Data Tables in Fulfillment of Monthly Reporting Requirements II. Outcomes Measures Pregnant Only tab Variable Name Previous Pregnancy Complications for all known previous events Outcomes of all known previous pregnancies; can have multiple complications "Other previous complication - miscarriage, multiple birth (eg triplets), high number of births, etc" Current Medical Complications Can have multiple complications "Other Diseases - Any other diseases, place note below this chart" Current Social Complications "Smoking - currently smoking, smoking while pregnant. If stopped before pregnant don't list" Other Social - Other complications. Put note below this table. Infant Tab "Infants born to participants (FPTM participants only) - Including deaths, Unduplicated (One Time Event)" Two sections to this tab - Infant death section and Live birth section Infant deaths Variable Name Infant deaths - Record time of death Pregnancy Complications at time of Delivery - record complications that occurred "Months since Previous Pregnancy or Delivery - Time interval of previous event to this conception, not event to event." Live Birth Variable Name Gestational Age at birth Birth weight Pregnancy Complications at time of Delivery "Months since Previous Pregnancy or Delivery - Time interval of previous event to this conception, not event to event." Miscarriage Abortion tab II. Outcome Measures Miscarriage Only - Unduplicated - At Time of Event Variable Name Pregnancy Loss - there are three parts to this table Spontaneous Abortion/Miscarriage - record gestational time Fetal Death/Stillbirth Elective Abortion - record gestation time Variable Name "Previous Pregnancy Complications - NOT this event but before, if any" "Other previous complication - miscarriage, multiple birth (eg triplets), high of number of births, etc" Current Pregnancy Complications- associated with this pregnancy loss Current Chronic Complications - associated with this pregnancy loss Current Social Complications - associated with this pregnancy loss Smoking - currently smoking or while pregnant. Not if stopped before pregnancy Months since Previous Pregnancy or Delivery - interval from previous event to conception if known Preconception tab "Preconception Program - Track over time - follow clients month to month, time in program, not visits" Variable Name Months between pregnancies - time since last pregnancy Current Medical Complications Current Social Complications Smoking - currently smoking in preconception program For Lost to Follow-up and Transfer tabs Lost to Follow-up Participants - Client no longer in your program after repeated attempts (call attempts and/or months lapse and client does not respond) """Lost"" varies by client type - preconception, pregnancy, infant care" There are four sections Pregnant Only Participants "Post-partum Program Participants, women - women getting postpartum care, not children" Preconception Program Participants Infants of participants - Infants in pediatric care program Variable Name Race White - Not Hispanic Black or African American - Not Hispanic American Indian or Alaskan Native Asian Native Hawaiian or Pacific Islander - Include Hispanic here Other - include Hispanic here Unknown Total Ethnicity "Hispanic or Latina - All Hispanics go here, W-H, B-H, etc" Transfers There are three sections Transferred Participants to Other Programs or Facilities - No longer under your care but care is elsewhere Not expected to return to your program Pregnant Only Participants "Post-partum & Preconception Participants, women - women getting postpartum care, not children" Infants of participants - Infants and toddlers under care Variable Name Race/ethnicity as above Lost to follow-up and Transfer guidelines "Postpartum and Preconception Care - All attempts should be made to engage the client into care. A provider may consider a client “lost to follow-up” if four appropriately spaced attempts to contact the client for a needed appointment or referral have been unsuccessful to communicate with the client (or another appropriate caretaker where needed). Where a client has not been able to comply with a visit or referral due to transportation, social or financial reasons, the communication should not be considered unsuccessful. The client is considered “transferred” when it is discovered that the client is under the appropriate full