Form 5 Falls Performance Report

Prevention and Public Health Fund
Evidence-Based Falls Prevention Program
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 (1) achieving target numbers of individuals that participate in the proposed falls
prevention programs, (2) establishing sustainable funding to provide the proposed falls
prevention programs, and 3) embedding the programs into an integrated, sustainable evidencebased prevention program network.
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.acl.gov/Funding_Opportunities/Grantee_Info/Reporting.aspx):
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 Appendices.
o Under the Activities and Accomplishments section, list the first question included on
the template, followed by your response to that question. Repeat for all 3 questions.
• See the next section for bulleted examples of what you may want to consider including under
each question in the Activities and Accomplishments section.
• 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 unless
such cumulative information is necessary for context.
• Include a quantitative report of your up-to-date participant data from the Falls Prevention
National Database as Appendix A of the report. To download a pre-populated report,
navigate to the Reports area, select the name of report, i.e., ‘Semi-Annual Performance
Report’ and select the appropriate reporting period.
• Include a copy of each project product as additional Appendices and identify each by capital
letters in sequence (i.e., Appendix B, C, etc.).
• Upload your completed report within 30 days after each six-month reporting period into
GrantSolutions (https://home.grantsolutions.gov/home/) and email a copy to your AoA
Project Officer. For additional resources about using Grants Solutions go to:
http://acl.gov/Funding_Opportunities/Grantee_Info/Grantee_Resources.aspx
• If you have any questions, please contact your AoA Project Officer.

Example Responses for Activities and Accomplishments Section:
1. What did you accomplish during this reporting period and how did these accomplishments
help you reach the project goal(s) and objective(s), tasks and measurable outcomes
identified in your project proposal narrative and work plan?
Please describe any relevant activities that occurred during this period related to the
following:
Sustainability Strategies: (Describe any business planning efforts; policy changes; contracts
or partnerships to secure sustainable funding; external funding received; activities such as
developing a value proposition, analyzing program costs, pricing or return on investment; or
other activities related to helping to sustain your falls prevention programs beyond the grant
period).
Example Responses:
• Met with the board of X organization on [date] to discuss entering into a contract to
provide X program. Next meeting scheduled on [date]
• Signed a contract with X partner on [date] to provide reimbursement for x falls
prevention program.
• Received X amount of funding from (name of foundation, corporation, etc.) on [date]
to be used for [purpose]
• Established X program as a covered service under the state’s Medicaid waiver.
• Established X program as a covered service through the Indian Health Service or
other Tribal entity.
Program Management/ Leadership Activities: (Describe statewide/ tribal coalition
building or other new management/ leadership structures; new staff and their roles and
responsibilities, etc.).
Example Responses:
• Hired project manager X who will be responsible for [key roles, e.g. state-wide
coordination of training and data entry].
• Established/ convened statewide/ tribal Falls Coalition [or steering committee or other
key planning/ advisory group] with X number of agencies. Held kickoff meeting on
[date].
Partnership Development: (Note any significant project partners and their role in project
activities. Describe activities to build effective partnerships to embed falls programs into
statewide/ tribal health and long-term services and supports systems including partnershipbuilding activities between public health, aging, Medicaid, Indian Health Service or other
state or tribal agencies, the State Coalition on Falls Prevention, and other strategic delivery
system and community/ tribal partners).
Example Responses:

•
•

Established memorandum of understanding effective on [date] with X organization
that has agreed to embed the X program and offer it on a quarterly basis through its X
number of sites.
Established partnership with the Tribe’s Senior Program to offer X program to tribal
elders starting on [date].

