Table of revisions

Attachment 2

The following Table of Revisions provides detailed information regarding the proposed changes to the data collection instrument.

Proposed Revisions to Data Items

Data Items from 2008 OMB submission	Section in attached SPIRS tool	Suggested changes to items	Description of changes
	Introduction	Please provide the following information for verification purposes: Your Name: State:	Added name and state completing the SPIRS to identify the state submitting their report and in case CDC needs to contact them for clarification of data entered.
I2: 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 and educational qualifications (select all that apply), the content area of their degree, % time dedicated to this effort, the source paying for the position (select all that apply and, if there are multiple sources, indicate the % FTE covered by each source), the date he/she started working on the project (month/year), staff type permanent/interim), and expertise areas (select all that apply). Be sure to capture all FTE’s dedicated to this effort in the State Health Department (including contracts). You must include all FTE dedicated to this effort, even if you reported them in a previous PMR. NOTE: You will be prompted to add additional FTE's following this screen, if applicable. Staff Name Position [drop down box] Degree Content Area [drop down box] Source of Funds (Check all that apply) __Nutrition and Physical Activity Program to Prevent Obesity and Other Chronic Diseases cooperative agreement __Other CDC funding __State funds __Foundation funds __Other (Please specify) If OTHER source of CDC funding, please specify: _________________ If OTHER source of funds, please specify: _____________________ Percent of salary covered by cooperative agreement Percent of salary covered by other CDC funding Percent of salary covered by state funds Percent of salary covered by foundation funds Percent of salary covered by other sources Staff Type __Permanent __Interim Expertise area [drop down box]	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 2. Position 3. Staff Type 4. Date Staff Started Working on Project (DD/MM/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? Note—Last question at end of staffing section: If Yes, how many?	Revise items for clarification; deleted expertise areas
I4: Please select all of the following CDC trainings in which state Nutrition and Physical Activity Program to Prevent Obesity and Other Chronic Diseases staff participated during the past 6 months. I4g: For California Child Obesity Conference: "Protecting the Future of Our Children" in Anaheim January 24 - 26, 2007, please provide the position(s) of Nutrition & Physical Activity Program to Prevent Obesity and Other Chronic Diseases staff who attended, making sure to mark all that apply. I4h: For Evaluation Workshop: The Big Picture: Getting to the Evaluation of the State Plan May 21-24, 2007, please provide the position(s) of Nutrition & Physical Activity Program to Prevent Obesity and Other Chronic Diseases staff who attended, making sure to mark all that apply. I9: Were there any other CDC trainings not previously listed in which state Nutrition & Physical Activity Program to Prevent Obesity and Other Chronic Diseases staff participated? I8: Please list the other training event, date attended, and the position(s) of Nutrition & Physical Activity Program to Prevent Obesity and Other Chronic Diseases staff who attended, making sure to mark all that app I10: Other than DNPA-provided training, were any trainings that you attended during this reporting period particularly useful for building capacity or staff expertise in the major program content areas (e.g., physical activity, fruits and vegetables, breastfeeding, TV watching, nutrition, social marketing, media advocacy, evaluation) or obesity prevention and control? I11: Please indicate which functional/content area(s) (e.g., physical activity, fruits and vegetables, breastfeeding, TV watching, nutrition, social marketing, media advocacy, evaluation) and briefly describe what you learned. I13: What actions were taken based on the training(s) program staff have attended to date (for example, describe how skills or "take away" messages have been applied or shared with partners)?			These items will be removed.
