New Web Survey

1. State and Community Awardee Project Director/Project Coordinator Needs
Asse...

Form Approved 
OMB No. 0920­0952 
Exp. 12/31/2015  

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 D­74, Atlanta, GA 30333, ATTN: 
PRA (0920­0952).  

2. Project Coordinator/Project Director Needs Assessment

The purpose of this assessment is to help your organization identify strengths and areas of potential growth regarding 
your ability to support the implementation of this project. This assessment is aligned with the key components of this 
project and requests information on your organizational background, partnerships, community mobilization, evidence­
based programs, training and technical assistance for program implementation, contraceptive services for youth, 
educating stakeholders, and cultural competence and diversity.  

Please respond to only those sections that apply to your project role. Please answer as honestly as possible. Results 
from this assessment will be used by CDC and the five funded National Organizations to develop a targeted training and 
technical assistance plan for your organization.  

Thank you for your candor in completing this important assessment.  

*1. Please select your organization.
j Alabama Department of Public Health
k
l
m
n

j Adolescent Pregnancy Prevention Campaign of North Carolina
k
l
m
n
j Family Planning Council
k
l
m
n

j Fund for Public Health New York
k
l
m
n

j Georgia Campaign for Adolescent Pregnancy Prevention
k
l
m
n
j City of Hartford
k
l
m
n

j Massachusetts Alliance on Teen Pregnancy
k
l
m
n

j South Carolina Campaign to Prevent Teen Pregnancy
k
l
m
n

j University of Texas Health Science Center at San Antonio
k
l
m
n

*2. Which of the following describes your role/title? (select all that apply)
c Project Director
d
e
f
g

c Project Coordinator
d
e
f
g

c Clinical technical assistance provider
d
e
f
g

c Program technical assistance provider
d
e
f
g
c Youth leadership team coordinator
d
e
f
g
c Evaluator
d
e
f
g

c Other (please specify) ______________________________________________
d
e
f
g

3. For how many years have you held your position?
j < 2 years
k
l
m
n

j 3­5 years
k
l
m
n
j > 5 years
k
l
m
n

4. For how many years have you worked in teen pregnancy prevention?
j < 2 years
k
l
m
n

j 3 to 5 years
k
l
m
n
j > 5 years
k
l
m
n

3. Section I. Organization Background

*5. How many years has your organization been working to prevent teen pregnancy?

(e.g., 2.5, 5, 14)
Number of years

6. How many hourly or salaried personnel in your organization work on this teen
pregnancy prevention cooperative agreement?
1­3

4­5

5­7

>7

Number of people full­time on this cooperative agreement

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Number of people part­time on this cooperative agreement

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

*7. How many external consultants do you use on this cooperative agreement?
j 0 external consultants
k
l
m
n
j 1 external consultant
k
l
m
n

j 2 external consultants
k
l
m
n

j > 2 external consultants
k
l
m
n

8. What topic area(s) do the consultant(s) cover?
Topic Area 1
Topic Area 2
Topic Area 3
Topic Area 4

*9. Does your organization routinely do the following?
Yes

No

Use logic models in planning the organization's projects?

j
k
l
m
n

j
k
l
m
n

Use adult learning theory or other applicable theory to enhance TA and Training effectiveness?

j
k
l
m
n

j
k
l
m
n

Monitor its program activities (e.g., who and how many you serve, quality assurance)?

j
k
l
m
n

j
k
l
m
n

Evaluate program outcomes?

j
k
l
m
n

j
k
l
m
n

4. Section II: Partnerships (Core Partner Leadership Team; CPLT)

*10. How many times did your CPLT meet in the past year?
j 1­2 times
k
l
m
n
j 3­4 times
k
l
m
n
j 5­6 times
k
l
m
n

j 7­8 times
k
l
m
n

j 9­10 times
k
l
m
n

j > 10 times
k
l
m
n

*11. How many people serve on the CPLT?
j < 5 people
k
l
m
n

j 5­10 people
k
l
m
n

j 16­20 people
k
l
m
n

j 11­15 people
k
l
m
n

j 21­25 people
k
l
m
n

j > 25 people
k
l
m
n

*12. Please check each group that is represented on the CPLT for the project.
c Local school board
d
e
f
g

c Local department of health
d
e
f
g
c Funders
d
e
f
g

c Teen pregnancy prevention program implementers (with 
d
e
f
g

c Health service providers (with MOU/MOA)
d
e
f
g

c Foundations
d
e
f
g

MOU/MOA) 

c Teen pregnancy prevention program implementers (without 
d
e
f
g

c Elected officials
d
e
f
g

MOU/MOA) 

c Health service providers (without MOU/MOA)
d
e
f
g
c Other
d
e
f
g

Other (please specify) 

13. Does your CPLT for this project include diversity in the following characteristics?
Yes

No

Gender

j
k
l
m
n

j
k
l
m
n

Age

j
k
l
m
n

j
k
l
m
n

Race/Ethnicity

j
k
l
m
n

j
k
l
m
n

Geographic location in the community

j
k
l
m
n

j
k
l
m
n

Type of organization (e.g., schools, governmental, community­based)

j
k
l
m
n

j
k
l
m
n

Other characteristic

j
k
l
m
n

j
k
l
m
n

Other (please specify) 

*14. Please describe any current gaps in CPLT membership. Which members and roles

do you still want to add or increase in your group?
c Local school board
d
e
f
g

c Local department of health
d
e
f
g
c Funders
d
e
f
g

MOU/MOA) 

c Health service providers (with MOU/MOA)
d
e
f
g

c Foundations
d
e
f
g

c Teen pregnancy prevention program implementers (with 
d
e
f
g

c Teen pregnancy prevention program implementers (without 
d
e
f
g

c Elected officials
d
e
f
g

MOU/MOA) 

c Health service providers (without MOU/MOA)
d
e
f
g
c Other
d
e
f
g

Other (please specify) 

