0920-23AA Att. 3a APR Tool

COMMUNITY ACTION PLAN APR FORM DRAFT

Attachment 3a. Annual Performance Report (APR) Tool
Form Approve
OMB No: xxxx-xxxx
Exp. Date: xx-xx-xxxx
Public Reporting burden of this collection of information is estimated at 10 hours, 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 NW, MS D-74, Atlanta, GA 30333; Attn: PRA (xxxx-xxxx).

Grantee:
Reporting Period:
Contact Person:
FORM 1: WORK PLAN
Instructions for Recipients:
The Work Plan form collects information about your DELTA AHEAD Program’s progress on work plan goals,
objectives, and milestones during the reporting period (September 1st – August 31st). The required goals and
objectives are prefilled for all recipients.
DELTA AHEAD REQUIRED GOALS AND OBJECTIVES

CATEGORY A WORKPLANS
GOAL

Goal 1: State-level planning,
implementation, and
evaluation

OBJECTIVE(S)

Objective 1: Develop, or enhance an existing, State Leadership Team (SLT)
Objective 2: Develop, or enhance an existing, State Action Plan (SAP) to
address Social Determinants of Health (SDoH) and to implement, evaluate, and
sustain primary prevention of IPV
Objective 3: Identify at least one Policy Effort that will be implemented at the
state level (by the SDVC) and the community level (in collaboration with the
CCR) and incorporate into the SAP
Objective 4: Participate in state and national activities to share knowledge,
skills, and practice of IPV primary prevention
Objective 5: Participate in the national evaluation for DELTA AHEAD
Objective 1: Partner with a Coordinated Community Response (CCR) Team to
finalize PPEs

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Goal 2: Community-level
planning, implementation,
and evaluation

Objective 2: Identify the SDoH that influence IPV risk and protective factors
and specify how they will be addressed through PPEs
Objective 3: Develop a Community Action Plan (CAP) that includes a logic
model, Implementation Plan, and Evaluation Plan
Objective 4: Implement and evaluate state- and community-level PPEs
according to SAP and CAP

CATEGORY B WORKPLANS
GOAL

Goal 1: State-level planning,
implementation, and
evaluation

Goal 2: Community-level
planning, implementation,
and evaluation
Goal 3: Program
Implementation & Evaluation

OBJECTIVE(S)

Objective 1: Develop, or enhance an existing, State Leadership Team (SLT)
Objective 2: Conduct an Environmental Scan to assess the current state of IPV
primary prevention in the state
Objective 2: Develop, or enhance an existing, State Action Plan (SAP) to
address Social Determinants of Health (SDoH) and to implement, evaluate, and
sustain primary prevention of IPV
Objective 3: Identify at least one Policy Effort that will be implemented at the
state level (by the SDVC) and the community level (in collaboration with the
CCR) and incorporate into the SAP
Objective 5: Participate in state and national activities to share knowledge,
skills, and practice of Intimate Partner Violence (IPV) primary prevention
Objective 1: Partner with a Coordinated Community Response (CCR) Team
Objective 2: Work with CCR to develop a Community Action Plan (CAP) that
includes a logic model, Implementation Plan, and Evaluation Plan
Objective 1: Implement and evaluate selected PPEs in collaboration with
community partners
Objective 2: Participate in the national evaluation of DELTA AHEAD

ECTION A: STATE ACTION PLAN PROGRESS
SECTION: OBJECTIVE #.#

There is a section of this form for each NOFO objective. Report on the objectives and add milestones for each.
For each objective, you will need to select the Objective Status and provide Comments on Objective if the status
is delayed or discontinued. Provide Milestones and Key Activities to achieve the milestone. You will also need to
select the Milestone Status and Program Year Completed for each milestone for the objective.
OBJECTIVE AND MILESTONE PROGRESS STATUS

The status options are for describing progress made during the reporting period. Report the status for all existing
and new items. The table below describes each status option.
PROGRESS STATUS

DESCRIPTION

IN PROGRESS (ON TRACK)

Work was in progress and on track as planned

DELAYED

Work had some delays (please add comments)
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COMPLETE

All Work has been completed

DISCONTINUED

Work has been stopped and discontinued (please add
comments)

OBJECTIVE PANEL

Select an Objective Status as described above to indicate your program’s progress during this reporting period.
Make comments for delayed or discontinued work.
Objective #.# Status: [Choose one from dropdown]
• In Progress (on track)
• Delayed: Please add comments
• Completed
• Discontinued: Please add comments
Please provide comments on delayed or discontinued work [3000]
MILESTONE TABLE

At least one milestone is required for each objective. Provide milestones and activities that make sense for your
program. The milestone status provided should fall within the status of the corresponding objective. For example,
a Milestone Status of “In Progress (on track)” would not be selected when the Objective Status is “Completed.”
Provide the Program Year the Milestone was completed. Options are Not Yet Complete and Year 1 (with
corresponding reporting year being added as an option each year).
Question
#.# Description [100]
#.# Key Activities [700]
#.# Milestone Status [Choose one from dropdown]