R5: Please select all sources of funds outside this CDC-DNPA cooperative agreement that have been obtained in the most recent reporting period for the state nutrition and physical activity program or the accomplishment of the state plan. R6: For federal programs, please provide the name of the funder, approximate amount, and the purpose of funding. Name of Federal Program(s) Providing Funding Amount Purpose of Funding _ Infrastructure (e.g., staffing) _Planning/programs _Evaluation/surveillance _Other (Please specify) If OTHER purpose, please specify R8: For state programs, please provide the approximate amount and purpose of funding. R9: For foundation grants, please provide the approximate amount and purpose of funding. R10: For contributions from private business, please provide the approximate amount and purpose of funding. If OTHER purpose, please specify R12: For this other source of non-CDC funds, please identify the source/program and provide the approximate amount and purpose of funding.	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. 2. For FEDERAL PROGRAMS, please provide the name of each funder and the approximate amount. 3. For STATE PROGRAMS, please provide the name of each funder and the approximate amount. 4. For FOUNDATION FUNDS, please provide the name of each funder and the approximate amount. 5. For CONTRIBUTIONS FROM PRIVATE BUSINESS, please provide the name of each funder and the approximate amount. 6. For OTHER FUNDS, please provide the name of each funder, and the approximate amount.	Removed sub-items about purpose of each funding source.
C3: Please provide your three most important partners (by organization—not individuals) for governmental health agencies (federal, state, or local). Use the check boxes to indicate how each partner contributed to the state plan or program during the past 6 months (i.e., not every partner will be included every 6-month reporting period). In addition, please indicate whether the partnership was pre-existing before this funding period or is a new partnership (i.e., the partner was added during the funding period). Finally, please indicate whether there is a Memorandum of Understanding (MOU) with the organization. C5: Please provide your three most important partners (by organization—not individuals) for voluntary agencies/community-based organizations. Use the check boxes to indicate how each partner contributed to the state plan or program within the past 6 months (i.e., not every partner will be included every 6-month reporting period). In addition, please indicate whether the partnership was pre-existing before this funding period or is a new partner (i.e., the partner was added during the funding period). Finally, please indicate whether there is a Memorandum of Understanding (MOU) with the organization. C7: Please provide your three most important partners (by organization—not individuals) for health care. Use the check boxes to indicate how each partner contributed to the state plan or program within the past 6 months (i.e., not every partner will be included every 6-month reporting period). In addition, please indicate whether the partnership was pre-existing before this funding period or is a new partner (i.e., the partner was added during the funding period). Finally, please indicate whether there is a Memorandum of Understanding (MOU) with the organization. C9: Please provide your three most important partners (by organization—not individuals) for private sector businesses. Use the check boxes to indicate how each partner contributed to the state plan or program within the past 6 months (i.e., not every partner will be included every 6-month reporting period). In addition, please indicate whether the partnership was pre-existing before this funding period or is a new partner (i.e., the partner was added during the funding period). Finally, please indicate whether there is a Memorandum of Understanding (MOU) with the organization. C11: Please provide your three most important partners (by organization—not individuals) for organizations focusing on health disparities (e.g., rural, racial/ethnic, aging). Use the check boxes to indicate how each partner contributed to the state plan or program within the past 6 months (i.e., not every partner will be included every 6-month reporting period). In addition, please indicate whether the partnership was pre-existing before this funding period or is a new partner (i.e., the partner was added during the funding period). Finally, please indicate whether there is a Memorandum of Understanding (MOU) with the organization. C13: Please provide your three most important partners (by organization—not individuals) for state/local departments of education. Use the check boxes to indicate how each partner contributed to the state plan or program within the past 6 months (i.e., not every partner will be included every 6-month reporting period). In addition, please indicate whether the partnership was pre-existing before this funding period or is a new partner (i.e., the partner was added during the funding period). Finally, please indicate whether there is a Memorandum of Understanding (MOU) with the organization. C15: Please provide your three most important partners (by organization—not individuals) for universities, medical schools or schools of public health. Use the check boxes to indicate how each partner contributed to the state plan or program within the past 6 months (i.e., not every partner will be included every 6-month