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pdfIntroduction
Welcome to the State Program Interim Reporting System (SPIRS). This system is for the exclusive use of CDC's
Division of Nutrition, Physical Activity and Obesity (DNPAO) staff and state grantees.
SPIRS was designed to serve the following purposes:
-- Monitor the activities and progress of funded states in CDC’s Nutrition, Physical Activity, and Obesity Program;
and
-- Assist CDC in providing funded states with appropriate technical assistance that will lead to program
effectiveness and improvement.
This Report includes the following sections:
1) Staffing
2) Resources
3) Partners
4) Planning
Other
5) Health Disparities
6) Legislation
7) Policy
8) Environmental Change
9) Implementation
10) Other Accomplishments and Summary
11) Stories from the Field
This Report includes a short section asking you to provide one "Story from the Field". This story fulfills the FOA
requirement
Other
for your state to provide Success Stories.
This report will serve as the required final program report for each fiscal year. Only activities that occurred between
July 1, 2008 and June 30, 2009 should to be entered on this report (unless otherwise specified).
As you work through the items in this System, you may come across items for which the answer may be “no,” “in
progress,” or “not yet". If an item does not apply to your circumstances, please enter “NA” or “nothing to report”
into the relevant text box. Because some legislative, policy and environmental change interventions take years to
fully implement, you are encouraged to report progress made during the fiscal year covered by this report even if
the project is not yet completed.
If you have any questions while filling out this form, please feel free to contact your Project Officer or the
Evaluation Team ([email protected]).
We appreciate your cooperation in this endeavor, and we welcome any feedback on the reporting content and
format.
Form Approved
OMB No.: XXX-XXX
Expiration Date:
Public reporting burden of this collection of information is estimated to average XX hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600
Clifton Road NE, MS E-11, Atlanta, Georgia 30333; ATTN: PRA (XXX-XXX).
* 1. Please provide the following information for verification purposes:
Your Name:
State:
Staffing
Please complete the following for each staff member with FTE’s dedicated to this effort. Reporting on one staff
member at a time, complete the staff member’s position, staff type (permanent/interim), the date he/she started
working on the project, percent time dedicated to this effort, and the percent of that effort covered by cooperative
agreement funds.
Be sure to capture all FTE’s dedicated to this effort in the State Health Department (including contracts), even if
you included them in a previous Report. Please report all staff who worked at least 6 months during this reporting
cycle.
NOTE: you will be prompted to add additional FTE’s following this screen if applicable (max of 20).
1. Staff Name
Other
2. Position
j
k
l
m
n
Program Coordinator
j
k
l
m
n
Epidemiologist
j
k
l
m
n
Physical Activity Coordinator
j
k
l
m
n
Administrative Assistant
j
k
l
m
n
Nutrition Coordinator
j
k
l
m
n
Worksite Wellness Coordinator
j
k
l
m
n
Health Educator
j Evaluator
k
l
m
n
Other
j
k
l
m
n
Communications Coordinator
j
k
l
m
n
Other (please specify)
3. Staff Type
j
k
l
m
n
Permanent
j
k
l
m
n
Interim
j
k
l
m
n
Other (please specify)
4. Date Staff Started Working on Project (MM/DD/YYYY)
NOTE: Please list the date staff began working on cooperative agreement activities
even if they have worked in the health department longer.
5. Percent of time on project
(enter whole number without % symbol)
6. In the most recent reporting period, please indicate the percent of SALARY
covered by the cooperative agreement.
[Example: If a person is 50% on the project (item 5 above) and all of that money is
coming from the cooperative agreement you would enter 100 in this field]
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Staff #2
1. Staff Name
Other
2. Position
j
k
l
m
n
Program Coordinator
j
k
l
m
n
Epidemiologist
j
k
l
m
n
Physical Activity Coordinator
j
k
l
m
n
Administrative Assistant
j
k
l
m
n
Nutrition Coordinator
j
k
l
m
n
Worksite Wellness Coordinator
j
k
l
m
n
Health Educator
j Evaluator
k
l
m
n
Other
j
k
l
m
n
Communications Coordinator
j
k
l
m
n
Other (please specify)
3. Staff Type
j
k
l
m
n
Permanent
j
k
l
m
n
Interim
j
k
l
m
n
Other (please specify)
4. Date Staff Started Working on Project (MM/DD/YYYY)
NOTE: Please list the date staff began working on cooperative agreement activities
even if they have worked in the health department longer.
5. Percent of time on project
(enter whole number without % symbol)
6. In the most recent reporting period, please indicate the percent of SALARY
covered by the cooperative agreement.
[Example: If a person is 50% on the project (item 5 above) and all of that money is
coming from the cooperative agreement you would enter 100 in this field]
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Staff #3
1. Staff Name
Other
2. Position
j
k
l
m
n
Program Coordinator
j
k
l
m
n
Epidemiologist
j
k
l
m
n
Physical Activity Coordinator
j
k
l
m
n
Administrative Assistant
j
k
l
m
n
Nutrition Coordinator
j
k
l
m
n
Worksite Wellness Coordinator
j
k
l
m
n
Health Educator
j Evaluator
k
l
m
n
Other
j
k
l
m
n
Communications Coordinator
j
k
l
m
n
Other (please specify)
3. Staff Type
j
k
l
m
n
Permanent
j
k
l
m
n
Interim
j
k
l
m
n
Other (please specify)
4. Date Staff Started Working on Project (MM/DD/YYYY)
NOTE: Please list the date staff began working on cooperative agreement activities
even if they have worked in the health department longer.
5. Percent of time on project
(enter whole number without % symbol)
6. In the most recent reporting period, please indicate the percent of SALARY
covered by the cooperative agreement.
[Example: If a person is 50% on the project (item 5 above) and all of that money is
coming from the cooperative agreement you would enter 100 in this field]
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Staff #4
1. Staff Name
Other
2. Position
j
k
l
m
n
Program Coordinator
j
k
l
m
n
Epidemiologist
j
k
l
m
n
Physical Activity Coordinator
j
k
l
m
n
Administrative Assistant
j
k
l
m
n
Nutrition Coordinator
j
k
l
m
n
Worksite Wellness Coordinator
j
k
l
m
n
Health Educator
j Evaluator
k
l
m
n
Other
j
k
l
m
n
Communications Coordinator
j
k
l
m
n
Other (please specify)
3. Staff Type
j
k
l
m
n
Permanent
j
k
l
m
n
Interim
j
k
l
m
n
Other (please specify)
4. Date Staff Started Working on Project (MM/DD/YYYY)
NOTE: Please list the date staff began working on cooperative agreement activities
even if they have worked in the health department longer.
5. Percent of time on project
(enter whole number without % symbol)
6. In the most recent reporting period, please indicate the percent of SALARY
covered by the cooperative agreement.
[Example: If a person is 50% on the project (item 5 above) and all of that money is
coming from the cooperative agreement you would enter 100 in this field]
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Staff #5
1. Staff Name
Other
2. Position
j
k
l
m
n
Program Coordinator
j
k
l
m
n
Epidemiologist
j
k
l
m
n
Physical Activity Coordinator
j
k
l
m
n
Administrative Assistant
j
k
l
m
n
Nutrition Coordinator
j
k
l
m
n
Worksite Wellness Coordinator
j
k
l
m
n
Health Educator
j Evaluator
k
l
m
n
Other
j
k
l
m
n
Communications Coordinator
j
k
l
m
n
Other (please specify)
3. Staff Type
j
k
l
m
n
Permanent
j
k
l
m
n
Interim
j
k
l
m
n
Other (please specify)
4. Date Staff Started Working on Project (MM/DD/YYYY)
NOTE: Please list the date staff began working on cooperative agreement activities
even if they have worked in the health department longer.
5. Percent of time on project
(enter whole number without % symbol)
6. In the most recent reporting period, please indicate the percent of SALARY
covered by the cooperative agreement.
[Example: If a person is 50% on the project (item 5 above) and all of that money is
coming from the cooperative agreement you would enter 100 in this field]
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Staff #6
1. Staff Name
Other
2. Position
j
k
l
m
n
Program Coordinator
j
k
l
m
n
Epidemiologist
j
k
l
m
n
Physical Activity Coordinator
j
k
l
m
n
Administrative Assistant
j
k
l
m
n
Nutrition Coordinator
j
k
l
m
n
Worksite Wellness Coordinator
j
k
l
m
n
Health Educator
j Evaluator
k
l
m
n
Other
j
k
l
m
n
Communications Coordinator
j
k
l
m
n
Other (please specify)
3. Staff Type
j
k
l
m
n
Permanent
j
k
l
m
n
Interim
j
k
l
m
n
Other (please specify)
4. Date Staff Started Working on Project (MM/DD/YYYY)
NOTE: Please list the date staff began working on cooperative agreement activities
even if they have worked in the health department longer.
5. Percent of time on project
(enter whole number without % symbol)
6. In the most recent reporting period, please indicate the percent of SALARY
covered by the cooperative agreement.
[Example: If a person is 50% on the project (item 5 above) and all of that money is
coming from the cooperative agreement you would enter 100 in this field]
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Staff #7
1. Staff Name
Other
2. Position
j
k
l
m
n
Program Coordinator
j
k
l
m
n
Epidemiologist
j
k
l
m
n
Physical Activity Coordinator
j
k
l
m
n
Administrative Assistant
j
k
l
m
n
Nutrition Coordinator
j
k
l
m
n
Worksite Wellness Coordinator
j
k
l
m
n
Health Educator
j Evaluator
k
l
m
n
Other
j
k
l
m
n
Communications Coordinator
j
k
l
m
n
Other (please specify)
3. Staff Type
j
k
l
m
n
Permanent
j
k
l
m
n
Interim
j
k
l
m
n
Other (please specify)
4. Date Staff Started Working on Project (MM/DD/YYYY)
NOTE: Please list the date staff began working on cooperative agreement activities
even if they have worked in the health department longer.
5. Percent of time on project
(enter whole number without % symbol)
6. In the most recent reporting period, please indicate the percent of SALARY
covered by the cooperative agreement.
[Example: If a person is 50% on the project (item 5 above) and all of that money is
coming from the cooperative agreement you would enter 100 in this field]
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Staff #8
1. Staff Name
Other
2. Position
j
k
l
m
n
Program Coordinator
j
k
l
m
n
Epidemiologist
j
k
l
m
n
Physical Activity Coordinator
j
k
l
m
n
Administrative Assistant
j
k
l
m
n
Nutrition Coordinator
j
k
l
m
n
Worksite Wellness Coordinator
j
k
l
m
n
Health Educator
j Evaluator
k
l
m
n
Other
j
k
l
m
n
Communications Coordinator
j
k
l
m
n
Other (please specify)
3. Staff Type
j
k
l
m
n
Permanent
j
k
l
m
n
Interim
j
k
l
m
n
Other (please specify)
4. Date Staff Started Working on Project (MM/DD/YYYY)
NOTE: Please list the date staff began working on cooperative agreement activities
even if they have worked in the health department longer.
5. Percent of time on project
(enter whole number without % symbol)
6. In the most recent reporting period, please indicate the percent of SALARY
covered by the cooperative agreement.
[Example: If a person is 50% on the project (item 5 above) and all of that money is
coming from the cooperative agreement you would enter 100 in this field]
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Staff #9
1. Staff Name
Other
2. Position
j
k
l
m
n
Program Coordinator
j
k
l
m
n
Epidemiologist
j
k
l
m
n
Physical Activity Coordinator
j
k
l
m
n
Administrative Assistant
j
k
l
m
n
Nutrition Coordinator
j
k
l
m
n
Worksite Wellness Coordinator
j
k
l
m
n
Health Educator
j Evaluator
k
l
m
n
Other
j
k
l
m
n
Communications Coordinator
j
k
l
m
n
Other (please specify)
3. Staff Type
j
k
l
m
n
Permanent
j
k
l
m
n
Interim
j
k
l
m
n
Other (please specify)
4. Date Staff Started Working on Project (MM/DD/YYYY)
NOTE: Please list the date staff began working on cooperative agreement activities
even if they have worked in the health department longer.
5. Percent of time on project
(enter whole number without % symbol)
6. In the most recent reporting period, please indicate the percent of SALARY
covered by the cooperative agreement.
[Example: If a person is 50% on the project (item 5 above) and all of that money is
coming from the cooperative agreement you would enter 100 in this field]
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Staff #10
1. Staff Name
Other
2. Position
j
k
l
m
n
Program Coordinator
j
k
l
m
n
Epidemiologist
j
k
l
m
n
Physical Activity Coordinator
j
k
l
m
n
Administrative Assistant
j
k
l
m
n
Nutrition Coordinator
j
k
l
m
n
Worksite Wellness Coordinator
j
k
l
m
n
Health Educator
j Evaluator
k
l
m
n
Other
j
k
l
m
n
Communications Coordinator
j
k
l
m
n
Other (please specify)
3. Staff Type
j
k
l
m
n
Permanent
j
k
l
m
n
Interim
j
k
l
m
n
Other (please specify)
4. Date Staff Started Working on Project (MM/DD/YYYY)
NOTE: Please list the date staff began working on cooperative agreement activities
even if they have worked in the health department longer.
5. Percent of time on project
(enter whole number without % symbol)
6. In the most recent reporting period, please indicate the percent of SALARY
covered by the cooperative agreement.
[Example: If a person is 50% on the project (item 5 above) and all of that money is
coming from the cooperative agreement you would enter 100 in this field]
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Staff #11
1. Staff Name
Other
2. Position
j
k
l
m
n
Program Coordinator
j
k
l
m
n
Epidemiologist
j
k
l
m
n
Physical Activity Coordinator
j
k
l
m
n
Administrative Assistant
j
k
l
m
n
Nutrition Coordinator
j
k
l
m
n
Worksite Wellness Coordinator
j
k
l
m
n
Health Educator
j Evaluator
k
l
m
n
Other
j
k
l
m
n
Communications Coordinator
j
k
l
m
n
Other (please specify)
3. Staff Type
j
k
l
m
n
Permanent
j
k
l
m
n
Interim
j
k
l
m
n
Other (please specify)
4. Date Staff Started Working on Project (MM/DD/YYYY)
NOTE: Please list the date staff began working on cooperative agreement activities
even if they have worked in the health department longer.