5
6

15. Please describe any successes your organization has had in engaging key
stakeholder groups in the CPLT.
5
6  

16. Please describe any challenges your organization has had in engaging key
stakeholder groups in the CPLT.
5
6  

5. Section II. Partnerships (Community Action Team: CAT)

*17. How many times did your CAT meet in the past year?
j 1­2 times
k
l
m
n
j 3­4 times
k
l
m
n
j 5­6 times
k
l
m
n

j 7­8 times
k
l
m
n

j 9­10 times
k
l
m
n

j > 10 times
k
l
m
n

*18. How many people serve on the CAT?
j < 5 people
k
l
m
n

j 5­10 people
k
l
m
n

j 16­20 people
k
l
m
n

j 21­25 people
k
l
m
n

j 11­15 people
k
l
m
n

j > 25 people
k
l
m
n

*19. Please check each group that is represented on the CAT for this project.
c Public sector
d
e
f
g

c Parents
d
e
f
g

c Nonprofit sector
d
e
f
g

c Youth from the Youth Leadership Team
d
e
f
g

c Business sector
d
e
f
g

c Religious leaders
d
e
f
g

c Health services (e.g., providers for adolescents)
d
e
f
g
c Education (e.g., school board, PTA, teachers)
d
e
f
g
c School and mental health services
d
e
f
g
c Minority health groups
d
e
f
g
c Juvenile justice
d
e
f
g

c Civic leaders and public servants
d
e
f
g

c Representatives from funding organizations
d
e
f
g

c Media members or those with media access
d
e
f
g

c Researchers
d
e
f
g

c Neighbors
d
e
f
g

c Service organization members (e.g., Kiwanis, Rotary, sororities 
d
e
f
g

and fraternities) 

c Other
d
e
f
g

Other (please specify) 

*20. Does your CAT for this project include diversity in the following characteristics?
Yes

No

Gender

j
k
l
m
n

j
k
l
m
n

Age

j
k
l
m
n

j
k
l
m
n

Race/Ethnicity

j
k
l
m
n

j
k
l
m
n

Geographic location in the community

j
k
l
m
n

j
k
l
m
n

Type of organization (e.g., schools, governmental, community­based)

j
k
l
m
n

j
k
l
m
n

Other characteristic

j
k
l
m
n

j
k
l
m
n

Other (please specify) 

21. Please describe any current gaps in CAT membership. Which members and roles
would you like to add to your group?
c Public sector
d
e
f
g

c Parents
d
e
f
g

c Nonprofit sector
d
e
f
g

c Youth from the Youth Leadership Team
d
e
f
g

c Business sector
d
e
f
g

c Religious leaders
d
e
f
g

c Health services (e.g., providers for adolescents)
d
e
f
g
c Education (e.g., school board, PTA, teachers)
d
e
f
g
c School and mental health services
d
e
f
g
c Minority health groups
d
e
f
g
c Juvenile justice
d
e
f
g

c Researchers
d
e
f
g

c Civic leaders and public servants
d
e
f
g
c Neighbors
d
e
f
g

c Representatives from funding organizations
d
e
f
g

c Media members or those with media access
d
e
f
g

c Service organization members (e.g., Kiwanis, Rotary, sororities 
d
e
f
g

and fraternities) 

c Other
d
e
f
g

Other (please specify) 

5
6

22. Please describe any successes your organization has had in engaging key
stakeholder groups in the CAT.
5
6  

23. Please describe any challenges your organization has had in engaging key
stakeholder groups in the CAT.
5
6  

6. Section II: Partnership (Youth Leadership Team: YLT)

*24. How many times did your YLT meet in the past year?
j 1­2 times
k
l
m
n
j 3­4 times
k
l
m
n
j 5­6 times
k
l
m
n

j 7­8 times
k
l
m
n

j 9­10 times
k
l
m
n

j > 10 times
k
l
m
n

*25. How many people serve on the YLT?
j < 5 people
k
l
m
n

j 5­10 people
k
l
m
n

j 16­20 people
k
l
m
n

j 11­15 people
k
l
m
n

j 21­25 people
k
l
m
n

j > 25 people
k
l
m
n

*26. Have you taken steps to assess whether the YLT represents the diversity of youth in

your community?

j Yes
k
l
m
n
j No
k
l
m
n

If Yes, please specify 

5
6

*27. Please indicate which of the following groups of youth are represented on your YLT.
c Youth younger than 15
d
e
f
g

c Youth aged 15­17 years
d
e
f
g
c Youth aged 18­19 years
d
e
f
g

c Youth older than 19 years
d
e
f
g
c Out of school youth
d
e
f
g

c Youth in post­secondary institutions
d
e
f
g
c Other
d
e
f
g

Other (please specify) 

28. Please describe any successes your team has had in involving youth in the YLT.
5
6  

29. Please describe any challenges your team has had in inolving key youth in the YLT.
5
6  

7. Section III. Community Mobilization

*30. Do you lead organizational efforts to work with community partners (e.g., core

partner leadership team) in developing action plans and implementing community
initiatives?

j Yes
k
l
m
n
j No
k
l
m
n

8. Section III. Community Mobilization (continued 1)

*31. Please indicate whether you received training on certain topics related to

leading/facilitating collaborative community wide efforts. Formal training refers to planned
teaching of standard knowledge and/or skills related to specific capacities.
Never

< 2 years

3 to 5 years

> 5 years

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

A theoretical justification for community mobilization in support of TPP

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Developing a long­range community mobilization plan

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Identifying and recruiting participants for a Core Partner Leadership Team

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Identifying and recruiting participants for a Community Action Team

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Identifying and recruiting participants for a Youth Leadership Team

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Supporting community participants to develop TPP goals and identify strategies to 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Preparing for possible opposition to TPP within communities

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Identifying strategies for long­term sustainability of TPP activities within communities

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Supporting community team members to evaluate their mobilization efforts

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Conducting a comprehensive community needs and asset assessment in support of 
TPP

address them

*32. How confident are you in your ability to lead a community group through the

following activities?

