Community-Based Organizations Capacity Building Assistan

Developing a Responsive Plan for Building the Capacity of Community Based Organizations (CBOs) to Implement HIV Prevention Services

Att 3 CBO Assessment Tool

Community-Based Organizations Capacity Building Assistance Needs Assessment--CBOs only funded under PS11-1113

OMB: 0920-0948

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Form Approved

OMB No. 0920-New

Expiration Date 00/00/2015

Developing a Responsive Plan for Building the Capacity of Community Based Organizations (CBOs) to Implement HIV Prevention Services

Community-Based Organizations (CBO)

Capacity Building Assistance (CBA)

Needs Assessment

Public reporting burden of this collection of information is estimated to average 3 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: OMB-PRA (0920-New)

Community-Based Organizations (CBO)

Capacity Building Assistance (CBA)

Needs Assessment

PS11-1113

Name of CBO: __________________________________

Date: _________________________________________

Check box if dually funded under both PS11-1113 and PS10-1003

Table of Contents

Topic	Page
About the Assessment Process	3
Organizational Summary	5
Domain #1: Program Implementation	8
Risk-Reduction Interventions and Services	8
Adaptation	12
Recruitment and Retention	14
Enhanced HIV Testing	17
Linkage to Care and Coordinated Referral Networks	19
Condom Distribution	23
Youth Advisory Board	24
Summary	25
Domain #2: Monitoring and Evaluation	27
Summary	36
Domain #3: Organizational Infrastructure	39
Strategic Planning	39
Governance	41
Fiscal Management	45
Resource Development and Grant Writing	48
Human Resource Management and Staff Development	50
Technology	53
Summary	56
CBA Provider Summary Sheets	59
Program Implementation	60
Monitoring and Evaluation	61
Organizational Infrastructure	62

About the Assessment Process

Why is my organization being asked to participate in this assessment process?

This assessment is designed to assist Capacity Building Assistance (CBA) Providers and CDC in identifying areas of need by your organization to implement your HIV prevention programs and services, as required under Funding Opportunity Announcement (FOA) PS11-1113.

My organization already has a strategic plan. Do we still need to participate in this process?

Yes. Even though your organization may have already developed a strategic plan, all CBOs funded under PS11-1113 are required to participate in this process. Many organizations’ existing strategic plans focus on goals and objectives to achieve program outcomes. The Strategic Plan for Enhanced CBO Capacity (a.k.a. “CBA Plan”) developed via this process will focus on capacity building goals and objectives recommended to help ensure successful implementation of your program.

How will this process help my organization?

Information collected via this process will be used to construct a Strategic Plan for Enhanced CBO Capacity (a.k.a., “CBA Plan”) for your organization in collaboration with CDC’s Capacity Building Branch (CBB) CBA Providers funded under PS09-906. CDC and CBA Providers will work with you to ensure that your organization has the support it needs to successfully implement its CDC-funded HIV prevention program.

Who should be involved in this process?

The ideal respondents for this process should be staff most familiar with information representative of the specific domains (Program Implementation, Monitoring and Evaluation, and Organizational Infrastructure) included within the tool. We recommend inclusion of those staff and individuals with relevant roles, responsibilities, and knowledge of your HIV prevention program.

How long will this process take?

Several CBOs found it helpful to reserve one week for completing this organizational needs assessment tool. Although it may actually take only a few hours to type your responses to the questions, you may want to consult with several members of your staff who are most familiar with different aspects of your program as you complete the tool. Such consultation may take one week, depending on the availability of your staff. Please provide detailed responses to each question. This will help to ensure that the CBA Providers have a complete picture of your program prior to the field visit so that more time can be spent during the field visit on strategic planning and less time on simple information gathering. The face-to-face field visit will be completed within one business day (i.e., 8 hours). After your field visit, your assigned CBA provider will discuss with you how long it will take to develop your CBA Plan. However, this step in the process is typically completed within 2-4 weeks of the field visit.

Who will have access to the information gathered via this process?

Your organization, your Project Officer, PS09-906 CBA Providers, and CDC staff (e.g., CBB’s Program Consultants) will have access to your information. This is necessary to help facilitate the assignment of the most appropriate CBA Provider(s) to help you to implement and sustain your CDC-funded HIV prevention program effectively.

If I am dually funded under both PS10-1003 and PS11-1113 and completed the CBO CBA Assessment Tool last year, do I have to go through the process again for PS11-1113?

Yes. We’ve revised the tool since last year to incorporate questions specific to your PS11-1113 program. The new questions relate to enhanced HIV testing, linkage to care and treatment, coordinated referral networks, and youth advisory boards. In addition, the Monitoring and Evaluation domain has been updated to reflect the latest National HIV Prevention Program Monitoring and Evaluation (NHM&E) guidance. All grantees funded under PS11-1113 must respond to the new and/or revised questions as well as complete the Organizational Summary. If you also are funded under PS10-1003, you don’t have to complete the remainder of the tool, since you completed it under PS10-1003. However, please update any sections that may have changed since PS10-1003.

