Section I Data Tables Pregnant - Worksheet I. Demographics "Pregnant Only - Unduplicated - New clients as they come into FPTM program, not visits or visits per month." Variable Name - Race White - Not Hispanic Black - Not Hispanic Other - Include Hispanic Here "Hispanic or Latina - All Hispanics go here, W-H, B-H, etc" Variable Name - Participant History Participants with NO existing medical chart (new to FPTM program) - New to FPTM and contractor I. Demographics (right side table) "Pregnant Only - All current participants to date. Running total, active in FPTM, - not necessary to have a visit in a given month" Variable Name - Race Categories as above Infant - Worksheet I. Demographics (left side table) "Infants Delivered to Program Participants - Birth event, Unduplicated, Report at time of discovery/notification" Variable Name - Race White - Not Hispanic Black - Not Hispanic Other - Include Hispanic Here "Hispanic or Latina - All Hispanics go here, W-H, B-H, etc" "ZIP Code - ZIP Code of mother, not hospital" I. Demographics (right side table) "Infants Delivered to Program Participants - All infants participating in infant/pediatric care program to 24 months, running total" Variable Name Race - categories as above Age in months - age as they move through program Postpartum I. Demographics (left side table) "Postpartum Program Participants - New participants in program, from your FPTM pregnancy program" Variable Name - Race White - Not Hispanic Black - Not Hispanic Other - Include Hispanic Here "Hispanic or Latina - All Hispanics go here, W-H, B-H, etc" I. Demographics (right side table) Variable Name - Race "Postpartum Only - All current participants to date. Running total, active in FPTM, - not necessary to have a visit in a given month" Categories as above Preconception - Worksheet I. Demographics (left side table) "Preconception Program Participants - All participants in program, new participants" Variable Name - Race White - Not Hispanic Black - Not Hispanic Other - Include Hispanic Here "Hispanic or Latina - All Hispanics go here, W-H, B-H, etc" I. Demographics (right side table) "Preconception Only - All current participants to date. Running total, active in FPTM, - not necessary to have a visit in a given month" Variable Name - Race Categories as above Payment Type I. Demographics Variable Pregnant only program Infants Born to Participants - Birth event only "Infant/pediatric in program - Kids getting post-partum care, birth through 24 months old" "ó 2 Years Post-partum/FPTM Program Part. - Women only, up to 24 months" Preconception Program Participants "Medicaid Eligible - Eligible as deemed from intake, not actual Medicaid approval" "Other Public Insurer - any other sources Medicare, Screening for Life, etc" Private Insurer Patient Pay Data Tables in Fulfillment of Monthly Reporting Requirements I. Demographics I. Demographics "Infants Delivered to Program Participants - Unduplicated, Report at time of discovery/notification" Infants Delivered to Program Participants - All infants participating in the infant/pediatric care program Variable Name Calendar Month Year 3 Variable Name Calendar Month Year 3 Race January February March April May June Total Race January February March April May June White 0 0 White Black or African American 0 Black or African American American Indian or Alaskan Native 0 0 American Indian or Alaskan Native 0 Asian 0 0 Asian 0 Native Hawaiian or Pacific Islander 0 0 Native Hawaiian or Pacific Islander 0 Other 0 Other Unknown 0 0 Unknown 0 Total 0 0 0 0 0 0 0 Total 0 0 0 0 0 0 Ethnicity Ethnicity Hispanic or Latina 0 Hispanic or Latina Variable Name Calendar Month Year 3 Variable Name "Zip code - Parent home, not hospital" January February March April May June Total Age in Months - Infants in program January February March April May June New Castle < 1 month 19701 0 0 1 - 2 months 19702 0 0 3 - 6 months 19703 0 0 7 - 12 months 19711 0 0 12 - 18 months 0 19713 0 0 19 - 24 months 0 19720 0 0 24+ 19801 0 0 Totals 0 0 0 0 0 0 19802 0 0 19805 0 0 19908 0 0 Kent 19901 0 0 19904 0 0 Sussex 19956 0 0 19966 0 0 19973 0 0 Other 0 Total 0 0 0 0 0 0 0 Data Tables in Fulfillment of Monthly Reporting Requirements Data Tables in Fulfillment of Monthly Reporting Requirements I. Demographics I. Demographics "Post partum Program Participants - Unduplicated - From FPTM pregnancy program, women only" "Postpartum program participants - All participants in program, Running