Illinois Administrative Code
Title 77 - PUBLIC HEALTH
Part 635 - FAMILY PLANNING SERVICES CODE
Appendix D - Instruction Manual For the BCHS Common Reporting Requirements

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

PUBLIC HEALTH SERVICE

Bureau of Community Health Services

Division of Monitoring and Analysis

5600 Fishers Lane

Rockville, Maryland 20857

(301)443-2376

BUREAU OF COMMUNITY HEALTH SERVICES

COMMON REPORTING REQUIREMENTS FACE SHEET

1) BCRR Reporting No.

2) Check one:

Initial Submission

Revision

3) REPORT FOR PERIOD (Check One & Complete Date)

January 198__ through June 198___

January 198__ through December 198___

_____ 198___ through _____ 198___

4) Sponsor/Grantee Name

5) Project Name and Address

6) Project Name/Address Change since last report?YesNo

7) Program(s)*

Grant Number

(a)

(b)

(c)

(d)

8) Name of Person Preparing Report

(e)

(f)

(g)

9) Area Code and Business Telephone Number of Person Preparing Report

10) Director (name)

Signature & Date

11)

Check those tables not submitted with this report because they are totally inapplicable for the reason listed: (do not submit blank tables)

2-A

Only applies to projects serving migratory and seasonal agricultural workers.

4

Only applies to primary care projects/grantees.

2-B

Only applies to CH, FP, MH and other projects designed by the Regional Office.

5

Only applies to projects affected by the Primary Care Effectiveness activity.

*Grantees receiving support from one or more BCHS program will report the identifying code for each program included and the grant number relating to each program (except in free-standing NHSC sites). The codes are as follows:

CH

- Community Health Center (includes RHI,

HC

- National Health Service Corps (BHPDS)

- UHI & Hospital-Affiliated).

MH

- Migrant Health

FP

- Title X Family Planning

1.

Submit:

a.

3 copies to:

the Data Manager

REGIONAL OFFICE

(unless the Regional Office specifies otherwise)

NOTE:

Grantees are in violation of Public Health Service policy if they fail to submit reports that are complete, timely, accurate and valid. Grantees are ineligible to receive continuation support if they have failed to comply with the submission requirements of the BCRR as established by the Regional Office.

2.

Direct questions to the Regional Data Manager.

3.

Check the appropriate reporting period and enter the terminal digit for the year in space 3 on the FACE SHEET and the upper right corner of each table.

4.

Attach an explanation to any table for which:

a. sampling is used or estimates have been made; and/or

b. the data is entered inconsistent with the definitions/instructions used in the BCRR Instruction Manual. Contact the Regional Data Manager if non-standard definitions are used.

5.

When submitting revisions of tables that have already been sent to the Regional Office or submitting for the first time a table which was omitted from a previous submission:

a. Submit only those tables which are being revised (changed) or being submitted for the first time.

b. Indicate the reporting period for the revised information on both the FACE SHEET and the table(s).

NOTE: The reporting period for the revised information should match the reporting period indicated on the FACE SHEET. Do not include tables with different due dates under one FACE SHEET;

c. Check the appropriate box (Initial Submission or Revision) on the FACE SHEET and each table revised;

d. Where a small number of cells are being revised they should be circled to avoid a re-keying of the entire table;

e. Follow the distribution schedule in 1 above.

(REV. 1/82)

AGE AND SEX

USERS* BY TYPE OF PROVIDER

MEDICAL

(a)

DENTAL

(b)

Female:

1)

0-4

2)

5-9

3)

10-14

4)

15-19

5)

20-34

6)

35-44

7)

45-64

8)

65 and over

9)

SUBTOTAL

(LINES 1 through 8)

Male:

10)

0-4

11)

5-9

12)

10-14

13)

15-19

14)

20-34

15)

35-44

16)

45-64

17)

65 and over

18)

SUBTOTAL

(LINES 10 through 17)

19)

TOTAL

(LINES 9 + 18)

TYPE OF USER

MEDICAL USERS*

(a)

DENTAL USERS*

(b)

1) Migratory Agricultural Workers and Family Members

2) Seasonal Agricultural Workers and Family Members

TYPE OF FAMILY PLANNING USER

FAMILY PLANNING USERS*

(a)