1 ­Not 
Confident at 

2

all

3 ­Somewhat 
Confident

4

5 ­Extremely 
Confident

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

A theoretical justification for community mobilization in support of TPP

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Developing a long­range community mobilization plan

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Identifying and recruiting participants for a Core Partner Leadership 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Identifying and recruiting participants for a Community Action Team

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Identifying and recruiting participants for a Youth Leadership Team

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Supporting community participants to develop TPP goals and identify 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Preparing for possible opposition to TPP within communities

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Identifying strategies for long­term sustainability of TPP activities within 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Conducting a comprehensive community needs and asset assessment in 
support of TPP

Team

strategies to address them

communities
Supporting community team members to evaluate their mobilization 
efforts

9. Section III. Community Mobilization (Group Facilitators)

*33. Do you lead organizational efforts to facilitate one or more of the 3 partnership

groups (i.e., Core Partner Leadership Team, Community Action Team, or Youth Leadership
Team)?

j Yes
k
l
m
n
j No
k
l
m
n

10. Section III. Community Mobilization (Group Facilitator; continued)

*34. With which of the three groups you are involved as a facilitator/group leader? (Select 
all that apply)
c Core Partner Leadership Team
d
e
f
g
c Community Action Team
d
e
f
g
c Youth Leadership Team
d
e
f
g

*35. How confident are you in your ability to do the following activities?
1 ­Not 
Confident at 

2

all
Facilitate the goal setting process within your project team to achieve 

3 ­Somewhat 
Confident

4

5 ­Extremely 
Confident

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

community mobilization in support of TPP
Work within your project team to identify, recruit and retain the best 
“mix” of persons for your community teams
Work within your project team to help community teams establish their 
legitimacy as spokespersons for TPP within their communities
Work within your project team to help community teams rally support for 
TPP within their communities
Work within your project team to evaluate the functioning of the 
community teams to achieve their goals

11. Section IV. Contraceptive Services for Youth

*36. Have you completed an assessment that has served to identify and describe the
components of the health care delivery system in your target community?

j Yes
k
l
m
n
j No
k
l
m
n

j Planned
k
l
m
n

j In Process
k
l
m
n

37. If Yes, Planned, or In Process, please describe the methods used to conduct the
assessment if planned or completed and indicate the month and year of your most recent
assessment.
Methods used to complete assessment
Start/End Date

*38. Does your Core Partner Leadership Team (CPLT) or Community Action Team (CAT)
include professionals from the community with expertise in the following areas?
Yes

No

Adolescent Contraceptive and Reproductive Health

j
k
l
m
n

j
k
l
m
n

Health Care Reform

j
k
l
m
n

j
k
l
m
n

Health Care Financing

j
k
l
m
n

j
k
l
m
n

*39. Please indicate which of the following health care delivery settings you have an MOU
with.
Yes, with an MOU(s)

Yes, no MOU(s)

No

Family Medicine Practice

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Pediatric Health Practice

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Adolescent Health Practice

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Private Ob/Gyn Practice

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Publicly funded family planning clinics

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Hospital­based Health Centers

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Mobile Health Units

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Health Department Clinics

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Community Health Centers

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

School Based Health Centers

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

School Linked Health Centers

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Other

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

12. Section IV. Contraceptive Services for Youth (Referrals and Linkages)

*40. Please indicate whether your organization has an established referral network to link
youth to reproductive health services. Referral refers to any mechanism or medium that
directs clients to care. Referral sources may include friends, family members, Internet
sources, schools, as well as linkage partner organizations/agencies/institutions.
j Yes, we have an established network
k
l
m
n

j Yes, we developed a network for this initiative
k
l
m
n
j No
k
l
m
n

j Other
k
l
m
n

Other (please specify) 

41. Please indicate which of the following steps you took to develop this referral network.
Select all that apply
c Identified reproductive health service providers/clinics in the community
d
e
f
g

c Assessed the capacity and quality of reproductive health service providers/clinics
d
e
f
g

c Contacted those reproductive health service providers/clinics identified as appropriate for meeting program goals/objectives
d
e
f
g
c Developed agreements with these reproductive health service providers/clinics on processes for referring youth to services
d
e
f
g
c Other
d
e
f
g

Other (please specify) 

*42. Does your community­wide initiative have a resource for youth that describes
available reproductive health services in your target community? Please select all that
apply.
c Yes, a website
d
e
f
g

c Yes, a pamphlet
d
e
f
g

c Yes, a call center
d
e
f
g
c Yes, other
d
e
f
g
c No
d
e
f
g

c Planned
d
e
f
g

c In Process of Developing
d
e
f
g
Other (please specify) 

*43. Does your organization have a referral network in place to help direct providers of
adolescent services in your community to providers of reproductive health services?

j Yes
k
l
m
n
j No
k
l
m
n

j Planned
k
l
m
n

j In Process of Developing
k
l
m
n

Other (please specify) 

44. Please indicate which of the following steps you took to develop this network.
Please check all that apply
c Identified youth­serving organizations/centers in community
d
e
f
g

c Assessed the capacity and quality of youth­serving organizations/centers
d
e
f
g

c Contacted those organizations/centers identified as appropriate for meeting program goals/objectives
d
e
f
g
c Developed agreements with these organizations/centers on processes for referring youth to services
d
e
f
g

c Developed agreements with these organizations/centers on how to track referrals made and referrals resulting in receipt of care
d
e
f
g
c Other
d
e
f
g

Other (please specify) 

45. Please indicate which of the following groups you involved in the development of your
referral network.
c Core Partner Leadership Team
d
e
f
g
c Community Action Team
d
e
f
g
c Youth Leadership Team
d
e
f
g
c Other
d
e
f
g

Other (please specify) 

*46. Please select the institutions that you have partnered with to build sustainable
sources of support for clinical partners in your community.
Please check all that apply
c American Academy of Pediatrics
d
e
f
g

c American Academy of Pediatric Section on Adolescent Health
d
e
f
g
c American Academy of Family Physicians
d
e
f
g

c Society for Adolescent Health and Medicine
d
e
f
g

c American Congress of Obstetricians and Gynecologists
d
e
f
g

c Federally Qualified Health Center Health Disparities Collaborative
d
e
f
g
c State Office of Minority Health Initiatives
d
e
f
g
c Public Health Associations
d
e
f
g

c Practice­based Research Networks
d
e
f
g

*47. Has your organization identified any of the following youth cohorts who are in need
of linkages to contraceptive and reproductive health care?
Yes

No

Planned

In Process

Foster youth

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Youth relying primarily on ER for care

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Youth enrolled in Medicaid but who have not received preventative care

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Uninsured youth

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Undocumented immigrant youth

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Youth not enrolled in school

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Youth participating in EBIs

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Non­English speaking youth

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Other

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Other (please specify) 

*48. Have you identified organizations that serve these youth?

j Yes
k
l
m
n
j No
k
l
m
n

j Planned
k
l
m
n

j In Process
k
l
m
n

*49. Have you supported the development of Linkage Agreements between the youth
serving organizations and reproductive health providers? Linkage refers to a formal
partnership between community organizations, agencies, or other institutions (which may
include but are not limited to health centers, schools, and churches). The partnership is
formalized through a written agreement (e.g., a MOU) that clearly defines how partners will
share resources and services related to teen pregnancy prevention.

j Yes
k
l
m
n
j No
k
l
m
n

j Planned
k
l
m
n

j In Process
k
l
m
n

*50. Have you completed an assessment of attitudes and beliefs related to youth access
to contraceptive and reproductive health care without parental consent for the following
community members?
Yes

No

Planned

In Process

Parents/Caregivers

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Youth

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Health care providers

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

School nurses

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Teachers

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

School administrators

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Local government officials

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Other

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Other (please specify) 

*51. Have you completed an assessment of attitudes and beliefs related to youth
utilization of highly reliable contraception (IUD and Implants) among the following
community members?
Yes

No

Planned

In Process

Parents/Caregivers

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Youth

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Health care providers

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

School nurses

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Teachers

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

School administrators

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Local government officials

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Other

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Other (please specify) 

*52. Please indicate whether or not your organization has provided technical assistance
or training in the past 2 years to health center partners utilizing the following performance
improvement tools and methods.
Yes

No

Planned

In Process

Conducting Clinical Provider Practice Assessment

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Analyzing and Sharing Provider Practice Assessment Results with Health Center

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Conducting a Work Flow Analysis (ie: Process Mapping, Mapping Steps in Visit)

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Examining Capacity of Health Center to Serve Clients (ie: examine current number of 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Conducting a Health Center Walk Through

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Using the IHI Model for Improvement to define and establish a performance 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Facilitating the development of a health center improvement team

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Facilitating and supporting health center improvement team meetings

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Designing and running a collaborative among health center partners

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Examining health center billing and reimbursement practices to support efforts to 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

clients served compared to staff FTE’s)
Examining and Re­aligning Staff Roles/Responsibilities to Increase Access to 
Contraceptive and Reproductive Health Care (ie: Task Shifting, scope of practice)
Examining Patient Appointment Scheduling Practices (ie: Appointment No Show 
Rates, Appointment Types, Appointment Framework)

improvement project
Using the Plan Do Study Act (PDSA) method to test small changes to improve health 
center performance
Developing a Work Plan (CQI Plan) to Improve Access to Contraceptive and 
Reproductive Health Care for Adolescents Using Information from the Clinical Provider 
Assessment
Establishing a set of performance measures related to the health center improvement 
plan and data systems and tools to support collection and analysis of relevant data
Facilitating and supporting the collection and analysis of performance measurement 
data

ensure fiscal sustainability of health center operations and maximize third party 
revenue opportunities
Other
Other (please specify) 

*53. Do you lead organizational efforts to provide training and technical assistance to
clinic partners as part of the Teen Pregnancy Prevention project?

j Yes
k
l
m
n
j No
k
l
m
n

13. Section IV. Contraceptive Service (TA Providers)

*54. Please indicate whether you have received formal training and the time frame in
which the formal training on certain topics related to reproductive health services was
received. Formal training refers to planned teaching of standard knowledge and/or skills
related to specific capacities.
Never

< 2 years

3 to 5 years

> 5 years

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

The use of the Quick Start Methods for dispensing IUDs

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Pap smear guidelines for adolescents

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Healthcare delivery system budgeting

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Business planning including maximizing coding, billing, and reimbursement strategies

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Coding confidentiality in billing for adolescent reproductive health services

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Work flow processes for patient visits

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Health care delivery systems productivity standards

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Appointment scheduling practices

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Contraceptive methods for adolescents

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Performance improvement or quality improvement methodologies

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Performance measurement

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Strategies for supporting time­alone between a provider and an adolescent client

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Strategies for supporting confidentiality in the delivery of contraceptive and 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Addressing social determinants of health in the clinical setting

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Male sexual and reproductive health services

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

The use of the Quick Start Method for dispensing hormonal contraception to 
adolescents

reproductive services for adolescents

*55. How knowledgeable are you about each of the following?
1 ­ Not at 
all

2

3 ­ 
Somewhat

4

5 ­ 
Extremely

Efficacy of Intrauterine devices (IUDs)

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Costs of Intrauterine devices (IUDs)

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Side effects of Intrauterine devices (IUDs)

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Dispensing procedures of Intrauterine devices (IUDs)

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Contraceptive implant (Implanon)

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Efficacy of Contraceptive implant (Implanon)

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Costs of Contraceptive implant (Implanon)

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Side effects of Contraceptive implant (Implanon)

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Dispensing procedures of Contraceptive implant (Implanon)

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Efficacy of Injectable contraception (Depo­provera)

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Costs of Injectable contraception (Depo­provera)

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Side effects of Injectable contraception (Depo­provera)

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Dispensing procedures of Injectable contraception (Depo­provera)

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Efficacy of Birth control pills

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Costs of Birth control pills

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Side effects of Birth control pills

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Dispensing procedures of Birth control pills

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Efficacy of Emergency contraception

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Costs of Emergency contraception

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Side effects of Emergency contraception

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Dispensing procedures of Emergency contraception

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Efficacy of Male condoms

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Costs of Male condoms

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Side effects of Male condoms

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Dispensing procedures of Male condoms

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Efficacy of Female condoms

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Costs of Female condoms

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Side effects of Female condoms

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Dispensing procedures of Female condoms

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Efficacy of Other methods

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Costs of Other methods

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Side effects of Other methods

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Dispensing procedures of Other methods

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Other (please specify) 

14. Section V. Educating Stakeholders

*56. Has your organization conducted an assessment of knowledge regarding evidence­
based teen pregnancy prevention strategies for any of the following stakeholder groups?
Yes, a formal assessment

Yes, an informal assessment

No

Adolescents

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Parents

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Local youth­serving coalitions or task forces

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Local organizations that directly serve youth

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Local organizations that serve underserved or at­risk 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

K12 school educators/leadership

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Local school board

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Health care providers/clinics

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Local/County Health Department

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Funders, such as community foundations

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Members of the media

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Faith­based leaders

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Community organizations such as voluntary civic 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Members of the business community

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Policymakers at the local level

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Mayor

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Regional youth­serving organizations

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

State youth­serving organizations

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Title XX directors

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Title X directors

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Title V directors

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

State Education Agency

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

State Health Department

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

State Human Service Agency

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

State Medicaid directors/officials

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Legislators at the state or local level

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Other policymakers in state or local government

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Governor

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Other key stakeholders

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

youth (e.g. juvenile justice; juvenile court; welfare 
agency)
Postsecondary educators/leadership(e.g. community 
colleges, colleges)

organizations

Other (please specify) 

*57. To which type of key stakeholders have you disseminated information on teen
pregnancy prevention (TPP) in the last 12 months?
Please check all that apply.
c Adolescents
d
e
f
g
c Parents
d
e
f
g

c Policymakers at the local level
d
e
f
g

c Mayor
d
e
f
g

c Local youth­serving coalitions or task forces
d
e
f
g

c Local organizations that directly serve youth
d
e
f
g

c State youth­serving organizations
d
e
f
g

juvenile justice; juvenile court; welfare agency) 

c Postsecondary educators/leadership(e.g. community colleges, 
d
e
f
g

c Title V directors
d
e
f
g

c Local/County Health Department
d
e
f
g

c Members of the media
d
e
f
g

c Legislators at the state or local level
d
e
f
g

c Other policymakers in state or local government
d
e
f
g

c Governor
d
e
f
g

c Community organizations such as voluntary civic organizations
d
e
f
g
c Members of the business community
d
e
f
g

c State Medicaid directors/officials
d
e
f
g

c Funders, such as community foundations
d
e
f
g

Other (please specify) 

c State Human Service Agency
d
e
f
g

c State Health Department
d
e
f
g

c Health care providers/clinics
d
e
f
g

c State Education Agency
d
e
f
g

c Faith­based leaders
d
e
f
g

c Title XX directors
d
e
f
g
c Title X directors
d
e
f
g

colleges) 

c Local school board
d
e
f
g

c Regional youth­serving organizations
d
e
f
g

c Local organizations that serve underserved or at­risk youth (e.g. 
d
e
f
g

c K12 school educators/leadership
d
e
f
g

c Other key stakeholders
d
e
f
g

*58. Which of the following methods have you used during the last 12 months to
disseminate information on teen pregnancy prevention (TPP)?
Please check all that apply
c Contact with local media (i.e., provide information for a story, meeting editorial staff, media campaign).
d
e
f
g

c Issued press releases
d
e
f
g

c Distributed fact sheets, reports, or journal articles on TPP.
d
e
f
g

c Offered an electronic newsletter with information on TPP.
d
e
f
g

c Regularly published a printed newsletter that highlights TPP
d
e
f
g
c Held an annual conference that included TPP.
d
e
f
g

c Held meetings, roundtables, or symposia related to TPP.
d
e
f
g
c Used social media (e.g., Twitter, Facebook).
d
e
f
g
c Held briefings on your program
d
e
f
g
c Hosted a site visit
d
e
f
g

c Provided latest scientific information
d
e
f
g

c Reported on a community needs assessment
d
e
f
g

c Responded to questions and requests for information
d
e
f
g
c Testified (if invited to a hearing)
d
e
f
g

c Told a story about how your program impacted a constituent a member of the community
d
e
f
g
c Given an award
d
e
f
g
c Other *
d
e
f
g

Other (please specify) 

*59. Do any of your core partners maintain a website that includes information on the
community wide initiative?

j Yes
k
l
m
n
j No
k
l
m
n

If Yes, please specify 

15. Section V. Educating Stakeholders (cont'd)

*60. Does your organization currently have (or do you expect to have) a dedicated staff
person besides the Executive Director who will focus on educating stakeholders (i.e.,
community leaders, parents, and other constituents) about relevant evidence­based
and/or evidence­informed strategies to reduce teen pregnancy and data on needs and
resources in target communities?

j Yes
k
l
m
n
j No
k
l
m
n

*61. Do you have a system in place for when controverial or unexpected issues arise, to
prepare spokespeople within your organization to publicly respond in a timely manner?
(or somethimg similar that addresses crisis communication, managing controversy, etc.)

j Yes
k
l
m
n
j No
k
l
m
n

62. How confident are you that the plan mentioned in the previous question will be
successful?
j 1 ­Very confident
k
l
m
n

j 2
k
l
m
n

j 3 ­Somewhat 
k
l
m
n

j 4
k
l
m
n

j 5 ­Not at all 
k
l
m
n

confident 

confident 

*63. Do you lead/co­lead organizational efforts to educate stakeholders in your
community?

j Yes
k
l
m
n
j No
k
l
m
n

16. Section V. Educating Stakeholders (Project Lead)

*64. How knowledgeable are you about each of the following?
3 ­

2

How to identify important stakeholders in your community

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

How to determine your target audiences for stakeholder education

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

How to determine goals and objectives and an action plan for stakeholder education 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Methods for raising awareness of your community­wide initiative

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

How to educate on statistics and trends in teen pregnancy, by age and race/ethnicity 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Somewhat

4

5 ­

1 ­Not at all

Extremely

using data from your community needs assessment

and for special populations
Methods for educating on evidence­based and/or evidence­informed strategies to 
reduce teen pregnancy and data on needs and resources in target communities
Methods for crisis communication and managing controversy

*65. How confident are you in your ability to conduct the following activities?
3 ­

2

Identify important stakeholders in your community

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Determine your target audiences for stakeholder education

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Determine goals and objectives and an action plan for stakeholder education using 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Raise awareness of your community­wide initiative

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Educate on evidence­based and/or evidence­informed strategies to reduce teen 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Somewhat

4

5 ­

1 ­Not at all

Extremely

data from your community needs assessment

pregnancy and data on needs and resources in target communities
Manage controversy through communication techniques/strategies

66. What resources or tools would increase your capacity to work with key stakeholders?
c Specific talking points
d
e
f
g
c Additional training
d
e
f
g

c Resources and fact sheets
d
e
f
g
c Individual TA
d
e
f
g
c Other
d
e
f
g

Other (please specify) 

5
6

17. Section VI. Working with Diverse Communities

*67. Please indicate how often your organization does the following activities.
Technical assistance and training activities are routinely and systematically reviewed 

1 ­Never

2 ­

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

3 ­

4 ­

5 ­Often

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Sometimes

to enhance delivery the culturally competent practices and strategies
Input from community members reflective of cultural composition is actively sought 
and utilized when assessing need for technical assistance and consultation.
Efforts are made to involve consultants who have knowledge of and experience with 
the cultural groups receiving technical assistance or consultation.
Representatives of diverse cultures are actively sought to participate in the planning 
and implementation of training activities.
Representatives of the diverse cultures are actively sought to participate in the 
planning of outreach activities. Training curriculum, materials, and activities are 
systematically evaluated to determine if they achieve cultural competence.
Learning opportunities to enhance staff understanding of diverse cultures of 
community youth (i.e. attitudes toward disability, LGBTQ youth, cultural beliefs and 
values, and health, spiritual, and religious practices) are provided.

*68. Please indicate the extent to which the following are consistent with your current
project's practices
3 ­

2

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Representatives of ethnic communities actively incorporate their knowledge and 

Somewhat

4

5 ­Great 

1 ­Not at all

extent

experience in organizational planning
Supports involvement with and/or utilization of the resources of regional and/or 
national forums that promote cultural competence.
Personnel recruitment, hiring, and retention practices reflect the goal to achieve 
ethnic diversity and cultural competence.
Resources are in place to support initial and ongoing training for personnel to develop 
cultural competence.
Fiscal resources are available to support translation and interpretation services.

*69. Do you lead/co­lead organizational efforts for working with diverse communities?

j Yes
k
l
m
n
j No
k
l
m
n

18. Section VI. Working with Diverse Communities (Project Lead)

*70. How knowledgeable are you regarding each of the following topics?
3 ­

2

Health equity

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Health disparities

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Social determinants of health

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Frameworks for examining and addressing social determinants of health

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Cultural competency

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Strategies for engaging marginalized youth (i.e. foster care, homeless, GLBTQ) in 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Somewhat

4

5 ­

1 ­Not at all

Extremely

teen pregnancy prevention efforts
Strategies for engaging non­traditional partners (i.e. business leaders, social service 
agencies) in teen pregnancy prevention efforts

*71. How confident do you feel about providing technical assistance or training to
individuals in your community around the following areas?
3 ­

2

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Assess attitudes and beliefs around social determinants among different audiences

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Facilitate a process to identify key social determinants of teen pregnancy with 

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Identify feasible strategies to address key social determinants of teen pregnancy

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Enhance levels of cultural competence for clinical providers and program facilitators

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Utilize community­based participatory approaches to evaluation

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Assess and evaluate progress on strategies to address social determinants of teen 

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Increase awareness around the impact of social determinants of teen pregnancy with 

Somewhat

4

5 ­

1 ­Not at all

Extremely

community partners
Actively engage informal community leaders and other influential community 
stakeholders (i.e. business leaders) around the significance of addressing social 
determinants of teen pregnancy

community partners

pregnancy.

19. Section VII. Evidence­based Programs

*72. On which evidence­based programs...
Note: "Partner" may include an organization with whom you have a formal agreement, an
organization funded by you, or an organization not funded by you but with whom you
work closely.
Are staff members from your 
organization currently trained?

Are staff members from your 

Are staff members from your 

organization able to provide a 

organization able to provide a 

Training of Trainers (TOT)?

Training of Educators (TOE)?

Aban Aya Youth Project

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Adult Identity Mentoring 

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

All4You!

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Assisting in Rehabilitating 

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Be Proud! Be Responsible!

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Be Proud! Be Responsible! 

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Cuidate!

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Draw the LIne/Respect the 

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

FOCUS

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Heritage Keepers 

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Horizons

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

It's Your Game: Keep it 

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

(Project AIM)

Kids (ARK)

Be Protective!
Becoming a Responsible 
Teen (BART)
Children's Aid Society 
(CAS) ­ Carrerra Programs

Line

Abstinence Education

Real
Making a Difference

*73. On which evidence­based programs...
Note: "Partner" may include an organization with whom you have a formal agreement, an
organization funded by you, or an organization not funded by you but with whom you
work closely.
Are staff members from your 
organization currently trained?

Are staff members from your 

Are staff members from your 

organization able to provide a 

organization able to provide a 

Training of Trainers (TOT)?

Training of Educators (TOE)?

Making Proud Choices!

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Project TALC

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Promoting Health Among 

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Raising Healthy Children

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Reducing the Risk

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Respeto/Proteger

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Rikers Health Advocacy 

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Safer Choices

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Safer Sex

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

SiHLE

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Sexual Health and 

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Sisters Saving Sisters

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Teen Health Project

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Teen Outreach Program

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

What Could You Do?

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Teens! Abstinence­Only 
Intervention
Promoting Health Among 
Teens! Comprehensive 
Abstinence and Safer Sex 
Intervention

Program (RHAP)

Adolescent Risk Prevention 
(SHARP)

74. Are there other agency(s) in your state/territory/region that are able to provide a
TOT/TOF on particular EBP(s)? If so, please specify the name of the agency(s), which type
of training they can provide (TOT and/or TOF), and on which EBP(s). If there is a specific
person to contact, please provide their name and contact information as well.
Name of Agency
State which type of training it is able to 
provide (TOT or TOF)
Which EBP?
Name of Agency
State which type of training it is able to 
provide (TOT or TOF)
Which EBP?
Name of Agency
State which type of training it is able to 
provide (TOT or TOF)
Which EBP?

75. On which other programs (outside of the HHS 28 approved programs) are your staff
trained?
c Circle of Life
d
e
f
g
c Flash
d
e
f
g

c Safe Dates
d
e
f
g

c STAND
d
e
f
g

c Live It (Native American Youth)
d
e
f
g

c Health & Responsible Relationships ­ Michigan Model
d
e
f
g
c Native STAND
d
e
f
g
c
d
e
f
g

Parents Matter

c Street Smart
d
e
f
g

c Tailoring Family Planning Services to the Special Needs of 
d
e
f
g
Adolescents 

c Teen Talk
d
e
f
g

c Power Through Choices
d
e
f
g

c The Fourth R (Relationships) ­ Alaska Perspectives (adapted 
d
e
f
g

c Real Talk/Sex Ed for Parents
d
e
f
g
c Relationship Smarts
d
e
f
g

version of original Fourth R curriculum from Canada) 

c Wise Guys
d
e
f
g

c WAIT Training
d
e
f
g

Other (please specify) 

76. Are you or any key partners planning an upcoming training that could potentially be
open to other grantees or grantee partners? If so, please provide the name of the
curriculum or training topic, as well as the date, time, location, organization, and contact
information for the training.
5
6  

77. The federal collaborative is evaluating the feasibility of creating a document or tool in
which TPP grantees could search for organizations capable of providing training on a
particular EBP, either by location or by EBP. We are interested in how useful your
organization might find such a tool. Please provide any comments you have regarding this
potential tool (for example, preferred type of tool, important features or information,
concerns, etc).
5
6  

78. Do you have suggestions as to how one or more of the Federal agencies funding teen
pregnancy prevention programs (OAH, ACF, CDC, etc) could help your organization with
these training needs? If so, please briefly describe your suggestion below.
5
6  

20. Section VII. Evidence­Based Programs (Technical Assistance Providers)

*79. Please indicate whether you have received formal training and the time frame in
which the formal training on certain topics related to evidence­based approaches to
planning, selection, implementation, and evaluation of evidence­based programs and
practices was received. Formal training refers to planned teaching of standard knowledge
and/or skills related to specific capacities.
Never

< 2 years ago

3 to 5 years ago

> 5 years ago

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Using logic models to plan general organizational activities

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Using logic models that link risk and protective factors to intervention 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Knowing how to conduct process evaluation

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Knowing how to conduct outcome evaluation

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Understanding the benefits of using evidence­based approaches such as 
the Getting To Outcomes (GTO) approach to prevent teen pregnancy
Knowing which evidence­based programs and/or practices have reduced 
sexual behaviors leading to teen pregnancy, STI, and/or HIV

activities for the purpose of selecting an appropriate TPP 
program/curriculum or practice.
Knowing how to plan and conduct effective trainings on evidence­based 
or evidence­informed programs to others
Knowing how to assess an evidence­based program for fit with one's 
priority population and community

*80. We are interested in the amount of experience you have providing technical
assistance and training on the topics listed in the previous question. Experience providing
training and TA refers to working with one or more client organizations on a particular
topic. Please indicate if you have at least 6 months of experience providing technical
assistance and training on the following.
Yes

No

The benefits of using evidence­based approaches such as the GTO approach to prevent teen pregnancy

j
k
l
m
n

j
k
l
m
n

Which programs, practices, or policies related to promoting adolescent sexual health have evidence of effectiveness

j
k
l
m
n

j
k
l
m
n

Using logic models to plan general organizational activities

j
k
l
m
n

j
k
l
m
n

Using logic models that link risk and protective factors to intervention activities for the purpose of selecting an 

j
k
l
m
n

j
k
l
m
n

How to plan and conduct effective trainings on evidence­based or evidence­informed programs to others

j
k
l
m
n

j
k
l
m
n

How to assess an evidence­based program for fit with one's priority population and community

j
k
l
m
n

j
k
l
m
n

How to conduct process evaluation

j
k
l
m
n

j
k
l
m
n

How to conduct outcome evaluation

j
k
l
m
n

j
k
l
m
n

appropriate TPP program/curriculum or practice.