total, continuing in program" Variable Name Calendar Month Year 3 Variable Name Calendar Month Year 3 Race January February March April May June Total Race January February March April May June White 0 0 White Black or African American 0 0 Black or African American 0 American Indian or Alaskan Native 0 0 American Indian or Alaskan Native 0 Asian 0 0 Asian 0 Native Hawaiian or Pacific Islander 0 0 Native Hawaiian or Pacific Islander 0 Other 0 0 Other 0 Unknown 0 0 Unknown 0 Total 0 0 0 0 0 0 0 Total 0 0 0 0 0 0 Ethnicity Ethnicity Hispanic or Latina 0 0 Hispanic or Latina 0 Variable Name Calendar Month Year 3 Variable Name Calendar Month Year 3 Age January February March April May June Total Age January February March April May June < 15 years old 0 0 < 15 years old 0 15 - 17 0 0 15 - 17 0 18 - 19 0 0 18 - 19 0 20 - 24 0 0 20 - 24 0 25 - 29 0 0 25 - 29 30 - 34 0 0 30 - 34 0 35 - 39 0 0 35 - 39 0 40+ 0 0 40+ 0 Total 0 0 0 0 0 0 0 Total 0 0 0 0 0 0 Variable Name Calendar Month Year 3 Zip code January February March April May June Total New Castle 19701 0 0 19702 0 0 19703 0 0 19711 0 0 19713 0 0 19720 0 0 19801 0 0 19802 0 0 19805 0 0 19908 0 0 Kent 19901 0 0 19904 0 0 Sussex 19956 0 0 19966 0 0 19973 0 0 Other 0 0 Total 0 0 0 0 0 0 0 Data Tables in Fulfillment of Monthly Reporting Requirements Data Tables in Fulfillment of Monthly Reporting Requirements I. Demographics I. Demographics "Preconception Program Participants - Unduplicated - New to Precon program, at entry, not visits" "Preconception Program Participants - All participants in program, Running total, continuing in program" Variable Name Calendar Month Year 3 Variable Name Calendar Month Year 3 Race January February March April May June Total Race January February March April May June White 0 0 White Black or African American 0 0 Black or African American 0 American Indian or Alaskan Native 0 0 American Indian or Alaskan Native 0 Asian 0 0 Asian 0 Native Hawaiian or Pacific Islander 0 0 Native Hawaiian or Pacific Islander 0 Other 0 0 Other 0 Unknown 0 0 Unknown 0 Total 0 0 0 0 0 0 0 Total 0 0 0 0 0 0 Ethnicity Ethnicity Hispanic or Latina 0 0 Hispanic or Latina 0 Variable Name Calendar Month Year 3 Variable Name Calendar Month Year 3 Age January February March April May June Total Age January February March April May June < 15 years old 0 0 < 15 years old 0 15 - 17 0 0 15 - 17 0 18 - 19 0 0 18 - 19 0 20 - 24 0 0 20 - 24 0 25 - 29 0 0 25 - 29 30 - 34 0 0 30 - 34 0 35 - 39 0 0 35 - 39 0 40+ 0 0 40+ 0 Total 0 0 0 0 0 0 0 Total 0 0 0 0 0 0 Variable Name Calendar Month Year 3 Zip code January February March April May June Total New Castle 19701 0 0 19702 0 0 19703 0 0 19711 0 0 19713 0 0 19720 0 0 19801 0 0 19802 0 0 19805 0 0 19908 0 0 Kent 19901 0 0 19904 0 0 Sussex 19956 0 0 19966 0 0 19973 0 0 Other 0 0 Total 0 0 0 0 0 0 0 Variable Name Calendar Month Year 3 Participant History January February March April May June Total Participants with NO existing medical chart (new to Precon & contractor) 0 0 Participants with medical chart (existing previously with contractor) 0 0 Total 0 0 0 0 0 0 0 Data Tables in Fulfillment of Monthly Reporting Requirements I. Demographics "New participants into programs, follows left side tables." " Infant born is event only, not care program" January Variable Payment Type Participant Description Medicaid Eligible Other Public Insurer Private Insurer Patient Pay Pregnant Only program 0 0 0 0 Infants Born to Participants 0 0 0 0 Infant/pediatric in program ó 2 Years Post-partum/FPTM Program Part. 0 0 0 0 Preconception Program Participants 0 0 0 0 Total 0 0 0 0 February Variable Payment Type Participant Description Medicaid Eligible Other Public Insurer Private Insurer Patient Pay Pregnant Only program Infants Born to Participants Infant/pediatric in program ó 2 Years Post-partum/FPTM Program Part. Preconception Program Participants Total 0 0 0 0 March Variable Payment Type Participant Description Medicaid Eligible Other Public Insurer Private Insurer Patient Pay Pregnant Only program Infants Born to Participants Infant/pediatric in program ó 2 Years Post-partum/FPTM Program Part. Preconception Program Participants Total 0 0 0 0 April Variable Payment Type Participant Description Medicaid Eligible Other Public Insurer Private Insurer Patient Pay Pregnant Only program Infants Born to Participants Infant/pediatric in program ó 2 Years Post-partum/FPTM Program Part. Preconception Program Participants Total 0 0 