federal from any of the following?*
Select all that apply, unless selecting "Not Applicable".
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State
Local
Other (Please Specify)
Not applicable

7a. [If Other] Please specify the “other” non-federal funding source.*

OHIC Profiles-Data Collection Form

SHIP Program
Questions for this section will populate if you indicate that your agency/organization receives
SHIP program funding.
1. Is this your agency/organization's first SHIP grant from ACL?*
 Yes
 No
1a. [If No] What year did your agency/organization first receive the SHIP grant from
ACL?*
Please enter the year in YYYY format (e.g., 2010).

2. Does your agency/organization have any partnerships for the SHIP program?*
These may be paid or unpaid partnerships.
 Yes
 No
2a. [If Yes] Which type(s) of agencies/organizations do you partner with?*
Please select all that apply.
Local Community-based Organizations
Federally Qualified Health Centers (FQHC)/Community Health Centers
Pharmacies
Providers
State Medicaid Office
Other State Agencies
Local or Regional Social Security Administration (SSA)
Local or Regional Centers for Medicare & Medicaid Services (CMS)
Local or Regional Federal Bureau of Investigation (FBI)
Local or Regional Office of Inspector General (OIG)
Area Agencies on Aging
Navigators
U.S. Department of Housing and Urban Development (HUD)
Aging and Disability Resource Center/No Wrong Door (ADRC/NWD)
Center for Independent Living (CIL)
Older American Act (OAA) Programs
State or Local AARP
 Other (Please Specify)
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2b. [If Other] Please specify the "other" agency/organization you partner with.*

OHIC Profiles-Data Collection Form
3. What population(s) does your SHIP program serve?*
Select all that apply.
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Low-Income (150% FPL)
Rural
English as a Second Language
Under 65
American Indian or Alaskan Native
Black or African American
Hispanic or Latino
Asian or Asian American
Native Hawaiian or other Pacific Islander
Other (Please Specify)

3a. [If Other] Please specify the "other" population(s) your SHIP program serves if not
listed above.*

4. What are your agency/organization's goals for this grant?*
Refer to the goals in your grant application (If you do not have access to your grant application,
please contact your Project Officer).
If your goals have changed since the original application, please enter updated goals. Please
make sure your goals are in the same format as your grant application.

5. What best practices has your agency/organization learned in these program areas?*
Select all that apply.
Please add an explanation to your selection(s) below.
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Team Member Training
Open Enrollment Practices
Volunteers and/or Team Member Management
Use of Technology
Outreach Practices
Intake Process
Team Member Certification Process
Counseling Practices
Grant Management
Data Collection and/or Management
Program Management

OHIC Profiles-Data Collection Form
5a. [If selected] Please describe the best practices for Team Member Training.*

5b. [If selected] Please describe the best practices for Open Enrollment Practices.*

5c. [If selected] Please describe the best practices for Volunteers and/or Team Member
Management.*

5d. [If selected] Please describe the best practices for Use of Technology.*

5e. [If selected] Please describe the best practices for Outreach Practices.*

5f. [If selected] Please describe the best practices for Intake Process.*

OHIC Profiles-Data Collection Form
5g. [If selected] Please describe the best practices for Team Member Certification Process.*

5h. [If selected] Please describe the best practices for Counseling Practices.*

5i. [If selected] Please describe the best practices for Grant Management.*

5j.[If selected] Please describe the best practices for Data Collection and/or Management.*

5k. [If selected] Please describe the best practices for Program Management.*

OHIC Profiles-Data Collection Form
6. What lessons has your agency/organization learned from challenges in these program
areas?*
Select all that apply.
Please add an explanation to your selection(s) below.
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Team Member Training
Open Enrollment Practices
Volunteers and/or Team Member Management
Use of Technology
Outreach Practices
Intake Process
Team Member Certification Process
Counseling Practices
Grant Management
Data Collection and/or Management
Program Management

6a. [If selected] Please describe the lessons learned from Team Member Training.*

6b. [If selected] Please describe the lessons learned from Open Enrollment Practices.*

6c. [If selected] Please describe the lessons learned from Volunteers and/or Team Member
Management.*

OHIC Profiles-Data Collection Form
6d. [If selected] Please describe the lessons learned from Use of Technology.*

6e. [If selected] Please describe the lessons learned from Outreach Practices.*

6f. [If selected] Please describe the lessons learned from Intake Process.*

6g. If selected] Please describe the lessons learned from Team Member Certification
Process.*

6h. [If selected] Please describe the lessons learned from Counseling Practices.*

6i. [If selected] Please describe the lessons learned from Grant Management.*

OHIC Profiles-Data Collection Form
6j. [If selected] Please describe the lessons learned from Data Collection and/or
Management.*

6k. [If selected] Please describe the lessons learned from Program Management.*

Thank you!
Thank you for taking the time to complete the SHIP program section. If you manage another
OHIC program, please fill out all applicable sections of this form.
Once you complete all applicable sections, please hit "Submit".

