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Development of an Evaluation Protocol for Assessing Impacts of OMH State Initiatives

Request for Modifications to OMB Clearance Previously Issued for the OMH Uniform Data Set (UDS)

Supporting Statement








May 25, 2007







Submitted by:

Development Services Group, Inc.
7315 Wisconsin Ave., Suite 800E
Bethesda, MD  20814
(301) 951‑0056



TABLE OF CONTENTS

	Background

A.	Justification

A.1	Explanation of the Circumstances that Make the
Data Collection Necessary
A.2	Use of the Data
A.3	Consideration of the Use of Improved Information Technology
A.4	Efforts to Identify Duplication
A.5	Minimizing Burden on Small Businesses and Entities
A.6	Consequences of Less Frequent Data Collection
A.7	Special Circumstances of Data Collection
A.8	Consultation with Persons Outside the Agency
A.9	Payment to Respondents
A.10	Assurances of Confidentiality
A.11	Sensitive Questions
A.12	Estimates of Respondent Burden
A.13	Annual Cost Burden to Respondents
A.14	Cost Estimates
A.15	Changes in Burden
A.16	Tabulation and Publication Plans
A.17	Display of Expiration Date
A.18	Exception to Certification Statement


B.	Collection of Information Employing Statistical Methods


APPENDIX

A.	Inventory of Data Items in Uniform Data Set

Background

Since its inception in 1985, OMH has been the unit of the U.S. Department of Health and Human Services (HHS) that coordinates Federal efforts to improve the health status of racial and ethnic minority populations. The agency was established with the passage of the Disadvantaged Minority Health Improvement Act (Pub. L. 101‑527) and given a broad mandate to advance efforts to improve minority health and address racial/ethnic disparities in health (recently reauthorized).  In order to achieve this broad mission, OMH supports research, demonstrations and evaluations of new and innovative programs, and strategies and interventions that increase understanding of ways to improve the health of minority communities and reduce the burden of disease, disability, and premature death that disparately impacts them.

As part of HHS, OMH works under an overall policy and strategic framework that includes key goals set forth in Healthy People 2010 and the 1993 Government Results and Performance Act or GPRA (Public Law 103‑62). Specifically, GPRA introduced requirements for performance measurement and benchmarking for Federal agencies. While performance measurement has been traditionally associated with cost factors and efficiency, e.g., the cost or number of hours per unit of output (Hatry, 1989), GPRA applied performance measurement to nonfinancial sectors of public management (Osborne and Gaebler, 1993), thus the increasing reliance by Federal agencies on strategic plans with goals and standards (such as the HHS Strategic Plan/Performance Goals). GPRA emphasizes public accountability and requires the development of strategic plans, performance goals, and an annual report filed with Congress on actual measured performance compared with pre‑established goals. More recently, OMB has implemented another accountability process, known as the Program Assessment Rating Tool (PART), designed to assess strategic planning, evaluation, and evidence of results for Federal agencies and their programs. 

As part of efforts to improve program monitoring and performance measurement with regard to its grant programs, OMH worked with the contractor to develop a system to collect standardized data on project activities from all of its grantees and cooperative partners.  This work encompassed several efforts.  The first was the Study of the Bilingual/Bicultural Service Demonstration Grant Program, focusing on grantees funded by OMH in fiscal years 1993B95 (hereinafter referred to as the Bilingual/Bicultural Study). This program was designed to improve bilingual/bicultural assistance in providing health services to designated racial and ethnic minority populations. The methodology involved: the empanelling of an expert, multicultural Advisory Committee; reviewing all grantee records; developing and administering a mail survey to FY 1993B94 grantees (including a telephone follow‑up interview); and conducting site visits to FY 1995 grantees. A key issue in conducting this study was the lack of standardized data across the spectrum of these projects, making it difficult to measure impact. Thus the resulting report included 12 recommendations, one of which was to develop the Uniform Data Set (AUDS Development@ project). 

Following that report, the contractor undertook development of the UDS through an extensive process of consultation with agency staff, grantees and cooperative agreement partners, and an Advisory Group composed of representatives from both the public (Federal agencies) and private (associations and foundations) sectors. A final paper-based UDS instrument and a limited, demonstration Web-based UDS prototype were developed as the outcome of those efforts. This UDS system was subsequently developed, under the recent UDS Implementation project (called “Implementation of an Internet and Paper-Based Uniform Data Set/UDS for all OMH Grants and Cooperative Agreements”), into a full Web-based system.

It is important to note that the UDS Development project has received significant recognition for excellence. Out of 26 evaluation projects submitted for consideration, the UDS Development project was one of only eight HHS evaluation projects nominated for and selected to be highlighted in the 2003 annual evaluation report to Congress.  The project was summarized in the Highlights/Excellent Evaluation chapter of Performance Improvement 2003, HHS=report to Congress on FY2002 ongoing and completed evaluation efforts. The project was deemed excellent by non-Federal evaluation experts on the basis that it was well designed, the developed product included data to measure the project=s qualitative impact, and that it contributed significantly to the goals of GPRA. 

The UDS is now being (or has been) used for reporting by the following types of OMH grants: Bilingual/Bicultural Service Demonstration Grant Program; Community Programs to Improve Minority Health; HIV/AIDS Health Promotion and Education Program; State and Territorial Minority HIV/AIDS Demonstration Grant Program; Youth Empowerment Demonstration Grant Program; Minority Community Health Partnership HIV/AIDS Demonstration Grant Program; and Technical Assistance and Capacity Development Demonstration Grant Program for HIV/AIDS-Related Services in Minority Communities.  The proposed modifications discussed herein are intended to adapt the UDS so that it can be used to report program and performance data for activities undertaken by States under the OMH State Initiative and grantees funded under the UCA program. 

Current UDS Data Elements 

The UDS includes routinely reported project/program uniform data, including: 1) core data, consisting of organizational and program information; and 2) activity data, consisting of project data pertinent to the 19 activity modules, which are standardized categories of project activity (e.g., health education and outreach) for which systematized, standard data are collected. Any project that conducts a given activity will report data pertinent to that activity.  Apart from the core data, the UDS asks grantees only for data on the activities they conduct.

Core Data Elements:  This refers to a limited, minimum data set across all OMH-funded programs and activity types, and includes very basic, largely descriptive and organizational data collectible across projects: 

    • grant type; 
    • grantee organization type;
    • project location and environment (region, urban, rural, etc.);
    • project services/activity types;
    • OMH‑specific funding and staffing information; 
    • OMH-specific partnerships and collaborations; and 
    • other similar information.

B.  Activity Type Data:  As noted, data categorization by activity type is necessary because each different program funds a number of activities per project, such that comparison of even two projects under the same program may not be possible, if done solely by project. Reporting data by activity type allows activities across projects to be evaluated, and for activity types to be assessed against each other. Thus, a comprehensive typology of project activities was developed. Table 1 shows the kinds of indicators/data elements that will serve to measure activities and the current list of “activity categories” and their definitions is included in Tables 2a and 2b.

Table 1: Data Elements for Each Activity Category
Data Element for Activity
Description
Demographics
Characteristics (e.g., age, gender, race, and ethnicity) of the persons served under the specific activity.
Number served
A count of the number of people/organizations served by the project while conducting the activity.
Process
The number of times a particular activity (e.g., training) was conducted, the number of materials developed and disseminated, the number of referrals made, organizations contacted, etc... 
Short term outcome
Short‑term gains made as a result of conducting the activity (e.g., gains in knowledge, awareness or skills, short‑term changes in diet, referrals made after health screenings).
Long‑term outcome
Data on long-term outcome will not be available for many activity categories. Where possible, however, such data will be collected. Examples include actual changes over the project period in specific health indicators (e.g., blood pressure, body fat), or changes in health risk behaviors (e.g., diet, smoking) that occurred as a result of the activity.
System changes
Changes in health systems or delivery of health for the target population that came about because of the activity (e.g., local task forces formed, new policies put in place at local health providers, new units formed).
Qualitative data
This type of data is intended to allow projects to record or describe (in a brief format) how the particular activity impacts clients in a way that is not necessarily reflected in the other data that is reported.  It is a place for each project to "tell the story" of this activity as they see it. 


The current set of 19 activity categories is divided into services impacting individuals and services impacting organizations or systems. The entire set of categories is displayed in Tables 2a and 2b.

