Form 5 Semi-annual Performance Report and sample template

OMB Control No. 0985-XXXX
Exp. Date XX/XX/201

Prevention and Public Health Fund
Chronic Disease Self-Management Education
Semi-Annual Performance Report Directions and Sample Template
Purpose of Semi-Annual Reports:
Briefly describe major or significant activities related to grantee goals, including key
steps towards achieving target numbers of individuals that complete an approved
Chronic Disease Self-Management Education Program, and in the development of an
integrated, sustainable, evidence-based CDSME delivery system.
Directions:
• Use the format outlined in the “Guidelines for Preparing Performance Reports for
Discretionary Grants Supported by the U.S. Administration for Community Living”
(http://www.ncoa.org/improve-health/center-for-healthy-aging/content-library/PPRInstructions_ACL_OMB_FiNAL_expires_12-31-15.pdf ):
o Double-space with 1-inch margins
o Use a font size of 12, preferably Times New Roman.
o Organize your report by the following headers: Title Page, Activities and
Accomplishments, and Appendix.
o Under the Activities and Accomplishments section, list the four questions
included on the template, followed by your response.
•

Please be thorough about any major or significant activities, but provide succinct
information, using either a bulleted-list format or short sentences to convey your
responses. We suggest that you limit your report to no more than 10-15 pages.

•

Only include information that pertains to the specified period, not cumulative to date.

•

See below for bulleted examples of what you may want to consider including under
each question in the Activities and Accomplishments section.

•

Include a quantitative report of your up-to-date participant and completer data from
the CDSME National Database as Appendix A of the report. To download a prepopulated report, navigate to the Additional Reports tab (State Reports section) and
select the appropriate reporting period under the Grantee Progress Reports header
at the bottom of the page.
Include a copy of each project product as additional Appendices and identify each by
capital letters in sequence (i.e. Appendix B, C, etc.).

•
•

If you have any questions, please contact your AoA Project Officer.

•

Send your completed report within 30 days after each six-month reporting period to
your AoA Project Officer and copy the following: Sean Lewis at
[email protected]; [email protected]; and NCOA to the attention of
Binod Suwal at [email protected].

PAPERWORK REDUCTION ACT STATEMENT
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 0985xxx. The time required to complete this information collection is estimated to average 8 hours 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: Administration for Community Living, 1 Massachusetts Avenue, N.W., Room 5203,
Washington, D.C. 20001, Attention: PRA Reports Clearance Officer

Activities and Accomplishments Examples:
1. What did you accomplish during this reporting period and how did these
accomplishments help you reach your stated project goal(s) and objective(s)?
Please note any significant project partners and their role in project activities.
Please describe any relevant activities that occurred during this period related to the
following:
Program Management and Statewide Leadership: (describe partnership-building
activities between public health, aging, or other state agencies or local partners;
statewide coalition building or other new management/ leadership structures; new
staff and their roles and responsibilities, etc.). For example:
• Hired project manager who will be responsible for [key roles, e.g. state-wide
coordination of training and data entry].
•

Established statewide Healthy Aging Coalition [or steering committee or other
key planning/ advisory group] with x number of agencies. Held kickoff meeting
on [date].

Partnership Development: (describe activities to build effective partnerships to
embed CDSME programs into statewide health and long-term services and supports
systems; note significant partners and their roles). For example:
• Established memorandum of understanding with x organization that has
agreed to embed the CDSMP and offer it on a quarterly basis through its 12
sites.
Statewide Infrastructure Development: (describe how you are expanding delivery
infrastructure/capacity to provide programs throughout your targeted geographic
area including workforce development/ recruitment/ training or retention activities
and new host organizations and implementation sites). For example:
• Obtained multi-site license from Stanford for the CDSMP and DSMP.
•

Conducted master training in [location] on [dates] using Stanford T-trainers. X
individuals completed the training.

Centralized or Coordinated Logistical Processes for Recruitment, Referral,
Enrollment, and Marketing: (describe any new, innovative strategies to make it
easier for potential participants to learn about and access programs and to improve
overall program efficiencies). For example:
• Established process for clients (from ADRC, Medicaid, Tobacco quit line,
SHIP, other agencies) to be referred to CDSMEs.
•

In collaboration with CDC-funded state health department arthritis program,
established state Healthy Aging website and marketing campaign which
includes CDSME and other evidence-based program information and a
workshop calendar.

