CBO CBA Assessment

Capacity Building Assistance Assessment for HIV Prevention

Att 3 CBO CBA Assessment Tool

CBO CBA Assessment Tool

OMB: 0920-1153

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OMB No. 0920-New

Expiration Date: XX/XX/XXXX









Capacity Building Assistance Assessment for HIV Prevention



Attachment 3

CBO CBA Assessment Tool











Public reporting burden of this collection of information is estimated to average 2 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 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: OMB-PRA (0920-New)



Table of Contents


Topic

Page

About the Assessment Process

4

Organizational Summary

4

  1. Program Component #1: Formalized Collaborations

5

  1. Program Component #2: Program Promotion, Outreach, and Recruitment

5

C. Program Component #3: Targeted HIV Testing

6

D. Program Component #4: Comprehensive HIV Prevention with HIV + and HRN Persons

7

D1. Linkage to and Retention in Medical Care

7

D2. Linkage and Retention Activities

8

D3. Medication Adherence Interventions/Services

8

D4. Navigation, Prevention and Essential Support Services and Interventions for HIV+ Persons

9

D5. Comprehensive HIV Prevention with High-risk Negative (HRN) Persons

11


E. Program Component #5: HIP Essential and Support Services for HIV+ and High-risk Negative (HRN) Persons

11

F. Program Component #6: Condom Distribution for HIV+ and HRN Persons

13

  1. Program Component #7: HIV and Organizational Planning

13

  1. Program Summary

14

  1. Monitoring and Evaluation

15

  1. Quality Assurance

15

  1. Organizational Infrastructure

15

K1. Governance

15

K2. Resource Development

16

K3. Fiscal Management

16

K4. Human Resource Management and Staff Development

16

K5. Technology

17

  1. Summary of Overall CBA Needs

17

  1. Partnership’s CBA Needs

18

  1. CBA Needs for Agencies Implementing Comprehensive High Impact Programs specifically for Young Men of Color who have sex with men (MSM) and young Transgender Persons (YTG) of color.

18

  1. Prioritization of CBA Needs

19


Information about the CBO Capacity Building Assistance Assessment Process


The community-based organization (CBO) Capacity Building Assistance (CBA) Assessment (CBO CBA Assessment) is designed to assist CBA Providers and the Centers for Disease Control and Prevention (CDC) in identifying areas of CBA needed by your organization to implement your comprehensive High Impact Prevention (HIP) programs and services as required under your Funding Opportunity Announcement. The CBO CBA Assessment Tool must be completed by all funded organizations. For those organizations funded as a Partnership, the CBO CBA Assessment Tool should be completed by the Lead CBO HIV Prevention Partnership Organization, in consultation with their partners (reflecting the services that are provided by each Partnership member, as a part of the overall Comprehensive High-Impact HIV Prevention program). In addition, the Lead Partnership Organization should complete Section M for Partnerships only. CBOs funded specifically for Young Men of Color who have sex with men (MSM) and young Transgender Persons (YTG) of color, should complete Section N. CBOs not funded for either Partnerships or MSM and YTG should skip to Section O, Prioritization of CBA Needs. All CBOs should Complete Section O.


The process for the assessment includes: (1) Completion and submission of the CBO CBA Assessment Tool by all CBOs or Lead Partnership Organizations; (2) Review of the information in preparation for the site visit/web conference by the CBA Provider; and, (3) Development of a CBA Strategic Plan (CBASP) for each CBO and Partnership. This CBASP will become part of the CBA Request Information System (CRIS) and will be used as a reference for responding to the CBA needs of the CBOs and Partnerships during the course of your five year cooperative agreement.





ORGANIZATIONAL SUMMARY



Date: _____________________



Name of CBO/Lead Partner: _______________________________________________________

Address: _______________________________________________________________________

City: __________________________ State: ____________ Zip Code: _____________________

Website: ________________________________________________________________________

Name of Executive Director: _______________________________________________________

Name and Title of Person Completing the CBA Assessment Tool: __________________________________________________________ _____________________

E-mail: _________________________________________________________________________

Phone Number:

A1. Do you need CBA to update/improve the service agreements you currently have with medical care providers for your HIV+ populations?

(check all that apply)

A1.1.

HIV Testing

A1.2.

Partner Services

A1.3.

Linkage to care and treatment

A1.4.

