0985New OHICProfilesSupplementalInstructions Ins 3

OHIC Profiles Data Collection

OHIC Profiles Data Collection Form Instructions
The data collection form includes questions from ACL about your organization/agency’s SHIP, SMP, and/or
MIPPA programs and requires you to prepare information ahead of time. This document is intended to serve as
a quick guide to help you prepare that information.
ACL will use the information gathered from this form to create an updated set of grantee profiles that are
accessible, visually appealing, and consistent across the SHIP, SMP, and MIPPA programs. As you recall, ACL
developed profiles for SHIP programs in 2016.
Please make sure to submit the most current data in this data collection.
General Instructions:
•

The form should be completed in one sitting. You will not be able to save your progress and return to
the form later.

•

Please note that additional sections and questions will populate throughout the form based on your
responses to previous questions. For this reason, the form may appear shorter when you first open it, but
this is not an adequate representation of the length of the form.

•

Depending on the number of programs your agency/organization manages, the form will take you
approximately 20 minutes to complete, with 30 minutes of preparation time.

The table below lists the questions in the order they appear on the form and information you may need to have
handy before completing the form:
What we will ask about

Agency/Organization
Name
Agency/Organization Type

Program Funding Type
OHIC Program
Management

All Respondents

What we need from you

The official name of your agency/organization as it appears on your grant application.
Select the type of agency/organization and explain your selection. Selection options include
State Department of Aging (Health and Human Services), State Department of Insurance,
Non-Profit Organization, or Other.
You will be asked to add an explanation to your selection in an open-ended response. If you
select “Other”, you will be asked to describe the agency/organization type in an open-ended
response.
Identify all types of OHIC program funding (e.g., SHIP, SMP, MIPPA Priority 1 (SHIP),
MIPPA Priority 2 (AAA), MIPPA Priority 3 (ADRC)).
Identify all types of OHIC programs that you currently manage (e.g., SHIP, SMP, MIPPA
Priority 1 (SHIP), MIPPA Priority 2 (AAA), MIPPA Priority 3 (ADRC)).

OHIC Profiles Data Collection
What we will ask about

Operational Model
(Centralized/Decentralized)

All Respondents

What we need from you

Identify if your agency/organization is centralized, decentralized, or another model of
operation.
Centralized is defined as a "federally funded grantee agency/organization doing all program
work out of central office(s)".
Decentralized is defined as a "federally funded grantee agency/organization primarily
regranting or subcontracting to do program work."

Funding Sources (Federal
and Non-Federal)

If you select “Other”, you will be asked to describe the operational model in an open-ended
response.
Identify all funding from federal and non-federal sources from the provided list.
Federal funding sources include 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), or Other.
Non-federal funding sources include State, Local, or Other.
If you select “Other” for either question, you will be asked to enter the source in an openended response.

For each SHIP, SMP, or MIPPA Grant Award
What we will ask about

What we need from you

Year Grant Received

If this is not your first SHIP/SMP/MIPPA grant award, provide the year your
agency/organization first received the grant award in the YYYY format.

Partnerships

Does your agency/organization have any partnerships for the SHIP/SMP/MIPPA grant?
If you work with partners, you will be asked to identify the types of partners such as
pharmacies, providers, community health centers, Area Agencies on Aging, local or regional
CMS, etc.
Partners may be provided funding to participate in shared work or may work in-kind.

Populations Served

If you select “Other”, you will be asked to print the partner organization’s name in an openended response.
Identify all populations served by this OHIC grant such as low-income (150% FPL), rural,
under 65, Hispanic or Latino, etc.

OHIC Profiles Data Collection
For each SHIP, SMP, or MIPPA Grant Award
What we will ask about

Subrecipients (SMP and
MIPPA only)

Goals for Grant

Best Practices

What we need from you

If you share SMP or MIPPA grant money with subrecipients, please prepare in
advance then upload an Excel file with subrecipients’ names and contact information.
Use the Annual SMP/MIPPA Sub-Recipients Report Template included in your invitation
email. This template includes the following fields:
•

Grantee Name

•

State

•

Report Period

•

Total # of Sub-Recipients

•

Total Annual Sub-Recipient Amount (Federal SMP/MIPPA Dollars Only)

•

Subrecipient Name, Address, City, State, ZIP Code, and Annual Federal
SMP/MIPPA Amount

•

If you have both SMP and MIPPA subrecipients, you will need to prepare and
upload two separate files, one for SMP and one for MIPPA.

Have ready the goals your agency/organization listed in your grant application. If you
do not have access to your grant application, please contact your ACL Project Officer.
If your goals have not changed since the original application, you can copy and paste your
response into the form. If your goals have changed since the original application, please
enter updated goals in the same format utilized in the application.
Select best practices learned from the SHIP/SMP/MIPPA program(s) from the following
list of categories:
• 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 (SMP Only)
Describe what your agency/organization has learned on the topic.
If you need guidance, review Best Practices responses from the most recent semi-annual
report.

OHIC Profiles Data Collection
For each SHIP, SMP, or MIPPA Grant Award
What we will ask about

Lessons Learned from
Challenges

What we need from you

Select lessons learned from challenges from the SHIP/SMP/MIPPA program(s), using the
following list of categories:
• 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 (SMP Only)
Describe what your agency/organization has learned on the topic.
If you need guidance, review Lessons Learned responses from the most recent semi-annual
report.