Form 0920-1156 Awardee Performance Measure Reporting Tool

Form Approved

OMB No. 0920-1156

Exp. Date xx/xx/xxxx

Awardee Performance Measure Reporting Tool

Public reporting burden of this collection of information is estimated to average 1 hour 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, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-1156).

Instructions: Please complete the items below for Fiscal Year 201X (October 201X to September 201X).

Partnerships

1. Total number of health center partners:

With MOU/MOA:____________________ Without MOU/MOA:___________________

2. Total number of health center partners that participate on the leadership team:_______

3. Total number of targeted practice settings within each health center:_________

4. Total number of youth serving organization partners:

With MOU/MOA: ____________________ Without MOU/MOA:___________________

5. Total number of youth serving organization partners that participate on the leadership team:______________

Health communication strategies

1. Please indicate the type of health communication strategies that were implemented during the reporting period and add a short description of the strategy. Examples of health communications strategies include social media, advertising and marketing campaigns (e.g., radio, tv, billboards, newspaper, posters, brochures). Describe the target audience, the estimated number reached within the target audience, and a brief description of the method used to estimate the number reached. Be sure to include your referral guide as one strategy.

Strategy	Description	Target audience(s)	Estimate of number reached in target audience	Method for estimating number reached

4