Retention in care and treatment

A1.5.

None Needed

A2. Do you need CBA to update/improve the service agreements you currently have with medical care providers for your high-risk negative populations?

(check all that apply)

A2.1.

HIV Testing

A2.2.

Partner Services

A2.3.

Linkage to prevention and treatment

A2.4.

Medication adherence

A2.5.

None Needed

A3. Do you need CBA for any of the following?

(check all that apply)

A3.1.


Revising or improving Memorandum of Understanding (MOU)

A3.2.


Communication with collaborators

A3.3.


Referrals

A3.4.


Billing

A3.5.

None Needed

A4. In 250 words or less, please share/explain other priority CBA needs, if any, for improving your formalized collaborations with agencies (e.g. health departments, clinics, other local organizations, etc.). ______________________________________________________________________________________________________________________________________________________________________________________

For the following, please check the boxes for CBA needed regarding Formalized Collaborations you have with other agencies, to help you address the needs of the populations you have selected for your PS15-1502 program.



  1. Component #1: Formalized Collaborations



For the following, please check the boxes for CBA needed regarding Program Promotion, Outreach and Recruitment.

  1. Program Component #2: Program Promotion, Outreach, and Recruitment

B1. Please identify your agency/partnership’s recruitment strategies for HIV+ persons?

(check all that apply)

B1.1.

Referral from another agency or clinic (testing site, ER, crisis center, etc.)

B1. 2.

Referral from within your agency’s programs

B1.3.


Peer/partner referral, core group referrals

B1.4.

Ads on social media or apps

B1.5.

Public Service Announcements (TV,

Radio, Billboards)


B2. Please identify your agency/partnership’s recruitment strategies for high-risk HIV-negative persons

B2.1.

Referral from another agency or clinic (testing site, ER, crisis center, etc.)

B2.2.

Referral from within your agency’s programs

B2.3.

Peer/partner referral, core group referrals

B2.4.

Ads on social media or apps

B2.5.

Public Service Announcements (TV,

Radio, Billboards)


B3. What capacity building needs does your agency/partnership have regarding recruitment?

(check all that apply)

B3.1

None

B3.2. Training for staff

B3.3. Planning for recruitment


B3.4. Locating target population (s)

B3.5.

Collecting and using data for recruitment,

B4. In 250 words or less, please share/explain other priority CBA needs if any, for improving your agency/partnership’s program promotion, outreach and recruitment strategies. __________________________________________________________________________________________________________________________________________________________________________________



For the following, please indicate Yes or No for the Targeted HIV Testing Interventions and Activities, your agency/partnership is implementing, if staff are trained to implement the intervention or service, and whether CBA is needed.

  1. Program Component #3: Targeted HIV Testing

Targeted HIV Testing Interventions and Activities

Yes/No

Do you have Trained Staff?

Need CBA for implementation?

C1. Is your agency/partnership currently implementing targeted HIV testing (e.g., venue-based, mobile, or large scale) among persons at high risk for HIV infection or of unknown HIV status?

C1a. Yes

C1b. No

C1c. Yes

C1d. No

C1e. Yes

C1f. No

C2. Is your agency/partnership currently implementing Couples HIV Testing and Counseling?

C2a. Yes

C2b. No

C2c. Yes

C2d. No

C2e. Yes

C2f. No

C3. Does your agency/partnership conduct integrated screening for STDs, viral hepatitis, and TB using CDC funds?

C3a. Yes

C3b. No

C3c. Yes

C3d. No

C3e. Yes

C3f. No

C4. Is your agency/partnership currently implementing Personalized Cognitive Counseling (PCC) with men who have sex with men who are repeat testers?

C4a. Yes

C4b. No

C4c. Yes

C4d. No

C4e. Yes

C4f. No

C5. In 250 words or less, please indicate the type of testing activities you are implementing and share/explain your priority CBA needs for improving your agency/partnership’s targeted HIV testing program. ____________________________________________________________________________________________________________________________________________________________________________________




For the following, please indicate Yes or No for Linkage to and Retention in Medical Care activities, interventions, and services your agency/partnership is implementing, and whether CBA is needed. Please check all responses that apply.

  1. Program Component #4: Comprehensive HIV Prevention with HIV+ Persons and High-Risk Negative Persons


D1. Linkage to and Retention in Medical Care


D1.1. Please identify your agency’s strategies for confirming the first appointment for newly identified HIV+ persons?

