| 
				Organizational Context | 
				Role in organization | 
				How would you describe
				your role within your organization? |  | 
		
			| 
				Implementation of the
				Cooperative Agreement (CA) 
				
 | 
				Core Components of the
				DP11-1111 Cooperative Agreement 
 | 
				Describe
				your participation in the DP11-1111 cooperative agreement (CA). 
 |  | 
		
			| 
				Describe
				the process your organization has used to manage and oversee the
				CA. 
 | 
					How
					does your organization use the communication plan?Describe
					the process your organization used to develop a management plan.How
					does your organization use the management plan? | 
		
			| 
				Describe the process your
				organization used to conduct a needs assessment. |  | 
		
			| 
				Describe if and how the CA
				affected your organization’s ability to create new or
				strengthen existing partnerships. |  | 
		
			| 
				Describe the process you
				organization used to create a program plan. | 
				
 | 
		
			| 
				Describe how your
				organization has worked to implement the program plan. | 
				
 | 
		
			| 
				Does your program have an
				evaluation plan?  If so, describe the process your organization
				used to create the evaluation plan. | 
				
 | 
		
			| 
				Describe how your
				organization has worked to implement the evaluation plan. | 
				
 | 
		
			| 
				Does your program have a
				sustainability plan? If so, describe the process your
				organization used to create a sustainability plan. | 
				
 | 
		
			| 
				Training/Technical
				Assistance | 
				What
				types of trainings has your organization participated in to help
				with the management of the CA? | How
					were these trainings delivered?How
					often did your organization participate in these trainings?Who
					delivered the trainings?How were you able
					to apply the training you received to help with program
					implementation and/or evaluation?
 | 
		
			| 
				What kinds of technical
				assistance (TA) has your organization received as a part of the
				CA. |  | 
		
			| 
				Describe
				your organization’s engagement with your CDC program
				consultant(s). | How
					often do you communicate?What
					are the primary methods of communication?What
					kinds of information does your program consultant share?How often did your
					organization receive TA from CDC assigned program consultant?
 | 
		
			| 
				Resources | 
				Describe
				the resources that your organization has used to implement the
				CA. | What
					are each staff member’s key tasks for the CA?Describe
					technology that supports your organization’s participation
					in the CA? Describe
					other materials that support your organization’s
					participation in the CA.
 | 
		
			| 
				Facilitators | 
				What factors, if any, have
				facilitated your organization’s participation in the
				CA?
 
 
 | What
					internal organizational factors (e.g., staff, resources,
					expertise) have helped your organization participate in the CA?What
					external factors (e.g., training, TA, partnerships) have helped
					your organization participate in the CA?
 | 
		
			| 
				Barriers | 
				What factors, if any, have
				challenged your organization’s participation in the
				CA? | What
					internal organizational factors (e.g., staff, resources,
					expertise) have challenged your organization’s
					participation in the CA?What
					external factors (e.g., training, TA, partnerships) have
					challenged your organization’s participation in the CA?
 | 
		
			| 
				What
				strategies has your organization used to overcome
				barriers/challenges related to the CA? | 
				
 | 
		
			| 
				
 
 
 
 
 
 
 
 Implementation
				of the YBCS Intervention 
				
 
				
 
				
 
				
 
				
 
				
 
				
 
				
 
 
  
				 | 
				Intervention Overview,
				History and Rationale | 
				Describe your
				organization’s YBCS intervention that is funded through the
				CA. | What
					are the key components of the YBCS intervention?Who
					is the target audience for the YBCS intervention?How have the key
					components of the YBCS intervention been tailored to meet the
					unique needs of the target audience?
 | 
		
			| 
				Describe your
				organization’s goals and objectives for the YBCS
				intervention. 
				 
 |  | 
		
			| 
				How did activities
				conducted as a part of the CA
				guide the development of the YBCS intervention? |  | 
		
			| 
				Describe the evidence base
				and/or factors that informed (e.g., behavioral/communication
				theory, scientific evidence, guidelines, formative research) the
				development of the YBCS intervention. |  | 
		
			| 
				What intervention
				components are new as a result of the CA? | 
				
 | 
		
			| 
				What intervention
				components were enhanced/expanded as a result of the CA? | 
				