Please provide reasons for delayed or discontinued
work [3000]
#.# Reporting Year Milestone was Completed
[Choose one from dropdown]

Question Instructions/Options
Provide a concise statement of the milestone.
Provide a brief description of activities conducted to
complete the milestone
• In Progress (on track)
• Delayed: Please add comments
• Completed
• Discontinued: Please add comments
*only if Milestone Status = Delayed or Discontinued

•
•
•

Not Yet Complete
Year 1
*additional year added each APR

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FORM 2: CONTINUATION APPLICATION
Instructions for Recipients
The Continuation Application Narrative Form is a summary of each aspect of your program for the next budget
period (March 2nd – March 1st). This form is not prefilled. The separate Work Plan form provides space for you to
describe specific details for the program objectives, milestones, and activities. This form has five sections.
Section 1: Summary of Work Plan Activities for Next Budget Year: Describe the activities planned for the next budget
period. Please include references and reasons for any key changes to the work plan for the next budget period. [6000]
Section 2: Implementation of New or Revised Program or Policy Efforts: Describe the planned implementation of
program or policy efforts in the next budget period. Explain any requests to change the current program or policy efforts
being implemented. [6000]. The CDC Project Officer must approve any changes to the program or policy efforts
approved upon award.
Section 3: Budget Implications: Provide any comments about budgetary issues that might impede the success or
completion of the project as originally proposed and approved for the next budget period. Describe any implications the
changes to the work plan may have on the budget. [6000]
Section 4: Needed Resources: What additional tools or resources do you need in order to accomplish the proposed
planned activities for the next budget period? How do you plan to obtain these resources?
Section 5: Technical Assistance Needs: What types of training and technical assistance (TTA) would benefit your
program in the next budget period? Include all TTA needed for the next budget period even if you have already
submitted a VPTAC request for the TTA. Please describe the areas or topics for TTA (e.g., program, evaluation). This
information will help us to understand what types of TTA are needed across DELTA AHEAD and will be used to plan
program-wide TTA for the upcoming budget year. Your Program Officer will also go over any requests you enter here to
determine any next steps (e.g., VPTAC request, program wide TTA). If TTA is not needed, please explain.
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Would your program like additional training or technical assistance in any specific area?
• No (Please explain)
• Yes (Include existing requests already entered in VPTAC. Complete table below)
Training and Technical Assistance Table
If your program would like additional training or technical assistance, you would enter your requests in the table provided.
Create a new row for each distinct TTA request, providing the Topic and Timeframe for each request. You will also need to
describe the TTA requested. Please note that this is not a replacement for a TTA request with the VPTAC.
When reporting TTA needed, make sure that:
•
•

Each entry is a distinct TTA request based on the drop-down for the topic.
The “Other” answer option for topic is selected only if the TTA request does not fall within the existing answer
options.
Topic: [Chose one from dropdown]
•
•
•
•
•
•
•
•
•

Description of TTA Request [1000]

Planning
Partnerships
Communication
Policy
Specific Strategy or Approach
Implementation and/or Adaptation
Evaluation and Data
Health Equity
Other (not listed): Please specify
topic

Timeframe [Chose one from
dropdown]
•
•
•
•
•

Submitted to VPTAC
Immediate
Within the next 6 months
Within the next year
No specific timeframe/Unknown

Section 6: 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? [6000]

Form 3 Section 4: Technical Assistance
1. During this reporting period, how often have you used CDC or VPTAC resources when selecting, planning,
implementing, or evaluating your program or strategies? (For example, technical packages, VETO Violence,
technical assistance resources) (Select one)
• Frequently
• Sometimes
• Rarely
• Never
2 Which CDC or VPTAC resources have you found most useful during this reporting period (optional)? [1000]
3 During this reporting period, how often have you shared these CDC or VPTAC resources with subrecipients or
partners?

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•
•
•
•

Frequently
Sometimes
Rarely
Never

•

Form 3 Section 5: Capacity Building and Training 1. To what extent has your organizational capacity
to select, plan, implement, and evaluate strategies increased over the reporting period? Not at all
To a small extent
To a moderate extent
To a great extent

•
•
•

2. To what extent has the capacity of your subrecipients or partners to select, plan, implement, and evaluate
strategies increased over the reporting period?
•
•
•
•

Not at all
To a small extent
To a moderate extent
To a great extent

3. Provide any additional information about changes in capacity?(Optional) [2000]

Capacity Building and Training Table
Please list all capacity building, training, and educational activities related to community and societal level
primary prevention that you provided within the state during this reporting period. [Optional]
Type of Activity
200 characters

Topic
200 characters

Audience
200 characters

Dates

Networking and Dissemination Table
Please list any networking and dissemination activities that you participated in related to community and
societal level primary prevention OUTSIDE the state during this reporting period. [Optional]
Type of Activity
200 characters

