0920-1412 APR Tool - 11JUL2025

COMMUNITY ACTION PLAN APR FORM DRAFT

Attachment 3a. Annual Performance Report (APR) Tool

Form Approved OMB No: 0920-1412 Exp. Date: 08-31-26

Public Reporting burden of this collection of information is estimated at 10 hours, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS H21-8, Atlanta, GA 30333; Attn: PRA (0920-1412).

Grantee:
Reporting Period:
Contact Person:

FORM 1: WORK PLAN

Instructions for Recipients:

The Work Plan form collects information about your DELTA AHEAD Program’s progress on work plan goals, objectives, and milestones during the reporting period (September 1^st – August 31^st). The required goals and objectives are prefilled for all recipients.

DELTA AHEAD REQUIRED GOALS AND OBJECTIVES

CATEGORY A WORKPLANS

GOAL	OBJECTIVE(S)
Goal 1: State-level planning, implementation, and evaluation	Objective 1: Develop, or enhance an existing, State Leadership Team (SLT)
	Objective 2: Develop, or enhance an existing, State Action Plan (SAP) to address Social Determinants of Health (SDoH) and to implement, evaluate, and sustain primary prevention of IPV
	Objective 3: Identify at least one Policy Effort that will be implemented at the state level (by the SDVC) and the community level (in collaboration with the CCR) and incorporate into the SAP
	Objective 4: Participate in state and national activities to share knowledge, skills, and practice of IPV primary prevention
	Objective 5: Participate in the national evaluation for DELTA AHEAD
	Objective 1: Partner with a Coordinated Community Response (CCR) Team to finalize PPEs

Goal 2: Community-level planning, implementation,	Objective 2: Identify the SDoH that influence IPV risk and protective factors and specify how they will be addressed through PPEs
and evaluation	Objective 3: Develop a Community Action Plan (CAP) that includes a logic model, Implementation Plan, and Evaluation Plan
	Objective 4: Implement and evaluate state- and community-level PPEs according to SAP and CAP

CATEGORY B WORKPLANS

GOAL	OBJECTIVE(S)
Goal 1: State-level planning, implementation, and evaluation	Objective 1: Develop, or enhance an existing, State Leadership Team (SLT)
	Objective 2: Conduct an Environmental Scan to assess the current state of IPV primary prevention in the state
	Objective 2: Develop, or enhance an existing, State Action Plan (SAP) to address Social Determinants of Health (SDoH) and to implement, evaluate, and sustain primary prevention of IPV
	Objective 3: Identify at least one Policy Effort that will be implemented at the state level (by the SDVC) and the community level (in collaboration with the CCR) and incorporate into the SAP
	Objective 5: Participate in state and national activities to share knowledge, skills, and practice of Intimate Partner Violence (IPV) primary prevention
Goal 2: Community-level planning, implementation, and evaluation	Objective 1: Partner with a Coordinated Community Response (CCR) Team
	Objective 2: Work with CCR to develop a Community Action Plan (CAP) that includes a logic model, Implementation Plan, and Evaluation Plan
Goal 3: Program Implementation & Evaluation	Objective 1: Implement and evaluate selected PPEs in collaboration with community partners
	Objective 2: Participate in the national evaluation of DELTA AHEAD

SECTION: OBJECTIVE #.#

There is a section of this form for each NOFO objective. Report on the objectives and add milestones for each. For each objective, you will need to select the Objective Status and provide Comments on Objective if the status is delayed or discontinued. Provide Milestones and Key Activities to achieve the milestone. You will also need to select the Milestone Status and Program Year Completed for each milestone for the objective.

OBJECTIVE AND MILESTONE PROGRESS STATUS

The status options are for describing progress made during the reporting period. Report the status for all existing and new items. The table below describes each status option.

PROGRESS STATUS	DESCRIPTION
IN PROGRESS (ON TRACK)	Work was in progress and on track as planned
DELAYED	Work had some delays (please add comments)

COMPLETE	All Work has been completed
DISCONTINUED	Work has been stopped and discontinued (please add comments)

OBJECTIVE PANEL

Select an Objective Status as described above to indicate your program’s progress during this reporting period. Make comments for delayed or discontinued work.

Objective #.# Status: [Choose one from dropdown]

• In Progress (on track)

• Delayed: Please add comments

• Completed

• Discontinued: Please add comments

Please provide comments on delayed or discontinued work [3000]

MILESTONE TABLE

At least one milestone is required for each objective. Provide milestones and activities that make sense for your program. The milestone status provided should fall within the status of the corresponding objective. For example, a Milestone Status of “In Progress (on track)” would not be selected when the Objective Status is “Completed.” Provide the Program Year the Milestone was completed. Options are Not Yet Complete and Year 1 (with corresponding reporting year being added as an option each year).

Question	Question Instructions/Options
#.# Description [100]	Provide a concise statement of the milestone.
#.# Key Activities [700]	Provide a brief description of activities conducted to complete the milestone
#.# Milestone Status [Choose one from dropdown]	In Progress (on track) Delayed: Please add comments Completed Discontinued: Please add comments
Please provide reasons for delayed or discontinued work [3000]	*only if Milestone Status = Delayed or Discontinued
#.# Reporting Year Milestone was Completed [Choose one from dropdown]	Not Yet Complete Year 1 *additional year added each APR

FORM 2: CONTINUATION APPLICATION

Instructions for Recipients

The Continuation Application Narrative Form is a summary of each aspect of your program for the next budget period (March 2^nd – March 1^st). This form is not prefilled. The separate Work Plan form provides space for you to describe specific details for the program objectives, milestones, and activities. This form has five sections.

Section 1: Summary of Work Plan Activities for Next Budget Year: Describe the activities planned for the next budget period. Please include references and reasons for any key changes to the work plan for the next budget period. [6000]

Section 2: Implementation of New or Revised Program or Policy Efforts: Describe the planned implementation of program or policy efforts in the next budget period. Explain any requests to change the current program or policy efforts being implemented. [6000]. The CDC Project Officer must approve any changes to the program or policy efforts approved upon award.

Section 3: Budget Implications: Provide any comments about budgetary issues that might impede the success or completion of the project as originally proposed and approved for the next budget period. Describe any implications the changes to the work plan may have on the budget. [6000]

Section 4: Needed Resources: What additional tools or resources do you need in order to accomplish the proposed planned activities for the next budget period? How do you plan to obtain these resources?

Section 5: Technical Assistance Needs: What types of training and technical assistance (TTA) would benefit your program in the next budget period? Include all TTA needed for the next budget period even if you have already submitted a VPTAC request for the TTA. Please describe the areas or topics for TTA (e.g., program, evaluation). This information will help us to understand what types of TTA are needed across DELTA AHEAD and will be used to plan program-wide TTA for the upcoming budget year. Your Program Officer will also go over any requests you enter here to

determine any next steps (e.g., VPTAC request, program wide TTA). If TTA is not needed, please explain.

Would your program like additional training or technical assistance in any specific area?

• No (Please explain)

• Yes (Include existing requests already entered in VPTAC. Complete table below)

Training and Technical Assistance Table

If your program would like additional training or technical assistance, you would enter your requests in the table provided. Create a new row for each distinct TTA request, providing the Topic and Timeframe for each request. You will also need to describe the TTA requested. Please note that this is not a replacement for a TTA request with the VPTAC.

