Workplan Program Quesions

Form Approved

OMB #: 0920-0106

Expiration: 2/29/2024

PHHS BLOCK GRANT INFORMATION SYSTEM DEVELOPMENT PROJECT

BGIS Recipient Information Data Collection Instruments

Attachment E: Workplan Program Questions

Recipient Health Objective Data Collection Instrument 3

Program Data Collection Instrument 9

Objectives and Activities Data Collection Instrument 15

The public reporting burden of this collection of information is estimated to average 10 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, HS 21-8, Atlanta, Georgia 30333 ATTN: PRA (0920-0106) 

Recipient Health Objective Data Collection Instrument

Recipients will add their Recipient Health Objectives in this module. Recipient Health Objectives are typically objectives that last longer than the performance period of the PHHS Block Grant; they are objectives to be met over roughly 5 years. BG/PM user roles should have the ability to add and delete Recipient Health Objective entries as needed. User should be able to place the information in the order they desire.

1. Add Recipient Health Objective: [Short Text]

Program Data Collection Instrument

In this UIC, the BG Coordinator or Program Manager will fill out the information for each program funded by the PHHS Block Grant. The Program UIC is connected to several other entities which contains pertinent information about the recipient’s program plan.

General Information

1. Program Name/Title*: [Short Text]

2. Recipient Name: [auto-populated from Program Allocation unit of Budget UIC]

3. Workplan Name: [Short Text]

4. Program Fiscal Year: *Choose one

   • 2023

   • 2024

   • 2025

   • 2026

   • 2027

Program Allocation Data Table

5. Current Year Total funds budgeted to this program*: [Short Text]

6. Current Year Basic Funds budgeted to this program*: [Short Text]

7. Current Year Sex Offense Funds budgeted to this program*: [Short Text]

Details about Program Funding

8. Amount of funding to populations disproportionately affected by the problem*:(If not applicable, enter 0) [Number]

9. Amount of funding to local agencies or organizations (if not applicable, enter 0)*: [Number]

10. Type of supported local agency/organization. Choose all that apply: *Choose one

    • Local Health Department

    • Tribal Health Department/Agency

    • Other Local Government

    • Local Organization

    • Other, please specify [Short Text]

Program Information

11. Healthy People 2030 Objective: *Choose one [options auto-populate]

12. Recipient Health Objective for this Program*: [Short Text]

13. Were PHHS Block Grant funds used to respond to an emerging need or outbreak as part of the program?* [Yes/No]

14. What was the funding role of the PHHS Block Grant for this program? *Choose one

    • Total source of funding (skip to question 13)

    • Supplement other existing funds

15. What percentage of the funding for this program is PHHS Block Grant funding? *Choose one

• Less than 10% - Minimal source of funding

• 10-49% - Partial source of funding

• 50-74% - Significant source of funding

• 75-99% - Primary source of funding

• 100% - Total source of funding

16. What existing funding source(s) will PHHS Block Grant funds supplement?*

    • State or local funding

    • Other federal funding (CDC); please specify [Short Text]

    • Other federal funding (non-CDC)

    • Funding from NGO or non-profit organization

    • Funding from for-profit organization

    • Tribal, district (i.e. DC) or territorial funding

    • None

    • Other; please specify [Short Text]

17. Role of PHHS Block Grant Funds in Supporting this Program: *Choose one

    • Startup of a new program

    • Maintain existing program (as is)

    • Enhance or expand the program

    • Restore program

Define the Problem this Program will Address

18. One-sentence summary of the problem this program will address*: [Text]

19. One-paragraph description of the problem this program will address*: [Text]

20. How was the public health problem prioritized? *Select all that apply

• Conducted, monitored, or updated a jurisdiction health assessment (e.g., state health assessment)

• Conducted a topic- or program-specific assessment (e.g., tobacco assessment, environmental health assessment)

• Identified via surveillance systems or other data sources

• Prioritized within a strategic plan

• Declared as an emergency within your jurisdiction

• Governor (or other political leader) established as a priority

• Legislature established as a priority

• Tribal government/elected official established as a priority

• Other (please specify): [Short Text]

21. Describe in one paragraph the key indicator(s) affected by this problem*: [Short Text]

22. Baseline value of the key indicator described above*: [Number]

23. Data source for key indicator baseline*: [Short Text]

24. Date key indicator baseline data was last collected*: [Short Text]

Program Strategy

25. One-sentence program goal*: [Short Text]

26. 1A. Is this program specifically addressing a Social Determinant of Health (SDOH)?* [Yes/No]

27. 1B.Which SDOH are you addressing with this program? *Select all that apply (Required if you answered yes to 1A.)