Topic
200 characters

SDVC Role in Activity
200 characters

Dates

FORM 3: BARRIERS, FACILITATORS, AND SUCCESSES
Instructions for Recipients
The Barriers, Facilitators and Success form collects information about challenges, facilitators, and successes that
experienced. This form has three sections: 1) Barriers Encountered, 2) Facilitators Encountered, and 3) Successes.
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 Add all barriers and facilitators encountered during the reporting period.
 Report on at least one success or accomplishment during the reporting period. (Or explain why no
successes are being reported)
 Do not leave any section blank. If no barriers or facilitators were encountered for the reporting period,
please select No barriers/facilitators encountered and then Save, Validate, and Check in.
SECTION 1: BARRIERS ENCOUNTERED

This section collects information about the barriers and challenges that your (Initiative) Program encountered
during the reporting period. This section is not prefilled. A Barrier is an identified person, resource, relationship,
or circumstance that hinders progress on a specific outcome or goal.
Barrier Status
Did you experience challenges or barriers during this reporting period?
• No, we did not experience any challenges or barriers (Save, Validate, and Check in)
• Yes, we experienced challenges or barriers (Record barriers in the table below).
Challenges and Barriers Table
If barriers were encountered you will enter them in the table provided, creating a new row for each distinct
barrier. For each barrier entered you will need to provide the Barrier Type and Program Component(s) that it
affected. You will also need to describe the barrier and how it impacts your program’s work, detail the actions
planned/taken to address the barrier, and describe the resources that were used or needed to overcome the
barrier.
When reporting barriers, make sure that:
• Each entry is a distinct barrier or challenge encountered during the reporting period based on the dropdown for the barrier type.
• The “Other” answer option for barrier type is selected only if the barrier does not fall within the existing
answer options.

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Barrier Type: [Choose
one from dropdown]

•

•
•
•
•
•
•

Describe the
barrier and how it
impacts your
program’s work:
[2000]

Lack of buy-in from
partners or
stakeholders
Insufficient funding
or resources
Inability to
access/collect data
Implementation
issues
Staffing issues
Inadequate training
Other (not listed):
Please specify

Program Component:
[Select all that apply]

•
•
•
•
•
•
•
•
•

•

•

•

What
actions were
taken or
would be
helpful to
address the
barrier?
[2000]

What
resources are
used or
would be
helpful to
address the
barrier?
[2000]

Barrier
Comments:
[500]

Work Plan
State Action
Plan/Strategic Plan
Sustainability
State Evaluation
Community Action
Plan
Community
Evaluation
State PPE 1
Implementation
State PPE 2
Implementation
Community-level
PPE 1
Implementation
Community-level
PPE 2
Implementation
Community-level
PPE 3
Implementation
Community-level
PPE 4
Implementation

SECTION 2: FACILITATORS ENCOUNTERED

This section collects information about the facilitators that enabled, accelerated, or expedited implementation
during the reporting period. This section is not prefilled. A Facilitator is an identified person, resource,
relationship, or circumstance that helps to reach a specific outcome or goal.

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Facilitator Status
Did you experience facilitators during this reporting period?
• No facilitators experienced (Save, Validate, and Check in).
• Yes, we experienced facilitators (Record facilitators in the table below).
Facilitators Table
If facilitators were experienced you will enter them in the table provided, creating a new row for each distinct
facilitator. For each facilitator entered you will need to provide the Facilitator Type and Program Component(s)
that it affected. You will also need to describe the facilitator and how it impacts your program’s work as well as
the resources that were related to this facilitator.
When reporting facilitators, make sure that:
• Each entry is a distinct facilitator encountered during the reporting period based on the drop-down for
the barrier type.
• The “Other” answer option is selected only if the facilitator does not fall within the existing answer
options.
Facilitator Type: [Choose one from
dropdown]

•
•
•
•
•
•
•
•

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): Please
Specify

Describe the
facilitator and
how it
impacts your
program’s
work: [2000]

Program Component:
[Select all that apply]

•
•
•
•
•
•
•
•
•
•

What
resources
were used
[2000]

Facilitator
Comments:
[500]

Work Plan
State Action
Plan/Strategic Plan
State Evaluation
Community Action Plan
Implementation
Community Evaluation
State PPE 1
Implementation
State PPE 2
Implementation
Community-level PPE 1
Implementation
Community-level PPE 2
Implementation
Community- level PPE 3
Implementation

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•
•

Community-level PPE 4
Implementation
Sustainability

SECTION 3: SUCCESSES

This section collects information about the successes and accomplishments of your (Initiative) program during
the reporting period through an open-end question. This section is not prefilled. You can add more than one
success or accomplishment.
Successes Status
Would you like to share any successes or accomplishments?
•
•

No (Please explain)
Yes (Record accomplishments in table below)