*81. How knowledgeable are you regarding each of the following teen pregnancy
prevention activities?
1 ­Not at all

2

3 ­Somewhat

4

5 ­Extremely

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Measure participant satisfaction with a prevention program or practice

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Evaluate an activity to ensure that it is meeting goals and objectives, 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Identify those who will be responsible for each program delivery task

j
k
l
m
n

j
k
l
m
n

j
k
l
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n

j
k
l
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n

j
k
l
m
n

Specify the amount of change to expect in program objectives

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Assess community strengths in programming by examining existing 

j
k
l
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n

j
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n

j
k
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n

j
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n

j
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j
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n

j
k
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n

j
k
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n

j
k
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n

j
k
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n

Develop program objectives that are linked to program goals

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Examine how a prevention program fits with the philosophy of a 

j
k
l
m
n

j
k
l
m
n

j
k
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n

j
k
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n

j
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j
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j
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j
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j
k
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n

j
k
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n

j
k
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n

j
k
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n

j
k
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j
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j
k
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j
k
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n

j
k
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n

j
k
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n

j
k
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n

j
k
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n

j
k
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n

j
k
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n

j
k
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n

j
k
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n

j
k
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n

j
k
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n

j
k
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n

j
k
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n

j
k
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n

j
k
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n

j
k
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n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Create timelines for completing all program tasks

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Develop a budget that outlines the funding required for each program 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
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n

j
k
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n

j
k
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n

j
k
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n

j
k
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n

j
k
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j
k
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n

j
k
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n

j
k
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n

j
k
l
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n

j
k
l
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n

j
k
l
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n

j
k
l
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n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Develop program goals for a teen pregnancy prevention activity or 
program
Assess how well program activities fit within other existing program 
activities offered to the same target population
Define a target population for teen pregnancy prevention program(s) or 
practices

including completing analysis and interpretation of data

resources such as existing programs and availability of volunteers
Determine if an existing program or practice is suited to a community 
program’s goals and objectives

community organization
Measure how well program implementation followed the original 
program design (i.e., fidelity) for each program activity
Ensure that all new program activities are linked to specific goals and 
objectives
Determine if any evidence­based programs are applicable to a 
target/priority population(s)
Specify by when one should expect the change in their objectives to 
occur
Assess the causes and underlying risk factors for teen pregnancy in a 
community
Assess the adequacy of resources to implement a (new) program (e.g., 
staff, technical resources, funding)

activity
Develop a plan to sustain successful programs or activities (i.e., 
determine future funding sources, staffing)
Use evaluation results to improve delivery of a teen pregnancy 
prevention program or practice the next time it is offered
Adapt an evidence­based teen pregnancy prevention program while 
maintaining the integrity of the program

*82. How confident would you be providing training or technical assistance in the
following areas to support other organizations as part of the TPP project?
1 ­Not at all

2

3 ­Somewhat

4

5 ­Extremely

j
k
l
m
n

j
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j
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j
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j
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j
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j
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j
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j
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j
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n

j
k
l
m
n

j
k
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m
n

j
k
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m
n

j
k
l
m
n

Measure participant satisfaction with a prevention program or practice

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Evaluate an activity to ensure that it is meeting goals and objectives, 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Identify those who will be responsible for each program delivery task

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Specify the amount of change to expect in program objectives

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Assess community strengths in programming by examining existing 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
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n

j
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n

j
k
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m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Develop objectives that are linked to goals

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Examine how a prevention program fits with the philosophy of a 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
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n

j
k
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n

j
k
l
m
n

j
k
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n

j
k
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n

j
k
l
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n

j
k
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n

j
k
l
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n

j
k
l
m
n

j
k
l
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n

j
k
l
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n

j
k
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n

j
k
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m
n

j
k
l
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n

j
k
l
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n

j
k
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n

j
k
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n

j
k
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n

j
k
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n

j
k
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n

j
k
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n

j
k
l
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n

j
k
l
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n

j
k
l
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n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Create timelines for completing all program tasks

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Develop a budget that outlines the funding required for each program 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
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n

j
k
l
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n

j
k
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n

j
k
l
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n

j
k
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n

j
k
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n

j
k
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n

j
k
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n

j
k
l
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n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
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n

j
k
l
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n

j
k
l
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n

j
k
l
m
n

j
k
l
m
n

j
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m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Develop program goals for a teen pregnancy prevention activity or 
program
Assess how well program activities fit within other existing program 
activities offered to the same target population
Define a target population for teen pregnancy prevention program(s) or 
practices

including completing analysis and interpretation of data

resources such as existing programs and availability of volunteers
Determine if an existing program or practice is suited to a community 
program’s goals and objectives

community organization
Measure how well program implementation followed the original 
program design (i.e., fidelity) for each program activity
Ensure that all new program activities are linked to specific goals and 
objectives
Determine if any evidence­based programs are applicable to a 
target/priority population(s)
Specify by when one should expect the change in their objectives to 
occur
Assess the causes and underlying risk factors for teen pregnancy in a 
community
Assess the adequacy of resources to implement a (new) program (e.g., 
staff, technical resources, funding)

activity
Develop a plan to sustain successful programs or activities (i.e., 
determine future funding sources, staffing)
Use evaluation results to improve delivery of a teen pregnancy 
prevention program or practice the next time it is offered
Adapt an evidence­based teen pregnancy prevention program while 
maintaining the integrity of the program
Document adaptations made to evidence­based programs to reflect and 
respond to the youth and community context.
Train program facilitators to develop their understanding around 
cultural and gender difference with respect to adolescent sexual risk 
behavior, teen pregnancy and implications of this on engagement and 
program implementation.

21. Section VIII. Organizational Technical Assistance Needs

CDC and the funded national organizations will use the following information to plan future TA and training.  

83. Please list topics, in order of priority, on which you would most like to receive technical
assistance and training through this project over the next year.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

22. End of Survey

Thank you for taking the time to complete this assessment. Your responses will be helpful in planning and coording