ORGANIZATIONAL SUMMARY

Date: _____________________

Name of Organization: ____________________________________________________________

Name of Executive Director: ____________________________________________________________

Name and Title of Lead Program Contact: ____________________________________________________________

Name of Person Completing the Assessment Tool: ____________________________________________________________

E-mail: _____________________________________

Phone Number: ______________________________

Organization Address: ______________________________________________________________

City: __________________________ State: ____________ Zip Code: _______________

Phone Number: ________________________ Fax Number: _______________________

Website: _________________________________

Location of Services: Rural Suburban Urban

UNDER WHICH CATEGORY OR CATEGORIES ARE YOU FUNDED FOR PS11-1113:

Category A: HIV prevention services for high-risk YMSM of color and their partners

Category B: HIV prevention services for high-risk YTG persons of color and their partners

SERVICES FUNDED TO IMPLEMENT WITH HIV+ CLIENTS:

Locally-developed intervention

CRCS with CLEAR

Healthy Relationships

Partnership for Health (PfH)

WILLOW

SERVICES FUNDED TO IMPLEMENT WITH HIGH-RISK HIV- CLIENTS:

Locally-developed intervention

CRCS with CLEAR

Community PROMISE

d-up! Defend Yourself

Many Men Many Voices (3MV)

MPowerment

Popular Opinion Leader (POL)

SISTA

Please indicate your organization’s funding source(s) and amounts for HIV prevention activities.

	Source of Revenue	Contract/Grant Period	Interventions/Activities Funded	Amount
	CDC PS11-1113			$
	CDC PS10-1003			$
	Other CDC PA/PS number(s): ___________________ ___________________			$
	Additional Federal Government Funds (e.g., HRSA, SAMSHA, etc.): Please Specify: _______ ___________________ ___________________			$
	State, City or Local Health Department Funds			$
	Private Funds			$
	Other:			$
	Other:			$
TOTAL:				$

Names of staff participating in assessment process:

Print Name	Position	Contact Info (Email/Phone)

DOMAIN #1: PROGRAM IMPLEMENTATION

The purpose of this section is to assess the organization’s experience with and ability to effectively and efficiently implement the funded program.

A. RISK-REDUCTION INTERVENTIONS AND SERVICES

A1. Please indicate whether your agency has implemented each of your currently funded evidence-based interventions (EBIs) and/or services under a previous funding cycle. If your agency has implemented the EBI or service before, please indicate for how many years you have been implementing the intervention or service and whether it was with current staff.

EBI/Service Name	Implemented during previous funding cycle?	# of years agency has been implementing	Implemented with current staff?
	Yes No	_____ yrs or N/A	Yes No N/A
	Yes No	_____ yrs or N/A	Yes No N/A
	Yes No	_____ yrs or N/A	Yes No N/A
	Yes No	_____ yrs or N/A	Yes No N/A

A2. Where are you in the process of implementing the EBI(s) or service funded through PS11-1113?

EBI/Service Name	Phase of Implementation	Current key activities (please list)
	Pre-implementation Implementation
	Pre-implementation Implementation
	Pre-implementation Implementation
	Pre-implementation Implementation

A3. Please list the staff that will be implementing the funded EBI or service.

Name	Position	Name of EBI or service	% Effort of Time

A4. What trainings (if any) have your staff attended or plan to attend regarding the specific EBI(s) you are funded to implement?

EBI Training Topic	Staff Name(s) and Positions	Attended ()/ Plan to Attend ()	Date of Attendance
EBI TOF:		Attended Plan to Attend
EBI TOF:		Attended Plan to Attend
CRCS for Program Managers		Attended Plan to Attend
CRCS for Case Managers		Attended Plan to Attend
Fundamentals of HIV Prevention Counseling		Attended Plan to Attend
Fundamentals of Waived Rapid HIV Testing and Prevention Services		Attended Plan to Attend
Counseling, Testing, and Linkage for Program Managers		Attended Plan to Attend
Quality Assurance for Program Managers		Attended Plan to Attend
Group facilitation		Attended Plan to Attend
Selecting an EBI		Attended Plan to Attend
Using Focus Groups to Adapt EBIs		Attended Plan to Attend
Interviewing and Observations for Adapting EBIs		Attended Plan to Attend
Bridging Theory and Practice		Attended Plan to Attend
Motivational Interviewing		Attended Plan to Attend
Other: _________________________		Attended Plan to Attend
Other: _________________________		Attended Plan to Attend
Other: _________________________		Attended Plan to Attend

A6. How many cycles of each intervention do you intend to implement per year?

A6a. EBI #1: ____________________________________ _____ cycles

Name #

A6b. EBI #2: ____________________________________ _____ cycles

Name #

A7. How many clients do you intend to reach per year? ________ clients

A8. Please indicate your organization’s CBA needs (i.e., training and technical assistance) related to EBIs by following the instructions below.

Instructions:

1. First, review the list of topics in the table below and put a check in the box next to any topic on which you would like CBA.

2. Next, for every topic that you checked off, indicate how pressing that need is. Is addressing that need a high, moderate, or low priority for your agency?

3. Finally, out of all of the needs that you just prioritized, which three are the most important to you? In other words, which three would you like to address first? Please do not assign tied rankings.