Successes Table
If you want to share your programs successes and accomplishments, you will enter them in the table provided,
creating a new row for each distinct success. For each success entered you will need to provide the program
components involved in the success and describe the success/accomplishment as well as the factors that made it
possible.
When reporting successes and accomplishments, make sure to:
• Make each response a specific story about a success or accomplishment, adding a new row for each
separate accomplishment.
• Report all distinct program successes or accomplishments your program had during the reporting period.
• Consider using the format for policy impact statements to report your successes. Please see the Policy
Impact Statement Appendix for supplemental information on how to write policy impact statements that
will be most impactful for policy makers.
To add a success/accomplishment, click on “+ Add” to open the modal (pop-out window) shown below. You can
add a row to the table by completing the modal and selecting “Save” when you are done.
Program Component: [Select all that apply]
What key accomplishments related to this NOFO has
your organization/state/territory achieved during
this reporting period? [6000]

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•
•
•
•
•
•
•
•

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): Please Specify

FORM 4-1: STRATEGIC PLAN
Instructions for Recipients
The State Action/Strategic Plan form collects information about progress on the State Action/Strategic Plan (e.g.,
enhancing partnerships, state violence prevention planning and coordination) during the reporting period
(September 1st – August 31st). This form has four sections:
A. Progress on State Action/Strategic Plan
B. Progress on Priorities
C. Partnerships
D. Activities
SECTION 1: PROGRESS ON STATE ACTION/STRATEGIC PLAN

This section collects information on changes made to the components in the State Action Plan. This section is not
prefilled.
CHANGES TO THE STATE ACTION/STRATEGIC PLAN

Were there any changes to the State Action/Strategic plan during this reporting period?
No (Save, Validate, and Check in)
Yes (Complete table below)

•
•

CHANGES TO THE STATE ACTION/STRATEGIC PLAN TABLE

Report on any changes to specific section(s) of the State action/Strategic plan changed during the reporting
period. Choose each component of the State action/Strategic Plan that was changed, describe the change, the
reason for the change, and how the change affects your program’s work.
Type of Change: [Choose one
from dropdown]
•

Description of Change (1000
characters)

Describe the reason for the
change and how it impacts your
overall work: [1000]

Approach or Strategy
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•
•
•
•
•
•
•
•

Stakeholder/Partner
State/Local collaboration
Resources/Funding
Training/Technical
Assistance
Sustainability
Health Equity
Data Use/Sources
Other (not listed): Specify

SECTION 2: PROGRESS ON PRIORITIES
Please describe the goals/priorities outlined in your state action plan. You can list up to 10 priorities. Add
additional sections as necessary.

Priority Area Name #1

(150 characters)
Insert Text

Description of Priority Area
(1750 characters)
Insert Text

Key Partners
(350 characters)
Insert Text

Key Accomplishments this Reporting Period
(1050 characters)
Insert Text

Resources Needed
(700 characters)
Insert Text

Key Activities Planned for Upcoming Year
(500 characters)
1. Insert text
2. Insert text
3. Insert text
4. Insert text

Policies

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Provide an update on state-level activities to support an increase in policies that promote health equity through
the improvement of social determinants of health related to IPV.
2000 characters
SECTION 3: PARTNERSHIP

This section collects information about all partner organizations the DELTA AHEAD program engaged with.
Information previously entered will be prefilled in this table. Report on all existing and new partners that your
program engaged with during this reporting period. Unless you need to add new partners, you will only need to
update three areas for existing partners: the status of the partnership, whether you provided any CDC funding to
the organization during the reporting period, and how your organization engaged this partner during the
reporting period.
PARTNERSHIPS & RESOURCES TABLES

Report on the partner status during this reporting period. If there are changes in how the partner is engaged in
the state IPV prevention work, please make updates. Each row is a distinct partner.
When entering any new partners that have not previously been entered, make sure that:
•
•
•
•

The organization name is spelled out. Do not use acronyms.
All current partner organizations, especially those listed in your State Action/Strategic Plan, are included.
Only choose “other” for organization Type or Sector if your answer does not fall within the existing
answer options.
Include state-level and community-level partners.

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Name of
Partner
Organization

Primary Sector

•
•
•

•
•
•
•
•
•
•
•

•

•
•

Business/Labor
Education (schools)
Justice (e.g., law
enforcement,
prisons, public
safety)
Research
Evaluation/Academic
Health Care/Services
Housing
Media
Public Health
Social Services
Victim Service
Government
(Federal, State,
County, Local)
Social Justice/
Community
Organizations (e.g.,
grassroots)
Faith-based
Other (not listed)

Role of Partner

•
•
•
•
•
•
•
•
•
•

Evaluation
Plan or implement efforts
Assist with data
collection/monitoring
Engage/convene partners
Capacity building
Provide resources other than
funding
Provide funding
Communications/promotions
Involved in strategic planning
Other (not listed)

Describe
how your
[Initiative]
program
engaged
this partner
in your
violence
prevention
work during
the
reporting
period.
[1000]

