Form 0920-1247 Delta Impact

Attachment 3a - Instrument: Annual Progress Report Tool

Items in green will be prepopulated based on planning documents received from recipients. Grey indicates it is the question narrative or instructions.

Everything in white is submitted annually. All narrative questions will have a word limit.

Recipients: Drop down with names of 10 grantees Reporting Period: Contact Person: Word Limit = 25

Work Plan Section

Section A: Progress on Goals

NOFO Project Period Goal 1: Increase the prioritization, resources, and capacity to implement community and societal level IPV prevention programs and policy efforts (REQUIRED)
Objective 1: Develop and implement the State Action Plan (SAP) (REQUIRED)				Status of Objective Completed In Progress Planned Discontinued New
Key Milestones	Target Date for Completion	Project Year	How will you know this Milestone is Completed?	Status of Milestone		Notes
	MM/DD/YYYY	Drop Down List (Year 1 – Year 5)		Completed In Progress Planned Discontinued New
	MM/DD/YYYY	Drop Down List (Year 1 – Year 5)		Completed In Progress Planned Discontinued New
More detail about this objective will be requested in other areas of the APR
Objective 2: Increase coordination of IPV work at the state and local level (REQUIRED)				Status of Objective Completed In Progress Planned Discontinued New
Key Milestones	Target Date for Completion	Project Year	How will you know this Milestone is Completed?	Status of Milestone		Notes
	MM/DD/YYYY	Drop Down List (Year 1 – Year 5)		Completed In Progress Planned Discontinued New
	MM/DD/YYYY	Drop Down List (Year 1 – Year 5)		Completed In Progress Planned Discontinued New
More detail about this objective will be requested in other areas of the APR
Objective 3: Increase the use of IPV prevention approaches that address the community and societal level of the SEM (REQUIRED)				Status of Objective Completed In Progress Planned Discontinued New
Key Milestones	Target Date for Completion	Project Year	How will you know this Milestone is Completed?	Status of Milestone	Notes
	MM/DD/YYYY	Drop Down List (Year 1 – Year 5)		Completed In Progress Planned Discontinued New
	MM/DD/YYYY	Drop Down List (Year 1 – Year 5)		Completed In Progress Planned Discontinued New
More detail about this objective will be requested in other areas of the APR
Please list all capacity building and training activities related to community and societal level primary prevention that you provided within the state over the past year
Type of Activity	Topic			Audience		Dates
Please list any networking and dissemination activities that you participated in related to community and societal level primary prevention OUTSIDE the state.
Type of Activity	Topic			SDVC Role in Activity		Dates

NOFO Project Period Goal 2 : Increase data on the impact of community and societal level IPV primary prevention programs and policy efforts (REQUIRED)

Objective 1: Increase the use of data for planning including monitoring of state-level outcome indicators (REQUIRED)

Status of Objective Completed In Progress Planned Discontinued New

Key Milestones

Target Date for Completion

Project Year

How will you know this Milestone is Completed?

Status of Milestone

Notes

MM/DD/YYYY

Drop Down List (Year 1 – Year 5)

Completed In Progress Planned Discontinued New

MM/DD/YYYY

Drop Down List (Year 1 – Year 5)

Completed In Progress Planned Discontinued New

More detail about this objective will be requested in other areas of the APR

Objective 2: Increase the evaluation of community and societal level IPV prevention programs and policy efforts within funded states (REQUIRED)

Status of Objective Completed In Progress Planned Discontinued New

Key Milestones

Target Date for Completion

Project Year

How will you know this Milestone is Completed?

Status of Milestone

Notes

MM/DD/YYYY

Drop Down List (Year 1 – Year 5)

Completed In Progress Planned Discontinued New

MM/DD/YYYY

Drop Down List (Year 1 – Year 5)

Completed In Progress Planned Discontinued New

More detail about this objective will be requested in other areas of the APR

Objective 3: Monitor changes in risk and protective factors associated with the NOFO activities being implemented (REQUIRED).

Status of Objective Completed In Progress Planned Discontinued New

Key Milestones

Target Date for Completion

Project Year

How will you know this Milestone is Completed?

Status of Milestone

Notes

MM/DD/YYYY

Drop Down List (Year 1 – Year 5)

Completed In Progress Planned Discontinued New

MM/DD/YYYY

Drop Down List (Year 1 – Year 5)

Completed In Progress Planned Discontinued New

More detail about this objective will be requested in other areas of the APR

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

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

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

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

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

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

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

Strategic Planning Section

Section A. Progress and Planning for State Action Plan Goals (can add up to 10)

Priority Area Name #1	Description of Priority Area	Key Partners	Key Accomplishments this Report Period
Key Activities Planned for Upcoming Year		Resources Needed
1.
2.
3.
4.

