Annual reporting for RPE data elements

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

Annual Reporting of the Rape Prevention and Education (RPE) Program: CE19-1902 Cooperative Agreement

Form Approved

OMB NO: 0920-1286

Exp. Date: 03/31/2023

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 D-74, Atlanta, GA 30333; Attn: PRA (0920-1286).

Note: Here is the color legend for carrying info forward for rest of the project years. All required except where noted as optional/conditionally required.

Color Legend

Populated, Not Editable

Populated, Editable

Not Populated, Required

Not Populated, Optional or Conditionally Required

Work Plan Form

Recipients report on progress towards their work plan goals, objectives, and milestones. Recipients can add up to 3 additional goals (max 8 goals) and have no more than 5 objectives per goal. You can add as many milestones to each objective as you’d like. Character limit counts include space.

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

Goal #. Statement

Objective #.#		Start Date	End Date	Progress Status (Reporting Period)	Progress Notes	Continuation Status (New Budget Period)	Continuation Notes
Text (Character Limit: 500) Objective statement		Date MM/DD/YY	Date MM/DD/YY	Drop Down ☐ Completed ☐ On track ☐ Delayed ☐ Planned ☐ Discontinued	Text (Character Limit: 500) Provide reasons for delayed or discontinued work, Conditionally Required	Drop Down ☐ New ☐ Continuing ☐ Repeating ☐ Revising ☐ Discontinuing ☐ Achieved	Text (Character Limit: 500) Provide reasons for redirecting/revising, Conditionally Required
Key Milestone	Key Activities	Start Date	End Date	Progress Status (Reporting Period)	Progress Notes	Continuation Status (New Budget Period)	Continuation Notes
Text (Character Limit: 1000) Milestone	Text (Character Limit: 1000) Activities	Date MM/DD/YY	Date MM/DD/YY	Drop Down ☐ Completed ☐ On track ☐ Delayed ☐ Planned ☐ Discontinued	Text (Character Limit: 500) Provide reasons for delayed or discontinued work, Conditionally Required	Drop Down ☐ New ☐ Continuing ☐ Repeating ☐ Revising ☐ Discontinuing ☐ Achieved	Text (Character Limit: 500) Provide reasons for redirecting/revising, Conditionally Required

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Is there anything else we should know about this objective?

(Character Limit: 1000) Optional

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Is there anything else we should know about this goal?

(Character Limit: 1000) Optional

Progress Status	What progress did you make so far during the reporting on this item?
Completed	All work is completed.
On Track	Work is in progress and is on track.
Delayed	Work has some delays.
Planned	Work is planned and has not yet started during the reporting period.
Discontinued	Work has been stopped and discontinued.
Continuation Status	What do you plan to do with this item in the next budget period?
New	This work is new for the next budget period.
Continuing	Work began in a previous budget period and will continue in the next budget period.
Revising	Focus will change; aspects of the work will change for the next budget period.
Discontinuing	Work is stopping and being discontinued for the next budget period.
Achieved	Work is achieved; no plans for next budget period

Barriers, Facilitators, and Successes Form

SECTION: Barriers Encountered

Each row should be a distinct barrier type.

Barrier Type	Describe the barrier and how it impacts your work.	NOFO Component	What actions were taken or would be helpful to address the barrier?	What resources are used or would be helpful to address the barrier?	Is this a barrier during this reporting period?	Do you anticipate this barrier for the next budget period?	Comments
Dropdown with Open Response ☐ Lack of Buy-in from partners/stakeholders ☐ Insufficient funding or resources ☐ Inability to access/collect data ☐ Implementation issues ☐ Staffing issues (e.g., turnover) ☐ Inadequate training ☐ Evaluation Capacity ☐ Other (not listed): specify (Character Limit: 100) ☐ No barriers encountered	Text (Character Limit: 2000) Concisely describe the barrier. Describe how the barrier has/may affect your efforts. In other words, how will it affect your efforts if actions were not in place to try to overcome it?	Multiple responses with other response ☐ Work Plan ☐ State Action Plan ☐ Prevention Strategy ☐ Evaluation ☐ Partnership ☐ Training and TA provided to others ☐ Other (not listed): specify (Character Limit: 100)	Text (Character Limit: 2000) Describe what action steps or resolutions were used or are planned to overcome it.	Text (Character Limit: 2000) Describe resources used or needed to overcome the barrier.	Drop Down ☐ Yes ☐ No	Drop Down ☐ Yes ☐ No	Text (Character Limit: 500) Optional

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SECTION: Facilitators Encountered

Each row should be a distinct facilitator type.