Partner Status during
this reporting period
[Choose one from
dropdown]

•

•
•
•
•

State or
Communitylevel Partner

New, acquired
during this reporting
period
Existing
partner/stakeholder
Re-engaged
partner/stakeholder
Increased
engagement
No longer a
partner/stakeholder

•
•
•

SECTION 4: ACTIVITIES

STATE ACTION PLAN ACTIVITIES TABLE

Type of Activity [Choose one from
dropdown]

Description of activity and
how it was leveraged for
violence prevention.
[1000]

Activity Status:
[Select one from
dropdown]

Project Year Completed:
[Select one from
dropdown]

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State
Community
Both

S
A
le

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COMMUNITY ACTION PLAN APR FORM DRAFT

Funding Acquisition
Training/Capacity Building
Partner engagement/convening
Implementation planning
Surveillance
Data to Action
Mass Media
Coalition
Sustainability planning
Other (not listed)

•
•
•
•
•
•
•
•
•
•

•
•
•
•

In Progress (on
track)
Delayed
Completed
Discontinued

•
•
•

Not Yet Complete
Year X
Additional years
added as appropriate

Social Determinants of Health [2800]: Provide a description of progress made to address the social
determinants of health that impact violence that are prioritized for your state and community-level activities.

FORM 4-2: COMMUNITY ACTION PLAN
The Community Action Plan form collects information about progress on the Community Action Plan (e.g.,
community-level engagement, activities, and partnerships) during the reporting period (September 1st – August
31st). This form has two sections:
A. Changes to the Community Action Plan
B. Progress and Planning
C. Activities

SECTION A: CHANGES TO THE COMMUNITY ACTION PLAN

This section collects information on changes made to the components in the Community Action Plan. This section
is not prefilled.
CHANGES TO THE COMMUNITY ACTION PLAN

Were there any changes to the Community Action Plan during this reporting period?
•
•

No (Save, Validate, and Check in)
Yes (Complete table below)

Community Action Plan Change
(Select one)

Description of Change (1000
characters)

Describe the reason for the change
and how it has/will impact your
overall work: [1000]

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COMMUNITY ACTION PLAN APR FORM DRAFT

•
•
•
•
•
•
•
•
•

Approach or Strategy
Stakeholder/Partner
State/Local collaboration
Resources/Funding
Training/Technical Assistance
Sustainability
Health Equity
Data Use/Sources
Other (not listed): Specify

SECTION B: PROGRESS AND PLANNING

Please describe the goals/priorities outlined in your community action plan. You can list up to 10 priorities. Add
additional sections as necessary.

Priority Area Name #1

(150 characters)
Insert Text

Description of Priority Area
(1750 characters)
Insert Text

Key Partners
(350 characters)
Insert Text

Key Accomplishments this Report Period
(1050 characters)
Insert Text

Resources Needed
(700 characters)
Insert Text

Key Activities Planned for Upcoming Year
(500 characters)
1. Insert text
2. Insert text
3. Insert text
4. Insert text

Policies
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Provide an update on community-level activities to support an increase in policies that promote health equity
through the improvement of social determinants of health related to IPV.
2000 characters

SECTION C: ACTIVITIES

COMMUNITY ACTION PLAN ACTIVITIES TABLE

Type of Activity [Choose one from
dropdown]

•
•
•
•
•
•
•
•
•
•

Funding Acquisition
Training/Capacity Building
Partner engagement/convening
Implementation planning
Surveillance
Data to Action
Mass Media
Coalition
Sustainability planning
Other (not listed)

Description of activity and
how it was leveraged for
violence prevention.
[1000]

Activity Status:
[Select one from
dropdown]
•
•
•
•

In Progress (on
track)
Delayed
Completed
Discontinued

Project Year Completed:
[Select one from
dropdown]
•
•
•

Not Yet Complete
Year X
Additional years
added as appropriate

Please click the checkbox at the bottom of this section to confirm that you have added any new activities from
the reporting period and have also updated any information that has changed for previously entered activities.
Have you added any new activities from this reporting period and updated the activity status for existing
activities in the table above? [Tick checkbox to confirm]

FORM 5-1: STATE-LEVEL PROGRAM OR POLICY EFFORT IMPLEMENTATION FORM
Instructions for Recipients
The Implementation Form collects information about each state-level program, policy, or practice that your
organization implemented using DELTA AHEAD funding during the reporting period (September 1st – August 31st).
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One Implementation form submission should be submitted for each program, policy, or practice. This form has
five sections: 1) Description of Program, Policy, or Practice, 2) Changes to Implementation Plan, 3)
Implementation Progress and Activities, 4) Adaptations, and 5) Population of Focus & Reach.
CDC’s Technical Packages provide strategies, approaches, and example programs, policies, and practices based
on the best available evidence. (Initiative specific Implementation requirements).

Strategy

•A strategy is one of the
focus areas from CDC's
Technial Packages that the
cooperative agreement
focuses on.