When reporting TTA needed, make sure that:

• Each entry is a distinct TTA request based on the drop-down for the topic.

• The “Other” answer option for topic is selected only if the TTA request does not fall within the existing answer options.

Topic: [Chose one from dropdown]	Description of TTA Request [1000]	Timeframe [Chose one from dropdown]
Planning Partnerships Communication Policy Specific Strategy or Approach Implementation and/or Adaptation Evaluation and Data Assures optimal level of health for all, and especially for those at greatest risk Other (not listed): Please specify topic		Submitted to VPTAC Immediate Within the next 6 months Within the next year No specific timeframe/Unknown

Section 6: Challenges: What general challenges/problems do you anticipate in the next funding year? What do you plan to use to solve or address those challenges or problems? [6000]

Form 3 Section 4: Technical Assistance

1. During this reporting period, how often have you used CDC or VPTAC resources when selecting, planning, implementing, or evaluating your program or strategies? (For example, technical packages, VETO Violence, technical assistance resources) (Select one)

   • Frequently

   • Sometimes

   • Rarely

   • Never

2. Which CDC or VPTAC resources have you found most useful during this reporting period (optional)? [1000]

3. During this reporting period, how often have you shared these CDC or VPTAC resources with subrecipients or partners?

   • Frequently

   • Sometimes

   • Rarely

   • Never

• Form 3 Section 5: Capacity Building and Training 1. To what extent has your organizational capacity to select, plan, implement, and evaluate strategies increased over the reporting period? Not at all

• To a small extent

• To a moderate extent

• To a great extent

2. To what extent has the capacity of your subrecipients or partners to select, plan, implement, and evaluate strategies increased over the reporting period?

   • Not at all

   • To a small extent

   • To a moderate extent

   • To a great extent

3. Provide any additional information about changes in capacity?(Optional) [2000]

Capacity Building and Training Table

Please list all capacity building, training, and educational activities related to community and societal level primary prevention that you provided within the state during this reporting period. [Optional]

Type of Activity	Topic	Audience	Dates
200 characters	200 characters	200 characters

Networking and Dissemination Table

Please list any networking and dissemination activities that you participated in related to community and societal level primary prevention OUTSIDE the state during this reporting period. [Optional]

Type of Activity	Topic	SDVC Role in Activity	Dates
200 characters	200 characters	200 characters

FORM 3: BARRIERS, FACILITATORS, AND SUCCESSES

Instructions for Recipients

The Barriers, Facilitators and Success form collects information about challenges, facilitators, and successes that experienced. This form has three sections: 1) Barriers Encountered, 2) Facilitators Encountered, and 3) Successes.

• Add all barriers and facilitators encountered during the reporting period.

• Report on at least one success or accomplishment during the reporting period. (Or explain why no successes are being reported)

• Do not leave any section blank. If no barriers or facilitators were encountered for the reporting period, please select No barriers/facilitators encountered and then Save, Validate, and Check in.

SECTION 1: BARRIERS ENCOUNTERED

This section collects information about the barriers and challenges that your (Initiative) Program encountered during the reporting period. This section is not prefilled. A Barrier is an identified person, resource, relationship, or circumstance that hinders progress on a specific outcome or goal.

Barrier Status

Did you experience challenges or barriers during this reporting period?

• No, we did not experience any challenges or barriers (Save, Validate, and Check in)

• Yes, we experienced challenges or barriers (Record barriers in the table below).

Challenges and Barriers Table

If barriers were encountered you will enter them in the table provided, creating a new row for each distinct barrier. For each barrier entered you will need to provide the Barrier Type and Program Component(s) that it affected. You will also need to describe the barrier and how it impacts your program’s work, detail the actions planned/taken to address the barrier, and describe the resources that were used or needed to overcome the barrier.

When reporting barriers, make sure that:

• Each entry is a distinct barrier or challenge encountered during the reporting period based on the drop- down for the barrier type.

• The “Other” answer option for barrier type is selected only if the barrier does not fall within the existing answer options.

Barrier Type: [Choose one from dropdown]	Describe the barrier and how it impacts your program’s work: [2000]	Program Component: [Select all that apply]	What actions were taken or would be helpful to address the barrier? [2000]	What resources are used or would be helpful to address the barrier? [2000]	Barrier Comments: [500]
Lack of buy-in from partners or stakeholders Insufficient funding or resources Inability to access/collect data Implementation issues Staffing issues Inadequate training Other (not listed): Please specify		Work Plan State Action Plan/Strategic Plan Sustainability State Evaluation Community Action Plan Community Evaluation State PPE 1 Implementation State PPE 2 Implementation Community-level PPE 1 Implementation Community-level PPE 2 Implementation Community-level PPE 3 Implementation Community-level PPE 4 Implementation

SECTION 2: FACILITATORS ENCOUNTERED

This section collects information about the facilitators that enabled, accelerated, or expedited implementation during the reporting period. This section is not prefilled. A Facilitator is an identified person, resource, relationship, or circumstance that helps to reach a specific outcome or goal.

Facilitator Status

Did you experience facilitators during this reporting period?

• No facilitators experienced (Save, Validate, and Check in).

• Yes, we experienced facilitators (Record facilitators in the table below).

Facilitators Table

If facilitators were experienced you will enter them in the table provided, creating a new row for each distinct facilitator. For each facilitator entered you will need to provide the Facilitator Type and Program Component(s) that it affected. You will also need to describe the facilitator and how it impacts your program’s work as well as the resources that were related to this facilitator.

When reporting facilitators, make sure that:

• Each entry is a distinct facilitator encountered during the reporting period based on the drop-down for the barrier type.

• The “Other” answer option is selected only if the facilitator does not fall within the existing answer options.

Facilitator Type: [Choose one from dropdown]	Describe the facilitator and how it impacts your program’s work: [2000]	Program Component: [Select all that apply]	What resources were used [2000]	Facilitator Comments: [500]
Strong partners/stakeholders Connection to community Access to funding or resources Access to data Strong implementation Adequate, experienced staff Access to training Other (not listed): Please Specify		Work Plan State Action Plan/Strategic Plan State Evaluation Community Action Plan Implementation Community Evaluation State PPE 1 Implementation State PPE 2 Implementation Community-level PPE 1 Implementation Community-level PPE 2 Implementation Community- level PPE 3 Implementation

Community-level PPE 4 Implementation Sustainability

SECTION 3: SUCCESSES

This section collects information about the successes and accomplishments of your (Initiative) program during the reporting period through an open-end question. This section is not prefilled. You can add more than one success or accomplishment.

Successes Status

Would you like to share any successes or accomplishments?

• No (Please explain)

• Yes (Record accomplishments in table below)

Successes Table

If you want to share your programs successes and accomplishments, you will enter them in the table provided, creating a new row for each distinct success. For each success entered you will need to provide the program components involved in the success and describe the success/accomplishment as well as the factors that made it possible.

When reporting successes and accomplishments, make sure to:

• Make each response a specific story about a success or accomplishment, adding a new row for each separate accomplishment.

• Report all distinct program successes or accomplishments your program had during the reporting period.

• Consider using the format for policy impact statements to report your successes. Please see the Policy Impact Statement Appendix for supplemental information on how to write policy impact statements that will be most impactful for policy makers.