Facilitator Type	Describe the facilitator and how it impacts your work.	What resources did you use?	NOFO Component	Is this a facilitator during this reporting period?	Comments
Dropdown with Open Response ☐ Strong partners/stakeholders ☐ Connection to community ☐ Access to funding or resources ☐ Access to data ☐ Strong implementation ☐ Adequate, experienced staff ☐ Access to training ☐ Other (not listed), specify: (Character Limit: 100) ☐ No facilitators encountered	Text (Character Limit: 2000) Concisely describe a facilitator that supports and helps you achieve and be successful. Describe how this facilitator was leveraged for your efforts, and what would have happened if you did not have this facilitator.	Text (Character Limit: 2000)	Multiple responses with other response ☐ Work Plan ☐ State Action Plan ☐ Prevention Strategy ☐ Evaluation ☐ Partnership ☐ Training and TA provided to others ☐ Other (not listed): specify (Character Limit: 100)	Drop Down ☐ Yes ☐ No	Text (Character Limit: 500) Optional

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SECTION: Successes

Add as many successes and accomplishments as you would like.

What specific successes and accomplishments have you made during this reporting period?

Text (Character limit: 8000)

Describe specific accomplishments and successes made during the reporting period.

Training and Technical Assistance Form

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: Participation in CDC-sponsored Training and Technical Assistance

Which CDC-sponsored training and TA activities have you participated in during the reporting period?

Multiple response with other and items that require further response

☐ Annual RPE Recipient Meeting in Atlanta

☐ Regional RPE Training: specify (Character Limit: 200)

☐ CDC site visit

☐ E-Learning Collaborative (Prevent Connect): specify (Character Limit: 200)

☐ State-specific training or TA: specify (Character Limit: 200)

☐ Training or TA from National Sexual Violence Resource Center (NSVRC): specify (Character Limit: 200)

☐ Training or TA from Violence Prevention TA Center (VPTAC): specify (Character Limit: 200)

☐ CDC Virtual Office Hours: specify (Character Limit: 200)

☐ CDC Webinar: specify (Character Limit: 200)

☐ <<insert additional CDC opportunities>>

☐ Other (not listed): specify (Character Limit: 200)

Is there anything else we should know about CDC-provided training and TA that you received?

(Character Limit: 1000)

Optional

SECTION: Training and Technical Assistance Provided by the Recipient

(includes TTA provided by sub-recipients)

What training and technical assistance (TA) did you offer during the reporting period?

Each training and TA have a distinct purpose. If 1-1 TA sessions have the same purpose, then report them as a set in one row

Name of Training or TA Topic
Text (Character Limit: 100) Provide name of the training or TA
Method of Training or TA	What is the purpose of the training or TA?		Is this a one-time or multi-session training or TA?	Describe the participants of the training or TA		What resources were provided to participants?
Dropdown with Open Response ☐ Online Resource (Self Study) ☐ Webinar ☐ One-on-One TA ☐ Peer-to-Peer Sharing ☐ Conference or Summit ☐ In-Person Skill-Building Workshop ☐ Workgroup ☐ Conference call or meeting ☐ Other (not listed): specify (Character Limit: 100) ☐ Multiple Methods: specify (Character Limit: 200)	Text (Character Limit: 2000) Concisely describe the purpose of the training or TA		Drop Down ☐ One-time ☐ Multiple sessions ☐ N/A	Text (Character Limit: 2000) Concisely describe the participants of the training or TA		Text (Character Limit: 2000) Concisely describe the resources provided to the participants
Total Number of Individuals Trained		Total Number of Organizations Participated			Total Number of Trainings or TA Delivered
Integer		Integer			Integer

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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 (Character Limit: 1000)

Optional

Form: Continuation Narrative

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

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 (Character Limit: 8000)

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 (Character Limit: 8000)

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 (Character Limit: 8000)

Needed Resources

What additional tools/resources do you need to accomplish the proposed planned activities for the next budget period?

Text (Character Limit: 8000)

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 (Character Limit:8000)

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

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. Each row is a distinct State Action Plan Component.

State Action Plan Required Components	Describe the Change	Describe the reason for the change	How does this change impact your overarching work?
Dropdown with Open Response ☐ No changes ☐ Approach or Strategy ☐ Stakeholder/Partner ☐ State/local collaboration ☐ Resources/Funding ☐ Training/Technical Assistance ☐ Sustainability ☐ Health Disparities/Population of Interest ☐ Other (not listed): specify (Character Limit: 100)	Text (Character Limit: 500)	Text (Character Limit: 1000)	Text (Character Limit: 1000).

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Table: State Action Plan Progress and Planned Activities

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.

Each row is a distinct State Action Plan Component.

State Action Required Priorities	Key Accomplishments	How did your accomplishments improve your state’s prevention efforts?	Key Activities Planned for Next Year	Needed Resources	Notes
Dropdown with Open Response ☐ Addressing Health Disparities ☐ Training/Technical Assistance ☐ Capacity-Building Support to Unfunded Organizations ☐ Strategy Implementation ☐ Evaluation & Data Use Capacity ☐ Public/Private Partnership ☐ Other (not listed): specify (Character Limit: 100)	Text (Character Limit: 2000) Concisely describe the accomplishments made to this State Action Plan component.	Text (Character Limit: 2000) Concisely describe how these accomplishments help your overall prevention efforts in the state.	Text (Character Limit: 2000) Concisely describe any planned activities related to this State Action Plan component in the next year.	Text (Character Limit: 1000) Concisely describe any needed resources to carry out and achieve those planned activities.	Text (Character Limit: 500) Optional Provide any additional information, if any not already captured about the State Action Plan component in this optional text field.

