OMB No.: 0915-0285. Expiration Date:9/30/2016

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration
NATIVE HAWAIIAN HEALTH CARE SYSTEM
REQUIRED AND OPTIONAL FINANCIALPERFORMANCE MEASURES / FORHRSAUSE ONLY
Grant Number / Application Tracking Number
1. Required Focus Area – Grant Costs
PerformanceMeasure / Total NHHCIA grant amount per patient
Is thisPerformanceMeasureApplicabletoyour Organization? / Yes
TargetGoalDescription
Numerator Description / Total NHHCIA grant amount drawn down for the calendar measurement year
Denominator Description / Total patients for the calendar measurement year
BaselineData / BaselineYear:
MeasureType:
Numerator:
Denominator:
CalculatedBaseline:
ProjectedData(byEnd ofProjectPeriod)
DataSourceMethodology
KeyFactorandMajor PlannedAction #1 / KeyFactor Type:[_]Contributing[_]Restricting
KeyFactor Description:
Major Planned ActionDescription:
KeyFactorandMajor PlannedAction #2 / KeyFactor Type:[_]Contributing[_]Restricting
KeyFactor Description:
Major Planned ActionDescription:
KeyFactorandMajor PlannedAction #3 / KeyFactor Type:[_]Contributing[_]Restricting
KeyFactor Description:
Major Planned ActionDescription:
Comments
DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration
NATIVE HAWAIIAN HEALTH CARE SYSTEM
REQUIRED AND OPTIONAL FINANCIALPERFORMANCE MEASURES / FORHRSAUSE ONLY
Grant Number / Application Tracking Number
2. Optional FocusArea – Total Costs
PerformanceMeasure / Total costper patient
Is thisPerformanceMeasureApplicabletoyour Organization? / [_]Yes[_]No
TargetGoalDescription
Numerator Description / Total accruedcostbefore donationsand after allocation of overhead
Denominator Description / Total numberof patients
BaselineData / BaselineYear:
MeasureType:
Numerator:
Denominator:
CalculatedBaseline:
ProjectedData(byEnd ofProjectPeriod)
DataSourceMethodology
KeyFactorandMajor PlannedAction #1 / KeyFactor Type:[_]Contributing[_]Restricting
KeyFactor Description:
Major Planned ActionDescription:
KeyFactorandMajor PlannedAction #2 / KeyFactor Type:[_]Contributing[_]Restricting
KeyFactor Description:
Major Planned ActionDescription:
KeyFactorandMajor PlannedAction #3 / KeyFactor Type:[_]Contributing[_]Restricting
KeyFactor Description:
Major Planned ActionDescription:
Comments
DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration
NATIVE HAWAIIAN HEALTH CARE SYSTEM
REQUIRED AND OPTIONAL FINANCIALPERFORMANCE MEASURES / FORHRSAUSE ONLY
Grant Number / Application Tracking Number
3. Optional FocusArea – Medical Costs
PerformanceMeasure / Medical costpermedicalvisit
Is thisPerformanceMeasureApplicabletoyour Organization? / [_]Yes[_]No
TargetGoalDescription
Numerator Description / Total accruedmedicalstaff and medicalothercosts after allocationof overhead(excludeslaband x-raycosts)
Denominator Description / Non-nursingmedicalvisits(excludesnursing[RN] and psychiatristvisits)
BaselineData / BaselineYear:
MeasureType:
Numerator:
Denominator:
CalculatedBaseline:
ProjectedData(byEnd ofProjectPeriod)
DataSourceMethodology
KeyFactorandMajor PlannedAction #1 / KeyFactor Type:[_]Contributing[_]Restricting
KeyFactor Description:
Major Planned ActionDescription:
KeyFactorandMajor PlannedAction #2 / KeyFactor Type:[_]Contributing[_]Restricting
KeyFactor Description:
Major Planned ActionDescription:
KeyFactorandMajor PlannedAction #3 / KeyFactor Type:[_]Contributing[_]Restricting
KeyFactor Description:
Major Planned ActionDescription:
Comments
DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration
NATIVE HAWAIIAN HEALTH CARE SYSTEM
REQUIRED AND OPTIONAL FINANCIALPERFORMANCE MEASURES / FORHRSAUSE ONLY
Grant Number / Application Tracking Number
4. Optional FocusArea –FinancialViability
PerformanceMeasure / Non-Federal Matching Funds (percentage of matching funds included in the total project budget)
Is thisPerformanceMeasureApplicabletoyour Organization? / [_]Yes[_]No
TargetGoalDescription
Numerator Description / Non-Federal Matching Funds
Denominator Description / TotalBudget
BaselineData / BaselineYear:
MeasureType:
Numerator:
Denominator:
CalculatedBaseline:
ProjectedData(byEnd ofProjectPeriod)
DataSourceMethodology
KeyFactorandMajor PlannedAction #1 / KeyFactor Type:[_]Contributing[_]Restricting
KeyFactor Description:
Major Planned ActionDescription:
KeyFactorandMajor PlannedAction #2 / KeyFactor Type:[_]Contributing[_]Restricting
KeyFactor Description:
Major Planned ActionDescription:
KeyFactorandMajor PlannedAction #3 / KeyFactor Type:[_]Contributing[_]Restricting
KeyFactor Description:
Major Planned ActionDescription:
Comments