Section B. Changes related to Prioritization, Resources and Capacity

Did you engage any new partners or stakeholders related to the work on the state action plan during the reporting period?

Name of Partner Organization	Type of Organization (Select one)	Primary Sector (Select one)	Partner Role(s) related to State Action Plan (Select multiple)
	Government/Quasi-Government Non-Profit/Tax-Exempt Coalition Business Other ________	Public Health/Health & Human Services Criminal Justice/Legal Education Policy Labor Media Business Faith Community Members/Grassroots Youth Multidisciplinary/Interdisciplinary Other ________	Data collection or monitoring Train/educate community members Engagement/convening Share funds or resources other than funding Communications/promotion Plan or implement efforts in the strategic plan Plan or implement process or outcome evaluations Other ________

Please describe any impacts of new partnerships with stakeholders in other sectors during this reporting period.

Were any new policies or procedures implemented by funding partners during the reporting period related to increasing the use of community and societal level primary prevention (CSPP) (e.g. new uses, required training, etc.)?

Policy/Procedure	Funding Partner(s)	Description and Potential Impact on Use of CSPP

Were any new resources obtained or redirected for CSPP during the reporting period?

Resource Name	Funder Name	Funder Type (Select one)	Total Annual Funding Amount Distributed	Previous Uses (Select all that apply)	New Uses Related to CSPP	Notes
		Gov-Federal Gov-State Gov - Local Foundation Non-Profit/Public Charity Business/Company Private Donor Other ________		Victims Services Legal Services and Law Enforcement Perpetrator Programs Primary Prevention Programs Public Education/Awareness Campaigns Advocacy and/or Policy Change N/A – New Funding

Please list any new CSPP programs or policy efforts implemented and/or evaluated during the reporting period.

Program/Policy Effort	Type (Select one)	Implementing Organization	CSPP Approach (Select one)	Population of Interest	Primary Setting (Select one)	Notes
	New Implementation New Evaluation Both		Bystander Empowerment and Education Improve School Climate and Safety Improve Organizational Policies and Workplace Climate Modify the Physical and Social Environments of Neighborhoods Strengthen Household Financial Security Strengthen Work-Family Supports Other_______		School Organization Community/Neighborhood Online/Media Other______________

Did you gain access to any new state or local data sources and/or implement any new uses of state or local data during the reporting period?

Dataset Name	Type (Select one)	“Dataset Owner”	Description (including level)	Availability	Current or Planned Use(s) (Select all that apply)
	New Access New Use New Access AND New Use			Publicly Available Purchase Shared Use/Data Share Agreement Unsure/Unknown Other ________	Quantify need Focus programming on an audience/health disparity Inform planning Track implementation Track progress or change in a population/environment Quantify impact Provide contextual data Collect program/strategy feedback for improvement Other ________

Meetings of Leadership Team or State Action Planning Committees During Reporting Period

Group	Participating Organizations	Date(s)	Topics Discussed

Section C. Facilitators and Barriers related to the State Action Plan

	Facilitator or Barrier			Action Planning			Impact in Reporting Period
Goal #	Facilitator or Barrier?	Potential or Actual	Facilitator or Barrier Description	Action Steps	Needed Resources	Responsible Party
#	☐ Facilitator ☐ Barrier	☐ Potential ☐ Actual

NOFO Evaluation Section

Section A. Progress on Evaluation Questions

Evaluation Question

Question 1. To what extent did the Coalition increase the use of primary prevention of IPV at the community and societal levels in defined communities as specified in their state level plan?

Question 2. To what degree have the state level and program/policy evaluations increased data on the impact of community and societal level IPV primary prevention programs and policy efforts, and increased the use of data for planning?

Question 3. To what extent has the Coalition increased the prioritization, resources, and capacity to implement community and societal level IPV prevention programs and policy efforts across the state?

Question 4. To what extent have targeted risk and protective factors of IPV outcomes across multiple levels of the social ecological model changed within targeted communities or populations?

Question 5. What factors are critical to implementing and sustaining community and societal level primary prevention approaches to prevent IPV?

Evaluation Progress Made and Data Collected During Reporting Period

Interim Findings	Corresponding Evaluation Questions (Select all that apply)
	1 2 3 4 5

Planned Evaluation Activities in Next Reporting Period

Section B. Changes to Evaluation Plan

Please describe any key changes have you made to this evaluation plan in the past year including the reason for making the changes.
Type of Change (Select one)	Describe the Change	Reason for Change	Notes
Change in Evaluation Design Change in Outcomes or Indicators Change in Data Collection Methods or Sources Change in Data Collection Population (including setting) Change in Data Analysis, Synthesis, Interpretation Strategy Change in Translation, Communication, Dissemination Strategy Other ____________

Section C. Outcomes Table

This should not include outcomes included within a specific program or policy effort evaluation UNLESS you are aggregating the outcome across the evaluations.