To add a success/accomplishment, click on “+ Add” to open the modal (pop-out window) shown below. You can add a row to the table by completing the modal and selecting “Save” when you are done.

Program Component: [Select all that apply]

What key accomplishments related to this NOFO has your organization/state/territory achieved during this reporting period? [6000]

FORM 4-1: STRATEGIC PLAN

Instructions for Recipients

The State Action/Strategic Plan form collects information about progress on the State Action/Strategic Plan (e.g., enhancing partnerships, state violence prevention planning and coordination) during the reporting period (September 1^st – August 31^st). This form has four sections:

1. Progress on State Action/Strategic Plan

2. Progress on Priorities

3. Partnerships

4. Activities

SECTION 1: PROGRESS ON STATE ACTION/STRATEGIC PLAN

This section collects information on changes made to the components in the State Action Plan. This section is not prefilled.

CHANGES TO THE STATE ACTION/STRATEGIC PLAN

Were there any changes to the State Action/Strategic plan during this reporting period?

• No (Save, Validate, and Check in)

• Yes (Complete table below)

CHANGES TO THE STATE ACTION/STRATEGIC PLAN TABLE

Report on any changes to specific section(s) of the State action/Strategic plan changed during the reporting period. Choose each component of the State action/Strategic Plan that was changed, describe the change, the reason for the change, and how the change affects your program’s work.

Type of Change: [Choose one from dropdown]	Description of Change (1000 characters)	Describe the reason for the change and how it impacts your overall work: [1000]
Approach or Strategy

Stakeholder/Partner State/Local collaboration Resources/Funding Training/Technical Assistance Sustainability Assures optimal level of health for all, and especially for those at greatest risk Data Use/Sources Other (not listed): Specify

SECTION 2: PROGRESS ON PRIORITIES

Please describe the goals/priorities outlined in your state action plan. You can list up to 10 priorities. Add additional sections as necessary.

Priority Area Name #1 (150 characters)	Description of Priority Area (1750 characters)
Insert Text	Insert Text
Key Partners (350 characters)
Insert Text
Key Accomplishments this Reporting Period (1050 characters)
Insert Text
Resources Needed (700 characters)
Insert Text
Key Activities Planned for Upcoming Year (500 characters)
1. Insert text
2. Insert text
3. Insert text
4. Insert text

Policies

Provide an update on state-level activities to support an increase in policies that assures optimal health for all, and especially for those at greatest risk through the improvement of social determinants of health related to IPV.

2000 characters

SECTION 3: PARTNERSHIP

This section collects information about all partner organizations the DELTA AHEAD program engaged with.

Information previously entered will be prefilled in this table. Report on all existing and new partners that your program engaged with during this reporting period. Unless you need to add new partners, you will only need to update three areas for existing partners: the status of the partnership, whether you provided any CDC funding to the organization during the reporting period, and how your organization engaged this partner during the reporting period.

PARTNERSHIPS & RESOURCES TABLES

Report on the partner status during this reporting period. If there are changes in how the partner is engaged in the state IPV prevention work, please make updates. Each row is a distinct partner.

When entering any new partners that have not previously been entered, make sure that:

• The organization name is spelled out. Do not use acronyms.

• All current partner organizations, especially those listed in your State Action/Strategic Plan, are included.

• Only choose “other” for organization Type or Sector if your answer does not fall within the existing answer options.

• Include state-level and community-level partners.

Name of Partner Organization	Primary Sector	Role of Partner	Describe how your [Initiative] program engaged this partner in your violence prevention work during the reporting period. [1000]	Partner Status during this reporting period [Choose one from dropdown]	State or Community- level Partner
	Business/Labor Education (schools) Justice (e.g., law enforcement, prisons, public safety) Research Evaluation/Academic Health Care/Services Housing Media Public Health Social Services Victim Service Government (Federal, State, County, Local) Social Justice/ Community Organizations (e.g., grassroots) Faith-based Other (not listed)	Evaluation Plan or implement efforts Assist with data collection/monitoring Engage/convene partners Capacity building Provide resources other than funding Provide funding Communications/promotions Involved in strategic planning Other (not listed)		New, acquired during this reporting period Existing partner/stakeholder Re-engaged partner/stakeholder Increased engagement No longer a partner/stakeholder	State Community Both

STATE ACTION PLAN ACTIVITIES TABLE

Type of Activity [Choose one from dropdown]

Description of activity and how it was leveraged for violence prevention. [1000]

Activity Status: [Select one from dropdown]

Project Year Completed: [Select one from dropdown]

Funding Acquisition Training/Capacity Building Partner engagement/convening Implementation planning Surveillance Data to Action Mass Media Coalition Sustainability planning Other (not listed)

In Progress (on track) Delayed Completed Discontinued

Not Yet Complete Year X Additional years added as appropriate

Social Determinants of Health [2800]: Provide a description of progress made to address the social determinants of health that impact violence that are prioritized for your state and community-level activities.

FORM 4-2: COMMUNITY ACTION PLAN

The Community Action Plan form collects information about progress on the Community Action Plan (e.g., community-level engagement, activities, and partnerships) during the reporting period (September 1^st – August 31^st). This form has two sections:

1. Changes to the Community Action Plan

2. Progress and Planning

3. Activities

SECTION A: CHANGES TO THE COMMUNITY ACTION PLAN

This section collects information on changes made to the components in the Community Action Plan. This section is not prefilled.

CHANGES TO THE COMMUNITY ACTION PLAN

Were there any changes to the Community Action Plan during this reporting period?

• No (Save, Validate, and Check in)

• Yes (Complete table below)

Community Action Plan Change (Select one)

Description of Change (1000 characters)

Describe the reason for the change and how it has/will impact your overall work: [1000]

Approach or Strategy Stakeholder/Partner State/Local collaboration Resources/Funding Training/Technical Assistance Sustainability Assures optimal level of health for all, and especially for those at greatest risk Data Use/Sources Other (not listed): Specify

SECTION B: PROGRESS AND PLANNING

Please describe the goals/priorities outlined in your community action plan. You can list up to 10 priorities. Add additional sections as necessary.

Priority Area Name #1 (150 characters)	Description of Priority Area (1750 characters)
Insert Text	Insert Text
Key Partners (350 characters)
Insert Text
Key Accomplishments this Report Period (1050 characters)
Insert Text
Resources Needed (700 characters)
Insert Text
Key Activities Planned for Upcoming Year (500 characters)
1. Insert text
2. Insert text
3. Insert text
4. Insert text

Policies

Provide an update on community-level activities to support an increase in policies that assures optimal level of health for all, and especially for those at greatest risk through the improvement of social determinants of health related to IPV.

2000 characters

COMMUNITY ACTION PLAN ACTIVITIES TABLE

Type of Activity [Choose one from dropdown]	Description of activity and how it was leveraged for violence prevention. [1000]	Activity Status: [Select one from dropdown]	Project Year Completed: [Select one from dropdown]
Funding Acquisition Training/Capacity Building Partner engagement/convening Implementation planning Surveillance Data to Action Mass Media Coalition Sustainability planning Other (not listed)		In Progress (on track) Delayed Completed Discontinued	Not Yet Complete Year X Additional years added as appropriate

Please click the checkbox at the bottom of this section to confirm that you have added any new activities from the reporting period and have also updated any information that has changed for previously entered activities.