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Is there anything else we should know about your progress on the State Action Plan?

Text (Character Limit: 1000)

Optional

SECTION: Partnership and Resources

Partnership

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. Each item is a distinct partner.

Name of the Organization
Text (Character Limit: 500) Provide the name of the partner organization. If the organization is an implementing organization, make sure the name matches with the name provided in the Prevention Strategy Form.
Type of Organization	Sector		Special Focus/Emphasis of the Organization
Dropdown with Open Response ☐ Coalition, State ☐ Coalition, Local ☐ Community-based Organization ☐ College or University ☐ For-Profit Organization (e.g., businesses) ☐ Health care facility (e.g., health clinic, hospital) ☐ Local Health department ☐ State Health department ☐ Non-governmental organizations ☐ Rape Crisis Center ☐ School ☐ School District ☐ Other Local Government Agency ☐ Other State Government Agency ☐ Other (not listed): Specify (Character Limit: 100)	Dropdown with Open Response ☐ Business/Labor ☐ Education ☐ Justice ☐ Health Services ☐ Housing ☐ Media ☐ Public Health ☐ Social Services ☐ Government (Federal, State, County, Local) ☐ Community Organizations ☐ Other (not listed): Specify (Character Limit: 100)		Dropdown with Open Response ☐ Survivor serving ☐ Tribal serving ☐ Culturally relevant ☐ Youth serving ☐ LGBTQ serving ☐ Military or Veteran serving ☐ Disability serving ☐ Research and/or evaluation ☐ Community services and/or prevention ☐ Healthcare or health services ☐ Students and/or campus ☐ Children ☐ None ☐ Other (not listed): Specify (Character Limit: 100)
Partner Status	Do you provide RPE funding to this partner?	How is this partner engaged in the state SV prevention work?	Comment
Drop Down ☐ New, acquired during this reporting period ☐ Existing partner/stakeholder ☐ Re-engaged partner/stakeholder ☐ Increased engagement ☐ No longer a partner/stakeholder	Drop Down ☐ Yes ☐ No	Text (Character Limit: 1000) Concisely describe how this partner is engaged in the state sexual violence prevention efforts.	Text (Character Limit: 500) Optional Provide any additional information, if any not already captured about the partner in this optional text field.

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Is there anything else we should know about your partnership and collaboration efforts?

Text (Character Limit: 1000)

Optional

Resources

What resources did you use for your State Action Plan work during the reporting period?

Each row should be a distinct resource type.

Type of Resource	Description of resources obtained or used	How did it improve your state’s prevention efforts?	Did you use this resource during this reporting period?	Comments
Dropdown with Open Response ☐ Funding ☐ Staffing ☐ Tools for SV Prevention ☐ Space ☐ Other (not listed): Specify (Character Limit: 100)	Text (Character Limit:1000) Concisely describe the resource that was used or obtained during this reporting period.	Text (Character Limit: 1000) Concisely describe how this resource improved your overall prevention efforts in the state.	Drop Down ☐ Yes ☐ No	Text (Character Limit: 500) Optional Provide any additional information, if any not already captured about the resource in this optional text field.

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Is there anything else we should know about resources?

Text (Character Limit: 1000)

Optional

SECTION: Data Use

What data have you used to select populations of focus, sub-recipients, select prevention strategies, and address health disparities during this reporting period?

What data have you used to…?	Data Source Type	Description of data source obtained or used to do?	Data Collector	Describe any barriers or challenges you encounter in accessing this data source.
Drop Down ☐ Select population of focus (Data Driven Population of Focus) ☐ Select prevention strategies (Data Driven Prevention Strategy) ☐ Select sub-recipients (Data Driven Sub-Recipients) ☐ Address health disparities	Dropdown with Open Response ☐ Needs Assessment ☐ Surveillance data ☐ Police data ☐ Hospital data ☐ Surveys ☐ Interviews ☐ Focus groups ☐ Administrative data ☐ Hospital data ☐ Other (not listed): specify (Character Limit: 100)	Text (Character Limit: 500) Concisely describe the data source that was used or obtained during this reporting period.	Text (Character Limit: 500) Concisely describe who collects the data or from where the data were obtained.	Text (Character Limit: 500) Concisely describe any barriers or challenges encountered in accessing this data source.

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Is there anything else we should know about data sources used/obtained and data use?

Text (Character Limit: 1000)

Optional

Form: Coalition Building

Recipients report on any of their coalition building efforts during the reporting period. Report on each coalition building effort that each implementing organization implements.

Were there any changes to the coalition building during this reporting period? If yes, explain:
Drop Down ☐ Yes ☐ No	Text (Character Limit: 2000) If yes, explain

Coalition Building

What is the name of the coalition building effort?

Text (Character Limit: 200)

Provide a succinct yet informative name for this coalition building effort.

