Recipient Evaluation Year 5 Health Impact Statement

Form Approved

OMB No. 0920-xxxx

Exp. Date XX/XX/20XX

[INSERT NOFO HERE]

Recipient Evaluation Deliverable Guidance & TA Tool

Year 5 – Health Impact Statement

Note:te 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 (0920-20HP) Public reporting burden of this collection of information is estimated to average 8 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 estima

Each year [INSERT NOFO HERE] recipients are required to submit a different evaluation deliverable for the specific core area outlined in the [INSERT NOFO HERE] Evaluation and Performance Measurement Plan Guidance. In Year 5, recipients are required to develop a Health Impact Statement for each evaluated strategy that describes the evaluation core area of Health Impact. Recipients may use data gathered from this evaluation year, previous evaluation years, and their performance measures to develop the health impact statements. This reporting deliverable is due to CDC on [INSERT DUE DATE HERE]. The reporting deliverable will require up to 8 hours to complete.

Health Impact Statements provide recipients with the opportunity to summarize the extent to which the strategies implemented by the recipient contributed to a measurable change in health, behavior, or environment in a defined community, population, organization, or system. While this statement will be submitted as a condition of the [INSERT NOFO HERE] award, recipients may also choose to use them for reports to local and state government officials, for developing communication messages for the media, or to report on the program’s success to funders and partners. When developing your health impact statement be sure to consider who all of the readers are and develop the statements with this audience in mind.

The Health Impact Statement includes (for each strategy evaluated):

• Problem: Description of the problem or issue that is affecting the selected population and why it is important to address

• Intervention: Description of the goal, key elements/activities, key partners, and funders of the strategy that has been implemented

• Health Impact: Description the health impact that resulted from the intervention, including measurable quantitative outcomes that indicate health impact and any qualitative outcomes that may have contributed to these changes. This achievement should be stated in terms of impact on real people in the target population, organization, or community.

The TA tool below provides space for the specific information that should be included in the Health Impact Statement. This statement should be no more than one page front and back for each strategy.

[Insert name of

Recipient]

1. Problem

2. Intervention

3. Health Impact

1. Problem

2. Intervention

3. Health Impact

1. Problem

1. Intervention

2. Health Impact