Form 0920-18FO APR Tool

Attachment 3 - Instrument: Annual Progress Report Tool

Form Approved

OMB No.: 0920-xxxx

Expiration Date: XX/XX/XXXX

Public Reporting burden of this collection of information varies from 10 to 15 hours with an estimated average of 13 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 NW, MS D-74, Atlanta, GA  30333; Attn:  PRA (0920-XXXX).

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Items in green will be prepopulated based on planning documents received from recipients. All narrative questions will have a word limit.

Grantee: Reporting Period: Contact Person:

Work Plan Section

Section A: Progress on Goals

NOFO Project Period Goal 1: Increase the prioritization, resources, and capacity to implement community and societal level IPV prevention programs and policy efforts (REQUIRED)
Objective 1: Develop and implement the State Action Plan (SAP) (REQUIRED)					Status of Objective Completed In Progress Planned Discontinued New
Key Milestones (Can add additional)		Target Date		Status of Milestone		Notes
				Completed In Progress Planned Discontinued New
				Completed In Progress Planned Discontinued New
More detail about this objective will be requested in other areas of the APR
Objective 2: Increase coordination of IPV work at the state and local level (REQUIRED)					Status of Objective Completed In Progress Planned Discontinued New
Key Milestones (Can add additional)		Target Date		Status of Milestone		Notes
				Completed In Progress Planned Discontinued New
				Completed In Progress Planned Discontinued New
More detail about this objective will be requested in other areas of the APR
Objective 3: Increase the use of IPV prevention approaches that address the community and societal level of the SEM (REQUIRED)					Status of Objective Completed In Progress Planned Discontinued New
Key Milestones (Can add additional)		Target Date		Status of Milestone		Notes
				Completed In Progress Planned Discontinued New
				Completed In Progress Planned Discontinued New
More detail about this objective will be requested in other areas of the APR
Please list all capacity building and training activities related to community and societal level primary prevention that you provided within the state over the past year
Type of Activity	Topic		Audience				Dates
Please list any networking and dissemination activities that you participated in related to community and societal level primary prevention OUTSIDE the state.
Type of Activity	Topic		SDVC Role in Activity				Dates

NOFO Project Period Goal 2 : Increase data on the impact of community and societal level IPV primary prevention programs and policy efforts (REQUIRED)
Objective 1: Increase the use of data for planning including monitoring of state-level outcome indicators (REQUIRED)			Status of Objective Completed In Progress Planned Discontinued New
Key Milestones (Can add Additional)	Target Date	Status of Milestone		Notes
		Completed In Progress Planned Discontinued New
		Completed In Progress Planned Discontinued New
More detail about this objective will be requested in other areas of the APR
Objective 2: Increase the evaluation of community and societal level IPV prevention programs and policy efforts within funded states (REQUIRED)			Status of Objective Completed In Progress Planned Discontinued New
Key Milestones (Can add additional)	Target Date	Status of Milestone		Notes
		Completed In Progress Planned Discontinued New
		Completed In Progress Planned Discontinued New
More detail about this objective will be requested in other areas of the APR
Objective 3: Monitor changes in risk and protective factors associated with the NOFO activities being implemented (REQUIRED).			Status of Objective Completed In Progress Planned Discontinued New
Key Milestones (Can add additional)	Target Date	Status of Milestone		Notes
		Completed In Progress Planned Discontinued New
		Completed In Progress Planned Discontinued New
More detail about this objective will be requested in other areas of the APR

NOFO Project Period Goal 3 (Optional – Can add additional):
Objective 1:				Status of Objective Completed In Progress Planned Discontinued New
Key Milestones (Can add additional)	Target Date		Status of Milestone			Notes
			Completed In Progress Planned Discontinued New
			Completed In Progress Planned Discontinued New
Objective 2:				Status of Objective Completed In Progress Planned Discontinued New			Estimated Completion Date
Key Milestones (Can add additional)	Target Date		Status of Milestone			Notes
			Completed In Progress Planned Discontinued New
			Completed In Progress Planned Discontinued New
Objective 3:				Status of Objective Completed In Progress Planned Discontinued New
Key Milestones (Can add additional)	Target Date		Status of Milestone			Notes
			Completed In Progress Planned Discontinued New
			Completed In Progress Planned Discontinued New
Briefly describe the overall successes and accomplishments you made toward this goal during the past year. Provide information about what helped you achieve these accomplishments.
Key Activities for Upcoming Year Related to Goal 3		Target Date			Notes

Section B: Continuation Application Narrative for Year #: <<insert dates for next funding year>

Summary of Work Plan for Next Budget Year: Summarize and reference any key changes to work plan (objectives, and milestones). Provide information about the reasons for or what led to those changes.