Description

Briefly describe the coalition building.
Text (Character Limit: 1000)
What is the purpose or role of the coalition building?	Briefly describe the purpose or role. What are the goals of the coalition building? What change do you intend to make?
Dropdown 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 ☐ Implement community/societal strategies ☐ Other (not listed): Specify (Character Limit: 100)	Text (Character Limit: 2000) Concisely describe the coalition building effort. What is intended to be accomplished by this effort?
Implementers: Provide a brief description who is involved in the coalition building effort.
Text (Character Limit: 500) Concisely describe the implementers of the coalition building. Who is involved in ensuring the efforts are carried out?
How many implementers implement the coalition building?
Integer: Provide the number of individuals who are the implementers for this effort during the reporting period.

Implementation Progress

Report on activities that demonstrate progress on this effort (e.g., dose delivery).

To add, copy and paste the row. Each row should be a distinct activity type.

Activity Type	Description of Activity	Purpose	Number of Activities Completed	Comments
Dropdown with Open Response ☐ Educational sessions ☐ Training sessions ☐ Projects ☐ Ads ☐ Web/Social Media Postings ☐ Text messages or emails ☐ Presentations ☐ Print materials ☐ Meetings ☐ Other (not listed): specify (Character Limit: 100)	Text (Character Limit: 2000) Concisely describe the activity and how this demonstrate progress on the coalition building or community mobilization implementation.	Text (Character Limit: 2000) Concisely describe how the activity serves and relates to the coalition building or community mobilization effort.	Integer: Report on the number of activities completed during the reporting period (e.g., number of educational sessions delivered).	Text (Character Limit: 500) Optional Any additional information you would like us to know

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Is there anything else we should know about this coalition building?

Text (Character Limit: 1000)

Optional

Prevention Strategy Form

This form collects information about the prevention strategies and approaches being implemented, and their implementation measures and progress (e.g., reach, delivery). Report on each program, policy, or practice that each implementing organization implements.

SECTION: Background and Program, Policy, or Practice Description

Were there any changes to the program, policy, or practice during this reporting period? If yes, explain:
Drop Down ☐ Yes ☐ No	Text (Character Limit: 2000) If yes, explain

Name of Program, Policy, or Practice
Dropdown with Open Response ☐ Adequate Work Supports ☐ Alcohol Policies ☐ Bringing in the Bystander ☐ Child Sexual Abuse program ☐ Coaching Boys into Men ☐ Comparable Worth Policies ☐ Council for Boys and Young Men ☐ CPTED ☐ Dating Matters ☐ Enhanced Assess, Acknowledge, Act ☐ Expect Respect ☐ Fourth R ☐ Girls Circle ☐ Green Dot			☐ Men of Strength Clubs ☐ Microfinance ☐ Powerful Voices ☐ Proactive Sexual Harassment Prevention Policies and Procedures ☐ Real Consent ☐ Safe Dates ☐ Safer Choices ☐ Second Step ☐ Shifting Boundaries Building-Level Intervention ☐ Strong African American Families – SAAF ☐ Other (not listed): specify (Character Limit: 100)
Briefly describe the program, policy, or practice.
Text (Character Limit: 2000) The description should explain clearly to someone who is not familiar with the prevention strategy: what the prevention strategy is, what it intends to do, how it is being implemented locally or in your State/Territory, and where the prevention strategy will occur (the setting).
Which STOP SV approach does this program, policy, or practice address?				Explain how this program, policy, or practice aligns or addresses the STOP SV approach selected.
Dropdown with Open Response ☐ Bystander approaches ☐ Mobilizing men and boys as allies ☐ Social-emotional learning ☐ Teach healthy, safe dating and intimate relationship skills to adolescents ☐ Promoting healthy sexuality ☐ Empowerment-based training ☐ Strengthening economic supports for women and families ☐ Strengthening leadership and opportunities for girls ☐ Improving safety and monitoring in schools ☐ Establishing and consistently applying workplace policies ☐ Addressing community-level risks through environmental approaches ☐ Other (not listed): specify the STOP SV strategy with which this best address (Character Limit: 100)				Text (Character Limit: 2000) Concisely explain how the program, policy, or practice aligns with or addresses the selected STOP SV approach. See the STOP SV technical package for description of the approaches for each STOP SV strategy.
What is the main way this program, policy, or practice is delivered?
Delivery Method		Description
Dropdown with Open Response ☐ Educational curriculum ☐ Social marketing ☐ Social media campaign ☐ Built environment change ☐ Organizational policy change ☐ Policy education or implementation ☐ Community mobilization ☐ Other (not listed): specify (Character Limit: 100)		Text (Character Limit: 2000) Concisely describe the way that the program, policy, or practice is delivered. How does it bring about immediate changes? What methods or principles does it use? The description and the selected category should align with each other.
If your response to the previous question indicated community mobilization, please further describe what is the focus of the community mobilization effort? If it was a program or practice, skip this question.
Text (Character Limit: 2000)
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		Focus
Dropdown with Open Response ☐ Policy ☐ Local ordinance ☐ Procedure ☐ Administrative action ☐ Incentive ☐ Organizational contract ☐ Rule/regulation ☐ Other (not listed): specify (Character Limit: 100)		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)
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		Description
Dropdown with Open Response ☐ Example approach listed in the technical package ☐ Based on best available research evidence ☐ Based on practice-based evidence ☐ Other (not listed): specify (Character Limit: 100)		Text (Character Limit: 2000) Concisely describe the evidence (evaluations results, research outcomes, etc.) available for the effectiveness of the program, policy, or practice in addressing the identified sexual violence problem. What is the evidence to support that this strategy will address the SV problem identified in the population of focus? The description and the selected category should align with each other.
What are the reasons for selecting this prevention strategy?
Text (Character Limit: 2000) Concisely describe the reason for selecting this program, policy, or practice. What data led you to selecting it to address sexual violence problem in your community?
If practice-based strategy, describe the essential content, delivery, and implementer characteristics of this prevention strategy.
What (Essential Content)	Text (Character Limit: 5000)
How (Essential Delivery)	Text (Character Limit: 5000)
Who (Essential Implementer’s Characteristics)	Text (Character Limit: 5000)
How did you determine these essential elements? Why are these considered essential elements for this prevention strategy?
Text (Character Limit: 5000)
Is there anything else we should know about the program, policy, or practice’s essential elements?
Text (Character Limit: 1000) Optional

