Rape Prevention and Education Program Report Tool - word
Att._4a_Program_Report_Tool_041416.docx
Monitoring and Reporting System for Rape Prevention and Education (RPE) Program Awardees
Rape Prevention and Education Program Report Tool - word
OMB: 0920-1130
Attachment 4a— Program Report Tool Word Version
Home Page
Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/xxxx
Public reporting burden of this collection of information is estimated to average 8 hours for the initial population of the tool and 3 hours for annual reporting 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 NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).
Rape Prevention and Education (RPE)
Program Report Tool
Before You Begin
The goals of the RPE cooperative agreement (14-1401) are to improve the ability of RPE-funded organizations to use the public health approach and effective prevention principles to implement and evaluate sexual violence prevention strategies. The Program Report Tool will capture key information to monitor progress toward the FOA goals. Sections of this tool relate to the steps in the public health approach, and questions are aligned with primary prevention principles. Information collected through this tool is intended to measure the extent to which FOA goals are met, and to provide RPE awardees with information you can use to plan, implement, and evaluate prevention strategies to prevent sexual violence.
Instructions: Please use this Tool to plan and report on your implementation of prevention strategies. For instructions on completing this tool, definitions and additional information about the questions, please refer to the reporting guidance.
Submission: In addition to uploading it onto grants.gov for your continuation application, please submit the completed Tool with your Annual Performance Report to your Project Officer and {email address}
Technical Tips: You may navigate this Tool by clicking on the navigation menu (shown below) located at the top of each spreadsheet or the tabs at the bottom of the window.
Please enter information into the yellow fields. If you enter an invalid character in any field that is not open text, an error message box will pop up.
If you need to add an additional tab to describe a prevention strategy, you may do so at any time by clicking here: [Button: Add Prevention Strategy] [Dynamic spreadsheet that allows adding a new spreadsheet for additional prevention strategy]
Questions and Support: If you have any content-related questions or need assistance, please contact your Project Officer. If you need technical support at any time, please send an email with a detailed description of your need to the following address: {email address}.
*denotes required field
Background
Please complete information about the organization implementing each prevention strategy and the alignment of the prevention strategies to your work plan goals and objectives.
[Navigational Menu of the Sections in this tab]
RPE Awardee Information
RPE awardees, please describe to which goals on your state-level work plan the prevention strategy(s) in this Prevention Strategy Tool aligns.
Which RPE awardee are you reporting about? Select from the drop down menu.* [Drop Down Menu]
-
Alabama
Hawaii
Massachusetts
New Mexico
South Dakota
District of Columbia
Alaska
Idaho
Michigan
New York
Tennessee
Guam
Arizona
Illinois
Minnesota
North Carolina
Texas
Marianna Island
Arkansas
Indiana
Mississippi
North Dakota
Utah
Puerto Rico
California
Iowa
Missouri
Ohio
Vermont
Virgin Islands
Colorado
Kansas
Montana
Oklahoma
Virginia
Connecticut
Kentucky
Nebraska
Oregon
Washington
Delaware
Louisiana
Nevada
Pennsylvania
West Virginia
Florida
Maine
New Hampshire
Rhode Island
Wisconsin
Georgia
Maryland
New Jersey
South Carolina
Wyoming
For each of the prevention strategy reported in this tool, please indicate which state-level RPE work plan goal(s) the prevention strategy relates to or addresses.*
-
Prevention Strategy Name
RPE State-level Work Plan Goals
{Prevention Strategy 1}
[Open Text Field]
{Prevention Strategy 2}
[Open Text Field]
{Prevention Strategy ...#}
[Open Text Field]
RPE Sub-Awardee or Implementer Information
What is the name of the implementing organization?* [Open Text Field]
Please select all that best describe the sector of the implementing organization. (Check all that apply)* [Check all that apply field with an open text field for “Other”]
-
Public
Child Welfare
Housing
Minority
Private
Civic/Volunteer
Justice/Law enforcement
Public Health
Governmental Agency
Disability
Low Socioeconomic Status
Social Services
Non-government Agency
Faith/Religious
Media
Transportation
Non-profit
Education
Mental Health
Tribal
Business
Healthcare
Military
Veteran Status
Other, please specify: _______________ [Open Text Field]
Other, please specify: _______________ [Open Text Field]
Other, please specify: _______________ [Open Text Field]
Overall Budget
What is the total annual RPE budget for the implementing organization?* [Open Numeric Field with two decimals]
$_____.___
How much funding is allocated for the implementation of each prevention strategy? Provide information in dollar amounts.