Table 2a: Definitions for Services Impacting Individuals
Activity Category
Description
1) Training health care providers
Structured instruction or education sessions administered to health providers (doctors, nurses, staff) on issues related to racial/ethnic minority health (this includes development/adaptation of a training curriculum).
2) Interpretation/ Translation
Interpreting for minority clients who do not speak English (or do not speak it well) while clients are at appointments with health providers, case managers, social services providers, and other related services or in connection with (or translation of) written materials that clients need to understand and fill out.  In addition, this involves interpreting what the client is saying for the health provider.
3) Target population health education and outreach
Any kind of educational activity (whether individual or group) concerning health information, promotion, and prevention directed to the minority target population(s), including workshops, home health parties, health fairs, and outreach.  Violence, substance abuse and delinquency prevention should be included under this category.  (NOTE: Materials development and dissemination are counted separately under Activity Category #4.) 
4) Target population health educational materials development/ dissemination
Original development or adaptation of educational materials (concerning health issues, risks, prevention, treatments, local health providers) to be provided to minority and/or under‑served populations, and dissemination of those materials, via outreach, presentations, in doctor's offices, etc.  This category is divided into print, audio and TV/video materials.   
5) Screening and referral
Any diagnostic screening procedure to detect health risk or presence of a health problem (e.g., cholesterol screening, mammograms, blood pressure, and others).  Referrals means that, as a result of the screening, the client was referred to actual medical services.
6) Case management
Planning, coordination and monitoring of specific prevention or treatment protocols for individual clients (e.g., through the use of individual treatment plans or other tools), and coordinating referrals and access to services based on the individual protocol.
7) Wellness and exercise
For the purpose of this database (to distinguish wellness from education), any structured physical/mental activities designed to address a health risk, such as   exercise classes, stretching, meditation, yoga, and others.
8) Academic support/career preparation
Any structured activity designed to improve client educational performance (e.g., remedial sessions, tutorial, academic enrichment) and improve skills/knowledge related to jobs/careers.  (NOTE: Organizational internships and staff development programs are to be included under Activity Category #16, Technical Assistance and Organizational Capacity Building.) Related to prevention of health risk behaviors related to violence and substance abuse.
9) Mentoring
Structured, ongoing adult‑youth relationships for a specified period of time in which the adult spends regularly scheduled time with the youth and provides support, information, encouragement, and role‑modeling to help prevent a range of health risk behaviors.
10) Parent skills training/family counseling
Any structured activities (e.g., workshops, regular meetings, classes, family counseling, and family education) with parents as participants, in which parents receive instruction and/or practice in parenting and family management skills.  
11) Self‑esteem building
Any structured activities (workshops, sessions, curriculum segments) designed to increase client self‑esteem.
12) Cultural activities
Any structured activities including workshops, curriculum segments, sessions, ceremonies/rituals or field trips whose primary purpose is to increase client youth awareness of their cultural background, and increase bonding to cultural background as part of their sense of identity.
13) Recreational/ sports
Any structured athletic or physical activities, outdoor or indoor.
14) Crisis intervention
Unplanned activities, directed to clients and/or the target community, that are deemed necessary in order to resolve a crisis, or solve a problem that poses a barrier to client participation in project activities, or to help solve a problem that is diverting attention from the health issues of importance to the project.
15) Conference planning and management
The planning and conduct of conferences, meetings, trainings and other events that require logistical support activities, materials development (e.g., agendas, notebooks), and on-site management and follow-up.


Table 2b: Definitions for Services Impacting Organizations or Systems
Activity Category
Description
16) Linkage‑building or community coordination
Linkage‑building is a broad category that includes the formation and maintenance of coalitions, the formation of referral arrangements, and any other activity that is specifically part of grant activities and is intended to expand the impact of the grantee by developing and maintaining linkages with other organizations and/or health providers.
17) Technical assistance and organizational capacity building
Activities that increase the capacity of the grantee organization and/or any of its linkage partners to provide improved services, improved health promotion, and improved access to health care for its target minority population(s).  This could mean staff training, hiring bilingual staff, instituting an internal training program or training materials, implementing internal policies designed to ensure the growth of cultural competence, mentoring client organizations, leadership development, adding administrative resources, technology, staff, or new systems, and other similar actions. 
18) Resource coordination
The identification, coordination, and facilitation of resources to aid minority/community health organizations in expanding access to prevention and health care for target minority populations.
19) Needs assessment
The conduct of a community or target population needs assessment as part of project activities (not as part of preparing a grant application).  The needs assessment may include surveys of community attitudes and practices, available services, and other factors which would inform the targeting of project activities.

The full instrument (data elements only) is included in Appendix A. As noted in the original application for clearance, the UDS has been pilot-tested, in both paper and Internet forms. According to the original pilot test data, participants (a selection of OMH grantees) typically reported data in two or three activity modules, for an average reporting time of 4.5 hours, as indicated in Section A.12.  The participants were also asked for feedback on the reporting instrument.  The majority of participants felt that the UDS was easy to use, and that they were also able to use the UDS for their own organizational needs and to help them organize their own data.

OMH uses this information for project management and performance monitoring. Aggregate data from the UDS will be included in reports to OMH leadership and other policy/decision makers. Individual project data will be available to that project=s key staff as well, who will be able to use it to improve the overall management of their projects, to enhance their service delivery capacity, and to assess project impacts. 



References

Hatry, Harry.  1999.  Performance Measurement: Getting Results.  Washington, D.C.:  Urban Institute Press.

Osborne, D., and T. Gaebler.  1992.  Reinventing Government: How the Entrepreneurial Spirit is Transforming the Public Sector.  Reading, MA: Addison-Wesley.  


A.  Justification

A.1	Explanation of the Circumstances that Make Additional Data Collection Necessary

The Office of Minority Health (OMH), OPHS, U.S. Department of Health and Human Services (HHS) is submitting a Request for OMB Review in support of modifications to the OMB-approved UDS for a project entitled “Development of an Evaluation Protocol for Assessing Impacts of OMH State Initiatives,” hereinafter referred to as the “State Initiative.”  The UDS received OMB clearance in March 2004 (OMB No. 0990-0275).

The modifications to the UDS presented in this request are intended to: 

    1) Continue the process of integrating all OMH-funded activities under a systematic, uniform reporting mechanism to maximize efficiency; and 
    2) Continue the development of the UDS as a reporting system that will capture the types of data needed to identify best practices and assess the progress of OMH-funded activities towards the achievement of OMH-specific goals and Healthy People 2010 goals.

The UDS was developed based on OMH’s portfolio of grant programs current at the time of development.  Two grant programs not included in the research to develop the UDS need to begin reporting through the system.  These are the State Initiatives to Eliminate Racial/Ethnic Disparities in Health program and the National Umbrella Cooperative Agreement (UCA) program.  Once the modifications are implemented, the UDS will serve as the regular system for reporting of program management and performance data for all active OMH-funded grant and cooperative agreement programs.

Additional modifications are requested as part of OMH’s efforts to improve the agency’s evaluation and planning capacities and compliance with Federal reporting requirements.  These modifications include the addition of selected impact measures.  Reporting and analyzing such data will allow the identification of best practices and evaluation of effective approaches. The ability to monitor and evaluate performance in this manner and to work towards continuous program improvement are basic functions that OMH must be able to accomplish in order to carry out its mandate with the most effective and appropriate use of resources.

Requested modifications therefore include both additions/changes to the data reported in order to increase the number of programs using the UDS (including the State Initiative and UCA grantees), and additions/changes intended to increase the reporting of program impacts. These changes will improve OMH evaluation and planning capacities and support program accountability.  

The steps to adapt the UDS are: 
    • Review program documents and determine whether program activities undertaken by State and UCA grantees can be reported within the categories of data in the current UDS.
    • If they cannot, identify the modifications that need to be made.
    • Where possible, add impact data items to the existing set of data to be reported.  The State Initiative (under which this request is submitted) includes activities related to the adaptation of the UDS as well as activities designed to develop an Evaluation Protocol for OMH-funded State efforts to eliminate racial/ethnic health disparities.  Impact data were selected in collaboration with this effort.
    • Make the necessary modifications to the UDS (text and programming)
    • Pilot test the modified UDS with a small sample of grantees
    • Upon OMB approval, train new grantees and implement the system.

The requested modifications to the UDS are detailed in Table 3.  [The complete set of data items in the UDS, including the proposed modifications, is included as Appendix A.]  These modifications are based only on the review of State Initiative grantee program documents; no revisions were deemed necessary to adapt the UDS for UCA grantees.  


Table 3: Recommended Modifications to the UDS
Module
Recommended Modification(s)
Core Project Data
Below Question 10, add the following question: 

If new staff were hired, were they:
    • Career staff
    • Temporary staff
Training Health Care Providers (Module 1)
Change name of module to “Training and education for health professionals and community stakeholders” to accommodate educational activities for individuals such as community leaders who are not health care providers, and individuals who are not receiving training as part of an organizational capacity-building effort (covered under Module 17).

Add the following response choices to the “type of training” in Sections II and IV:
    • Health disparities
    • Education and outreach training
    • Data and evaluation
    • Planning

In Section III, add the following question: 

Who attended your training/education sessions (e.g., health care providers, community leaders, CBO staff member, etc…)?
Language Interpretation (Module 2)
In Section II, after Question 1, add the following question:

How many clients accessed services as a result of your language interpretation services?
Target population health education and outreach (Module 3)
In Section II, Question 2, change the follow-up question to read:

If yes, please complete the following:
[add Table 3-3 to capture, by activity type (individual or group education), 
    • the number of referrals to services as a result of education and outreach
    • the number of individuals accessing services as a result of referral

Add new Section IV: Short-Term Outcomes

For those education sessions where trainee outcome was evaluated:
Was it with (check one)?
    • Pre and post-test 
    • Post-test only
What was evaluated (check all that apply)?
    • Attitudes
    • Practices
    • Knowledge
    • Satisfaction
    • Other 

If Pre and Post Tests:
Add Table 3-6 to capture, by type of training (individual or group):
    • Type of Education (Single Session Individual Education, Single Session Group Education, Multiple Session Individual Education, Multiple Session Group Education)
    • Number of People who took Pre-Tests
    • Number of People who took Post-Tests
    • Number with Increase In Score from Pre- to Post-Test
Target population health educational materials development and dissemination  (Module 4)
Change title of module to “Materials development and dissemination.”