5. Percent of time on project
(enter whole number without % symbol)
6. In the most recent reporting period, please indicate the percent of SALARY
covered by the cooperative agreement.
[Example: If a person is 50% on the project (item 5 above) and all of that money is
coming from the cooperative agreement you would enter 100 in this field]
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Staff #12
1. Staff Name
Other
2. Position
j
k
l
m
n
Program Coordinator
j
k
l
m
n
Epidemiologist
j
k
l
m
n
Physical Activity Coordinator
j
k
l
m
n
Administrative Assistant
j
k
l
m
n
Nutrition Coordinator
j
k
l
m
n
Worksite Wellness Coordinator
j
k
l
m
n
Health Educator
j Evaluator
k
l
m
n
Other
j
k
l
m
n
Communications Coordinator
j
k
l
m
n
Other (please specify)
3. Staff Type
j
k
l
m
n
Permanent
j
k
l
m
n
Interim
j
k
l
m
n
Other (please specify)
4. Date Staff Started Working on Project (MM/DD/YYYY)
NOTE: Please list the date staff began working on cooperative agreement activities
even if they have worked in the health department longer.
5. Percent of time on project
(enter whole number without % symbol)
6. In the most recent reporting period, please indicate the percent of SALARY
covered by the cooperative agreement.
[Example: If a person is 50% on the project (item 5 above) and all of that money is
coming from the cooperative agreement you would enter 100 in this field]
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Staff #13
1. Staff Name
Other
2. Position
j
k
l
m
n
Program Coordinator
j
k
l
m
n
Epidemiologist
j
k
l
m
n
Physical Activity Coordinator
j
k
l
m
n
Administrative Assistant
j
k
l
m
n
Nutrition Coordinator
j
k
l
m
n
Worksite Wellness Coordinator
j
k
l
m
n
Health Educator
j Evaluator
k
l
m
n
Other
j
k
l
m
n
Communications Coordinator
j
k
l
m
n
Other (please specify)
3. Staff Type
j
k
l
m
n
Permanent
j
k
l
m
n
Interim
j
k
l
m
n
Other (please specify)
4. Date Staff Started Working on Project (MM/DD/YYYY)
NOTE: Please list the date staff began working on cooperative agreement activities
even if they have worked in the health department longer.
5. Percent of time on project
(enter whole number without % symbol)
6. In the most recent reporting period, please indicate the percent of SALARY
covered by the cooperative agreement.
[Example: If a person is 50% on the project (item 5 above) and all of that money is
coming from the cooperative agreement you would enter 100 in this field]
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Staff #14
1. Staff Name
Other
2. Position
j
k
l
m
n
Program Coordinator
j
k
l
m
n
Epidemiologist
j
k
l
m
n
Physical Activity Coordinator
j
k
l
m
n
Administrative Assistant
j
k
l
m
n
Nutrition Coordinator
j
k
l
m
n
Worksite Wellness Coordinator
j
k
l
m
n
Health Educator
j Evaluator
k
l
m
n
Other
j
k
l
m
n
Communications Coordinator
j
k
l
m
n
Other (please specify)
3. Staff Type
j
k
l
m
n
Permanent
j
k
l
m
n
Interim
j
k
l
m
n
Other (please specify)
4. Date Staff Started Working on Project (MM/DD/YYYY)
NOTE: Please list the date staff began working on cooperative agreement activities
even if they have worked in the health department longer.
5. Percent of time on project
(enter whole number without % symbol)
6. In the most recent reporting period, please indicate the percent of SALARY
covered by the cooperative agreement.
[Example: If a person is 50% on the project (item 5 above) and all of that money is
coming from the cooperative agreement you would enter 100 in this field]
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Staff #15
1. Staff Name
Other
2. Position
j
k
l
m
n
Program Coordinator
j
k
l
m
n
Epidemiologist
j
k
l
m
n
Physical Activity Coordinator
j
k
l
m
n
Administrative Assistant
j
k
l
m
n
Nutrition Coordinator
j
k
l
m
n
Worksite Wellness Coordinator
j
k
l
m
n
Health Educator
j Evaluator
k
l
m
n
Other
j
k
l
m
n
Communications Coordinator
j
k
l
m
n
Other (please specify)
3. Staff Type
j
k
l
m
n
Permanent
j
k
l
m
n
Interim
j
k
l
m
n
Other (please specify)
4. Date Staff Started Working on Project (MM/DD/YYYY)
NOTE: Please list the date staff began working on cooperative agreement activities
even if they have worked in the health department longer.
5. Percent of time on project
(enter whole number without % symbol)
6. In the most recent reporting period, please indicate the percent of SALARY
covered by the cooperative agreement.
[Example: If a person is 50% on the project (item 5 above) and all of that money is
coming from the cooperative agreement you would enter 100 in this field]
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Staff #16
1. Staff Name
2. Position
j
k
l
m
n
Program Coordinator
Other
j Physical Activity Coordinator
k
l
m
n
j
k
l
m
n
Epidemiologist
j
k
l
m
n
Administrative Assistant
j
k
l
m
n
Nutrition Coordinator
j
k
l
m
n
Worksite Wellness Coordinator
j
k
l
m
n
Evaluator
j
k
l
m
n
Health Educator
j
k
l
m
n
Communications Coordinator
j
k
l
m
n
Other (please specify)
3. Staff Type
j
k
l
m
n
Permanent
j
k
l
m
n
Interim
j
k
l
m
n
Other (please specify)
4. Date Staff Started Working on Project (MM/DD/YYYY)
NOTE: Please list the date staff began working on cooperative agreement activities
even if they have worked in the health department longer.
5. Percent of time on project
(enter whole number without % symbol)
6. In the most recent reporting period, please indicate the percent of SALARY
covered by the cooperative agreement.
[Example: If a person is 50% on the project (item 5 above) and all of that money is
coming from the cooperative agreement you would enter 100 in this field]
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Staff #17
1. Staff Name
2. Position
j
k
l
m
n
Program Coordinator
j
k
l
m
n
Epidemiologist
j
k
l
m
n
Physical Activity Coordinator
j
k
l
m
n
Administrative Assistant
j
k
l
m
n
Nutrition Coordinator
j
k
l
m
n
Worksite Wellness Coordinator
j
k
l
m
n
Evaluator
j
k
l
m
n
Health Educator
j
k
l
m
n
Communications Coordinator
j
k
l
m
n
Other (please specify)
3. Staff Type
j
k
l
m
n
Permanent
j
k
l
m
n
Interim
j
k
l
m
n
Other (please specify)
4. Date Staff Started Working on Project (MM/DD/YYYY)
NOTE: Please list the date staff began working on cooperative agreement activities
even if they have worked in the health department longer.
5. Percent of time on project
(enter whole number without % symbol)
6. In the most recent reporting period, please indicate the percent of SALARY
covered by the cooperative agreement.
[Example: If a person is 50% on the project (item 5 above) and all of that money is
coming from the cooperative agreement you would enter 100 in this field]
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Staff #18
1. Staff Name
2. Position
j
k
l
m
n
Program Coordinator
j
k
l
m
n
Epidemiologist
j
k
l
m
n
Physical Activity Coordinator
j
k
l
m
n
Administrative Assistant
j
k
l
m
n
Nutrition Coordinator
j
k
l
m
n
Worksite Wellness Coordinator
j
k
l
m
n
Evaluator
j
k
l
m
n
Health Educator
j
k
l
m
n
Communications Coordinator
j
k
l
m
n
Other (please specify)
3. Staff Type
j
k
l
m
n
Permanent
j
k
l
m
n
Interim
j
k
l
m
n
Other (please specify)
4. Date Staff Started Working on Project (MM/DD/YYYY)
NOTE: Please list the date staff began working on cooperative agreement activities
even if they have worked in the health department longer.
Other
5. Percent of time on project
(enter whole number without % symbol)
6. In the most recent reporting period, please indicate the percent of SALARY
covered by the cooperative agreement.
[Example: If a person is 50% on the project (item 5 above) and all of that money is
coming from the cooperative agreement you would enter 100 in this field]
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Staff #19
1. Staff Name
2. Position
j
k
l
m
n
Program Coordinator
j
k
l
m
n
Epidemiologist
j
k
l
m
n
Physical Activity Coordinator
j
k
l
m
n
Administrative Assistant
j
k
l
m
n
Nutrition Coordinator
j
k
l
m
n
Worksite Wellness Coordinator
j
k
l
m
n
Evaluator
j
k
l
m
n
Health Educator
j
k
l
m
n
Communications Coordinator
j
k
l
m
n
Other (please specify)
3. Staff Type
j
k
l
m
n
Permanent
j
k
l
m
n
Interim
j
k
l
m
n
Other (please specify)
4. Date Staff Started Working on Project (MM/DD/YYYY)
NOTE: Please list the date staff began working on cooperative agreement activities
even if they have worked in the health department longer.
5. Percent of time on project
(enter whole number without % symbol)
6. In the most recent reporting period, please indicate the percent of SALARY
covered by the cooperative agreement.
[Example: If a person is 50% on the project (item 5 above) and all of that money is
coming from the cooperative agreement you would enter 100 in this field]
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Staff #20
1. Staff Name
2. Position
j
k
l
m
n
Program Coordinator
j
k
l
m
n
Epidemiologist
j
k
l
m
n
Physical Activity Coordinator
j
k
l
m
n
Administrative Assistant
j
k
l
m
n
Nutrition Coordinator
j
k
l
m
n
Worksite Wellness Coordinator
j
k
l
m
n
Evaluator
j
k
l
m
n
Health Educator
j
k
l
m
n
Communications Coordinator
j
k
l
m
n
Other (please specify)
3. Staff Type
j
k
l
m
n
Permanent
j
k
l
m
n
Interim
j
k
l
m
n
Other (please specify)
4. Date Staff Started Working on Project (MM/DD/YYYY)
NOTE: Please list the date staff began working on cooperative agreement activities
even if they have worked in the health department longer.
5. Percent of time on project
(enter whole number without % symbol)
6. In the most recent reporting period, please indicate the percent of SALARY
covered by the cooperative agreement.
[Example: If a person is 50% on the project (item 5 above) and all of that money is
coming from the cooperative agreement you would enter 100 in this field]
7. Do you have additional staff to report?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, how many? You will not be able to provide information about them.
Resources
Please report specific details about each source of funding outside DNPAO Cooperative Agreement funds that was
used to support the implementation of the cooperative agreement.
Only report funds from the last 12 months. If a funding source is ongoing, list only the funds received during the
current reporting cycle.
1. Please select all sources of funding outside this DNPAO Cooperative Agreement
that have been leveraged in the most recent reporting period for the state nutrition
and physical activity program or the accomplishment of the state plan.
c
d
e
f
g
No funding outside DNPAO
c
d
e
f
g
Foundation Grants
c
d
e
f
g
Other Federal Programs
c
d
e
f
g
Contributions from private businesses
c
d
e
f
g
State Programs
c
d
e
f
g
Other (please specify)
2. For FEDERAL PROGRAMS, please provide the name of each funder and the
approximate amount.
Name of 1st Federal Program Providing Funding
Amount
Name of 2nd Federal Program Providing Funding
Amount
Name of 3rd Federal Program Providing Funding
Amount
3. For STATE PROGRAMS, please provide the name of each funder and the
approximate amount.
Name of 1st State Program Providing Funding
Amount
Name of 2nd State Program Providing Funding
Amount
Name of 3rd State Program Providing Funding
Amount
4. For FOUNDATION FUNDS, please provide the name of each funder and the
approximate amount.
Name of 1st Foundation Providing Funding
Amount
Name of 2nd Foundation Providing Funding
Amount
Name of 3rd Foundation Providing Funding
Amount
5. For CONTRIBUTIONS FROM PRIVATE BUSINESS, please provide the name of each
funder and the approximate amount.
Name of 1st Business Providing Funding
Amount
Name of 2nd Business Providing Funding
Amount
Name of 3rd Business Providing Funding
Amount
6. For OTHER FUNDS, please provide the name of each funder, approximate amount,
and the purpose of funding.
Name of 1st Entity Providing Funding
Amount
Purpose
Name of 2nd Entity Providing Funding
Amount
Purpose
Name of 3rd Entity Providing Funding
Amount
Purpose
Collaboration
These items deal with collaboration between your state program and other organizations, agencies and individuals.
You will also have the opportunity to highlight a specific accomplishment of your state program in more depth in the
Stories from the Field section.
1. Please give at least one example of a successful collaboration with an internal
partner (e.g. within state health department) during the past year in the
development, use and/or implementation of the state plan.
2. Please give at least one example of a successful collaboration with an EXTERNAL
partner (e.g. partners other than state health department) in the development, use
and/or implementation of the state plan.
3. Do you have one or more "champion" organizations external to the state health
department that helped move the obesity prevention and control program forward?
j
k
l
m
n
Yes
j
k
l
m
n
No
4. Please list the "champion" organization(s) and describe their actions taken on
behalf of the state program.
Planning
1. Has a state plan for nutrition and physical activity been produced during the past
twelve months?
(Check all that apply)
c
d
e
f
g
Not Yet
c
d
e
f
g
Draft in progress
c
d
e
f
g
Draft undergoing CDC review
c
d
e
f
g
State plan in effect
c
d
e
f
g
Revising existing plan
Comments:
Health Disparities
1. In which way(s) does your state program and/or state plan include efforts to
address health disparities?
c
d
e
f
g
Surveillance activities underway to identify specific NPAO-related disparities within your state
c
d
e
f
g
Planning process(es) underway to develop/identify interventions to address identified disparities
c
d
e
f
g
Interventions (including policy, environmental changes and/or legislation) currently in place to address identified disparities
c
d
e
f
g
Other (please specify)
Legislation
1. Were any legislative acts or local ordinances affecting overweight/obesity (e.g.
nutrition, physical activity, TV viewing) initiated or enacted in the past 12 months?
[NOTE: A legislative act is defined as a formal legal action taken by local or state
government. Examples include line items in the state budget related to obesity, bills
supporting breastfeeding, etc.]
j
k
l
m
n
No
j
k
l
m
n
Yes
If YES, how many?
