0920-1132 Evaluation Plan Template

Performance Monitoring and Program Report: Evaluation and Performance Measurement Plan Template

OMB Control Number: 0920-1132

Expiration Date: XX/XX/XXXX

1. Federal Agency, Center, and Division to Which Report is Submitted:	2. Federal NOFO or Other Identifying Number Assigned by Federal Agency:	3. Name of Submitting Organization	4. Reporting Period

A. Evaluation Plan Overview

1. Strategies to Evaluate: Select strategies from your work plan that you would like to evaluate during the funding period.

• [Insert strategy]

• [Insert strategy]

• [Insert strategy]

2. Overall Evaluation Approach and Context: Describe the general approach that you will undertake to evaluate these strategies. Provide information on relevant contextual factors for your program, such as how the program is situated in your state and how it connects to other programs or initiatives.

3. Evaluation Stakeholders and Primary Intended Users of the Evaluation: Describe individuals or groups who have a stake in the evaluation and who will use the evaluation results. Include a brief description of how you have (or plan to) engaged these evaluation stakeholders.

4. Communication/Dissemination: Describe your broad plans for communicating/sharing your findings and provide examples of products that you will develop. Describe how your evaluation results or findings will be published on a publicly available website.

5. Use of Evaluation Findings: Describe how your evaluation findings will be used to ensure continuous quality and programmatic improvement.

6. Health Impact: Describe here what you want to be able to say about the contribution of your program to changes in health, behavior, or environment in a defined community, population, organization, or system by the end of the cooperative agreement. Consider what types of evaluation you will need to conduct in years 4, 3, 2, 1 if you want to be able to report health impact at the end of the cooperative agreement in year 5.

B. Evaluation Design and Data Collection Matrix

1. Strategy-Specific Evaluation Approach and Context:
2. Strategy:
3. Activity(s):
4. Evaluation Questions	5. Indicator(s)	6. Data Source	7. Data Collection Method	8. Data Collection Time Frame		9. Data Analysis	10. Person(s) Responsible
				Start	End
What you want to know.	A specific, observable, and measurable characteristic or change that shows progress toward achieving a specified objective or outcome.	Where you will collect the data (i.e. program records, surveys, etc.). List a source for each indicator.	How you will collect the data (i.e. abstraction from spreadsheet, database, etc.).	When will you start data collection?	When you will end data collection.	What type of analysis will you apply to the data (i.e. descriptive statistics, thematic analysis)?	Who is responsible for collecting the data for this indicator?

Performance Measure Plan Narrative

1. Ensure Data Quality: Describe your plans for assessing the validity, accuracy, and consistency of your performance measure data.

2. Use of Performance Measure Data: Describe how your performance measure data will be used to demonstrate progress towards achieving the NOFO goals and to ensure continuous quality and programmatic improvement.

3. Communication/Dissemination: Describe your plans for communicating/sharing your performance measure data and provide examples of products that you will develop.

4. Performance Measure Narrative: Describe the performance measure(s).

5. Performance Measure

6. Baseline

7. Year [X] Target

8. Year [X] Target

9. Year [X] Target

10. Data Source

11. Frequency of Data Collection

12. Measure Note

Enter the relevant performance measure based on program guidance.

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Where you will collect the data (i.e., program records, surveys, etc.).

How often you are collecting data for this performance measure.

Describe any notes about data measurement.

