Enhanced Awardees Annual Evaluation Plan

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/XXXX

Attachment F

Evaluation Plan Template: Enhanced

[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 Enhanced Component should address the two process questions (Part 1) and two core questions for each of the four strategies selected for evaluation (Parts 2-5.)

• Key activities to implement the evaluation plan should be noted in the narrative summary for years 2-5 (a separate summary should be provided for each of the five parts.)

Public reporting of this collection of information varies from 3 to 6 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 Enhanced 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. surveys, surveillance data, partner data, etc.)

• Data Collection Method: List the data collection methods that will be used (i.e. primary data collection, 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.

Evaluation Plan for Enhanced States – Part 1 Process 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.
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.)

Evaluation Plan for Enhanced States – Part 2 (DNPAO Strategy)
Choose one of the following strategies for evaluation: ☐ Domain 2, Strategy 1: Increase Access to Healthy Foods and Beverages ☐ Domain 2, Strategy 2: Implement Food Service Guidelines/Nutrition Standards ☐ Domain 2, Strategy 4: Increase Physical Activity and Outreach ☐ Domain 2, Strategy 5: Implement Physical Education and Physical Activity in Early Care and Education ☐ Domain 2, Strategy 7: Increase Access to Breastfeeding Friendly Environments
Describe the specific intervention being evaluated (for strategies with multiple interventions, please choose a single intervention for evaluation.) The description should be 300 words or less.
Describe the target population to be included in the evaluation: (check one) ☐ Same as described in workplan ☐ Subset of target population described in workplan: please describe___________________________________________________
Describe the purpose of evaluating this strategy: (choose all that apply) ☐ Accountability ☐ Program Improvement ☐ Program Requirement ☐ Other: __________________________________________________________________________________________________________
Core Evaluation Questions	Performance Measure(s) or Indicator(s)	Data Sources	Data Collection Methods	Data Analysis Methods	Lead Person Responsible
Enter the question associated with the selected strategy from Attachment B. Choose either the start-up or implementation level.	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.
Enter the question associated with the selected strategy from Attachment B. Choose either the start-up or implementation level.	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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Enhanced Evaluation Plan Narrative: Description of Key Activities in Years 2-5 (1-2 pages)

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

Evaluation Plan for Enhanced States – Part 3 (School Health Strategy)
Choose one of the following strategies for evaluation: ☐ Domain 2, Strategy 3: Create Supportive Nutrition Environments in Schools ☐ Domain 2, Strategy 6: Implement Quality Physical Education and Physical Activity in K-12 Schools ☐ Domain 4, Strategy 5: Implement Policies, Processes, and Protocols in Schools to Meet the Management and Care Needs of Students with Chronic Conditions
Describe the specific intervention being evaluated (for strategies with multiple interventions, please choose a single intervention for evaluation.) The description should be 300 words or less.
Describe the target population to be included in the evaluation: (check one) ☐ Same as described in workplan ☐ Subset of target population described in workplan: please describe___________________________________________________
Describe the purpose of evaluating this strategy: (choose all that apply) ☐ Accountability ☐ Program Improvement ☐ Program Requirement ☐ Other: __________________________________________________________________________________________________________
Core Evaluation Questions	Performance Measure(s) or Indicator(s)	Data Sources	Data Collection Methods	Data Analysis Methods	Lead Person Responsible
Enter the question associated with the selected strategy from Attachment B. Choose either the start-up or implementation level.	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.
Enter the question associated with the selected strategy from Attachment B. Choose either the start-up or implementation level.	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)
	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.
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Enhanced Evaluation Plan Narrative: Description of Key Activities in Years 2-5 (1-2 pages)

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

Evaluation Plan for Enhanced States – Part 4 (HDSP Strategy)
Choose one of the following strategies for evaluation: ☐ Domain 3, Strategy 1: Increase Implementation of Quality Improvement Processes in Health Systems ☐ Domain 3, Strategy 2: Increase Use of Team-Based Care in Health Systems ☐ Domain 4, Strategy 3: Increase Use of Health Care Extenders in the Community in Support of Self-Management of High Blood Pressure
Describe the specific intervention being evaluated (for strategies with multiple interventions, please choose a single intervention for evaluation.) The description should be 300 words or less.
Describe the target population to be included in the evaluation: (check one) ☐ Same as described in workplan ☐ Subset of target population described in workplan: please describe___________________________________________________
Describe the purpose of evaluating this strategy: (choose all that apply) ☐ Accountability ☐ Program Improvement ☐ Program Requirement ☐ Other: __________________________________________________________________________________________________________
Core Evaluation Questions	Performance Measure(s) or Indicator(s)	Data Sources	Data Collection Methods	Data Analysis Methods	Lead Person Responsible
Enter the question associated with the selected strategy from Attachment B. Choose either the start-up or implementation level.	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.
Enter the question associated with the selected strategy from Attachment B. Choose either the start-up or implementation level.	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)
	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.
	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.
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Enhanced Evaluation Plan Narrative: Description of Key Activities in Years 2-5 (1-2 pages)

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

Evaluation Plan for Enhanced States – Part 4 (Diabetes Strategy)
Choose one of the following strategies for evaluation: ☐ Domain 4, Strategy 1: Increase Use of Diabetes Self-Management Programs in Community Settings ☐ Domain 4, Strategy 2: Increase Use of Lifestyle Intervention Programs in Community Settings
Describe the specific intervention being evaluated (for strategies with multiple interventions, please choose a single intervention for evaluation.) The description should be 300 words or less.
Describe the target population to be included in the evaluation: (check one) ☐ Same as described in workplan ☐ Subset of target population described in workplan: please describe___________________________________________________
Describe the purpose of evaluating this strategy: (choose all that apply) ☐ Accountability ☐ Program Improvement ☐ Program Requirement ☐ Other: __________________________________________________________________________________________________________
Core Evaluation Questions	Performance Measure(s) or Indicator(s)	Data Sources	Data Collection Methods	Data Analysis Methods	Lead Person Responsible
Enter the question associated with the selected strategy from Attachment B. Choose either the start-up or implementation level.	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.
Enter the question associated with the selected strategy from Attachment B. Choose either the start-up or implementation level.	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)
	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.
	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.
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Enhanced Evaluation Plan Narrative: Description of Key Activities in Years 2-5 (1-2 pages)

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

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