Have you added any new activities from this reporting period and updated the activity status for existing activities in the table above? [Tick checkbox to confirm]

FORM 5-1: STATE-LEVEL PROGRAM OR POLICY EFFORT IMPLEMENTATION FORM

Instructions for Recipients

The Implementation Form collects information about each state-level program, policy, or practice that your organization implemented using DELTA AHEAD funding during the reporting period (September 1^st – August 31^st).

One Implementation form submission should be submitted for each program, policy, or practice. This form has five sections: 1) Description of Program, Policy, or Practice, 2) Changes to Implementation Plan, 3) Implementation Progress and Activities, 4) Adaptations, and 5) Population of Focus & Reach.

CDC’s Technical Packages provide strategies, approaches, and example programs, policies, and practices based on the best available evidence. (Initiative specific Implementation requirements).

• A strategy is one of the focus areas from CDC's Technial Packages that the cooperative agreement focuses on.

• An approach is a specific way to advance the strategy.

• Examples include street outreach and community- norm change, public engagement and education campaigns, family-friendly work policies, and modifying the physical and social environment.

• A program, policy, or practice is a specific group of activities that work together to achieve the intended outcome of the approach.

As you answer questions about the implementation efforts, please reference the table below:

Program, Policy, and Practice Definitions and Examples

Program	Uses set educational/training (manualized curriculum) materials with a planned audience.	Educational sessions, Staff/Provider trainings.
Policy	Includes any work done to create, develop, or put a policy into practice. Does not include work done to implement a recently enacted policy or policy scans. (Note: Advocacy is not allowed under NOFO funded projects.)	Policy recommendations, Policy training, Policy development.
Practice	Made up of activities or meetings that do not follow a set curriculum.	Social media campaign, environmental scans, Coalition meetings, Youth group meetings, Mentoring, Curriculum development, Hot

Spot Mapping, Community outreach.

When creating new Implementation submissions, make sure:

• Each program, policy, or practice is reported separately—one implementation submission form for each program, policy, or practice.

• Any training associated with TA, capacity building, or strategic planning should be reported in other forms instead of the Implementation Form.

• Report each component of a multicomponent effort in a separate implementation form submission. This applies if the implementation effort is made up of a combination of program, policy, and/or practice or if the components are using different strategies and approaches. When providing a name for a component of a multicomponent strategy, be sure to use the same main name and include “multicomponent:” in the name. For example: Inspire (Multicomponent)- Workplace Policy; Inspire (Multicomponent)- Hotspot Mapping.

• The name of your implementation form submission should be the name of the program, policy, or practice being implemented.

SECTION 1: DESCRIPTION OF IMPLEMENTATION EFFORT

This section collects information about the program, policy, or practice. In this section you will need to provide the type of implementation (program, policy, or practice), the name of the program, policy, or practice, and the associated approaches from CDC’s Technical Packages.

Program, Policy, or practice

To enter new program, policy, or practice please first identify the implementation effort as a program, policy, or practice. Reference the table above or discuss with your PO if you are unsure which category your effort falls into.

Are you implementing a Program, Policy, or Practice? [Choose one from dropdown]

• Program

• Policy

• Practice

• Unknown/Unsure

Implementation effort name and description

For this question you will select from a list of programs, policies, and practices from CDC’s Technical Packages. Make sure your answer does not fall within a listed answer option before choosing “other.”

Program, Policy, or Practice Name: [Choose one from dropdown]

• List of Example Programs, Policies, and Practices from CDC Technical Package(s) most closely associated with NOFO

• Other (not listed): Specify

Please provide a short description of how your organization is implementing this program, policy, or practice:

[500] In a few sentences describe the program, policy, or practice in way that someone who is not familiar with

the effort would understand. This should include what it intends to do, how it’s implemented, where it will occur, and evidence of effectiveness. Specific activities implemented as part of this program, policy, or practice will be collected in Section 3.

Approach

The last question in this section is asking for the 1-2 approaches from Violence Prevention in Practice that best align with the implementation effort.

• If you selected a program, policy, or practice name included in the dropdown in the previous section you may select “N/A – We selected from CDC’s Technical Packages” for this question. All of the named programs, policies, and practices above are aligned with specific strategies and approaches from CDC’s Technical packages, and we will fill this in for you later to ensure the correct approach is assigned.

• If you selected “Other” as your Program, Policy, or Practice name, please select one or two approaches that align with your implementation effort. Refer to the Approach Search Tool on Veto Violence to select the appropriate approaches.

• If you are unsure which approach to choose, discuss this with your Project Officer or select “Unknown/Unsure”.

Please select the Approach for this implementation effort: [Select one or two that apply]

• N/A – We selected from CDC’s Technical Packages

• List of Approaches from Violence Prevention in Practice most closely associated with NOFO

• Unknown/Unsure

SEM Level

Which SEM Level(s) does this Implementation Effort target? [Select all that apply]

• Individual - Prevention strategies at this level promote attitudes, beliefs, and behaviors that prevent violence. Examples include conflict resolution and life skills training.

• Relationship - Prevention strategies here focus on communication, parenting practices, and other bonds and connections. Examples include parenting and family-focused prevention programs, mentoring, and peer programs.

• Community - Prevention strategies at this level impact the social, economic, and environmental characteristics of settings. Examples include reducing social isolation; enhancing economic and housing opportunities; and improving the processes, policies, and settings in schools and workplaces.

• Societal - Prevention strategies at this level impact broad societal factors that help create a level of acceptance or intolerance for violence. Examples include strategies to change social norms that support violence as an acceptable way to resolve conflicts, state and federal policies that offer economic and other supports to families, and policies that support early childhood education to help pave the way for children to achieve lifelong opportunity and well-being.

SECTION 2: CHANGES TO IMPLEMENTATION PLAN

This section collects information on changes that have been made to the Implementation plan during the reporting period.

Implementation Plan Status

Were there any changes made to the implementation plan during this reporting period?

• No (Select Save, Validate, and Check in below)

• Yes (Complete table below)

Implementation plan Changes Table

Report on any changes made to the Implementation Plan, referring to your Program’s Implementation Plan document as appropriate. If you answered No to the question above, you do not need to fill out this table.

When you report on any changes made during the reporting period, make sure to only select the “Other” answer option for Type of Change if your answer does not fall within the existing answer options.

Type of Change: [Select one from dropdown]	Describe the Change [1000] Provide a concise description of the change and the reason for the change.
Recruitment and Retention Delivery Method Setting/Population of Focus Timeline Monitoring Staffing/Implementers Stakeholder/Partnership Other: Please Specify

SECTION 3: IMPLEMENTATION PROGRESS AND ACTIVITIES

This section collects information about the progress made on the implementation of the prevention strategy.

Implementation Progress table

This table collects information on the progress made implementing the prevention strategy. Each reporting period you will need to add new activities started during the reporting period and update the information for activities from previous reporting periods if anything has changed. When entering new activity, make sure that each entry is a discrete type of activity that best measures and demonstrates implementation progress. You will need to enter the Activity Type, a description of the activity, Activity Status, and the Project Year the activity was completed.