Business Planning and Financial Sustainability: (describe any policy changes,
planning activities, external funding received, or other activities related to helping to
sustain your CDSME programs beyond the grant period). For example:
• Convened a Sustainability Task Force with x key stakeholders to develop a
sustainability plan.
•

X partner completed a business plan for implementing the DSMP with a
Medicare provider.

•

Received x amount of funding from (name of foundation, corporation, etc.)

•

Completed NCOA cost calculator and determined average workshop cost to
be X$.

•

Established CDSME as a covered service under the state’s Medicaid waiver.

Quality Assurance/Fidelity: (include activities related to monitoring whether the
CDSMEs are being implemented appropriately and grant objectives are being met).
For example:
• Identified performance indicators and developed a quality assurance/ fidelity
monitoring plan.
•

Completed the following fidelity monitoring/ quality assurance activities during
this period included: (e.g. five master trainers conducted 10 workshop site
visits).

2. What, if any, challenges did you face during this reporting period and what
actions did you take to address these challenges? Please note in your response
changes, if any, to your project goal(s), objective(s), or activities that were made
as a result of challenges faced.
Describe key challenges related to partnerships, infrastructure and delivery
system, coordinated processes, financial sustainability, and program
fidelity/quality assurance and describe how you tried to address each challenge.
For example:
• Had to cancel one workshop due to insufficient registration. Rescheduled the
workshop at a different time and successfully filled the class.
•

High rate of non-completers in one workshop. Called drop outs and
discovered primary reason for dropouts was health problems.

3. How have the activities conducted during this project period helped you to
achieve the measurable outcomes identified in your project proposal?
Describe how your activities have helped you address your proposed outcomes
such as the CDSME programs implemented, target number of completers,
targeted populations (low-income, minority, rural, disabled, Native American,
etc.), and geographic area covered.

4. What was produced during the reporting period and how have these products
been disseminated? Products may include articles, issue briefs, fact sheets,
newsletters, survey instruments, sponsored conferences and workshops,
websites, audiovisuals, and other informational resources.
Possible resources to share include:
• New print materials, e.g. business or quality assurance plans, how-to
manuals, tip sheets, promotional materials
•

Electronic, e.g. web addresses of new websites; listservs for leaders/ trainers

•

Presentations at conferences (e.g. copies of PowerPoints)

•

Reports (e.g. summaries of workshop satisfaction or outcome data)

Prevention and Public Health Fund
Chronic Disease Self-Management Education Grant
Semi-Annual Performance Report for the State of XXXXXXX
Title Page
1. Grant Award Number:
2. Project Title:
3. Grantee Agency Name:
Address:
4. Project Director/Principle Investigator Name:
Telephone #:
Email:
5. Report Author Name(s):
6. Total Project Period:
7. Reporting Period:
8. Date of Report:
9. ACL Program Officer:
10. ACL Grants Management Specialist:

Prevention and Public Health Fund
Chronic Disease Self-Management Education Grant
Semi-Annual Performance Report for the State of XXXXXXX
Activities and Accomplishments
1. What did you accomplish during this reporting period and how did these
accomplishments help you reach your stated project goal(s) and objective(s)?
Please note any significant project partners and their role in project activities.
2. What, if any, challenges did you face during this reporting period and what
actions did you take to address these challenges? Please note in your response
changes, if any, to your project goal(s), objective(s), or activities that were made
as a result of challenges faced.
3. How have the activities conducted during this project period helped you to
achieve the measurable outcomes identified in your project proposal?
4. What was produced during the reporting period and how have these products
been disseminated? Products may include articles, issue briefs, fact sheets,
newsletters, survey instruments, sponsored conferences and workshops,
websites, audiovisuals, and other informational resources.

Prevention and Public Health Fund
Chronic Disease Self-Management Education Grant
Semi-Annual Performance Report for the State of XXXXXXX
Appendix A

Quantitative Report (This section is populated by system)
Prior
Month
Period
1
2
To
Date
Participants
Completers

Period Cumulative Target Variance
Total
Total
3

4

5

6