SMP Program
Questions for this section will populate if you indicate that your agency/organization receives
SMP program funding.
1. Is this your agency/organization's first SMP grant from ACL?*
 Yes
 No
1a. [If No] What year did your agency/organization first receive the SMP grant from
ACL?*
Please enter the year in YYYY format (e.g., 2010).

2. Does your agency/organization have any partnerships for the SMP program?*
These may be paid or unpaid partnerships.
 Yes
 No

OHIC Profiles-Data Collection Form
2a. [If Yes] Which type(s) of agencies/organizations do you partner with?*
Please select all that apply.
Local Community-based Organizations
Federally Qualified Health Centers (FQHC)/Community Health Centers
Pharmacies
Providers
State Medicaid Office
Other State Agencies
Local or Regional Social Security Administration (SSA)
Local or Regional Centers for Medicare & Medicaid Services (CMS)
Local or Regional Federal Bureau of Investigation (FBI)
Local or Regional Office of Inspector General (OIG)
Area Agencies on Aging
Navigators
U.S. Department of Housing and Urban Development (HUD)
Aging and Disability Resource Center/No Wrong Door (ADRC/NWD)
Center for Independent Living (CIL)
Older American Act (OAA) Programs
State or Local AARP
 Other (Please Specify)
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2b. [If Other] Please specify the "other" agency/organization you partner with.*

3. What population(s) does your SMP program serve?*
Select all that apply.
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Low-Income (150% FPL)
Native American
Non-English Speaking
People with Disabilities
Racial/Ethnic Minority
Rural
Other (Please Specify)

3a. [If Other] Please specify the "other" population(s) your SMP program serves if not
listed above.*

4. Do you share grant money with any subrecipients?*
 Yes
 No

OHIC Profiles-Data Collection Form
4a. [If Yes] How many subrecipients do you share grant money with?*
Please enter a number.
Please upload an Excel file that lists your SMP subrecipients in Question 4b in the MIPPA Grant section
of this form.

5. What are your agency/organization's goals for this program?*
Refer to the goals in your grant application (If you do not have access to your grant application,
please contact your Project Officer).
If your goals have changed since the original application, please enter updated goals. Please
make sure your goals are in the same format as your grant application.

6. What best practices has your agency/organization learned in these program areas?*
Select all that apply.
Please add an explanation to your selection(s) below.
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Team Member Training
Open Enrollment Practices
Volunteers and/or Team Member Management
Use of Technology
Outreach Practices
Intake Process
Team Member Certification Process
Counseling Practices
Grant Management
Data Collection and/or Management
Program Management
Casework

6a. [If selected] Please describe the best practices for Team Member Training.*

OHIC Profiles-Data Collection Form
6b. [If selected] Please describe the best practices for Open Enrollment Practices.*

6c. [If selected] Please describe the best practices for Volunteers and/or Team Member
Management.*

6d. [If selected] Please describe the best practices for Use of Technology.*

6e. [If selected] Please describe the best practices for Outreach Practices.*

6f. [If selected] Please describe the best practices for Intake Process.*

6g. [If selected] Please describe the best practices for Team Member Certification Process.*

OHIC Profiles-Data Collection Form
6h. [If selected] Please describe the best practices for Counseling Practices.*

6i. [If selected] Please describe the best practices for Grant Management.*

6j.[If selected] Please describe the best practices for Data Collection and/or Management.*

6k. [If selected] Please describe the best practices for Program Management.*

6l. Please describe the best practices for Casework.*

OHIC Profiles-Data Collection Form
7. What lessons has your agency/organization learned from challenges in these program
areas?*
Select all that apply, unless selecting "None".
Please add an explanation to your selection(s) below.
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Team Member Training
Open Enrollment Practices
Volunteers and/or Team Member Management
Use of Technology
Outreach Practices
Intake Process
Team Member Certification Process
Counseling Practices
Grant Management
Data Collection and/or Management
Program Management
Casework

7a. [If selected] Please describe the lessons learned from Team Member Training.*

7b. [If selected] Please describe the lessons learned from Open Enrollment Practices.*

7c. [If selected] Please describe the lessons learned from Volunteers and/or Team Member
Management.*

OHIC Profiles-Data Collection Form
7d. [If selected] Please describe the lessons learned from Use of Technology.*

7e. [If selected] Please describe the lessons learned from Outreach Practices.*

7f. [If selected] Please describe the lessons learned from Intake Process.*

7g. If selected] Please describe the lessons learned from Team Member Certification
Process.*

7h. [If selected] Please describe the lessons learned from Counseling Practices.*

7i. [If selected] Please describe the lessons learned from Grant Management.*

OHIC Profiles-Data Collection Form
7j. [If selected] Please describe the lessons learned from Data Collection and/or
Management.*

7k. [If selected] Please describe the lessons learned from Program Management.*

7l. [If selected] Please describe the lessons learned from Casework.*

Thank you!
Thank you for taking the time to complete the SMP program section. If you manage another
OHIC program, please fill out all applicable sections of this form.
Once you complete all applicable sections, please hit "Submit".