Program, Policy, or
Practice

Approach

•An approach is a specific
way to advance the
strategy.
•Examples include street
outreach and communitynorm change, public
engagement and education
campaigns, family-friendly
work policies, and modifying
the physical and social
environment.

•A program, policy, or
practice is a specific group
of activities that work
together to achieve the
intended outcome of the
approach.

As you answer questions about the implementation efforts, please reference the table below:

Program, Policy, and Practice Definitions and Examples
Program

Uses set educational/training
(manualized curriculum)
materials with a planned
audience.

Educational sessions,
Staff/Provider trainings.

Policy

Includes any work done to
create, develop, or put a policy
into practice. Does not include
work done to implement a
recently enacted policy or policy
scans. (Note: Advocacy is not
allowed under NOFO funded
projects.)

Policy recommendations, Policy
training, Policy development.

Practice

Made up of activities or
meetings that do not follow a
set curriculum.

Social media campaign,
environmental scans, Coalition
meetings, Youth group
meetings, Mentoring,
Curriculum development, Hot

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COMMUNITY ACTION PLAN APR FORM DRAFT

Spot Mapping, Community
outreach.
When creating new Implementation submissions, make sure:
• Each program, policy, or practice is reported separately—one implementation submission form for each
program, policy, or practice.
• Any training associated with TA, capacity building, or strategic planning should be reported in other
forms instead of the Implementation Form.
• Report each component of a multicomponent effort in a separate implementation form submission. This
applies if the implementation effort is made up of a combination of program, policy, and/or practice or if
the components are using different strategies and approaches. When providing a name for a component
of a multicomponent strategy, be sure to use the same main name and include “multicomponent:” in the
name. For example: Inspire (Multicomponent)- Workplace Policy; Inspire (Multicomponent)- Hotspot
Mapping.
• The name of your implementation form submission should be the name of the program, policy, or
practice being implemented.
SECTION 1: DESCRIPTION OF IMPLEMENTATION EFFORT

This section collects information about the program, policy, or practice. In this section you will need to provide
the type of implementation (program, policy, or practice), the name of the program, policy, or practice, and the
associated approaches from CDC’s Technical Packages.
Program, Policy, or practice
To enter new program, policy, or practice please first identify the implementation effort as a program, policy, or
practice. Reference the table above or discuss with your PO if you are unsure which category your effort falls into.
Are you implementing a Program, Policy, or Practice? [Choose one from dropdown]
• Program
• Policy
• Practice
• Unknown/Unsure
Implementation effort name and description
For this question you will select from a list of programs, policies, and practices from CDC’s Technical Packages.
Make sure your answer does not fall within a listed answer option before choosing “other.”
Program, Policy, or Practice Name: [Choose one from dropdown]
•
•

List of Example Programs, Policies, and Practices from CDC Technical Package(s) most closely
associated with NOFO
Other (not listed): Specify

Please provide a short description of how your organization is implementing this program, policy, or practice:
[500] In a few sentences describe the program, policy, or practice in way that someone who is not familiar with
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COMMUNITY ACTION PLAN APR FORM DRAFT

the effort would understand. This should include what it intends to do, how it’s implemented, where it will occur,
and evidence of effectiveness. Specific activities implemented as part of this program, policy, or practice will be
collected in Section 3.
Approach
The last question in this section is asking for the 1-2 approaches from Violence Prevention in Practice that best
align with the implementation effort.
•

•

•

If you selected a program, policy, or practice name included in the dropdown in the previous section you
may select “N/A – We selected from CDC’s Technical Packages” for this question. All of the named
programs, policies, and practices above are aligned with specific strategies and approaches from CDC’s
Technical packages, and we will fill this in for you later to ensure the correct approach is assigned.
If you selected “Other” as your Program, Policy, or Practice name, please select one or two approaches
that align with your implementation effort. Refer to the Approach Search Tool on Veto Violence to select
the appropriate approaches.
If you are unsure which approach to choose, discuss this with your Project Officer or select
“Unknown/Unsure”.

Please select the Approach for this implementation effort: [Select one or two that apply]
•
•
•

N/A – We selected from CDC’s Technical Packages
List of Approaches from Violence Prevention in Practice most closely associated with NOFO
Unknown/Unsure

SEM Level
Which SEM Level(s) does this Implementation Effort target? [Select all that apply]
•
•

•

•

Individual - Prevention strategies at this level promote attitudes, beliefs, and behaviors that prevent
violence. Examples include conflict resolution and life skills training.
Relationship - Prevention strategies here focus on communication, parenting practices, and other bonds
and connections. Examples include parenting and family-focused prevention programs, mentoring, and
peer programs.
Community - Prevention strategies at this level impact the social, economic, and environmental
characteristics of settings. Examples include reducing social isolation; enhancing economic and housing
opportunities; and improving the processes, policies, and settings in schools and workplaces.
Societal - Prevention strategies at this level impact broad societal factors that help create a level of
acceptance or intolerance for violence. Examples include strategies to change social norms that support
violence as an acceptable way to resolve conflicts, state and federal policies that offer economic and
other supports to families, and policies that support early childhood education to help pave the way for
children to achieve lifelong opportunity and well-being.