D1.1a. Assigned patient navigator at your clinic or the Collaborator/

Partner’s clinic

D1.1b. Reminder calls, texts or emails for the first medical appointment

D1.1c. Incentive for completing the first medical appointment

(e.g. monetary, transportation, provision of child care)

D1.1d. Peer/navigator accompanies client to the first appointment

D1.1e. Using contact self-addressed card to submit to medical agency which is then returned to your agency

D1.1f. Other, please specify: ________________________________________________________________________________________

D1.2. Please identify your agency’s strategies for ensuring follow-through and engagement in medical care for HIV+ persons?


D1.2.a. Assigned patient navigator at your clinic or the Collaborator/

Partner’s clinic

D1.2b. Reminder calls, texts or emails for medical appointments

D1.2c. Incentives for completed appointments

(monetary, transportation, provision of child care)

D1.2d.


Face-to-face or home visit

D1.2e. Using contact information given for family members, friends others


D1.2f. Other, please specify: ________________________________________________________________________________________

D1.3. In 250 words or less, please share/explain your priority CBA needs for improving your agency/partnership’s strategies for confirming the first appointment of newly identified HIV+ persons, and for linking, engaging and retaining HIV positive persons in medical care. __________________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________

­­­­­­­­­­­­­­­












For the following, please indicate Yes or No for the Linkage and Retention Activities your agency/partnership is implementing, and whether CBA is needed.

D2. Linkage and Retention Activities


Linkage and Retention Activities

Yes/No

Need CBA?

D2.1. Does your agency have linkage to care networks and processes for linking HIV+ clients to medical care?

D2.1a. Yes

D2.1b. No

D2.1c. Yes

D2.1d. No

D2.2. Is your agency able to consistently link 90% of newly diagnosed persons to HIV medical care?

D2.2a. Yes

D2.2b. No

D2.2c. Yes

D2.2d. No

D2.3. Is your agency able to retain 90% of HIV+ persons in HIV medical care?

D2.3a. Yes

D2.3b. No

D2.3c. Yes

D2.3d. No

D2.4. Has your agency been able to identify previously diagnosed, out-of-care HIV+ persons to re-engage 90% of them in HIV medical care?

D2.4a. Yes

D2.4b. No

D2.4c. Yes

D2.4d. No

D2.5. In 250 words or less, please share/explain your priority CBA needs for your agency/partnership’s linkage and retention activities. __________________________________________________________________________________________________________________________________________________________________________



For the following, please indicate Yes or No for the Medication Adherence Interventions your agency/partnership is implementing, if you have staff trained to implement the intervention, and whether CBA is needed. Please indicate N/A for those interventions your agency/partnership is not implementing.

D3. Medication Adherence Interventions/Services

Medication Adherence Interventions

Yes/No

Currently have trained staff?

Need CBA for implementation?


D3.1. Anti-Retroviral Treatment and Access to Services (ARTAS)

D3.1a. Yes

D3.1b. No

D3.1c. Yes

D3.1d. No

D3.1e. N/A

D3.1f. Yes

D3.1g. No

D3.1h. N/A

D3.2. Every Dose Every Day Mobile Application

D3.2a. Yes

D3.2b. No

D3.2c. Yes

D3.2d. No

D3.2e. N/A

D3.2f. Yes

D3.2g. No

D3.2h. N/A

D3.3. Peer Support

D3.3a. Yes

D3.3b. No

D3.3c. Yes

D3.3d. No

D3.3e. N/A

D3.3f. Yes

D3.3g. No

D3.3h. N/A

D3.4. Sharing Medication Adherence Responsibilities Together (SMART Couples)

D3.4a. Yes

D3.4b. No

D3.4c. Yes

D3.4d. No

D3.4e. N/A

D3.4f. Yes

D3.4g. No

D3.4h. N/A

D3.5. Helping Enhance Adherence to Antiretroviral Therapy (HEART)


D3.5a. Yes

D3.5b. No

D3.5c. Yes

D3.5d. No

D5.5e. N/A

D3.5f. Yes

D3.5g. No

D3.5h. N/A

D3.6. Local intervention for Medication Adherence Services


D3.6a. Yes

D3.6b. No

D3.6c. Yes

D3.6d. No

D3.6e. N/A

D3.6f. Yes

D3.6g. No

D3.6h. N/A

D3.7. In 250 words or less, please share/explain your priority CBA needs for your agency/partnership’s medication adherence interventions. ______________________________________________________________________________________________________________________________________________________________________



For the following, please indicate Yes or No for the Navigation, Prevention and Essential Support Services and Interventions your agency/partnership is implementing, if you have staff trained to implement the service/intervention, and your priority CBA needs. Please indicate N/A for those services and interventions your agency/partnership is not implementing.

