Family to Family Form

 In this section, the grantee may expand the accordion menu to view the following details:

• Goal
• Measure
• Definition
• Benchmark Data Sources
• Grantee Data Sources
• Significance

• In this section, the grantee must provide objectives in New Competing Performance Reports (NCPRs):
  • Objectives (%): Enter an integer from 0–100.
• For Non-Competing Continuation Performance Reports (NCCPRs) and Project Period End Reports (PPERs):
  • Pre-population: All budget period objectives will be prepopulated from the previously approved report.
  • For current and previous years, annual objective fields will not be editable.
  • For NCCPRs, grantees will have the ability to edit/modify the annual objective fields for future years if needed.

In this section, the grantee must answer the following question:

The estimated number of families with CYSHCN in your state (Denominator: data from the National Survey of Children’s Health)

• This is a required question, and the grantee will enter this number in the New Competing Performance Report (NCPR). The value entered into the NCPR will stay the same throughout an entire grant cycle and will pre-populate into subsequent DGIS reports.

NOTE: The values for the NCPR will be provided by MCHB.

• For Non-Competing Continuation Performance Reports (NCCPRs) and Project Period End Reports (PPERs), the grantee will have the ability to edit/modify this field, if needed.

NOTE: While this question is editable in NCCPRs and PPERs, the value should be the same for the entire grant and can only be changed if approved by MCHB.

• The following validation will display on the integer box: Enter an integer: 0 – 999,999.

In this section, the grantee provides information on the families served via “one-to-one” services conducted where one-to-one services include all services for which an F2F can collect recipient demographic/identifier information to be able to collect an unduplicated number.  Examples include but are not limited to family navigation, consultation, counseling, education, referrals, case management, mentoring and individualized assistance.

Total number of families receiving one-to-one services from Family-To-Family Health Information Centers. (Unduplicated count): (Numerator)

• This is a required question, and the following validation will display on the integer box: Enter an integer: 0 – 999,999.

This is a required section, and the grantee answers the following question:

 Of the total number of families served/trained, how many families identified their Ethnicity as

• Hispanic: Enter an integer from 0–999,999.
• Non-Hispanic: Enter an integer from 0–999,999.
• Unknown: Enter an integer from 0–999,999.
• Total: This will be automatically calculated as the sum of all the above fields.
  • The value of the Total field should match the Total number of families receiving one-to-one services; if it does not match, the system will show an error.

This value should match the Total number of families receiving one-to-one services (11)

 NOTE: The above value (11) is based on the sample counts used in the screenshot. This total value is for illustrative purposes only and will differ in the system depending on the values submitted by the grantee.

This is a required section, and the grantee answers the following question:

Of the total number of families served/trained, how many families identified their Race as

• White: Enter an integer from 0–999,999.
• Black or African American: Enter an integer from 0–999,999.
• Asian: Enter an integer from 0–999,999.
• Native Hawaiian or Other Pacific Islander: Enter an integer from 0–999,999.
• American Indian or Alaska Native: Enter an integer from 0–999,999.
• Some other race: Enter an integer from 0–999,999.
• More than one race: Enter an integer from 0–999,999.
• Unknown: Enter an integer from 0–999,999.
• Total: This will be automatically calculated as the sum of all the above fields.
  • The value of the Total field should match the Total number of families receiving one-to-one services; if it does not match, the system will show an error.

This value should match the Total number of families receiving one-to-one services (11)

NOTE: The above value (11) is based on the sample counts used in the screenshot. This total value is for illustrative purposes only and will differ in the system depending on the values submitted by the grantee.

In this section, the grantee answers the following questions:

Total number of service/trainings provided to families:

• This is a required question, and the following validation will display on the integer box: Enter an integer: 0 – 999,999.
• The value of the Total number of service/trainings provided to families field should be greater than or equal to the value in Total number of families receiving one-to-one services; if this criteria is not met, the system will show an error.

This value should be greater than or equal to Total number of families receiving one-to-one services (11)

NOTE: The above value (11) is based on the sample counts used in the screenshot. This total value is for illustrative purposes only and will differ in the system depending on the values submitted by the grantee.

Of the total numbers of service/trainings, how many provided:

• Individual assistance (Includes one-on-one instruction, consultation, counseling, case management and mentoring): Enter an integer from 0–999,999.
• Basic contact information and referrals: Enter an integer from 0–999,999.
• Group training opportunities: Enter an integer from 0–999,999.
• Meetings/Conferences and Public Events (includes outreach events and presentations): Enter an integer from 0–999,999.

In this section, the grantee provides information on professionals/providers that were provided health care information/education by the organization.

Total number of professionals/providers served/trained (unduplicated count):

• This is a required question, and the following validation will display on the integer box: Enter an integer: 0 – 999,999.

In this section, the grantee provides information on the total number of services provided to professionals/providers which includes the duplicated count of one-to-one services and trainings, group trainings, meetings/conferences, and outreach events. This does not include social media impressions or web hits (that will be reported in Section 5).

Total number of services provided to professionals/providers (duplicated count):

• This is a required question, and the following validation will display on the integer box: Enter an integer: 0 – 999,999.
• The value of the Total number of services provided to professionals/providers field should be greater than or equal to the value in Total number of professionals/providers served/trained; if this criteria is not met, the system will show an error.

This value should be greater than or equal to Total number of professionals/providers served/trained (16)

NOTE: The above value (16) is based on the sample counts used in the screenshot. This total value is for illustrative purposes only and will differ in the system depending on the values submitted by the grantee.