Revise the choices for type of media (print, audio, TV/video, web) to reflect a blend of type of media and material.  We recommend the following list of types:
    • Print health educational material
    • Video/audio health educational material
    • Directory of services or other resources
    • Public service announcement/broadcast
    • Report
    • Curriculum
    • Fact sheet
    • Sample guidelines/instructions
    • Program information and/or application
    • Educational websites
    • Other

After Table 4-2, add the following questions:

If you developed a Web site or disseminated materials on the Web:
How many Web site hits did you have?
How many materials were downloaded from your Web site?
Screening and referral (Module 5)
Add column to Table 5-2:

Screening Site:
    • clinic
    • mobile unit

Add column to Table 5-3:

Number of Successful Referrals
Case Management (Module 6)
Add Table 6-3: Number of Clients Receiving Services Through Case Management By Type of Service

Type of Service
    • Nutrition
    • Transportation
    • Medication
    • Medical Check-up
    • Benefits Counseling
    • Housing Assistance
    • Family Mental Health Counseling
    • Individual Mental Health Counseling
    • Testing/Screening and Counseling
    • Job Placement/Income Support
    • Other
    • Number of Clients Receiving Services
Wellness and Exercise (Module 7)
In Section II, Question 1, add blood glucose test and weight/BMI change as evaluation criteria.
Academic support and career preparation (Module 8)
In Section I, Table 8-2 and Section II, Question 1, change types of activity to:
    • Individual academic support (school tutoring)
    • Career counseling
        ◦ Career assessment
        ◦ Linkage to resources
        ◦ Counseling sessions
    • Group career education
    • Job skills training
    • Career mentoring
    • Other

In Section I, add Table 8.3 to capture, by activity type:

Program Issue Addressed:
    • Workforce Diversity
    • Health Care Careers
    • Other
Education Level of Participants
    • Elementary
    • High School
    • College
    • Post-Graduate
    • Professional
    • Other
Number of Participants
Number of New Participants Recruited in this Reporting Period

In Section II, add the following questions: 

Did any participants apply to or gain acceptance into medical school, other health service training programs, or programs in the health sciences?  
If yes, how many individuals submitted applications?
How many applications were accepted?
Mentoring (Module 9)
Add Section III Short-Term Outcomes

For those sessions where participant outcome was evaluated:
Was it with (check one)?
    • Pre and post-test 
    • Post-test only
What was evaluated (check all that apply)?
    • School performance
    • Bonding to school
    • Prosocial future expectations
    • Other 

Add Table 9-2:
If Pre- and Post-Test
    • Number of People Who Took Pre- Tests
    • Number of People Who Took Post- Tests
    • Number of People Who Took STANDARDIZED Pre-Tests
    • Number of People Who Took STANDARDIZED Post-Tests
    • Number of People with Increase in Score From Pre- to Post-Tests
    • If standardized tests were used, please list the names of the test(s)
Parent skills training (Module 10)
In Section II, Question 1, change the topics of evaluation to:
    • Knowledge of family management
    • Family functioning
    • Family violence
    • Other
Self-esteem building (Module 11)
In Section II, Question 1, change the topics of evaluation to:
    • Self-esteem
    • Self efficacy
    • Future expectations
    • Other
Cultural activities (Module 12)
In Section II, Question 1, change the topics of evaluation to:
    • Participant knowledge of his/her culture
    • Participant knowledge of cultural diversity
    • Other
Recreational/sports (Module 13)
Add Section II: Short-term Outcomes

For those activities where participant outcome was evaluated:
Was it with:
    • Pre and post-test
    • Post-test only
What was evaluated (check all that apply)?
    • Self-Reported Involvement in Risk Behavior
    • Other

If Pre- and Post-Tests
Add Table 13-2 to capture by type of activity (sports, other recreational):
    • Number of People Who Took Pre- Tests	
    • Number of People Who Took Post- Tests	
    • Number of People Who Took STANDARDIZED Pre- Tests	
    • Number of People Who Took STANDARDIZED POST- Tests
    • Number of People with Increase in Score From Pre- to Post- Tests
If standardized tests were used, please list the names of the test(s)	
Linkage-building and community coordination (Module 16)
In Section II, add the following questions: 

Did you form any new coalitions or collaborations in the past reporting period?  

Add Table 16-3 to capture for each collaboration:
    • Name of Organization	
    • Type of Agreement 
    • Type of Organization
    • Role in Grant Activity

For those coalitions or collaborations you formed or participated in, how many times did they meet?

Were any of these collaborations part of ongoing task forces or committees?
If yes, how many times did they meet?
If yes, are there plans for this partnership to continue meeting?
If no, did the partnership complete its goals?

In Sections I and II, add the following to the list of response choices for “role in grant activity”:
    • Co-sponsor programs/activities
    • Planning and/or evaluation
Technical assistance and organizational capacity building (Module 17)
Add “strategic planning for internal improvement” to list of types of TA provided.

In Table 17-2, add “grantee organization” to list of response choices for “organization type”

Change follow-up question in Section II, Question 3 to table to include information on the:
    • number of applications submitted by clients (as a result of TA/training)
    • type of funding source (e.g., foundation, state, national)
    • number who received an award/dollar amount.
Resource coordination (Module 18)
Add the following questions: 

Did you provide mini-grants to organizations as a project activity?  If Yes, please describe.
    • Did you develop/maintain a Web site for the purpose of making information available to community organizations?  If Yes, please describe.
Needs assessment (Module 19)
Change title of module to “Planning and Evaluation.”

Change Question 1 to read: 
Which of the following methodologies were employed in your planning and evaluation activities (check all that apply)?

Change Question 2 to read: 
Did your planning and evaluation activities address specific health conditions?  If yes, which health conditions were addressed?

Add the following question: 

Did your planning and evaluation activities address specific populations?  If yes, which populations were addressed?

Change Question 3 to read: 
Which of the following areas were addressed in your planning and evaluation activities?

Change Question 4 to read: 
What were the main findings or results of your planning and evaluation activities?

Add the following question: 

Were data collected for planning purposes or to target resources?  If yes, please describe.

Add the following question: 

Did you implement any changes in the data collection (such as collecting new kinds of data, enhancing data technology) to improve internal data systems?  If yes, please describe.

Change Question 5 to read: 
Does your project address gaps or problems identified through your planning and evaluation activities?  If yes, please describe.

Add the following questions: 

Did you evaluate efforts funded under your grant?  If yes, please describe. 
Were your evaluation criteria related to goals or other targets in your strategic plan? If yes, please describe. 


Pilot-Test Summary

Protocol.  After the modifications to the Web-based system were completed, a pilot-test of the modified UDS was conducted with a small sample of State grantees.  The contractor worked with OMH to select grantee sites to contact for the pretest.  The sample included 3 State Initiative grantees.  UCA grantees were not included in the pilot test as no specific changes were needed to accommodate this grant program in the UDS.  

Each grantee in the sample was contacted by email and phone to introduce the UDS effort and invite participation in the pretest.  The grantees participating were:

    • Delaware Office of Minority Health, Division of Public Health, Department of Health and Social Services
    • Michigan Office of Minority Health, Department of Community Health
    • New Mexico Office of Policy and Multicultural Health, Department of Health

Since the current UDS has already been extensively tested with OMH grantees, a complete test of the system was not necessary.  The pilot test focused primarily on modules that include new, untested questions.  These were:

    • Module 4 – Materials development and dissemination
    • Module 8 – Academic support/career preparation
    • Module 16 – Linkage-building and community coordination
    • Module 18 – Resource coordination
    • Module 19 – Planning and evaluation

An account was set up in the UDS for each participant.  Three activities were selected for each grantee based on our need to test activity modules and the specific activities conducted by the grantee project.  An evaluation form was provided for feedback on several aspects of the UDS.  Participants were asked to assess:

    • The ease of use of the UDS
    • The time needed to complete a report through the UDS
    • Whether it would take more or less time to report through the UDS
    • Whether a report could be completed using data that are already collected, or if new data would be needed
    • The applicability of the data items/questions in the UDS to their project activities

A conference call was held on May 16, 2007 to train the grantees on the basic use and functions of the UDS.  During this session, grantees were given a brief discussion of the background and structure of the UDS, training on data entry, and instruction on the protocol for the pilot test.  Participants were instructed to:

    1. Enter provided project data into activity module(s) and submit a report
    2. Utilize the online help/technical assistance functions
    3. Notify the Deputy Project Director upon completion of the report
    4. Complete and return the pilot test evaluation form within 1 week of the training conference call

Follow-up instructions, sample data, and the evaluation form were sent to participants following the training session. Phone and online technical assistance was offered as necessary during the pilot test period.  Data submissions were monitored and checked for completeness and accuracy.  Evaluation forms were received and reviewed.


Pilot-Test Results 

Data accuracy:  Data submissions from each participant were accurate and complete.

Ease of use:  Two participants said the UDS was “easy” to use and the remaining participant said it was “very easy” to use.  [Note: the response choices were: very easy, easy, somewhat easy, somewhat difficult, difficult, and very difficult.]

Time to complete a report:  The participants said it would take an average of 2 hours to complete a report using the UDS.  This is significantly less than the average of 4.5-hour estimate given by participants during the original pilot test of the system.

UDS reporting vs. standard reporting:  Two participants said that it would take “about the same time” to complete a report and the third said it would take “a bit less time.” [Note: the response choices were: significantly less time, a bit less time, about the same time, a bit more time, and significantly more time.]

Data needs:  All of the participants said that they already collect the data required in the UDS and would not have to collect additional data to complete a report.

Applicability of data items:  Generally-speaking, the participants felt that the questions were applicable to their project activities.  They did, however, say that they would not be able to report information on community meetings, advisory council meetings, and speaker’s bureau presentations using the selected activity modules.  

Recommendations.  No additional changes are recommended based on the results of the pilot-test.  Activity Module 15 (Conference/meeting planning) is designed to capture information on community meetings and advisory council meetings.  This activity module was not tested during the pilot test because it would not change under this request for modification.  Since the UDS is already able to collect the information identified by grantees above, no further modifications are needed.


A.2	Use of the Data 

The overall purpose of the UDS – for the State Initiative as well as current UDS applications -- is to enable the OMH-funded grantees, cooperative agreement partners and others to routinely report uniform data to a central coordinating center where the uniform data will be routinely received, analyzed and coordinated into reports to 1) monitor the project=s status, and 2) generate information regarding best practices, program inputs, outcomes and return on investment. As noted, the UDS has already received OMB approval. This application requests approval to modify the UDS so that OMH-funded State and UCA grantees can utilize the system. 