Activity Type: [Select one from dropdown]	Description of activity: [2000]	Activity Status: [Select one from dropdown]	Project Year Completed: [Select one from dropdown]
Planning Training/Coaching Executing Coordinating Monitoring Gathering or Using Data Other (not listed): specify	Provide a description of the activity and include with sufficient detail what the activity entailed, who was involved and if any resources are needed.	In Progress (on track) Delayed Completed Discontinued	Not Yet Complete Year X Additional years added as appropriate

Implementation Progress Checkbox

Please click the checkbox at the bottom of this section to confirm that you have added any new activities from the reporting period and have also updated any information that has changed for previously entered activities.

Have you added any new activities from this reporting period and updated the activity status for existing activities in the table above? [Tick checkbox to confirm]

SECTION 4: ADAPTATIONS

This section collects information about the adaptations made to the program, policy, or practice. For resources on using essential elements to track adaptations, see https://vetoviolence.cdc.gov/apps/adaptation-guidance/.

Adaptation Table

This table collects information on any adaptations made to the essential elements of the prevention strategy. Each reporting period you will need to add new adaptations started during the reporting period and update the information for adaptations from previous reporting periods if anything has changed. If an adaptation is no longer being implemented during this reporting period, please delete that row from the table.

Type of Adaptation: [Choose one from dropdown]	Adaptation Description [1000]	Reason for Adaptation: [Choose one from dropdown]	What resources are needed for this adaption? (700 characters)	How was this adaptation evaluated and what was the impact of the adaptation? [2000]
Added content Deleted content Changed sequence Modified delivery or methods Added or deleted	Describe in adequate detail what change was made to the design and implementation of the effort. What essential what, how, and who is changed? How is it changed?	To increase participation To respond to a resource, space, or time limitation To increase relevancy to or fit with context To align with the implementer's facilitation style To address shared risk and protective factors To address multiple forms of violence To address inequities To address social determinants of health Other (not listed): specify		Describe the impact this adaptation has had on the prevention effort including the impact on the implementers of the effort and the population targeted by the effort.
policy component Modified an
environmental
design element Changed the type
of recommended
implementer Other (not listed):
specify

Adaptation Checkbox

Please click the checkbox at the bottom of this section to confirm that you have added any new adaptations from the reporting period, have updated any information that has changed for previously entered adaptations, and have deleted any discontinued adaptations.

Have you added any new adaptations from the reporting period, updated any information that has changed for previously entered adaptations, and deleted any discontinued adaptations in the table above? [Tick checkbox to confirm]

SECTION 5: POPULATION OF FOCUS AND REACH

Population of Focus

Provide a narrative description of the population or setting of focus for this implementation effort. [2000]

Why was this population or setting selected and how is the implementation effort appropriate for the selected population or setting? [ 2000] Provide reasons and data sources that were used for selecting the population and setting of focus for this prevention effort. Also provide reasons and data sources that were used to show that the selected program, policy, or practice will be effective for reaching these populations.

Population Groups

Is there a specific community or population you are focusing on? [Chose one from dropdown]

• No Specific Community or Population (Skip to Reach tables below)

• Specific Community or Population (Check all that apply below)

If your program is focusing on a specific population, please select all that are applicable from below. Only select other if your answer does not fall within the existing options.

Racial/ethnic groups [Select all that apply]

• Black/African American

• Asian

• Arabic/North African

• Pacific Islander

• American Indian/Alaskan Native Peoples

• Hispanic/Latinx

• White

• Mixed race persons

• Other: Please Specify

• Other: Please Specify

Age groups: [Select all that apply]

• Infants (0-2)

• Young children (2-10)

• Youth (11-17)

• Young adults (18-24)

• Adults (25+)

• Older adults (65+)

• Other: Please Specify

Groups with disabilities/health risks: [Select all that apply]

• Intellectual/developmental disabilities

• Mobility/ambulatory disabilities

• People with disabilities (general)

• Substance use

• Mental illness

• Other: Please Specify

Sexual orientation groups: [Select all that apply]

• Gay/lesbian

• Straight (heterosexual)

• Queer

• Bisexual

• Pansexual

• Other: Please Specify

Economically disadvantaged groups: [Select all that apply]

• Experiencing homelessness

• Experiencing poverty

• Receiving government aid

• Other: Please Specify

Geographical groups: [Select all that apply]

• Tribal

• Rural

• Urban

• Low-income neighborhoods

• Suburban

• Other: Please Specify

Other Groups: [Select all that apply]

• Foster youth

• Single parents

• Incarcerated or formerly incarcerated

• Veterans

• Military (active)

• Victims of crimes/violence

• Perpetrators of crimes/violence

• Gang members

• Students

• Non-English speaking

• Other Population(s) not listed above and not belonging to any grouping above: Please specify

Individual Reach table

This table collects information on the number of individuals reached during the reporting period. Enter a new row for each specific population reached.

Description of Population [1000]	Year 5 Target for Individuals	Number of Individuals Reached This Reporting Period	Number of Total Individuals Reached Since Start of NOFO	Reach Type [Choose one from dropdown]	Progress Notes (2000 characters)
Describe the population that you are reaching.	Insert Numeric Value	List the number of individuals reached during the reporting period across all settings (primary and secondary) that began implementation by the end of the reporting period. This should include number of individuals reached and should not include individuals that you anticipate reaching in the future. Data are missing (program unable to collect this reporting period) Data are not applicable (program does not collect)Value	Insert Numeric Value	Individuals reached can be described in terms of Primary Reach – that is individuals directly impacted by the prevention strategy (e.g., employees, parents, youth serving providers, students); and Secondary Reach – which is an estimate of individuals with potential exposure to the prevention strategy, but not necessarily directed at them (e.g., community members). Primary Secondary	Insert Text

Setting Reach table

This section collects information on the number of settings reached during the reporting period. Enter a new row for each type of setting reached.

Type	Setting [Select one]	Description (1000 characters)	Year 5 Target for Settings	Number of Settings Reached this Reporting Period	Progress Notes (2000 characters)
Primary Setting	Community County Territory State NGO CBO Business Faith-based Organization Elementary School Middle School High School College/University Bar Other: Please Specify	Insert Text	Insert Numeric Value	Insert Numeric Value List the number of settings in which implementation has begun as of the end of the reporting period. This should include actual number of settings where implementation has started and should not include any projected data. Data are missing (program unable to collect this reporting period) Data are not applicable (program does not collect)	Insert Text

Secondary Setting (if applicable)			Insert Numeric Value	Insert Numeric Value	Insert Text

FORM 5-2: COMMUNITY-LEVEL PROGRAM OR POLICY EFFORT IMPLEMENTATION FORM

Instructions for Recipients

The Implementation Form collects information about each community-level program, policy, or practice that your organization implemented using DELTA AHEAD funding during the reporting period (September 1^st – August 31^st). One Implementation form submission should be submitted for each program, policy, or practice. This form has five sections: 1) Description of Program, Policy, or Practice, 2) Changes to Implementation Plan, 3) Implementation Progress and Activities, 4) Adaptations, and 5) Population of Focus & Reach.

CDC’s Technical Packages provide strategies, approaches, and example programs, policies, and practices based on the best available evidence. (Initiative specific Implementation requirements).

• A strategy is one of the focus areas from CDC's Technial Packages that the cooperative agreement focuses on.

• An approach is a specific way to advance the strategy.

• Examples include street outreach and community- norm change, public engagement and education campaigns, family-friendly work policies, and modifying the physical and social environment.

• A program, policy, or practice is a specific group of activities that work together to achieve the intended outcome of the approach.

