Form 0920-XXXX Annual Reporting Data Elments for RPE

CE19-1902: Rape Prevention & Education (RPE) Using The Best Available Evidence for Sexual Violence Prevention

Annual Reporting Data Elements for RPE
Form Approved
OMB NO: 0920-xxxx
Exp. Date: X/XX/XXXX
Public reporting burden of this collection of information is estimated at 4 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/Information Collection Review Office, 1600 Clifton Road, NE, MS D74, Atlanta, GA 30333; Attn: PRA (0920-xxxx).

To access the Annual Reporting for RPE, respondents will need to securely access the DVP Partners Portal via CDC’s Secure
Access Management System (SAMS) authentication.

Background about DVP Partners Portal Structure
Forms are a grouping of sections related to a single subject area. One or more Sections make a Form. Sections are used to
group questions related to a single topic.
o Sections should be small enough that all of the questions can be completed in one sittings: this is for reasons both
functional and related to user experience. Questions are checked out and saved at the Section level. Checking out
Sections keeps multiple users from editing the same Section, at the same time, and overwriting each other’s work.
o Panels are used for visually grouping questions together by surrounding the set with a border. This allows
for collapsing this set of questions. Panels may contain tables.
o Repeatable panels include a button to generate a new copy of the same panel for the end-user to
complete.
 Tables provide a way to repeatedly ask the same questions. Questions in a Table Question Set
are displayed with their Question Text in the table head and their responses as rows in the table.
Tables provide functionality for viewing, adding, editing, and deleting rows, collapsing the table,
as well as exporting their contents to PDF or CSV. When rows are added or edited, a page will
pop up separately to display the questions for editing.
Questions can be grouped into a single on-screen element within a section (e.g., panel, table) or a page.
No data are pre-populated during Year 1 data collection or initial entry of a field. In Year 2, fields will be pre-populated from
Year 1’s submission as indicated below (and so on and so forth). Certain fields will be locked for editing as indicated below.
Color
Pre-populated From Previous Year‘s Editable or Locked
Required or Optional
Submission
Gray Shaded
Pre-populated
Locked
Required
Green Shaded
Pre-populated
Editable
Required
Blue Shaded
Not Pre-populated
Editable
Required
White/Not Shaded Not Pre-populated
Editable
Optional
Red Text
Not required in Year 1

Table of Contents
Summary of Forms and Sections ................................................................................................................................2
Form: Work Plan .........................................................................................................................................................3
Form: Barriers and Facilitators ...................................................................................................................................4
Form: Training and Technical Assistance ...................................................................................................................5
Form: Continuation Narrative ....................................................................................................................................6
Annual Reporting Data Elements for RPE

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CE19-1902: Rape Prevention & Education (RPE) Using The Best Available Evidence for Sexual Violence Prevention

Form: State Action Plan ..............................................................................................................................................7
Form: Coalition Building and Community Mobilization .............................................................................................9
Form: Prevention Strategy ...................................................................................................................................... 11
Form: Evaluation ..................................................................................................................................................... 18

Summary of Forms and Sections
The following table shows the panels per section per form:
Form
Work Plan
Barriers and
Facilitators
Training and
Technical Assistance

Continuation
Narrative

Section
Goal
Barriers Encountered
Facilitators Encountered
Successes
Training and Technical Assistance
Provided by CDC
Training and Technical Assistance
Provided by the Recipients

Continuation Narrative

State Action Plan Progress
State Action Plan

Partnership and Resources
Data Use

Coalition Building
and Community
Mobilization

Coalition Building and Community
Mobilization
Background and Program, Policy, or
Practice Description
Population of Focus and Reach

Prevention Strategy

Risk and Protective Factors and Violence
Outcomes
Adaptation
Implementation Measures

Evaluation

Program, Policy, or Practice Resources
Evaluation Progress
Process Measures
Outcomes
Translation, Communication, and
Dissemination

Annual Reporting Data Elements for RPE

Panel/Table
Objective
Barriers Encountered
Facilitators Encountered
Successes and Accomplishments
Training and Technical Assistance Provided by CDC
Training and Technical Assistance Provided by the
Recipients
Summary of Work Plan Activities for Next Budget Year
Implementation of Prevention Strategies
Budgetary Implications
Needed Resources
Technical Assistance
Changes to State Action Plan
State Action Plan Progress and Planned Activities
Partnership
Resources
Data Sources Used
Description
Implementers
Implementation Progress
Changes
Evidence of Effectiveness
Essential Elements
Changes
Population of Focus
Reach

Adaptation
Implementers
Implementation Progress
Progress on Evaluation Questions
Process Measures
Outcomes
Translation and Communication Products

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CE19-1902: Rape Prevention & Education (RPE) Using The Best Available Evidence for Sexual Violence Prevention