In this section, the grantee answers the following question:

Select the modes of how print/media information and resources are disseminated (Select all that apply)

• This is a required question, and the following validation should be displayed above the checkboxes: You are required to select at least one communication method
• In this question, the grantee selects one or more communication methods from the following options:
  • Electronic newsletters
  • Listservs
  • Hardcopy/print
  • Public television/ radio
  • Text messaging
  • Social media - Facebook
  • Social media - Twitter
  • Social media - Instagram
  • Social media – Other
  • Other (Specify)

NOTE: If the grantee selects Social media - Other, then the grantee must provide the description in Social media platform description field and a validation will display: Provide a description for “Other social media”. The Social media platform description field accepts text, numbers, and special characters (not to exceed 1,000 characters).

If the grantee selects Other (specify), then the grantee must provide the description in Other Description field and a validation will display: Provide a description for “Other”. The Other Description field accepts text, numbers, and special characters (not to exceed 1,000 characters).

This is a required section, and the grantee provides information on states agencies/programs assisted by the organization in providing services to their populations and/or to obtain their information to better serve the families.

Total number of State agencies/programs with which your organization has worked:

• This is a required question, and the following validation will display on the integer box: Enter an integer: 0 – 999,999.

Indicate the types of State agencies/programs with which your organization has worked:

• This is a required question, and the following validation should be displayed above the checkboxes: You are required to select at least one type of state agencies/programs
• In this question, the grantee selects one or more type of state agencies/programs with which the organization has worked from the following options:
  • Title V MCH/CYSHCN Program
  • Newborn Screening Program
  • Early Hearing Detection and Intervention/Newborn Hearing Screening
  • Emergency Medical Services for Children
  • Home Visiting
  • State Medicaid
  • State CHIP
  • State Mental and/or Behavioral Health
  • Government Housing Program
  • Early Intervention/Part C
  • Head Start Collaboration Office
  • None
  • Other (specify)

• If the grantee selects ‘None’ then they should not be able to select any other check boxes.

NOTE: If the grantee selects Other (specify), then the grantee must provide the description in Other State agencies/programs description field and a validation will display: Provide a description for “Other”. The Other State agencies/programs description field accepts text, numbers, and special characters (not to exceed 1,000 characters).

This is a required section, and the grantee answers the following questions:

Total number of community-based organizations:

• This is a required question, and the following validation will display on the integer box: Enter an integer: 0 – 999,999.

Indicate the types of community-based organizations with which your organization has worked:

• This is a required question, and the following validation should be displayed above the checkboxes: You are required to select at least one type of community based organization
• In this question, the grantee selects one or more types of community-based organizations with which the organization has worked from the following options:
  • Medical homes, providers, clinics, hospitals
  • Provider organizations (for example, American Academy of Pediatrics chapter)
  • Provider training programs (for example, residency programs; schools of medicine, nursing, public health, LEND programs, social work, etc.)
  • Schools (K-12, pre-school)
  • Faith-based organizations, places of worship
  • Condition-specific organizations (for example, United Cerebral Palsy, March of Dimes, etc.)
  • Child care programs
  • Local Head start
  • None
  • Other community organization (specify)

• If the grantee selects ‘None’ then they should not be able to select any other check boxes.

NOTE: If the grantee selects Other community organization (specify), then the grantee must provide the description in Other community-based organization description field and a validation will display: Provide a description for “Other”. The Other community-based organization description field accepts text, numbers, and special characters (not to exceed 1,000 characters).

Of those community-based organizations, indicate if any were dedicated to specific racial and/or ethnic populations:

• This is a required question, and the following validation should be displayed above the checkboxes: You are required to select at least one type of specific populations
• In this question, the grantee selects one or more type of specific racial and/or ethnic populations from the following options:
  • American Indian or Alaska Native
  • Black or African-American
  • Hispanic or Latino
  • Asian-American, Native Hawaiian or Pacific Islander
  • Other (specify)

NOTE: If the grantee selects Other (specify), then the grantee must provide the description in Specify Other Population description field and a validation will display: Provide a description for “Other”. The Specify Other Population description field accepts text, numbers, and special characters (not to exceed 1,000 characters).

In this section, the grantee must answer the following question:

Number of staff who work on Family-to-Family HIC activities:

• This is a required question, and the following validation will display on the integer box: Enter an integer: 0 – 999,999.

In this section, the grantee must answer the following question:

Number of F2F staff who are family/have a disability:

• This is a required question, and the following validation will display on the integer box: Enter an integer: 0 – 999,999.

This section will be automatically populated based on the information provided in Section II, Data Collection for Detail Sheet – F2F.

• Calculation for Indicator (%) = [Total number of families receiving one-to-one services from Family-To-Family Health Information Centers. (Unduplicated count) (Numerator)]/The estimated number of families with CYSHCN in your state (Denominator: data from the National Survey of Children’s Health)] * 100

In this section the grantee can enter additional information (not to exceed 5,000 characters). The Comments field accepts text, numbers, and special characters.

The grantee must click on Save or Save and Continue buttons before navigating away from this form to ensure all data entered is saved successfully.

• The Save button will save the validated information captured in the form and grantee will remain on the same form.
• The Save and Continue button will save the validated information and grantee will navigate to the next form.

The Go to Previous Page button will navigate to the previous form without saving any previously unsaved information.