California Department of Public Health Maternal, Child and Adolescent Health/Office of Family Planning Branch
MCAH/OFP Branch Programs Annual Report Cover Sheet FY:
Check with an “x” all programs included in this report: MCAH BIH Agency Name: Street Address: Mailing Address:
(Blank if same as above)
SIDS AFLP
BIH-FIMR FIMR
City, State, Zip Code: Representative: Title: Telephone Number: Facsimile Number: E-mail: Allocation Number: MCAH Toll-Free Telephone Number: Is Technical Assistance Requested? (Check”x”, on the one that applies.) Identify the program and briefly describe help that is needed: Program Fiscal None at this time
List Any Current Key Staff Waivers: (MCAH Director or PSC)
Certification by MCAH or AFLP Director
(e-signature/ print name)
Date
California Department of Public Health Maternal, Child and Adolescent Health/Office of Family Planning Branch
MCAH Scope of Work Progress, Form 3A: FY
Agency Name: Fiscal Year: Allocation Number:
Objective(s) and Activity (ies)
Progress: Accomplishments, Barriers, Challenges, Solutions
California Department of Public Health Maternal, Child and Adolescent Health/Office of Family Planning Branch
Black Infant Health Scope of Work Progress, Form 3B: FY
Agency Name: Fiscal Year: Allocation Number:
Objective(s) and Activity (ies)
Progress: Accomplishments, Barriers, Challenges, Solutions
California Department of Public Health Maternal, Child and Adolescent Health/Office of Family Planning Branch
Fetal and Infant Mortality Review Program Scope of Work Progress, Form 3C: FY Agency Name: Fiscal Year: Allocation Number: Objective(s) and Activity (ies)
Progress: Accomplishments, Barriers, Challenges, Solutions
California Department of Public Health Maternal, Child and Adolescent Health/Office of Family Planning Branch
Black Infant Health Fetal and Infant Mortality Review Program Scope of Work Progress, Form 3D: FY Agency Name: Fiscal Year: Allocation Number: Objective(s) and Activity (ies)
Progress: Accomplishments, Barriers, Challenges, Solutions
California Department of Public Health Maternal, Child and Adolescent Health/Office of Family Planning Branch
Sudden Infant Death Syndrome Scope of Work Progress, Form 3E FY:
Agency Name: Fiscal Year: Allocation Number: Objective(s) and Activity (ies)
Progress: Accomplishments, Barriers, Challenges, Solutions
California Department of Public Health Maternal, Child and Adolescent Health/Office of Family Planning Branch
MCAH-Related Collaboratives, Form 4 FY:
Agency Name: Fiscal Year: Allocation Number: Description of Collaborative Name:
Type of membership (e.g., voluntary agencies, consumers, providers, etc.)
Purpose of the collaborative:
Frequency of meetings:
List activities and accomplishments of the collaborative during this FY.
California Department of Public Health Maternal, Child and Adolescent Health/Office of Family Planning Branch
Toll-Free Telephone Report, Form 6 FY:
Agency Name: Fiscal Year: Allocation Number: How is the Toll-Free Telephone Number Advertised? Check “x” on all that apply: Handouts and/or pamphlets: Incentives (list types): Media (list type): Other (please describe):
Toll-Free Call Volume 1. If the numbers of calls were not counted or the volume is the same as the previous two years, nothing else is required. 2. If the numbers of calls were documented and they were higher or lower than the previous two years, answer either a or b. a. If the toll free call volume is low or reduced from the past two years, briefly state the possible cause, and identify interventions to increase use below.
OR b. If the toll free call volume significantly increased, greater than 10 percent from the past two years, briefly state the possible reasons or new method/s that increased volume below.