Check the box if this is a need 	Topic	Priority Level for Addressing the Need			Ranking of Top 3 Priorities (1, 2, 3)
		High	Moderate	Low
	Population-based Needs Assessment
	Selection of Evidence Based Intervention
	Recruitment and Retention
	Adaptation of an EBI
	Implementation of an EBI (please specify: ________________________________)
	Group Facilitation
	Bridging Behavioral Science and Practice
	Cultural Competence in Prevention Activities
	Intervention Development
	Motivational Interviewing
	Monitoring and Evaluation
	Integrating CLEAR into CRCS (i.e., using a CLEAR model for CRCS)
	Policies and Procedures
	HIV Rapid Testing
	Other: _______________________________

(Before you move on, did you remember to complete each of the three steps for the table above?)

Comments:

B. ADAPTATION

B1. Do you intend to adapt the EBI(s) that you have been funded to implement?

B1a. EBI#1: _________________________________________ Yes No

B1b. EBI#2: _________________________________________ Yes No

Note: If you respond “no” to both sections, please skip to Section C: Recruitment and Retention.

B2. Have you reviewed CDC’s document entitled “The Adaptation Guide: Adapting HIV Behavioral Change Interventions for Gay and Bisexual Latino and Black Men” or a similar comprehensive guidance on the adaptation process? Yes No

B3. Please describe plans your organization has to adapt your funded intervention(s) for your target population and location.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

B4. How did you assess the need for adaptation?

B5. Have you adapted an intervention in the past? Yes No

B5a. If yes, please give an example of a successful adaptation. What made it successful?

B5b. If yes, please give an example of a challenging adaptation for your agency. What were the barriers?

B6. What support do you think your agency will need in order to adapt your funded EBIs?

Comments:

C. RECRUITMENT AND RETENTION

C1. Who is/are your target population(s) for each EBI and/or service? (Race/Ethnicity, Risk, Age)

C1a. Target population(s) for EBI #1 (_________________________):

EBI Name

_______________________________________________________________

Target Population(s)

C1a. Target population(s) for EBI #2 (_________________________):

EBI Name

_______________________________________________________________

Target Population(s)

C2. Please describe your recruitment strategy (e.g., outreach, social networks, referrals, other) for the EBIs and/or services that you are implementing. What worked well in previous recruitment efforts?

C3. What factors might positively affect the recruitment of participants into your program? How do you intend to capitalize on those factors?

C4. What factors might negatively affect the recruitment of participants into your program? How do you intend to address those factors?

C5. What strategies will you use to retain participants in your program?

C6. Do you use incentives to retain participants? Yes No

C6a. If yes, please list your incentives: __________________________________________________________________________________________________________________________________________________________________________________________________________________

C7. What factors might positively affect the retention of participants in your program? How do you intend to capitalize on those factors?

C8. What factors might negatively affect the retention of participants in your program? How do you intend to address those factors?

C9. What support do you need around recruitment and retention of program participants?

Comments:

D. ENHANCED HIV TESTING

D1. Please list staff trained in Personalized Cognitive Counseling (PCC).

Name	Position	Name of EBI or service	% Effort of Time

D2. How will you plan, implement, monitor, and evaluate recruitment efforts among YMSM and YTG communities to meet the minimum testing targets specified in the Funding Opportunity Announcement (FOA)? Please describe your plans to use both traditional (i.e., non-Internet-based) and/or innovative approaches.

D2a. Plan: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

D2b. Implement:

D2c. Monitor:

D2d. Evaluate:

D3. Please describe your plans to use social marketing and/or Internet-based outreach to promote HIV testing among YMSM and YTG of color communities by responding to the questions below.

D3a. What types of new media will you use to engage YMSM/YTG communities?

Facebook

Twitter

Webinars

Fotonovelas

Texting

Other __________________________________________________

D3b. How will you use the selected new media to promote HIV testing?

D3c. What support do you need around Internet-based outreach to promote HIV testing?

D4. What support do you need around social marketing to promote HIV testing?

Formative evaluation

Designing the campaign

Implementing the campaign

Evaluating the campaign

Other __________________________________________________

E. LINKAGE TO CARE AND COORDINATED REFERRAL NETWORKS

Linkage to Care

E1. How will you plan, implement, monitor, and evaluate recruitment efforts to increase linkage to care and treatment among YMSM and YTG communities? Please describe your plans to use both traditional (i.e., non-Internet-based) and/or innovative approaches.

E1a. Plan: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

E1b. Implement:

E1c. Monitor:

E1d. Evaluate:

E2. How do you plan to work with community stakeholders and other service providers to promote and ensure access to and uptake of culturally appropriate HIV care, treatment, and medication adherence for HIV positive individuals?

E3. Please describe your plans to use social marketing and/or Internet-based outreach to promote linkage to care and medication adherence among YMSM and YTG of color communities by responding to the questions below.

E3a. What types of new media will you use to engage YMSM/YTG communities?

Facebook

Twitter

Webinars

Fotonovelas

Texting

Other __________________________________________________

E3b. How will you use the selected new media to promote linkage to care and medication adherence?

E3c. What support do you need around Internet-based outreach for linkage to care and medication adherence efforts?

E4. What support do you need around social marketing related to linkage to care and medication adherence?