reporting period). In addition, please indicate whether the partnership was pre-existing before this funding period or is a new partner (i.e., the partner was added during the funding period). Finally, please indicate whether there is a Memorandum of Understanding (MOU) with the organization. C17: Please provide your three most important partners (by organization—not individuals) for nutrition organizations. Use the check boxes to indicate how each partner contributed to the state plan or program within the past 6 months (i.e., not every partner will be included every 6-month reporting period). In addition, please indicate whether the partnership was pre-existing before this funding period or is a new partner (i.e., the partner was added during the funding period). Finally, please indicate whether there is a Memorandum of Understanding (MOU) with the organization. C19: Please provide your three most important partners (by organization—not individuals) for physical activity organizations. Use the check boxes to indicate how each partner contributed to the state plan or program within the past 6 months (i.e., not every partner will be included every 6-month reporting period). In addition, please indicate whether the partnership was pre-existing before this funding period or is a new partner (i.e., the partner was added during the funding period). Finally, please indicate whether there is a Memorandum of Understanding (MOU) with the organization. C21: Please provide your most important partners (by organization—not individuals) for professional organizations. Use the check boxes to indicate how each partner contributed to the state plan or program within the past 6 months (i.e., not every partner will be included every 6-month reporting period). In addition, please indicate whether the partnership was pre-existing before this funding period or is a new partner (i.e., the partner was added during the funding period). Finally, please indicate whether there is a Memorandum of Understanding (MOU) with the organization. C23: Are there other types of organization (e.g., non-profits, coalitions) partners you'd like to list? C24: Please provide your three most important partners (by organization—not individuals) for other types of organizations (e.g., non-profits, coalitions). Use the check boxes to indicate how each partner contributed to the state plan or program within the past 6 months (i.e., not every partner will be included every 6-month reporting period). In addition, please indicate whether the partnership was pre-existing before this funding period or is a new partner (i.e., the partner was added during the funding period). Finally, please indicate whether there is a Memorandum of Understanding (MOU) with the organization. C26: Were any new coalitions/task forces/committees/work groups related to the Nutrition & Physical Activity Program to Prevent Obesity and Other Chronic Diseases initiative (i.e., groups formally organized to address a specific issue, topic, or program objective in order to move forward) established during this reporting period? (Examples include evaluation advisory boards, evaluation task forces, surveillance task forces, task force on funding & resources, task force on older adults, task force on school-aged children.) C27: Please provide the name of the group/organization and its purpose. C29: Please provide the 3 main activities that existing coalitions/task forces/committees/work groups conducted in this reporting period. (Briefly describe new efforts of the group, progress on current efforts, and accomplishments.) C30: Were any coalitions/task forces/committees/work groups disbanded during this reporting period? This includes any organizations that are no longer partners. C31: Please provide the names of the coalitions/task forces/committees/work groups that were disbanded during this reporting period. This includes any organizations that are no longer partners.			These items will be removed.
C32: Please give at least one example of a successful collaboration with an internal partner (i.e., within state health department) in the development, use and/or implementation of the state plan. C33: Please give at least one example of successful collaboration with an external partner (i.e., partners other than state health department) in the development, use and/or implementation of the state plan.	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.	Same questions
C34: Please briefly describe any lessons learned through working with internal partners (i.e., state government), including the issues that arose and how they were addressed. C35: Please briefly describe any lessons learned through working with external partners (i.e., other than state government), including the issues that arose and how they were addressed.			These items will be removed.
C36: Do you have one or more “champions” external to the DOH that helped move the obesity prevention and control program forward? C37: Please list the "champion" organization and describe their actions taken on behalf of the state program during this report period.		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? 4. Please list the "champion" organization(s) and describe their actions taken on behalf of the state program.	Similar questions
PL3: Has a state plan for nutrition and physical activity been produced during the past 6 months?	Planning	1. Has a state plan for nutrition and physical activity been produced during the past twelve months?	Time frame is revised.
