NIRS Activity Form FY 2017

NIRS Activity Form – FY 2017

*Response Required

*Program Type:

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£ UCEDD

£ LEND

£ LEAH

£ PPC

£ DBP

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*Fiscal Year: 2017

*Core Function: Technical Assistance

*Title of Activity: ______

Brief Activity Description (This field may be used to provide brief explanatory information (up to 50 words) on the activity being reported in this record) ____________

______

Staff Involvement ______

(List the first and last name of all staff members who were involved in conducting this activity.)

*The primary target audience is (select one):

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Local

State

Tribal

Another State

Regional

National

International

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*Type of Activity (Select one)

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Advocacy

Capacity Building

Systemic Change

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*Area of Emphasis (Check one)

Areas listed in the DD Act:

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Quality Assurance Activities

Child Care-Related Activities

Employment-Related Activities

Transportation-Related Activities

Education & Early Intervention

Health-Related Activities

Housing-Related Activities

Recreation-Related Activities

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Areas not listed in the DD Act:

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Quality of Life Activities

Other-Cultural Diversity

Other, Please Specify: ______

Other-Assistive Technology

Other-Leadership

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*Intensity of TA (Select one)

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One time brief (single)

One time extended (multi-day contact provided one time)

On-going Infrequent (3 or less contacts per year)

On-going frequent (more than 3 contacts per year)

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*Types and Numbers of Participants (Supply number for all that apply)

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Trainees Total ______

Other Classroom Students ______

Professionals & Para-Professionals ______

Family Members/Caregivers ______

Adults with Disabilities ______

Children/Adolescents with Disabilities/SHCN ______

Legislators/Policymakers ______

General Public/Community Members ______

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Customer Satisfaction

*Was the Center the lead on this activity?

Yes (If Yes, please enter the survey results below.)

Total number surveyed ______Supply total number responding:

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Strongly Agree ______

Agree ______

Disagree ______

Strongly Disagree ______

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*Initial Outcome Measure

For TA recipients with a sustained relationship with the UCEDD, percent reporting an increase in any of the identified or requested item(s) below:

· Enhanced resources

· Enhanced services

· Strengthened networking of public and private entities across communities

· Increased awareness of evidence based practices

· Enhanced capacity to assess current practices in relation to evidence-based approaches

· Identification of policy changes needed within the area of emphasis

Total number surveyed ______

Supply total number responding:

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Strongly Agree ______

Agree ______

Disagree ______

Strongly Disagree ______

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£ Not Applicable

*Primary Recipient of TA/Collaborator (Select one)

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State Title V Agency

Other MCHB Funded or Related Program

State Health Dept.

Clinical Programs/Hospitals

State Adolescent Health

Other Health-Related Program

Health Insurance/Managed Care Organization

Medicaid

Development Disabilities Council

Protection & Advocacy Agency (P&A)

Another UCEDD

Childcare/Early Childhood/Part C Infants and Toddlers

Head Start/Early Head Start

State/Local Special Education (3-21)

State/Local General Education

Post Secondary Education (Community College-University)

Employment/Voc Rehab

State/Local MR/DD Agency or Provider

State/Local Social Services

Aging Organization

Health Agency - Public/Private

Mental Health/Substance Abuse Agency

Housing Agency/Provider

Recreation Agency

Transportation Agency

Provider Organization

Consumer/Advocacy Organization

State/Local Coalition

Legislative Body

Justice/Legal Organization

Community or Faith-Based Organization

National Association

Independent research or policy organization

Foundation

Other

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*All Agencies Receiving TA/Collaborating on the Activity (Must check all that apply)

Name of agency/ies and a short description of the nature of their effort or contribution may be supplied in space provided

£ State Title V Agency ______

£ Other MCHB Funded or Related Program ______

£ State Health Dept. ______

£ Clinical Programs/Hospitals ______

£ State Adolescent Health ______

£ Other Health-Related Program ______

£ Health Insurance/Managed Care Organization ______

£ Medicaid ______

£ Development Disabilities Council ______

£ Protection & Advocacy Agency (P&A) ______

£ Another UCEDD ______

£ Childcare/Early Childhood/Part C Infants and Toddlers ______

£ Head Start/Early Head Start ______

£ State/Local Special Education (3-21) ______

£ State/Local General Education ______

£ Post Secondary Education (Community College-University) ______

£ Employment/Voc Rehab ______

£ State/Local MR/DD Agency or Provider ______

£ State/Local Social Services ______

£ Aging Organization ______

£ Health Agency - Public/Private ______

£ Mental Health/Substance Abuse Agency ______

£ Housing Agency/Provider ______

£ Recreation Agency ______

£ Transportation Agency ______

£ Provider Organization ______

£ Consumer/Advocacy Organization ______

£ State/Local Coalition ______

£ Legislative Body ______

£ Justice/Legal Organization ______

£ Community or Faith-Based Organization ______

£ National Association ______

£ Independent research or policy organization ______

£ Foundation ______

£ Other ______

*Topic of Technical Assistance

*List A (select one)

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Clinical care related (including medical home)

Cultural Competence Related

Data, Research, Evaluation Methods (Knowledge Translation)

Family Involvement

Interdisciplinary Teaming

Healthcare Workforce Leadership

Policy

Prevention

Systems Development/ Improvement

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*List B (select all that apply)

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£ Women’s /Reproductive/ Perinatal Health

£ Early Childhood Health/ Development (birth to school age)

£ School Age Children

£ Adolescent

£ CSHCN/Developmental Disabilities

£ Autism

£ Emergency Preparedness

£ Health Information Technology

£ Mental Health

£ Nutrition

£ Oral Health

£ Patient Safety

£ Respiratory Disease

£ Vulnerable Populations

£ Racial and Ethnic Diversity or Disparities

£ Other, please specify: ______

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*Project Affiliation

£ Not Applicable/No Affiliated Project

Primary Affiliated Project – List Title: ______

Secondary Affiliated Project– List Title: ______

*Duration (Report to the nearest full hour)

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£ Not Applicable

Date of Activity ______

(mm/dd/yyyy)

£ Recurring activity?

(For on-going activities, you may just enter the date the activity began)

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