D4. Navigation, Prevention and Essential Support Services and Interventions for HIV+ Persons

Navigation, Prevention and Essential Support Services Interventions

Yes/No

Currently have trained staff?

Need CBA for implementation?

D4.1 HIV Navigation Services


D4.1a. Yes


D4.1b. No

D4.1c. Yes

D4.1d. No

D4.1.e. N/A

D4.1f. Yes

D4.1g. No D4.1h. N/A


D4.2. Partner Elicitation



D4.2a. Yes


D4.2b. No

D4.2c. Yes

D4.2d. No

D4.2e. N/A

D4.2f. Yes

D4.2g. No

D4.1h. N/A

D4.3. Partner Services



D4.3a. Yes


D4.3b. No

D4.3c. Yes

D4.3d. No

D4.3e. N/A

D4.3f. Yes

D4.3g. No

D4.3h. N/A

D4.4. d-Up

D4.4a. Yes


D4.4b. No


D4.4c. Yes

D4.4d. No

D4.4e. N/A

D4.4f. Yes

D4.4g. No

D4.4h. N/A

D4.5. Peers Reaching Out and Modeling Intervention Strategies (PROMISE)

D4.5a. Yes


D4.5b. No

D4.5c. Yes

D4.5d. No

D4.5e. N/A

D4.5f. Yes

D4.5g. No

D4.5h. N/A

D4.6. MPowerment

D4.6a. Yes


D4.6b. No



D4.6.c. Yes

D4.6d. No

D4.6e. N/A

D4.6f. Yes

D4.6g. No

D4.6h. N/A

D4.7. Opinion Leader (POL)

D4.7a. Yes


D3.7b. No


D4.7c. Yes

D4.7d No

D4.7e. N/A

D4.7f. Yes

D4.7g. No

D4.7h. N/A

D4.8. Choosing Life: Empowerment! Action! Results! (CLEAR)

D4.8a. Yes


D4.8b. No

D4.8c. Yes

D4.8d. No

D4.8e. N/A

D4.8f. Yes

D4.8g. No

D4.8h. N/A

D4.9. Women Involved in Life Learning from Other Women (WILLOW)

D4.9a. Yes


D4.9b. No


D4.9c. Yes

D4.9d. No

D4.9e. N/A

D4.9f. Yes

D4.9g. No

D4.9h. N/A

D4.10. Healthy Relationships

D4.10a. Yes


D4.10b. No


D4.10c. Yes

D4.10d. No

D4.10e. N/A

D4.10f. Yes

D4.10g. No

D4.10h. N/A

D4.11. CONNECT

D4.11a. Yes

D4.11b. No

D4.11c. Yes

D4.11d. No

D4.11.e N/A

D4.11f. Yes

D4.11g No

D4.11h N/A

D4.12. Partnerships for Health (PfH)

D4.12a. Yes

D4.12b. No

D4.12c. Yes

D4.12d. No

D4.12e. N/A

D4.12f. Yes

D4.12g No

D4.12h. N/A

D4.13. START

D4.13a. Yes


D4.13b. No

D4.13c. Yes

D4.13d. No

D4.13e. N/A

D3.13f. Yes

D4.13g. No

D4.13h. N/A

D4.14. Locally developed intervention for HIV+ persons?

D4.14a. Yes

D4.14b. No

D4.14c. Yes

D4.14d. No

D4.14e. N/A

D4.14f. Yes

D4.14g. No

D4.14h. N/A

D4.15. In 250 words or less, please share/explain your priority CBA needs for your agency/partnership’s navigation, prevention and essential support services and interventions for HIV+ Persons. ____________________________________________________________________________________________________________________________________________________________________



For the following, please indicate Yes or No for the services and interventions your agency/partnership is implementing for High-Risk HIV-Negative Persons, if you have staff trained to implement the service or intervention, and whether CBA is needed. Please indicate N/A for those interventions your agency/partnership is not implementing.