PL4: Please briefly describe the status of your state plan for nutrition and physical activity. PL5: Please submit two copies of this report, if it has not been submitted previously. Please provide the title, publication date and whom it was distributed to. PL9: Was the state plan revised during this reporting period? If so, please briefly describe the status of the revision, and note when it was (or will be) shared with CDC. PL10: Did you use the State Plan Index (SPI) to guide the development or the revision of your state plan? If so, please describe. PL11: Did your state involve members of the general state population in developing the state plan? PL12: Please select from the following choices those activities your state conducted to include and involve members of the general state population in developing the state plan. PL13: Summarize the main feedback or recommendations resulting from the town hall meetings. PL14: Summarize the main feedback or recommendations resulting from the hearings. PL16: Summarize the main feedback or recommendations resulting from the focus groups about the state planning process or plan. PL17: Summarize the main feedback or recommendations resulting from the solicited written comments. PL19: Was there another activity not covered earlier that you would like to report? PL20: Identify the activity and summarize the main feedback or recommendations resulting from this activity. PL21: In about 150 words or less, tell us about what you’ve done as part of the state planning process to understand your target populations as part of the State Planning Process. This can include the processes or methods, sources of information, organizations consulted, and so on. PL22: Did you use the Guide to Community Preventive Services (i.e., the Community Guide, found at www.thecommunityguide.org) to guide the plan and/or identify evidence-based interventions? If so, please describe. PL23: Is the logic model for the overall state plan developed? If so, please provide the date of completion. PL24: We want the PMR to capture all your state plan objectives. Since your objectives probably won't change a great deal once they are developed as part of the state planning process, you won't need to enter them every reporting period. Please briefly state an objective contained in the plan. Remember that objectives are supposed to be specific, measurable, achievable, relevant, and time-bound (SMART). We will refer to these objectives again later in this progress report. PL26: Please describe any actions your state took as part of the state planning process to assess existing obesity prevention and control efforts. PL27: Please describe any other actions taken (not described previously) to assess gaps in service and/or opportunities for additional service. PL28: Please describe any other actions taken (not described previously) to assess barriers to service. PL30: Please describe an example of how utilizing the social-ecologic model has been particularly helpful in preparing your state plan—in its development or its implementation—(e.g., selection of target populations, data sources, partners, etc.).			These items will be removed.
	Health Disparities	1. In which way(s) does your state program and/or state plan include efforts to address health disparities?	Question added to assess a new emphasis area in the new cooperative agreement.
PO3: Were there any policy changes affecting overweight/obesity (e.g., nutrition, physical activity, TV watching, breastfeeding) initiated, modified, or enforced in your state during this reporting period? {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.} NOTE: Legislative acts involving policy and environmental changes should only be included in the legislative section (PO11). If yes, how many? PO5: The next couple of questions will be asked regarding each policy affecting overweight/obesity that was initiated or modified in the last 6 months one at a time. Please briefly describe the policy. Was this policy initiated locally or at the state level? Was this policy enacted?	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] 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). 3. Was this policy initiated locally or at the state level? 4. Describe the policy: 5. Was this policy designed to address health disparities? If yes, briefly describe the disparity and/or disparate population. 6. Do you have another policy intervention to report? Note—Last question at end of policy section: If Yes, how many? You will not be able to provide additional information about them.	Timeframe is revised. Health disparity question added.
PO11: Were any legislative acts or local ordinances affecting overweight/obesity (e.g., nutrition, physical activity, TV watching, breastfeeding) initiated, modified, or enforced during this reporting period? {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 to include obesity funding, bills supporting breastfeeding, bills supporting physical activity and proper nutrition in schools, etc.} If yes, how many? PO13: The next couple of questions will be asked regarding each legislative act or local ordinance initiated or modified in the past 6 months one at a time. Please briefly describe the legislative act or local ordinance. Name Senate or House Number Describe Was this legislation or local ordinance initiated locally or at the state level? Was this legislation or local ordinance enacted in your state?	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.] 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 3. Describe: 4. Was this legislation or local ordinance INITIATED locally or at the state level? 5. Was this legislation or local ordinance ENACTED in your state? If yes, provide the date enacted. 6. Was this legislation designed to address health disparities? If yes, briefly describe the disparity and/or disparate population. 7. Do you have additional legislation or local ordinances to report? Note--Last question at end of legislation section: If Yes, how many? You will not be able to provide additional information about them.	Timeframe is revised. Health disparity question added.