Implementation of New or Revised Program or Policy Efforts: Explain requests to change the current program or policy efforts being implemented. The CDC Project Officer must approve any changes to the program or policy efforts approved upon award.

Budget: Provide comments to budgetary issues that might impede the success or completion of the project as originally proposed and approved. Describe any implications the changes to the work plan may have on the budget.

Challenges: What general challenges/problems do you anticipate in the next funding year? What do you plan to use to solve or address those challenges or problems?

Resources: What additional resources do you need? How do you plan to obtain these resources?

Technical Assistance: Do you need technical assistance from CDC? If yes, provide a description of your needs.

Strategic Planning Section

Section A. Progress and Planning for State Action Plan Goals

SAP Goal # 1	Topic	Key Partners	Key Accomplishments
	Prioritization/Use Access to Data Use of Data Other
Key Activities Planned for Upcoming Year		Resources Needed
1.
2.
3.
4.

SAP Goal # 2	Topic	Key Partners	Key Accomplishments
	Prioritization/Use Access to Data Use of Data Other
Key Activities Planned for Upcoming Year		Resources Needed
1.
2.
3.
4.

SAP Goal # 3	Topic	Key Partners	Key Accomplishments
	Prioritization/Use Access to Data Use of Data Other
Key Activities Planned for Upcoming Year		Resources Needed
1.
2.
3.
4.

SAP Goal # 4	Topic	Key Partners	Key Accomplishments
	Prioritization/Use Access to Data Use of Data Other
Key Activities Planned for Upcoming Year		Resources Needed
1.
2.
3.
4.

Section B. Changes related to Prioritization, Resources and Capacity

Did you engage any new partners or stakeholders related to the work on the state plan in the past year?

Partner	Sector	Role

Were any new policies or procedures implemented in the past year related to increasing the use of community and societal level primary prevention (CSPP)?

Policy/Procedure	Partner(s)	Description

Were any new resources obtained or redirected for CSPP in the past year?

Resource Name	Source	Amount Available	Use	Timeline

Please list any new CSPP programs or policy efforts implemented in the past year

Program/Policy Effort	Implementing Organization	Scope/Audience	Description

Please list any new CSPP programs or policy efforts evaluated in the past year

Program/Policy Effort	Implementing Organization	Evaluating Organization/Entity	Description/Summary

Did you gain access to any new state or local data sources in the past year?

Dataset	“Owner”	Description (including level)	Potential Use

Did you implement any new uses of state or local data sources in the past year?

Dataset	“Owner”	Description (including level)	Use

Meetings of Leadership Team or State Action Planning Committees

Group	Participating Organizations	Date(s)	Topics Discussed

Section C. Facilitators and Barriers related to the State Action Plan (Can add additional)

	Facilitator or Barrier			Action Planning			Notes
Goal #	Facilitator or Barrier?	Potential or Actual	Facilitator or Barrier Description	Needed Resources	Action Steps	Responsible Party
	☐ Facilitator ☐ Barrier	☐ Potential ☐ Actual	Insert Text	Insert Text	Insert Text	Insert Text	Insert Text

NOFO Evaluation Section

Section A. Progress on Evaluation Questions

Evaluation Question	Progress Made/Data Collected	Planned Activities for Next Year	Summary of Interim Findings (if available) – Include attachments when appropriate

Section B. Changes to Evaluation Plan (Can add additional)

Please describe any key changes have you made to this evaluation plan in the past year including the reason for making the changes.
Type of Change	Reason for Change	Notes
Change in Outcome Change in Data Collection Measure Change in Methodology Change in Population Change in Data Analysis Other _________________

Section C. Outcomes Table (Can add additional)