C. Performance Measurement Plan

Item	Data Elements	Instructions
1	Federal Agency, Center, and Division to Which Report is Submitted	Enter the name of the awarding Federal agency, Center, and Division identified in the award document or otherwise instructed by the agency.
2	Federal NOFO or Other Identifying Number Assigned by Federal Agency:	Enter the grant/award number contained in the award document.
3a	DUNS Number	Enter the recipient organization's Data Universal Numbering System (DUNS) number or Central Contract Registry extended DUNS number.
3b	EIN	Enter the recipient organization's Employer Identification Number (EIN) provided by the Internal Revenue Service.
4	Reporting Period	Enter the reporting period as indicated by the award document and guidance documentation.
A. Evaluation Plan Overview
A.1	Strategies to Evaluate	Select strategies from your work plan that you would like to evaluate during the funding period. Include as many strategies as prescribed by the funding agency or funding award. (Awarding Federal agencies may provide guidance on strategies for evaluation. For example, an agency may prescribe specific strategies that need to be evaluated or may permit awarded agencies to select or design strategies).
A.2	Overall Evaluation Approach and Context	Describe the general approach that you will undertake to evaluate these strategies. Provide information on relevant contextual factors for your program, such as how the program is situated in your state and how it connects to other programs or initiatives. Consider that this document may be viewed separately from your work plan; therefore, provide enough detail for CDC to understand the program and evaluation context. There will be an opportunity to fill out strategy specific evaluation approach and context in another section.
A.3	Evaluation Stakeholders and Primary Intended Users of the Evaluation	Describe individuals or groups who have a stake in the evaluation and who will use the evaluation results. Include a brief description of how you have (or plan to) engaged these evaluation stakeholders.
A.4	Communication/Dissemination	Describe your broad plans for communicating/sharing your findings and provide examples of products that you will develop. Describe how your evaluation reports or findings will be published on a publicly available website.
A.5	Use of Evaluation Findings	Describe how your evaluation findings will be used to ensure continuous quality and programmatic improvement.
A.6	Health Impact	Describe here what you want to be able to say about the contribution of your program to changes in health, behavior, or environment in a defined community, population, organization, or system by the end of the cooperative agreement. Consider what types of evaluation you will need to conduct in years 4, 3, 2, 1 if you want to be able to report health impact at the end of the cooperative agreement in year 5.
B. Evaluation Design and Data Collection Matrix
B.1	Strategy-Specific Evaluation Approach and Context	Describe the evaluation approach that you will undertake to evaluate this strategy. Provide information on relevant contextual factors for your program, such as how the program is situated in your state and how it connects to other programs or initiatives. Consider that this document may be viewed separately from your work plan; therefore, provide enough detail for CDC to understand the program and evaluation context.
B.2	Strategy	Enter the specific strategy that will be evaluated. Guidance will be provided by the agency or funding award on which strategy to include in this section.
B.3	Activity	Enter the related activity being evaluated if applicable. Guidance will be provided by the agency or funding award if an activity is included here.
B.4	Evaluation Questions	Enter the evaluation question that will be answered. This evaluation question is something that you want to know or find out through the evaluation.
B.5	Indicators	A specific, observable, and measurable characteristic or change that shows progress toward achieving a specified objective or outcome.
B.6	Data Source	Enter where you will collect the data (i.e. program records, surveys, etc.). List a source for each indicator.
B.7	Data Collection Method	Enter how you will collect the data (i.e. abstraction from spreadsheet, database, etc.).
B.8	Data Collection Time Frame	Enter the data collection time frame. Include a start and end date.
B.9	Data Analysis	Enter the type of analysis that will be applied to the data (i.e. descriptive statistics, thematic analysis).
B.10	Person(s) Responsible	Enter the person responsible for collecting data on this indicator.
C. Performance Measurement Plan
C.1	Ensure Data Quality	Describe your plans for assessing the validity, accuracy, and consistency of your performance measure data.
C.2	Use of Performance Measure Data	Describe how your performance measure data will be used to demonstrate progress towards achieving the NOFO goals and to ensure continuous quality and programmatic improvement.
C.3	Communication/Dissemination	Describe your plans for communicating/sharing your performance measure data and provide examples of products that you will develop.
C.4	Performance Measure Narrative	Describe the performance measure.
C.5	Performance Measure	Enter the relevant performance measure based on program guidance.
C.6	Baseline	Enter the baseline data (number, denominator, and percent) for the performance measure based on program guidance.
C.7	Year [X] Target	Enter the target year and target data (number, denominator, and percent) for the performance measure based on program guidance.
C.8	Year [X] Target	Enter the target year and target data (number, denominator, and percent) for the performance measure based on program guidance.
C.9	Year [X] Target	Enter the target year and target data (number, denominator, and percent) for the performance measure based on program guidance.
C.10	Data Source	Enter where you will collect the data (i.e., program records, surveys, etc.) from.
C.11	Frequency of Data Collection	Enter how often you are collecting data for this performance measure.
C.12	Measure Note	Describe any notes about data measurement.

– The agency may provide guidance on format and purpose of each field, and whether it is required. For example, an agency may prescribe specific strategies or activities to be evaluated, may prescribe how to map activities to specific strategies or program/priority areas, may prescribe evaluation questions, may prescribe performance measures, or may leave the determination to the recipient.

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