2. The next couple of questions will be asked of each legislative act or local ordinance
initiated or modified in the past 12 months, one at a time.
NOTE: you will be prompted to add additional pieces of legislation following this
screen if applicable (max of 10).
Please briefly describe the legislative act or local ordinance:
Name
Senate or House Number
(if applicable)
3. Describe:
4. Was this legislation or local ordinance INITIATED locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
5. Was this legislation or local ordinance ENACTED in your state?
j
k
l
m
n
No
j
k
l
m
n
Yes
If YES, provide the date enacted
6. Was this legislation designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
7. Do you have additional legislation or local ordinances to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Legislation #2
1. The next couple of questions will be asked of each legislative act or local ordinance
initiated or modified in the past 12 months, one at a time.
NOTE: you will be prompted to add additional pieces of legislation following this
screen if applicable (max of 10).
Please briefly describe the legislative act or local ordinance:
Name
Senate or House Number
(if applicable)
2. Describe:
3. Was this legislation or local ordinance INITIATED locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
4. Was this legislation or local ordinance ENACTED in your state?
j
k
l
m
n
No
j
k
l
m
n
Yes
If YES, provide the date enacted
5. Was this legislation designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
6. Do you have additional legislation or local ordinances to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Legislation #3
1. The next couple of questions will be asked of each legislative act or local ordinance
initiated or modified in the past 12 months, one at a time.
NOTE: you will be prompted to add additional pieces of legislation following this
screen if applicable (max of 10).
Please briefly describe the legislative act or local ordinance:
Name
Senate or House Number
(if applicable)
2. Describe:
3. Was this legislation or local ordinance INITIATED locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
4. Was this legislation or local ordinance ENACTED in your state?
j
k
l
m
n
No
j
k
l
m
n
Yes
If YES, provide the date enacted
5. Was this legislation designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
6. Do you have additional legislation or local ordinances to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Legislation #4
1. The next couple of questions will be asked of each legislative act or local ordinance
initiated or modified in the past 12 months, one at a time.
NOTE: you will be prompted to add additional pieces of legislation following this
screen if applicable (max of 10).
Please briefly describe the legislative act or local ordinance:
Name
Senate or House Number
(if applicable)
2. Describe:
3. Was this legislation or local ordinance INITIATED locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
4. Was this legislation or local ordinance ENACTED in your state?
j
k
l
m
n
No
j
k
l
m
n
Yes
If YES, provide the date enacted
5. Was this legislation designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
6. Do you have additional legislation or local ordinances to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Legislation #5
1. The next couple of questions will be asked of each legislative act or local ordinance
initiated or modified in the past 12 months, one at a time.
NOTE: you will be prompted to add additional pieces of legislation following this
screen if applicable (max of 10).
Please briefly describe the legislative act or local ordinance:
Name
Senate or House Number
(if applicable)
2. Describe:
3. Was this legislation or local ordinance INITIATED locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
4. Was this legislation or local ordinance ENACTED in your state?
j
k
l
m
n
No
j
k
l
m
n
Yes
If YES, provide the date enacted
5. Was this legislation designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
6. Do you have additional legislation or local ordinances to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Legislation #6
1. The next couple of questions will be asked of each legislative act or local ordinance
initiated or modified in the past 12 months, one at a time.
NOTE: you will be prompted to add additional pieces of legislation following this
screen if applicable (max of 10).
Please briefly describe the legislative act or local ordinance:
Name
Senate or House Number
(if applicable)
2. Describe:
3. Was this legislation or local ordinance INITIATED locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
4. Was this legislation or local ordinance ENACTED in your state?
j
k
l
m
n
No
j
k
l
m
n
Yes
If YES, provide the date enacted
5. Was this legislation designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
6. Do you have additional legislation or local ordinances to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Legislation #7
1. The next couple of questions will be asked of each legislative act or local ordinance
initiated or modified in the past 12 months, one at a time.
NOTE: you will be prompted to add additional pieces of legislation following this
screen if applicable (max of 10).
Please briefly describe the legislative act or local ordinance:
Name
Senate or House Number
(if applicable)
2. Describe:
3. Was this legislation or local ordinance INITIATED locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
4. Was this legislation or local ordinance ENACTED in your state?
j
k
l
m
n
No
j
k
l
m
n
Yes
If YES, provide the date enacted
5. Was this legislation designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
6. Do you have additional legislation or local ordinances to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Legislation #8
1. The next couple of questions will be asked of each legislative act or local ordinance
initiated or modified in the past 12 months, one at a time.
NOTE: you will be prompted to add additional pieces of legislation following this
screen if applicable (max of 10).
Please briefly describe the legislative act or local ordinance:
Name
Senate or House Number
(if applicable)
2. Describe:
3. Was this legislation or local ordinance INITIATED locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
4. Was this legislation or local ordinance ENACTED in your state?
j
k
l
m
n
No
j
k
l
m
n
Yes
If YES, provide the date enacted
5. Was this legislation designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
6. Do you have additional legislation or local ordinances to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Legislation #9
1. The next couple of questions will be asked of each legislative act or local ordinance
initiated or modified in the past 12 months, one at a time.
NOTE: you will be prompted to add additional pieces of legislation following this
screen if applicable (max of 10).
Please briefly describe the legislative act or local ordinance:
Name
Senate or House Number
(if applicable)
2. Describe:
3. Was this legislation or local ordinance INITIATED locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
4. Was this legislation or local ordinance ENACTED in your state?
j
k
l
m
n
No
j
k
l
m
n
Yes
If YES, provide the date enacted
5. Was this legislation designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
6. Do you have additional legislation or local ordinances to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Legislation #10
1. The next couple of questions will be asked of each legislative act or local ordinance
initiated or modified in the past 12 months, one at a time.
NOTE: you will be prompted to add additional pieces of legislation following this
screen if applicable (max of 10).
Please briefly describe the legislative act or local ordinance:
Name
Senate or House Number
(if applicable)
2. Describe:
3. Was this legislation or local ordinance INITIATED locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
4. Was this legislation or local ordinance ENACTED in your state?
j
k
l
m
n
No
j
k
l
m
n
Yes
If YES, provide the date enacted
5. Was this legislation designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
6. Do you have additional legislation or local ordinances to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
If Yes, how many? You will not be able to provide additional information about them.
Policy
1. Were there any policy changes affecting overweight/obesity (e.g. nutrition,
physical activity, TV viewing, breastfeeding) initiated or enacted in your state in the
past 12 months?
Please DO NOT include school wellness policies.
Legislative acts or local ordinances should NOT be reported in this section.
[NOTE: a policy is defined as those regulations, formal, and informal rules and
understandings that are adopted on a collective basis to guide individual and
collective behavior]
c
d
e
f
g
Not during this reporting period
c
d
e
f
g
Yes
If Yes, How Many
2. The next questions will be asked regarding each policy affecting
overweight/obesity that was initiated or enacted in the last 12 months. Please
briefly describe each policy one at a time.
NOTE: you will be prompted to add additional policies following this screen if
applicable (max of 10).
Name of Policy:
3. Was this policy initiated locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
4. Describe the policy:
5. Was this policy designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
6. Do you have another policy intervention to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Policy #2
1. The next questions will be asked regarding each policy affecting
overweight/obesity that was initiated or enacted in the last 12 months. Please
briefly describe each policy one at a time.
NOTE: you will be prompted to add additional policies following this screen if
applicable (max of 10).
Name of Policy:
2. Was this policy initiated locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
3. Describe the policy:
4. Was this policy designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
5. Do you have another policy intervention to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Policy #3
1. The next questions will be asked regarding each policy affecting
overweight/obesity that was initiated or enacted in the last 12 months. Please
briefly describe each policy one at a time.
NOTE: you will be prompted to add additional policies following this screen if
applicable (max of 10).
Name of Policy:
2. Was this policy initiated locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
3. Describe the policy:
4. Was this policy designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
5. Do you have another policy intervention to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Policy #4
1. The next questions will be asked regarding each policy affecting
overweight/obesity that was initiated or enacted in the last 12 months. Please
briefly describe each policy one at a time.
NOTE: you will be prompted to add additional policies following this screen if
applicable (max of 10).
Name of Policy:
2. Was this policy initiated locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
3. Describe the policy:
4. Was this policy designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
5. Do you have another policy intervention to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Policy #5
1. The next questions will be asked regarding each policy affecting
overweight/obesity that was initiated or enacted in the last 12 months. Please
briefly describe each policy one at a time.
NOTE: you will be prompted to add additional policies following this screen if
applicable (max of 10).
Name of Policy:
2. Was this policy initiated locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
3. Describe the policy:
4. Was this policy designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
5. Do you have another policy intervention to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Policy #6
1. The next questions will be asked regarding each policy affecting
overweight/obesity that was initiated or enacted in the last 12 months. Please
briefly describe each policy one at a time.
NOTE: you will be prompted to add additional policies following this screen if
applicable (max of 10).
Name of Policy:
2. Was this policy initiated locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
3. Describe the policy:
4. Was this policy designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
5. Do you have another policy intervention to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Policy #7
1. The next questions will be asked regarding each policy affecting
overweight/obesity that was initiated or enacted in the last 12 months. Please
briefly describe each policy one at a time.
NOTE: you will be prompted to add additional policies following this screen if
applicable (max of 10).
Name of Policy:
2. Was this policy initiated locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
3. Describe the policy:
4. Was this policy designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
5. Do you have another policy intervention to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Policy #8
1. The next questions will be asked regarding each policy affecting
overweight/obesity that was initiated or enacted in the last 12 months. Please
briefly describe each policy one at a time.
NOTE: you will be prompted to add additional policies following this screen if
applicable (max of 10).
Name of Policy:
2. Was this policy initiated locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
3. Describe the policy:
4. Was this policy designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
5. Do you have another policy intervention to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Policy #9
1. The next questions will be asked regarding each policy affecting
overweight/obesity that was initiated or enacted in the last 12 months. Please
briefly describe each policy one at a time.
NOTE: you will be prompted to add additional policies following this screen if
applicable (max of 10).
Name of Policy:
2. Was this policy initiated locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
3. Describe the policy:
4. Was this policy designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
5. Do you have another policy intervention to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Policy #10
1. The next questions will be asked regarding each policy affecting
overweight/obesity that was initiated or enacted in the last 12 months. Please
briefly describe each policy one at a time.
NOTE: you will be prompted to add additional policies following this screen if
applicable (max of 10).
Name of Policy:
2. Was this policy initiated locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
3. Describe the policy:
4. Was this policy designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
5. Do you have another policy intervention to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
If Yes, how many? You will not be able to provide additional information about them.
Environmental Changes
1. Did your state implement any environmental changes (environmental
interventions that alter or control the legal, social, economic, and physical
environment) affecting overweight/obesity (e.g. nutrition, physical activity, TV
watching, breastfeeding)?
[Examples include Rails to Trails programs, the closing of a dangerous street located
near a school property, zoning/planning for parks]
Legislative acts and local ordinances should NOT be reported in this section
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, how many?
2. The next questions will be asked regarding each environmental change affecting
overweight/obesity. Please briefly describe each change one at a time.
NOTE: you will be prompted to add additional environmental changes following this
screen if applicable (max of 10).
Name of Environmental Change:
3. Was this environmental change initiated locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
4. Describe
5. Was this environmental change designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
6. Do you have another environmental change to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Environmental Changes #2
1. The next questions will be asked regarding each environmental change affecting
overweight/obesity. Please briefly describe each change one at a time.
NOTE: you will be prompted to add additional environmental changes following this
screen if applicable (max of 10).
Name of Environmental Change:
2. Was this environmental change initiated locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
3. Describe
4. Was this environmental change designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
5. Do you have another environmental change to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Environmental Changes #3
1. The next questions will be asked regarding each environmental change affecting
overweight/obesity. Please briefly describe each change one at a time.
NOTE: you will be prompted to add additional environmental changes following this
screen if applicable (max of 10).
Name of Environmental Change:
2. Was this environmental change initiated locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
3. Describe
4. Was this environmental change designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
5. Do you have another environmental change to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Environmental Changes #4
1. The next questions will be asked regarding each environmental change affecting
overweight/obesity. Please briefly describe each change one at a time.
NOTE: you will be prompted to add additional environmental changes following this
screen if applicable (max of 10).
Name of Environmental Change:
2. Was this environmental change initiated locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
3. Describe
4. Was this environmental change designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
5. Do you have another environmental change to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Environmental Changes #5
1. The next questions will be asked regarding each environmental change affecting
overweight/obesity. Please briefly describe each change one at a time.
NOTE: you will be prompted to add additional environmental changes following this
screen if applicable (max of 10).
Name of Environmental Change:
2. Was this environmental change initiated locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
3. Describe
4. Was this environmental change designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
5. Do you have another environmental change to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Environmental Changes #6
1. The next questions will be asked regarding each environmental change affecting
overweight/obesity. Please briefly describe each change one at a time.
NOTE: you will be prompted to add additional environmental changes following this
screen if applicable (max of 10).
Name of Environmental Change:
2. Was this environmental change initiated locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
3. Describe
4. Was this environmental change designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
5. Do you have another environmental change to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Environmental Changes #7
1. The next questions will be asked regarding each environmental change affecting
overweight/obesity. Please briefly describe each change one at a time.
NOTE: you will be prompted to add additional environmental changes following this
screen if applicable (max of 10).
Name of Environmental Change:
2. Was this environmental change initiated locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
3. Describe
Other
4. Was this environmental change designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
5. Do you have another environmental change to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Environmental Changes #8
1. The next questions will be asked regarding each environmental change affecting
overweight/obesity. Please briefly describe each change one at a time.
NOTE: you will be prompted to add additional environmental changes following this
screen if applicable (max of 10).
Name of Environmental Change:
2. Was this environmental change initiated locally or at the state level?
j Local
k
l
m
n
Other
j
k
l
m
n
State
3. Describe
4. Was this environmental change designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
5. Do you have another environmental change to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Environmental Changes #9
1. The next questions will be asked regarding each environmental change affecting
overweight/obesity. Please briefly describe each change one at a time.
NOTE: you will be prompted to add additional environmental changes following this
screen if applicable (max of 10).