	This is the second reporting year of full implementation of the OMB-approved UDS with OMH grantees and cooperative agreement partners.  The UDS has been used to generate reports at two levels.  First, OMH program officers use the system to review individual grantee reports and aggregate reports on projects in their grant stream and to improve the overall management of their projects.  Secondly, The UDS has generated program data on populations served, health issues addressed, and funding that has been used to respond to inquiries made to OMH leadership and other policy/decision makers.

Tables 4 and 5 display the State and UCA grantees currently funded by OMH who will be using the UDS upon approval of this request.

Table 4: OMH State Initiative Grantees
State/Territory
Grantee
ALABAMA
Department of Public Health, Minority Health Section
ARIZONA
Department of Health Services, Center for Minority Health
CALIFORNIA
Department of Health Services, Office of Multicultural Health
COLORADO
Department of Public Health & Environment, Office of Health Disparities
DELAWARE
Department of Health & Social Services, Division of Public Health
FLORIDA
Department of Health, Office of Minority Health
GEORGIA
Department of Community Health, Office of Minority Health
ILLINOIS
Department of Public Health, Center for Minority Health Services
INDIANA
State Department of Health, Office of Minority Health
MAINE
Department of Health & Human Services, Office of Minority Health
MARYLAND
Department of Health & Mental Hygiene, Office of Minority Health/Health Disparities
MASSACHUSETTS
Department of Public Health, Office of Multicultural Health
MICHIGAN
Department of Community Health, Health Disparities Reduction & Minority Health Program
MINNESOTA
Department of Health, Office of Minority & Multicultural Health
MISSISSIPPI
Department of Health, Office of Health Disparity
MISSOURI
Department of Health & Senior Services, Office of Minority Health
NEBRASKA
Health & Human Services System, Office of Minority Health
NEVADA
Department of Health & Human Services, Office of Minority Health
NEW HAMPSHIRE
Department of Health & Human Services, Office of Minority Health
NEW JERSEY
Department of Health & Senior Services, Office of Minority & Multicultural Health
NEW MEXICO
Department of Health, Office of Policy & Multicultural Health
NEW YORK
Department of Health, Office of Minority Health
NORTH CAROLINA
Department of Health & Human Services, Office of Minority Health & Health Disparities
OHIO
Commission on Minority Health
OREGON
Department of Human Services, Office of Multicultural Health
PUERTO RICO
Department of Health, Office of External Affairs/Office of Minority Health
RHODE ISLAND
Department of Health, Office of Minority Health
SOUTH CAROLINA
Department of Health & Environmental Control, Office of Minority Health
TENNESSEE
Department of Health, Office of Minority Health
TEXAS
Department of State Health Services, Office for the Elimination of Health Disparities
UTAH
Department of Health, Center for Multicultural Health
WISCONSIN
Department of Health and Family Services, Minority Health Program


Table 5: OMH National Umbrella Cooperative Agreement Grantees
Grantee
University of Notre Dame du Lac, Inter-University Program for Latino Research
Association of American Indian Physicians
National Minority AIDS Council
Association of Asian Pacific Community Health Organizations
Auxiliary to the National Medical Association, Inc.
Hispanic Association of Colleges and Universities
Quality Education for Minorities
The President and Fellows of Harvard College
Interamerican College of Physicians and Surgeons


These projects represent a wide variety of health conditions, target populations, State systems, community situations, and project modalities. As noted, the UDS has been configured as an activity‑based, core and module data set. To minimize respondent burden, a given project will provide “core data” together with data only for those “activity categories” that are applicable to the project.  These data are discussed in detail above under “UDS Data Elements.”  Thus cross‑site comparisons of project performance and implementation can be made in the only way feasible given project variety, by comparing data by activity category. The activity categories were developed in close consultation with OMH and OMH-funded grantees and cooperative agreement partners, building upon already developed tools. They are an attempt to obtain reasonable documentation of process and outcome (intermediate outcome) for each category, through the standardized reporting of both quantitative and qualitative data. 


A.3	Consideration of the Use of Improved Information Technology

The UDS is specifically designed as an Internet application.  There will always be paper-based forms available; however, there have been no requests for the UDS in this format from grantees. The Internet system was selected for implementation as a result of pilot-testing the paper-based UDS.  The participants= sole and unanimous suggestion on improving the UDS was to provide it as a computer-based system. A wide range of grantees preferred the Internet over the paper format for the UDS as the tool to minimize burden and maximize utility.  Virtually all grantees had the technical capability to access the Internet for this purpose. 

Many community grantees have limited staff time and capacity to collect and report their project data, and the Web-based UDS provides a range of features that augment their capacity and thus improve the quality and regularity of reported data. For example, the Web-based format offers:

    • Well-defined, easily understandable data items for reporting
    • Explanation boxes for every data item in the system
    • On-line technical assistance
    • Downloadable reported data records and forms to help with ongoing data reporting  
    • A “Frequently Asked Questions” (FAQs) function
    • Automatic edit checks to “flag” possible errors or inconsistencies
    • Usability by OMH-partners  


A.4	Efforts to Identify Duplication

Reporting data under the UDS system does not duplicate other data reporting, but instead replaces the previous data reporting process. It is the first such system implemented at OMH. Prior to the UDS, a small amount of project data was reported on a voluntary basis using a limited, though standard, form and each project provided evaluation data based on its project-specific evaluation format. The latter data were not, however, standardized across projects. The UDS incorporated the data items included on the voluntary form, and standardized evaluation/performance data for all projects B thus creating an entirely new data system that supersedes that which previously existed. 


In addition, during the UDS Development project, an extensive effort was made to identify any other uniform data systems among Federal agencies or private foundations that were duplicative, and found none. In fact, that effort was also intended to identify any similar data items included in these data sets or methodology so that the OMH data could conform to cross-agency standards where applicable. In our review, only a few such data items were identified. The definitions utilized for these data items were adopted in the initial development of the UDS in order to maximize the utility of UDS data for cross-agency comparison where possible, as well as to avoid re-inventing the wheel.


A.5	Minimizing Burden on Small Businesses and Entities

Grantees and cooperative agreement partners funded by OMH are, for the most part, public or private non-profit minority community based organizations, as well as State agencies (State Offices of Minority Health or other appropriate agency). Whether or not the UDS existed, these projects would have to provide some project and evaluation data. The modifications recommended here represent the minimum data needed to be useful for project reporting, program monitoring, and performance measurement by OMH and its partners.

The UDS was specifically designed to provide additional support for OMH partners in order to facilitate their efforts to report data, and to standardize and simplify the nature of reported data.  Moreover, the UDS was designed to provide additional capacity to grantees and cooperative agreement partners in ways that they do not now have available, by providing online technical assistance, online guidance in filling out data forms, and downloadable sample forms and worksheets to help each project report its data. In addition, the UDS system has built-in edit checks to identify inconsistencies and errors in the data entered into the system, thus bypassing the need to use valuable staff time to accomplish such tasks. In short, the UDS system includes many features that both minimize respondent burden and increase respondent capacity.


A.6	Consequences of Less Frequent Data Collection

UDS data is reported every six months, as it was under the previous reporting system.  UDS reporting is required for all new OMH grantee and cooperative agreement partners.  The grantees these modifications are for would have to report every six months, regardless of whether the UDS existed.  The modifications proposed here do not change the frequency of project reporting by OMH partners.

There are no legal obstacles to reduce the burden of this data collection.


A.7	Special Circumstances of Data Collection	

This request fully complies with the regulation.


A.8	Consultation with Persons Outside the Agency

The agency’s 60-day notice appeared in the Federal Register Thursday, May 24, 2007, Vol.72, No. 100, pp. 29166 as required by 5 CFR 1320. (d). No public comments were received in response to the notice.  There was no outside consultation on the UDS modifications presented in this request; however, the original OMB-approved UDS was developed with extensive input from industry specialists in public and private sectors, as well as OMH grantees and cooperative agreement partners.


A.9	Payment to Respondents	

This study does not involve payment or gifts as incentives for respondents.


A.10	Assurances of Confidentiality
Only aggregate, periodic project data from each project or other agency activity is reported. Nevertheless, these data are password-protected and each project manager selects a unique ID once they begin using the UDS. That ID is necessary in order to log on to the Internet system, and it allows access only to that project=s own records. 

All data is maintained in aggregate form at a Central Coordinating Center supported under contract to OMH. This Center manages operations of the UDS and provides reports to OMH as requested.  


A.11	Sensitive Questions

The UDS requests data on program structure and characteristics, program operation, program implementation, services provided numbers/types of clients served, and short-term or intermediate outcomes. These data do not include any items of a personal or sensitive nature.


A.12	Estimates of Respondent Burden

It is estimated that the hour burden for this project will be approximately 9 hours per OMH partner per year, which is the sum of the hour burden for the OMH partners to report the data via UDS (regular gathering of data is not included in this estimate because that is already a customary part of project activities). While reporting such data is a regular part of project activities, it will be systematized under the new UDS and automated at the Central Coordinating Center. Depending upon the number of activities a given project conducts, and the number of clients served, we estimate the following time ranges for completing regular UDS requirements:

    • In terms of time burden, the day-to-day gathering/recording of data is not different under the UDS system from what it has been under the previous data management system. Projects already gather data; it is just not systematized as it will be for the UDS.  
    • For routine data reporting through the UDS, we estimate that each OMH-funded entity will spend approximately 4.5 hours to report the data each period, estimating the OMH partner has two to three activity modules to complete. This estimate is based on the results of a small pilot test during the UDS development effort where grantees were trained to use the system and used it to submit a routine report.  With semiannual reporting frequency, this calculates to approximately 9 hours total time burden for the task over a year.

