Basic Evaluation Plan

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/XXXX

Attachment E

Evaluation Plan Template: Basic

[Insert Applicant Name]

Overall Plan and Key Activities: 7/1/2014 – 6/30/2015

Instructions:

GENERAL

• Grantees are encouraged to use the Template to document their evaluation plan and key evaluation activities for year 2.

• The applicant’s evaluation plan for the Basic Component should address the four core evaluation questions. The Template is pre-populated with the questions.

• Key activities to implement the evaluation plan should be noted in the narrative summary for years 2-5.

Public reporting of this collection of information varies from 2 to 4 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden sample estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

Completing the Basic Evaluation Plan Template

For each core evaluation question listed on the template, complete the following information:

• Performance Measure(s) and/or Indicators: List any required performance measures that will be linked to this question. If there are no linked performance measures, please specify an alternate indicator.

• Data Sources: List the data sources that will be used to answer the evaluation question (i.e. meeting notes, organizational charts, surveys, etc.)

• Data Collection Method: List the data collection methods that will be used (i.e. document review, focus groups, key informant interviews, etc.)

• Data Analysis: List the types of analysis that will be conducted

• Lead Person: Specify the individual with primary responsibility

State Supplemental Evaluation Questions are optional. Spaces are provided for states choosing to add evaluation questions.

Core Evaluation Questions	Performance Measure(s) or Indicator(s)	Data Sources	Data Collection Methods	Data Analysis Methods	Lead Person Responsible
How has coordination with critical partners changed due to the implementation of 1305? Critical partners are those partners essential to the successful implementation of the required intervention strategies.	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.
Synergy: Please include information on ways working across categorical program areas may have enhanced coordination with critical partners.	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.
How has your organizational structure and approach changed due to the implementation of 1305?	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.
Synergy: Please include information on ways working across categorical program areas may have increased or decreased operational efficiencies.	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.
What were the major facilitators and barriers to achieving the basic accomplishments of 1305, which are to (1) increase community clinical linkages, (2) improve quality, effectiveness, delivery and use of clinical or other preventive services, and (3) promote and reinforce healthful behaviors and practices across the life span?	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.
How were the barriers overcome?	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.	Click here to enter text.
Supplemental (state level) Evaluation Questions (OPTIONAL)
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Basic Evaluation Plan Narrative: Description of Key Activities in Years 2-5 (5 pages or less)

(Include time frames for key activities by quarter and list any key evaluation products that will result from activities.)

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