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

Section D. Facilitators and Barriers

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

Program or Policy Effort Section

(1 per program/policy being implemented)

Program or Policy Effort Name: PREPOPULATED Implementing Organization: PREPOPULATED

Section A. Progress on Implementation Plan

Program or Policy Effort Description

Please provide a general update on PPE implementation during this reporting period.

Please describe the partners (including role) that have been key to implementing this program or policy effort.

Key Milestone (can add additional)	Target Date	Project Year	Status	Key Accomplishments	Key Activities in Upcoming Year	Resources Needed
1.	MM/DD/YYYY	Drop Down List (Year 1 – Year 5)	Completed In Progress Planned Discontinued
2.	MM/DD/YYYY	Drop Down List (Year 1 – Year 5)	Completed In Progress Planned Discontinued
3.	MM/DD/YYYY	Drop Down List (Year 1 – Year 5)	Completed In Progress Planned Discontinued

Section B. Reach

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

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

Please describe your plans to ensure that you will reach your year 5 target by the end of the project period.

Section C. Change to Implementation Plan

Please describe any key changes have you made to this implementation plan in the past year including the reason for making the changes.
Type of Change	Describe the Change	Reason for Change	Impact of Change During Reporting Period	Notes
Select one (1) Change in setting Change in population Change in recruitment strategy Change in implementation timeline Change in partnerships/collaboration strategy Change in staffing Change in key activities or method of delivery Other

Section D. Adaptations Made

Adaptations
Adaptation Description	Planned or Field	What Led to the Adaptation?	Does adaptation impact essential elements?	What resources are needed for this adaptation?	Describe how you are tracking and evaluating this adaptation	Impact of Adaptation	Future Plans
	Select one (1) ☐ Planned ☐ Field Was this adaptation planned or did it occur spontaneously during implementation?	Describe the reason for this adaptation.	Describe how this adaptation impacts any essential elements.			What was the influence or result(s) of the adaptation?	Select one (1) Continue adaptation in current sites Continue adaptation and implement adaptation in additional sites Discontinue adaptation Modify adaptation (Please describe): ___________ Other ___________

Section E. Progress on Evaluation Questions

Evaluation Question

Question 1. To what extent did the Coalition or CCRs achieve high quality implementation of the program or policy effort during the project period?

Question 2. To what extent have targeted risk and protective factors of IPV outcomes across multiple levels of the social ecological model changed within the targeted communities or populations as a result of the program or policy effort?

Question 3. What factors are critical to implementing and sustaining this program or policy effort?

Question 4. In what ways has this program or policy effort contributed to achieving the overall NOFO objectives?

Evaluation Progress Made and Data Collected During Reporting Period

Interim Findings	Corresponding Evaluation Questions (Select all that apply)
	1 2 3 4
	1 2 3 4

Planned Evaluation Activities in Next Reporting Period

Section F. Changes to Evaluation Plan

Please describe any key changes you have made to this evaluation plan in the past year including the reason for making the changes.
Type of Change	Describe the Change	Reason for Change	Notes
Select one (1) Change in Evaluation Design Change in Outcomes or Indicators Change in Data Collection Methods or Sources Change in Data Collection Population (including setting) Change in Data Analysis, Synthesis, Interpretation Strategy Change in Translation, Communication, Dissemination Strategy - Other ____________

Section G. Outcomes

Outcome Examined	Type	SEM Level	Indicator Description	Unit	Data Source/Measure	Indicator Population	Year 5 Target	Current Value	Progress Notes
Insert Text	Select one (1) ☐ Risk Factor ☐ Protective Factor ☐ Violence Outcome ☐ Implementation ☐ Other (please specify)	Select one (1) ☐ Individual ☐ Relationship ☐ Community ☐ Societal	Insert Text Provide indicator and data source, method, and frequency of collection or availability Include the level of analysis	Select one (1) ☐ Number ☐ Percent ☐ Proportion ☐ Other, Unit Description:			Insert Numeric Value

Section H. Facilitators and Barriers

	Facilitator or Barrier			Action Planning			Impact in Reporting Period
Type	Facilitator or Barrier?	Potential or Actual Factor	Facilitator or Barrier Description	Action Steps	Needed Resources	Responsible Party
Select one (1) ☐ Implementation ☐ Evaluation	Select one (1) ☐ Facilitator ☐ Barrier	Select one (1) ☐ Potential ☐ Actual