-
Prevention Strategy Name
Amount allocated in $
{Prevention Strategy 1}
[Open Numeric Field with two decimals]
{Prevention Strategy 2}
[Open Numeric Field with two decimals]
{Prevention Strategy ...#}
[Open Numeric Field with two decimals]
Budget Related to Evaluation
Are funds allocated to evaluate the prevention strategy(s)?* [Closed Options]
Yes, funds are allocated for evaluation for each prevention strategy. [Answer Q7a]
Yes, funds are allocated for evaluation, but only at the implementing organization level. [Skip to Q7b]
No, funds are not allocated at all for evaluation. [Skip to Q8]
Not applicable, evaluation is only being implemented at the state. [Skip to Q8]
How much funding is allocated for the evaluation for each prevention strategy? Provide information in dollar amounts.
-
Prevention Strategy Name
Amount allocated in $
{Prevention Strategy 1}
[Open Numeric Field with two decimals]
{Prevention Strategy 2}
[Open Numeric Field with two decimals]
{Prevention Strategy ...#}
[Open Numeric Field with two decimals]
How much funding is allocated for evaluation? Provide information in dollar amounts. [Open Numeric Field with two decimals]
$_____.___
Provide any additional information or elaborate on any of the above questions as needed. [Open Text Field]
Prevention Strategy #
[Navigational Menu of the Sections in this tab]
Prevention Strategy Description
One of the effective prevention principle is that prevention strategy should be based on the best available evidence (See CDC’s Understanding Evidence for more information about levels of evidence). At a minimum, prevention strategies should have an articulated theory base to address modifiable risk and protective factors related to sexual violence.
What is the prevention strategy you are implementing?* [Drop Down Menu]
Bringing in the Bystander
Coaching Boys into Men
Fourth R
Green Dot
Safer Choices
Safe Dates
Second Step
Shifting-Boundaries
Other, please specify the name of the prevention strategy: _______________ [Open Text Field]
Describe your prevention strategy. Use the following questions to help you describe the strategy. What are the goals of the prevention strategy? What does it aim to change? What methods are used to affect that change (e.g., potential impact)? What are the components and activities of the prevention (e.g., theory of change, roadmap, or logic)? What are the key messages or topics of the strategy?* [Open Text Field]
Prevention Strategy Characteristics
This section asks about the prevention strategy selected to implement to address sexual violence problems in the selected target population, and the “how” or approach used to address the defined sexual violence problems.
Which of the following strategies from the RPE Cooperative Agreement (14-1401) does this prevention strategy relate to? According to the Violence against Women Act of 1994 (VAWA), allotments of RPE funds may only be used for seven permitted uses (first seven listed).* [Drop Down Menu]
Educational seminars
Operation of hotlines
Training programs for professionals
Preparation of informational materials
Training programs for students and campus personnel designed to reduce the incidence of sexual assault at colleges and universities
Education to increase awareness about drugs and alcohol used to facilitate rape or sexual assault; and
Other efforts to increase awareness of the facts about or to help prevent sexual assault, including efforts to raise awareness in under-served communities and awareness among people with disabilities as defined in Section 3 of the Americans with Disabilities Act of 1990 (42 U.S.C. Section 12102)
Community Change Strategy [If selected, choose one of the sub-group below]
Community mobilization
Coalition building
Policy education
Social norms change
Capacity Building, please specify: ________________ [Open Text Field]
Not Applicable, please specify: ________________ [Open Text Field]
If Other, Capacity Building, or Not Applicable please specify the name of the prevention strategy ________
[Open Text Field]
What sources of information or data did you use to inform your selection of the prevention strategy and determine that it may be effective in changing sexual violence-related outcomes and/or address identified risk and protective factors? (Check all that apply).* [Check all that apply field with an open text field for “Other”]
Needs assessment
Capacity or assets assessment
Environmental scan
Strategy theory or Logic model
Evaluation report
Literature review
Other, please specify: __________________ [Open Text Field]
Other, please specify: __________________ [Open Text Field]
Other, please specify: __________________ [Open Text Field]
Provide any additional information or elaborate on any of the above as needed. [Open Text Field]
Prevention Strategy Selection
This section asks about the extent to which a public health approach was used in selecting the prevention strategy.
Describe the rationale for selecting this prevention strategy to implement. Use the following questions to help you describe the rationale: To what extent does the prevention strategy align with the needs and defined sexual violence problem in the selected target population? How will this strategy achieve the intended outcomes for the selected target population? A later section will ask about the selected target population.* [Open Text Field]
At what level of the Social Ecological Model do you expect change to occur? (Check all that apply)* [Check all that apply field with an open text field for “Other”]
Individual
Relationship
Community
Societal
Other: Capacity Building
Other, please specify: [Open Text Field]
Risk and Protective Factors
This section asks about the “what” or the defined sexual violence problems needing to be addressed.