care of another provider(s)." "Pregnancy program, prenatal clients – All attempts should be made to engage a pregnant client into care throughout the pregnancy. A provider should only discontinue attempts (and consider a client “transferred”) when it is discovered that the client is in the appropriate full care of another provider(s). If there is not a transfer of care, then the client is lost to follow-up." "Infant Care/pediatric - All attempts should be made to engage a child under the age of 1 into care. A provider should only discontinue attempts (and consider a client “transferred”) when it is discovered that the child under the age of 1 is in the appropriate full care of another provider(s). Where a child is over the age of 1 (and has had all immunizations required through age 1), a child may be considered “lost to follow-up” if four appropriately spaced attempts to communicate with an appropriate adult caretaker have been unsuccessful. Where a client has not been able to comply with a visit or referral due to transportation, social or financial reasons, the communication should not be considered unsuccessful. The client is considered “transferred” when it is discovered that the client is under the appropriate full care of another provider(s)." Data Tables in Fulfillment of Monthly Reporting Requirements II. Outcome Measures Miscarriage Only - Unduplicated - At Time of Event Variable Name Calendar Month Year 3 Pregnancy Loss January February March April May June Total Spontaneous Abortion/Miscarriage ? 10 weeks gestation 0 0 11 - 20 weeks gestation 0 0 Total 0 0 0 0 0 0 0 Fetal Death/Stillbirth Total 0 0 Elective Abortion ? 10 weeks gestation 0 0 > 11 weeks gestation 0 0 Total 0 0 0 0 0 0 0 Total all three events 0 0 0 0 0 0 0 Variable Name Calendar Month Year 3 Previous Pregnancy Complications January February March April May June Total Previous premature birth (EGA < 37 weeks) 0 0 Previous low birth weight delivery (? 2500 grams; 5lbs. 8ozs.) 0 0 Previous infant death Other previous complication 0 0 Total Number of Conditions 0 0 0 0 0 0 0 Variable Name Calendar Month Year 3 Current Pregnancy Complications January February March April May June Total Pre-eclampsia/Eclampsia 0 0 Gestational Diabetes 0 0 Total Number of Conditions 0 0 0 0 0 0 0 Variable Name Calendar Month Year 3 Current Chronic Complications January February March April May June Total Heart disease 0 0 Type II Diabetes 0 0 Hypertension/HBP 0 0 Thyroid 0 0 Pulmonary Disease Depression/Mental Health Other Diseases Total Number of Conditions 0 0 0 0 0 0 0 Variable Name Calendar Month Year 3 Current Social Complications January February March April May June Total Domestic violence 0 0 Rape victim 0 0 Homeless/living in shelter 0 0 Substance abuse Smoking Other Social 0 0 Total Social Conditions 0 0 0 0 0 0 0 Variable Name Calendar Month Year 3 Months since Previous Pregnancy or Delivery January February March April May June Total Never Pregnant 0 0 <= 9 Months 0 0 10 - 18 Months 0 0 19 - 24 Months 0 0 25+ Months 0 0 Total 0 0 0 0 0 0 0 Data Tables in Fulfillment of Monthly Reporting Requirements II. Outcome Measures Preconception Program - Track over time - follow clients month to month "Time in program, not visits" Variable Name Calendar Month Year 3 January February March April May June Total Months between pregnancies Never Pregnant 0 <= 9 Months 0 0 10 - 18 Months 0 0 19 - 24 Months 0 0 25+ Months 0 0 Total 0 0 0 0 0 0 0 Variable Name Calendar Month Year 3 Current Medical Complications January February March April May June Total Heart disease 0 0 Type II Diabetes 0 0 Hypertension/HBP 0 0 Thyroid Pulmonary Disease Depression/Mental Health Other Diseases 0 0 Total Medical Conditions 0 0 0 0 0 0 0 Variable Name Calendar Month Year 3 Current Social Complications January February March April May June Total Domestic violence 0 0 Rape victim 0 0 Homeless/living in shelter 0 0 Substance abuse Smoking Other Social Total Social Conditions 0 0 0 0 0 0 0 Data Tables in Fulfillment of Monthly Reporting Requirements II. Outcome Measures Lost to Follow-up Participants - Client no longer in your program after repeated attempts (call attempts and/or months lapse and client does not respond See Comments sheet) Pregnant Only Participants Variable Name Calendar Month Year 3 Race January February March April May June Total White 0 0 Black or African