SECTION: Population of Focus and Reach

Were there any changes to the population and setting of focus during this reporting period? If yes, explain:
Drop Down ☐ Yes ☐ No	Text (Character Limit: 2000) If yes, explain

Population of Focus

Provide a narrative description of the population and setting of focus for this program, policy, or practice.			Why was this population or setting selected and how is the program, policy, or practice appropriate for the selected population or setting?
Text (Character Limit: 2000) Concisely describe the population and setting of focus that the program, policy or practice intended to address or be implemented with. The description and the selected categories in the next questions should align with each other.			Text (Character Limit: 2000) Concisely describe the reasons that the population and setting of focus was selected and the ways the selected program, policy, or practice are appropriate for them. What data led you to selecting them? How is the selected program, policy, or practice appropriate for the selected population and setting?
Is there a specific community or population you are focusing on? (If the program, policy, or practice is focusing on a specific type of community or population, then select all categories that apply. If it does not have a specific or special emphasis, then select no)
☐ No If yes, multiple responses with other response:
☐ LGBTQ Communities ☐ Homeless ☐ Incarcerated or Formerly Incarcerated ☐ Migrant Workers ☐ Military ☐ Poor or Economically Disadvantaged ☐ People with Disabilities ☐ Perpetrators of Crimes or Violence ☐ Rural ☐ Tribal Communities ☐ Urban Communities ☐ Veterans ☐ Victims of Crimes or Violence ☐ Vulnerable or At-Risk Population		☐ Adolescent ☐ African American or Black Population ☐ Asian Population ☐ Children and Families ☐ Elder ☐ Foster Youths or Families ☐ Hispanic or Latino Population ☐ Immigrants or Refugees ☐ Men and Boys ☐ Pacific Islanders Population ☐ Parents and Families ☐ Single Parents ☐ Women and Girls			☐ 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. (Select the types of individuals, organizations, or communities that the program, policy, or practice intend to affect. The selected categories should align with the description.)
Multiple responses with other response:
Types of Individuals	Types of Organizations			Types of Communities
☐ Students ☐ Youths ☐ Teachers/Professors ☐ School Administrators ☐ School Staff ☐ Policy Makers ☐ Parents ☐ Healthcare Professionals ☐ Mental Health Providers ☐ 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))	☐ Schools or Universities ☐ Governmental Agencies ☐ Non-Government Agencies ☐ Non-Profits ☐ Businesses ☐ Bars ☐ Homes ☐ Employers ☐ Other (not listed): specify (Character Limit: 100) ☐ Other (not listed): specify (Character Limit: 100) ☐ Other (not listed): specify (Character Limit: 100)			☐ School District ☐ County ☐ City ☐ Census Tract/Zip Code ☐ Commercial District ☐ Neighborhood ☐ Territory Area ☐ Park and Recreational Area ☐ Other (not listed): specify (Character Limit: 100) ☐ Other (not listed): specify (Character Limit: 100) ☐ Other (not listed): specify (Character Limit: 100) )
Is there anything else we should know about the population and setting of focus?
Text (Character Limit: 1000) Optional

Reach

Actual Number of Individuals Reached	Possible Number of Individuals that can be Reached
Integer: Enter the number of individuals from the population of focus affected by or exposed to the program, policy, or practice	Integer: Enter the number of possible individuals from the population of focus that could be affected by or exposed

If implementing community/societal strategy, then also report reach for at least one of the following populations of focus:

Actual Number of Schools Reached	Possible Number of Schools that can be Reached
Integer: Enter the number of Schools from the population of focus affected by or exposed to the program, policy, or practice	Integer: Enter the number of possible Schools from the population of focus that could be affected by or exposed
Actual Number of Organizations Reached	Possible Number of Organizations that can be Reached
Integer: Enter the number of organizations from the population of focus affected by or exposed to the program, policy, or practice	Integer: Enter the number of possible organizations from the population of focus that could be affected by or exposed
Actual Number of Communities Reached	Possible Number of Communities that can be Reached
Integer: Enter the number of communities from the population of focus affected by or exposed to the program, policy, or practice	Integer: Enter the number of possible communities from the population of focus that could be affected by or exposed
Is there anything else we should know about the population and setting of focus reached?
Text (Character Limit: 1000)

SECTION: Risk and Protective Factors and Violence Outcomes

Were there any changes to the risk and protective factors and violence outcomes during this reporting period? If yes, explain:
Drop Down ☐ Yes ☐ No	Text (Character Limit: 2000) If yes, explain

Provide a narrative description of the outcomes and risk and protective factors that is the policy, program, or practice intend to change.
Text (Character Limit: 2000) Concisely describe risk and protective factors that the program, policy, or practice intend to directly affect.
What risk and protective factors does this program, policy, or practice address?
Multiple responses with other response:
Individual Risk Factors	Relationship Risk Factors	Community Risk Factors	Societal Risk Factors
☐ Alcohol and drug use ☐ Delinquency ☐ Lack of empathy ☐ General aggressiveness and acceptance of violence ☐ Early sexual initiation ☐ Coercive sexual fantasies ☐ Preference for impersonal sex and sexual risk taking ☐ Exposure to sexually explicit media ☐ Hostility towards women ☐ Adherence to traditional gender role norms ☐ Hyper-masculinity ☐ Suicidal behavior ☐ Prior sexual victimization or perpetration ☐ Other (not listed): specify (Character Limit: 100) ☐ Other (not listed): specify (Character Limit: 100) ☐ Other (not listed): specify (Character Limit: 100)	☐ Family environment characterized by physical violence and conflict ☐ Childhood history of physical, sexual, or emotional abuse ☐ Emotionally unsupportive family environment ☐ Poor parent-child relationships, particularly with fathers ☐ Association with sexually aggressive, hypermasculine, and delinquent peers Involvement in a violent or abusive intimate relationship ☐ Other (not listed): specify (Character Limit: 100) ☐ Other (not listed): specify (Character Limit: 100) ☐ Other (not listed): specify (Character Limit: 100)	☐ Poverty ☐ Lack of employment opportunities ☐ Lack of institutional support from police and judicial system ☐ General tolerance of sexual violence within the community ☐ Weak community sanctions against sexual violence perpetrators ☐ High alcohol outlet density ☐ Diminished economic opportunities ☐ Poor neighborhood or community support and cohesion ☐ Other (not listed): specify (Character Limit: 100) ☐ Other (not listed): specify (Character Limit: 100) ☐ Other (not listed): specify (Character Limit: 100)	☐ 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)
Individual Protective Factors	Relationship Protective Factors	Community Protective Factors	Societal Protective Factors
☐ Parental use of reasoning to resolve family conflict ☐ Emotional health and connectedness ☐ Academic achievement ☐ Empathy and concern for how one’s actions affect others ☐ Skills in solving problems non-violently ☐ Other (not listed): specify (Character Limit: 100) ☐ Other (not listed): specify (Character Limit: 100) ☐ Other (not listed): specify (Character Limit: 100)	☐ Family support and connectedness ☐ Connection to a caring adult ☐ Association with pro-social peers ☐ Connection/commitment to school ☐ Other (not listed): specify (Character Limit: 100) ☐ Other (not listed): specify (Character Limit: 100) ☐ Other (not listed): specify (Character Limit: 100)	☐ Neighborhood or Community support/connectedness ☐ Access to mental and health services ☐ Availability of safe and affordable housing and the ability of families to access housing assistance ☐ Other (not listed): specify (Character Limit: 100) ☐ Other (not listed): specify (Character Limit: 100) ☐ Other (not listed): specify (Character Limit: 100)	☐ 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)
What types of violence and injury outcomes does the program, policy, or practice directly address?
Multiple responses with other response: ☐ Sexual Violence ☐ Child Abuse and Neglect ☐ Child Sexual Abuse ☐ Human Trafficking ☐ Youth Violence ☐ Intimate Partner Violence ☐ Teen Dating 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 (Character Limit: 2000) Concisely describe how the program, policy, or practice addresses the selected risk and protective factors among the population of focus. How is the program, policy, or practice appropriate for the sexual violence problem identified among the selected population and setting of focus?
Is there anything else we should know about the risk and protective factors and violence outcomes?
Text (Character Limit: 1000) Optional

SECTION: Adaptation

What adaptations to the essential elements of the program, policy, or practice did you plan to make or have made during implementation?