Form: Work Plan
Recipients report on progress towards their work plan goals, objectives, and milestones. Goals 1-5 and objectives specified
below are prescribed and will be preset for all recipients. Recipients can add up to 3 additional goals (max 8 goals) and have
no more than 5 objectives per goal.
CE19-1902 Required Goals and Objectives
Goal 1
Increase the use of partnerships to implement relationship/community-level strategies and improve coordination
of state SV prevention efforts
Objective 1.1
Develop an approach to improve partner coordination as specified in the State Action Plan
Objective 1.2
Implement an approach to improve partner coordination as specified in the State Action Plan
Goal 2
Increase use of data driven decision making for program delivery
Objective 2.1
Increase the use of data for selection of focus populations and prevention approaches
Objective 2.2
Demonstrate the selection of sub-recipients based on data-driven decision
Goal 3
Increase use of indicator data to track implementation and outcomes
Objective 3.1
Identify state-level indicators and data sources to include in the state evaluation plan
Objective 3.2
Track and report on indicators annually
Goal 4
Create environmental and community changes that result from selected community-level strategies
Objective 4.1
Develop plans for implementation for environmental and community-level prevention strategies
Goal 5
Demonstrate changes in selected risk and protective factors
Objective 5.1
Increase tracking of selected risk and protective factors
Objective 5.2
Implement state-level evaluation plan with process and outcome measures

SECTION: Goal #
Repeatable Section Limit: 8
Goal #
Text Area (Character Limit: 250)

Repeatable Panel: Objective #.#
Repeatable Panel Limit: 5
Objective #.#
Text Area (Character Limit:
250)

Start Date

End Date

Date Range

Progress
Status
Dropdown
o Completed
o On track
o Delayed
o Planned
o Discontinued

Progress Notes
Text Area
(Character Limit:
500)
Provide reasons for
delayed or
discontinued work

Continuation
Status
Dropdown
o New
o Continuing
o Repeating
o Revising
o Discontinuing
o Achieved

Continuation
Notes
Text Area
(Character
Limit: 500)
Provide
reasons for
redirecting/
revising

Continuation
Status
Dropdown
o New
o Continuing
o Repeating
o Revising
o Discontinuing
o Achieved

Continuation
Notes
Text Area
(Character
Limit: 250)
Provide
reasons for
redirecting/
revising

Table: Milestones
Table Row Limit: 20
Key
Key
Milestones
Activities
Text Area
Text Area
(Character
(Character
Limit: 250)
Limit: 250)

Start Date

End Date

Date Range

Progress
Status
Dropdown
o Completed
o On track
o Delayed
o Planned
o Discontinued

Progress Notes
Text Area
(Character Limit:
500)
Provide reasons for
delayed or
discontinued work

Is there anything else we should know about this objective?
Text Area (Character Limit: 1000)

Is there anything else we should know about this goal?
Text Area (Character Limit: 1000)

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CE19-1902: Rape Prevention & Education (RPE) Using The Best Available Evidence for Sexual Violence Prevention

Form: Barriers and Facilitators
Recipients report on barriers and facilitators encountered during the reporting period.

SECTION: Barriers Encountered
Table: Barriers Encountered
Table Row Limit: 30
Barriers Encountered
Barrier Type

Barrier
Description
Text Area
(Character
Limit: 500)

NOFO Component

Dropdown with Open Response
Checkbox
 Work Plan
o Lack of Buy-in from
 State Action
partners/stakeholders
Plan
o Insufficient funding or
 Prevention
resources
Strategy
o Inability to access/collect data

Evaluation
o Implementation issues
 Training and TA
o Staffing issues (e.g., turnover)
provided to
o Inadequate training
others
o Other (not listed): specify
(Character Limit: 100)
o No barriers encountered
Do you anticipate this barrier for the next budget period?
Dropdown
o Yes
o No

Action Planning to Address Barrier
Action Steps
Needed
Parties
to Resolve
Resources
Involved
Text Area
Text Area
Text Area
(Character
(Character
(Character
Limit: 500)
Limit: 500)
Limit: 500)

Impact of
Barrier
Text Area
(Character
Limit: 500)

If yes, explain:
Text Area (Character Limit: 1000)

If you anticipate additional challenges or barriers, please list here.
Table Row Limit: 10
What is the challenge or barrier? Why do you anticipate this will be a
challenge/barrier?
Text Area (Character Limit: 1000)

How do you plan to address this challenge/barrier?
Text Area (Character Limit: 1000)

SECTION: Facilitators Encountered
Table: Facilitators Encountered
Table Row Limit: 30
Facilitators Encountered
Facilitator Type
Dropdown with Open Response
o Strong partners/stakeholders
o Connection to community
o Access to funding or resources
o Access to data
o Strong implementation
o Adequate, experienced staff
o Access to training
o Other (not listed): specify
(Character Limit: 100)
o No facilitators encountered

Facilitator
Description
Text Area
(Character
Limit: 500)

Annual Reporting Data Elements for RPE

NOFO Component
Checkbox
 Work Plan
 State Action Plan
 Prevention Strategy
 Evaluation
 Training and TA
provided to others

Resources
Used
Text Area
(Character
Limit: 500)

Supports
Parties
Involved
Text Area
(Character
Limit: 500)

Impact of
Facilitator
Text Area
(Character Limit:
500)

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CE19-1902: Rape Prevention & Education (RPE) Using The Best Available Evidence for Sexual Violence Prevention

SECTION: Successes
Repeatable Panel: Successes & Accomplishments
Limit: 30
What specific successes and accomplishments have you made during this reporting period?
Text Area (Character Limit: 5000)

Form: Training and Technical Assistance
Recipients report on their participation in training and technical assistance (TA) provided by CDC and on the recipient’s
provision of training and TA offered during the reporting period.