SECTION 2: CHANGES TO IMPLEMENTATION PLAN

This section collects information on changes that have been made to the Implementation plan during the
reporting period.

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COMMUNITY ACTION PLAN APR FORM DRAFT

Implementation Plan Status
Were there any changes made to the implementation plan during this reporting period?
• No (Select Save, Validate, and Check in below)
• Yes (Complete table below)
Implementation plan Changes Table
Report on any changes made to the Implementation Plan, referring to your Program’s Implementation Plan
document as appropriate. If you answered No to the question above, you do not need to fill out this table.
When you report on any changes made during the reporting period, make sure to only select the “Other” answer
option for Type of Change if your answer does not fall within the existing answer options.
Type of Change: [Select one from dropdown]

•
•
•
•
•
•
•
•

Describe the Change [1000] Provide a concise
description of the change and the reason for
the change.

Recruitment and Retention
Delivery Method
Setting/Population of Focus
Timeline
Monitoring
Staffing/Implementers
Stakeholder/Partnership
Other: Please Specify

SECTION 3: IMPLEMENTATION PROGRESS AND ACTIVITIES

This section collects information about the progress made on the implementation of the prevention strategy.

Implementation Progress table
This table collects information on the progress made implementing the prevention strategy. Each reporting
period you will need to add new activities started during the reporting period and update the information for
activities from previous reporting periods if anything has changed. When entering new activity, make sure that
each entry is a discrete type of activity that best measures and demonstrates implementation progress. You will
need to enter the Activity Type, a description of the activity, Activity Status, and the Project Year the activity was
completed.

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COMMUNITY ACTION PLAN APR FORM DRAFT

Activity Type: [Select one from
dropdown]

•
•
•
•
•
•
•

Planning
Training/Coaching
Executing
Coordinating
Monitoring
Gathering or Using Data
Other (not listed): specify

Description of
activity: [2000]

Provide a description of
the activity and include
with sufficient detail
what the activity
entailed, who was
involved and if any
resources are needed.

Activity Status: [Select one
from dropdown]

•
•
•
•

In Progress (on track)
Delayed
Completed
Discontinued

Project Year
Completed: [Select one
from dropdown]

•
•

Not Yet Complete
Year X

Additional years added as
appropriate

Implementation Progress Checkbox
Please click the checkbox at the bottom of this section to confirm that you have added any new activities from
the reporting period and have also updated any information that has changed for previously entered activities.
Have you added any new activities from this reporting period and updated the activity status for existing
activities in the table above? [Tick checkbox to confirm]
SECTION 4: ADAPTATIONS

This section collects information about the adaptations made to the program, policy, or practice. For resources
on using essential elements to track adaptations, see https://vetoviolence.cdc.gov/apps/adaptation-guidance/.
Adaptation Table
This table collects information on any adaptations made to the essential elements of the prevention strategy.
Each reporting period you will need to add new adaptations started during the reporting period and update the
information for adaptations from previous reporting periods if anything has changed. If an adaptation is no
longer being implemented during this reporting period, please delete that row from the table.

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COMMUNITY ACTION PLAN APR FORM DRAFT

Type of Adaptation:
[Choose one from
dropdown]

•
•
•
•
•
•

•

•

Added content
Deleted content
Changed sequence
Modified delivery
or methods
Added or deleted
policy component
Modified an
environmental
design element
Changed the type
of recommended
implementer
Other (not listed):
specify

Adaptation
Description
[1000]

Describe in
adequate detail
what change was
made to the design
and
implementation of
the effort. What
essential what,
how, and who is
changed? How is it
changed?

Reason for Adaptation:
[Choose one from
dropdown]

•
•
•
•

•
•
•
•
•

To increase participation
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
To address shared risk and
protective factors
To address multiple forms
of violence
To address racial inequity
To address social
determinants of health
Other (not listed): specify

What
resources are
needed for
this
adaption?
(700
characters)

How was this
adaptation evaluated
and what was the
impact of the
adaptation? [2000]

Describe the impact this
adaptation has had on the
prevention effort including
the impact on the
implementers of the effort
and the population
targeted by the effort.