Infrastructure Development: (Describe how you are expanding delivery infrastructure/
capacity to provide falls prevention programs throughout your targeted geographic area
including workforce development/ recruitment/ training or retention activities and new host
organizations and implementation sites).
Example Responses:
• Obtained multi-site license for the X program.
• Conducted leader training for X program in [location] on [dates]. X individuals
completed the training.
Coordinated Public Awareness, Education, Marketing and Recruitment Processes:
(Describe any new, innovative strategies to identify those at risk for falls and to make it
easier for potential participants to learn about and access programs and to improve overall
program efficiencies).
Example Responses:
• In collaboration with the State or Tribal Coalition on Falls Prevention, implemented
Falls Prevention Day activities including: [conducted program demonstrations,
obtained Governor’s proclamation, conducted falls risk screenings, etc.]
• Established procedure for clients/members [from Aging and Disability Resource
Center, Medicaid, Tobacco Quit Line, State Health Insurance Program, Indian Health
Service, X health care entity, X large employer group, other agencies, etc.] to be
referred to X program.
• In collaboration with X partner, established state marketing campaign and launched
website on [date] that includes falls prevention program information and calendar of
classes.
Quality Assurance/Fidelity: (Include activities related to monitoring whether the proposed
falls prevention programs are being implemented appropriately and grant objectives are
being met).
Example Responses:
• Completed the following fidelity monitoring/ quality assurance activities during this
period: [X trainers conducted X program site visits].
• Established mechanism to monitor BRFSS falls injury rate data in X counties.

2. What, if any, challenges did you face during this reporting period and what actions did you
take to address these challenges?

Describe key challenges related to sustainability, partnerships, infrastructure and delivery
system, coordinated marketing and recruitment processes, program fidelity/quality assurance,
need for cultural adaptations, etc. and describe how you tried to address each challenge.
Example Responses:
• Had to cancel X number of programs due to insufficient registration. Rescheduled the
program at a different date/time and successfully filled the class.
• Experienced high rate of non-completers in X program. Called drop outs and
discovered primary reason for dropouts was health problems.
• Experienced [X problems] in negotiating contract with X agency; are working on X
(e.g., a value proposition, pricing or return on investment calculations, business plan,
etc.).
3. What was produced during the reporting period and how have these products been
disseminated?
Products may include articles, issue briefs, fact sheets, business plans, market analysis, howto manuals, promotional materials, newsletters, survey instruments and reports, conference
and workshop presentations, websites, audiovisuals, and other informational resources.
Example Responses:
• Developed new culturally-relevant promotional brochure and distributed it at tribal
meetings. (See Appendix X.)
• Established new website [give URL]
• Created new listserv for instructors/ trainers which went live on [date]
• Gave presentation at X conference; copy of PowerPoint is in Appendix X.
• Completed the X report (e.g., summaries of program satisfaction or outcome data,
etc.) contained in Appendix X and disseminated to X audience.

Prevention and Public Health Fund
Evidence-Based Falls Prevention Program
Semi-Annual Performance Report Template
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
Evidence-Based Falls Prevention Program
Semi-Annual Performance Report for [Organization Name]
Activities and Accomplishments
1. What did you accomplish during this reporting period and how did these accomplishments
help you reach the project goal(s) and objective(s), tasks and measurable outcomes
identified in your project proposal narrative and work plan?
Sustainability Strategies
Program Management/ Leadership Activities
Partnership Development
Infrastructure Development
Coordinated Public Awareness, Education, Marketing and Recruitment Processes
Quality Assurance/Fidelity Activities
2. What, if any, challenges did you face during this reporting period and what actions did you
take to address these challenges?
3. What was produced during the reporting period and how have these products been
disseminated?

Prevention and Public Health Fund
Evidence-Based Falls Prevention Program
Semi-Annual Performance Report for [Organization Name]

Month 6

Month 5

Month 4

Month 3

Prior
Period
To
Date

Month 2

Program A

Month 1

Appendix A: Quantitative Report (This section is populated by the National Falls Database
System and will include all data entered on programs completed by the report due date)

Period Cumulative
Total
Total

To
Variance
Date
Target

Period Cumulative
Total
Total

To
Variance
Date
Target

Period Cumulative
Total
Total

To
Variance
Date
Target

Period Cumulative
Total
Total

To
Variance
Date
Target

Month 6

Month 5

Month 4

Month 3

Prior
Period
To
Date

Month 2

Program B

Month 1

Participants
Completers*

Month 6

Month 5

Month 4

Month 3

Prior
Period
To
Date

Month 2

Program C

Month 1

Participants
Completers*

Month 6

Month 5

Month 4

Month 3

Prior
Period
To
Date

Month 2

Totals

Month 1

Participants
Completers*

Participants
Completers*

*Number who attended at least 60% of the possible classes, excluding Session 0