Description of Adaptation
Text (Character Limit: 1000) Concisely describe how the program, policy, or practice addresses the selected risk and protective factors among the population of focus. How is the program, policy, or practice appropriate for the sexual violence problem identified among the selected population and setting of focus?
Which element of the program did you change or adapt?	Type of Adaptation		Reason for Adaptation		Describe the reason for this adaptation.
Drop Down ☐ Content ☐ Design element ☐ Policy component ☐ Delivery or method ☐ Implementer	Dropdown with Open Response ☐ Added content ☐ Deleted content ☐ Changed sequence of sessions ☐ Modified delivery or method ☐Added policy component ☐Deleted policy component ☐ Modified an environmental design element ☐ Changed the type of recommended implementer ☐ Other (not listed): specify (Character Limit: 100)		Drop Down ☐ To increase relevancy of material for participants ☐ To increase participant participation ☐ To create or maintain relationships with participants ☐ To respond to limited time and resources ☐ To respond to a resource, space or time limitation ☐To increase relevancy to or fit with context ☐ To align with the implementer’s facilitation style ☐ Other (not listed): specify (Character Limit: 100)		Text (Character Limit: 2000) Concisely describe what led to this adaptation and how the adaptation was decided.
Was this adaptation made before or made during delivery?		What was the result or impact of the adaptation?		Plan for this Adaptation in Future Implementation Cycles	Is there anything else we should know about this adaptation?
Drop Down ☐ Made before implementation started ☐ Made during implementation		Text (Character Limit: 2000) How did the adaptation affect implementation or uptake of the program, policy, or practice? How did the adaptation affect its effectiveness?		Drop Down ☐ Keep ☐ Change ☐ Omit ☐ Adapt across sites ☐ No plans	Text (Character Limit: 500) Optional

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What resources do you need to make and monitor these adaptations?

Text (Character Limit: 2000)

Describe the resources needed make the adaptations and monitor them.

How you plan to track and monitor these adaptations?

Text (Character Limit: 2000)

Describe how the adaptations will be tracked and monitored.

SECTION: Implementation Measures

Were there any changes to your implementation during this reporting period? If yes, explain:
Drop Down ☐ Yes ☐ No	Text (Character Limit: 2000) If yes, explain

Provide a brief description about the implementers of this program, policy, or practice.

Text (Character Limit: 1000)

Concisely describe the implementers of the program, policy, or practice. Who is involved in ensuring the efforts are carried out?

How many implementers have been trained to deliver or implement the program, policy, or practice during Year #?

Integer: Provide the number of individuals who are the implementers during the reporting period.

Implementation Progress

Report on activities that demonstrate progress on this effort (e.g., dose delivery).

To add, copy and paste the row. Each row should be a distinct activity type.

Activity Type	Description of Activity	Purpose	Number of Activities Completed	Comments
Dropdown with Open Response ☐ Educational sessions ☐ Training sessions ☐ Projects ☐ Ads ☐ Web/Social Media Postings ☐ Text messages or emails ☐ Presentations ☐ Print materials ☐ Meetings ☐ Other (not listed): specify (Character Limit: 100)	Text (Character Limit: 2000) Concisely describe the activity and how this demonstrate progress on the coalition building or community mobilization implementation.	Text (Character Limit:2000) Concisely describe how the activity serves and relates to the coalition building or community mobilization effort.	Integer: Report on the number of activities completed during the reporting period.	Text (Character Limit: 500) Optional Any additional information you would like us to know

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Is there anything else we should know about the implementation of this program, policy, or practice?

Text (Character Limit: 1000) Optional

SECTION: Program, Policy, or Practice Resources

Were there any changes to your resources for this program, policy, or practice during this reporting period? If yes, explain:
Drop Down ☐ Yes ☐ No	Text (Character Limit: 1000) If yes, explain

How much of this program, policy, or practice was funded by RPE?

Drop Down

☐ Fully funded by RPE

☐ Funded in part by RPE

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) Optional

Form: Evaluation

Recipients report on their progress on evaluation activities and on indicators measuring the outcomes of their efforts for CE19-1902.

SECTION: Evaluation Plan

Table: Changes to Evaluation Plan

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	Describe the Change	Reason for Change	Notes
Dropdown with Open Response ☐ No changes ☐ Evaluation Design ☐ Evaluation Question ☐ Data Analysis, Synthesis, and Interpretation ☐ Data Collection Method or Data Source ☐ Measures and Indicators ☐ Translation, Communication, and Dissemination ☐ Evaluation Team ☐ Other (not listed): specify (Character Limit: 100)	Text (Character Limit: 2000) Concisely describe the change	Text (Character Limit: 2000) Concisely describe the reason for the change	Text (Character Limit: 500) Optional Provide any additional information about this change that has not yet been captured.

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Analysis, Interpretation, and Synthesis

Please describe your approach to analyzing and summarizing your evaluation data including, primary focus of youryoru analysis, methods used to analyze data, staff and consultants who will work on analysis, and how you plan to report findings to stakeholders? How will evaluation data be analyzed, synthesized, interpreted?