	An adjustment was reported on OMB Form 83-I.  This adjustment represents an adjustment from the original PRA submission in the estimated number of responses per year.  The original number of responses per year per respondent was estimated to be 4.  In implementation, the number of responses per year per respondent was changed to 2, reducing the total burden hours by approximately one half.

Table 6. Estimated Annualized Burden Hours

Type of Respondent
Form Name
No. of Respondents
No. Responses per Respondent
Average Burden per Response (in hours)
Total Burden Hours
OMH Grantee
UDS
150
2
270/60
1350

Table 7. Estimated Annualized Cost to Respondents

Type of Respondent
Total Burden Hours
Hourly Wage Rate
Total Respondent Costs
Project or Evaluation Manager
1350
$30.00 
$40, 500.00


A.13	Capital Costs

As with the OMB-approved UDS, the modified UDS described in this request does not constitute an additional effort for respondents beyond regular project duties/obligations.  No additional staff time or cost is anticipated other than the time/cost allocated for regular project administrative requirements.  No additional materials or equipment are needed to use the UDS.


A.14	Cost Estimates

The overall cost to the Federal government for modifying the UDS for use with OMH-funded State grantees will be $71,582, distributed according to the following categories: 

Category
Cost


Personnel
$69,887
Other Direct Costs (including travel, consultants, computer equipment, etc.)
$1,695
Total
$71,582*

*G&A and fee included in total.

This includes the completed modification and testing of the UDS system, training of and technical assistance for State and UCA grantees in its use, and ongoing operation of the system (e.g., processing data, monitoring, generating reports). 


A.15	Changes in Burden

This is a request for a modification to an existing, OMB-approved data collection.  The modifications include additional questions intended to capture the nature and extent of activities conducted by grantees under funding programs that were not active during the development of the UDS.  There will be a slight increase in burden as the system is implemented among these new grantees - the burden of learning to use the system. Following that, no additional burden or changes in burden are anticipated. 

The modifications covered under this request represent minimal additional burden on existing users of the UDS.  The activity modules that would be changed most with this revision apply to a minority of existing users.  Additional impact measures were included in this revision above and beyond what was needed to accommodate State and UCA grantees.  As a result, the number of data items to respond to in any activity module may increase by one or two for some grantees.


A.16	Tabulation and Publication Plans

The purpose of the UDS, as described herein, is to serve as the regular, ongoing system of data reporting for all grants and cooperative agreements funded by OMH. Data reported as part of this system will be used for project management and monitoring, assessment of project implementation and performance, and to identify best practices and approaches in support of OMH goals and the goals of Healthy People 2010 and HealthierUS.  In addition, aggregate program data will also be used in periodic reports to OMH leadership and other HHS policymakers and decision makers as needed and appropriate.  

No specific plans to publish results from the UDS system are underway at this time.


A.17	Display of Expiration Date

This section does not apply to this submission.


A.18	Exception to Certification Statement

There are no exceptions to the certification.


B.	Collection of Information Employing Statistical Methods

This section does not apply to the UDS.  The project does not involve sampling. All OMH grantees/cooperative agreement partners will be reporting uniform data on their activities using this system to analyze performance and identify best practices.







Appendix A

Data Items in Modified Uniform Data Set















UNIFORM DATA SET DATA ITEMS 
(modifications highlighted)

Organization and Grant Information
DATA ITEM
RESPONSE
Organization Name

Grant Award Year
    • Before 2000 
    • 2000 
    • 2001 
    • 2002 
    • 2003 
    • 2004 
    • 2005 
    • 2006
Address

Phone/Fax

Contact Person/ Phone/Email

Organization Key Code

Organization Type
    • Faith-Based Organization
    • Health Care Entity 
    • Institution of Higher Education: Hispanic-Serving Institution 
    • Institution of Higher Education: Historically Black College/University
    • Institution of Higher Education: Other College/University 
    • Institution of Higher Education: Tribal College/University 
    • Minority-Serving Community-Based Organization: Health Focused 
    • Minority-Serving Community-Based Organization: Non-Health Focused 
    • National Minority-Serving Organization: Health Focused 
    • National Minority-Serving Organization: Non-Health Focused 
    • Public Institutions: Federal government agency 
    • Public Institutions: Local government agency 
    • Public Institutions: State government agency 
    • Public Institutions: Tribal Entity/Government 
    • Other
Select if reporting for multiple programs

Project Name

Project Director/ Email

Contact Person

Number of Positions (FTE's) Filled Using OMH Funding

Number of OMH-Funded Staff

Number of Consultants

Number of Individuals Paid on a Fee-For-Service Basis (e.g., interpreters paid per interpretation)

Number of New Staff Hired

If new staff were hired, were they:
    • Career staff
    • Temporary staff
Number of Volunteers

Current Grant Year

Grant Number

Grant Type
    • Bilingual/Bicultural Service Demonstration Grant Program 
    • Community Programs to Improve Minority Health 
    • Health Disparities in Minority Health Program 
    • HIV/AIDS Cooperative Agreement 
    • HIV/AIDS Minority Health Coalition Demonstration Program 
    • Minority Health Coalition 
    • National Umbrella Cooperative Agreement Program 
    • Standard Cooperative Agreement Program 
    • State and Territorial Minority HIV/AIDS Demonstration Program 
    • State Partnership Grant Program to Improve Minority Health 
    • TACD Program for HIV/AIDS Services 
    • Other Grant/Contract
Total Annual Budget of Grantee Organization

OMH Funding

What additional funding did you receive to conduct your OMH-funded activities?
Federal Funding (amount)
State Funding (amount)
Local Funding (amount)
Private Funding (amount)
In-Kind Contributions (amount)

How were your OMH funds distributed across health issues, activities, and demographic categories?
TABLE (for each category, enter)
Health Issues
Select Health Issue/ Enter Percent of Funding Used
Activities
Select Activity Modules/ Enter Percent of Funding Used
Race
Select Race/ Enter Percent of Funding Used
Ethnicity
Select Ethnicity/ Enter Percent of Funding Used
Gender
Select Gender/ Enter Percent of Funding Used
Age
Select Age/ Enter Percent of Funding Used
What other activities does your organization do that are not funded by OMH? (Note: This question only applies to grantees receiving funding through the State Partnership Initiative)
Enter Other Activities Funded and Funding Source
Were you involved with any partnerships or collaborating organizations as an essential part of the project?
TABLE (for each partnership, enter)
Name of Organization

Type of Agreement
Select:
    • informal
    • formal cooperative
    • subcontract
    • other
Type of Organization
Select
Role in Project Activity
Select:
    • referral source
    • provide service
    • other
Postal zip codes where your project conducts its activities

Project Environment
Check all that apply:
    • Urban 
    • Suburban 
    • Rural 
    • US-Mexican Border 
Report Information

Project Name

Reporting Period

Report Narrative
TEXT /Attach Document
Activities Conducted
Select Activity Modules (checkbox)


Module 1 - Training and education for health professionals and community stakeholders
DATA ITEM
RESPONSE
Section I: Number of Individuals Trained and Sessions Conducted

Table 1-1: Number of Individuals Served and Demographics
Demographic Characteristics of Individuals Served
Section II: Number of Sessions Conducted

Type of Training
    • Cultural Competence 
    • Disease Management/Health Information 
    • Interpretation
    • Language 
    • Health Disparities
    • Education and Outreach Training
    • Data and Evaluation
    • Planning
    • Other (specify)
Number of Sessions

Total Served in All Sessions

Length of Each Session in Hours

Evaluated?
Yes/No
Section III: Additional Training Information

What were the training topics?

Who attended your training/education sessions? (e.g., health care providers, community leaders, CBO staff member, etc…)

Section IV: Short-term Outcomes of Training and Education

For those trainings where trainee outcome was evaluated

 Was it with
    • Pre and post-test 
    • Post-test only
What was evaluated (check all that apply)?
    • Attitudes
    • Practices
    • Knowledge
    • Satisfaction
    • Other
If Pre and Post Tests
TABLE (for each type of training, enter)
Type of Training
    • Cultural Competence 
    • Disease Management/Health Information 
    • Interpretation 
    • Language 
    • Health Disparities
    • Education and Outreach Training
    • Data and Evaluation
    • Planning
    • Other (specify)
Number of People who took Pre Tests

Number of People who took Post Tests

Number with Increase In Score from Pre- to Post-Test

Section V: Qualitative Impacts

Please describe how your trainings have impacted on three sample trainees. To fill out this section, you can draw from evaluation responses, conversations with or observations of trainees, your own notes, or your experience with trainees



Module 2 - Language interpretation
DATA ITEM
RESPONSE
Section I: Number of Individuals Served

Table 2-1: Number of Individuals Served and Demographics
Demographic Characteristics of Individuals Served
Section II: Sessions Conducted and Short-term Outcomes

1. Please enter the total number of interpretations provided by language and the percentage of clients that received a follow-up health/medical referral or assessment as a result of language interpretation.  
TABLE (for each language, enter)
Language
Select from list
Total Interpretations

Total Clients Served

Total Providers Served

Number Receiving Referral/Assessment

2. How many clients accessed services as a result of your language interpretation services?

3. What was the average duration of each session of language interpretation?  
hour(s)
4. What was the average amount of preparation or other additional time (e.g., transportation time, waiting room time, etc.) per session?  
hour(s)
5. Did you translate any materials as part of the service you provided?
Yes/No
For each language, enter total number of materials

6. Please list the kinds of materials you translated

7. Did you provide any simultaneous translation for group sessions or meetings?
Yes/No
If yes, for each language, enter:

Number of Sessions

Approximate Number of People Per Session

Section III: Qualitative Impacts

1. Please describe how the interpretations you provide have impacted on three sample clients. To fill out this section, you can draw from client evaluation responses, conversations with or observations of clients, notes, or your experience with clients.