D5. Comprehensive HIV Prevention with High-risk Negative (HRN) Persons


Interventions/Services for

High-Risk Negatives

Yes/No

Currently have trained staff?

Need CBA for implementation?

D5.1. Implementing HIV Navigation Services

D5.1a. Yes


D5.1b. No


D5.1c. Yes

D5.1d. No

D5.1e. N/A

D5.1f. Yes

D5.1g. No

D5.1h. N/A

D5.2. Screening for STDs, hepatitis, and TB

D5.2a. Yes

D5.2b. No


D5.2c. Yes

D5.2d. No

D5.2e. N/A

D5.2f. Yes

D5.2g. No

D5.2h. N/A

D5.3. Referrals for the treatment of STDs, viral hepatitis, and TB

D5.3a. Yes


D5.3b. No


D5.3c Yes

D5.3d. No

D5.3e. N/A

D5.3f. Yes

D5.3g. No

D5.3h. N/A

D5.4 Pre-Exposure Prophylaxis (PrEP)

D5.4a. Yes


D5.4b. No


D5.4c. Yes

D4.4d. No

D5.4e N/A

D5.4f. Yes

D5.4g. No

D5.4h. N/A

D5.5. Post-Exposure Prophylaxis (nPEP)

D5.5a Yes


D5.5b. No


D5.5c. Yes

D5.5d. No

D5.5e. N/A

D5.5f. Yes

D5.5g. No

D5.5h. N/A

D5.6. In 250 words or less, please share/explain your priority CBA needs for your agency/partnership’s interventions and services for High Risk Negative Persons. ______________________________________________________________________________________________________________________________________________________________________



For the following, please indicate Yes or No for the services and interventions your agency/partnership is implementing for HIV-positive and High-Risk HIV-Negative Persons, or if you are referring clients to another agency.

  1. HIP Essential and Support Services with HIV Positive and High-risk Negative (HRN) Persons


Essential and Support Services for HIV+ & HRN Persons

Referring Clients to another agency

E1. Insurance, Navigation and Enrollment Services

E1a. Yes for HIV+ Persons

E1b. No, Providing referrals for HIV+

Persons

E1c. Yes for HRN Persons

E1d. No, Providing referrals for HRN

Persons

E2. Mental Health Counseling



E2a. Yes for HIV+ Persons

E2b. No, Providing referrals for HIV+

Persons

E2c. Yes for HRN Persons

E2d. No, Providing referrals for HRN

Persons

E3 Substance Abuse Treatment and Services


E3a. Yes for HIV+ Persons

E3b. No, Providing referrals for HIV+

Persons

E3c. Yes for HRN Persons

E3d. No, Providing referrals for HRN

Persons

E4. Housing Services

E4a. Yes for HIV+ Persons

E4b. No, Providing referrals for HIV+

Persons

E4c. Yes for HRN Persons

E4d. No, Providing referrals for HRN

Persons

E5. Employment Services

E5a. Yes for HIV+ Persons

E5b. No, Providing referrals for HIV+

Persons

E5c. Yes for HRN Persons

E5d. No, Providing referrals for HRN

Persons

E6. Basic Education Services


E6a. Yes for HIV+ Persons

E6b. No, Providing referrals for HIV+

Persons

E6c. Yes for HRN Persons

E6d. No, Providing referrals for HRN

Persons

E7. Sex/HIV Education

E7a. Yes for HIV+ Persons

E7b. No, Providing referrals for HIV+

Persons

E7c. Yes for HRN Persons

E7d. No, Providing referrals for HRN

Persons

E8. In 250 words or less, please share/explain your priority CBA needs for your agency/partnership’s essential and support services for HIV + and high-risk negative persons. ____________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________













For the following, please check each of the Condom Distribution Activities you are offering for HIV+ and high-risk HIV-negative persons. Please indicate the specific CBA services that are needed, and check N/A if your agency is not offering this service, or if it is not relevant to your program. Please check all responses that apply.

  1. Program Component #6: Condom Distribution for HIV+ and high-risk negative (HRN) persons

Condom Distribution Activities

Implementation of Condom Distribution Program

CBA Needs

F1. Is your agency directly implementing a Condom Distribution Program for HIV+ & HRN persons, or providing referrals to other organizations?