    • Economic Stability (e.g. poverty, unemployment, food insecurity, housing instability)

    • Education (e.g. low high school graduation rates, low literacy levels, poor early childhood education)

    • Social and Community Context (e.g. discrimination, low civic participation, poor workplace conditions, incarceration)

    • Health and Health Care (e.g. poor access to healthcare, low health insurance coverage, low health literacy)

    • Neighborhood and Built Environment (e.g. poor quality of housing, limited access to transportation, food desert, poor water/air quality, neighborhood crime and violence)

    • Adverse Childhood Experiences (ACEs)

28. Summary/Description of program strategy*: [Text]

29. List of primary strategic partners*: [Text]

30. Planned non-monetary support to local agencies or organizations: *Select all that apply

• Technical Assistance

• Training

• Resources/Job Aids

• None

• Other (please specify) [Short Text]

31. One-paragraph summary of evaluation methodology: [Text]

32. Program Setting(s): *Select all that apply

• Business, corporation or industry

• Child care center

• Community based organization

• Faith based organization

• Home

• Local health department

• Medical or clinical site

• Parks or playgrounds

• Rape crisis center

• Schools or school district

• Senior residence or center

• State health department

• Tribal nation or area

• University or college

• Work site

• Other, please specify [Short Text]

Positions Funded by PHHS Block Grant

33. Total positions in this program funded with PHHS Block grant dollars?* [Number]

34. Number of FTEs in this program funded with PHHS Block grant dollars?* [Numbers]

User will ‘Create Position’ and answer the following questions for each position funded with PHHSBG money.

35. Position Title*: [Position Title]

36. Program Name/Title: [auto-populates from program data]

37. Recipient Name: [auto-populates from User Account]

38. Work Plan Name: [auto-populates from workplan]

39. 1A. Is this position vacant?* [Yes/No]

40. (If answer to question 1A is yes, skip this question, if no, answer this question) Staff Name in Position (Required if you answered No to 1A): [Short Text]

41. Percent of staff member’s time spent working in each area (funded with PHHS Block Grant dollars):* Choose all that apply and input percentage of time for each selected option

• Jurisdiction-level*: [% Time]*

• Local*: [% Time]*

• Other*: [% Time]*

• Total*: [% Total time funded with PHHSBG dollars]*

42. 1C. If the position is vacant, describe the recruitment/hiring plan to fill the vacant position: [Short Text]

Target Population of Program*

In the target population section, only answer the questions that apply to your overall target population of the Program. You will be able to specify your target population to each Program SMART Objective in the Objectives and Activities UIC.

43. Target Population is for: *Choose one [Program/Objective]

44. Target population data source. Please include Date: [Short Text]

45. Number of people served: [Number]

46. Ethnicity: *Select all that apply

• Hispanic or Latino

• Not Hispanic or Latino

47. Race: *Select all that apply

• American Indian or Alaskan Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

48. Age: *Select all that apply

• Under 1 year

• 1 - 4 years

• 5 - 14 years

• 15 - 24 years

• 25 - 34 years

• 35 - 44 years

• 45 – 54 years

• 55 - 64 years

• 65 – 74 years

• 75 – 84 years

• 85 years and older

49. Sexual Orientation: *Select all that apply

• Gay (lesbian or gay)

• Straight, this is not gay (or lesbian or gay)

• Bisexual

• Something else

• I don’t know the answer

50. Gender Identity: *Select all that apply

• Male

• Female

• Transgender

• None of these

51. Geography: *Choose one

• Rural

• Urban

• Both

52. Location: [Short Text]

53. Occupation: [Short Text]

54. Educational Attainment: *Select all that apply

• Some High School

• High School Diploma

• Some College

• College Degree

• Graduate Degree

55. Health Insurance Status: *Select all that apply

• Uninsured

• Medicaid

• Medicare

• Private Health Insurance

• Affordable Care Act Plan

56. Primarily Low Income: *Choose one

• Yes

• No

57. Are members of this target population disproportionately affected by the problem? /Experience Health Disparities* [Yes/No]

58. Is the entire target population disproportionately affected by the problem, or only part? *Choose one

• All

• Part (Answer all the questions in the Target Population section about the population disproportionately affected by the problem)

Objectives and Activities Data Collection Instrument

The Block Grant Coordinator or Program Manager will fill in the following information about Program SMART Objectives and Activities for each program funded by the PHHS Block Grant. The Objective and Activity UIC is connected to several other entities which contains pertinent information about the recipient’s program plan.

