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Form Approved
OMB No. 0990-XXXX
Exp. Date XX/XX/20XX
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| OUTPUT MEASURES |
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| Number of Recovery Act-funded communities in which the National Organizations’ are co-branding media messages and materials from national media campaign and/or where the National Organization itself is using and distributing co-branded materials. |
Name of community supported |
CPPW Community (Y/N) |
Where materials used and distributed |
Type and description of co-branded message/material |
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| Example |
Alabama - Jefferson County |
Y |
Public Housing Residence A |
Posters |
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New York - Kings County |
N |
Town Hall meeting |
Posters |
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| Number of peer-to-peer mentorships/technical assistance relationships provided by the National Organizations’ to programs in CPPW-funded communities and/or instances of direct consultation/assistance by the national organization to programs in CPPW-funded communities. |
Name of community supported |
CPPW Community (Y/N) |
Program assisted (i.e. name) |
Description of TA or consultation |
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| Example |
Arizona - County of Pima |
Y |
School District A |
Sign placement |
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Arizona - County of Pima |
Y |
School District B |
Coalition building |
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| Estimated financial and in-kind additional support national organizations were successful in leveraging for sustaining community prevention activities. |
Type of activity sustained |
Type of support (Financial or In-kind) |
If financial amount ($) |
Description of support |
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| Example |
Annual Training |
In-kind |
NA |
All incoming newly elected officials will receive training from organization X local affiliate on health benefits of limiting the amount of advertisements |
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Number of policy issue briefs/policy documents developed and issued by the National Org or its local affiliates.
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Title of policy brief/document |
Subject |
Distribution location |
Summary of Policy brief/document |
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| Example |
Prevention of Childhood Obesity - School-based Interventions |
Childhood obesity prevention |
Organization listserv |
This policy brief discusses the prevention of childhood obesity through school based interventions and why schools are a good place to intervene, providing research on the effectiveness of this strategy. |
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| Number of community programs using the policy issue briefs/policy documents in their policy mobilization work |
Name of community program using materials |
CPPW Community (Y/N) |
Where materials used and distributed |
Summary of policy brief/document used |
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| Example |
Community Program Name |
N |
distributed at all national affiliate locations |
This policy brief discusses the prevention of childhood obesity through school based interventions and why schools are a good place to intervene, providing research on the effectiveness of this strategy. |
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| Number of policy workshops, roundtables, forums or similar activities organized by the National Organizations or its local affiliates and the number of participants. |
Location of event |
types of participants |
Number of participants |
Name/Type of of event and summary description |
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| Example |
Webinar |
Public School Officials |
50 |
The webinar brought together public school officials across multiple states working on policy-based systems across a range of application areas including… |
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| According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average 1 hour per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer |
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| OUTPUT MEASURE |
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| Number of Recovery Act-funded communities in which the National Organizations’ are co-branding media messages and materials from national media campaign and/or where the National Organization itself is using and distributing co-branded materials. |
Name of community supported |
CPPW Community (Y/N) |
Where materials used and distributed |
Type and description of co-branded message/material |
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| Number of peer-to-peer mentorships/technical assistance relationships provided by the National Organizations’ to programs in CPPW-funded communities and/or instances of direct consultation/assistance by the national organization to programs in CPPW-funded communities. |
Name of community supported |
CPPW Community (Y/N) |
Program assisted (i.e. name) |
Description of TA or consultation |
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| Estimated financial and in-kind additional support national organizations were successful in leveraging for sustaining community prevention activities. |
Type of activity sustained |
Type of support (Financial or In-kind) |
If financial amount ($) |
Description of support |
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Number of policy issue briefs/policy documents developed and issued by the National Org or its local affiliates.
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Title of policy brief/document |
Subject |
Distribution location |
Summary of Policy brief/document |
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| Number of community programs using the policy issue briefs/policy documents in their policy mobilization work |
Name of community program using materials |
CPPW Community (Y/N) |
Where materials used and distributed |
Summary of policy brief/document used |
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| Number of policy workshops, roundtables, forums or similar activities organized by the National Organizations or its local affiliates and the number of participants. |
Location of event |
types of participants |
Number of participants |
Name/Type of of event and summary description |
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| OUTPUT MEASURE |
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| Number of Recovery Act-funded communities in which the National Organizations’ are co-branding media messages and materials from national media campaign and/or where the National Organization itself is using and distributing co-branded materials. |
Name of community supported |
CPPW Community (Y/N) |
Where materials used and distributed |
Type and description of co-branded message/material |
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| Number of peer-to-peer mentorships/technical assistance relationships provided by the National Organizations’ to programs in CPPW-funded communities and/or instances of direct consultation/assistance by the national organization to programs in CPPW-funded communities. |
Name of community supported |
CPPW Community (Y/N) |
Program assisted (i.e. name) |
Description of TA or consultation |
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| Estimated financial and in-kind additional support national organizations were successful in leveraging for sustaining community prevention activities. |
Type of activity sustained |
Type of support (Financial or In-kind) |
If financial amount ($) |
Description of support |
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Number of policy issue briefs/policy documents developed and issued by the National Org or its local affiliates.
