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RSR Technical Assistance Referral Form

Division and Branch:

Referral Date:

/
Month

/
Day

Year

Referring Person Name:

Organization Name:

Grantee of Record:

Subgrantee

Core Grant Number

Grant Number Is Unknown

Date of Request:

/
Month

/
Day

Year

Grantee Funding Type (Check all that apply):

Part A

Part B

Part C

Part D

Part F

Contact Person: First Name:

Last Name:

ADDRESS:

Street (Suite/Apt.#):

City:

State:

ZIP:

Telephone:

Email:

TA Description

Data System Readiness:

COMPLETED DATA SYSTEM READINESS FORM

(If not, go to https://performance.hrsa.gov/hab/CLDXMLSchema/content.aspx before continuing)

AIRS

eCompas

Home-grown or
customized
system/database

Other vendor not listed
in situation 1.
Specify System:

ARIES

LabTracker

CAREWare

Provide Enterprise

Casewatch Millenium

Sage

Request Concerns: (See Data Flow: Collect it, Manage it, Report it and Use it.)

Step 1: Identifying and defining data elements- what data we need to collect

Step 2: Identifying data sources- where we can find the data we need

Step 3: Data collection -- how we will collect data

Step 4: Data validation and quality procedures -- how we know the data is accurate

Step 5: Data reporting- how we submit our data

Step 6: Communicating about data-- how we use our data to inform our program

Step 7: Using the data-- how our data can guide decisions

Data security, privacy and confidentiality

Other, describe:

Required fields are marked with red asterix - *