Ill. Admin. Code tit. 77, § 635.APPENDIX D – Instruction Manual for the BCHS Common Reporting Requirements

FORM APPROVED

OMB NO. 0915-0004

EXPIRES 12/31/82

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

7) Program(s)*

Grant Number

(a)

(b)

6) Project Name/Address Change

(c)

since last report?

Yes No

(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.

Only applies to primary care projects/grantees.

2-B

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

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:

- Community Health Center (includes RHI,

- National Health Service Corps (BHPDS)

- UHI & Hospital-Affiliated).

- Migrant Health

- Title X Family Planning

Submit:

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.

Direct questions to the Regional Data Manager.

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.

Attach an explanation to any table for which:

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

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.

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:

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

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;

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

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

Follow the distribution schedule in 1 above.

(REV. 1/82)