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pdfIntroduction
Form Approved
OMB No.: 0920-0669
Expiration Date: TBD
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
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 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.
* 1. Please provide the following information for verification purposes:
Your Name:
State:
Public reporting burden of this collection of information is estimated to average 10 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 D-74, Atlanta, Georgia 30333;
ATTN: PRA (0920-0669).
Page 1
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
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)
Page 2
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
Page 3
Staff #2
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]
Page 4
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Page 5
Staff #3
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]
Page 6
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Page 7
Staff #4
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]
Page 8
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Page 9
Staff #5
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]
Page 10
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Page 11
Staff #6
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]
Page 12
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Page 13
Staff #7
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]
Page 14
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Page 15
Staff #8
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]
Page 16
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Page 17
Staff #9
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]
Page 18
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Page 19
Staff #10
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]
Page 20
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Page 21
Staff #11
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]
Page 22
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Page 23
Staff #12
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]
Page 24
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Page 25
Staff #13
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]
Page 26
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Page 27
Staff #14
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]
Page 28
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Page 29
Staff #15
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]
Page 30
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Page 31
Staff #16
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]
Page 32
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Page 33
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]
Page 34
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Page 35
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.
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]
Page 36
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Page 37
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]
Page 38
7. Do you have additional staff to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Page 39
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]
Page 40
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.
Page 41
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
Page 42
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
Page 43
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.
Page 44
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:
Page 45
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)
Page 46
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
Page 47
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
Page 48
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
Page 49
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
Page 50
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
Page 51
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
Page 52
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
Page 53
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
Page 54
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
Page 55
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
Page 56
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:
Page 57
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.
Page 58
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:
Page 59
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
Page 60
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
Page 61
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
Page 62
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
Page 63
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
Page 64
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
Page 65
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
Page 66
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
Page 67
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
Page 68
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.
Page 69
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
Page 70
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
Page 71
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
Page 72
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
Page 73
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
Page 74
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
Page 75
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
Page 76
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
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
Page 77
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
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
Page 78
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
Page 79
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.
Page 80
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:
Page 81
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
Page 82
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
Page 83
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
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)
Page 84
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
Page 85
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.
Page 86
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 longterm 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:
Page 87
32. Do you have another intervention to report?
j
k
l
m
n
Yes
j
k
l
m
n
No
Page 88
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
Page 89
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
Page 90
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
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)
Page 91
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
Page 92
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
Page 93
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 longterm 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.
Page 94
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
Page 95
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
Page 96
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
Page 97
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
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)
Page 98
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
Page 99
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
Page 100
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 longterm 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.
Page 101
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
Page 102
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
Page 103
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
Page 104
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
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)
Page 105
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
Page 106
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
Page 107
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 longterm 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.
Page 108
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
Page 109
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
Page 110
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
Page 111
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
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)
Page 112
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
Page 113
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
Page 114
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 longterm 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.
Page 115
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
Page 116
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
Page 117
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
Page 118
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
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)
Page 119
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
Page 120
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
Page 121
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 longterm 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.
Page 122
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
Page 123
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
Page 124
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
Page 125
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
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)
Page 126
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
Page 127
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
Page 128
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 longterm 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.
Page 129
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
Page 130
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
Page 131
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
Page 132
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
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)
Page 133
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
Page 134
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
Page 135
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 longterm 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.
Page 136
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
Page 137
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
Page 138
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
Page 139
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
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)
Page 140
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
Page 141
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
Page 142
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 longterm 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.
Page 143
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
Page 144
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
Page 145
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
Page 146
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
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)
Page 147
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
Page 148
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
Page 149
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 longterm 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.
Page 150
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.
Page 151
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.
Page 152
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:
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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)
Page 154
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.
Page 155
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.
Page 156
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?
Page 157
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 follow-up.
Page 158
| File Type | application/pdf |
| File Title | SPIRS draft Aug 31.pdf |
| Author | hwu5 |
| File Modified | 2009-08-31 |
| File Created | 2009-08-31 |