SECTION: Training and Technical Assistance Provided by CDC
Which CDC training and TA activities have you participated in during the reporting period?
Checkbox with Open Response
 Annual RPE Recipient Meeting
 Regional RPE Training
 CDC site visit
 E-Learning Collaborative
 State-specific training or TA from the Sexual Violence Technical Assistance Center
 Other (not listed): specify (Character Limit: 100)
Is there anything else we should know about CDC-provided training and TA that you received?
Text Area (Character Limit: 1000)

SECTION: Training and Technical Assistance Provided by the Recipient
Repeatable Panel Limit: 20

What training and technical assistance (TA) did you offer during the reporting period?
Name of Training or TA Topic
Text (Character Limit: 100)
Method of Training or TA

Purpose

Dropdown with Open Response
o Online Resource (Self
Study)
o Webinar
o One-on-One TA
o Peer-to-Peer Sharing
o Conference or Summit
o In-Person Skill-Building
Workshop
o Other (not listed): specify
(Character Limit: 100)
o Multiple Methods: specify
(Character Limit: 100)

Text Area
(Character
Limit: 500)

Total Number of Individuals Trained
during Year #
Integer

How many sessions? Was this
one-time or multiple sessions
Dropdown with Open Response
o One-time
o Multiple sessions: Specify
how many sessions (Integer)
o N/A

Total Number of Organizations
Participated during Year #
Integer

Description of
Participants
Text Area
(Character Limit:
500)

Resources Provided to
Participants
Text Area (Character
Limit: 500)

Total Number of Trainings Delivered
during Year #
Integer

Is there anything else we should know about this training or TA that you offered? For example, did you make changes to the
training or TA during this reporting period?
Text Area (Character Limit: 1000)

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CE19-1902: Rape Prevention & Education (RPE) Using The Best Available Evidence for Sexual Violence Prevention

Form: Continuation Narrative
Recipients are required to answer the following questions about plans and needs for the next budget year.

SECTION: Continuation Narrative
Panel: Summary of Work Plan Activities for Next Budget Year
Describe the activities planned for the upcoming budget period. Provide reasons for and reference any key changes to the work
plan for the upcoming budget period.
Text Area (Character Limit: 5000)

Panel: Implementation of Prevention Strategies
Describe the planned implementation of prevention strategies in the upcoming budget period. Explain any requests to change the
implementation of the current prevention strategies. The CDC project officer must approve any changes to the prevention
strategies.
Text Area (Character Limit: 5000)

Panel: Budgetary Implications
Provide any 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.
Text Area (Character Limit: 5000)

Panel: Needed Resources
What additional tools/resources do you need to accomplish the proposed planned activities for the next budget period?
Text Area (Character Limit: 5000)
What tool/resources do you need to leverage your existing partnerships and resources to increase your primary prevention efforts?
Text Area (Character Limit: 5000)

Panel: Technical Assistance
What types of training and technical assistance (TA) do you need? Please describe the areas or topics for TA (e.g., program,
evaluation). If TA is not needed, please explain
Text Area (Character Limit: 5000)

Annual Reporting Data Elements for RPE

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CE19-1902: Rape Prevention & Education (RPE) Using The Best Available Evidence for Sexual Violence Prevention

Form: State Action Plan
Recipients report on their progress towards required components of the State Action Plan (e.g., enhancing partnership,
data use, state sexual violence prevention planning and coordination) during the reporting period.

SECTION: State Action Plan Progress
Table: Changes to State Action Plan
Table Row Limit: 20

Provide a summarized list of changes, if any, to the State Action Plan during the reporting period. Describe the reason(s)
for the change and refer to the plan as needed. (Not required in Year 1)
State Action Plan Required
Components
Dropdown With Open Response
o No changes
o Approach or Strategy
o Stakeholder/Partner
o State/local collaboration
o Prevention Strategies
o Resources/Funding
o Training/Technical Assistance
o Sustainability
o Health Disparities/Population of
Interest
o Other (not listed): specify
(Character Limit: 100)

Describe the Change

Reason for Change

Notes

Text Area (Character Limit:
500)

Text Area (Character Limit:
500)

Text Area (Character Limit:
500)

Table: State Action Plan Progress and Planned Activities
Table Row Limit: 10

Provide a summary of key accomplishments related to each component of the State Action Plan during the reporting
period and how and which key partners/stakeholders were involved. Indicate a summary of key activities planned for
next year and any resources needed.
State Action Required
Priorities

Key
Accomplishments

Dropdown With Open
Response
o Addressing Health
Disparities
o Training/Technical
Assistance
o Capacity-Building Support
to Unfunded Organizations
o Strategy Implementation
o Evaluation & Data Use
Capacity
o Other (not listed): specify
(Character Limit: 100)

Text Area (Character
Limit: 500)

How did your
accomplishments
improve your state’s
prevention efforts?
Text Area (Character
Limit: 500)

Key Activities
Planned for
Next Year

Needed
Resources

Notes

Text Area
(Character
Limit: 500)

Text Area
(Character
Limit: 500)

Text Area
(Character
Limit: 500)

Is there anything else we should know about your progress on the State Action Plan?
Text Area (Character Limit: 1000)

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CE19-1902: Rape Prevention & Education (RPE) Using The Best Available Evidence for Sexual Violence Prevention

SECTION: Partnership and Resources
Panel: Partnership
Table: Partners
Table Row Limit: 100

What partners did you engage in the State Action Plan work during the reporting period? Describe the partners, sector,
whether new partner or existing, role, and impact on your efforts and sustainability planning.
Name of the
Organization
Text Area (Character
Limit: 500)