1) Women at or below 150% of Poverty Level

2) Women above 150% of Poverty Level

3) Men

4) TOTAL (LINES 1+2)

Female Adolescent Users of Family Planning Services (Subset of LINE 4)

5) Under 20 years old

6) 15-19 Year Olds

PERSONNEL BY FUNCTIONAL COST CENTER*

STAFF* PERSONNEL EQUIVALENTS

ENCOUNTERS

Onsiite With Staff Providers

All Other (Including Offsite and Nonstaff)

(a)**

(b)***

(c)

(d)

MEDICAL SERVICES

(A)

1) Primary Care Physicians

2) Psychiatrists

3) Other Medical/Surgical Specialists

4) Midlevel Practitioners

5) Nurses -- Medical

6) Medical Support

ANCIL- LARY SERVICES

(B)

7) Laboratory-Medical

(C)

8) X-Ray-Medical

(D)

9) Pharmacy-Medical & Dental

DENTAL SERVICES

10) Dentists

(E)

11) Dental Hygienists/

Oral Therapists

12) Dental Support

OTHER HEALTH SERVICES

(G)

13) Education/Social Service

14) Other Health

15)

16) Other Health Support

SUPPORT SERVICES

(H)

17) Community Service

(I)

18) Environmental Health

(J)

19) Patient Transportation

20) Patient Records

CLINIC OVER- HEAD

(K)

21) Administration

(L)

22) Facility

23) TOTAL (LINES 1 through 22)

* Assign staff time by function performed, not title. See instructions for this table.

** Include only NHSC personnel in Column (a).

*** Include salaried personnel, as well as the personnel equivalents of any non-salaried personnel (contractual or donated) who work for the grantee on a scheduled time basis. (See definition of "Staff.") Include WIC, VISTA and volunteer staff, where appropriate.

TYPE OF SERVICE

PATIENT ADMISSIONS BY PROJECT STAFF

(a)

HOSPITAL INPATIENT ENCOUNTERS BY PROJECT STAFF*

(b)

1) Pediatrics

2) Internal Medicine

3) Obstetrics

4) Other (Specify)

_____________

_____________

Clinical

User Category

Records Sampled

(a)

Records in Compliance

(b)

1)

Immunization

24-27 months

2)

Immunization

6 year olds

3)

Adolescent Family Planning

Counseling (under 20 years)

4)

Pap Smear Follow-up

5)

Hypertension Follow-up

(10 years and over)

6)

Anemia Screening

24-27 months

FUNCTIONAL COST CENTER

SALARIED PERSONNEL* (WORKSHEET A, COL. h)

OTHER (INCLUDING CONSULTANT AND CONTRACT SERVICES)

VALUE OF DONATED MATERIAL & SERVICE**

TOTAL BEFORE DISTRIBUTION (COLS.

a + b + c + d)

TOTAL AFTER DISTRIBUTION OF FACILITY COSTS *** (WORKSHEET B, COL. e)

TOTAL AFTER FINAL DIST. OF CLINIC OVERHEAD COSTS (WORKSHEET B, COL. h)

(a)

(c)

(d)

(e)

(f)

(g)

HEALTH CARE FUNCTIONS

1)

Medical (A)

2)

Laboratory-Medical (B)

3)

X-Ray Medical (C)

4)

Pharmacy-Medical & Dental (D)

5)

Dental (inc. Lab & X-Ray) (E)

6)

Inpatient (F)

7)

Other Health (G)

8)

Community Service (H)

9)

Environment (I)

10)

Patient Transportation (J)

CLINIC OVERHEAD FUNCTIONS

11)

Administration (K)

- 0 -

12)

Facility (L)

- 0 -

- 0 -

13)

TOTAL (LINES 1 though 12)

DISTRIBUTION OF PATIENT RECORDS COSTS

DISTRIBUTION OF FRINGE

BENEFITS COSTS

Other Costs

Value of Donated Mat. & Svcs.