 | 
		
			| 
				Describe your role in the
				YBCS intervention. |  | 
		
			| 
				Intervention execution | 
				Describe how the YBCS
				intervention is implemented. | How
					often is each component of the YBCS intervention implemented?What
					is the duration of the YBCS intervention?Who
					is responsible for delivering key components of the YBCS
					intervention?How
					are YBCS intervention participants recruited?How
					has the delivery of the YBCS intervention been tailored to meet
					the unique needs of the target audience?How do you engage
					members of the target audience (e.g., YBCS, families/caregivers,
					health care providers) in the implementation of the YBCS
					intervention?
 | 
		
			| 
				What
				communication strategies is your organization using to promote or
				implement the YBCS intervention? | How
					is mass media (e.g., radio, newspaper, Internet) being utilized
					to deliver or promote YBCS intervention components?How
					is small media (e.g., newsletter, email, brochures) being
					utilized to deliver or promote YBCS intervention components?How
					is social media (e.g., Facebook, Twitter) being utilized to
					deliver or promote YBCS intervention components?How
					is earned media (e.g., free or donated media) being utilized to
					deliver or promote YBCS intervention components?
 | 
		
			| 
				What tools, guidelines
				and/or protocols are used to direct the implementation of the
				YBCS intervention? | What,
					if any, manuals have been created to support implementation of
					the YBCS intervention?Who
					created these guidelines?How are these used
					to implement the YBCS intervention?
 | 
		
			| 
				What
				trainings are offered to staff to implement the YBCS
				intervention?  
				 | How
					are trainings identified?Who
					delivers these trainings?What
					is the duration of each of these trainings?How
					often are trainings offered to staff?Are there external
					trainings that your organization has participated in to support
					implementation of the YBCS intervention?
 | 
		
			| 
				Implementation Fidelity | 
				To what extent has the
				YBCS intervention been implemented as planned? |  | 
		
			| 
				How does implementation of
				the YBCS intervention vary across sites? | Are there
					differences in the way that the YBCS intervention is delivered
					across sites (e.g., setting, geographic location, target
					population)?  If so, how is implementation different?
 | 
		
			| 
				Does your organization use
				any process improvement strategies to improve the delivery of the
				YBCS interventions? | 
				
 | 
		
			| 
				Resources | 
				How
				does your organization use funding received through the CA to
				implement the YBCS intervention? | 
				
 | 
		
			| 
				What other, if any,
				monetary(leveraged) or non-monetary(in-kind) resources have been
				provided to your organization to support the YBCS intervention?
				If so, please explain.
				
				 | Have
					you received additional funding from other organizations to help
					support implementation of the YBCS intervention?Have
					you received donated resources, such as materials and/or
					supplies, to help support implementation of the YBCS
					intervention? 
					Have
					people offered their time and/or expertise to help support
					implementation of the YBCS intervention? 
					Have you received
					any in-kind, earned media donations to promote and/or implement
					the YBCS intervention?
 | 
		
			| 
				Facilitators | 
				What factors, if any, have
				facilitated your organization’s implementation of the YBCS
				intervention? | What
					internal organizational factors (e.g., leadership, staff,
					resources, expertise) have helped your organization implement
					the YBCS intervention?What
					external factors (e.g., training, TA, partnerships) have helped
					your organization implement the YBCS intervention?
 | 
		
			| 
				Barriers | 
				What factors, if any, have
				challenged your organization’s implementation of the YBCS
				intervention? | What
					internal organizational factors (e.g., leadership staff,
					resources, expertise) have challenged your organization’s
					implementation of the YBCS intervention?What
					external factors (e.g., training, TA, partnerships) have
					challenged your organization’s implementation of the YBCS
					intervention?
 | 
		
			| 
				What
				strategies have your organization used to overcome barriers
				related to implementation of the YBCS intervention? | 
				
 | 
		
			| 
				Evaluation | 
				Knowledge | 
				Describe your
				understanding of program monitoring and/or evaluation.
				