Name of Environmental Change:
2. Was this environmental change initiated locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
3. Describe
4. Was this environmental change designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
5. Do you have another environmental change to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Environmental Changes #10
1. The next questions will be asked regarding each environmental change affecting
overweight/obesity. Please briefly describe each change one at a time.
NOTE: you will be prompted to add additional environmental changes following this
screen if applicable (max of 10).
Name of Environmental Change:
2. Was this environmental change initiated locally or at the state level?
j
k
l
m
n
Local
j
k
l
m
n
State
3. Describe
4. Was this environmental change designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
5. Do you have another environmental change to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
If Yes, how many? You will not be able to provide additional information about them.
Implementation
For this section, please include any additional interventions NOT ALREADY REPORTED in the Legislation & Local
Ordinances, Policy, and Environmental Change sections in which your NPAO program is primary sponsor.
We define an intervention operationally as “A prescribed series of activities with the main purpose of changing
existing obesity-, nutrition-, or physical activity-related behaviors and/or practices.”
An intervention should address one or more levels of the Social-Ecological Model (individual, interpersonal,
organizational, community, society) and be designed to:
• Establish supportive environments, making healthier lifestyle options (i.e., healthy eating and physical activity) in
communities more readily accessible, affordable, comfortable, and safe.
• Establish policies and standards to support healthy eating and physical activity in communities.
• Change rules, regulations or structures of institutions and organizations.
• Establish programs in communities to increase physical activity and/or reduce caloric intake through healthy eating
habits.
• Teach skills needed to make individual behavior changes related to nutrition, physical activity, and healthy weight,
and designed to provide opportunities to practice these skills.
The following projects or activities are not considered interventions:
• Curriculum that has been purchased or designed and not put into use
• Curriculum that has been purchased or designed and not tailored to the target audience
• Training alone (can be an important part of an intervention)
• Conference participation and health fairs
• Presentations at conferences and forums
• Coalition or task force meetings
For multi-site interventions (e.g. community mini-grants programs), include the overall program ONCE. In the
description fields, indicate the grantees/sites included in the program. Do not enter each mini-grant site as its own
intervention.
NOTE: you will be prompted to add additional interventions following this screen if applicable (max of 10).
1. Name of the Intervention
2. Please specify the dates of the intervention's activities (MM/DD/YYYY)
Start Date
End Date
3. Was this intervention designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
4. Is this a multi-site intervention (e.g. community mini-grant programs)?
j
k
l
m
n
No
j
k
l
m
n
Yes
If YES, how many sites does the program have?
If this intervention is multi-site, enter it only ONCE. In the description fields, you may enter information about the grantees/sites
included in the intervention.
5. Please indicate the developmental stage of your intervention
j
k
l
m
n
Planning
j
k
l
m
n
In the field
j
k
l
m
n
Concluded
6. Intended Outcomes (check all that apply)
c
d
e
f
g
Policy change
c
d
e
f
g
Environmental change
c
d
e
f
g
Behavioral change
Description of Intended Outcomes
7. Describe the purpose and where the intervention will be provided
8. Describe the intervention methodology and strategy for implementation
9. In the next series of items, please describe the specific demographics of the state
population that are addressed by the intervention. Check all that apply.
Ethnicity:
c
d
e
f
g
Hispanic or Latino
c
d
e
f
g
Not Hispanic or Latino
c
d
e
f
g
General Population (no specific ethnic audiences
addressed)
10. Race
c
d
e
f
g
American Indian or Alaska native
c
d
e
f
g
Native Hawaiian or other Pacific Islander
c
d
e
f
g
Asian
c
d
e
f
g
White
c
d
e
f
g
Black or African-American
c
d
e
f
g
General Population (no specific racial audiences addressed)
11. Gender
c
d
e
f
g
Male
c
d
e
f
g
Female
12. Region/Population
c
d
e
f
g
Rural
c
d
e
f
g
Urban
c
d
e
f
g
Suburban
c
d
e
f
g
Low Income
13. Age Group
c
d
e
f
g
< 2 yrs
c
d
e
f
g
11-13 yrs
c
d
e
f
g
65+
c
d
e
f
g
2-3 yrs
c
d
e
f
g
14-17 yrs
c
d
e
f
g
All Ages
c
d
e
f
g
4-5 yrs
c
d
e
f
g
18-29 yrs
c
d
e
f
g
6-10 yrs
c
d
e
f
g
30-64 yrs
14. Which of the following principal target areas does this intervention specifically
address? (check all that apply)
c
d
e
f
g
Decreasing high energy dense foods
c
d
e
f
g
Increasing fruit and vegetable consumption
c
d
e
f
g
Decreasing sweetened beverage intake
c
d
e
f
g
Increasing physical activity
c
d
e
f
g
Increasing breastfeeding
c
d
e
f
g
Reducing TV viewing
c
d
e
f
g
Other (please specify)
15. Which levels of Socio-Ecologic Framework does this intervention specifically
address?
[See www.cdc.gov/nccdphp/dnpa/obesity/state_programs/se_model.htm for
definitions of each level]
(Check all that apply)
c
d
e
f
g
Individual
c
d
e
f
g
Interpersonal
c
d
e
f
g
Organizational
c
d
e
f
g
Community
c
d
e
f
g
Society
Other
This
section asks you to provide the REACH of the intervention.
Notes:
- If you collected intervention specific data on reach, please use those numbers.
- If you did NOT collect data on reach, please estimate the reach of this particular intervention. In the "comments" box, justify and
explain your estimates (i.e. individuals reached is the total number of children at these schools)
16. Please indicate the places or settings in which you are making your intervention
available to your primary audience.
c
d
e
f
g
Community-wide
c
d
e
f
g
Religious organizations/houses of worship
c
d
e
f
g
Schools
c
d
e
f
g
Childcare centers
c
d
e
f
g
Families
c
d
e
f
g
Worksites
c
d
e
f
g
Hospitals, health facilities
c
d
e
f
g
Other (please specify)
17. If you chose COMMUNITY-WIDE
Please indicate the number of communities in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all communities. If
these are estimates, please justify them.
Community Count
Individuals Reached
If Estimated, Justify Estimates
18. If you chose SCHOOLS
Please indicate the number of schools in which you are making your intervention
available
to your primary audience. Then indicate the total number of individuals that
Other
were likely reached by your intervention across all schools. If these are estimates,
please justify them.
School Count
Individuals Reached
If Estimated, Justify Estimates
19. If you chose FAMILIES
Please indicate the number of family units in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all families. If these are estimates,
please justify them.
Family Unit Count
Individuals Reached
If Estimated, Justify Estimates
20. If you chose HOSPITALS, HEALTH SETTINGS
Please indicate the number of healthcare facilities in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all facilities (e.g. total
number of staff reached). If these are estimates, please justify them.
Healthcare Facility Unit Count
Individuals Reached
If Estimated, Justify Estimates
21. If you chose RELIGIOUS ORGANIZATIONS
Please indicate the number of religious organizations in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all organizations. If
these are estimates, please justify them.
Religious Organization Unit Count
Individuals Reached
If Estimated, Justify Estimates
22. If you chose CHILDCARE SETTINGS
Please indicate the number of childcare settings in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all childcare settings.
If these are estimates, please justify them.
Childcare Settings Unit Count
Individuals Reached
If Estimated, Justify Estimates
23. If you chose WORKSITES
Please indicate the number of worksites in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all worksites (e.g. total number of
employees at all sites). If these are estimates, please justify them.
Worksites Unit Count
Individuals Reached
If Estimated, Justify Estimates
24. If you chose OTHER
Please indicate the number of sites in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all sites. If these are estimates,
please justify them.
Site Count
Individuals Reached
If Estimated, Justify Estimates
The following items pertain to any evaluation activities you have conducted related to this intervention.
25. Has your state started to measure process or implementation indicators for this
intervention?
j
k
l
m
n
Not yet
j
k
l
m
n
Yes
26. Please describe the process or implementation indicator(s) (e.g. number of
people attending a particular training; number of hits to website). You may use
bullets and/or a list.
27. Please describe any results you have from these process or implementation
indicator(s):
28. Has your state started to measure short-term, intermediate or long-term
outcomes from the intervention?
j
k
l
m
n
Not yet
j
k
l
m
n
Yes
29. Please describe the outcome indicator(s) (e.g. decreased TV viewing among high
school students). You may use bullets and/or a list.
30. Please describe any results you have from these outcome indicator(s):
31. Please describe any progress on the intervention that has not already been
reported:
32. Do you have another intervention to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Intervention #2
NOTE: you will be prompted to add additional interventions following this screen if applicable (max of 10).
1. Name of the Intervention
2. Please specify the dates of the intervention's activities (MM/DD/YYYY)
Start Date
End Date
3. Was this intervention designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
4. Is this a multi-site intervention (e.g. community mini-grant programs)?
j
k
l
m
n
No
j
k
l
m
n
Yes
If YES, how many sites does the program have?
If this intervention is multi-site, enter it only ONCE. In the description fields, you may enter information about the grantees/sites
included in the intervention.
5. Please indicate the developmental stage of your intervention
j
k
l
m
n
Planning
j
k
l
m
n
In the field
j
k
l
m
n
Concluded
6. Intended Outcomes (check all that apply)
c
d
e
f
g
Policy change
c
d
e
f
g
Environmental change
c
d
e
f
g
Behavioral change
Description of Intended Outcomes
7. Describe the purpose and where the intervention will be provided
8. Describe the intervention methodology and strategy for implementation
9. In the next series of items, please describe the specific demographics of the state
population that are addressed by the intervention.
Ethnicity:
c
d
e
f
g
Hispanic or Latino
c
d
e
f
g
Not Hispanic or Latino
c
d
e
f
g
General Population (no specific ethnic audiences
addressed)
10. Race
c
d
e
f
g
American Indian or Alaska native
c
d
e
f
g
Native Hawaiian or other Pacific Islander
c
d
e
f
g
Asian
c
d
e
f
g
White
c
d
e
f
g
Black or African-American
c
d
e
f
g
General Population (no specific racial audiences addressed)
11. Gender
c
d
e
f
g
Male
c
d
e
f
g
Female
12. Region/Population
c
d
e
f
g
Rural
c
d
e
f
g
Urban
c
d
e
f
g
Suburban
c
d
e
f
g
Low Income
13. Age Group
c
d
e
f
g
< 2 yrs
c
d
e
f
g
11-13 yrs
c
d
e
f
g
65+
c
d
e
f
g
2-3 yrs
c
d
e
f
g
14-17 yrs
c
d
e
f
g
All Ages
c
d
e
f
g
4-5 yrs
c
d
e
f
g
18-29 yrs
c
d
e
f
g
6-10 yrs
c
d
e
f
g
30-64 yrs
14. Which of the following principal target areas does this intervention specifically
address? (check all that apply)
c
d
e
f
g
Decreasing high energy dense foods
c
d
e
f
g
Increasing fruit and vegetable consumption
c
d
e
f
g
Decreasing sweetened beverage intake
c
d
e
f
g
Increasing physical activity
c
d
e
f
g
Increasing breastfeeding
c
d
e
f
g
Reducing TV viewing
c
d
e
f
g
Other (please specify)
15. Which levels of Socio-Ecologic Framework does this intervention specifically
address?
[See www.cdc.gov/nccdphp/dnpa/obesity/state_programs/se_model.htm for
definitions of each level]
(Check all that apply)
c
d
e
f
g
Individual
c
d
e
f
g
Interpersonal
c
d
e
f
g
Organizational
c
d
e
f
g
Community
c
d
e
f
g
Society
Other
This section asks you to provide the REACH of the intervention.
Notes:
- If you collected intervention specific data on reach, please use those numbers.
- If you did NOT collect data on reach, please estimate the reach of this particular intervention. In the "comments" box, justify and
explain your estimates (i.e. individuals reached is the total number of children at these schools)
16. Please indicate the places or settings in which you are making your intervention
available to your primary audience.
c
d
e
f
g
Community-wide
c
d
e
f
g
Religious organizations/houses of worship
c
d
e
f
g
Schools
c
d
e
f
g
Childcare centers
c
d
e
f
g
Families
c
d
e
f
g
Worksites
c
d
e
f
g
Hospitals, health facilities
c
d
e
f
g
Other (please specify)
17. If you chose COMMUNITY-WIDE
Please indicate the number of communities in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all communities. If
these are estimates, please justify them.
Community Count
Individuals Reached
If Estimated, Justify Estimates
18. If you chose SCHOOLS
Please indicate the number of schools in which you are making your intervention
available
to your primary audience. Then indicate the total number of individuals that
Other
were likely reached by your intervention across all schools. If these are estimates,
please justify them.
School Count
Individuals Reached
If Estimated, Justify Estimates
19. If you chose FAMILIES
Please indicate the number of family units in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all families. If these are estimates,
please justify them.
Family Unit Count
Individuals Reached
If Estimated, Justify Estimates
20. If you chose HOSPITALS, HEALTH SETTINGS
Please indicate the number of healthcare facilities in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all facilities (e.g. total
number of staff reached). If these are estimates, please justify them.
Healthcare Facility Unit Count
Individuals Reached
If Estimated, Justify Estimates
21. If you chose RELIGIOUS ORGANIZATIONS
Please indicate the number of religious organizations in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all organizations. If
these are estimates, please justify them.
Religious Organization Unit Count
Individuals Reached
If Estimated, Justify Estimates
22. If you chose CHILDCARE SETTINGS
Please indicate the number of childcare settings in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all childcare settings.
If these are estimates, please justify them.
Childcare Settings Unit Count
Individuals Reached
If Estimated, Justify Estimates
23. If you chose WORKSITES
Please indicate the number of worksites in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all worksites (e.g. total number of
employees at all sites). If these are estimates, please justify them.
Worksites Unit Count
Individuals Reached
If Estimated, Justify Estimates
24. If you chose OTHER
Please indicate the number of sites in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all sites. If these are estimates,
please justify them.
Site Count
Individuals Reached
If Estimated, Justify Estimates
The following items pertain to any evaluation activities you have conducted related to this intervention.
25. Has your state started to measure process or implementation indicators for this
intervention?
j
k
l
m
n
Not yet
j
k
l
m
n
Yes
26. Please describe the process or implementation indicator(s) (e.g. number of
people attending a particular training; number of hits to website). You may use
bullets and/or a list.