Total Before Distribution

FUNCTIONAL COST CENTERS

Number of Encounters

% of Total Encounters

Amount of Personnel Distrb. to Functions

Amount of Other Distrb. to Functions

Salaried Personnel Costs (inc. Col. C)

% of Total Salaries

Amount of Fringe Benefits Distrb. to Functions

Total Salaried Personnel Costs

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

(i)

(j)

(k)

HEALTH CARE FUNCTIONS

1) Medical (A)

2) Laboratory-Medical (B)

3) X-Ray - Medical (C)

4) Pharmacy-Medical & Dental (D)

5) Dental (Lab & X-Ray) (E)

6) Inpatient (F)

7) Other Health (G)

8) Community Service (H)

9) Environmental (I)

10) Patient Transportation (J)

11) Patient Records

( )

( )

CLINIC OVERHEAD FUNCTIONS:

12) Administration (K)

13) Facility (L)

14) Fringe Benefits

( )

15) TOTAL (LINES 1 though 14)

100%

-0-

-0-

100%

-0-

FUNCTIONAL COST CENTERS

Total before Distribution

Worksheet A, Col (k)

DISTRIBUTION OF FACILITY COSTS

Total after Distrb. of Facility Costs

(a + d)

DISTRIBUTION OF ADMINISTRATION COSTS

Total after Final Distrb.

of Clinic Overhead Costs

(e + g)

Square Feet

of Space Used

% of Square

Footage

Amount of Facility Distrb. to Functions

% of Health Care Cost Subtotal

Amount of Admin. Distrb. to Functions

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

HEALTH CARE FUNCTIONS

1) Medical (A)

2) Laboratory -- Medical (B)

3) X-Ray -- Medical (C)

4) Pharmacy-Medical & Dental (D)

5) Dental (Lab & X-Ray) (E)

6) Inpatient (F)

7) Other Health (G)

8) Community Service (H)

9) Environmental (I)

10) Patient Transportation (J)

11) SUBTOTAL (LINES 1 through 10)

100%

CLINIC OVERHEAD FUNCTIONS:

12) Administration (K)

( )

-0-

13) Facility (L)

( )

-0-

-0-

14) SUBTOTAL (LINES 12 + 13)

15) GRAND TOTAL

100%

-0-

-0-

CONSISTENCY CHECKS:

1. COL. (a) equals TABLE 6: COL. (e)

2. COL. (e) equals TABLE 6: COL. (f)

3. COL. (h) equals TABLE 6: COL. (g)

4. LINE 15, COL. (a), COL. (e), COL. (h) should all be equal.

SOURCE OF FUNDS

ACCOUNTS RECEIVABLE AT BEGINNING OF THIS PERIOD

FULL CHARGES AND PREMIUMS DURING THIS PERIOD*

AMOUNT COLLECTED DURING THIS PERIOD

ADJUSTMENTS (identify below)**

ACCOUNTS RECEIVABLE AT END OF THIS PERIOD

(a)

(b)

(c)

(d)

(e)

1) Medicare (Title XVIII)

2) Medicaid (Title XIX)

3) Title XX

4) Other Third Parties

5) Patient Fees/Premiums

6) TOTAL (LINES

1+2+3+4+5)

DESCRIPTION

AMOUNT

7) Disallowances and Reductions (Contractual Allowances)

$

8) Sliding Payment Scale Adjustments

$

9) Bad Debt Write Off

$

10) Other (Specify)

$

Summary of Receipts and Expenditures

Actual for Reporting Period

(a)

Federal Grants

1) Section 329 (Migrant Health)

2) Section 330 (Community Health Center)

3) MCH Block Grants*

4) Title X (Family Planning)**

5) Section 340 (Primary Care R & D)

6) Appalachian Health

7) Black Lung Clinic Program

8) WIC***

9) Other (Specify)****_____________

10) SUBTOTAL (LINES 1 through 9)

Payment for Services

11) Title XVIII (Medicare)

12) Title XIX (Medicaid)

13) Title XX

14) Other Third Parties

15) Patient Collections

16) SUBTOTAL (LINES 11 through 15)

Other Sources

17) State

18) Local

19) Other (Specify)**** _____________

20) SUBTOTAL (LINES 17 through 19)

Expenditures

21) Capital Expenditures

22) Non-Capital Expenditures*****

23) SUBTOTAL (LINES 21 + 22)