				 
 | Have
					you participated in any past evaluation efforts?  If so, please
					describe.Do you have
					experience creating program logic models?
 | 
		
			| 
				Measurement 
 
				
 
 | 
				For what the YBCS
				intervention is trying to accomplish, how would you define
				success? 
				 |  | 
		
			| 
				How is success measured or
				documented? 
				 | Do
					you have baseline data? Do you intend to collect follow-up data?
					At what time?Do
					you collect data at specified points over time (time
					series)? What
					length of time?Do
					you follow a sample of participants over time (cohort
					study)? What
					length of time?Do
					you have a comparison group?What does the
					evaluation activity tell you about the success of the YBCS
					intervention?
 | 
		
			| 
				Describe how your
				organization defines and assesses reach for the YBCS
				intervention. | 
				
 | 
		
			| 
				Describe how your
				organization measures the implementation of the YBCS
				intervention. | What
					data do you collect?Who
					is responsible for measuring/monitoring implementation?Are
					other staff members involved in data collection? How so?Are
					there plans to expand or change how your organization monitors
					implementation of the YBCS intervention?  If so, please explain?
 | 
		
			| 
				What are the available
				data sources used to support program monitoring and evaluation
				for the YBCS intervention? 
				 
 | What
					data collection tools or instruments does your organization use
					in relation to the YBCS intervention? (Request to see or obtain
					copies of data, data collection tools, or evaluation reports.)Describe the data
					collection methods used to collect evaluation data for the YBCS
					intervention.
 | 
		
			| 
				How does your organization
				analyze data from the YBCS evaluation in order to collect program
				monitoring and evaluation? | What
					analytic techniques does your organization use to conduct
					program monitoring and evaluation for the YBCS intervention? 
					Who within your
					organization, who is responsible for conducting analysis for the
					YBCS intervention?
 | 
		
			| 
				How does your organization
				use evaluation findings to inform implementation of the YBCS
				intervention? | 
				
 | 
		
			| 
				Describe how your
				organization shares evaluation findings from the YBCS
				intervention. 
				 |  | 
		
			| 
				Facilitators | 
				What, if any, facilitators
				have helped your organization conduct program monitoring and
				evaluating for the YBCS intervention? | 
				
 
 | 
		
			| 
				Barriers | 
				What, if any, barriers has
				your organization encountered in evaluating the YBCS
				intervention? | 
				
 | 
		
			| 
				What
				strategies has your organization used to overcome barriers
				related to program monitoring and evaluation of the YBCS
				intervention? | 
				
 | 
		
			| 
				Partnerships | 
				Development and Engagement 
 | 
				Describe
				the process your organization has used to identify and develop
				partnerships. |  | 
		
			| 
				How
				has your organization’s involvement in the CA helped you to
				develop and maintain partnerships? | Have
					you collaborated with other grantees as a part of the CA?Has
					access to other programs serving YBCS helped your organization
					develop new partnerships? If so, please explain.
 | 
		
			| 
				How
				would you describe partners’ engagement in the YBCS
				intervention? |  | 
		
			| 
				Contribution to the
				intervention 
 | 
				Describe
				how partners participate in the planning or implementation of the
				YBCS intervention. | How
					does your organization interact with partners?How
					does your organization communicate with partners?How
					often does your organization communicate with
					partners?How
					long has your organization worked partners?
					
					
 | 
		
			| 
				What partnerships have
				been the most beneficial for your organization in the
				implementation of the YBCS intervention? |  | 
		
			| 
				What additional
				partnerships would [insert Grantee Organization name] benefit
				from to support the implementation of the YBCS intervention? | 
				
 | 
		
			| 
				Capacity and
				Sustainability | 
				Capacity to meet the
				requirement of the CA. | 
				Describe
				your organization’s capacity to meet the requirements of
				the CA and how capacity has changed over time. | 
				
 | 
		
			| 
				Describe
				how support received from CDC through the CA has affected your
				organization’s ability to meet the requirements of the CA. |  | 
		
			| 
				Capacity to implement
				intervention | 
				Describe
				your organization’s capacity to implement the YBCS
				intervention and how capacity has changed over time. | 
				
 | 
		
			| 
				Describe
				how the CA has enabled your organization to implement the YBCS
				intervention. 
 | To
					what extent was your organization able to utilize CDC’s TA
					to improve the implementation of the YBCS intervention?To what extent was
					your organization able to utilize CDC training opportunities to
					improve the implementation of the YBCS intervention?
 | 
		
			| 
				Capacity to evaluate | 
				Describe your
				organization's capacity to plan and implement program monitoring
				and evaluation activities, such as creating data collection
				tools, collecting data, conducing analysis, and reporting. 
 | Describe
					program staff members who have the expertise/experience to
					collect and/or analyze data.What
					additional outside resources does your organization rely on to
					help with evaluation (e.g., does your organization use an
					external evaluator)?
 