Type	Description	SEM Level	Population of Interest Description	Indicator Description	Year 5 Target	Unit	Value	Progress Notes
Select one (1) ☐ Risk Factor ☐ Protective Factor ☐ Violence Outcome ☐ Other	Insert Text	Select one (1) ☐ Individual ☐ Relationship ☐ Community ☐ Societal	Insert Text	Insert Text Provide indicator and data source, method, and frequency of collection or availability	Insert Numeric Value	Select one (1) ☐ Number ☐ Percent ☐ Proportion ☐ Other, specify Unit Description:	Insert Numeric Value	Insert Text

Section D. Facilitators and Barriers (Can add additional)

Facilitator or Barrier			Action Planning			Impact in Reporting Period
Facilitator or Barrier?	Potential or Actual Factor	Facilitator or Barrier Description	Needed Resources	Action Steps	Responsible Party
Select one (1) ☐ Facilitator ☐ Barrier	Select one (1) ☐ Potential ☐ Actual (e.g., encountered)	Insert Text	Insert Text	Insert Text	Insert Text	Insert Text

Program or Policy Effort Section

(1 per program/policy being implemented)

Program or Policy Effort Name: Implementing Organization:

Section A. Progress on Implementation Plan

Milestone (Can add additional)	Target Date	Status	Key Accomplishments	Key Activities in Upcoming Year	Resources Needed
1.		Completed In Progress Planned Discontinued
2.		Completed In Progress Planned Discontinued
3.		Completed In Progress Planned Discontinued

Section B. Reach

Type of Setting	Description of Setting	Year 5 Target for Settings	Number of Settings Reached	Progress Notes
Select one (1) ☐ Communities ☐ Schools ☐ Organizations		Insert Numeric Value	Insert Numeric Value	Insert Text

Population of Interest Description	Year 5 Target for Individuals (across settings)	# new individuals reached this reporting period (across settings)	# total individuals reached since start of NOFO	Progress Notes
Insert Text	Insert Numeric Value	Insert Numeric Value	Insert Numeric Value	Insert Text

Section C. Change to Implementation Plan (Can add additional)

Please describe any key changes have you made to this implementation plan in the past year including the reason for making the changes.
Type of Change	Reason for Change	Notes
Change in target population Change in timeline Adaptation to program or policy effort (describe below) Change in delivery method Change in key activities Other _________________

Section D. Adaptations Made (Can add additional)

Adaptations
Adaptation Description	Planned or Field	What Led to the Adaptation?	Does adaptation impact essential elements?	(APR) Impact	(APR) Future Plans
Insert Text	Select one (1) ☐ Planned ☐ Field	Insert Text	Insert Text	Insert Text What was the immediate influence or result(s) of the adaptation?	Select one (1) ☐ Keep ☐ Change ☐ Omit ☐ Adapt across site

Section E. Progress on Evaluation Questions

Evaluation Question	Progress Made/Data Collected	Planned Activities for Next Year	Summary of Interim Findings (if available)
1.
2.
3.
4.
5.

Section F. Changes to Evaluation Plan (Can add additional)

Please describe any key changes you have made to this evaluation plan in the past year including the reason for making the changes.
Type of Change	Reason for Change	Notes
Change in Outcome Change in Data Collection Measure Change in Methodology Change in Population Change in Data Analysis Other _________________

Section G. Outcomes (Can add additional)

Type	Description	SEM Level	Population of Interest Description	Indicator Description	Year 5 Target	Unit	Value	Progress Notes
Select one (1) ☐ Risk Factor ☐ Protective Factor ☐ Violence Outcome ☐ Other	Insert Text	Select one (1) ☐ Individual ☐ Relationship ☐ Community ☐ Societal	Insert Text	Insert Text Provide indicator and data source, method, and frequency of collection or availability	Insert Numeric Value	Select one (1) ☐ Number ☐ Percent ☐ Proportion ☐ Other, specify Unit Description:	Insert Numeric Value	Insert Text

Section H. Facilitators and Barriers (Can add additional)

	Facilitator or Barrier			Action Planning			Impact of Facilitator or Barrier
Type	Facilitator or Barrier?	Potential or Actual Factor	Facilitator or Barrier Description	Needed Resources	Action Steps	Responsible Party
Select one (1) ☐ Implementation ☐ Evaluation	Select one (1) ☐ Facilitator ☐ Barrier	Select one (1) ☐ Potential ☐ Actual (e.g., encountered)	Insert Text	Insert Text	Insert Text	Insert Text	Insert Text