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Title of policy brief/document |
Subject |
Distribution location |
Summary of Policy brief/document |
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| Number of community programs using the policy issue briefs/policy documents in their policy mobilization work |
Name of community program using materials |
CPPW Community (Y/N) |
Where materials used and distributed |
Summary of policy brief/document used |
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| Number of policy workshops, roundtables, forums or similar activities organized by the National Organizations or its local affiliates and the number of participants. |
Location of event |
types of participants |
Number of participants |
Name/Type of of event and summary description |
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| OUTPUT MEASURE |
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| Number of Recovery Act-funded communities in which the National Organizations’ are co-branding media messages and materials from national media campaign and/or where the National Organization itself is using and distributing co-branded materials. |
Name of community supported |
CPPW Community (Y/N) |
Where materials used and distributed |
Type and description of co-branded message/material |
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| Number of peer-to-peer mentorships/technical assistance relationships provided by the National Organizations’ to programs in CPPW-funded communities and/or instances of direct consultation/assistance by the national organization to programs in CPPW-funded communities. |
Name of community supported |
CPPW Community (Y/N) |
Program assisted (i.e. name) |
Description of TA or consultation |
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| Estimated financial and in-kind additional support national organizations were successful in leveraging for sustaining community prevention activities. |
Type of activity sustained |
Type of support (Financial or In-kind) |
If financial amount ($) |
Description of support |
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Number of policy issue briefs/policy documents developed and issued by the National Org or its local affiliates.
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Title of policy brief/document |
Subject |
Distribution location |
Summary of Policy brief/document |
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| Number of community programs using the policy issue briefs/policy documents in their policy mobilization work |
Name of community program using materials |
CPPW Community (Y/N) |
Where materials used and distributed |
Summary of policy brief/document used |
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| Number of policy workshops, roundtables, forums or similar activities organized by the National Organizations or its local affiliates and the number of participants. |
Location of event |
types of participants |
Number of participants |
Name/Type of of event and summary description |
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| OUTPUT MEASURE |
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| Number of Recovery Act-funded communities in which the National Organizations’ are co-branding media messages and materials from national media campaign and/or where the National Organization itself is using and distributing co-branded materials. |
Name of community supported |
CPPW Community (Y/N) |
Where materials used and distributed |
Type and description of co-branded message/material |
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|
|
|
|
|
|
|
|
|
| Number of peer-to-peer mentorships/technical assistance relationships provided by the National Organizations’ to programs in CPPW-funded communities and/or instances of direct consultation/assistance by the national organization to programs in CPPW-funded communities. |
Name of community supported |
CPPW Community (Y/N) |
Program assisted (i.e. name) |
Description of TA or consultation |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Estimated financial and in-kind additional support national organizations were successful in leveraging for sustaining community prevention activities. |
Type of activity sustained |
Type of support (Financial or In-kind) |
If financial amount ($) |
Description of support |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Number of policy issue briefs/policy documents developed and issued by the National Org or its local affiliates.
|
Title of policy brief/document |
Subject |
Distribution location |
Summary of Policy brief/document |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Number of community programs using the policy issue briefs/policy documents in their policy mobilization work |
Name of community program using materials |
CPPW Community (Y/N) |
Where materials used and distributed |
Summary of policy brief/document used |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Number of policy workshops, roundtables, forums or similar activities organized by the National Organizations or its local affiliates and the number of participants. |
Location of event |
types of participants |
Number of participants |
Name/Type of of event and summary description |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
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|
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|
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|
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| OUTPUT MEASURE |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Number of Recovery Act-funded communities in which the National Organizations’ are co-branding media messages and materials from national media campaign and/or where the National Organization itself is using and distributing co-branded materials. |
Name of community supported |
CPPW Community (Y/N) |
Where materials used and distributed |
Type and description of co-branded message/material |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Number of peer-to-peer mentorships/technical assistance relationships provided by the National Organizations’ to programs in CPPW-funded communities and/or instances of direct consultation/assistance by the national organization to programs in CPPW-funded communities. |
Name of community supported |
CPPW Community (Y/N) |
Program assisted (i.e. name) |
Description of TA or consultation |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
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|
|
|
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Estimated financial and in-kind additional support national organizations were successful in leveraging for sustaining community prevention activities. |
Type of activity sustained |
Type of support (Financial or In-kind) |
If financial amount ($) |
Description of support |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Number of policy issue briefs/policy documents developed and issued by the National Org or its local affiliates.