Module 3 - Target population health education and outreach 
DATA ITEM
RESPONSE


Section I: Number of Individuals Served and Sessions Conducted

Table 3-1: Number of Individuals Served and Demographics
Demographic Characteristics of Individuals Served
Table 3-2: Number of Sessions Conducted
TABLE (For each type of session, enter)
Type of Session
    • Single Session Individual Education 
    • Single Session Group Education 
    • Multiple Session Individual Education 
    • Multiple Session Group Education
Number Of Sessions

Number Of Sessions Per Course

Number Of Courses Conducted

Evaluated?
Yes/No
Section II: Additional Information

1. What were the education session topics?

For Individual Education

For Group Education

2. During the course of your health education and outreach activities, were any clients given referrals to medical, mental health, or other services?
Yes/No
If yes, how many referrals were given?

How many of these clients accessed services as a result of referrals?

Section III: Health Fairs and Other Events

1. Did you conduct or participate in any health fairs during this reporting period?
Yes/No
If YES, what is the total number of health fairs conducted/participated in?


TABLE (for each health fair enter)
Target Population

Health Issue(s)

Approximate Number Served

Date: (MM/DD/YYYY)

2. Did you conduct or participate in any type of educational event other than those reported above (examples, performing arts, rallies, walks/runs, benefit events)?
Yes/No
If YES, what is the total number of other events conducted/participated in?


TABLE (for each other event enter)
Event Type

Target Population

Health Issue(s)

Approximate Number Served

Date: (MM/DD/YYYY)

Section IV: Short-term Outcomes of Health Education and Outreach

For those education sessions where trainee outcome was evaluated

 Was it with
    • Pre and post-test 
    • Post-test only
What was evaluated (check all that apply)?
    • Attitudes
    • Practices
    • Knowledge
    • Satisfaction
    • Other
If Pre and Post Tests
TABLE (for each type of training, enter)
Type of Education
    • Single Session Individual Education 
    • Single Session Group Education 
    • Multiple Session Individual Education 
    • Multiple Session Group Education
Number of People who took Pre-Tests

Number of People who took Post-Tests

Number with Increase In Score from Pre- to Post-Test

Section V: Qualitative Impacts

1. Please describe how your health education and outreach activities have impacted on three sample clients. To fill out this section, you can draw from evaluation responses, conversations with or observations of clients or members of the target population, your own notes, or your experience with clients.



Module 4 - Materials development and dissemination 
DATA ITEM
RESPONSE


Section I: Number of Individuals Trained and Sessions Conducted

Table 4-1: Number of Individuals Served and Demographics
Demographic Characteristics of Individuals Served
Table 4-2: Materials Development
TABLE (For each material developed, enter)

Type of Material
    • Print health educational material
    • Video/Audio health educational material
    • Directory of services or other resources
    • Public service announcement/broadcast
    • Report
    • Curriculum or Training Manual
    • Fact sheet
    • Sample guidelines/instructions
    • Program information and/or application
    • Educational Web site
    • Other
Source
    • Developed
    • Adapted
Target Audience

Health Issue

Language

Number Developed

If you developed a Web site or disseminated materials on the Web:

How many Web site hits did you have?

How many materials were downloaded from your Web site?

Section II: Qualitative Impacts

1. For each type of material you developed/adapted, please describe how the language and graphics are appropriate for the intended targeted audience and how you determined this.

2. What kinds of organizations and/or individuals received, heard or saw the materials you developed?



Module 5 - Screening and referral 
DATA ITEM
RESPONSE


Section I: Number of Individuals Served and Sessions Conducted

Table 5-1: Number of Individuals Served and Demographics
Demographic Characteristics of Individuals Served
Table 5-2: Number of Screenings Conducted
TABLE (for each type of screening, enter)
Type of Screening
    • Cancer 
    • Cardiovascular disease 
    • Diabetes 
    • HIV 
    • Mental health 
    • Other 
    • Respiratory disease 
    • STDs 
    • Substance abuse 
    • Tuberculosis
Number of Screenings

Screening Site
    • Clinic
    • Mobile unit
Table 5-3: Number of Referrals Given
TABLE (for each type of referral, enter)
Type of Referral
    • Further testing
    • Medical services
    • Other
Number of Referrals

Number of Successful Referrals

Section II: Qualitative Impacts

1. Please describe how your work providing screenings and referrals has impacted on three sample clients. To fill out this section, you can draw from client evaluation responses, conversations with or observations of project clients, notes, or your experience with clients.



Module 6 - Case Management 
DATA ITEM
RESPONSE


Section I: Number of Individuals Served

Table 6-1: Demographic Characteristics of Individuals
Demographic Characteristics of Individuals Served
Table 6-2: Number and Type of Case Management Contacts (With Clients)

Total Number of Case Management Contacts: In-Person

Total Number of Case Management Contacts: By Telephone

Table 6-3: Number of Clients Receiving Services Through Case Management By Type of Service 

Type of Service
    • Nutrition
    • Transportation
    • Medication
    • Medical Check-up
    • Benefits Counseling
    • Housing Assistance
    • Family Mental Health Counseling
    • Individual Mental Health Counseling
    • Testing/Screening and Counseling
    • Job Placement/Income Support
    • Other
Number of Clients Receiving Services

Section II: Qualitative Impacts

1. Please describe how your case management activities have impacted on three sample clients. To fill out this section, you can draw from (non-confidential) case notes, client evaluation responses, conversations with or observations of clients, other notes, or your experience with clients.



Module 7 - Wellness and exercise activities
DATA ITEM
RESPONSE


Section I: Number of Individuals Served

Table 7-1: Demographic Characteristics of Individuals Served
Demographic Characteristics of Individuals Served
Table 7-2: Number of Sessions Conducted

Type of Class
    • Diet/Food 
    • Exercise 
    • Other 
    • Stress Reduction
Total Number of Sessions

Average Number of Participants Per Session

How many individuals received individual physical/wellness training?

Section II: Short-term Impacts

1. Were the wellness/exercise participants evaluated using pre-post tests or screenings?
Yes/No 
If Yes
TABLE (for each activity enter)
Type of Wellness Activity
    • Diet/Food 
    • Exercise 
    • Other 
    • Stress Reduction
Evaluation Method
    • Blood glucose test 
    • Blood pressure 
    • Cholesterol test 
    • Fitness test
    • Weight/BMI
    • Other
Number of People Taking Pre-Test

Number of People Taking Post-Test

Number of People with Improved Score From Pre- to Post-Tests

Section III: Qualitative Impacts

1. Please describe how your wellness activities have impacted on three sample clients. To fill out this section, you can draw from client evaluation responses, conversations with or observations of clients, notes, or your experience with clients.




Module 8 - Academic support/career preparation 
DATA ITEM
RESPONSE


Section I: Number of Individuals Served

Table 8-1: Demographic Characteristics of Individuals Served
Demographic Characteristics of Individuals Served
Table 8-2: Number of Sessions Conducted
TABLE (for each type of session, enter)
Type of Activity
    • Individual Academic Support (school tutoring)
    • Career Counseling
        ◦ Career Assessment
        ◦ Linkage to Resources
        ◦ Counseling Sessions
    • Group Career Education
    • Job Skills Training
    • Career Mentoring
    • Other (specify)
Total Number of Sessions

Average Number of Participants Per Session

Evaluated?
Yes/No
Table 8-3: Program Information

Type of Activity
    • Individual Academic Support (school tutoring)
    • Career Counseling
        ◦ Career Assessment
        ◦ Linkage to Resources
        ◦ Counseling Sessions
    • Group Career Education
    • Job Skills Training
    • Career Mentoring
    • Other (specify)
Program Issue Addressed
    • Workforce Diversity
    • Health Care Careers
    • Other
Education Level of Participants
    • Elementary
    • High School
    • College
    • Post-Graduate
    • Professional
    • Other
Number of Participants 

Number of New Participants Recruited in this Reporting Period

Section II: Short-term Outcomes

Did any participants apply to or gain acceptance into medical school, other health service training programs, or programs in the health sciences?
Yes/No
If yes, how many individuals submitted applications?

How many applicants were accepted?

For those sessions where participant outcome was evaluated:

 Was it with
    • Pre and post-test
    • Post-test only
What was evaluated (check all that apply)?
    • Attitudes
    • Practices
    • Knowledge
    • Satisfaction 
    • Other
If Pre and Post Tests 
TABLE (for each type of session, enter)
Type of Activity
    • Individual Academic Support (school tutoring)
    • Career Counseling
        ◦ Career Assessment
        ◦ Linkage to Resources
        ◦ Counseling Sessions
    • Group Career Education
    • Job Skills Training
    • Career Mentoring
    • Other (specify)
Number of People Who Took Pre-Tests

Number of People Who Took Post-Tests

Number of People Who Took STANDARDIZED Pre-Tests

Number of People Who Took STANDARDIZED Post-Tests

Number of People with Increase in Score From Pre- to Post-Tests

If standardized tests were used, please list the names of the test(s)

Section III: Qualitative Impacts

1. Please describe how your work in academic support/career preparation has impacted on three sample clients. To fill out this section, you can draw from client evaluation responses, feedback from teachers/school personnel, conversations with or observations of clients, notes, or your experience with clients.