MIPPA Program
Questions for this section will populate if you indicate that your agency/organization receives
MIPPA program funding.
1. Is this your agency/organization's first MIPPA grant from ACL?*
 Yes
 No

OHIC Profiles-Data Collection Form
1a. [If No] What year did your agency/organization first receive the MIPPA grant from
ACL?*
Please enter the year in YYYY format (e.g., 2010).
2. Does your agency/organization have any partnerships for the MIPPA program?*
These may be paid or unpaid partnerships.
 Yes
 No
2a. [If Yes] Which type(s) of agencies/organizations do you partner with?*
Please select all that apply.
Local Community-based Organizations
Federally Qualified Health Centers (FQHC)/Community Health Centers
Pharmacies
Providers
State Medicaid Office
Other State Agencies
Local or Regional Social Security Administration (SSA)
Local or Regional Centers for Medicare & Medicaid Services (CMS)
Local or Regional Federal Bureau of Investigation (FBI)
Local or Regional Office of Inspector General (OIG)
Area Agencies on Aging
Navigators
U.S. Department of Housing and Urban Development (HUD)
Aging and Disability Resource Center/No Wrong Door (ADRC/NWD)
Center for Independent Living (CIL)
Older American Act (OAA) Programs
State or Local AARP
 Other (Please Specify)
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2b. [If Other] Please specify the "other" agency/organization you partner with.*
3.What population(s) does your MIPPA program serve?*
Select all that apply.
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Under 65
Rural
Native American
English as a Second Language
American Indian or Alaskan Native
Asian or Asian American
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
Other (Please Specify)

OHIC Profiles-Data Collection Form
3a. [If Other] Please specify the "other" population(s) your MIPPA program serves if not
listed above.*

4. Do you share grant money with any subrecipients?*
 Yes
 No
4a. [If Yes] How many subrecipients do you share grant money with?*
Please enter a number.
4b. [If Yes] Please upload an Excel file that lists your subrecipients for SMP and/or
MIPPA.*
Please upload an individual Excel file for SMP and MIPPA (if applicable).
Please follow the format provided in the supplemental instructions.

Drag and drop files here or browse files

5. What are your agency/organization's goals for this program?*
Refer to the goals in your grant application (If you do not have access to your grant application,
please contact your Project Officer).
If your goals have changed since the original application, please enter updated goals. Please
make sure your goals are in the same format as your grant application.

6. What best practices has your agency/organization learned in these program areas?*
Select all that apply.
Please add an explanation to your selection(s) below.
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Team Member Training
Open Enrollment Practices
Volunteers and/or Team Member Management
Use of Technology
Outreach Practices

OHIC Profiles-Data Collection Form
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Intake Process
Team Member Certification Process
Counseling Practices
Grant Management
Data Collection and/or Management
Program Management

6a. [If selected] Please describe the best practices for Team Member Training.*

6b. [If selected] Please describe the best practices for Open Enrollment Practices.*

6c. [If selected] Please describe the best practices for Volunteers and/or Team Member
Management.*

6d. [If selected] Please describe the best practices for Use of Technology.*

6e. [If selected] Please describe the best practices for Outreach Practices.*

OHIC Profiles-Data Collection Form
6f. [If selected] Please describe the best practices for Intake Process.*

6g. [If selected] Please describe the best practices for Team Member Certification Process.*

6h. [If selected] Please describe the best practices for Counseling Practices.*

6i. [If selected] Please describe the best practices for Grant Management.*

6j. [If selected] Please describe the best practices for Data Collection and/or Management.*

6k. [If selected] Please describe the best practices for Program Management.*

OHIC Profiles-Data Collection Form
7. What lessons has your agency/organization learned from challenges in these program
areas?*
Select all that apply.
Please add an explanation to your selection(s) below.
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Team Member Training
Open Enrollment Practices
Volunteers and/or Team Member Management
Use of Technology
Outreach Practices
Intake Process
Team Member Certification Process
Counseling Practices
Grant Management
Data Collection and/or Management
Program Management

7a. [If selected] Please describe the lessons learned from Team Member Training.*

7b. [If selected] Please describe the lessons learned from Open Enrollment Practices.*

7c. [If selected] Please describe the lessons learned from Volunteers and/or Team Member
Management.*

OHIC Profiles-Data Collection Form
7d. [If selected] Please describe the lessons learned from Use of Technology.*

7e. [If selected] Please describe the lessons learned from Outreach Practices.*

7f. [If selected] Please describe the lessons learned from Intake Process.*

7g. If selected] Please describe the lessons learned from Team Member Certification
Process.*

7h. [If selected] Please describe the lessons learned from Counseling Practices.*

7i. [If selected] Please describe the lessons learned from Grant Management.*

OHIC Profiles-Data Collection Form
7j. [If selected] Please describe the lessons learned from Data Collection and/or
Management.*

7k. [If selected] Please describe the lessons learned from Program Management.*

Thank you!
Thank you for taking the time to complete the MIPPA program section. If you have completed
all applicable sections, please hit "Submit".