Initial population - Annual reporting - Progress Report

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Overview

Home
Implementation Questions
YR1_PDMP
YR1_INSURER
YR1_POLICY
YR1_RAPID
Successes and Challenges
YR2_PDMP
YR2_INSURER
YR2_POLICY
YR2_RAPID

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Sheet 1: Home

Form Approved OMB No. 0920-XXX Exp. Date xx/xx/20xx
			Prevention for States
			APR Template
				Select State
			The following navigation bar is available on all worksheets
			Click a tab to jump to the corresponding sheet:
			Instructions:
			Please use this template to prepare an APR for Prevention for States. Please refer to the supplemental guidance toolkit and state support teams for support and additional information.
			Affected Population: When addressing the affected population fields, please ensure the affected population is specific to the objective (e.g., the population could be the # of prescribers, patients, dispensers, policy makers, stakeholders, etc.).
			Success and Challenges: Utilize the embedded documents to enter successes and challenges. Double click the embed document to edit it. When complete with editing simply press Crtl+S to save the contents and then close the document. Do not attempt to save the document to another location as your edits will not appear in this template.
			Notes on Data Entry: All light yellow cells are available for user input. Before finalizing this document ensure that all yellow colored sections have been filled in.
			Printing: When printing this document, because it contains multiple worksheets, please select to "Print Entire Workbook" within the print settings.
			Technical Support:
			If technical support is needed, please send an email to your assigned CDC Project Officer with with a detailed description of your need or questions you may have.
Public reporting burden of this collection of information is estimated to average 20 hours for initial population and 4 hours for annual reporting, per response. The response time includes 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

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Sheet 2: Implementation Questions

Strategy	Activity	Sub-Activity
	Staffing
	1. Using the table below, please describe the staff that were available to assist with implementing PfS activities when you received the Notice of Award from CDC. (Includes activities related to contracting, hiring, drafting the evaluation plan, participating in PDO/PfS conference calls or meetings, implementing one or more of the strategies selected from the FOA, or other PDO/PfS related activities).
	Staff Position Title				Percentage of time spent on PfS activities		Description of work performed				Was this person re-assigned (either temporarily or permanently) from another program within the agency to conduct PfS activities? (Yes/No)				If the person was re-assigned (either temporarily or permanently) from another program, please indicate which program and how the position is normally funded.
	Example:	Evaluator			15%		Developed evaluation plan template				Yes				Asthma Program (state general funds)
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	2. Did any Staff member who was working on a program within your agency move into a position fully or partially funded through PfS? If so, please indicate previously held position and program, and currently held position.
	Previous Position, Program, and Funding Source										Current position in PfS				% of time
	Example:	Epidemiologist, RPE Program, Federal									Epidemiologist				100%
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	3. Have you hired all of the PfS positions identified in your application/budget? (Yes/No)
	If yes, on what date did you have a full staff on-board for PfS?
	If no, at what date do you expect to have a full staff on-board for PfS?
	4. What challenges, if any, did you encounter with hiring Staff for PfS?
	Fiscal
	5.a. Did you have previously established contracting or other mechanisms in place to fund PDO activities that were utilized for PfS purposes? (Yes/No)
	5.b. Please describe any Federal, state or other funds/programs that assisted with originally establishing the PDO-related contracts prior to receiving PfS funds.
	Partners
	6. Using the table below, please describe any partnerships that were previously established prior to PfS that have been beneficial with implementing PfS in your state.
	List the partner				Describe how this partner has helped implement PfS activities.					How was the partnership initially established?					Prior to PfS funding, did you have already-established MOU’s or MOA’s with this partner? (Yes/No)
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	Additional Funding for PDO or Injury:
	7. Using the table below, please describe any other funding that your state receives that has been beneficial in either establishing PDO-related activities and partnerships, or implementing PfS-related activities.
	Funding Source (e.g., RPE, NVDRS, Core VIPP, Hal Rogers, Robert Wood Johnson, State general funds, non-profit or community funding, etc.)								How has this funding leveraged the work you are doing to develop or implement PfS activities?
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	Data and Surveillance
	8. Using the table below, please describe your access to PDO-related data prior to PfS funding.
	Data Source								Describe any Federal, state, or other programs or funding that assisted with obtaining access to the data prior to PfS funding.
	Example:	PDMP Data							Established a DUA with the agency that houses the PDMP through the Core VIPP program (Federal funding)
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	Leadership
	9. Using the table below, please describe activities related to leadership and informing/educating decision-makers about PDO-related initiatives.
	Leadership Questions							Yes/No	If yes, please describe.
	9.a. Prior to receiving PfS funding, were there any state leaders or decision-makers who championed PDO-related initiatives?
	9.b. Prior to funding, was your program or agency involved in informing and educating decision makers about PDO and best practices for programs and policies?
	9.c. Has your agency’s role in informing and educating decision makers about PDO and best practices changed since receiving PfS funding?