PO19: Did your state implement any other 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)? {NOTE: Examples include Rails to Trails programs, the closing of a dangerous street located near a school property, zoning/planning for parks and other recreational areas, etc.} If yes, how many? PO21: The next couple of questions will be asked regarding each environmental change initiated affecting overweight/obesity one at a time. Please briefly describe the environmental change. Name Describe Was this environmental change initiated locally or at the state level? Was this environmental change implemented?	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. 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? 4. Describe 5. Was this environmental change designed to address health disparities? If yes, briefly describe the disparity and/or disparate population. 6. Do you have another environmental change to report? Note—Last question after environmental changes section: If Yes, how many? You will not be able to provide additional information about them.	Same questions. Health disparity question added.
DS3: Did your state use data sources to monitor (a) the burden of obesity and other chronic diseases, (b) physical activity trends, or (c) nutrition trends as related to obesity and other chronic diseases? DS4: Indicate the data sources your state uses for monitoring over time. (Check all that apply.) DS5: Indicate the variables from the Behavioral Risk Factor Surveillance System (BRFSS) your state uses for monitoring over time. (Check all that apply.) DS8: Indicate the variables from Youth Risk Behavior Surveillance System your state uses for monitoring over time. (Check all that apply.) DS11: Indicate the variables from Pediatric Nutrition Surveillance System your state uses for monitoring over time. (Check all that apply.) DS14: Indicate the variables from Pregnancy Nutrition Surveillance System your state uses for monitoring over time. (Check all that apply.) DS17: Indicate the variables from Pregnancy Risk Assessment Monitoring System (PRAMS) your state uses for monitoring over time. (Check all that apply.) DS21: Indicate the variables from Youth Tobacco Survey your state uses for monitoring over time. (Check all that apply.) DS18: Indicate the variables from State developed surveillance system(s) or surveys your state uses for monitoring over time. (Check all that apply.) DS19: Please indicate how BMI was collected. DS24: Is there another data source/system you would like to report? DS25: Identify the data source/system and indicate the variables your state uses for monitoring over time. (Check all that apply.) DS27: Is it a state-developed surveillance system established for some other purpose? DS28: Please indicate the original purpose of the system. DS29: Please indicate how BMI was collected. DS31a: In how many different media has your state reported results in the last 6 months? Please also provide the titles of papers, speeches, etc. that you used to report the results and attach relevant examples. DS31b: To whom (audience) and on what topic has your state reported within the last 6 months?			These items will be removed.