0 0 May Variable Payment Type Participant Description Medicaid Eligible Other Public Insurer Private Insurer Patient Pay Pregnant Only program Infants Born to Participants Infant/pediatric in program ó 2 Years Post-partum/FPTM Program Part. Preconception Program Participants Total 0 0 0 0 June Variable Payment Type Participant Description Medicaid Eligible Other Public Insurer Private Insurer Patient Pay Pregnant Only program Infants Born to Participants Infant/pediatric in program ó 2 Years Post-partum/FPTM Program Part. Preconception Program Participants Total 0 0 0 0 Data Tables in Fulfillment of Monthly Reporting Requirements I. Demographics "New participants into programs, follows left side tables." " Infant born is event only, not care program" January Variable Payment Type Participant Description Medicaid Eligible Other Public Insurer Private Insurer Patient Pay Pregnant Only program 0 0 0 0 Infants Born to Participants 0 0 0 0 Infant/pediatric in program ó 2 Years Post-partum/FPTM Program Part. 0 0 0 0 Preconception Program Participants 0 0 0 0 Total 0 0 0 0 February Variable Payment Type Participant Description Medicaid Eligible Other Public Insurer Private Insurer Patient Pay Pregnant Only program Infants Born to Participants Infant/pediatric in program ó 2 Years Post-partum/FPTM Program Part. Preconception Program Participants Total 0 0 0 0 March Variable Payment Type Participant Description Medicaid Eligible Other Public Insurer Private Insurer Patient Pay Pregnant Only program Infants Born to Participants Infant/pediatric in program ó 2 Years Post-partum/FPTM Program Part. Preconception Program Participants Total 0 0 0 0 April Variable Payment Type Participant Description Medicaid Eligible Other Public Insurer Private Insurer Patient Pay Pregnant Only program Infants Born to Participants Infant/pediatric in program ó 2 Years Post-partum/FPTM Program Part. Preconception Program Participants Total 0 0 0 0 May Variable Payment Type Participant Description Medicaid Eligible Other Public Insurer Private Insurer Patient Pay Pregnant Only program Infants Born to Participants Infant/pediatric in program ó 2 Years Post-partum/FPTM Program Part. Preconception Program Participants Total 0 0 0 0 June Variable Payment Type Participant Description Medicaid Eligible Other Public Insurer Private Insurer Patient Pay Pregnant Only program Infants Born to Participants Infant/pediatric in program ó 2 Years Post-partum/FPTM Program Part. Preconception Program Participants Total 0 0 0 0 Data Tables in Fulfillment of Monthly Reporting Requirements I. Demographics "New participants into programs, follows left side tables." " Infant born is event only, not care program" January Variable Payment Type Participant Description Medicaid Eligible Other Public Insurer Private Insurer Patient Pay Pregnant Only program 0 0 0 0 Infants Born to Participants 0 0 0 0 Infant/pediatric in program ó 2 Years Post-partum/FPTM Program Part. 0 0 0 0 Preconception Program Participants 0 0 0 0 Total 0 0 0 0 February Variable Payment Type Participant Description Medicaid Eligible Other Public Insurer Private Insurer Patient Pay Pregnant Only program Infants Born to Participants Infant/pediatric in program ó 2 Years Post-partum/FPTM Program Part. Preconception Program Participants Total 0 0 0 0 March Variable Payment Type Participant Description Medicaid Eligible Other Public Insurer Private Insurer Patient Pay Pregnant Only program Infants Born to Participants Infant/pediatric in program ó 2 Years Post-partum/FPTM Program Part. Preconception Program Participants Total 0 0 0 0 April Variable Payment Type Participant Description Medicaid Eligible Other Public Insurer Private Insurer Patient Pay Pregnant Only program Infants Born to Participants Infant/pediatric in program ó 2 Years Post-partum/FPTM Program Part. Preconception Program Participants Total 0 0 0 0 May Variable Payment Type Participant Description Medicaid Eligible Other Public Insurer Private Insurer Patient Pay Pregnant Only program Infants Born to Participants Infant/pediatric in program ó 2 Years Post-partum/FPTM Program Part. Preconception Program Participants Total 0 0 0 0 June Variable Payment Type Participant Description Medicaid Eligible Other Public Insurer Private Insurer Patient Pay Pregnant Only program Infants Born to Participants Infant/pediatric in program ó 2 Years Post-partum/FPTM Program Part. Preconception Program Participants Total 0 0 0 0