American 0 0 American Indian or Alaskan Native 0 0 Asian 0 0 Native Hawaiian or Pacific Islander 0 0 Other 0 0 Unknown 0 0 Total 0 0 0 0 0 0 0 Ethnicity Hispanic or Latina 0 0 Variable Name Calendar Month Year 3 Age January February March April May June Total Average < 15 years old 0 0 15 - 17 0 0 18 - 19 0 0 20 - 24 0 0 25 - 29 0 0 30 - 34 0 0 35 - 39 0 0 40+ 0 0 Total 0 0 0 0 0 0 0 Variable Name Calendar Month Year 3 Initiation of Prenatal Care January February March April May June Total Average 1st Trimester (1 - 14 weeks) 0 0 2nd Trimester (15 - 27 weeks) 0 0 3rd Trimester (28 - 40 weeks) 0 0 Total 0 0 0 0 0 0 0 "Post-partum Program Participants, women" Variable Name Calendar Month Year 3 Race January February March April May June Total White 0 0 Black or African American 0 0 American Indian or Alaskan Native 0 0 Asian 0 0 Native Hawaiian or Pacific Islander 0 0 Other 0 0 Unknown 0 0 Total 0 0 0 0 0 0 0 Ethnicity Hispanic or Latina 0 0 Variable Name Calendar Month Year 3 Age January February March April May June Total Average < 15 years old 0 0 15 - 17 0 0 18 - 19 0 0 20 - 24 0 0 25 - 29 0 0 30 - 34 0 0 35 - 39 0 0 40+ 0 0 Total 0 0 0 0 0 0 0 Preconception Program Participants Variable Name Calendar Month Year 3 Race January February March April May June Total White 0 0 Black or African American 0 0 American Indian or Alaskan Native 0 0 Asian 0 0 Native Hawaiian or Pacific Islander 0 0 Other 0 0 Unknown 0 0 Total 0 0 0 0 0 0 0 Ethnicity Hispanic or Latina 0 0 Variable Name Calendar Month Year 3 Age January February March April May June Total Average < 15 years old 0 0 15 - 17 0 0 18 - 19 0 0 20 - 24 0 0 25 - 29 0 0 30 - 34 0 0 35 - 39 0 0 40+ 0 0 Total 0 0 0 0 0 0 0 Infants of participants Variable Name Calendar Month Year 3 Race January February March April May June Total White 0 0 Black or African American 0 0 American Indian or Alaskan Native 0 0 Asian 0 0 Native Hawaiian or Pacific Islander 0 0 Other 0 0 Unknown 0 0 Total 0 0 0 0 0 0 0 Ethnicity Hispanic or Latina 0 0 Data Tables in Fulfillment of Monthly Reporting Requirements II. Outcome Measures Transferred Participants to Other Programs or Facilities - No longer under your care but care is elsewhere Not expected to return See Comments sheet Pregnant Only Participants Variable Name Calendar Month Year 3 Race January February March April May June Total White 0 0 Black or African American 0 0 American Indian or Alaskan Native 0 0 Asian 0 0 Native Hawaiian or Pacific Islander 0 0 Other 0 0 Unknown 0 0 Total 0 0 0 0 0 0 0 Ethnicity Hispanic or Latina 0 0 Variable Name Calendar Month Year 3 Age January February March April May June Total < 15 years old 0 0 15 - 17 0 0 18 - 19 0 0 20 - 24 0 0 25 - 29 0 0 30 - 34 0 0 35 - 39 0 0 40+ 0 0 Total 0 0 0 0 0 0 0 Variable Name Calendar Month Year 3 Initiation of Prenatal Care January February March April May June Total 1st Trimester (1 - 14 weeks) 0 0 2nd Trimester (15 - 27 weeks) 0 0 3rd Trimester (28 - 40 weeks) 0 0 Total 0 0 0 0 0 0 0 Post-partum Participants Variable Name Calendar Month Year 3 Race January February March April May June Total White 0 0 Black or African American 0 0 American Indian or Alaskan Native 0 0 Asian 0 0 Native Hawaiian or Pacific Islander 0 0 Other 0 0 Unknown 0 0 Total 0 0 0 0 0 0 0 Ethnicity Hispanic or Latina 0 0 Variable Name Calendar Month Year 3 Age January February March April May June Total < 15 years old 0 0 15 - 17 0 0 18 - 19 0 0 20 - 24 0 0 25 - 29 0 0 30 - 34 0 0 35 - 39 0 0 40+ 0 0 Total 0 0 0 0 0 0 0 Preconception Participants Variable Name Calendar Month Year 3 Race January February March April May June Total White 0 0 Black or African American 0 0 American Indian or Alaskan Native 0 0 Asian 0 0 Native Hawaiian or Pacific Islander 0 0 Other 0 0 Unknown 0 0 Total 0 0 0 0 0 0 0 Ethnicity Hispanic or Latina 0 0 Variable Name Calendar Month Year 3 Age January February March April May June Total < 15 years old 0 0 15 - 17 0 0 18 - 19 0 0 20 - 24 0 0 25 - 29 0 0 30 - 34 0 0 35 - 39 0 0 40+ 0 0 Total 0 0 0 0 0 0 0 Infants of participants Variable Name Calendar Month Year 3 Race January February March April May June Total White 0 0 Black or African American 0 0 American Indian or Alaskan Native 0 0 Asian 0 0 Native Hawaiian or Pacific Islander 0 0 Other 0 0 Unknown 0 0 Total 0 0 0 0 0 0 0 Ethnicity Hispanic or Latina 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