IM4: Please provide the name of the intervention and a description of the intervention. Intervention Name Describe the purpose and where the intervention will be provided Description of intervention methodology and strategy for implementation Please check the intended outcomes of your intervention and briefly describe them in the text box below. IM7: Please specify the dates of the intervention's activities: Start Date (MM/YYYY) End Date (MM/YYYY) IM8: What specific demographics of the state population are addressed by this intervention? (Check all that apply.) Ethnicity Race Gender Area Age Group IM24: Which of the following principal target areas does this intervention specifically address? (Check all that apply.) IM25: Which levels of social structure does this intervention specifically address? (Check all that apply.) IM34: Please indicate the places or settings in which you are making your intervention available to your primary audience. In the questions that follow, we will ask you about the number of locations that are available for each (e.g., how many communities, how many schools, etc.), and the total number of individuals reached in that setting. IM34a: Please indicate the number of communities in which you are making your intervention available to your primary audience (the count) and the total number of individuals reached in that community. IM34b: Please indicate the number of schools in which you are making your intervention available to your primary audience (the count) and the total number of individuals reached in those schools. IM34c: Please indicate the number of worksites in which you are making your intervention available to your primary audience (the count) and the total number of individuals reached in those worksites. IM34d: Please indicate the number of family settings in which you are making your intervention available to your primary audience (the count) and the total number of individuals reached in those settings. IM34e: Please indicate the number of hospital settings in which you are making your intervention available to your primary audience (the count) and the total number of individuals reached in those hospital settings. IM34f: Please indicate the number of places of worship in which you are making your intervention available to your primary audience (the count) and the total number of individuals reached in those places of worship. IM34g: Please indicate the number of childcare settings in which you are making your intervention available to your primary audience (the count) and the total number of individuals reached in those childcare settings. IM34h: Please indicate the number of other places or settings in which you are making your intervention available to your primary audience (the count) and the total number of individuals reached in those other settings. EV29a: Has your state started to measure process or implementation indicators from the interventions? EV29b: Please describe the process or implementation indicator(s) (e.g., number of people reached by the intervention) and the results of any statistical analyses from the evaluation. EV30: Has your state started to measure short-term, intermediate, or long-term outcomes from the interventions? EV31: Please describe the outcome indicator(s) (e.g., decreased television viewing among high school students or passing new school vending machine policies) and the results of any analyses from the evaluation. EV34a: Please describe any progress on the intervention that has not already been reported.	Implementa-tion	1. Name of the Intervention 2. Please specify the dates of the intervention's activities (DD/MM/YYYY) 3. Was this intervention designed to address health disparities? If yes, briefly describe the disparity and/or disparate population. 4. Is this a multi-site intervention (e.g. community mini-grant programs)? If YES, how many sites does the program have? 5. Please indicate the developmental stage of your intervention 6. Intended Outcomes (check all that apply) 7. Describe the purpose and where the intervention will be provided 8. Describe the intervention methodology and strategy for implementation In the next series of items, please describe the specific demographics of the state population that are addressed by the intervention. 9. Ethnicity 10. Race 11. Gender 12. Region/Population 13. Age Group 14. Which of the following principal target areas does this intervention specifically address? 15. Which levels of Socio-Ecologic Framework does this intervention specifically address? 16. Please indicate the places or settings in which you are making your intervention available to your primary audience. 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. 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. 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. 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. 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. 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. 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. 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. 25. Has your state started to measure process or implementation indicators for this intervention? 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? 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? Note—Last question at end of implementation section: If Yes, how many? You will not be able to provide additional information about them.	Similar questions