Type of Organization

Sector

Dropdown With Open Response
o Coalition, State
o Coalition, Local
o Community-based Organization
o College or University
o For-Profit Organization (e.g.,
businesses)
o Health care facility (e.g., health
clinic, hospital)
o Local Health department
o State Health department
o Non-governmental organizations
o Rape Crisis Center
o School
o School District
o Other Local Government Agency
o Other State Government Agency
o Other (not listed): Specify
(Character Limit: 100)

Dropdown With Open Response
o Business/Labor
o Education
o Justice
o Health Services
o Housing
o Media
o Public Health
o Social Services
o Government (Federal, State,
County, Local)
o Community Organizations
o Other (not listed): Specify
(Character Limit: 100)

Partner Status
Dropdown
o New, acquired during this
reporting period
o Existing partner/stakeholder
o Re-engaged partner/stakeholder
o No longer a partner/stakeholder

Do you provide RPE funding
to this partner?
Dropdown
o Yes
o No

Special Focus/Emphasis of the
Organization
Dropdown With Open
Response
o Survivor serving
o Tribal serving
o Culturally- relevant
o Youth serving
o LGBTQ serving
o Military or Veteran serving
o Disability serving
o None
o Other (not listed): Specify
(Character Limit: 100)

How is this partner engaged in
the state SV prevention work?
Text Area (Character Limit: 500)

Comment
Text Area (Character
Limit: 500)

Is there anything else we should know about your partnership and collaboration efforts?
Text Area (Character Limit: 1000)

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CE19-1902: Rape Prevention & Education (RPE) Using The Best Available Evidence for Sexual Violence Prevention

Panel Resources
Table: Resources
Table Row Limit: 50

What resources did you use for your State Action Plan work during the reporting period?
Type of Resource
Dropdown With Open
Response
 Funding
 Staffing
 Tools for SV Prevention
 Space
 Other (not listed): Specify
(Character Limit: 100)

Description of resources
obtained or used
Text Area (Character Limit:
500)

How did it improve your state’s
prevention efforts?
Text Area (Character Limit: 500)

Comments
Text Area (Character
Limit: 500)

Is there anything else we should know about resources?
Text Area (Character Limit: 1000)

SECTION: Data Use
Table: Data Sources Used
Table Row Limit: 50

What data sources did you use during the reporting period?
Description of data
source obtained or
used
Text Area (Character
Limit: 500)

Data Source
Owner (where
obtained)
Text Area
(Character Limit:
500)

Which of the following did you
use this data source to do?
Checkbox
 Address health disparities
 Select population of focus
(Data Driven Population of
Focus)
 Select prevention strategies
(Data Driven Prevention
Strategy)
 Select sub-recipients (Data
Driven Sub-Recipients)

For what other
purpose, if any, did
you use this data?
Text Area
(Character Limit:
500)

Describe any barriers or
challenges you encounter in
accessing this data source.
Text Area (Character Limit:
500)

Is there anything else we should know about data sources used/obtained and data use?
Text Area (Character Limit: 1000)

Form: Coalition Building and Community Mobilization
Recipients report on any of their coalition building and community mobilization efforts during the reporting period.

SECTION: Coalition Building and Community Mobilization
Repeatable Section Limit: 20
What is the name of the coalition building or community mobilization effort?
Text (Character Limit: 100)

Panel: Description
Briefly describe the coalition building or community mobilization effort.
Text Area (Character Limit: 1000)

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CE19-1902: Rape Prevention & Education (RPE) Using The Best Available Evidence for Sexual Violence Prevention
What is the purpose or role of the coalition building or community mobilization?
Checkbox with Open Response
 Collect and organize data
 Conduct needs assessments
 Train community members
 Leverage funds from sources other than RPE
 Leverage resources other than funding (e.g., personnel, space, supplies)
 Plan or implement prevention interventions
 Ensure that RPE-funded prevention interventions address issues related to
cultural competence
 Plan or implement process or outcome evaluations of prevention interventions
 Educate others about needed changes in policy at the organizational, local, or
state/tribal/jurisdiction level
 Mobilize community to take ownership of issues
 Other (not listed): Specify (Character Limit: 100)

Briefly describe the purpose or role. What do
you hope to achieve through these efforts?
Text Area (Character Limit: 500)

Panel: Implementers
Provide a brief description about the implementers of this coalition building or community mobilization effort.
Text Area (Character Limit: 1000)
How many implementers implement the coalition building or community mobilization effort during Year 1?
Integer

Panel: Implementation Progress
Table: Activities
Table Row Limit: 20
Activity Type
Dropdown with Open Response
o Educational sessions
o Training sessions
o Projects
o Ads
o Web/Social Media Postings
o Text messages or emails
o Presentations
o Print materials
o Meetings
o Other (not listed): specify
(Character Limit: 100)

Description of Activity
Text Area (Character Limit:
500)

Purpose
Text Area (Character Limit:
500)

Number of Activities
Completed
Integer

Panel: Changes
Were there any changes to the coalition building or the community
mobilization during this reporting period? (not required in year 1)
Dropdown
 Yes
 No

If yes, explain:
Text Area (Character Limit: 1000)

Is there anything else we should know about this coalition building or the community mobilization effort?
Text Area (Character Limit: 1000)

Annual Reporting Data Elements for RPE

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CE19-1902: Rape Prevention & Education (RPE) Using The Best Available Evidence for Sexual Violence Prevention

Form: Prevention Strategy
This form collects information about the prevention strategies and approaches being implemented, and their
implementation measures and progress (e.g., reach, delivery).