As you answer questions about the implementation efforts, please reference the table below:

Program, Policy, and Practice Definitions and Examples

Program

Uses set educational/training (manualized curriculum) materials with a planned audience.

Educational sessions, Staff/Provider trainings.

Policy	Includes any work done to create, develop, or put a policy into practice. Does not include work done to implement a recently enacted policy or policy scans. (Note: Advocacy is not allowed under NOFO funded projects.)	Policy recommendations, Policy training, Policy development.
Practice	Made up of activities or meetings that do not follow a set curriculum.	Social media campaign, environmental scans, Coalition meetings, Youth group meetings, Mentoring, Curriculum development, Hot Spot Mapping, Community outreach.

When creating new Implementation submissions, make sure:

• Each program, policy, or practice is reported separately—one implementation submission form for each program, policy, or practice.

• Any training associated with TA, capacity building, or strategic planning should be reported in other forms instead of the Implementation Form.

• Report each component of a multicomponent effort in a separate implementation form submission. This applies if the implementation effort is made up of a combination of program, policy, and/or practice or if the components are using different strategies and approaches. When providing a name for a component of a multicomponent strategy, be sure to use the same main name and include “multicomponent:” in the name. For example: Inspire (Multicomponent)- Workplace Policy; Inspire (Multicomponent)- Hotspot Mapping.

• The name of your implementation form submission should be the name of the program, policy, or practice being implemented.

SECTION 1: DESCRIPTION OF IMPLEMENTATION EFFORT

This section collects information about the program, policy, or practice. In this section you will need to provide the type of implementation (program, policy, or practice), the name of the program, policy, or practice, and the associated approaches from CDC’s Technical Packages.

Program, Policy, or practice

To enter new program, policy, or practice please first identify the implementation effort as a program, policy, or practice. Reference the table above or discuss with your PO if you are unsure which category your effort falls into.

Are you implementing a Program, Policy, or Practice? [Choose one from dropdown]

• Program

• Policy

• Practice

• Unknown/Unsure

Implementation effort name and description

For this question you will select from a list of programs, policies, and practices from CDC’s Technical Packages. Make sure your answer does not fall within a listed answer option before choosing “other.”

Program, Policy, or Practice Name: [Choose one from dropdown]

• List of Example Programs, Policies, and Practices from CDC Technical Package(s) most closely associated with NOFO

• Other (not listed): Specify

Please provide a short description of how your organization is implementing this program, policy, or practice:

[500] In a few sentences describe the program, policy, or practice in way that someone who is not familiar with the effort would understand. This should include what it intends to do, how it’s implemented, where it will occur, and evidence of effectiveness. Specific activities implemented as part of this program, policy, or practice will be collected in Section 3.

Approach

The last question in this section is asking for the 1-2 approaches from Violence Prevention in Practice that best align with the implementation effort.

• If you selected a program, policy, or practice name included in the dropdown in the previous section you may select “N/A – We selected from CDC’s Technical Packages” for this question. All of the named programs, policies, and practices above are aligned with specific strategies and approaches from CDC’s Technical packages, and we will fill this in for you later to ensure the correct approach is assigned.

• If you selected “Other” as your Program, Policy, or Practice name, please select one or two approaches that align with your implementation effort. Refer to the Approach Search Tool on Veto Violence to select the appropriate approaches.

• If you are unsure which approach to choose, discuss this with your Project Officer or select “Unknown/Unsure”.

Please select the Approach for this implementation effort: [Select one or two that apply]

• N/A – We selected from CDC’s Technical Packages

• List of Approaches from Violence Prevention in Practice most closely associated with NOFO

• Unknown/Unsure

SEM Level

Which SEM Level(s) does this Implementation Effort target? [Select all that apply]

• Individual - Prevention strategies at this level promote attitudes, beliefs, and behaviors that prevent violence. Examples include conflict resolution and life skills training.

• Relationship - Prevention strategies here focus on communication, parenting practices, and other bonds and connections. Examples include parenting and family-focused prevention programs, mentoring, and peer programs.

• Community - Prevention strategies at this level impact the social, economic, and environmental characteristics of settings. Examples include reducing social isolation; enhancing economic and housing opportunities; and improving the processes, policies, and settings in schools and workplaces.

• Societal - Prevention strategies at this level impact broad societal factors that help create a level of acceptance or intolerance for violence. Examples include strategies to change social norms that support violence as an acceptable way to resolve conflicts, state and federal policies that offer economic and other supports to families, and policies that support early childhood education to help pave the way for children to achieve lifelong opportunity and well-being.

SECTION 2: CHANGES TO IMPLEMENTATION PLAN

This section collects information on changes that have been made to the Implementation plan during the reporting period.

Implementation Plan Status

Were there any changes made to the implementation plan during this reporting period?

• No (Select Save, Validate, and Check in below)

• Yes (Complete table below)

Implementation plan Changes Table

Report on any changes made to the Implementation Plan, referring to your Program’s Implementation Plan document as appropriate. If you answered No to the question above, you do not need to fill out this table.

When you report on any changes made during the reporting period, make sure to only select the “Other” answer option for Type of Change if your answer does not fall within the existing answer options.

Type of Change: [Select one from dropdown]	Describe the Change [1000] Provide a concise description of the change and the reason for the change.
Recruitment and Retention Delivery Method Setting/Population of Focus Timeline Monitoring Staffing/Implementers Stakeholder/Partnership Other: Please Specify

SECTION 3: IMPLEMENTATION PROGRESS AND ACTIVITIES

This section collects information about the progress made on the implementation of the prevention strategy.

Implementation Progress table

This table collects information on the progress made implementing the prevention strategy. Each reporting period you will need to add new activities started during the reporting period and update the information for activities from previous reporting periods if anything has changed. When entering new activity, make sure that each entry is a discrete type of activity that best measures and demonstrates implementation progress. You will need to enter the Activity Type, a description of the activity, Activity Status, and the Project Year the activity was completed.

Activity Type: [Select one from dropdown]	Description of activity: [2000]	Activity Status: [Select one from dropdown]	Project Year Completed: [Select one from dropdown]
Planning Training/Coaching Executing Coordinating Monitoring Gathering or Using Data Other (not listed): specify	Provide a description of the activity and include with sufficient detail what the activity entailed, who was involved and if any resources are needed.	In Progress (on track) Delayed Completed Discontinued	Not Yet Complete Year X Additional years added as appropriate

Implementation Progress Checkbox

Please click the checkbox at the bottom of this section to confirm that you have added any new activities from the reporting period and have also updated any information that has changed for previously entered activities.

Have you added any new activities from this reporting period and updated the activity status for existing activities in the table above? [Tick checkbox to confirm]

SECTION 4: ADAPTATIONS

This section collects information about the adaptations made to the program, policy, or practice. For resources on using essential elements to track adaptations, see https://vetoviolence.cdc.gov/apps/adaptation-guidance/.

Adaptation Table

This table collects information on any adaptations made to the essential elements of the prevention strategy. Each reporting period you will need to add new adaptations started during the reporting period and update the information for adaptations from previous reporting periods if anything has changed. If an adaptation is no longer being implemented during this reporting period, please delete that row from the table.