27. Please describe any results you have from these process or implementation
indicator(s):
28. Has your state started to measure short-term, intermediate or long-term
outcomes from the intervention?
j
k
l
m
n
Not yet
j
k
l
m
n
Yes
29. Please describe the outcome indicator(s) (e.g. decreased TV viewing among high
school students). You may use bullets and/or a list.
30. Please describe any results you have from these outcome indicator(s):
31. Please describe any progress on the intervention that has not already been
reported:
32. Do you have another intervention to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Intervention #3
NOTE: you will be prompted to add additional interventions following this screen if applicable (max of 10).
1. Name of the Intervention
2. Please specify the dates of the intervention's activities (MM/DD/YYYY)
Start Date
End Date
3. Was this intervention designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
4. Is this a multi-site intervention (e.g. community mini-grant programs)?
j
k
l
m
n
No
j
k
l
m
n
Yes
If YES, how many sites does the program have?
If this intervention is multi-site, enter it only ONCE. In the description fields, you may enter information about the grantees/sites
included in the intervention.
5. Please indicate the developmental stage of your intervention
j
k
l
m
n
Planning
j
k
l
m
n
In the field
j
k
l
m
n
Concluded
6. Intended Outcomes (check all that apply)
c
d
e
f
g
Policy change
c
d
e
f
g
Environmental change
c
d
e
f
g
Behavioral change
Description of Intended Outcomes
7. Describe the purpose and where the intervention will be provided
8. Describe the intervention methodology and strategy for implementation
9. In the next series of items, please describe the specific demographics of the state
population that are addressed by the intervention.
Ethnicity:
c
d
e
f
g
Hispanic or Latino
c
d
e
f
g
Not Hispanic or Latino
c
d
e
f
g
General Population (no specific ethnic audiences
addressed)
10. Race
c
d
e
f
g
American Indian or Alaska native
c
d
e
f
g
Native Hawaiian or other Pacific Islander
c
d
e
f
g
Asian
c
d
e
f
g
White
c
d
e
f
g
Black or African-American
c
d
e
f
g
General Population (no specific racial audiences addressed)
11. Gender
c
d
e
f
g
Male
c
d
e
f
g
Female
12. Region/Population
c
d
e
f
g
Rural
c
d
e
f
g
Urban
c
d
e
f
g
Suburban
c
d
e
f
g
Low Income
13. Age Group
c
d
e
f
g
< 2 yrs
c
d
e
f
g
11-13 yrs
c
d
e
f
g
65+
c
d
e
f
g
2-3 yrs
c
d
e
f
g
14-17 yrs
c
d
e
f
g
All Ages
c
d
e
f
g
4-5 yrs
c
d
e
f
g
18-29 yrs
c
d
e
f
g
6-10 yrs
c
d
e
f
g
30-64 yrs
14. Which of the following principal target areas does this intervention specifically
address? (check all that apply)
c
d
e
f
g
Decreasing high energy dense foods
c
d
e
f
g
Increasing fruit and vegetable consumption
c
d
e
f
g
Decreasing sweetened beverage intake
c
d
e
f
g
Increasing physical activity
c
d
e
f
g
Increasing breastfeeding
c
d
e
f
g
Reducing TV viewing
c
d
e
f
g
Other (please specify)
15. Which levels of Socio-Ecologic Framework does this intervention specifically
address?
[See www.cdc.gov/nccdphp/dnpa/obesity/state_programs/se_model.htm for
definitions of each level]
(Check all that apply)
c
d
e
f
g
Individual
c
d
e
f
g
Interpersonal
c
d
e
f
g
Organizational
c
d
e
f
g
Community
c
d
e
f
g
Society
Other
This section asks you to provide the REACH of the intervention.
Notes:
- If you collected intervention specific data on reach, please use those numbers.
- If you did NOT collect data on reach, please estimate the reach of this particular intervention. In the "comments" box, justify and
explain your estimates (i.e. individuals reached is the total number of children at these schools)
16. Please indicate the places or settings in which you are making your intervention
available to your primary audience.
c
d
e
f
g
Community-wide
c
d
e
f
g
Religious organizations/houses of worship
c
d
e
f
g
Schools
c
d
e
f
g
Childcare centers
c
d
e
f
g
Families
c
d
e
f
g
Worksites
c
d
e
f
g
Hospitals, health facilities
c
d
e
f
g
Other (please specify)
17. If you chose COMMUNITY-WIDE
Please indicate the number of communities in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all communities. If
these are estimates, please justify them.
Community Count
Individuals Reached
If Estimated, Justify Estimates
18. If you chose SCHOOLS
Please indicate the number of schools in which you are making your intervention
available
to your primary audience. Then indicate the total number of individuals that
Other
were likely reached by your intervention across all schools. If these are estimates,
please justify them.
School Count
Individuals Reached
If Estimated, Justify Estimates
19. If you chose FAMILIES
Please indicate the number of family units in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all families. If these are estimates,
please justify them.
Family Unit Count
Individuals Reached
If Estimated, Justify Estimates
20. If you chose HOSPITALS, HEALTH SETTINGS
Please indicate the number of healthcare facilities in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all facilities (e.g. total
number of staff reached). If these are estimates, please justify them.
Healthcare Facility Unit Count
Individuals Reached
If Estimated, Justify Estimates
21. If you chose RELIGIOUS ORGANIZATIONS
Please indicate the number of religious organizations in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all organizations. If
these are estimates, please justify them.
Religious Organization Unit Count
Individuals Reached
If Estimated, Justify Estimates
22. If you chose CHILDCARE SETTINGS
Please indicate the number of childcare settings in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all childcare settings.
If these are estimates, please justify them.
Childcare Settings Unit Count
Individuals Reached
If Estimated, Justify Estimates
23. If you chose WORKSITES
Please indicate the number of worksites in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all worksites (e.g. total number of
employees at all sites). If these are estimates, please justify them.
Worksites Unit Count
Individuals Reached
If Estimated, Justify Estimates
24. If you chose OTHER
Please indicate the number of sites in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all sites. If these are estimates,
please justify them.
Site Count
Individuals Reached
If Estimated, Justify Estimates
The following items pertain to any evaluation activities you have conducted related to this intervention.
25. Has your state started to measure process or implementation indicators for this
intervention?
j
k
l
m
n
Not yet
j
k
l
m
n
Yes
26. Please describe the process or implementation indicator(s) (e.g. number of
people attending a particular training; number of hits to website). You may use
bullets and/or a list.
27. Please describe any results you have from these process or implementation
indicator(s):
28. Has your state started to measure short-term, intermediate or long-term
outcomes from the intervention?
j
k
l
m
n
Not yet
j
k
l
m
n
Yes
29. Please describe the outcome indicator(s) (e.g. decreased TV viewing among high
school students). You may use bullets and/or a list.
30. Please describe any results you have from these outcome indicator(s):
31. Please describe any progress on the intervention that has not already been
reported:
32. Do you have another intervention to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Intervention #4
NOTE: you will be prompted to add additional interventions following this screen if applicable (max of 10).
1. Name of the Intervention
2. Please specify the dates of the intervention's activities (MM/DD/YYYY)
Start Date
End Date
3. Was this intervention designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
4. Is this a multi-site intervention (e.g. community mini-grant programs)?
j
k
l
m
n
No
j
k
l
m
n
Yes
If YES, how many sites does the program have?
If this intervention is multi-site, enter it only ONCE. In the description fields, you may enter information about the grantees/sites
included in the intervention.
5. Please indicate the developmental stage of your intervention
j
k
l
m
n
Planning
j
k
l
m
n
In the field
j
k
l
m
n
Concluded
6. Intended Outcomes (check all that apply)
c
d
e
f
g
Policy change
c
d
e
f
g
Environmental change
c
d
e
f
g
Behavioral change
Description of Intended Outcomes
7. Describe the purpose and where the intervention will be provided
8. Describe the intervention methodology and strategy for implementation
9. In the next series of items, please describe the specific demographics of the state
population that are addressed by the intervention.
Ethnicity:
c
d
e
f
g
Hispanic or Latino
c
d
e
f
g
Not Hispanic or Latino
c
d
e
f
g
General Population (no specific ethnic audiences
addressed)
10. Race
c
d
e
f
g
American Indian or Alaska native
c
d
e
f
g
Native Hawaiian or other Pacific Islander
c
d
e
f
g
Asian
c
d
e
f
g
White
c
d
e
f
g
Black or African-American
c
d
e
f
g
General Population (no specific racial audiences addressed)
11. Gender
c
d
e
f
g
Male
c
d
e
f
g
Female
12. Region/Population
c
d
e
f
g
Rural
c
d
e
f
g
Urban
c
d
e
f
g
Suburban
c
d
e
f
g
Low Income
13. Age Group
c
d
e
f
g
< 2 yrs
c
d
e
f
g
11-13 yrs
c
d
e
f
g
65+
c
d
e
f
g
2-3 yrs
c
d
e
f
g
14-17 yrs
c
d
e
f
g
All Ages
c
d
e
f
g
4-5 yrs
c
d
e
f
g
18-29 yrs
c
d
e
f
g
6-10 yrs
c
d
e
f
g
30-64 yrs
14. Which of the following principal target areas does this intervention specifically
address? (check all that apply)
c
d
e
f
g
Decreasing high energy dense foods
c
d
e
f
g
Increasing fruit and vegetable consumption
c
d
e
f
g
Decreasing sweetened beverage intake
c
d
e
f
g
Increasing physical activity
c
d
e
f
g
Increasing breastfeeding
c
d
e
f
g
Reducing TV viewing
c
d
e
f
g
Other (please specify)
15. Which levels of Socio-Ecologic Framework does this intervention specifically
address?
[See www.cdc.gov/nccdphp/dnpa/obesity/state_programs/se_model.htm for
definitions of each level]
(Check all that apply)
c
d
e
f
g
Individual
c
d
e
f
g
Interpersonal
c
d
e
f
g
Organizational
c
d
e
f
g
Community
c
d
e
f
g
Society
Other
This section asks you to provide the REACH of the intervention.
Notes:
- If you collected intervention specific data on reach, please use those numbers.
- If you did NOT collect data on reach, please estimate the reach of this particular intervention. In the "comments" box, justify and
explain your estimates (i.e. individuals reached is the total number of children at these schools)
16. Please indicate the places or settings in which you are making your intervention
available to your primary audience.
c
d
e
f
g
Community-wide
c
d
e
f
g
Religious organizations/houses of worship
c
d
e
f
g
Schools
c
d
e
f
g
Childcare centers
c
d
e
f
g
Families
c
d
e
f
g
Worksites
c
d
e
f
g
Hospitals, health facilities
c
d
e
f
g
Other (please specify)
17. If you chose COMMUNITY-WIDE
Please indicate the number of communities in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all communities. If
these are estimates, please justify them.
Community Count
Individuals Reached
If Estimated, Justify Estimates
18. If you chose SCHOOLS
Please indicate the number of schools in which you are making your intervention
available
to your primary audience. Then indicate the total number of individuals that
Other
were likely reached by your intervention across all schools. If these are estimates,
please justify them.
School Count
Individuals Reached
If Estimated, Justify Estimates
19. If you chose FAMILIES
Please indicate the number of family units in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all families. If these are estimates,
please justify them.
Family Unit Count
Individuals Reached
If Estimated, Justify Estimates
20. If you chose HOSPITALS, HEALTH SETTINGS
Please indicate the number of healthcare facilities in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all facilities (e.g. total
number of staff reached). If these are estimates, please justify them.
Healthcare Facility Unit Count
Individuals Reached
If Estimated, Justify Estimates
21. If you chose RELIGIOUS ORGANIZATIONS
Please indicate the number of religious organizations in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all organizations. If
these are estimates, please justify them.
Religious Organization Unit Count
Individuals Reached
If Estimated, Justify Estimates
22. If you chose CHILDCARE SETTINGS
Please indicate the number of childcare settings in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all childcare settings.
If these are estimates, please justify them.
Childcare Settings Unit Count
Individuals Reached
If Estimated, Justify Estimates
23. If you chose WORKSITES
Please indicate the number of worksites in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all worksites (e.g. total number of
employees at all sites). If these are estimates, please justify them.
Worksites Unit Count
Individuals Reached
If Estimated, Justify Estimates
24. If you chose OTHER
Please indicate the number of sites in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all sites. If these are estimates,
please justify them.
Site Count
Individuals Reached
If Estimated, Justify Estimates
The following items pertain to any evaluation activities you have conducted related to this intervention.
25. Has your state started to measure process or implementation indicators for this
intervention?
j
k
l
m
n
Not yet
j
k
l
m
n
Yes
26. Please describe the process or implementation indicator(s) (e.g. number of
people attending a particular training; number of hits to website). You may use
bullets and/or a list.
27. Please describe any results you have from these process or implementation
indicator(s):
28. Has your state started to measure short-term, intermediate or long-term
outcomes from the intervention?
j
k
l
m
n
Not yet
j
k
l
m
n
Yes
29. Please describe the outcome indicator(s) (e.g. decreased TV viewing among high
school students). You may use bullets and/or a list.
30. Please describe any results you have from these outcome indicator(s):
31. Please describe any progress on the intervention that has not already been
reported:
32. Do you have another intervention to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Intervention #5
NOTE: you will be prompted to add additional interventions following this screen if applicable (max of 10).
1. Name of the Intervention
2. Please specify the dates of the intervention's activities (MM/DD/YYYY)
Start Date
End Date
3. Was this intervention designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
4. Is this a multi-site intervention (e.g. community mini-grant programs)?
j
k
l
m
n
No
j
k
l
m
n
Yes
If YES, how many sites does the program have?
If this intervention is multi-site, enter it only ONCE. In the description fields, you may enter information about the grantees/sites
included in the intervention.
5. Please indicate the developmental stage of your intervention
j
k
l
m
n
Planning
j
k
l
m
n
In the field
j
k
l
m
n
Concluded
6. Intended Outcomes (check all that apply)
c
d
e
f
g
Policy change
c
d
e
f
g
Environmental change
c
d
e
f
g
Behavioral change
Description of Intended Outcomes
7. Describe the purpose and where the intervention will be provided
8. Describe the intervention methodology and strategy for implementation
9. In the next series of items, please describe the specific demographics of the state
population that are addressed by the intervention.