F1a. Yes for HIV+ Persons

F1b. No, Providing Referrals for HIV+ Persons

F1c. Yes for HRN Persons

F1d. No, Providing Referrals for HRN Persons

F1.1. Does your agency need CBA for the following related to your condom distribution program? (check all that apply):


F1.1a. Finalizing/updating MOUs

F1.1b. Training for staff

F1.1c. Developing/Updating protocols and

strategies for HIV+ Persons

F1.1d. Developing/Updating protocols and

strategies for HRN Persons

F1.1e. Providing referrals to increase access to

condom distribution and related services

F1.1f. Educational materials that are appropriate

to the target population

F1.1g. Other _______________

F1.1h. N/A

F2. In 250 words or less, please share/explain your priority CBA needs for your agency/partnership’s condom distribution program. _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



For the following, please indicate Yes or No if CBA is needed to improve your organizational strategic plan for your HIP program.

  1. Program Component #7: HIV and Organizational Planning

G1. Do you need capacity building assistance to improve and/or update your agency’s organizational strategic plan to include your funded program?

G1a. Yes

G1b. No

G2. Do you need capacity building assistance to improve and/or update your agency’s organizational strategic plan to include your collaborative work with the organizations in your Partnership?

G1a. Yes

G1b. No

G1b. N/A

G3. In 250 words or less, please share/explain your specific needs to improve and/or update your agency/partnership’s organizational strategic plan. _____________________________________________________________________________________________________________________________________________________________





For the following “Program Summary” please share your agency’s primary strengths and the ways you would like to see your agency strengthened in the next 12 months to implement your HIP program. For those agencies involved in a Partnership, the lead agency should respond for their agency only and NOT the Partnership.

  1. Program Summary

H1. What are your agency’s primary strengths related to the implementation of your HIP program? (Limit 250 words)

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

­­­­­­­­­­­­­­­­­­­­­­­

H2. In what ways would you like to see your agency’s HIP program strengthened in the next 12 months? (Limit 250 words). ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



This section of the tool is intended to assess your agency’s monitoring and evaluation CBA needs for your HIP program. Please check Yes or No, or indicate other if yes or no does not apply. For those agencies involved in a Partnership, the lead agency should respond for their agency only and NOT the Partnership.

I. Monitoring & Evaluation



I1. Does your agency have staff to oversee monitoring and evaluation activities?


I1a. Yes (agency staff)

I1b. No (contractor/consultant is used)

I1c. No

I2. In 250 words or less, please share/explain your specific needs to improve and/or update your agency/partnership’s monitoring and evaluation plan and activities within the next 12 months. ________________________________________________________________________

____________________________________________________________________________











This section of the tool is intended to assess the QA CBA needs for your HIP program. Please check Yes or No, or indicate other if yes or no does not apply. For those agencies involved in a Partnership, the lead agency should respond for their agency only and NOT the Partnership.

J. Quality Assurance (QA)

J1. Does your agency have staff to oversee quality assurance activities?


J1a. Yes

J1b. No (contractor/consultant is used)

J1c. No

J2. In 250 words or less, please share/explain your specific needs to improve and/or update your agency/partnership’s Quality Assurance Plan and activities within the next 12 months. ______________________________________________________________________________________________________________________________________________________________



K. Organizational Infrastructure



The purpose of the following sections is to assess your agency’s infrastructure, (management, operation, systems and resources). Please respond to all items and explain the specific CBA needs in each area. For those agencies involved in a Partnership, the lead agency should respond for their agency only and NOT the Partnership.

K1. Governance

K1.1. Do you need capacity building assistance to improve your agency’s governance structure?


K.1.1a. Yes K1.1b. No

K1.2. In 250 words or less, please share/explain your specific needs to improve your agency’s governance structure within the next 12 months.

___________________________________________________________________________________







K2. Resource Development



K2.1. Does your agency have staff responsible for carrying out your agency’s fundraising plan?

K2.1a. Yes K2.1b. No

K2.2. In 250 words or less, please share/explain your specific needs to improve your agency’s resource development activities within the next 12 months.

___________________________________________________________________________________

___________________________________________________________________________________



K3. Fiscal Management

K3.1. Who is responsible for the fiscal management systems for your agency?