SECTION: Background and Program, Policy, or Practice Description
What is the name of the implementing organization?
Text (Character Limit: 100)
Name of Program, Policy, or Practice
Dropdown With Open Response
o Adequate Work Supports
o Alcohol Policies
o Bringing in the Bystander
o Coaching Boys into Men
o Comparable Worth Policies
o Enhanced Assess, Acknowledge, Act
o Expect Respect
o Fourth R
o Green Dot
o Powerful Voices
o Proactive Sexual Harassment Prevention Policies and Procedures
o Safe Dates
o Safer Choices
o Second Step
o Shifting Boundaries Building-Level Intervention
o Strong African American Families – SAAF
o Other (not listed): specify (Character Limit: 100)
Briefly describe the program, policy, or practice.
Text Area (Character Limit: 1000)
Which STOP SV approach does this program, policy, or practice address?
Dropdown
o Bystander approaches
o Empowerment-based training
o Mobilizing men and boys as allies
o Social-emotional learning
o Teach healthy, safe dating and intimate relationship skills to adolescents
o Promoting healthy sexuality
o Strengthening economic supports for women and families
o Strengthening leadership and opportunities for girls
o Improving safety and monitoring in schools
o Establishing and consistently applying workplace policies
o Addressing community-level risks through environmental approaches
Explain how this program, policy, or practice aligns or addresses the STOP SV approach selected.
Text Area (Character Limit: 1000)

What is the main way this program, policy, or practice is delivered?
Delivery Method
Dropdown With Open Response
o Educational curriculum
o Social marketing
o Social media campaign
o Built environment change
o Organizational policy change
o Policy education or implementation
o Other (not listed): specify (Character Limit: 100)

Annual Reporting Data Elements for RPE

Description
Text Area (Character Limit: 1000)

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CE19-1902: Rape Prevention & Education (RPE) Using The Best Available Evidence for Sexual Violence Prevention
If your response to the previous question indicated policy, please further describe the type and focus of the effort. If it
was a program or practice, skip this question.
Type
Dropdown with Open Response
o Policy
o Local ordinance
o Procedure
o Administrative action
o Incentive
o Organizational contract
o Rule/regulation
o Other (not listed): specify
(Character Limit: 100)

Focus
Dropdown with Open Response
 Climate and safety
 Sexual harassment
 Alcohol
 Comparable worth/Pay equity
 Paid leave
 Housing
 Trauma informed
 Family friendly workplace
 Other (not listed): specify (Character Limit: 100)

Panel: Evidence of Effectiveness
What is the evidence (evaluations results, research outcomes, etc.) for the effectiveness of the program, policy, or
practice in addressing the identified sexual violence problem?
Evidence
Dropdown with Open Response
o Example approach listed in the technical package
o Based on best available research evidence
o Based on practice-based evidence
o Other (not listed): specify (Character Limit: 100)

Description
Text Area (Character Limit: 1000)

What are the reasons for selecting this prevention strategy?
Text Area (Character Limit: 1000)

Panel: Essential Elements
Describe the essential content, delivery, and implementer characteristics of this prevention strategy. Please refer to
resources on estimating essential elements. (Not required for Year 1)
What (Essential Content)
Text Area (Character Limit: 1000)
How (Essential Delivery)
Text Area (Character Limit: 1000)
Who (Essential Implementer’s Characteristics)
Text Area (Character Limit: 1000)
Is there anything else we should know about the program, policy, or practice’s essential elements?
Text Area (Character Limit: 1000)

Panel: Changes
Were there any changes to the program, policy, or practice during this
reporting period? (not required in year 1)
Dropdown
o Yes
o No

Annual Reporting Data Elements for RPE

If yes, explain:
Text Area (Character Limit: 1000)

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CE19-1902: Rape Prevention & Education (RPE) Using The Best Available Evidence for Sexual Violence Prevention

SECTION: Population of Focus and Reach
Panel: Population of Focus
Provide a narrative description of the population and
setting of focus for this program, policy, or practice.
Text Area (Character Limit: 1000)

Why was this population or setting selected and how is the program,
policy, or practice appropriate for the selected population or setting?
Text Area (Character Limit: 1000)

Is there a specific community or population you are focusing on?
Checkbox With Open Response
 No
 Immigrants or Refugees
 Adolescent
 LGBTQ Communities
 African-American or Black Population
 Homeless
 Asian Population
 Incarcerated or Formerly Incarcerated
 Children and Families
 Migrant Workers
 Elder
 Military
 Foster Youths or Families
 Poor or Economically Disadvantaged
 Hispanic or Latino Population
 People with Disabilities
 Men and Boys
 Perpetrators of Crimes or Violence
 Pacific Islanders Population
 Rural
 Parents and Families
 Tribal Communities
 Single Parents
 Urban Communities
 Women and Girls
 Veterans
 Victims of Crimes or Violence
 Vulnerable or At Risk Population

 Other (not listed): specify
(Character Limit: 100)
 Other (not listed): specify
(Character Limit: 100)
 Other (not listed): specify
(Character Limit: 100)
 Other (not listed): specify
(Character Limit: 100)
 Other (not listed): specify
(Character Limit: 100)