Type of Adaptation: [Choose one from dropdown]	Adaptation Description [1000]	Reason for Adaptation: [Choose one from dropdown]	What resources are needed for this adaption? (700 characters)	How was this adaptation evaluated and what was the impact of the adaptation? [2000]
Added content Deleted content Changed sequence Modified delivery or methods Added or deleted policy component Modified an environmental design element Changed the type of recommended implementer Other (not listed): specify	Describe in adequate detail what change was made to the design and implementation of the effort. What essential what, how, and who is changed? How is it changed?	To increase participation To respond to a resource, space, or time limitation To increase relevancy to or fit with context To align with the implementer's facilitation style To address shared risk and protective factors To address multiple forms of violence To address inequities To address social determinants of health Other (not listed): specify		Describe the impact this adaptation has had on the prevention effort including the impact on the implementers of the effort and the population targeted by the effort.

Adaptation Checkbox

Please click the checkbox at the bottom of this section to confirm that you have added any new adaptations from the reporting period, have updated any information that has changed for previously entered adaptations, and have deleted any discontinued adaptations.

Have you added any new adaptations from the reporting period, updated any information that has changed for previously entered adaptations, and deleted any discontinued adaptations in the table above? [Tick checkbox to confirm]

SECTION 5: POPULATION OF FOCUS AND REACH

Population of Focus

Provide a narrative description of the population or setting of focus for this implementation effort. [2000]

Why was this population or setting selected and how is the implementation effort appropriate for the selected population or setting? [ 2000] Provide reasons and data sources that were used for selecting the population and setting of focus for this prevention effort. Also provide reasons and data sources that were used to show that the selected program, policy, or practice will be effective for reaching these populations.

Population Groups

Is there a specific community or population you are focusing on? [Chose one from dropdown]

• No Specific Community or Population (Skip to Reach tables below)

• Specific Community or Population (Check all that apply below)

If your program is focusing on a specific population, please select all that are applicable from below. Only select other if your answer does not fall within the existing options.

Racial/ethnic groups [Select all that apply]

• Black/African American

• Asian

• Arabic/North African

• Pacific Islander

• American Indian/Alaskan Native Peoples

• Hispanic/Latinx

• White

• Mixed race persons

• Other: Please Specify

Non-citizen groups: [Select all that apply]

• Immigrants

• Migrant workers

• Refugees

• Asylum seekers

• Other: Please Specify

Age groups: [Select all that apply]

• Infants (0-2)

• Young children (2-10)

• Youth (11-17)

• Young adults (18-24)

• Adults (25+)

• Older adults (65+)

• Other: Please Specify

Groups with disabilities/health risks: [Select all that apply]

• Intellectual/developmental disabilities

• Mobility/ambulatory disabilities

• People with disabilities (general)

• Substance use

• Mental illness

• Other: Please Specify

Sexual orientation groups: [Select all that apply]

• Gay/lesbian

• Straight (heterosexual)

• Queer

• Bisexual

• Pansexual

• Other: Please Specify

Economically disadvantaged groups: [Select all that apply]

• Experiencing homelessness

• Experiencing poverty

• Receiving government aid

• Other: Please Specify

Geographical groups: [Select all that apply]

• Tribal

• Rural

• Urban

• Low-income neighborhoods

• Suburban

• Other: Please Specify

Other Groups: [Select all that apply]

• Foster youth

• Single parents

• Incarcerated or formerly incarcerated

• Veterans

• Military (active)

• Victims of crimes/violence

• Perpetrators of crimes/violence

• Gang members

• Students

• Non-English speaking

• Other Population(s) not listed above and not belonging to any grouping above: Please specify

Individual Reach table

This table collects information on the number of individuals reached during the reporting period. Enter a new row for each specific population reached.

Description of Population [1000]	Year 5 Target for Individuals	Number of Individuals Reached This Reporting Period	Number of Total Individuals Reached Since Start of NOFO	Reach Type [Choose one from dropdown]	Progress Notes (2000 characters)
Describe the population that you are reaching.	Insert Numeric Value	List the number of individuals reached during the reporting period across all settings (primary and secondary) that began implementation by the end of the reporting period. This should include number of individuals reached and should not include individuals that you anticipate reaching in the future. Data are missing (program unable to collect this reporting period) Data are not applicable (program does not collect)Value	Insert Numeric Value	Individuals reached can be described in terms of Primary Reach – that is individuals directly impacted by the prevention strategy (e.g., employees, parents, youth serving providers, students); and Secondary Reach – which is an estimate of individuals with potential exposure to the prevention strategy, but not necessarily directed at them (e.g., community members). Primary Secondary	Insert Text

Setting Reach table

This section collects information on the number of settings reached during the reporting period. Enter a new row for each type of setting reached.

Type	Setting [Select one]	Description (1000 characters)	Year 5 Target for Settings	Number of Settings Reached this Reporting Period	Progress Notes (2000 characters)
Primary Setting	Community County Territory State NGO CBO Business Faith-based Organization Elementary School Middle School High School College/University Bar Other: Please Specify	Insert Text	Insert Numeric Value	Insert Numeric Value List the number of settings in which implementation has begun as of the end of the reporting period. This should include actual number of settings where implementation has started and should not include any projected data. Data are missing (program unable to collect this reporting period) Data are not applicable (program does not collect)	Insert Text

Secondary Setting (if applicable)			Insert Numeric Value	Insert Numeric Value	Insert Text

FORM 6-1: NOFO EVALUATION : STATE EVALUATION

Instructions for Recipients

The Evaluation Form collects information about state-level evaluation and progress on evaluation activities conducted during the reporting period (September 1^st – August 31^st). Information from the state evaluation plan will be reported here. This form has three sections: 1) Evaluation Plan, 2) Progress on Addressing Evaluation Questions, and 3) Outcomes & Indicators.

SECTION 1: EVALUATION PLAN

Changes to the Evaluation Plan

Were there any changes to the evaluation plan during this reporting period?

• No (Select Save, Validate, and Check in below)

• Yes (Complete table below)

Changes to the Evaluation plan table

Report on any changes to specific section(s) of the evaluation plan changed during the reporting period. Choose each component of the Evaluation Plan that was changed, describe the change, the reason for the change, and how the change affects your program’s work.

Evaluation Plan Change: [Choose one from dropdown]	Description of change: [1000]	Describe the reason for the change and how it will impact your overall work: [1000]
Evaluation Design Evaluation Question Data Analysis, Synthesis, and Interpretation Data Collection Method/Source Outcomes and Indicators Translation, Communication, and Dissemination Evaluation Team Other (not listed): Specify

SECTION 2: PROGRESS ON ADDRESSING EVALUATION QUESTIONS

Evaluation Questions Table

This section collects information about the progress your program has made on the evaluation questions. Required evaluation questions are included below, and you may add # additional evaluation questions specific to your program (optional). For each question provide a summary of findings, including any qualitative results.

Quantitative results will be collected in the next section: Outcomes & Indicators.

Evaluation Question

• Q1: To what extent has the Coalition accomplished the short term and intermediate outcomes in the NOFO Logic Model?

• Q2: To what extent did the Coalition achieve high quality implementation of community and societal level primary prevention PPEs based on the best available evidence during the period of performance?

• Q3: To what extent was there an increase in statewide capacity to implement, evaluate and sustain primary prevention of IPV?

• Q4: What factors are critical to implementing and sustaining community and societal level primary prevention approach to prevent IPV?