|
Title of policy brief/document |
Subject |
Distribution location |
Summary of Policy brief/document |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
|
|
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|
|
|
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|
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Number of community programs using the policy issue briefs/policy documents in their policy mobilization work |
Name of community program using materials |
CPPW Community (Y/N) |
Where materials used and distributed |
Summary of policy brief/document used |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Number of policy workshops, roundtables, forums or similar activities organized by the National Organizations or its local affiliates and the number of participants. |
Location of event |
types of participants |
Number of participants |
Name/Type of of event and summary description |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| OUTPUT MEASURE |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Number of Recovery Act-funded communities in which the National Organizations’ are co-branding media messages and materials from national media campaign and/or where the National Organization itself is using and distributing co-branded materials. |
Name of community supported |
CPPW Community (Y/N) |
Where materials used and distributed |
Type and description of co-branded message/material |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Number of peer-to-peer mentorships/technical assistance relationships provided by the National Organizations’ to programs in CPPW-funded communities and/or instances of direct consultation/assistance by the national organization to programs in CPPW-funded communities. |
Name of community supported |
CPPW Community (Y/N) |
Program assisted (i.e. name) |
Description of TA or consultation |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Estimated financial and in-kind additional support national organizations were successful in leveraging for sustaining community prevention activities. |
Type of activity sustained |
Type of support (Financial or In-kind) |
If financial amount ($) |
Description of support |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Number of policy issue briefs/policy documents developed and issued by the National Org or its local affiliates.
|
Title of policy brief/document |
Subject |
Distribution location |
Summary of Policy brief/document |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Number of community programs using the policy issue briefs/policy documents in their policy mobilization work |
Name of community program using materials |
CPPW Community (Y/N) |
Where materials used and distributed |
Summary of policy brief/document used |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Number of policy workshops, roundtables, forums or similar activities organized by the National Organizations or its local affiliates and the number of participants. |
Location of event |
types of participants |
Number of participants |
Name/Type of of event and summary description |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| OUTPUT MEASURE |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Number of Recovery Act-funded communities in which the National Organizations’ are co-branding media messages and materials from national media campaign and/or where the National Organization itself is using and distributing co-branded materials. |
Name of community supported |
CPPW Community (Y/N) |
Where materials used and distributed |
Type and description of co-branded message/material |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Number of peer-to-peer mentorships/technical assistance relationships provided by the National Organizations’ to programs in CPPW-funded communities and/or instances of direct consultation/assistance by the national organization to programs in CPPW-funded communities. |
Name of community supported |
CPPW Community (Y/N) |
Program assisted (i.e. name) |
Description of TA or consultation |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Estimated financial and in-kind additional support national organizations were successful in leveraging for sustaining community prevention activities. |
Type of activity sustained |
Type of support (Financial or In-kind) |
If financial amount ($) |
Description of support |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
|
|
|
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|
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|
|
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|
|
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Number of policy issue briefs/policy documents developed and issued by the National Org or its local affiliates.
|
Title of policy brief/document |
Subject |
Distribution location |
Summary of Policy brief/document |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
|
|
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|
|
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Number of community programs using the policy issue briefs/policy documents in their policy mobilization work |
Name of community program using materials |
CPPW Community (Y/N) |
Where materials used and distributed |
Summary of policy brief/document used |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Number of policy workshops, roundtables, forums or similar activities organized by the National Organizations or its local affiliates and the number of participants. |
Location of event |
types of participants |
Number of participants |
Name/Type of of event and summary description |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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| OUTPUT MEASURE |
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| Number of Recovery Act-funded communities in which the National Organizations’ are co-branding media messages and materials from national media campaign and/or where the National Organization itself is using and distributing co-branded materials. |
Name of community supported |
CPPW Community (Y/N) |
Where materials used and distributed |
Type and description of co-branded message/material |
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| Number of peer-to-peer mentorships/technical assistance relationships provided by the National Organizations’ to programs in CPPW-funded communities and/or instances of direct consultation/assistance by the national organization to programs in CPPW-funded communities. |
Name of community supported |
CPPW Community (Y/N) |
Program assisted (i.e. name) |
Description of TA or consultation |
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| Estimated financial and in-kind additional support national organizations were successful in leveraging for sustaining community prevention activities. |
Type of activity sustained |
Type of support (Financial or In-kind) |
If financial amount ($) |
Description of support |
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|
Number of policy issue briefs/policy documents developed and issued by the National Org or its local affiliates.
|
Title of policy brief/document |
Subject |
Distribution location |
Summary of Policy brief/document |
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| Number of community programs using the policy issue briefs/policy documents in their policy mobilization work |
Name of community program using materials |
CPPW Community (Y/N) |
Where materials used and distributed |
Summary of policy brief/document used |
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| Number of policy workshops, roundtables, forums or similar activities organized by the National Organizations or its local affiliates and the number of participants. |
Location of event |
types of participants |
Number of participants |
Name/Type of of event and summary description |
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