Ethnicity:
c
d
e
f
g
Hispanic or Latino
c
d
e
f
g
Not Hispanic or Latino
c
d
e
f
g
General Population (no specific ethnic audiences
addressed)
10. Race
c
d
e
f
g
American Indian or Alaska native
c
d
e
f
g
Native Hawaiian or other Pacific Islander
c
d
e
f
g
Asian
c
d
e
f
g
White
c
d
e
f
g
Black or African-American
c
d
e
f
g
General Population (no specific racial audiences addressed)
11. Gender
c
d
e
f
g
Male
c
d
e
f
g
Female
12. Region/Population
c
d
e
f
g
Rural
c
d
e
f
g
Urban
c
d
e
f
g
Suburban
c
d
e
f
g
Low Income
13. Age Group
c
d
e
f
g
< 2 yrs
c
d
e
f
g
11-13 yrs
c
d
e
f
g
65+
c
d
e
f
g
2-3 yrs
c
d
e
f
g
14-17 yrs
c
d
e
f
g
All Ages
c
d
e
f
g
4-5 yrs
c
d
e
f
g
18-29 yrs
c
d
e
f
g
6-10 yrs
c
d
e
f
g
30-64 yrs
14. Which of the following principal target areas does this intervention specifically
address? (check all that apply)
c
d
e
f
g
Decreasing high energy dense foods
c
d
e
f
g
Increasing fruit and vegetable consumption
c
d
e
f
g
Decreasing sweetened beverage intake
c
d
e
f
g
Increasing physical activity
c
d
e
f
g
Increasing breastfeeding
c
d
e
f
g
Reducing TV viewing
c
d
e
f
g
Other (please specify)
15. Which levels of Socio-Ecologic Framework does this intervention specifically
address?
[See www.cdc.gov/nccdphp/dnpa/obesity/state_programs/se_model.htm for
definitions of each level]
(Check all that apply)
c
d
e
f
g
Individual
c
d
e
f
g
Interpersonal
c
d
e
f
g
Organizational
c
d
e
f
g
Community
c
d
e
f
g
Society
Other
This section asks you to provide the REACH of the intervention.
Notes:
- If you collected intervention specific data on reach, please use those numbers.
- If you did NOT collect data on reach, please estimate the reach of this particular intervention. In the "comments" box, justify and
explain your estimates (i.e. individuals reached is the total number of children at these schools)
16. Please indicate the places or settings in which you are making your intervention
available to your primary audience.
c
d
e
f
g
Community-wide
c
d
e
f
g
Religious organizations/houses of worship
c
d
e
f
g
Schools
c
d
e
f
g
Childcare centers
c
d
e
f
g
Families
c
d
e
f
g
Worksites
c
d
e
f
g
Hospitals, health facilities
c
d
e
f
g
Other (please specify)
17. If you chose COMMUNITY-WIDE
Please indicate the number of communities in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all communities. If
these are estimates, please justify them.
Community Count
Individuals Reached
If Estimated, Justify Estimates
18. If you chose SCHOOLS
Please indicate the number of schools in which you are making your intervention
available
to your primary audience. Then indicate the total number of individuals that
Other
were likely reached by your intervention across all schools. If these are estimates,
please justify them.
School Count
Individuals Reached
If Estimated, Justify Estimates
19. If you chose FAMILIES
Please indicate the number of family units in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all families. If these are estimates,
please justify them.
Family Unit Count
Individuals Reached
If Estimated, Justify Estimates
20. If you chose HOSPITALS, HEALTH SETTINGS
Please indicate the number of healthcare facilities in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all facilities (e.g. total
number of staff reached). If these are estimates, please justify them.
Healthcare Facility Unit Count
Individuals Reached
If Estimated, Justify Estimates
21. If you chose RELIGIOUS ORGANIZATIONS
Please indicate the number of religious organizations in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all organizations. If
these are estimates, please justify them.
Religious Organization Unit Count
Individuals Reached
If Estimated, Justify Estimates
22. If you chose CHILDCARE SETTINGS
Please indicate the number of childcare settings in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all childcare settings.
If these are estimates, please justify them.
Childcare Settings Unit Count
Individuals Reached
If Estimated, Justify Estimates
23. If you chose WORKSITES
Please indicate the number of worksites in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all worksites (e.g. total number of
employees at all sites). If these are estimates, please justify them.
Worksites Unit Count
Individuals Reached
If Estimated, Justify Estimates
24. If you chose OTHER
Please indicate the number of sites in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all sites. If these are estimates,
please justify them.
Site Count
Individuals Reached
If Estimated, Justify Estimates
The following items pertain to any evaluation activities you have conducted related to this intervention.
25. Has your state started to measure process or implementation indicators for this
intervention?
j
k
l
m
n
Not yet
j
k
l
m
n
Yes
26. Please describe the process or implementation indicator(s) (e.g. number of
people attending a particular training; number of hits to website). You may use
bullets and/or a list.
27. Please describe any results you have from these process or implementation
indicator(s):
28. Has your state started to measure short-term, intermediate or long-term
outcomes from the intervention?
j
k
l
m
n
Not yet
j
k
l
m
n
Yes
29. Please describe the outcome indicator(s) (e.g. decreased TV viewing among high
school students). You may use bullets and/or a list.
30. Please describe any results you have from these outcome indicator(s):
31. Please describe any progress on the intervention that has not already been
reported:
32. Do you have another intervention to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Intervention #6
NOTE: you will be prompted to add additional interventions following this screen if applicable (max of 10).
1. Name of the Intervention
2. Please specify the dates of the intervention's activities (MM/DD/YYYY)
Start Date
End Date
3. Was this intervention designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
4. Is this a multi-site intervention (e.g. community mini-grant programs)?
j
k
l
m
n
No
j
k
l
m
n
Yes
If YES, how many sites does the program have?
If this intervention is multi-site, enter it only ONCE. In the description fields, you may enter information about the grantees/sites
included in the intervention.
5. Please indicate the developmental stage of your intervention
j
k
l
m
n
Planning
j
k
l
m
n
In the field
j
k
l
m
n
Concluded
6. Intended Outcomes (check all that apply)
c
d
e
f
g
Policy change
c
d
e
f
g
Environmental change
c
d
e
f
g
Behavioral change
Description of Intended Outcomes
7. Describe the purpose and where the intervention will be provided
8. Describe the intervention methodology and strategy for implementation
9. In the next series of items, please describe the specific demographics of the state
population that are addressed by the intervention.
Ethnicity:
c
d
e
f
g
Hispanic or Latino
c
d
e
f
g
Not Hispanic or Latino
c
d
e
f
g
General Population (no specific ethnic audiences
addressed)
10. Race
c
d
e
f
g
American Indian or Alaska native
c
d
e
f
g
Native Hawaiian or other Pacific Islander
c
d
e
f
g
Asian
c
d
e
f
g
White
c
d
e
f
g
Black or African-American
c
d
e
f
g
General Population (no specific racial audiences addressed)
11. Gender
c
d
e
f
g
Male
c
d
e
f
g
Female
12. Region/Population
c
d
e
f
g
Rural
c
d
e
f
g
Urban
c
d
e
f
g
Suburban
c
d
e
f
g
Low Income
13. Age Group
c
d
e
f
g
< 2 yrs
c
d
e
f
g
11-13 yrs
c
d
e
f
g
65+
c
d
e
f
g
2-3 yrs
c
d
e
f
g
14-17 yrs
c
d
e
f
g
All Ages
c
d
e
f
g
4-5 yrs
c
d
e
f
g
18-29 yrs
c
d
e
f
g
6-10 yrs
c
d
e
f
g
30-64 yrs
14. Which of the following principal target areas does this intervention specifically
address? (check all that apply)
c
d
e
f
g
Decreasing high energy dense foods
c
d
e
f
g
Increasing fruit and vegetable consumption
c
d
e
f
g
Decreasing sweetened beverage intake
c
d
e
f
g
Increasing physical activity
c
d
e
f
g
Increasing breastfeeding
c
d
e
f
g
Reducing TV viewing
c
d
e
f
g
Other (please specify)
15. Which levels of Socio-Ecologic Framework does this intervention specifically
address?
[See www.cdc.gov/nccdphp/dnpa/obesity/state_programs/se_model.htm for
definitions of each level]
(Check all that apply)
c
d
e
f
g
Individual
c
d
e
f
g
Interpersonal
c
d
e
f
g
Organizational
c
d
e
f
g
Community
c
d
e
f
g
Society
Other
This section asks you to provide the REACH of the intervention.
Notes:
- If you collected intervention specific data on reach, please use those numbers.
- If you did NOT collect data on reach, please estimate the reach of this particular intervention. In the "comments" box, justify and
explain your estimates (i.e. individuals reached is the total number of children at these schools)
16. Please indicate the places or settings in which you are making your intervention
available to your primary audience.
c
d
e
f
g
Community-wide
c
d
e
f
g
Religious organizations/houses of worship
c
d
e
f
g
Schools
c
d
e
f
g
Childcare centers
c
d
e
f
g
Families
c
d
e
f
g
Worksites
c
d
e
f
g
Hospitals, health facilities
c
d
e
f
g
Other (please specify)
17. If you chose COMMUNITY-WIDE
Please indicate the number of communities in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all communities. If
these are estimates, please justify them.
Community Count
Individuals Reached
If Estimated, Justify Estimates
18. If you chose SCHOOLS
Please indicate the number of schools in which you are making your intervention
available
to your primary audience. Then indicate the total number of individuals that
Other
were likely reached by your intervention across all schools. If these are estimates,
please justify them.
School Count
Individuals Reached
If Estimated, Justify Estimates
19. If you chose FAMILIES
Please indicate the number of family units in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all families. If these are estimates,
please justify them.
Family Unit Count
Individuals Reached
If Estimated, Justify Estimates
20. If you chose HOSPITALS, HEALTH SETTINGS
Please indicate the number of healthcare facilities in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all facilities (e.g. total
number of staff reached). If these are estimates, please justify them.
Healthcare Facility Unit Count
Individuals Reached
If Estimated, Justify Estimates
21. If you chose RELIGIOUS ORGANIZATIONS
Please indicate the number of religious organizations in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all organizations. If
these are estimates, please justify them.
Religious Organization Unit Count
Individuals Reached
If Estimated, Justify Estimates
22. If you chose CHILDCARE SETTINGS
Please indicate the number of childcare settings in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all childcare settings.
If these are estimates, please justify them.
Childcare Settings Unit Count
Individuals Reached
If Estimated, Justify Estimates
23. If you chose WORKSITES
Please indicate the number of worksites in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all worksites (e.g. total number of
employees at all sites). If these are estimates, please justify them.
Worksites Unit Count
Individuals Reached
If Estimated, Justify Estimates
24. If you chose OTHER
Please indicate the number of sites in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all sites. If these are estimates,
please justify them.
Site Count
Individuals Reached
If Estimated, Justify Estimates
The following items pertain to any evaluation activities you have conducted related to this intervention.
25. Has your state started to measure process or implementation indicators for this
intervention?
j
k
l
m
n
Not yet
j
k
l
m
n
Yes
26. Please describe the process or implementation indicator(s) (e.g. number of
people attending a particular training; number of hits to website). You may use
bullets and/or a list.
27. Please describe any results you have from these process or implementation
indicator(s):
28. Has your state started to measure short-term, intermediate or long-term
outcomes from the intervention?
j
k
l
m
n
Not yet
j
k
l
m
n
Yes
29. Please describe the outcome indicator(s) (e.g. decreased TV viewing among high
school students). You may use bullets and/or a list.
30. Please describe any results you have from these outcome indicator(s):
31. Please describe any progress on the intervention that has not already been
reported:
32. Do you have another intervention to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Intervention #7
NOTE: you will be prompted to add additional interventions following this screen if applicable (max of 10).
1. Name of the Intervention
2. Please specify the dates of the intervention's activities (MM/DD/YYYY)
Start Date
End Date
3. Was this intervention designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
4. Is this a multi-site intervention (e.g. community mini-grant programs)?
j
k
l
m
n
No
j
k
l
m
n
Yes
If YES, how many sites does the program have?
If this intervention is multi-site, enter it only ONCE. In the description fields, you may enter information about the grantees/sites
included in the intervention.
5. Please indicate the developmental stage of your intervention
j
k
l
m
n
Planning
j
k
l
m
n
In the field
j
k
l
m
n
Concluded
6. Intended Outcomes (check all that apply)
c
d
e
f
g
Policy change
c
d
e
f
g
Environmental change
c
d
e
f
g
Behavioral change
Description of Intended Outcomes
7. Describe the purpose and where the intervention will be provided
8. Describe the intervention methodology and strategy for implementation
9. In the next series of items, please describe the specific demographics of the state
population that are addressed by the intervention.
Ethnicity:
c
d
e
f
g
Hispanic or Latino
c
d
e
f
g
Not Hispanic or Latino
c
d
e
f
g
General Population (no specific ethnic audiences
addressed)
10. Race
c
d
e
f
g
American Indian or Alaska native
c
d
e
f
g
Native Hawaiian or other Pacific Islander
c
d
e
f
g
Asian
c
d
e
f
g
White
c
d
e
f
g
Black or African-American
c
d
e
f
g
General Population (no specific racial audiences addressed)
11. Gender
c
d
e
f
g
Male
c
d
e
f
g
Female
12. Region/Population
c
d
e
f
g
Rural
c
d
e
f
g
Urban
c
d
e
f
g
Suburban
c
d
e
f
g
Low Income
13. Age Group
c
d
e
f
g
< 2 yrs
c
d
e
f
g
11-13 yrs
c
d
e
f
g
65+
c
d
e
f
g
2-3 yrs
c
d
e
f
g
14-17 yrs
c
d
e
f
g
All Ages
c
d
e
f
g
4-5 yrs
c
d
e
f
g
18-29 yrs
c
d
e
f
g
6-10 yrs
c
d
e
f
g
30-64 yrs
14. Which of the following principal target areas does this intervention specifically
address? (check all that apply)
c
d
e
f
g
Decreasing high energy dense foods
c
d
e
f
g
Increasing fruit and vegetable consumption
c
d
e
f
g
Decreasing sweetened beverage intake
c
d
e
f
g
Increasing physical activity
c
d
e
f
g
Increasing breastfeeding
c
d
e
f
g
Reducing TV viewing
c
d
e
f
g
Other (please specify)
15. Which levels of Socio-Ecologic Framework does this intervention specifically
address?