Program Information*

1. Program SMART Objective (this is the SMART Objective at the program level)*: [Text]

2. Is the problem for this objective the same as the problem for the program as a whole, or is it a subset of the larger problem?*

   1. The problem is the same

   2. This Program SMART Objective focuses on a subset of the larger problem

3. Please provide a one-sentence summary of the problem for this objective*: [Text]

4. Please provide a one-paragraph description of the problem for this objective*: [Text]

5. Describe in one paragraph the key health indicator(s) affected by this problem*: [Text]

6. Baseline value for the key indicator described above*: [Number]

7. Data source for key indicator baseline*: [Text]

8. Date key indicator baseline data was last collected- example 20XX: [Date – can be full date or just year]*

Intervention Information*

9. One-sentence summary of intervention*: [Text]

10. One-paragraph description of intervention*: [Text]

11. Is this an evidence-based intervention, or an innovative/promising practice? *Choose one

• Evidence-Based Intervention

• Innovative/Promising Practice

12. Evidence Source for Intervention: *Select all that apply

• Best Practice Initiative (U.S. Department of Health and Human Services)

• Guide to Clinical Preventive Services (Task Force on Community Preventive Services)

• MMWR Recommendations and Reports (Centers for Disease Control and Prevention)

• Model Practices Database (National Association of City and County Health Officials)

• National Guideline Clearinghouse (Agency for Healthcare Research and Quality)

• Promising Practices Network (RAND Corporation)

• Other (describe)[Short Text]

13. Rationale for choosing the intervention*: [Text]

14. Item to be Measured*: [Short Text]

15. Unit of Measurement*: [Short Text]

16. Baseline value for the item to be measured*: [Number]

17. Data source for baseline value*: [Text

18. Date baseline was last collected*: [Date]

19. Interim target value to be achieved by the Annual Progress Report*: [Number]

20. Final target value to be achieved by the Final Progress Report*: [Number]

Target Population of Program*

In the target population section, only answer the questions that apply to your target population of the Program SMART Objective.

21. Is the Target Population of this Program SMART Objective the same as the Target Population of the Program or a subset of the Program Target Population?*

    1. Same as the Program

    2. Sub-set of the Program

Users will then click “Create” to fill out the below questions to describe their target population for this objective if it is a subset of the program target population.

22. Target Population Data Source (Include Date)*: [Short Text]

23. Number of People Served*: [Number]

24. Ethnicity: *Select all that apply

• Hispanic or Latino

• Not Hispanic or Latino

25. Race: *Select all that apply

• American Indian or Alaskan Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

26. Age: *Select all that apply

• Under 1 year

• 1 - 4 years

• 5 - 14 years

• 15 - 24 years

• 25 - 34 years

• 35 - 44 years

• 45 – 54 years

• 55 - 64 years

• 65 – 74 years

• 75 – 84 years

• 85 years and older

27. Sexual Orientation: *Select all that apply

• Straight, this is not gay (or lesbian or gay)

• Gay (lesbian or gay); Bisexual

• Something else; please specify_______________

28. Gender Identity: *Select all that apply

• Female

• Male

• Transgender

• Additional gender category (or other); please specify ______________

29. Geography: *Choose one

• Rural

• Urban

• Both

30. Location*: [Short Text]

31. Occupation*: [Short Text]

32. Educational Attainment: *Select all that apply

    1. Some High School

    2. High School Diploma

    3. Some College

    4. College Degree

    5. Graduate Degree

33. Health Insurance Status*:

    1. Uninsured

    2. Medicaid

    3. Medicare

    4. Private Health Insurance

    5. Affordable Care Act Plan

34. Primarily Low Income: *Choose one

• Yes

• No

35. Are any members of this target population disproportionately affected by the Problem described above?*

• Yes

• No

36. Does the entire target population experience health disparities, or only part? *Choose one

• All

• Part (Present a disparate population form that contains the same fields as the target population)

Activities

Recipients will add multiple activities for each Program SMART Objective. They will push “Create” and answer questions 41-45 for each activity.

37. Activity Title*: [Activity Title]

38. Objective Name: [auto-populates from workplan data]

39. Recipient Name: [auto-populates from User Account]

40. Work Plan Name: [auto-populates from workplan]

41. Activity Fiscal Year*: [drop down]

42. One-sentence summary of the Activity*: [Short Text]

43. One-paragraph description of the Activity*: [Text]

44. Does the activity include the collection, generation, or analysis of data?* [Yes/No]

45. Does the data collection involve public health data?* [Yes/No]

46. Additional Information about the Activity:[Text]

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