Text Area (Character Limit: 8000)

Please describe your progress on analysis, interpretation, and synthesis during this reporting period

Text Area (Character Limit: 5000)

Continuous Quality Improvement (CQI)

Please describe your approach and methods to program improvement and facilitating use of data. Please include a description of 1) the process and plan for evaluation findings and how data will be used for CQI, 2) the process for engaging and promoting CQI among sub-recipients, and 3) methods for CQI and how lessons learned will be shared with sub-recipients.

Text Area (Character Limit: 8000)

Please describe your progress on CQI and facilitating use of data during this reporting period.

Text Area (Character Limit: 5000)

Where in the evaluation do you need additional evaluation TA or help?

Components	Description
Dropdown with Open Response ☐ None ☐ Evaluation Design ☐ Evaluation Question ☐ Data Analysis, Synthesis, and Interpretation ☐ Data Collection Method or Data Source ☐ Measures and Indicators ☐ Translation, Communication, and Dissemination ☐ Evaluation Team ☐ Other (not listed): specify (Character Limit: 100)	Text (Character Limit: 2000) Provide any additional information about this change that has not yet been captured.

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SECTION: Progress on Addressing Evaluation Questions

Evaluation Question	What progress have you made on this evaluation question? (e.g., data collected to date)	Summary of Findings (if available)	Planned Activities for Next Budget Year	Notes
Drop Down ☐ Q1 Partnership: To what extent has the state built or enhanced partnerships for SV prevention? ☐ Q2 Data Use: To what extent has the recipient used data to select and prioritize the sub-recipients, the prevention strategies and approaches and the population of focus? ☐ Q3 Risk and Protective Factors: To what extent have targeted risk and protective factors for SV outcomes changed at the state level? ☐ Q4 Implementation: To what extent have selected prevention strategies been implemented in the state? ☐ Q5 Contextual Factors: Which factors are critical for implementing selected prevention strategies and approached? ☐ Q6 Alignment: To what extent are sub-recipient activities aligned with state level goals and outcomes stated in the state action plan and recipient work plan? ☐ Other (not listed): specify (Character Limit: 250)	Text Area (Character Limit: 5000)	Text Area (Character Limit: 8000)	Text Area (Character Limit: 5000)	Text Area (Character Limit: 1000) Optional

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Is there anything else we should know about the evaluation efforts during this reporting period?

Text Area (Character Limit: 1000) Optional

SECTION: Indicators

Risk and Protective Factors & Violence Outcomes

Description of Outcome	Risk and Protective Factor Category	Names of Prevention Strategy Being Implemented	Indicator	Data Source	Summary of Trends for the Outcome	Notes
Text Area (Character Limit: 2000)	Drop Down ☐ Knowledge, Skills, Attitudes ☐ Behavior Change ☐ Awareness ☐ Caring Adults Connectedness ☐ Community Connectedness ☐ Economic stability ☐ Equitable Access ☐ Family Connectedness ☐ Financial supports ☐ Gender Norms ☐ Neighborhood Environments ☐ Organizational Climate/environment ☐ Policies or procedures ☐ Prosocial Peer Connectedness ☐ School Connectedness ☐ School environment/climate ☐ Social Norms ☐ Violence Victimization ☐ Violence Perpetration ☐ Other (not listed): specify (Character Limit: 100)	Text Area (Character Limit: 5000)	Text Area (Character Limit: 5000)	Text Area (Character Limit: 5000)	Text Area (Character Limit: 8000)	Text Area (Character Limit: 1000) Optional

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Other (Optional)

Description of Outcome	Names of Prevention Strategy or other Effort Being Implemented	Indicator	Data Source	Summary of Trends for the Outcome	Notes
Text Area (Character Limit: 2000)	Text Area (Character Limit: 5000)	Text Area (Character Limit: 5000)	Text Area (Character Limit: 5000)	Text Area (Character Limit: 8000)	Text Area (Character Limit: 1000) Optional

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SECTION: Translation, Communication, Dissemination

Please describe your approach to how you will translate evaluation findings into actionable and useful information, disseminate lessons learned, and facilitate use of data to advance program among recipients and sub-recipients and to advance the field? This may include considering your key audiences, types of products, and strategies used to communicate and disseminate them.

Text Area (Character Limit: 8000)

Describe your progress on your translation, communication, and dissemination efforts and their impact or contribution to your state’s prevention efforts.

Description of Product	Product Type	How will you use this product in your work?	Primary Audiences	Audience Type	Impact & Contribution	To how many are you disseminating?
Text Area (Character Limit: 2000)	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: 2000)	Text Area (Character Limit: 2000)	Checkbox with Open Response ☐ Funders ☐ General Public ☐ Implementers ☐ Local/State Government ☐ News/Press ☐ Participants ☐ Partners ☐ Policymakers ☐ Sexual Violence Field ☐ Other (not listed): specify (Character Limit: 100)	Text Area (Character Limit: 5000)	Integer	Unit Drop Down ☐ Individuals ☐ Groups or Organizations

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Is there anything else we should know about your translation, communication, and dissemination efforts?

Text Area (Character Limit: 1000)

Optional

Annual Reporting for RPE Word Template 23