[See www.cdc.gov/nccdphp/dnpa/obesity/state_programs/se_model.htm for
definitions of each level]
(Check all that apply)
c
d
e
f
g
Individual
c
d
e
f
g
Interpersonal
c
d
e
f
g
Organizational
c
d
e
f
g
Community
c
d
e
f
g
Society
Other
This section asks you to provide the REACH of the intervention.
Notes:
- If you collected intervention specific data on reach, please use those numbers.
- If you did NOT collect data on reach, please estimate the reach of this particular intervention. In the "comments" box, justify and
explain your estimates (i.e. individuals reached is the total number of children at these schools)
16. Please indicate the places or settings in which you are making your intervention
available to your primary audience.
c
d
e
f
g
Community-wide
c
d
e
f
g
Religious organizations/houses of worship
c
d
e
f
g
Schools
c
d
e
f
g
Childcare centers
c
d
e
f
g
Families
c
d
e
f
g
Worksites
c
d
e
f
g
Hospitals, health facilities
c
d
e
f
g
Other (please specify)
17. If you chose COMMUNITY-WIDE
Please indicate the number of communities in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all communities. If
these are estimates, please justify them.
Community Count
Individuals Reached
If Estimated, Justify Estimates
18. If you chose SCHOOLS
Please indicate the number of schools in which you are making your intervention
available
to your primary audience. Then indicate the total number of individuals that
Other
were likely reached by your intervention across all schools. If these are estimates,
please justify them.
School Count
Individuals Reached
If Estimated, Justify Estimates
19. If you chose FAMILIES
Please indicate the number of family units in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all families. If these are estimates,
please justify them.
Family Unit Count
Individuals Reached
If Estimated, Justify Estimates
20. If you chose HOSPITALS, HEALTH SETTINGS
Please indicate the number of healthcare facilities in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all facilities (e.g. total
number of staff reached). If these are estimates, please justify them.
Healthcare Facility Unit Count
Individuals Reached
If Estimated, Justify Estimates
21. If you chose RELIGIOUS ORGANIZATIONS
Please indicate the number of religious organizations in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all organizations. If
these are estimates, please justify them.
Religious Organization Unit Count
Individuals Reached
If Estimated, Justify Estimates
22. If you chose CHILDCARE SETTINGS
Please indicate the number of childcare settings in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all childcare settings.
If these are estimates, please justify them.
Childcare Settings Unit Count
Individuals Reached
If Estimated, Justify Estimates
23. If you chose WORKSITES
Please indicate the number of worksites in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all worksites (e.g. total number of
employees at all sites). If these are estimates, please justify them.
Worksites Unit Count
Individuals Reached
If Estimated, Justify Estimates
24. If you chose OTHER
Please indicate the number of sites in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all sites. If these are estimates,
please justify them.
Site Count
Individuals Reached
If Estimated, Justify Estimates
The following items pertain to any evaluation activities you have conducted related to this intervention.
25. Has your state started to measure process or implementation indicators for this
intervention?
j
k
l
m
n
Not yet
j
k
l
m
n
Yes
26. Please describe the process or implementation indicator(s) (e.g. number of
people attending a particular training; number of hits to website). You may use
bullets and/or a list.
27. Please describe any results you have from these process or implementation
indicator(s):
28. Has your state started to measure short-term, intermediate or long-term
outcomes from the intervention?
j
k
l
m
n
Not yet
j
k
l
m
n
Yes
29. Please describe the outcome indicator(s) (e.g. decreased TV viewing among high
school students). You may use bullets and/or a list.
30. Please describe any results you have from these outcome indicator(s):
31. Please describe any progress on the intervention that has not already been
reported:
32. Do you have another intervention to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Intervention #8
NOTE: you will be prompted to add additional interventions following this screen if applicable (max of 10).
1. Name of the Intervention
2. Please specify the dates of the intervention's activities (MM/DD/YYYY)
Start Date
End Date
3. Was this intervention designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
4. Is this a multi-site intervention (e.g. community mini-grant programs)?
j
k
l
m
n
No
j
k
l
m
n
Yes
If YES, how many sites does the program have?
If this intervention is multi-site, enter it only ONCE. In the description fields, you may enter information about the grantees/sites
included in the intervention.
5. Please indicate the developmental stage of your intervention
j
k
l
m
n
Planning
j
k
l
m
n
In the field
j
k
l
m
n
Concluded
6. Intended Outcomes (check all that apply)
c
d
e
f
g
Policy change
c
d
e
f
g
Environmental change
c
d
e
f
g
Behavioral change
Description of Intended Outcomes
7. Describe the purpose and where the intervention will be provided
8. Describe the intervention methodology and strategy for implementation
9. In the next series of items, please describe the specific demographics of the state
population that are addressed by the intervention.
Ethnicity:
c
d
e
f
g
Hispanic or Latino
c
d
e
f
g
Not Hispanic or Latino
c
d
e
f
g
General Population (no specific ethnic audiences
addressed)
10. Race
c
d
e
f
g
American Indian or Alaska native
c
d
e
f
g
Native Hawaiian or other Pacific Islander
c
d
e
f
g
Asian
c
d
e
f
g
White
c
d
e
f
g
Black or African-American
c
d
e
f
g
General Population (no specific racial audiences addressed)
11. Gender
c
d
e
f
g
Male
c
d
e
f
g
Female
12. Region/Population
c
d
e
f
g
Rural
c
d
e
f
g
Urban
c
d
e
f
g
Suburban
c
d
e
f
g
Low Income
13. Age Group
c
d
e
f
g
< 2 yrs
c
d
e
f
g
11-13 yrs
c
d
e
f
g
65+
c
d
e
f
g
2-3 yrs
c
d
e
f
g
14-17 yrs
c
d
e
f
g
All Ages
c
d
e
f
g
4-5 yrs
c
d
e
f
g
18-29 yrs
c
d
e
f
g
6-10 yrs
c
d
e
f
g
30-64 yrs
14. Which of the following principal target areas does this intervention specifically
address? (check all that apply)
c
d
e
f
g
Decreasing high energy dense foods
c
d
e
f
g
Increasing fruit and vegetable consumption
c
d
e
f
g
Decreasing sweetened beverage intake
c
d
e
f
g
Increasing physical activity
c
d
e
f
g
Increasing breastfeeding
c
d
e
f
g
Reducing TV viewing
c
d
e
f
g
Other (please specify)
15. Which levels of Socio-Ecologic Framework does this intervention specifically
address?
[See www.cdc.gov/nccdphp/dnpa/obesity/state_programs/se_model.htm for
definitions of each level]
(Check all that apply)
c
d
e
f
g
Individual
c
d
e
f
g
Interpersonal
c
d
e
f
g
Organizational
c
d
e
f
g
Community
c
d
e
f
g
Society
Other
This section asks you to provide the REACH of the intervention.
Notes:
- If you collected intervention specific data on reach, please use those numbers.
- If you did NOT collect data on reach, please estimate the reach of this particular intervention. In the "comments" box, justify and
explain your estimates (i.e. individuals reached is the total number of children at these schools)
16. Please indicate the places or settings in which you are making your intervention
available to your primary audience.
c
d
e
f
g
Community-wide
c
d
e
f
g
Religious organizations/houses of worship
c
d
e
f
g
Schools
c
d
e
f
g
Childcare centers
c
d
e
f
g
Families
c
d
e
f
g
Worksites
c
d
e
f
g
Hospitals, health facilities
c
d
e
f
g
Other (please specify)
17. If you chose COMMUNITY-WIDE
Please indicate the number of communities in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all communities. If
these are estimates, please justify them.
Community Count
Individuals Reached
If Estimated, Justify Estimates
18. If you chose SCHOOLS
Please indicate the number of schools in which you are making your intervention
available
to your primary audience. Then indicate the total number of individuals that
Other
were likely reached by your intervention across all schools. If these are estimates,
please justify them.
School Count
Individuals Reached
If Estimated, Justify Estimates
19. If you chose FAMILIES
Please indicate the number of family units in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all families. If these are estimates,
please justify them.
Family Unit Count
Individuals Reached
If Estimated, Justify Estimates
20. If you chose HOSPITALS, HEALTH SETTINGS
Please indicate the number of healthcare facilities in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all facilities (e.g. total
number of staff reached). If these are estimates, please justify them.
Healthcare Facility Unit Count
Individuals Reached
If Estimated, Justify Estimates
21. If you chose RELIGIOUS ORGANIZATIONS
Please indicate the number of religious organizations in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all organizations. If
these are estimates, please justify them.
Religious Organization Unit Count
Individuals Reached
If Estimated, Justify Estimates
22. If you chose CHILDCARE SETTINGS
Please indicate the number of childcare settings in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all childcare settings.
If these are estimates, please justify them.
Childcare Settings Unit Count
Individuals Reached
If Estimated, Justify Estimates
23. If you chose WORKSITES
Please indicate the number of worksites in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all worksites (e.g. total number of
employees at all sites). If these are estimates, please justify them.
Worksites Unit Count
Individuals Reached
If Estimated, Justify Estimates
24. If you chose OTHER
Please indicate the number of sites in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all sites. If these are estimates,
please justify them.
Site Count
Individuals Reached
If Estimated, Justify Estimates
The following items pertain to any evaluation activities you have conducted related to this intervention.
25. Has your state started to measure process or implementation indicators for this
intervention?
j
k
l
m
n
Not yet
j
k
l
m
n
Yes
26. Please describe the process or implementation indicator(s) (e.g. number of
people attending a particular training; number of hits to website). You may use
bullets and/or a list.
27. Please describe any results you have from these process or implementation
indicator(s):
28. Has your state started to measure short-term, intermediate or long-term
outcomes from the intervention?
j
k
l
m
n
Not yet
j
k
l
m
n
Yes
29. Please describe the outcome indicator(s) (e.g. decreased TV viewing among high
school students). You may use bullets and/or a list.
30. Please describe any results you have from these outcome indicator(s):
31. Please describe any progress on the intervention that has not already been
reported:
32. Do you have another intervention to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Intervention #9
NOTE: you will be prompted to add additional interventions following this screen if applicable (max of 10).
1. Name of the Intervention
2. Please specify the dates of the intervention's activities (MM/DD/YYYY)
Start Date
End Date
3. Was this intervention designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
4. Is this a multi-site intervention (e.g. community mini-grant programs)?
j
k
l
m
n
No
j
k
l
m
n
Yes
If YES, how many sites does the program have?
If this intervention is multi-site, enter it only ONCE. In the description fields, you may enter information about the grantees/sites
included in the intervention.
5. Please indicate the developmental stage of your intervention
j
k
l
m
n
Planning
j
k
l
m
n
In the field
j
k
l
m
n
Concluded
6. Intended Outcomes (check all that apply)
c
d
e
f
g
Policy change
c
d
e
f
g
Environmental change
c
d
e
f
g
Behavioral change
Description of Intended Outcomes
7. Describe the purpose and where the intervention will be provided
8. Describe the intervention methodology and strategy for implementation
9. In the next series of items, please describe the specific demographics of the state
population that are addressed by the intervention.
Ethnicity:
c
d
e
f
g
Hispanic or Latino
c
d
e
f
g
Not Hispanic or Latino
c
d
e
f
g
General Population (no specific ethnic audiences
addressed)
10. Race
c
d
e
f
g
American Indian or Alaska native
c
d
e
f
g
Native Hawaiian or other Pacific Islander
c
d
e
f
g
Asian
c
d
e
f
g
White
c
d
e
f
g
Black or African-American
c
d
e
f
g
General Population (no specific racial audiences addressed)
11. Gender
c
d
e
f
g
Male
c
d
e
f
g
Female
12. Region/Population
c
d
e
f
g
Rural
c
d
e
f
g
Urban
c
d
e
f
g
Suburban
c
d
e
f
g
Low Income
13. Age Group
c
d
e
f
g
< 2 yrs
c
d
e
f
g
11-13 yrs
c
d
e
f
g
65+
c
d
e
f
g
2-3 yrs
c
d
e
f
g
14-17 yrs
c
d
e
f
g
All Ages
c
d
e
f
g
4-5 yrs
c
d
e
f
g
18-29 yrs
c
d
e
f
g
6-10 yrs
c
d
e
f
g
30-64 yrs
14. Which of the following principal target areas does this intervention specifically
address? (check all that apply)
c
d
e
f
g
Decreasing high energy dense foods
c
d
e
f
g
Increasing fruit and vegetable consumption
c
d
e
f
g
Decreasing sweetened beverage intake
c
d
e
f
g
Increasing physical activity
c
d
e
f
g
Increasing breastfeeding
c
d
e
f
g
Reducing TV viewing
c
d
e
f
g
Other (please specify)
15. Which levels of Socio-Ecologic Framework does this intervention specifically
address?
[See www.cdc.gov/nccdphp/dnpa/obesity/state_programs/se_model.htm for
definitions of each level]
(Check all that apply)
c
d
e
f
g
Individual
c
d
e
f
g
Interpersonal
c
d
e
f
g
Organizational
c
d
e
f
g
Community
Other
c Society
d
e
f
g
This section asks you to provide the REACH of the intervention.
Notes:
- If you collected intervention specific data on reach, please use those numbers.
- If you did NOT collect data on reach, please estimate the reach of this particular intervention. In the "comments" box, justify and
explain your estimates (i.e. individuals reached is the total number of children at these schools)
16. Please indicate the places or settings in which you are making your intervention
available to your primary audience.
c
d
e
f
g
Community-wide
c
d
e
f
g
Religious organizations/houses of worship
c
d
e
f
g
Schools
c
d
e
f
g
Childcare centers
c
d
e
f
g
Families
c
d
e
f
g
Worksites
c
d
e
f
g
Hospitals, health facilities
c
d
e
f
g
Other (please specify)
17. If you chose COMMUNITY-WIDE
Please indicate the number of communities in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all communities. If
these are estimates, please justify them.