Formative evaluation

Designing the campaign

Implementing the campaign

Evaluating the campaign

Other __________________________________________________

Coordinated Referral Networks

Please describe your plans to develop and sustain a coordinated referral network that responds to the unique circumstances of YMSM and YTG communities by responding to the questions below.

E5. Do you have a protocol for making referrals to Partner Services?

Yes (answer questions below) No (skip to E6)

If yes, please answer the following questions:

E5a. Does your protocol include multiple referral sources? Yes No

E5b. Does your protocol track MOUs? Yes No

E5c. Does your protocol track referrals? Yes No

E6. Do you have a protocol to ensure effective linkage to care (e.g., ARTAS, navigator models)? Yes No

E7. How will you track whether clients successfully accessed referral services?

E8. What support do you need around development and sustainability of referral networks?

Identification of stakeholders

Garnering stakeholder buy-in

Ongoing maintenance of the network

Referral tracking system development and maintenance

Other _________________________________________________________

E9. For which types of referrals do you have established Memoranda of Understanding/Agreement (MOU/MOA)? For which types of referrals do you need assistance establishing a partnership?

Referral Type	Have Current MOU/MOA	Need Assistance Establishing Partnership
a. Linkage to HIV/AIDS care and treatment services
b. Linkage to CD4 cell count and viral load screening
c. Linkage to treatment adherence services
d. Partner Services
e. Integrated screening and treatment (i.e., screening and treatment for STDs, hepatitis, and TB)
f. Drug treatment programs
g. Mental health counseling programs experienced in working with YMSM and/or YTG youth and young adults
h. Pre-exposure prophylaxis and post-exposure prophylaxis
i. Housing
j. Basic education continuation/completion services
k. Employment readiness

Comments:

F. CONDOM DISTRIBUTION

Please describe your plans to implement culturally appropriate condom distribution programs that increase access to and use of condoms by YMSM of color and YTG persons of color by responding to the questions below.

F1. What are your plans for promoting and distributing condoms at the individual, organizational, and community levels? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

F2. How will you use social marketing to promote condom use, increase awareness of condom benefits, increase condom use acceptability, and normalize condom use among YMSM and YTG communities?

F3. Will you partner with community stakeholders and service providers in the design and implementation of your condom distribution program?

Yes No

F3a. If yes, with whom will you partner?

________________________________________________________________________________________________________________________________

F3b. If yes, what will be your role and what will be the role of the partner agency? ________________________________________________________________________________________________________________________________________________________________________________________________

F4. What support do you need around your condom distribution program?

Designing the program

Implementing the program

Managing the program

Evaluating the program

Other ___________________________________________________

Comments:

G. YOUTH ADVISORY BOARD

G1. Do you have a Youth Advisory Board (YAB)? Yes No (Please explain and then skip to G3 below): __________________________________________________________________________________________________________________________________________________________________________________________________________________

G1a. How many people are on the YAB? _______

G1b. What is the age range of members? ____ to ____ years

G1c. What percentage (%) of YAB membership is comprised of YMSM of color?

<25% 25 to 50% 51 to 75% 76-99% 100%

G1d. What percentage (%) of YAB membership is comprised of YTG persons of color?

<25% 25 to 50% 51 to 75% 76-99% 100%

G1e. What percentage (%) of YAB membership is comprised of HIV+ persons?

<25% 25 to 50% 51 to 75% 76-99% 100%

G2. What types of activities are conducted by and/or with your YAB members?

Reviewing program materials

Providing input about appropriate participant incentives

Locating culturally and age appropriate safe spaces for program activities

Identifying program participant recruitment and retention strategies

Hosting events

Other ways your YAB is involved in program development: ________________________________________________________

G3. What support do you need around your YAB?

Recruitment & retention of YAB members

Facilitation of YAB meetings

Evaluation of YAB functioning

Skills building for YAB members (please specify: _____________________)

Other ________________________________________________________

Comments:

H. SUMMARY

H1. What are your organization’s primary strengths related to program implementation?

H2. What are your organization’s primary challenges related to program implementation?

H3. In what ways would you like to see your organization’s HIV prevention program strengthened in the next 12 months?

DOMAIN #2: MONITORING AND EVALUATION (M&E)

This section of the tool is intended to assess your organization’s ability to collect, manage, store and report process data on the services your organization provides and to use these data to plan future interventions and improve available programs. In addition we would like to understand your organization’s level of program evaluation expertise and to make sure you are aware of the M&E resources and tools offered by CDC’s Division of HIV/AIDS Prevention (DHAP).

Q1. Which agency staff members are responsible for your HIV prevention program’s monitoring and evaluation (M&E) activities?

(First list responsible staff by position and percent time and then identify the main point of contact for M&E for the agency.)

M&E Activity	Responsible Staff – Position(s)	Total # of Staff	Total FTE (% Effort)
Data collection
Data entry
Data management
Data analysis
Data reporting
Data review/use
Data security
Data quality assurance
Other:

Main point of contact for M&E:

Name: 

Position: 

Phone Number: 

E-mail address: 

Q2. On what topics related to M&E has your agency’s current staff previously received training? (Check all that apply)

Yes	M&E training topic
	Process monitoring and evaluation
	CDC data collection and reporting requirements
	Conducting quality assurance for the intervention/service
	Data collection methods
	Maintaining client records
	Data management
	Data analysis
	Data review and use
	Data quality assurance
	Data security
	Other topics:

Q3. What evaluation trainings have your staff attended?

Q4. Does your agency have a written M&E plan for current HIV prevention EBIs and/or public health strategies?

Yes – In progress

Yes – Completed plan (please attach a copy of the plan)

What interventions/services does the plan address? (Check all that apply)

EBIs (Specify which interventions are addressed in the plan): ____________________________________________________________

CRCS

CTR

Q5. Which of the following components does the evaluation plan address?

(Check all that apply)

Addressed in the plan? (X = yes)	Component of M&E plan
	Program goals based on formative/ needs assessments
	Measurable (SMART) objectives
	Activities conducted to meet objectives
	Data collection plan
	Data collection timelines
	Data collection tools/instruments
	How data will be used and by whom
	How progress toward objectives is measured
	Data quality assurance
	Data security/confidentiality
	Data reporting and dissemination
	Other:

Q6. What are your agency’s current process monitoring activities? If you have not begun process monitoring activities for your PS11-1113 funded-interventions, what have you done in the past and how will they apply to your PS11-1113 interventions?

(This is an open-ended question. After responding to the open-ended questions, please check all that apply below.)

Yes	Process monitoring activity
	Observe service delivery
	Assess appropriateness of venues where prevention activities are implemented
	Collect and analyze data to plan and respond to target population needs
	Monitor progress made on overall program goals and objectives
	Other comments & questions:

Q7. How does your agency determine if your HIV prevention program meets its goals and objectives? If you have not begun process monitoring activities for your PS11-1113 funded-interventions, what have you done in the past and how will they apply to your PS11-1113 interventions?

(This is an open-ended question. After you have answered the open-ended questions, please check all that apply below.)

Yes	Approach used to determine if goals/objectives are met
	Establish baselines (before start of intervention)
	Assess progress toward objectives by tracking number of clients recruited
	Assess progress toward objectives by percent of clients completing all sessions
	Assess progress toward objectives by percent of tested clients who receive their test result
	Assess client satisfaction (e.g., surveys, focus groups, interviews)
	Track linking positives to care
	Other comments & questions:

Q8. What types of HIV prevention data does your agency collect (in general)? (Check all that apply)

Yes	HIV prevention data collected
	Agency data (i.e. agency name, budget data)
	HIV testing data
	Aggregate data for outreach
	Aggregate data for recruitment
	Activities associated with each session/intervention
	Number of clients enrolled (or served)
	Other comments & questions:

Q9. What information does your agency collect about individual clients served by HIV prevention activities?

(Check all that apply)

Yes	Client-level data collected
	Demographic characteristics
	Previous HIV test results
	Behavioral risk characteristics
	Number of sessions the client completes
	Health services utilization
	Referrals (e.g., to medical or prevention services)
	Behaviors before and after the intervention (e.g., 3 or 6 month f/u)
	Other comments & questions:

Q10. What system(s) has your agency used in the past for managing HIV prevention program data (including client-level data)? What system(s) does your agency currently use?

Yes, In past	Yes, Currently	Data management system
		Paper system
		Electronic system (specify):
		Web-based system (specify):
		Other comments & questions:

Q11. Is your agency familiar with the National HIV Monitoring and Evaluation (NHM&E) Plan?

Yes

Don’t know

Q12. Has anyone at your agency participated in a webinar to describe the new, reduced NHM&E data collection and reporting burden for CDC-funded CBOs?

Yes

Don’t know

Q13. Is your agency aware of the two types (collected data and projected data) that will be collected and reported?

Yes

Don’t know

Q14. Does your agency understand the different types of collected data that are required (test level variables, client level variables, and aggregate variables)?

Yes

Don’t know

Q15. Has anyone at your agency participated in a webinar to present the new HIV testing variables?

Yes

Don’t know

Q16. Does your agency have a written quality assurance (QA) plan or protocol for PS11-1113 HIV prevention program data? (If yes, please attach a copy of the QA plan)

Yes (Please attach a copy of the QA plan and note which of the following components are addressed.)

Addressed in the plan? (X = yes)	Component of QA plan/protocol
	Client record maintenance
	Data management
	Client confidentiality
	Data security and web-based reporting
	Referral tracking systems to ensure timely access to referrals
	Internet/Web based protocols
	Other comments & questions:

Q17. What processes does your agency have in place to ensure data quality and completeness?

(Check all that apply)

Yes	Process to ensure data quality/completeness
	Performance standards for staff
	Tracking system to document client access to referrals
	Activities to assess quality of data collection
	Activities to assess quality of data entry
	Other comments & questions:

Finally, the last questions address your agency’s reporting and use of HIV prevention program data.

Q18. How has your agency used M&E data to strengthen HIV prevention programs?

(Check all that apply)

Yes	Use of data
	Develop program materials
	Modify strategic plans
	Modify program structure
	Develop/improve procedures and policies
	Improve intervention activities and services
	Redefine venues/target areas and populations
	Work with other agencies to improve referrals
	Seek additional funding
	Assess staff performance
	Other comments & questions:

Q19. To what funding sources and/or sponsors has your agency reported data about HIV prevention activities? (Check all that apply)

Yes	Funding source/sponsor
	CDC
	State or local government
	Non-governmental agency
	Advocacy/Policy Group
	Board of Directors
	Other sponsors:

SUMMARY

S1. What do you feel is working well regarding your HIV prevention M&E activities?

S2. What are the main areas of improvement regarding your HIV prevention M&E activities?

S3. Please indicate your organization’s CBA needs (i.e., training and technical assistance) related to M&E by following the instructions below.

1. First, review the list of topics in the table below and put a check in the box next to any topic on which you would like CBA.

2. Next, for every topic that you checked off, indicate how pressing that need is. Is addressing that need a high, moderate, or low priority for your agency?

Check the box if this is a need 	Topic	Priority Level for Addressing the Need			Ranking of Top 3 Priorities (1, 2, 3)
		High	Moderate	Low
	CDC Data Collection and Reporting Requirements
	Conducting Quality Assurance for the Intervention/Service
	Data Collection Methods
	Maintaining Client Records
	Data Management
	Data Analysis
	Data Review and Use
	Data Quality Assurance
	Data Security
	Process Monitoring and Evaluation
	Outcome Monitoring
	NHM&E Training
	Other:

S4. In what ways would you like to see your organization’s HIV prevention program strengthened with respect to monitoring and evaluation activities in the next 12 months?

DOMAIN #3: ORGANIZATIONAL INFRASTRUCTURE

The purpose of this section is to assess the organization’s capacity to effectively and efficiently sustain the funded program.

A. STRATEGIC PLANNING

A1. Has your agency ever conducted a strategic planning process that included your HIV prevention program? Yes No (Skip to Section B. Governance)

A2. When was the last time your organization conducted a strategic planning process that involved your HIV prevention program? (year)

A3. Who was involved in the strategic planning process? [Check all that apply]

Executive Director

Program Director

Program Staff

Board of Directors

Advisory Group

Volunteers

Other: ______________________________________

A4. Does your organization have a written strategic plan from your latest strategic planning session? Yes (If yes, please attach a copy of it) No

A5. Please describe the process your organization used to develop the most recent strategic plan.

A5a. To what degree was your HIV prevention program explicitly addressed in the planning process?

A5b. To what extent was lead HIV prevention staff involved in the planning process?

A5c. What worked well during that process?

A5d. What would you change about the process?

A6. To what extent has your organization developed an operational plan that translates the strategic goals into concrete activities at the HIV prevention program level?

Have not started developing an operational plan

Have partially developed an operational plan (If yes, please attach a copy of the plan)

Have fully developed an operational plan (If yes, please attach a copy of the plan)

A7. Please describe how you use the strategic plan.

Comments:

B. GOVERNANCE

B1. Do you have a Board of Directors? Yes No

B2. How are board members recruited?

B3. How many people currently serve on your board? people

B4. What percentage of your board members are experts in HIV/AIDS related services?

<25% 25 to 50% 51 to 75% 76-99% 100%

B5. How, if at all, does the board address gaps in board member expertise?

B6. Does your board have written bylaws? Yes No

B6a. If yes, does your bylaws…

State the role and function of the board

Clearly specify the roles and responsibilities of board members

State how officers are selected

State the frequency of meetings

Describe policy related to Conflict of Interest

Describe fiscal policies (e.g., start and end date of fiscal year)

B6b. According to your bylaws, how many members should comprise your board? _______ members

B6c. How frequently (e.g., quarterly, annually) are your bylaws reviewed? ____________________

B7. Do you have an orientation for board members? Yes No

B7a. If yes, what topics are covered in the orientation? (Check all that apply)

Overview of organization

Overview of specific programs

Roles and responsibilities of governing board

Overview of board structure (e.g., officers, committees)

Overview of board operations (e.g., bylaws)

Review of strategic plan

Other: ___________________________________________________

B8. How often does the board meet? (Check only one)

Monthly

Quarterly

Semi-Annually

Annually

Other: _______________________________________________________

B9. Are minutes of the board meetings maintained?

Yes (If yes, attach a copy of minutes from the previous 12 months) No

B10. What are typical activities at board meetings? (Check all that apply)

Review current HIV program reports

Review financial reports

Discuss/Plan needed programs

Discuss fundraising and/or other grant opportunities

Other: _______________________________________________________

B11. Please describe in detail the involvement of the board in fundraising and fund development.

B12. Do board members have an annual target to “give or get?” Yes No

B9a. If yes, what is the annual individual target? $__________

B13. How involved is your board in your organization’s day-to-day operations?

B14. What role does the board play in the evaluation of the Executive Director’s performance?

B15. How, if at all, does the board evaluate its own performance?

B16. How, if at all, does the board identify training/development needs? What board development needs have been identified over the past 12 months?

Comments/Recommendations:

C. FISCAL MANAGEMENT

Accounting System and Budgetary Controls

C1. What type(s) of financial/accounting system(s) does your organization use? (Check all that apply)

Electronic tracking system software

(Software Name: _____________________)

Manual tracking system

C2. Who is responsible for the oversight/review of the accounting system, including bookkeeping?

(Check one)

Certified Public Accountant on staff

Certified Public Accountant outsourced

Staff accountant or bookkeeper with at least 2 years of experience

Staff accountant or bookkeeper with less than 2 years of experience

Executive Director or board member

Other: _______________________________________________________

C3. Does your organization have written fiscal management policies and procedures (e.g., travel and procurement, accountability, internal controls)?

Yes No

C4. Does the accounting system adequately identify receipt and disbursement for each grant or contract? Yes No

C5. Does the accounting system provide for the recording of expenditures for each program by required budget cost categories? Yes No

C6. Does the accounting system provide for recording the non-Federal share and in-kind contributions? Yes No

C7. Are all accounting entries supported by appropriate documentation (e.g., purchase orders, vouchers, and vendor payments)? Yes No

C8. Are all checks approved by an authorized official before they are signed?

Yes No

Please explain.

C9. Have the financial statements been audited within the last 2 years by an independent public accountant? Yes No

C10. Does your organization use an operating budget to control project funds?

Yes No

C11. What budgetary controls are in effect to preclude incurring obligations in excess of (a) total funds available and (b) total funds available for a budget cost category?

C12. What works well in terms of your accounting system?

C13. What areas of your accounting system could be improved?

C14. Who signs and certifies time and attendance? (Name and Position) ______________________________________________________________________

C15. Is the payroll verified at regular intervals against time sheets?

Yes No

C15a. If yes, at what intervals? _____________________________

C16. Is the payroll double-checked as to:

C16a. Hours? Yes No

C16b. Rates? Yes No

C16c. Deductions? Yes No

C16d. Extensions? Yes No

C17. Is the payroll signed prior to payment by:

C17a. The employee preparing the payroll? Yes No

C17b. The employee rechecking the payroll? Yes No

C18. Is there a separate payroll bank account? Yes No

C19. Is the payroll bank account reconciled by someone other than payroll staff or personnel who sign or distribute the paychecks? Yes No

C19a. If yes, who reconciles the account? (Name and position) _______________________________________________________________

C20. Have there been any delays in your payroll process?

Yes No

C20a. If yes, please describe.

C20b. If yes, how were the problems resolved?

Comments:

D. RESOURCE DEVELOPMENT AND GRANT WRITING

D1. Please describe your organization’s fundraising plan and the extent to which it addresses fundraising for your HIV prevention program.

D1a. Who is responsible for carrying out your organization’s fundraising plan? To what extent is your HIV prevention program staff involved in the fundraising plan?

D1b. What are your organizations fundraising goals? To what extent has your organization been successful in achieving your goals?

D2. How many grant proposals did your organization write and submit during the last fiscal year to support your HIV prevention program?  proposals

D2a. Approximately how many of those applications were funded?

None

Less than half

About half

More than half

All

N/A

D3. Does your organization have a lead grant writer or grant writing team?

Yes No

D4. Who is involved in reviewing the grant applications prior to submission?

D5. What has been the most difficult aspect of the grant process for your organization?

Comments:

E. HUMAN RESOURCE MANAGEMENT AND STAFF DEVELOPMENT

E1. Does your organization have a personnel policy manual?

Yes (If yes, please attach copy of manual) No

E1a. Has the manual been disseminated to all staff? Yes No

E1b. Does the policy manual require signature statements? Yes No

Does your manual cover…

E1c. Staff expectations and responsibilities related to maintaining client confidentiality? Yes No

E1d. Non-discrimination policies? Yes No

E1e. Policies to address employee safety in the workplace? Yes No

E1f. Policies to address employee safety in the community? Yes No

E2. Do you have written job descriptions for each staff position?

Yes (If yes, please submit copies of job descriptions) No

E3. Please describe the current process used by your organization for evaluating staff performance.

E4. Does your organization conduct regular employee performance reviews?

Yes, quarterly

Yes, biannually

Yes, annually

Yes, at some other interval (please specify: __________________________)

E5. How does your organization assess staff development needs?

E6. Does each staff member have a training/staff development plan?

Yes No

E7. How are staff development needs addressed?

Mentoring by peer

Mentoring by senior staff

In-service training

External face-to-face training

Distance learning

Other (please specify: ____________________________________)

E8. Has your organization been through a major leadership transition (e.g., departure/replacement of Executive Director, Program Director, etc.) within the last 12 months? Yes No

E8a. If yes, please explain the transition and your plans for filling key positions. In addition, please provide an updated organizational chart.

E9. Has your organization downsized staff within the last 12 months?

Yes No

E9a. If yes to E9 above, please describe what led to the change.

E9b. If yes to E9 above, what percentage of your staff was downsized in the last 12 months?

None

Less than half

About half

More than half

All

E10. What percentage of your staff was hired in the last 6 months?

None

Less than half

About half

More than half

All

E11. How does your organization ensure continuity of services in case of staff turnover?

Cross training of staff

Standard operating procedures in place

Two-week notification prior to resignation

Recruitment plan to replace staff

Other (please specify: ___________________________________________)

E12. Does your organization have a written succession plan to sustain the program in the event of the departure of key staff?

Yes (If yes, please attach copy of plan) No

E13. Does your organization conduct exit interviews when employees vacate their positions? Yes No

E13a. If yes, how is this information used?