Please indicate the types of individuals or organizations that you are focusing on and who you intend to affect. Selected items
should match the narrative description provided above.
Checkbox With Open Response
Types of Individuals
Types of Organizations
Types of Communities
 Students
 School Administrators
 County
 Youths
 Governmental Agencies
 City
 Teachers/Professors
 Non-Government Agencies
 Census Tract/Zip Code
 School Staff
 Non-Profits
 Commercial District
 Policy Makers
 Businesses
 Neighborhood
 Parents
 Bars
 Territory Area
 Healthcare Professionals
 Homes
 Park and Recreational Area
 Mental Health Providers
 Employers
 Other (not listed): specify (Character
 Employees of an Organization
 Other (not listed): specify (Character
Limit: 100)
 Other (not listed): specify (Character
Limit: 100)
 Other (not listed): specify (Character
Limit: 100)
 Other (not listed): specify (Character
Limit: 100)
 Other (not listed): specify (Character
Limit: 100)
 Other (not listed): specify (Character
Limit: 100)
 Other (not listed): specify (Character
Limit: 100)
 Other (not listed): specify (Character
Limit: 100)
Limit: 100)
Were there any changes to the population and setting of focus during
this reporting period? (not required in year 1)
Dropdown
o Yes
o No

If yes, explain:
Text Area (Character Limit: 1000)

Is there anything else we should know about the population and setting of focus?
Text Area (Character Limit: 1000)

Panel: Reach
Number of Individuals Reached
Integer

Possible Number of Individuals that can be Reached (not required for Year 1)
Integer

Number of Organizations Reached
Integer

Possible Number of Organizations that can be Reached (not required for Year 1)
Integer

Annual Reporting Data Elements for RPE

13

CE19-1902: Rape Prevention & Education (RPE) Using The Best Available Evidence for Sexual Violence Prevention
Number of Communities Reached
Integer

Possible Number of Communities that can be Reached (not required for Year 1)
Integer

Is there anything else we should know about the population and setting of focus reached?
Text Area (Character Limit: 1000)

SECTION: Risk and Protective Factors and Violence Outcomes
Provide a narrative description of the outcomes and risk and protective factors that is the policy, program, or practice intend to
change.
Text Area (Character Limit: 1000)
What risk and protective factors does this program, policy, or practice address?
Checkbox With Open Response
Individual Risk Factors
Relationship Risk Factors
Community Risk Factors
 Alcohol and drug use
 Family environment
 Poverty
 Delinquency
characterized by physical
 Lack of employment
 Lack of empathy
violence and conflict
opportunities
 General aggressiveness
 Childhood history of
 Lack of institutional support
and acceptance of
physical, sexual, or
from police and judicial
violence
emotional abuse
system
 Early sexual initiation
 Emotionally unsupportive
 General tolerance of sexual
 Coercive sexual fantasies
family environment
violence within the
 Preference for impersonal  Poor parent-child
community
sex and sexual-risk taking
relationships, particularly
 Weak community sanctions
 Exposure to sexually
with fathers
against sexual violence
explicit media
 Association with sexually
perpetrators
 Hostility towards women
aggressive, hypermasculine,
 High alcohol outlet density
 Adherence to traditional
and delinquent peers
 Diminished economic
gender role norms
 Involvement in a violent or
opportunities
 Hyper-masculinity
abusive intimate relationship  Poor neighborhood or
 Suicidal behavior
 Other (not listed): specify
community support and
 Prior sexual victimization
(Character Limit: 100)
cohesion
or perpetration
 Other (not listed): specify
 Other (not listed): specify
 Other (not listed): specify
(Character Limit: 100)
(Character Limit: 100)
(Character Limit: 100)
 Other (not listed): specify
 Other (not listed): specify
 Other (not listed): specify
(Character Limit: 100)
(Character Limit: 100)
(Character Limit: 100)
 Other (not listed): specify
 Other (not listed): specify
(Character Limit: 100)
(Character Limit: 100)
Individual Protective Factors Relationship Protective Factors
Community Protective Factors
 Parental use of reasoning
 Family support and
 Neighborhood or
to resolve family conflict
connectedness
Community
 Emotional health and
 Connection to a caring adult
support/connectedness
connectedness
 Association with pro-social
 Access to mental and
 Academic achievement
peers
health services
 Empathy and concern for
 Connection/commitment to
 Availability of safe and
how one’s actions affect
school
affordable housing and the
others
 Other (not listed): specify
ability of families to access
 Skills in solving problems
(Character Limit: 100)
housing assistance
non-violently
 Other (not listed): specify
 Other (not listed): specify
 Other (not listed): specify
(Character Limit: 100)
(Character Limit: 100)
(Character Limit: 100)
 Other (not listed): specify
 Other (not listed): specify
 Other (not listed): specify
(Character Limit: 100)
(Character Limit: 100)
(Character Limit: 100)
 Other (not listed): specify
 Other (not listed): specify
(Character Limit: 100)
(Character Limit: 100)

Annual Reporting Data Elements for RPE

Societal Risk Factors
 Societal norms that support
sexual violence
 Societal norms that support
male superiority and sexual
entitlement
 Societal norms that
maintain women’s
inferiority and sexual
submissiveness
 Weak laws and policies
related to sexual violence
and gender equity
 High levels of crime and
other forms of violence
 Other (not listed): specify
(Character Limit: 100)
 Other (not listed): specify
(Character Limit: 100)
 Other (not listed): specify
(Character Limit: 100)

Societal Protective Factors
 Societal norms that
violence is unacceptable
 Other (not listed): specify
(Character Limit: 100)
 Other (not listed): specify
(Character Limit: 100)
 Other (not listed): specify
(Character Limit: 100)
 Other (not listed): specify
(Character Limit: 100)
 Other (not listed): specify
(Character Limit: 100)

14

CE19-1902: Rape Prevention & Education (RPE) Using The Best Available Evidence for Sexual Violence Prevention
What types of violence and injury outcomes does the program, policy, or practice directly address?
Checkbox With Open Response
 Sexual Violence
 Child Abuse and Neglect
 Child Sexual Abuse
 Human Trafficking
 Youth Violence
 Intimate Partner Violence
 Suicide
 Other (not listed): specify (Character Limit: 100)
How does this program, policy, or practice address those risk and protective factors among the population of focus?
Text Area (Character Limit: 1000)
Is there anything else we should know about the risk and protective factors and violence outcomes?
Text Area (Character Limit: 1000)
Were there any changes to the risk and protective factors and violence
outcomes during this reporting period? (not required in year 1)
Dropdown
o Yes
o No

If yes, explain:
Text Area (Character Limit: 1000)

SECTION: Adaptation
What adaptations to the essential elements of the program, policy, or practice did you plan to make or have made during
implementation? (Not required in year 1)

Panel: Adaptation #
Repeatable Panel Limit: 20
Description of Adaptation: Open-Text
Text Area (Character Limit: 1000)
Essential Element
(To which essential
element was this
adaptation made?)

Dropdown
o Content
o Delivery
o Implementer

Type of Adaptation

Reason for Adaptation

Describe the
reason for
this
adaptation.

Dropdown with Open
Response
o Addition
o Deletion
o Reordering Sequence
o Modification
o Other (not listed):
specify (Character Limit:
100)

Checkbox with Open Response
 To increase relevancy of
material and participant
understanding
 To increase participant
participation
 To create or maintain
relationships with
participants
 To respond to limited time
and resources
 Other (not listed): specify
(Character Limit: 100)

Text Area
(Character
Limit: 500)

Annual Reporting Data Elements for RPE

Impact of Adaptation on
Essential Elements
(How will the adaptation
support the strategy’s
essential elements instead
of undermining the
underlying theory or
effectiveness of the
program, policy, or
practice?)
Text Area (Character Limit:
500)

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CE19-1902: Rape Prevention & Education (RPE) Using The Best Available Evidence for Sexual Violence Prevention
Adaptation Made
(Was this adaptation planned or made during delivery?)

Result of Adaptation
(What was the result, impact of the adaptation?)

Dropdown
o Planned
o Field

Text Area (Character Limit: 500)

Plan for this Adaptation in Future
Implementation Cycles
Dropdown
o Keep
o Change
o Omit
o Adapt across sites
o No plans

Resources needed

Describe how you plan to track and
monitor this adaptation
Text Area (Character Limit: 500)

Text Area (Character Limit: 500)

Is there anything else we should know about this adaptation?
Text Area (Character Limit: 1000)

SECTION: Implementation Measures
Panel: Implementers
Provide a brief description about the implementers of this program, policy, or practice.
Text Area (Character Limit: 1000)
How many implementers have been trained to deliver or implement the program, policy, or practice during Year 1?
Integer

Panel: Implementation Progress
Table: Activity
Table Row Limit: 20
Activity Type
Dropdown with Open Response
o Educational sessions
o Training sessions
o Projects
o Ads
o Web/Social Media Postings
o Text messages or emails
o Presentations
o Print materials
o Meetings
o Other (not listed): specify
(Character Limit: 100)

Description of Activity
Text Area (Character Limit:
500)

Purpose
Text Area (Character Limit:
500)

Number of Activities
Completed
Integer

Is there anything else we should know about the implementation of this program, policy, or practice?
Text Area (Character Limit: 1000)

Annual Reporting Data Elements for RPE

16

CE19-1902: Rape Prevention & Education (RPE) Using The Best Available Evidence for Sexual Violence Prevention

SECTION: Program, Policy, or Practice Resources
How much of this
program, policy,
or practice was
funded by RPE?
Dropdown
o 100%
o 51 – 99%
o 50%
o 1- 49%
o 0%

If less than 100%, how many
sources or partners
contribute to this program,
policy, or practice?
Integer

Please describe the sector of
those partners.

In what ways did
partners contribute?

Notes

Checkbox With Open Response
 Business/Labor
 Education
 Justice
 Health Services
 Housing
 Media
 Public Health
 Social Services
 Other (not listed): specify
(Character Limit: 100)

Checkbox With Open
Response
 Funding
 Resources
 Staffing
 Other (not listed):
specify (Character
Limit: 100)

Text Area
(Character Limit:
500)

Is there anything else we should know about the implementing organization and the resources for this program, policy, or practice?
Text Area (Character Limit: 1000)
Were there any changes to contributing partners
during this reporting period? (not required in year 1)
Dropdown
o Yes
o No

Annual Reporting Data Elements for RPE

If yes, explain:
Text Area (Character Limit: 1000)

17

CE19-1902: Rape Prevention & Education (RPE) Using The Best Available Evidence for Sexual Violence Prevention

This form will not be shown in the DVP Partners Portal in Year 1.

Form: Evaluation
(Not required in Year 1)
Recipients report on their progress on evaluation activities and on indicators measuring the outcomes of their efforts for
CE19-1902.

SECTION: Evaluation Progress
Table: Changes to Evaluation Plan
Table Row Limit: 20

Provide a summarized list of changes (e.g., methods or data sources) made to the evaluation plan during the reporting
period. Describe the reason(s) for the change and refer to the plan as needed.
Evaluation Plan Sections
Dropdown with Open Response
o No changes
o Evaluation Design
o Evaluation Question
o Data Analysis, Synthesis, and
Interpretation
o Data Collection Method or Data
Source
o Measures and Indicators
o Translation, Communication, and
Dissemination
o Evaluation Team
o Other (not listed): specify
(Character Limit: 100)

Describe the Change
Text Area (Character Limit:
500)

Reason for Change
Text Area (Character Limit:
500)

Notes
Text Area (Character Limit:
500)

Progress on Evaluation Questions
Table Row Limit: 10
Evaluation Question
Text Area (Character
Limit: 250)

Progress Made/Data
Collected
Text Area (Character
Limit: 500)

Summary of Findings (if
available)
Text Area (Character Limit:
500)

Planned Activities for
Next Year
Text Area (Character
Limit: 500)

Notes
Text Area (Character
Limit: 500)

Is there anything else we should know about the evaluation efforts?
Text Area (Character Limit: 1000)

SECTION: Process Measures
Table: Process Measures
Table Row Limit: 30
Process
Data Source
Measure
Text Area
Text Area
(Character
(Character
Limit: 250)
Limit: 250)

Component
Being Measured
Text Area
(Character Limit:
250)

Annual Reporting Data Elements for RPE

Unit
Dropdown with
Open Response
o Number
o Percent*
o Proportion*
o Rate*
o Cost
o Other (not
listed):
specify
(Character
Limit: 100)

Year 5 Desired
Value
Decimal

Year #
Value
Decimal

*Provide
numerator and
denominator if
available
Fraction

*Provide
numerator and
denominator if
available
Fraction

Date Data
Pulled
Date

Notes
Text Area
(Character
Limit:
500)

18

CE19-1902: Rape Prevention & Education (RPE) Using The Best Available Evidence for Sexual Violence Prevention

SECTION: Outcomes
Repeatable Panel: Outcomes #
Repeatable Panel Limit: 30
Outcome Construct
Dropdown with Open
Response
o Access to Care or
Services
o Alcohol or Drug Use
o Bystander Behaviors
o Social Emotional Skills
o Community
Connectedness
o Education
o Economic Supports or
Opportunities
o Environmental
Conditions
o Family Connectedness
o Gender Norms
o Inequity
o Policies
o Social Connections
o Social Norms
o Violence Victimization
o Violence Perpetration
o Other (not listed):
specify (Character
Limit: 100)

Description of
Outcome
Text Area
(Character Limit:
250)

Type of Outcome

SEM Level

Dropdown
o Risk Factor
o Protective Factor
o Violence outcome
o Other (not listed):
specify (Character
Limit: 100)

Drop-Down
o Individual
o Relationship
o Community
o Societal
o Other (not listed):
specify (Character
Limit: 100)

Component Being
Measured
Text Area (Character
Limit: 250)

Table: Outcome Indicators
Table Row Limit: 10
Indicator
Data
Source

Text Area
(Character
Limit:
250)

Text Area
(Character
Limit:
250)

Unit

Dropdown
with Open
Response
o Number
o Percent*
o Proportion*
o Rate*
o Cost
o Other (not
listed):
specify
(Character
Limit: 100)

Annual Reporting Data Elements for RPE

Year 5
Desired
Value

Baseline
Value

Decimal

Decimal

*Provide
numerator
and
denominator
if available
Fraction

*Provide
numerator
and
denominator
if available
Fraction

Description
of how
Baseline
and Desired
Values were
determined.
Text Area
(Character
Limit: 500)

Year #
Value

Decimal

*Provide
numerator
and
denominator
if available
Fraction

Date Data
Pulled

Notes

Date

Text Area
(Character
Limit:
500)

19

CE19-1902: Rape Prevention & Education (RPE) Using The Best Available Evidence for Sexual Violence Prevention

SECTION: Translation, Communication, Dissemination
What products have you developed to communicate key findings or messages about your sexual violence prevention
efforts to different audiences? Note that these products may result from the use of data and for purposes that include but
are not limited to marketing, planning, program improvement, evaluation.

Table: Translation and Communication Products
Table Row Limit: 50
Product Type

Description of
Product

Purpose and Main
Message

Primary Audience

Checkbox with Open Response
 Brief (e.g. Fact Sheet)
 Communities of Practice
 Conference
 Email
 Manuscript/Scientific
Publication
 Mass Media Campaign
 Meeting
 Newsletter
 Report
 Resource Guide
 Social Media
 Workshop/Training
 Webinar
 Press Release
 Other (not listed): specify
(Character Limit: 100)

Text Area
(Character
Limit: 500)

Text Area (Character Limit:
500)

Text Area (Character
Limit: 500)

How did it improve or
contribute to your state
prevention efforts?
Text Area (Character
Limit: 500)

Button to add row to table
Is there anything else we should know about your translation, communication, and dissemination efforts?
Text Area (Character Limit: 1000)

Annual Reporting Data Elements for RPE

20