California Department of Public Health Maternal, Child and Adolescent Health/Office of Family Planning Branch
Annotation of Products Developed, Form 7 FY:
Agency Name: Fiscal Year: Allocation Number:
Title: Objective: Description or Ad Copy: (Attach or describe the final approved publication developed exclusively with Allocation funds.) Format: (e.g. calendar, magnet, brochure, report, etc.) Target Population: Language: Date Produced: Contact Person Name: Telephone Number:
California Department of Public Health Maternal, Child and Adolescent Health/Office of Family Planning Branch
Committee Membership, Form 8, FY:
Page of
Agency Name: Fiscal Year: Allocation Number: Directions: Check “x” one committee and complete a separate section for each member. BIH Community Advisory Committee BIH - FIMR Community Action Team FIMR Community Action Team
Member Name: Occupation/Title: Race/Ethnicity: Briefly summarize member’s Committee Experience. Identify reason/s why this individual is a member:
BIH - FIMR Case Review Team FIMR Case Review Team
Time Served:
Member Name: Occupation/Title: Race/Ethnicity:
Time Served:
Briefly summarize member’s Committee Experience. Identify reason/s why this individual is a member:
Member Name: Occupation/Title: Race/Ethnicity:
Time Served:
Briefly summarize member’s Committee Experience. Identify reason/s why this individual is a member:
California Department of Public Health Maternal, Child and Adolescent Health/Office of Family Planning Branch
FIMR Issues Checklist, FY: Agency Name: Fiscal Year: Allocation Number: Please “x” applicable Boxes
1. Medical Mother Teen Pregnancy Pregnancy> 35 Cord Problem Placenta abruptio Diabetes Incompetent cervix Infection during pregnancy Insufficient weight gain Multiple gestations Obesity Poor nutrition Pre-eclampsia/eclampsia Preterm labor Pre-existing hypertension STD Pregnancy < 1 yr apart PROM Previous TABs/SABs Previous fetal loss Previous infant loss Previous LBW delivery Previous preterm delivery 1st pregnancy < 18 yrs old > 4 live births Other: Unknown Not a factor 3. Payment for Care/Services Self-pay/medically indigent Medi-Cal/ Other government program Medi-Cal Managed Care Military payment Private Insurance - fee for service Private HMO/managed care plan Barriers related to insurance coverage Eligibility unclear Other: Unknown Not a factor 2. Medical: Fetal/Infant Intrauterine growth retardation Congenital anomalies Prematurity/Extreme prematurity Inadequate fetal monitoring Failure to thrive Substance exposure Feeding problems Respiratory distress syndrome Inappropriate level of care facility Other: Unknown Not a factor 5. Pediatric Care
Page 1 of 2
Review Date: Case Number:
4. Prenatal Care/Delivery Standard of care not met Inadequate assessment No prenatal care Late entry into prenatal care Lack of referral to additional services Missed appointments Multiple providers/sites Other: Unknown Not a factor
6. Substance Use OTC/Prescription Drugs Positive drug test Tobacco Alcohol Illicit drug: Other: Unknown Not a factor
7. Social Support Lack of supportive friends/family Negative influence friends/ family FOB not involved Other: Unknown Not a factor
Standard of care not met Inadequate assessment No pediatric care Not/Minimally breastfed Lack of referral to additional services Missed appointments Multiple providers/sites Other: Unknown Not a factor
8. Family Transition Frequent/ recent moves Job loss Concern-citizenship Single parent Married/ living together Divorce/separation Parent: prison/parole/probation Living in Shelter/Homeless Major illness/ death in family Other: Unknown Not a factor
California Department of Public Health Maternal, Child and Adolescent Health/Office of Family Planning Branch
FIMR Issues Checklist, FY: Agency Name: Fiscal Year: Allocation Number: Please “x” applicable Boxes
9. Mental Health/Stress Maternal history-mental illness Depression/mental illness during pregnancy/postpartum Multiple stresses during pregnancy/infancy Other: Unknown Not a factor 13. Provision/Design of Services Inadequate patient/client education/information Service unavailable in area Mother/child ineligible Lack of communication among providers/services Dissatisfaction/Fear of services Other: Unknown 10. Family Violence-Neglect Abuse/harassment of mother Child abuse Child neglect Other: Unknown Not a factor 14. Environment Substandard housing Overcrowding Exposure to toxic substance Second hand smoke Car seat none/improperly used 11. Culture Language/cultural differences, inability to communicate with provider Cultural Beliefs- pregnancy/health Other: Unknown Not a Factor Infant sleeping with others Sleep in non-infant bed Soft bedding Infant overheating Non-supine sleeping position Lack of adult visual supervision Other: 12. Transportation No public transportation Inadequate/unreliable transportation Other: Unknown Not a factor Unknown Not a factor Not a factor
Page 2 of 2
Review Date: Case Number:
15. Family Planning (FP) Lacks knowledge of FP methods/resources No B/C: intended pregnancy No B/C: unintended pregnancy Failed contraceptive Other: Unknown Not a factor
16. Injuries MV Occupant Suffocation Choking/strangulation Fire/burn Drowning/ near drown Poison/toxicity Shaken baby syndrome Other: Unknown Not a factor
17. Other Infant in Foster Care
California Department of Public Health Maternal, Child and Adolescent Health/Office of Family Planning Branch
FIMR Tracking Log
Agency Name:
Case # Review Date DOD Cause of Death
Fiscal Year:
Issues Questions
Allocation Number:
Recommendations Status