					Describe
					the resources your organization reserves to support data
					collection (e.g., time, materials, technology) to support
					program monitoring and/or evaluation?What
					other resources does your organization designate for program
					evaluation/monitoring (e.g., staff, time, technology,
					materials)? | 
		
			| 
				Describe how the CA has
				enabled your organization to plan and implement program
				monitoring and evaluation activities for the YBCS intervention. 
 | To
					what extent was your organization able to utilize CDC’s TA
					to improve the program monitoring and evaluation for the YBCS
					intervention?To what extent was
					your organization able to utilize CDC training opportunities to
					improve the program monitoring and evaluation for the YBCS
					intervention?
 | 
		
			| 
				Sustainability of
				intervention | 
				Describe
				the sustainability of the YBCS intervention and how
				sustainability has changed over time. |  | 
		
			| 
				Describe how the CA has
				enabled your organization to plan for and ensure the
				sustainability of the YBCS intervention? 
 | To
					what extent has your organization able to utilize CDC’s TA
					to improve the sustainability of your YBCS intervention?To what extent has
					your organization been able to utilize CDC’s training
					opportunities to improve the sustainability of the YBCS
					intervention?
 | 
		
			| 
				Perceptions | 
				Awareness | 
				How has the YBCS
				intervention affected awareness for the existence of support
				services and/or educational resources among the target audience? | In
					your opinion, what aspect of the YBCS intervention has been the
					most effective in increasing awareness for support
					services and/or educational resources?
					
					In
					your opinion, what communication strategies were the most
					effective in promoting and increasing awareness for the YBCS
					intervention?Does your
					organization have data to support the effectiveness of this?  If
					so, explain how this data is used. (Request to see or obtain
					copies of data, data collection tools, or reports pertaining to
					how a program has assessed awareness.)
 | 
		
			| 
				Access | 
				How has the YBCS
				intervention affected access to support services and/or
				educational resources for the target audience? | In
					your opinion, what aspect of the YBCS intervention has been the
					most effective in increasing access to support
					services and/or educational resources?
					
					Does your
					organization have data to support the effectiveness of this?  If
					so, explain how this data is used. (Request to see or obtain
					copies of data, data collection tools, or reports pertaining to
					how a program has assessed access.)
 | 
		
			| 
				Utilization | 
				How has the YBCS
				intervention affected utilization of support services and/or
				educational resources by the target audience? | In
					your opinion, what aspect of the YBCS intervention has been the
					most effective in increasing utilization of support
					services and/or educational resources?
					
					Does your
					organization have data to support the effectiveness of this?  If
					so, explain how this data is used. (Request to see or obtain
					copies of data, data collection tools, or reports pertaining to
					how a program has assessed utilization.)
 | 
		
			| 
				YBCS knowledge, attitudes,
				and beliefs (KAB) | 
				What knowledge, attitudes,
				and beliefs does the YBCS intervention aim to affect? How has the
				YBCS intervention impacted those specific knowledge, attitudes,
				and/or beliefs among the target population? (Examples of KAB
				targets include: strategies for reducing
				the risk of recurrence and the development of new malignancies,
				chronic disease onset, and improving overall health and quality
				of life). | In
					your opinion, what aspect of the YBCS intervention has been the
					most effective in KAB among the target population?
					
					Does your
					organization have data to support the effectiveness of this?  If
					so, explain how this data is used. (Request to see or obtain
					copies of data, data collection tools, or reports pertaining to
					how a program has assessed KAB among target audience(s).)
 | 
		
			| 
				Value of the CA | 
				What has been the value
				for your organization to participate in the CA? | 
				
 | 
		
			| 
				Value of the YBCS
				intervention | 
				What has been the value of
				the YBCS intervention? | In
					your opinion, how did the YBCS intervention impact the target
					audience?In your opinion,
					how did the YBCS intervention contribute to the evidence base
					for promising strategies to reach YCBS, YBCS caregivers, and/or
					YBCS health care providers?
 | 
		
			| 
				Lessons learned | 
				What have been some key
				lessons learned from your organization’s experience with
				the CA? | In
					your opinion, what aspects of your CA worked well?In your opinion,
					what aspects of your CA did not work well?
 | 
		
			| 
				What have been some key
				lessons learned from your organization’s experience with
				the YBCS intervention? |  | 
		
			| 
				Recommendations | 
				What ideas do you have for
				improving your organization’s YBCS intervention? | 
				
 |