Form 0920-1097 Work Plan

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Overview

Home Page
Prevention
Secondhand Smoke
Cessation
Mass Reach Communications
Surveillance & Evaluation
Infrastructure, Admin & Mngmt

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Sheet 1: Home Page

							Form Approved: 0920-XXXX
							Expiration Date: xx/xx/xxxx
	National Tobacco Control Programs
Work Plan Template
				Year [X]
			[Choose your state name…]
				The following navigation bar is available on all worksheets
				Click a tab to jump to the corresponding sheet:
	Instructions:
	You may use this template to prepare a work plan for NTCP. Please refer to the supplemental guidance document for more information.
	Notes on Data Entry: All light yellow cells are available for user input.
	Technical Support:
	If you need technical support at any time, please send an email with a detailed description of your need to the following address:
	[email protected]
	Public reporting burden of this collection of information is estimated to average 6 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: PRA [0920-XXXX].

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Sheet 2: Prevention

	Goal 1
	Prevent initiation among youth and young adults.
	Project Period Objective 1
	Select a Project Period Outcome	Key outcome indicator (KOI)
	Project Period Objective 2 (Optional)
	Select a Project Period Outcome	Key outcome indicator (KOI)
	Strategy 1
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks
	Race/Ethnicity
	Strategy 2 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks
	Strategy 3 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks
	Strategy 4 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks
	Race/Ethnicity
	Strategy 5 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks
	Strategy 6 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks
	Strategy 7 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
	Strategy 8 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
	Strategy 9 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks

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Sheet 3: Secondhand Smoke

	Goal 2
	Eliminating nonsmokers’ exposure to secondhand smoke.
	Project Period Objective 1
	Select a Project Period Outcome	Key outcome indicator (KOI)
	Project Period Objective 2 (Optional)
	Select a Project Period Outcome	Key outcome indicator (KOI)
	Strategy 1
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks
	Strategy 2 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks
	Strategy 3 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks
	Strategy 4 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks
	Strategy 5 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks
	Strategy 6 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks

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Sheet 4: Cessation

	Goal 3
	Promoting quitting among among youth and young adults.
	Project Period Objective 1
	Select a Project Period Outcome	Key outcome indicator (KOI)
	Project Period Objective 2 (Optional)
	Select a Project Period Outcome	Key outcome indicator (KOI)
	Strategy 1
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
	National Networks
	Race/Ethnicity
	Strategy 2 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
	National Networks
	Race/Ethnicity
	Strategy 3 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
	National Networks
	Race/Ethnicity
	Strategy 4 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks
	Race/Ethnicity
	Strategy 5 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
	National Networks
	Race/Ethnicity

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Sheet 5: Mass Reach Communications

	Mass Reach Communications
	Project Period Objective 1
	Select a Project Period Outcome	Key outcome indicator (KOI)
	Project Period Objective 2 (Optional)
	Select a Project Period Outcome	Key outcome indicator (KOI)
	Strategy 1
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy, including any key messages in your campaign, if known.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels increase reach:
		National Networks
	Race/Ethnicity
	Please choose the type of media planned for this strategy:
	Strategy 2 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy, including any key messages in your campaign, if known.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels increase reach:
		National Networks
	Please choose the type of media planned for this strategy:
	Strategy 3 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy, including any key messages in your campaign, if known.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels increase reach:
		National Networks
	Please choose the type of media planned for this strategy:

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Sheet 6: Surveillance & Evaluation

	Surveillance and Evaluation
	Project Period Objective 1
	Project Period Objective 2 (Optional)
	Strategy 1
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks
	Strategy 2 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks
	Strategy 3 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks
	Strategy 4 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks
	Strategy 5 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks
	Strategy 6 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:

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Sheet 7: Infrastructure, Admin & Mngmt

	Infrastructure, Administration and Management
	Project Period Objective 1
	Project Period Objective 2 (Optional)
	Strategy 1
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks
	Strategy 2 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks
	Strategy 3 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks
	Strategy 4 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks
	Strategy 5 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks
	Strategy 6 (Optional)
	[Select a strategy…]
	Annual Objective
		Population Description: Specify the populations and channels being targeted for each activity (if applicable) and check the corresponding box below	Responsible Party:	Timeframe
	Activity Description: Describe up to five planned activities related to the above strategy.		Specify the TCP position or partner responsible for this activity.	Start Month	End Month
	Population Checkboxes: Within this strategy, indicate if you are targeting the general population, population(s) of focus and/or channels in the listed activities above.
	Populations of Focus	Indicate if you will be using any of the following channels to increase reach:
		National Networks