IM5: List the SMART objectives of the intervention. IM6: Which specific objective(s) from your state plan does this intervention address? (Please refer to the objectives you identified previously in the Planning section of this questionnaire. You may copy and paste the relevant objectives.) IM9: Please briefly describe how you selected this target population. IM25: An intervention should be grounded in theory and applied within the Socio-Ecologic Framework [i.e., should foster behavior change by mobilizing multiple levels of social structure (individual, interpersonal, organizational, community, and societal)]. Which of the following theories provides the basis for your intervention? IM26: Briefly describe how this intervention fosters behavior change by mobilizing the Individual level of social structure (e.g., promote increased awareness, knowledge, and motivation). IM27: Briefly describe how this intervention fosters behavior change by mobilizing the Interpersonal level of social structure (e.g., teach families or enhance their skills needed to make desired changes). IM28: Briefly describe how this intervention fosters behavior change by mobilizing the Organizational level of social structure (e.g., foster a supportive social environment; provide opportunities to practice new skills and behaviors in a safe setting). IM29: Briefly describe how this intervention fosters behavior change by mobilizing the Community level of social structure (e.g., establish and maintain a supportive physical environment). IM30: Briefly describe how this intervention fosters behavior change by mobilizing the Societal/Media level of social structure (e.g., establish and enforce supportive policies; conduct media campaign). IM35: Please describe any barriers that have been encountered with regard to implementing the intervention. IM36: Please describe the solutions that were developed to overcome these barriers. IM38a: Did your worksite activities fit the definition of the worksite-based multi-component nutrition and physical activity strategies? [The Obesity Chapter of the Guide to Community Preventive Services found sufficient evidence of the effectiveness of multi-component intervention programs to prevent obesity in the worksite setting.] IM39: Please indicate which, if any, of the following recommended strategies from CDC's Increasing Physical Activity: A Report on Recommendations of the Task Force on Community Preventive Services were included in the intervention. IM40: In less than 100 words please specifically describe how your activities fit the definition. Community-wide campaigns IM42: In less than 100 words please specifically describe how your activities fit the definition. Individually adapted health behavior change programs IM44: In less than 100 words please specifically describe how your activities fit the definition. School-based PE IM46: In less than 100 words please specifically describe how your activities fit the definition. Social support interventions in community settings IM48: In less than 100 words please specifically describe how your activities fit the definition. Creation of or enhanced access to places for physical activity combined with informational outreach activities IM50: In less than 100 words please specifically describe how your activities fit the definition. Point-of-decision prompts IM51a: In less than 100 words please specifically describe how your activities fit the definition. Community-scale urban design and land use policies and practices IM51c: In less than 100 words please specifically describe how your activities fit the definition. Street-scale urban design and land use policies and practices IM52: Please indicate which, if any, of the following recommended strategies from CDC's Breastfeeding --Strategy for Reducing Childhood Overweight and Related Chronic Diseases were included in the intervention. IM53: In less than 100 words please specifically describe how your activities fit the definition. Breastfeeding education and programs IM55: In less than 100 words please specifically describe how your activities fit the definition. Telephone or in-home breastfeeding support (peer counseling) IM57: In less than 100 words please specifically describe how your activities fit the definition. Implementation of Ten Steps to Successful Breastfeeding IM59: In less than 100 words please specifically describe how your activities fit the definition. Training for Health Care Professionals IM61: In less than 100 words please specifically describe how your activities fit the definition. Prenatal breastfeeding education for women who work IM63: In less than 100 words please specifically describe how your activities fit the definition. Policies providing information on breastfeeding and services that are available for women who work IM65: In less than 100 words please specifically describe how your activities fit the definition. Breastfeeding Mothers’ Room on the worksite IM67: In less than 100 words please specifically describe how your activities fit the definition. Social marketing and/or media campaigns IM71: Complete this item for all nutrition interventions. Please check which of the following specific components were included in the intervention, making sure to check only those boxes for which your intervention activities conform to the definition. IM72: In less than 100 words, please describe how your activities fit the definition. Social support IM74: In less than 100 words, please describe how your activities fit the definition. Interactive activities involving food IM76: In less than 100 words, please describe how your activities fit the definition. Goal setting IM84: In less than 100 words, please describe how your activities fit the definition. Community-wide campaigns IM86: In less than 100 words, please describe how your activities fit the definition. Informational campaigns IM88: In less than 100 words, please describe how your activities fit the definition. Policies IM90: In less than 100 words, please describe how your activities fit the definition. Creation or modification of physical environment IM92: In less than 100 words, please describe how your activities fit the definition. Point-of-decision prompts IM94: In less than 100 words, please describe how your activities fit the definition. Informational outreach activities IM96: In less than 100 words, please describe how your activities fit the definition. Screening IM98: Did you use any of the following promising strategies (interventions that we have reason to believe will be effective; however, they do not appear in the Community Guide as recommended