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Page 4 of 5 <br />Template rev. July 2020 <br />IV. Performance Measures/Reporting Requirements: <br />A. Electronic submission of service logs is required monthly of the CHAC and are due to State EHDI <br />Program staff by the fifth day of the following month. The monthly services logs shall include: <br />1. Performance Measure #1: Evidence of having provided a total of at least 25 instances each <br />month of consultations, technical assistance, or training sessions for hospitals and other EHDI <br />stakeholders. <br />2. Performance Measure #2: Evidence of timely interventions with 95% of families whose children <br />need follow-up from a newborn hearing screening. Entries will be made in the WCSWeb <br />Hearing Link notes section to document counseling and education provided to families of <br />children who failed the newborn hearing screening, and to document consultation with their <br />direct service providers. <br />3. Performance Measure #3: Evidence of timely coordination of service delivery for children with <br />or at risk of hearing loss. This will include: <br />a. At least four in-service sessions provided to community collaborators or private providers <br />per year <br />b. At least three public awareness activities per year. <br />V.Performance Monitoring and Quality Assurance: <br />A. The Local Health Department shall adhere to the following Quality Assurance measures: <br />1. Ensure that the CHAC is board certified and is licensed in North Carolina. <br />2. Ensure that services are provided in a culturally and linguistically appropriate manner. <br />B. The state EHDI Program staff will monitor the CHAC’s work plan progress through: <br />1. Monthly reviews of electronic service logs. <br />2. Quarterly contacts (phone and email) with the CHAC. <br />3. An annual site visit with the Local Health Department, and with additional visits if needed. <br />4. Semi-annual in-person review of CHAC's work on the same schedule as VIP performance <br />reviews for DPH employees. <br />5. Quarterly reviews of data from the WCSWeb Hearing Link data tracking system on hospitals <br />served by the CHAC. <br />6. Meetings with the CHAC during DPH EHDI Team Meetings and other DPH required activities. <br />C. Should the performance of the CHAC be deemed inadequate because of non-completion of expected <br />activities, poor communication with team members or community collaborators, or insufficient <br />documentation, a meeting will be convened with the Local Health Department supervisor to develop <br />a corrective action plan which will define next steps. <br />VI. Funding Guidelines or Restrictions: <br />1. Requirements for pass-through entities: In compliance with 2 CFR §200.331 – Requirements for <br />pass-through entities, the Division of Public Health provides Federal Award Reporting Supplements <br />to the Local Health Department receiving federally funded Agreement Addenda. <br />a. Definition: A Supplement discloses the required elements of a single federal award. Supplements <br />address elements of federal funding sources only; state funding elements will not be included in <br />the Supplement. Agreement Addenda (AAs) funded by more than one federal award will receive <br />a disclosure Supplement for each federal award. <br />     <br /> <br />DocuSign Envelope ID: 36D07572-B1EC-4E6B-BB09-ECF88788B8AA