K3.1a. Agency staff responsible (job title) _____________

K3.1b. Agency uses an outside contractor

K3.1c. Agency uses internal staff and an outside contractor

K3.1d. Other:___________________________________

K3.2. In 250 words or less, please share/explain your agency’s fiscal management needs for which you would you like to receive CBA within the next 12 months.

____________________________________________________________________________________
____________________________________________________________________________________



K4. Human Resource Management and Staff Development

K4.1. Who is responsible for your agency’s (including the lead agency for the partnership) human resources and staff development?

K4.1a. Agency Staff responsible (job title) ______________

K4.1b. Agency uses an outside contractor

K4.1c. Agency uses internal staff and an outside contractor

K4.1d. Other:___________________________________

4.2. In 250 words or less, please share/explain your agency (including the lead agency for the partnership) human resource management and staff development needs for which you would you like to receive CBA within the next 12 months. _____________________________________________________________________________________
_____________________________________________________________________________________







K5. Technology

K5.1. Does your agency have in-house Information Technology (IT) staff?

K5.1a. Yes

K5.1b. No

K5.1c. Other: ___________

K5.2. Does your agency have a contract for IT support?

K5.3a. Yes

K5.2b. No

K5.2c. Other_______________

K5.3. In 250 words or less, please share/explain your agency’s IT needs for which you would you like to receive CBA within the next 12 months

________________________________________________________________________________________________________________________________________________________________________________





L. SUMMARY: Overall CBA Needs

The purpose of this section is to summarize the agency’s overall strengths and challenges. Please respond to all items and add any additional information you feel will help explain or clarify your CBA needs. For those agencies involved in a Partnership, the lead agency should respond for their agency only and NOT the Partnership.



L1. What do you feel is working well regarding your agency’s infrastructure?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



L2. What are the main challenges regarding your agency’s infrastructure that have impact on the implementation of your CDC-funded HIP program?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________




M. Partnership CBA Needs (to be completed only by the lead agency in the Partnership). Agencies not involved in a partnership should skip to section “O” Prioritization of CBA Needs.


The purpose of this section is to determine the CBA needs of the Partnership to effectively and efficiently facilitate and collaborate within the Partnership to implement the Components of their HIP funded program. Please explain or clarify the Partnership’s CBA needs in the appropriate field.



M1. Name of Partnership Leader/Manager:


_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

­­­­­­­­­­­­

M2. Strengths of Partnership: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

M3. What are your CBA Needs related to the Partnership’s ability to work together to implement the HIP funded Program? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



N. CBA Needs for Agencies Implementing Comprehensive High Impact Programs specifically for Young Men of Color who have sex with men (MSM) and young Transgender Persons (YTG) of color. Agencies, including Partnerships, not funded to specifically target MSM and YTG should skip to section “O” Prioritization of CBA Needs)


The purpose of this section is to determine the CBA needs for those agencies funded to effectively reach and engage their target population (YSM of color and YTG persons of color), and to provide competent, cultural sensitive services. Please explain or clarify CBA needs in the appropriate field.



N1. Strengths of the agency related to providing culturally sensitive services to YMSM and YTG Persons _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

­­­­­­­­

N2. What are your CBA Needs related to your agency’s ability to implement your funded Program for YMSM of color and YTG persons of color? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



  1. Prioritization of CBA Needs

Please indicate your agency/partnership’s top 4 prioritized CBA needs for your CDC-funded HIP program, that you will like to see addressed? Indicate the Program Component and justify in 250 words or less why this area is prioritized. (e.g. Program Components: Targeted Testing, HIV Prevention with Positive persons, Fiscal Management, etc.).



Top Priority Needs to be addressed

O1. Program Component: _________________________

______________________________________________________________________________________________________________________________________________________________________

O2. Program Component: _________________________ ______________________________________________________________________________________________________________________________________________________________________

O3. Program Component: __________________________

______________________________________________________________________________________________________________________________________________________________________

O4. Program Component: __________________________

______________________________________________________________________________________________________________________________________________________________________




Thank you

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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleCOMMUNITY BASED ORGANIZATIONS (CBO) CAPACITY BUILDING ASSISTANCE ASSESSMENT
Authorrnl3
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File Created2021-01-23
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