interventions because we don’t yet have sufficient scientific evidence of their effectiveness)? IM99: Please describe your use of this promising strategy: Increased fruit and vegetable consumption in diet for weight management. IM100: Please describe your use of this promising strategy: Decreased soft drinks or sweetened beverages in diet for weight management IM101: Please describe your use of this promising strategy: Paying attention to portion sizes. IM102: Were any other intervention strategies used? If so, please describe the intervention strategy and its source or evidence that it is effective in changing body weight and/or health behavior. EV18: Have you developed an evaluation plan for this intervention? If so, please provide the date of completion. EV19: Did you use the CDC Framework for Program Evaluation in Public Health to develop the evaluation plan or conduct evaluations? EV20: If you didn’t use this, what evaluation framework did you use? EV21: Is there a separate logic model related to the evaluation plan for the intervention? EV22: Did stakeholders participate in designing or conducting the evaluation of your intervention(s)? EV23: Please check those activities your state specifically conducted to include and involve stakeholders in the evaluation of the intervention. EV24: Describe the major recommendations with regard to your evaluation advisory board. EV25: Describe the major recommendations with regard to your community advisory group. EV26: Describe the major recommendations with regard to focus groups about evaluating the intervention. EV27: Describe the major recommendations with regard to solicited written comments. EV28: Describe the major recommendations with regard to other activities where stakeholders participated in designing or conducting the evaluation of your intervention. EV29: Please briefly describe in 100 words or less your methods for evaluating the intervention. EV29c: Please list what data sources were used to measure these indicators. EV32: Please list what data sources were used to measure these outcomes. EV37: Please explain what you have done to ensure that you will be able to detect realistic changes in postintervention outcome measures when compared with pre-intervention measures (e.g., power calculations). EV33: Have you reported any evaluation results during the past 6 months, including process or implementation evaluation results? EV34: Please list the topic, and to whom (i.e., the audience) and how (i.e., the medium) you reported these results. Please also provide the title of the paper, speech, etc. that you used to report the results and attach relevant example(s).			These items will be removed
EV3: Have you developed a plan for monitoring the implementation of the state plan objectives? If so, please provide the date of completion. EV14: Please briefly describe in 100 words or less how you are monitoring your implementation of the state plan objectives. EV15: For each of the state objectives you identified earlier in this instrument, please list the indicator(s) you are using to track progress toward that objective. Party Responsible Implementation Indicator(s) Outcome Indicator(s) Results To Date IM110: Are you funded as a basic implementation state? IM111: In regard to collaboration with partners on secondary prevention strategies, please describe any secondary prevention programs in place (i.e., treatment of obesity), in less than 250 words. EV39: Briefly describe how the State DOH assisted with disseminating the resources/training in the last 6 months (in 250 words or less). S1: Please use this space to tell us about any thing that has occurred during this reporting period that you don’t feel you had the chance to address under a specific recipient activity. You may upload attachments if you find them relevant. S4: We welcome your comments and suggestions for improving this progress report.			These items will be removed
EV38: Please describe any resources and/or training that you (the state DOH) developed that other states could use as a part of their obesity prevention programs in the last 6 months (in 250 words or less). S2: Please briefly describe your five most significant accomplishments in the last 6 months. This would include products or accomplishments of the state program, partners, mini-grant recipients, etc. Consider this an opportunity to highlight the results of your efforts. S3: Please describe what you consider the most important success of your program to date.	Other Accomplish-ments 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? 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. 3. Please describe what you consider the most important success of your program to date.	Timeframe is modified.
	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. 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. 2. Please indicate a theme or focus for your story: 3. Please provide a TITLE for your story: 4. Which levels of Socio-Ecologic Framework does this story address? 5. If applicable, which of the following principal target areas does this story address? 1. What need did your efforts address? 2. In 1-2 paragraphs, please explain the actions you took. 1. Please write 1- 2 paragraphs describing the results of your efforts (intended or unintended). 2. Quotes If possible, please include a specific quote from program staff or partners that would support your story. 1. Facilitators to Planning, Implementation, and Development -- Write 1-2 paragraphs describing three key elements that facilitated your efforts. 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 describe your organization to overcome these challenges? 1. What tips do you have for using /adapting this approach in another organization/community? 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 follow-up.	This is a new section to the questionnaire reflecting a requirement from the new cooperative agreement that all states should share success stories with CDC annually.

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