• Q5: To what extent did the Coalition achieve alignment of state and local level PPE implementation?

• Q6: To what extent was the Coalition able to address SDoH and assures optimal level of health for all and they relate to IPV into their state-level planning, implementation, and evaluation?

• Q7:

• Q8:

• Q9:

• Q10:

• Q11:

• Q12:

• Q13:

• Q14:

• Q15:

Summary of Findings (include any qualitative results) [2000] Provide a summary of the progress your organization has made in relation to the evaluation question. You may also summarize any qualitative results you have collected related to the evaluation question.

Planned Evaluation Activities in Next Reporting Period: Please provide a general description of evaluation activities planned for the next reporting period. [2250]

SECTION 3: OUTCOMES AND INDICATORS

This section collects data on the indicators you are using to measure your selected outcomes.

Outcome and Indicator Table

Only enter one outcome per row. If an outcome has more than one indicator, add a row for each indicator. Data entered in this table will be pulled forward each APR and you will only need to update the Current Value in future APRs. For this NOFO, recipients may be assessing numerous outcomes. However, for the purpose of reporting in

the partners portal, we ask that you enter a maximum of 30 outcomes with up to 5 indicators per outcome. To help streamline your efforts, we recommend entering 20 of the most relevant, high-priority outcomes each with 1-3 indicators. Recipients can continue to assess other outcomes, but report on the high-priority ones annually.

SEM Level [Select all that apply] (guidance below will be visible when users hover over the field)

• Individual – biological and personal history factors that increase or decrease the likelihood of becoming a victim or perpetrator of violence. Factors may include age, education, income, substance use, and history of abuse.

• Relationship – close relationships that may increase or decrease the risk of experiencing violence as a victim or perpetrator. A person’s closest social circle — peers, partners, and family members — influence their behavior and shape their experience.

• Community - local settings and characteristics associated with becoming victims or perpetrators of violence. Settings include neighborhoods, schools, and workplaces.

• Societal - broad societal factors that help create a level of acceptance or intolerance for violence. It also includes the health, economic, educational, and social policies that help to maintain economic or social inequalities between groups in society.

Associated Effort(s) (Select all that apply)

Evaluatio n Question s Addresse d [Select all that Apply]

Description of Outcome

Type

SEM Level

Indicator Description [500]

Data Source Type [Select all that apply]

Data Source Name and Descripti on [500]

Indicator Populati on

Baselin e Value

Curren t Value

Year 5 Target

Chan Outc since repor perio

NOFO Evaluation

Questions

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Description of Outcome

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Data Source Name and Descripti on [500]

Indicator Populati on

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Year 5 Target

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FORM 6-2: COMMUNITY-LEVEL EVALUATION FORM

Instructions for Recipients

The Evaluation Form collects information about community-level evaluation and progress on evaluation activities conducted during the reporting period (September 1^st – August 31^st). Information from the Community Action Plan evaluation plan will be reported here. This form has three sections: 1) Evaluation Plan, 2) Progress on Addressing Evaluation Questions, and 3) Outcomes & Indicators.

SECTION 1: EVALUATION PLAN

Changes to the Evaluation Plan

Were there any changes to the evaluation plan during this reporting period?

• No (Select Save, Validate, and Check in below)

• Yes (Complete table below)

Changes to the Evaluation plan table

Report on any changes to specific section(s) of the evaluation plan changed during the reporting period. Choose each component of the Evaluation Plan that was changed, describe the change, the reason for the change, and how the change affects your program’s work.

Evaluation Plan Change: [Choose one from dropdown]	Description of change: [1000]	Describe the reason for the change and how it will impact your overall work: [1000]	Notes
Evaluation Design Evaluation Question Data Analysis, Synthesis, and Interpretation Data Collection Method/Source Outcomes and Indicators Translation, Communication, and Dissemination Evaluation Team Other (not listed): Specify

SECTION 2: PROGRESS ON ADDRESSING EVALUATION QUESTIONS

Evaluation Questions Table

This section collects information about the progress your program has made on the evaluation questions. Required evaluation questions are included below, and you may add # additional evaluation questions specific to your program (optional). For each question provide a summary of findings, including any qualitative results.

Quantitative results will be collected in the next section: Outcomes & Indicators.

Evaluation Question

• Q1: To what extent has the Coalition accomplished outcomes in the CAP logic model?

• Q2: To what extent, and how, did the comprehensive PPEs work together to achieve common outcomes?

• Q3: To what extent did the Coalition achieve alignment of state and local level PPE implementation?

• Q4: To what extent was the Coalition able to address SDoH and assures optimal level of health for all as they relate to IPV into their community-level planning, implementation, and evaluation?

• Q5:

• Q6:

• Q7:

• Q8:

• Q9:

• Q10:

• Q11:

• Q12:

• Q13:

• Q14:

• Q15:

Summary of Findings (include any qualitative results) [2000] Provide a summary of the progress your organization has made in relation to the evaluation question. You may also summarize any qualitative results you have collected related to the evaluation question.

Planned Evaluation Activities in Next Reporting Period: Please provide a general description of evaluation activities planned for the next reporting period. [2250]

COMMUNITY ACTION PLAN APR FORM DRAFT

SECTION 3: OUTCOMES AND INDICATORS

This section collects data on the indicators you are using to measure your selected outcomes.

Outcome and Indicator Table

Only enter one outcome per row. If an outcome has more than one indicator, add a row for each indicator. Data entered in this table will be pulled forward each APR and you will only need to update the Current Value in future APRs. For this NOFO, recipients may be assessing numerous outcomes. However, for the purpose of reporting in the partners portal, we ask that you enter a maximum of 30 outcomes with up to 5 indicators per outcome. To help streamline your efforts, we recommend entering 20 of the most relevant, high-priority outcomes each with 1-3 indicators. Recipients can continue to assess other outcomes, but report on the high-priority ones annually.

Associated Effort(s) [Select all that apply]

Evaluation Questions Addressed [Select all that Apply]

Description of Outcome

Type

SEM Level

Indicator Description [500]

Data Source Type [Select all that apply]

Data Source Name and Description [500]

Indicator Population

Year 5 Target

Current Value

Change in Outcome since last reportin g period

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Select all that

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Select one (1) Implementation/ Process Risk Factor Protective Factor Violence Outcome Other (not listed)

Select one (1) Individual Relationship Community Societal

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Needs Assessment Surveillance Data Law Enforcemen t Data Hospital Data Surveys Interviews Focus Groups Administrati ve Data National Data State-level data Other (not listed): Please Specify

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[Enter a Unit and Number] OR N/A [Chose one from dropdow n] This should be the most recent known value at the end of the reporting period. e

Inser

apply Community

15

outcome that is being

Define the

Numeric Value

Text

Evaluation

measured. As

indicator being

Community-

a reminder,

used to measure

level PPE1

outcome

the outcome. As

Community-

statements

a reminder, an

level PPE2

typically

indicator is a

Community

include

documentable or

level PPE3

directionality

measurable

Community-

(increase,

piece of

level PPE4

decrease,

information,

maintain),

from a specific

what will

data source,

change

used to

(specific

determine if the

outcome) and

outcome was

for whom

achieved. Also

(target

describe what

population).

level of

disaggregation

you collect this

indicator at.

COMMUNITY ACTION PLAN APR FORM DRAFT

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