Which of the following risk factors does this strategy seek to address? (Check all that apply)* [Check all that apply field with an open text field for “Other”]
Individual |
Relationship |
|
|
Community |
Societal |
|
|
Which of the following protective factors does this strategy seek to address? (Check all that apply)* [Check all that apply field with an open text field for “Other”]
Individual |
Relationship |
|
|
Community |
Societal |
|
|
Target population
This section asks about the “who” or the entities (e.g., individual, organization, community, or other setting) expected to be affected or to change as a result of the prevention strategy to address the defined sexual violence problems.
Who or what entities will change or be affected as a result of the prevention strategy? (Check all that apply) Specify characteristics of the target population in the question that follows.* [Check all that apply field with an open text field for “Other”]
Individuals |
Organizations |
Communities |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
What are the characteristics related to the selected target population described above? (Check all that apply)* [Check all that apply field with an open text field for “Other”]
Gender |
Race |
Age |
|
|
|
Sexual Identity |
Other Characteristics |
|
|
|
|
Ethnicity |
||
|
Briefly provide any additional information about the selected target population for this prevention strategy or elaborate on the above as needed. [Open Text Field]
What information or data, and from what sources, did you use to identify and select the target population for this prevention strategy? (Check all that apply).* [Check all that apply field with open text fields]
Needs assessment
Evaluation/Evaluation report
In-depth interviews
Surveys
Focus groups
Police reports
Medical examiner files
Vital records
Hospital charts
Registries
Population-based surveys
Other, please specify: _____________ [Open Text Field]
Other, please specify: _____________ [Open Text Field]
Other, please specify: _____________ [Open Text Field]
Reach
This section asks about how much of the target population defined above were actually reached and affected.
To what extent does the prevention strategy reach or affect change in the selected target population?* (Reach Impact = Potential or Intended / Actual number of individuals, organizations, or communities affected by or who received the prevention strategy). Complete this for each of your target populations for this prevention strategy. You may use the button below to add as many rows as needed to this table.
Unit of Analysis |
Target Population Description |
Potential Reach |
Actual Reach |
Reach Impact |
[Drop Down Menu]
|
[Open Text Field]
|
[Open Numeric Field]
|
[Open Numeric Field]
|
{auto calculation} |
[Button: Add Reach Table] [Dynamic Button that allows respondent to add as many rows as they want]
Briefly provide any additional information or elaborate on the above as needed. [Open Text Field]
Information Collection and Evaluation
This section asks about information collection or evaluation activities and use of collected information.
Do you collect information or data on the implementation of the prevention strategy?* [Drop Down Menu]
Yes
No [Skip to Q17]
16a. What types of information or data do you collect about the implementation of the prevention strategy? [Open Text Field]
16b. What are the sources of information or data that you use? (Check all that apply). [Check all that apply field with an open text field for “Other”]
Needs assessment
Capacity or assets assessment
Environmental scan
Strategy theory or Logic model
Evaluation report
Literature review
Administrative records
Tracking logs
Other, please specify: __________________ [Open Text Field]
Other, please specify: __________________ [Open Text Field]
Other, please specify: __________________ [Open Text Field]
Do you collect information or data on the outcomes of the prevention strategy?* [Drop Down Menu]
Yes
No [Skip to Q18]
17a. What types of data or information do you collect about the outcomes of the prevention strategy (e.g., risk/protective factors, knowledge, skills, behaviors, attitudes, victimization, perpetration, practices)? [Open Text Field]
17b. What sources of information or data do you use to measure those outcomes? (Check all that apply). [Check all that apply field with open text fields]
Needs assessment
Evaluation/Evaluation report
In-depth interviews
Surveys
Focus groups
Police reports
Medical examiner files
Vital records
Hospital charts
Registries
Population-based surveys
Other, please specify: _____________ [Open Text Field]
Other, please specify: _____________ [Open Text Field]
Other, please specify: _____________ [Open Text Field]
Do you use information or data that you collect for program improvement?* [Drop Down Menu]
Yes
No [Skip to Q19]
18a. How do you use information or data you collect? [Open Text Field]
Do you disseminate information (e.g., impact) or lessons learned about the prevention strategy?* [Drop Down Menu]
Yes
No [Completed]
19a. What information or lessons learned do you share? [Open Text Field]
19b. To whom and how do you disseminate or share the information or lessons learned? [Open Text Field]
Attachment 4a— Program Report Tool Word Version
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Pari Chowdhary |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |
© 2024 OMB.report | Privacy Policy