E14. What incentives does your organization use to retain key staff?

401K

Medical insurance

Paid leave

Incentive/recognition programs

Training/professional development

Promotion opportunities

Other: _______________________________________________________

Comments:

F. TECHNOLOGY

F1. What operating system(s) does your organization use? (Check all that apply)

Windows

Macintosh

F2. What version of Windows do computers in your organization have?

Windows 7

Windows Vista

Windows XP

Windows 2000

Windows ME

Windows 98

I don’t know

N/A

F3. What version of Macintosh do computers in your organization have?

Mac OS 9 or earlier

Mac X

Mac 10.5 (“Leopard”)

Mac 10.6 (“Snow Leopard”)

I don’t know

Other: _______________________________________________________

N/A

F4. What type of Internet connection do the computers have?

Modem/Dial up

High-speed connection (e.g., cable, DSL, fiber optic/FIOS)

None

I don’t know

F5. During the past 12 months, did staff report any technical problems accessing or viewing webinars/Net-meetings in “real time” – that is, while they were being given? Yes No

F5a. If yes, what problems were reported?

F5b. If yes, how were the problems resolved?

F6. During the past 12 months, did staff report any technical problems accessing or viewing webinars/Net-meetings later – that is, after they were recorded and posted on the Internet? Yes No

F6a. If yes, what problems were reported?

F6b. If yes, how were the problems resolved?

F7. During the past 12 months, did staff report any technical problems accessing, viewing or hearing work-related online courses or trainings?

Yes No

F7a. If yes, what problems were reported?

F7b. If yes, how were the problems resolved?

F8. Does your organization have in-house Information Technology (IT) staff?

Yes No

F9. Does your organization have a contract for IT support? Yes No

F10. How do staff access IT support, if needed?

Comments:

G. SUMMARY

G1. What do you feel is working particularly well regarding your organization’s infrastructure?

G2. What are the main areas of improvement regarding your organization’s infrastructure?

G3. Please indicate your organization’s CBA needs (i.e., training and technical assistance) related to Organizational Infrastructure by following the instructions below.

1. First, review the list of topics in the table below and put a check in the box next to any topic on which you would like CBA.

2. Next, for every topic that you checked off, indicate how pressing that need is. Is addressing that need a high, moderate, or low priority for your agency?

Check the box if this is a need 	Topic	Priority Level for Addressing the Need			Ranking of Top 3 Priorities (1, 2, 3)
		High	Moderate	Low
	Board Development or Governance
	Fiscal Management
	Grant Writing/Proposal Development
	Personnel Management
	Resource Development
	Strategic Planning
	Technology
	Information System and Data Management
	Leadership Development
	Monitoring and Evaluation at the Organizational Level
	Policy Development
	Program Collaboration and Service Integration (PCSI)
	Program Marketing
	Public Relations
	Quality Assurance
	Other:_____________________________

G4. In what ways would you like to see your organization’s infrastructure strengthened in the next 12 months?

CBA PROVIDER SUMMARY SHEETS

Name of CBO: ___________________________

Date of Assessment: __________________

Name of CBA Provider Conducting the Assessment: __________________________________________

**Add Additional Sheets as Needed**

Program Implementation

Strengths:

Areas of Improvement:

Identified CBA Needs Related to Program Implementation:

What is/are the best CBA mechanism(s) for addressing the identified need within the next 12 months? (Check all that apply)

Information Transfer

Skills Building/Training

Technical Consultation

Technical Services

Technology Transfer

Identified CBA Needs Related to Program Implementation:

What is/are the best CBA mechanism(s) for addressing the identified need within the next 12 months? (Check all that apply)

Information Transfer

Skills Building/Training

Technical Consultation

Technical Services

Technology Transfer

Monitoring and Evaluation (M&E)

Strengths:

Areas of Improvement:

Identified CBA Needs Related to M&E:

What is/are the best CBA mechanism(s) for addressing the identified need within the next 12 months? (Check all that apply)

Information Transfer

Skills Building/Training

Technical Consultation

Technical Services

Technology Transfer

Identified CBA Needs Related to M&E:

What is/are the best CBA mechanism(s) for addressing the identified need within the next 12 months? (Check all that apply)

Information Transfer

Skills Building/Training

Technical Consultation

Technical Services

Technology Transfer

Organizational Infrastructure

Strengths:

Areas of Improvement:

Identified CBA Needs Related to Organizational Infrastructure:

What is/are the best CBA mechanism(s) for addressing the identified need within the next 12 months? (Check all that apply)

Information Transfer

Skills Building/Training

Technical Consultation

Technical Services

Technology Transfer

Identified CBA Needs Related to Organizational Infrastructure:

What is/are the best CBA mechanism(s) for addressing the identified need within the next 12 months? (Check all that apply)

Information Transfer

Skills Building/Training

Technical Consultation

Technical Services

Technology Transfer

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	COMMUNITY BASED ORGANIZATIONS (CBO) CAPACITY BUILDING ASSISTANCE ASSESSMENT
Author	Hearn Murray, Kimberly (CDC/OID/NCHHSTP)
File Modified	0000-00-00
File Created	2021-01-30