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Sheet 3: YR1_PDMP

Strategy	Activity	Sub-Activity
				PDMP				Community/Insurer				Policy Evaluation				Rapid Response
				Strategy 1:		Enhance and Maximize PDMPs
				Project Period Activities
1	1			Activity 1.01			Select Activity
1	1			Activity 1.01 Description:
				(500 Character Limit)
				Related Annual Sub-Activities
1	1	1		Sub-Activity 1:
				(500 Character Limit)
1	1	1		Sub-Activity 1 Status:			Select Status
1	1	1		Sub-Activity 1 Progress:
				(500 Character Limit)
1	1	1		Sub-Activity 1 Dates:			Start Date:				End Date:
1	2

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Sheet 4: YR1_INSURER

Strategy	Activity	Sub-Activity
				PDMP				Community/Insurer				Policy Evaluation				Rapid Response
				Strategy 2:		Implement Community or Insurer/Health System Interventions
				Project Period Activities
2	1			Activity 2.01			Select Activity
2	1			Activity 2.01 Description:
				(500 Character Limit)
				Related Annual Sub-Activities
2	1	1		Sub-Activity 1:
				(500 Character Limit)
2	1	1		Sub-Activity 1 Status:			Select Status
2	1	1		Sub-Activity 1 Progress:
				(500 Character Limit)
2	1	1		Sub-Activity 1 Dates:			Start Date:				End Date:
2	2

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Sheet 5: YR1_POLICY

Strategy	Activity	Sub-Activity
				PDMP				Community/Insurer				Policy Evaluation				Rapid Response
				Strategy 3:		Evaluate Laws, Policies, or Regulations
				Project Period Activities
3	1			Activity 3.01			Conduct a rigorous evaluation on a law, policy, or regulation designed to prevent opioid overuse, misuse, abuse, and overdose
3	1			Activity 3.01 Description:
				(500 Character Limit)
				Related Annual Sub-Activities
3	1	1		Sub-Activity 1:
				(500 Character Limit)
3	1	1		Sub-Activity 1 Status:			Select Status
3	1	1		Sub-Activity 1 Progress:
				(500 Character Limit)
3	1	1		Sub-Activity 1 Dates:			Start Date:				End Date:
3	2

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Sheet 6: YR1_RAPID

Strategy	Activity	Sub-Activity
				PDMP				Community/Insurer				Policy Evaluation				Rapid Response
				Strategy 4:		Develop and Implement Rapid Response Projects
				Project Period Activities
4	1			Activity 4.01			Implement an RRP to advance an innovative prevention approach
3	1			Activity 4.01 Description:
				(500 Character Limit)
				Related Annual Sub-Activities
3	1	1		Sub-Activity 1:
				(500 Character Limit)
3	1	1		Sub-Activity 1 Status:			Select Status
3	1	1		Sub-Activity 1 Progress:
				(500 Character Limit)
3	1	1		Sub-Activity 1 Dates:			Start Date:				End Date:
3	2

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Sheet 7: Successes and Challenges

Successes

Challenges

Successes for PDMP:

Challenges for PDMP:

Successes for Community/Insurer:

Challenges for Community/Insurer:

Successes for Policy Evaluation:

Challenges for Policy Evaluation

Successes for Rapid Response

Challenges for Rapid Response

Double click to edit

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Sheet 8: YR2_PDMP

Strategy

Activity

Sub-Activity

PDMP

Community/Insurer

Policy Evaluation

Rapid Response

Strategy 1:

Strategy Description

Project Period Activities

1

1

Activity 1.01

Select Activity

1

1

Activity 1.01 Description:

(500 Character Limit)

1

1

CDC Assistance Necessary to Complete this Activity:

(500 Character Limit)

Related Annual Sub-Activities

1

1

1

Sub-Activity 1:

(500 Character Limit)

1

1

1

Sub-Activity 1 Dates:

Start Date:

End Date:

1

2

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Sheet 9: YR2_INSURER

Strategy

Activity

Sub-Activity

PDMP

Community/Insurer

Policy Evaluation

Rapid Response

Strategy 2:

Implement Community or Insurer/Health System Interventions

Project Period Activities

2

1

Activity 2.01

Select Activity

2

1

Activity 2.01 Description:

(500 Character Limit)

2

1

CDC Assistance Necessary to Complete this Activity:

(500 Character Limit)

Related Annual Sub-Activities

2

1

1

Sub-Activity 1:

(500 Character Limit)

2

1

1

Sub-Activity 1 Dates:

Start Date:

End Date:

2

2

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Sheet 10: YR2_POLICY

Strategy

Activity

Sub-Activity

PDMP

Community/Insurer

Policy Evaluation

Rapid Response

Strategy 3:

Evaluate Laws, Policies, or Regulations

Project Period Activities

3

1

Activity 3.01

Conduct a rigorous evaluation on a law, policy, or regulation designed to prevent opioid overuse, misuse, abuse, and overdose

3

1

Activity 3.01 Description:

(500 Character Limit)

3

1

CDC Assistance Necessary to Complete this Activity:

(500 Character Limit)

Related Annual Sub-Activities

3

1

1

Sub-Activity 1:

(500 Character Limit)

3

1

1

Sub-Activity 1 Dates:

Start Date:

End Date:

3

2

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Sheet 11: YR2_RAPID

Strategy

Activity

Sub-Activity

PDMP

Community/Insurer

Policy Evaluation

Rapid Response

Strategy 4:

Develop and Implement Rapid Response Projects

Project Period Activities

4

1

Activity 4.01

Implement an RRP to advance an innovative prevention approach

4

1

Activity 4.01 Description:

(500 Character Limit)

4

1

CDC Assistance Necessary to Complete this Activity:

(500 Character Limit)

Related Annual Sub-Activities

4

1

1

Sub-Activity 1:

(500 Character Limit)

4

1

1

Sub-Activity 1 Dates:

Start Date:

End Date:

4

2