Module 9 - Mentoring 
DATA ITEM
RESPONSE
Section I: Number of Individuals Served

Table 9-1: Demographic Characteristics of Individuals Served
Demographic Characteristics of Individuals Served
Section II: Additional Information on Mentoring

1. What was the average length of the mentoring relationship (months)?

2. Typically, what was the frequency of face-to-face contact between mentors and mentees?
times per week
times per month

3. Typically, what was the frequency of telephone contact between mentors and mentees?
times per week
times per month

4. How many mentors were involved in your project activities?

Section III: Short-term Outcomes Mentoring

For those sessions where participant outcome was evaluated: (If no sessions were evaluated, skip to section III)

Was it with:
    • Pre and post-test
    • Post-test only
What was evaluated (check all that apply)?
    • School Performance
    • Bonding to School
    • Prosocial Future Expectations
    • Other
If Pre- and Post-Test

Number of People Who Took Pre- Tests

Number of People Who Took Post- Tests

Number of People Who Took STANDARDIZED Pre-Tests

Number of People Who Took STANDARDIZED Post-Tests

Number of People with Increase in Score From Pre- to Post-Tests

If standardized tests were used, please list the names of the test(s)

Section IV: Qualitative Impacts

1. Please describe how your work providing mentoring has impacted on three sample clients. To fill out this section, you can draw from client evaluation responses, feedback from teachers/school personnel, conversations with or observations of clients, notes, or your experience with clients.



Module 10 - Parent skills training/family counseling
DATA ITEM
RESPONSE
Section I: Number of Individuals Served

Table 10-1: Number of Individuals Served and Demographics
Demographic Characteristics of Individuals Served
Section II: Number of Sessions Conducted and Other Information

Total Number of Sessions Conducted: Individual Counseling

Total Number of Sessions Conducted: Group Session or Class

1. What was the average duration of the individual counseling?  
hours per session
total sessions per person

2. What was the average duration of the group sessions?
hours per session
total sessions per person

Section III: Short-term Outcomes of Parent Skills Training/Family Counseling

For those sessions where participant outcome was evaluated: (If no sessions were evaluated, skip to section III)

Was it with:
    • Pre and post-test
    • Post-test only
What was evaluated (check all that apply)?
    • Knowledge of Family Management
    • Family Functioning
    • Family Violence
    • Other
If Pre- and Post-Test
TABLE (for each type of activity, enter)
Type of Activity
    • Group Sessions 
    • Individual Counseling
    • Other (specify)
Number of People Who Took Pre- Tests

Number of People Who Took Post- Tests

Number of People Who Took STANDARDIZED Pre

Number of People Who Took STANDARDIZED Post

Number of People with Increase in Score From Pre

If standardized tests were used, please list the names of the test(s)

Section IV: Qualitative Impacts

1. Please describe how your parenting skills training/family counseling activities have impacted on three sample clients. To fill out this section, you can draw from client evaluation responses, (non-confidential) case notes, conversations with or observations of training clients, other notes, or your general experience with clients.

Module 11 - Self-esteem building 
DATA ITEM
RESPONSE
Section I: Number of Individuals Served and Sessions Conducted

Table 11-1: Demographic Characteristics of Individuals Served
Demographic Characteristics of Individuals Served
Table 11-2: Total Number of Sessions Conducted by Type of Activity

Individual Sessions (Total)

Group Sessions or Classes (Total)

Evaluated?
Yes/No
1. What (self esteem) curricula were used (if curriculum was developed by project, write "self developed")?

Section II: Short-term Outcomes

For those sessions where participant outcome was evaluated: (If no sessions were evaluated, skip to section III)

 Was it with:
    • Pre and post-test
    • Post-test only
What was evaluated (check all that apply)?
    • Self-Esteem
    • Self-Efficacy
    • Future Expectations
    • Other

TABLE (for each type of activity, enter)
Type of Activity
    • Group
    • Individual
    • Other (specify)
Number of People Who Took Pre- Tests

Number of People Who Took Post- Tests

Number of People Who Took STANDARDIZED Pre- Tests

Number of People Who Took STANDARDIZED POST- Tests

Number of People with Increase in Score From Pre- to Post- Tests

1. If standardized tests are used, please list the name(s) of the test(s)?

Section III: Qualitative Impacts

1. Please describe how your work in self-esteem building has impacted on three sample clients. To fill out this section, you can draw from client evaluation responses, conversations with or observations of project clients, notes, or your experience with clients.



Module 12 - Cultural activities 
DATA ITEM
RESPONSE
Section I: Number of Individuals Served

Table 12-1: Demographic Characteristics of Individuals Served
Demographic Characteristics of Individuals Served
Table 12-2: Number of Individuals Served and Type of Activity
TABLE (for each type of activity, enter)
Type of Activity
    • Experimental/Group Workshop
    • Field Trip/Special Event 
    • Other (specify)
Total Number Served

Total Number of Events

Section II: Short-term Outcomes

For those activities where participant outcome was evaluated: (If no sessions were evaluated, skip to section III)

 Was it with
    • Pre and post-test
    • Post-test only
What was evaluated (check all that apply)?
    • Participant Knowledge of His/Her Culture
    • Participant Knowledge of Cultural Diversity
    • Other

TABLE (for each type of activity, enter)
Type of Activity
    • Group
    • Individual
    • Other (specify)
Number of People Who Took Pre- Tests

Number of People Who Took Post- Tests

Number of People Who Took STANDARDIZED Pre- Tests

Number of People Who Took STANDARDIZED POST- Tests

Number of People with Increase in Score From Pre- to Post- Tests

If standardized tests were used, please list the names of the test(s)

Section III: Qualitative Impacts

1. Please describe how your cultural activities have impacted on three sample clients. To fill out this section, you can draw from client evaluation responses, conversations with or observations of project clients, notes, or your experience with clients.



Module 13 - Recreational sports 
DATA ITEM
RESPONSE
Section I: Number of Individuals Served

Table 13-1: Demographic Characteristics of Individuals Served
Demographic Characteristics of Individuals Served
Total Number of Sessions Conducted by Type

Sports

Other Recreational

Section II: Short-term Outcomes

For those activities where participant outcome was evaluated: (If no sessions were evaluated, skip to section III)

 Was it with
    • Pre and post-test
    • Post-test only
What was evaluated (check all that apply)?
    • Self-Reported Involvement in Risk Behavior
    • Other
If Pre- and Post-Tests,
TABLE (for each type of activity, enter)
Type of Activity
    • Sports
    • Other Recreational
Number of People Who Took Pre- Tests

Number of People Who Took Post- Tests

Number of People Who Took STANDARDIZED Pre- Tests

Number of People Who Took STANDARDIZED POST- Tests

Number of People with Increase in Score From Pre- to Post- Tests

If standardized tests were used, please list the names of the test(s)



Module 14 - Crisis Intervention
DATA ITEM
RESPONSE
Section I: Number of Individuals Served

Table 14-1: Demographic Characteristics of Individuals Served
Demographic Characteristics of Individuals Served
Table 14-2: Number of Interventions
TABLE (for each type of intervention, enter)
Type of Intervention
    • Conflict Mediation 
    • Emergency Language Interpretation 
    • Housing (e.g., related to utilities, evictions) 
    • Legal 
    • Medical 
    • Other (please specify) 
    • Transportation  
Total Number of Interventions by Type

Average Number of Participants Per Intervention

Section II: Short Term Outcomes
TABLE (for each type of intervention, enter)
Type of Intervention
    • Conflict Mediation
    • Emergency Language Interpretation
    • Housing (e.g., related to utilities, evictions)
    • Legal
    • Medical
    • Other (please specify)
    • Transportation  
Number of Situations Resolved

Number of Situations Unresolved

Section III: Qualitative Impacts

1. Please describe how your work in crisis intervention has impacted on three sample clients. To fill out this section, you can draw from project client responses, conversations with or observations of clients, incident reports or notes, or your general experience with clients.



Module 15 - Conference planning and management 
DATA ITEM
RESPONSE


If you have more than one contract for this activity, a separate module should be filled out for each contract. Are you are filling out more than one Module 15?
Yes/No
IF YES: Which one is this?
1 2 3 4 5
If Other, please list number:

What is the role of conferences/meetings with respect to your OMH contract, cooperative agreement, or grant?

For your OMH project, were you supposed to conduct (check one):
    • One conference/meeting 
    • One conference/meeting and evaluation
    • More than one conference/meeting (number)
    • More than one conference/meeting and evaluations (number)
As your only task, or as part of other project activities? 
    • Only task 
    • Part of other activities
Please describe:

Section I: Number of Individuals Served and Sessions Conducted

Table 15-1: Number of Individuals Served and Demographics
Demographic Characteristics of Individuals Served
Table 15-2: Number Served by Type of Event
TABLE (for each type of event, enter)
Type of Event
    • Conference
    • Expert or other panel
    • Meeting
    • Other
Total Number Attending all Events

Section II: Additional Conferences/Meetings Information

Table 15-3: Conference/Meeting Chronology and Type of Event

1. Please complete the following table for all conferences/meetings conducted (as part of your OMH contract, cooperative agreement or grant) during this reporting period
TABLE (for each event, enter)
Duration in Days

Conference Name

Date

Target Population

Health Issues

Type of Event
    • Conference
    • Expert or other panel
    • Meeting
    • Other
Table 15-4: Number of Materials Developed/Disseminated (at Conferences/Meetings)
TABLE (for each material, enter)
Conference Name 
   

Date

Type of Material

Number Developed
    • Brochure/Pamphlet
    • Fact sheet
    • Meeting packet
    • Notebook
    • Other
Total Number Distributed

1. Conference/Meeting Purpose and Topics Please identify the primary purpose of each conference/meeting and list the major topics presented by event
TABLE (for each event, enter)
Conference Name
    • Present information/education 
    • Promote organizational linkages and networking
    • Planning and strategy 
    • Other
Primary Purpose

Topic

2. Conference/Meeting Collaborations 
Please complete the following table for the same events listed above. On this table, we are asking for information concerning partners or collaborators you may have had in conducting the conferences/meetings.
TABLE (for each event, enter)
Table 15-5: Conference/Meeting Collaborations
 
Conference Name

Collaboration?
Yes/No
Number of Partners

Type of Organizations
Select An Organization Type
Nature of Collaborations
    • Funding 
    • Materials 
    • Staff or volunteers 
    • Speakers/presenters 
    • Meeting space 
    • Meals 
    • Logistics assistance 
    • Other
Section III: Evaluation of Conferences/Meetings

1. Please complete the following table for the same events listed above. On this table, we are asking for information concerning evaluations you conducted for each conference/meeting
TABLE (for each event, enter)
Table 15-6: Evaluation

Conference Name

Evaluated?
Yes/No
Type of Evaluation
    • Satisfaction (with conference/meeting)
    • Knowledge or skill gain
    • Change in behavior or practices
    • Other (please specify)
Conduct Follow up?
Yes/No
Type of Follow up
    • Change in behavior or practices 
    • Knowledge or skill gain 
    • Other  
Follow up Method
    • Mail survey 
    • Other 
    • Telephone survey
Section IV: Qualitative Impacts

1. Please describe how your work in conference planning and management has impacted on three sample clients. To fill out this section, you can draw from client evaluation responses, feedback from event attendees, conversations with or observations of clients, notes, or your experience with clients.



Module 16 - Linkage-building/community coordination 
DATA ITEM
RESPONSE


Section I: Process Information

1. Were you involved with any partnerships or collaborating organizations as an essential part of your OMH project?
Yes/No
If Yes, please describe
TABLE (for each partnership, enter)
Name of Organization

Type of Agreement
    • Informal 
    • Formal Cooperative Agreement
    • Subcontract 
    • Other
Type of Organization
Select An Organization Type
Role in Grant Activity
    • referral source 
    • provide service 
    • co-sponsor programs/activities
    • planning and/or evaluation
    • other
Total Number of Meetings Conducted with that Organization

Total Number of Activities conducted with that Organization

Section II: Short-term Outcomes of Linkage-building and Community Coordination

1. How many NEW organizations have you formed linkages with over the past reporting period? Please list
TABLE (for each new linkage, enter)
Name of Organization

Type of Agreement
    • Informal 
    • Formal Cooperative Agreement 
    • Subcontract 
    • Other   
Type of Organization
Select type of organization
Role in Grant Activity
    • referral source 
    • provide service 
    • co-sponsor programs/activities
    • planning and/or evaluation
    • other
2. Did you form any new coalitions or collaborations in the past reporting period? Please list
TABLE (for each new coalition, enter)
Name of Organization

Type of Agreement
    • Informal 
    • Formal Cooperative Agreement 
    • Subcontract 
    • Other   
Type of Organization
Select type of organization
Role in Grant Activity
    • referral source 
    • provide service 
    • co-sponsor programs/activities
    • planning and/or evaluation
    • other
For those coalitions or collaborations you formed or participated in, how many times did they meet?

Were any of these collaborations part of ongoing task forces or committees?
Yes/No
If Yes, How many times did they meet?

Are there plans for this partnership to continue meeting?
Yes/No
If No, did the partnership complete its goals?
Yes/No
Section III: System Change Data

1. As a result of your work on linkage-building/community coordination, were any new polices or procedures implemented at the linked organizations?
Yes/No/N/A
If YES, please describe:

2. As a result of your work on linkage-building/community coordination, has the grantee or partner organization (or their staff) become part of a local/regional coalition, committee, or other policy-related body?
Yes/No
If Yes, please describe
TABLE (for each coalition, enter)
Name of Committee

Description of Task Force/Committee/Coalition

Types of Members

Other Information (IF APPLICABLE)



3. As a result of your work on linkage-building/community coordination did any local providers form task forces, committees, coalitions, or other groups in order to address health services provided to the target population(s)?
Yes/No
If YES, please describe
TABLE (for each task force, enter)
Name of Provider

Description of Task Force/Committee/Coalition

Types of Members

Other Information (IF APPLICABLE)

4. As a result of your work on linkage-building/community coordination, did any community organizations collaborate to increase services, obtain funds, or engage in other collaborative activities?
Yes/No/N/A
If YES, please describe

5. As a result of your work on linkage-building/community coordination, did the city, county or state initiate any changes in legislation or regulations regarding access to health care by your target community/ies?
Yes/No/N/A
If YES, please describe

6. As a result of your work on linkage-building/community coordination, did the city, county or state draft any policy statements or guidelines regarding access to health care by your target community/ies?
Yes/No/N/A
If YES, please describe:

Section IV: Qualitative Impacts

Please describe how your work in linkage building/community coordination has impacted on three sample clients (either individuals or organizations). To fill out this section you can draw from project client evaluation responses, conversations with or observations of clients, notes, or your general experience with clients

Module 17 – Technical assistance and organizational capacity building 
DATA ITEM
RESPONSE
Section I: Number of Individuals Served and Sessions Conducted

Table 17-1: Number of Individuals Served
Demographic Characteristics of Individuals Served
Table 17-2: Organizations Served and TA Provided
TABLE (for each organization, enter)
Name of Organization

Type of Organization
Select An Organization Type
New / Existing
    • Existing 
    • New
TA Provided
    • Staff received health issue training 
    • Staff received program skills training 
    • Staff received training in fundraising 
    • Staff received leadership training 
    • Staff received MIS training 
    • Staff received fiscal management training 
    • Recommendations for new policies 
    • Staffing 
    • Recommendations for new technology or systems 
    • Board development 
    • Strategic planning for internal improvement
    • Program planning and implementation
    • Evaluation 
    • Other
Target Population

Table 17-3: Number of Activities Conducted
TABLE (for each organization, enter)
Type of Activity (TA)
    • Staff received health issue training 
    • Staff received program skills training 
    • Staff received training in fundraising 
    • Staff received leadership training 
    • Staff received MIS training 
    • Staff received fiscal management training 
    • Recommendations for new policies 
    • New staff hired 
    • Recommendations for new technology or systems 
    • Board development 
    • Strategic planning for internal improvement
    • Planning 
    • Evaluation 
    • Other
Number of Times Activity Provided

Total Number Served

Section II: Short-Term Outcomes

1) As a result of your work on organizational capacity building: Were any new polices or procedures developed at client organizations?
Yes/No N/A
If YES, please describe

2. As a result of your work in this activity, were any new programs (e.g., HIV/AIDS education) implemented?
Yes/No
If YES, please describe

3. As a result of your work in this activity, were any new funding applications submitted (by client organizations)?
Yes/No N/A
If YES, please describe?
TABLE (for each funding source, enter)
Funding Source
    • Federal Government
    • State/Local Government
    • Private Foundation
    • Other
Number of Applications Submitted

Number of Applications Funded

4. As a result of your work in this activity, were any new technologies or systems implemented?
Yes/No N/A
If YES, please describe.

Section III: Qualitative Impacts

Please describe three case examples of how your work in technical assistance and organizational capacity building has impacted on different, sample organizations, noting their situation and capacity before and after your assistance. To fill out this section you can draw from project client evaluation responses, conversations with or observations of clients, notes, or your general experience with clients.



Module 18 - Resource coordination 
DATA ITEM
RESPONSE
Section I: Resources Provided to Organizations

Table 18-1: Resources Provided to Organizations
TABLE (for each activity, enter)
Organization Name

Organization Type
Select An Organization Type
Funding
Yes/No
Materials
Yes/No
Technology or Equipment
Yes/No
People
Yes/No
Other
Yes/No
1. Did you provide mini-grants to organizations as a project activity?
Yes/No
If Yes, please describe the recipient organization and the purpose of the grant in the space below.

2. Did you develop/maintain a Web site for the purpose of making information available to community organizations?
Yes/No
If Yes, please describe the Web site in the space below.



Module 19 – Planning and evaluation 
DATA ITEM
RESPONSE
Section I: Basic Information on Planning and Evaluation

1. Which of the following methodologies were employed in your planning and evaluation activities (check all that apply)?
    • Focus groups
    • Obtaining local health data
    • Meetings
    • Local/State reports
    • Interviews with key informants
    • Surveys
    • Newspaper/media review
    • Literature searches
    •  Other (Specify)
2. Did your planning and evaluation activities address specific health conditions?
Yes/No
If YES, which health conditions were addressed?

3. Did your planning and evaluation activities address specific populations?
Yes/No
If YES, which populations were addressed?

4. Which of the following areas were covered in your planning and evaluation activities? (Check all that apply)?
    • Barriers to accessing health care for target population 
    • Target population (health) behavior 
    • Cultural/linguistic training needs for area health provider/staff
    • Target population health status
    • Existence of culturally appropriate health education materials
    • Target population knowledge/awareness
    • Existence of culturally/linguistically competent health services
    • Other (Specify)
4. What were the main findings or results of your planning and evaluation activities? Please summarize, but include all key findings.

5.  Were data collected for planning purposes or to target resources?
Yes/No
If yes, please describe.

6.  Did you implement any changes in the data collection (such as collecting new kinds of data or enhancing data technology) to improve internal data systems?
Yes/No
If yes, please describe.

7. Does your project address gaps or problems identified through your planning and evaluation activities?  
Yes/No
If yes, please describe

8.  Did you evaluate efforts funded under your grant?
Yes/No
If yes, please describe.

8a.  Were your evaluation criteria related to goals or other targets in your strategic plan?
Yes/No
If yes, please describe.