Community Count
Individuals Reached
If Estimated, Justify Estimates
18. If you chose SCHOOLS
Other
Please indicate the number of schools in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all schools. If these are estimates,
please justify them.
School Count
Individuals Reached
If Estimated, Justify Estimates
19. If you chose FAMILIES
Please indicate the number of family units in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all families. If these are estimates,
please justify them.
Family Unit Count
Individuals Reached
If Estimated, Justify Estimates
20. If you chose HOSPITALS, HEALTH SETTINGS
Please indicate the number of healthcare facilities in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all facilities (e.g. total
number of staff reached). If these are estimates, please justify them.
Healthcare Facility Unit Count
Individuals Reached
If Estimated, Justify Estimates
21. If you chose RELIGIOUS ORGANIZATIONS
Please indicate the number of religious organizations in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all organizations. If
these are estimates, please justify them.
Religious Organization Unit Count
Individuals Reached
If Estimated, Justify Estimates
22. If you chose CHILDCARE SETTINGS
Please indicate the number of childcare settings in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all childcare settings.
If these are estimates, please justify them.
Childcare Settings Unit Count
Individuals Reached
If Estimated, Justify Estimates
23. If you chose WORKSITES
Please indicate the number of worksites in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all worksites (e.g. total number of
employees at all sites). If these are estimates, please justify them.
Worksites Unit Count
Individuals Reached
If Estimated, Justify Estimates
24. If you chose OTHER
Please indicate the number of sites in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all sites. If these are estimates,
please justify them.
Site Count
Individuals Reached
If Estimated, Justify Estimates
The following items pertain to any evaluation activities you have conducted related to this intervention.
25. Has your state started to measure process or implementation indicators for this
intervention?
j
k
l
m
n
Not yet
j
k
l
m
n
Yes
26. Please describe the process or implementation indicator(s) (e.g. number of
people attending a particular training; number of hits to website). You may use
bullets and/or a list.
27. Please describe any results you have from these process or implementation
indicator(s):
28. Has your state started to measure short-term, intermediate or long-term
outcomes from the intervention?
j
k
l
m
n
Not yet
j
k
l
m
n
Yes
29. Please describe the outcome indicator(s) (e.g. decreased TV viewing among high
school students). You may use bullets and/or a list.
30. Please describe any results you have from these outcome indicator(s):
31. Please describe any progress on the intervention that has not already been
reported:
32. Do you have another intervention to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Intervention #10
1. Name of the Intervention
2. Please specify the dates of the intervention's activities (MM/DD/YYYY)
Start Date
End Date
3. Was this intervention designed to address health disparities?
j
k
l
m
n
No
j
k
l
m
n
Yes
If Yes, briefly describe the disparity and/or disparate population:
4. Is this a multi-site intervention (e.g. community mini-grant programs)?
j
k
l
m
n
No
j
k
l
m
n
Yes
If YES, how many sites does the program have?
If this intervention is multi-site, enter it only ONCE. In the description fields, you may enter information about the grantees/sites
included in the intervention.
5. Please indicate the developmental stage of your intervention
j
k
l
m
n
Planning
j
k
l
m
n
In the field
j
k
l
m
n
Concluded
6. Intended Outcomes (check all that apply)
c
d
e
f
g
Policy change
c
d
e
f
g
Environmental change
c
d
e
f
g
Behavioral change
Description of Intended Outcomes
7. Describe the purpose and where the intervention will be provided
8. Describe the intervention methodology and strategy for implementation
9. In the next series of items, please describe the specific demographics of the state
population that are addressed by the intervention.
Ethnicity:
c
d
e
f
g
Hispanic or Latino
c
d
e
f
g
Not Hispanic or Latino
c
d
e
f
g
General Population (no specific ethnic audiences
addressed)
10. Race
c
d
e
f
g
American Indian or Alaska native
c
d
e
f
g
Native Hawaiian or other Pacific Islander
c
d
e
f
g
Asian
c
d
e
f
g
White
c
d
e
f
g
Black or African-American
c
d
e
f
g
General Population (no specific racial audiences addressed)
11. Gender
c
d
e
f
g
Male
c
d
e
f
g
Female
12. Region/Population
c
d
e
f
g
Rural
c
d
e
f
g
Urban
c
d
e
f
g
Suburban
c
d
e
f
g
Low Income
13. Age Group
c < 2 yrs
d
e
f
g
Other
c
d
e
f
g
11-13 yrs
c
d
e
f
g
65+
c
d
e
f
g
All Ages
c
d
e
f
g
2-3 yrs
c
d
e
f
g
14-17 yrs
c
d
e
f
g
4-5 yrs
c
d
e
f
g
18-29 yrs
c
d
e
f
g
6-10 yrs
c
d
e
f
g
30-64 yrs
14. Which of the following principal target areas does this intervention specifically
address? (check all that apply)
c
d
e
f
g
Decreasing high energy dense foods
c
d
e
f
g
Increasing fruit and vegetable consumption
c
d
e
f
g
Decreasing sweetened beverage intake
c
d
e
f
g
Increasing physical activity
c
d
e
f
g
Increasing breastfeeding
c
d
e
f
g
Reducing TV viewing
c
d
e
f
g
Other (please specify)
15. Which levels of Socio-Ecologic Framework does this intervention specifically
address?
[See www.cdc.gov/nccdphp/dnpa/obesity/state_programs/se_model.htm for
definitions of each level]
(Check all that apply)
c
d
e
f
g
Individual
c
d
e
f
g
Interpersonal
c Organizational
d
e
f
g
Other
c
d
e
f
g
Community
c
d
e
f
g
Society
This section asks you to provide the REACH of the intervention.
Notes:
- If you collected intervention specific data on reach, please use those numbers.
- If you did NOT collect data on reach, please estimate the reach of this particular intervention. In the "comments" box, justify and
explain your estimates (i.e. individuals reached is the total number of children at these schools)
16. Please indicate the places or settings in which you are making your intervention
available to your primary audience.
c
d
e
f
g
Community-wide
c
d
e
f
g
Religious organizations/houses of worship
c
d
e
f
g
Schools
c
d
e
f
g
Childcare centers
c
d
e
f
g
Families
c
d
e
f
g
Worksites
c
d
e
f
g
Hospitals, health facilities
c
d
e
f
g
Other (please specify)
17. If you chose COMMUNITY-WIDE
Please indicate the number of communities in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all communities. If
these are estimates, please justify them.
Community Count
Individuals Reached
If Estimated, Justify Estimates
18. If you chose SCHOOLS
Please indicate the number of schools in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all schools. If these are estimates,
please justify them.
School Count
Individuals Reached
If Estimated, Justify Estimates
19. If you chose FAMILIES
Please indicate the number of family units in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all families. If these are estimates,
please justify them.
Family Unit Count
Individuals Reached
If Estimated, Justify Estimates
20. If you chose HOSPITALS, HEALTH SETTINGS
Please indicate the number of healthcare facilities in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all facilities (e.g. total
number of staff reached). If these are estimates, please justify them.
Healthcare Facility Unit Count
Individuals Reached
If Estimated, Justify Estimates
21. If you chose RELIGIOUS ORGANIZATIONS
Please indicate the number of religious organizations in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all organizations. If
these are estimates, please justify them.
Religious Organization Unit Count
Individuals Reached
If Estimated, Justify Estimates
22. If you chose CHILDCARE SETTINGS
Please indicate the number of childcare settings in which you are making your
intervention available to your primary audience. Then indicate the total number of
individuals that were likely reached by your intervention across all childcare settings.
If these are estimates, please justify them.
Childcare Settings Unit Count
Individuals Reached
If Estimated, Justify Estimates
23. If you chose WORKSITES
Please indicate the number of worksites in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all worksites (e.g. total number of
employees at all sites). If these are estimates, please justify them.
Worksites Unit Count
Individuals Reached
If Estimated, Justify Estimates
24. If you chose OTHER
Please indicate the number of sites in which you are making your intervention
available to your primary audience. Then indicate the total number of individuals that
were likely reached by your intervention across all sites. If these are estimates,
please justify them.
Site Count
Individuals Reached
If Estimated, Justify Estimates
The following items pertain to any evaluation activities you have conducted related to this intervention.
25. Has your state started to measure process or implementation indicators for this
intervention?
j
k
l
m
n
Not yet
j
k
l
m
n
Yes
26. Please describe the process or implementation indicator(s) (e.g. number of
people attending a particular training; number of hits to website). You may use
bullets and/or a list.
27. Please describe any results you have from these process or implementation
indicator(s):
28. Has your state started to measure short-term, intermediate or long-term
outcomes from the intervention?
j
k
l
m
n
Not yet
j
k
l
m
n
Yes
29. Please describe the outcome indicator(s) (e.g. decreased TV viewing among high
school students). You may use bullets and/or a list.
30. Please describe any results you have from these outcome indicator(s):
31. Please describe any progress on the intervention that has not already been
reported:
32. Do you have another intervention to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
If Yes, how many? You will not be able to provide additional information about them.
Other Accomplishments and Summary
1. Please describe any resource material and/or training that you (the state DOH)
developed that other states could potentially use as a part of their obesity
prevention programs?
Only include tools that you have developed during the last 12 months. (in 250 words
or less)
2. Please briefly describe your FIVE most significant accomplishments in the last 12
months. This may include products or accomplishments of the state program,
partners, mini-grant recipients, etc.
You will also have the opportunity to highlight a specific accomplishment of your state
program in more depth in the Stories from the Field section.
3. Please describe what you consider the most important success of your program to
date.
Stories from the Field
The questions in this section enable you to tell the story of the efforts you’ve accomplished in planning, developing,
and implementing your State program. For the purposes of this section, please choose ONE story that illustrates the
innovative, unique, and/or exciting activities in which you are involved. The items below will guide you through the
process of describing the story in detail. As you work through this section you may come across items which are not
applicable to your circumstances. If so, please enter "NA" in the relevant text box.
Where indicated, please write 1-2 paragraphs addressing the relevant portion of the story. Use complete sentences
and consistent tense throughout the responses where appropriate and provide as much depth as possible. We
encourage you to use quotes to illustrate aspects of your story.
After submitting your responses, staff will compile the information into a narrative story so that it can be used for
accountability, program improvement and technical assistance. Before the information is shared with others, you will
be asked to provide feedback on the compiled content to ensure accuracy.
If you have questions while filling out this section, please contact the DNPAO Evaluation Team
([email protected]). Thanks for taking the time to share your story with us!
1. Please provide the name and contact information for the primary contact related
to this story. CDC staff may contact this person to obtain additional details or
feedback.
Name
Phone Number
Email Address
2. Please indicate a theme or focus for your story. The options below represent five
of the awardee activities presented in the FOA and can be used as a guideline to
focus your story. If your story does not fit the topics presented, feel free to use the
"Other" field that is provided.
j
k
l
m
n
Developing and maintaining program infrastructure
j
k
l
m
n
Leading a planning process to develop a state plan
j
k
l
m
n
Implementing the state plan in collaboration with partners
j
k
l
m
n
Supporting and/or developing capacity for surveillance
j
k
l
m
n
Evaluation progress of meeting objectives in the state plan, implementation plan, work plan, partnership plan.
j
k
l
m
n
Other (please specify)
3. Please provide a TITLE for your story:
4. Which levels of Socio-Ecologic Framework does this story address?
[See www.cdc.gov/nccdphp/dnpa/obesity/state_programs/se_model.htm for
definitions of each level]
(Check all that apply)
c
d
e
f
g
Individual
c
d
e
f
g
Interpersonal
c
d
e
f
g
Organizational
c
d
e
f
g
Community
c
d
e
f
g
Society
5. If applicable, which of the following principal target areas does this story address?
(check all that apply)
c
d
e
f
g
Decreasing high energy dense foods
c
d
e
f
g
Increasing fruit and vegetable consumption
c
d
e
f
g
Decreasing sweetened beverage intake
c
d
e
f
g
Increasing physical activity
c
d
e
f
g
Increasing breastfeeding
c
d
e
f
g
Reducing TV viewing
c
d
e
f
g
Other (please specify)
Stories from the Field - The Story
1. What need did your efforts address?
In 1-2 paragraphs, please describe the circumstances or problem(s) that initiated
the action.
2. In 1-2 paragraphs, please explain the actions you took.
Be sure to include all parties involved and any costs or other resources associated
with your efforts. Please provide sufficient detail in case others would like to
replicate your actions.
Stories from the Field - Results
1. Please write 1- 2 paragraphs describing the results of your efforts (intended or
unintended).
Where appropriate include information about
(a) new partnerships formed;
(b) new organizational processes (e.g. changes in culture/norms, organization
behavior, policies initiated, policies considered, etc);
(c) how your approach led to a more effective program;
(d) the potential public health impact of your efforts
2. Quotes
If possible, please include a specific quote from program staff or partners that would
support your story.
If we use the quote we will only identify the person by their title, and not their name.
However, please include the full contact information for the person being quoted so
we may contact them to gain their approval to use the quote.
Stories from the Field - Facilitators and Challenges
1. Facilitators to Planning, Implementation, and Development
Write 1-2 paragraphs describing three key elements that facilitated your efforts.
Examples of potential facilitating elements include:
(a) specific resources (including personnel or funding mechanisms) that facilitated
your efforts;
(b) support from particular stakeholders;
(c) partnerships with new or existing partners.
2. Barriers to Planning, Implementation, and Development
Write 1-2 paragraphs describing the challenges or barriers you faced in your efforts.
3. Overcoming Barriers
Write 1-2 paragraphs describing how your organization was able to overcome the
challenges/barriers you described above. If you were not able to, what could help
your organization to overcome these challenges?
Stories from the Field - Lessons for Moving Forward
1. What tips do you have for using /adapting this approach in another
organization/community?
Feel free to use bullets or a list format if you prefer.
2. What would your organization do differently to enhance your planning,
implementation, or development processes related to this effort?
3. OPTIONAL: While we are only soliciting information about ONE story, if your
program has additional successes that would make a good story, please let us know.
In the box below, please briefly (1-2 sentences) describe any additional stories your
program would like to share and the contact information for a person who could
elaborate on the story. DNPAO Evaluation Staff may contact that person to followup.
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| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |