0920-0952 Attachment 5 (electronic)

Form Approved
OMB No. 0920-xxxx
Exp. xx/xx/xxxx

State and Community Awardee
Program Implementation Partner Needs Assessment

Public reporting burden of this collection of information is estimated to average 45 minutes 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, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-xxxx).

1

ID:

Program Implementation Partner Needs Assessment (PIPNA)
The purpose of this assessment is to help your organization identify current strengths, as well as
areas of potential growth, related to the implementation of evidence-based programs to prevent teen
pregnancy. This information will be used to help you adopt or strengthen evidence-based programs.
Name of Local Organization
Phone of Local Organization
Address of Local Organization
Name of CDC grantee organization
Name of person conducting
assessment
Please complete the following information for each individual involved in completing this
organizational assessment.
Name:
Length of time in organization:
Current position in your organization (select from the following options)
Executive Director
Health/sexuality educator
Program Director
Outreach Worker
Assistant Director
Teacher/Coach
Program staff member
Other (please describe):___________________________________
Name:
Length of time in organization:
Current position in your organization (select from the following options)
Executive Director
Health/sexuality educator
Program Director
Outreach Worker
Assistant Director
Teacher/Coach
Program staff member
Other (please
describe):_____________________________________
Name:
Length of time in organization:
Current position in your organization (select from the following options)
Executive Director
Health/sexuality educator
Program Director
Outreach Worker
Assistant Director
Teacher/Coach
Program staff member
Other (please
describe):_____________________________________
How was this assessment conducted (please select one):
In-person interview
Telephone interview
Mail
Web-based survey

2

PART I: Please provide some information about your organization.
1. Which statement best describes your organization? (Please select one)
School
School district

Community-Based Organization (CBO) focusing primarily on
teen pregnancy
CBO where adolescent reproductive health is one of many
programs
Faith-based organization

Health department (non-clinical
section)
Planned Parenthood affiliate
Health care facility (hospital, clinic)
Other (please describe): _________________________________________________________
Comment:
2. a. How long has your organization existed in years?
Years:
b. How long has your organization focused on teen pregnancy prevention (TPP)?
<2 yrs
2-5 yrs
6-10 yrs
>10 yrs
TPP is a new focus for us
TPP is not a focus for us

3. How many hourly or salaried personnel do you have in your organization? Schools, school
districts, and health departments may skip this question.
Fulltime (≥ 35 hours)
Part-time
4. How many hourly or salaried personnel in your local organization work (or will work if this is a
new focus) on teen pregnancy prevention (TPP) programming?
Full-time on TPP
Part-time on TPP
5. How many volunteer or in-kind individuals work (or will work if this is a new focus) on TPP
programming?
Volunteer/In-kind
6. Does your organization have written job descriptions for the executive director (or equivalent)
and other staff positions?
Yes
No
Don’t Know

3

7. Does your organization have written personnel policies and procedures (e.g., a Human
Resources Manual)?
Yes
No
Don’t Know
8. Does your organization have someone on the staff or board who interviews candidates and
obtains their references?
Yes
No
Don’t Know
9. What is the current annual budget (approximate) of your organization? ____________________
10. Does your current budget cover all programming and administrative costs?
Yes
No
Don’t Know
11. a. Which of the following fundraising strategies has your organization used during the past 12
months to support teen pregnancy prevention programs?
Strategy
A direct mail campaign
Fees for services
Cause-related marketing which collects a portion of sales on consumer items
Special events such as dinners, fund-raising events, etc.
Grant-writing
Other: Please describe___________________________________
Not applicable: We have not been involved in teen pregnancy prevention in the
past 12 months.______

Yes

No

b. Please tell us about the funding sources for your organization during the past 12 months to
support teen pregnancy prevention programs and indicate the percentage of total funding for
TPP at your organization obtained from that source. Please select all that apply. Approximate
values should sum up to 100%.
Funding Source
% of total funding
Federal government
State government
Local government
Corporate donors
Individual/Private
United Way
Foundations (national, community, other)
Other source (please describe):________________________________
Not applicable: We have not been involved in teen pregnancy prevention during the past 12 months.

4

12. How would you rate your organization’s success in raising funds during the past 12 months for
TPP programs?
Excellent
Good
Fair
Poor
N/A we have not raised funds for this purpose
13. Does your organization have a clearly defined mission?
Yes
No
Don’t Know
14. Does your organization have a written strategic plan to guide work and development over the
next 3-5 years?
Yes
No, Skip to question 17
Don’t Know
15. Is your current strategic plan realistic given the current resources of the organization?
Yes
No
Don’t Know
16. Is there support from the board and staff of your organization for the strategic plan?
Yes
No
Don’t Know
17. Does your organization have a board of directors?
Yes
No
Don’t Know

5

PART II: Please provide some information about the TPP programs you currently provide or plan
to provide.
18. In what setting do you carry out (or plan to carry out if this is a new focus) your TTP programs?
Please select all that apply.
Schools
After-school
Foster care youth program
Residential or group home
Clinic-based facility
Community Center or similar location
Faith institution
Other (please describe):
Don’t know
19. What age group(s) do you intend to reach with your current (or future if this is a new focus) teen
pregnancy prevention programs? Please select all that apply.
10 years and younger
11-12 years
13-14 years
15-17 years
18-19 years
20 years and older
Parents of Teens/Preteens
Don’t Know
20. Do you intend to select programming to use with a single racial/ethnic group? Please select all
that apply.
Black or African American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Asian
White
Hispanic or Latino
Don’t know
No, we do not plan to use a program for a single racial/ethnic group
21. a. Approximately how many young people participate in your teen pregnancy prevention
programs each year? If you haven’t provided teen pregnancy prevention programs enter 0.
Enter number
b. If you do not currently offer teen pregnancy prevention programs, but plan to in the future,
approximately how many young people do you aim to target in the next year?
Enter number

6

PART III: Please tell us about available data and planning activities.
22. Has your organization decided to use Getting To Outcomes (GTO) approach to planning,
implementing, and evaluating evidence-based TPP programs?
Yes
No
Don’t Know
23. Has your organization had formal training on Getting To Outcomes?
Yes
No
Don’t Know
24. Have you received assistance and/or coaching in using Getting To Outcomes?
Yes
No
Don’t Know
25. a. Which of the following data for the population that you serve do you now have access to?
Please select all that apply.
Teen birth rates by county
Teen birth rates by age
Teen birth rates by race/ethnicity
Teen abortion rates
Teen rates of STI/HIV
A list of teen pregnancy prevention programs that currently exist in the community
None of these
b. Did you consider data such as these when selecting target populations with whom to work?
Yes
No
Don’t Know
26. a. In the past 12 months, have you conducted a needs assessment to gather information about
the needs, assets and resources related to TPP in your community?
Yes, continue to question 26b
No, skip to question 27
Don’t Know, skip to question 27
b. How did you conduct the needs assessment (check all that apply):
Informal discussions with teens
Focus groups
Community survey
Used existing Youth Risk Behavior Survey data
Used recent needs assessment data from another group (please describe):_____________________
Other (please describe):______________________________________________________________

7

27.

a. Do you currently have a logic model for your TPP program?
Yes, please continue to questions 27b-d
No, please skip to question 28
Don’t Know, please skip to question 28
b. Does the logic model indicate which teen pregnancy-related behaviors you are targeting
(e.g., age at first sex, contraceptive use)?
Yes
No
Don’t Know
c. Does the logic model identify both risk and protective factors for each behavior
(i.e., what affects age at first sex or contraceptive use)?
Yes
No
Don’t Know
d. Does the logic model include activities addressing these risk and protective factors?
Yes
No
Don’t Know

28.

a. Has your organization delivered a TPP program in the past 12 months?
Yes, continue to question 28b
No, skip to question 35
b. Thinking about the TPP program you delivered most recently, did you identify and think
about various existing science-based programs before you chose your program?
Yes
No
Don’t Know

29. Before the TPP program you delivered most recently, did you assess the program to determine if
it fit with the needs and goals of your community?
Yes
No
Don’t Know
30. Before the TPP program you delivered most recently, did you assess your internal capacity to
deliver the program (e.g., number of staff, staff training, technical resources, and program budget)?
Yes
No
Don’t Know

8

31. Thinking about the TPP program you delivered most recently, did you develop a written work
plan for your program delivery?
Yes
No
Don’t Know
32. a. During the past 12 months, did you evaluate the effectiveness of your teen pregnancy
prevention program.
Yes, continue to question 32b
No, skip to question 34
Don’t Know, please skip to question 34
b. Which of the following evaluation strategies did you use to assess the effectiveness of your
program? Please select all that apply.
Evaluation of the way each activity was implemented to see if it was delivered exactly as designed (with
fidelity)
Evaluation of youth participation to determine recruitment and retention by the intended target
population.
Outcome evaluation to measure the change in each targeted behavior
Outcome evaluation to measure whether you are changing the risk or protective factors associated with
said behaviors
Don’t know
Other (please specify):__________________________________________
33. a. Did you plan changes to the program based on the evaluation results?
Yes, continue to question 33b
No, please skip to question 34
Don’t Know, please skip to question 34
b. Which of the following describes the changes made to the program? (Check all that apply)
Selected a program that was a better fit (please specify):__________________________________
Modified the existing curriculum using adaptation guidance
Discontinued the current program
Other (please specify): ___________________________________________________________
34. During the past 12 months, did you market your TPP programs to partners, funders, or others
who might help you continue delivering or funding the programs in the future?
Yes
No
Don’t Know
35. How familiar are you with Getting to Outcomes (GTO)?
Not at all
Somewhat
Very

9

36. Have you ever been trained on the iGTO web-based system for teen pregnancy prevention?
Yes
No
Don’t Know
37. Have you used the iGTO web-based system to complete any of the above activities?
Yes
No
Don’t Know
38. How much do you and your team agree or disagree with each of the following statements [by
team, we mean those who will work with you to provide TPP programs]?
Skill set

Strongly
Agree
1

2

3

Neutral
4

5

6

Strongly
Disagree
7

Goals and objectives are primarily for funders
and grant applications
Our programs would be improved by modifying
them based on evaluation data
The extra time and costs required to implement
scientifically proven programs greatly outweigh
the benefits
Program staff often know whether a program is
working well without having to do a formal
evaluation
Implementing a program that is mismatched
with the values of the local community will lead
to poor implementation and outcomes
Time spent writing out all the activities of a
program on a timeline could be better spent on
implementation
We could better achieve our mission by
devoting resources to regularly gathering
information about the teen pregnancy
prevention needs of the community
Funding is available for a teen pregnancy
prevention program that produces positive
results.
Changing programs based on evaluation data
will likely cause problems
When implementing new programs we would
benefit from only choosing ones that are
scientifically proven
Given all the time constraints on staff, formal
evaluations of programs are not critical to do
It is likely that a successful teen pregnancy
prevention program will continue to receive
funding with little effort
Programs should be changed over time if
evaluation data says so

10

38. How much do you and your team agree or disagree with each of the following statements [by
team, we mean those who will work with you to provide TPP programs]?

Resources (e.g., staff time, funds) devoted to
data collection to understand the teen
pregnancy prevention needs of our community
could be better spent elsewhere
Staff should only implement program activities
that can be linked to our goals and objectives
Using measurable objectives in the planning
process is a step that must be taken in order to
demonstrate our success
Before implementing programs, it is important
to critically assess whether we have adequate
resources/ capacity to implement the program
(e.g., number of staff, staff training, technical
resources, program budget)

11

39. Imagine that your team is thinking about implementing a new program in your community.
For the tasks listed below, please rate each item on a scale of 1 to 5 based on how much
assistance you think that you and your team would need in order to complete each task. A
rating of 1 indicates the need for a great deal of assistance, while a rating of 5 indicates the
ability to complete the task without any assistance.

Task

A great
deal of
assistance
needed
1

2

Some
assistance
needed
3

4

No
assistance
needed
5

Develop program goals for your new activity
Assess how well your new program activity will fit
within other existing program activities offered to
the same target population
Define a target population for your new activity
Measure participant satisfaction
Evaluate the activity to ensure that it is meeting
goals and objectives by analyzing and interpreting
data
Identify those who will be responsible for each
task
Specify the amount of change expected in your
objectives
Assess community strengths in programming by
examining existing resources such as existing
programs and availability of volunteers
Determine if an existing evidence-based program
would meet your goals and objectives
Examine how the new program will fit with the
values of your organization
For each program activity, measure how well the
implementation followed the original program
design (i.e., fidelity)
Ensure that all new program activities are linked
to the goals and objectives by using a logic model
Determine if any evidence-based programs are
applicable to your target population
Assess the causes and underlying risk factors for
teen pregnancy in your community
Assess whether there are adequate resources to
implement the new program (e.g., number of
staff, staff training, technical resources, funding)
Create timelines for completing all program tasks
Develop a budget that outlines the funding
required for each program activity
Develop a plan to sustain the program if it is
successful (i.e., determine future funding sources)
Use results from an evaluation to improve
program delivery the next time it is offered

12

40. Listed below are the same tasks from question 26. Place a check by those tasks for which your
team would like technical assistance or training in the next 12 months.
Task
Develop program goals for your new activity
Assess how well your new program activity will fit within other existing program activities
offered to the same target population
Define a target population for your new activity
Measure participant satisfaction
Evaluate the activity to ensure that it is meeting goals and objectives by analyzing and
interpreting data
Identify those who will be responsible for each task
Specify the amount of change expected in your objectives
Assess community strengths in programming by examining existing resources such as
existing programs and availability of volunteers
Determine if an existing science-based program would meet your goals and objectives
Examine how the new program will fit with the values of your organization
For each program activity, measure how well the implementation followed the original
program design (i.e., fidelity)
Ensure that all new program activities are linked to the goals and objectives by using a
logic model
Determine if any science-based programs are applicable to your target population
Assess the causes and underlying risk factors for teen pregnancy in your community
Assess whether there are adequate resources to implement the new program (e.g.,
number of staff, staff training, technical resources, funding)
Create timelines for completing all program tasks
Develop a budget that outlines the funding required for each program activity
Develop a plan to sustain the program if it is successful (i.e., determine future funding
sources)
Use results from an evaluation to improve program delivery the next time it is offered
Use iGTO to support program selection and implementation
No TA requested on any of these topics.

THANK YOU!

Save File as

Submit Form

13