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COMMUNITY ACTION PLAN APR FORM DRAFT

Adaptation Checkbox
Please click the checkbox at the bottom of this section to confirm that you have added any new adaptations from
the reporting period, have updated any information that has changed for previously entered adaptations, and
have deleted any discontinued adaptations.
Have you added any new adaptations from the reporting period, updated any information that has changed
for previously entered adaptations, and deleted any discontinued adaptations in the table above? [Tick
checkbox to confirm]
SECTION 5: POPULATION OF FOCUS AND REACH

Population of Focus
Provide a narrative description of the population or setting of focus for this implementation effort. [2000]
Why was this population or setting selected and how is the implementation effort appropriate for the
selected population or setting? [ 2000] Provide reasons and data sources that were used for selecting the
population and setting of focus for this prevention effort. Also provide reasons and data sources that were used
to show that the selected program, policy, or practice will be effective for reaching these populations.
Population Groups
Is there a specific community or population you are focusing on? [Chose one from dropdown]
•
•

No Specific Community or Population (Skip to Reach tables below)
Specific Community or Population (Check all that apply below)

If your program is focusing on a specific population, please select all that are applicable from below. Only select
other if your answer does not fall within the existing options.
Racial/ethnic groups [Select all that apply]
•
•
•
•
•
•
•
•
•

Black/African American
Asian
Arabic/North African
Pacific Islander
American Indian/Alaskan Native Peoples
Hispanic/Latinx
White
Mixed race persons
Other: Please Specify

Non-citizen groups: [Select all that apply]
•
•
•
•
•

Immigrants
Migrant workers
Refugees
Asylum seekers
Undocumented status

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COMMUNITY ACTION PLAN APR FORM DRAFT

•

Other: Please Specify

Age groups: [Select all that apply]
•
•
•
•
•
•
•

Infants (0-2)
Young children (2-10)
Youth (11-17)
Young adults (18-24)
Adults (25+)
Older adults (65+)
Other: Please Specify

Groups with disabilities/health risks: [Select all that apply]
•
•
•
•
•
•

Intellectual/developmental disabilities
Mobility/ambulatory disabilities
People with disabilities (general)
Substance use
Mental illness
Other: Please Specify

Gender groups: [Select all that apply]
•
•
•
•
•

Men
Women
Non-binary
Transgender
Other: Please Specify

Sexual orientation groups: [Select all that apply]
•
•
•
•
•
•

Gay/lesbian
Straight (heterosexual)
Queer
Bisexual
Pansexual
Other: Please Specify

Economically disadvantaged groups: [Select all that apply]
•
•
•
•

Experiencing homelessness
Experiencing poverty
Receiving government aid
Other: Please Specify

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COMMUNITY ACTION PLAN APR FORM DRAFT

Geographical groups: [Select all that apply]
•
•
•
•
•
•

Tribal
Rural
Urban
Low-income neighborhoods
Suburban
Other: Please Specify

Other Groups: [Select all that apply]
•
•
•
•
•
•
•
•
•
•
•

Foster youth
Single parents
Incarcerated or formerly incarcerated
Veterans
Military (active)
Victims of crimes/violence
Perpetrators of crimes/violence
Gang members
Students
Non-English speaking
Other Population(s) not listed above and not belonging to any grouping above: Please specify

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COMMUNITY ACTION PLAN APR FORM DRAFT

Individual Reach table
This table collects information on the number of individuals reached during the reporting period. Enter a new row
for each specific population reached.
Description
of
Population
[1000]

Year 5
Target for
Individuals

Number of Individuals
Reached This Reporting
Period

Describe the
population that
you are
reaching.

Insert Numeric
Value

List the number of individuals
reached during the reporting
period across all settings (primary
and secondary) that began
implementation by the end of the
reporting period. This should
include number of individuals
reached and should not include
individuals that you anticipate
reaching in the future.
•Data are missing (program
unable to collect this reporting
period)
• Data are not applicable
(program does not collect)Value

Number of
Total
Individuals
Reached
Since Start of
NOFO
Insert Numeric
Value

Reach Type [Choose one
from dropdown]

Progress
Notes
(2000
characters)

Individuals reached can be
described in terms of Primary Reach
– that is individuals directly
impacted by the prevention
strategy (e.g., employees, parents,
youth serving providers, students);
and Secondary Reach – which is an
estimate of individuals with
potential exposure to the
prevention strategy, but not
necessarily directed at them (e.g.,
community members).
•Primary
•Secondary

Insert Text

Setting Reach table
This section collects information on the number of settings reached during the reporting period. Enter a new row
for each type of setting reached.
Type
Primary Setting

Setting [Select one]

•
•
•
•

Community
County
Territory
State
NGO
CBO
Business
Faith-based
Organization
Elementary
School
Middle School
High School
College/University
Bar

•

Other: Please

•
•
•
•
•
•
•
•
•

Description
(1000 characters)

Year 5 Target
for Settings

Insert Text

Insert Numeric
Value

Number of Settings
Reached this Reporting
Period
Insert Numeric Value

Progress Notes
(2000
characters)
Insert Text

List the number of settings
in which implementation
has begun as of the end of
the reporting period. This
should include actual
number of settings where
implementation has started
and should not include any
projected data.
•

•

Data are missing
(program unable to
collect this reporting
period)
Data are not applicable
(program does not
collect)

Specify

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COMMUNITY ACTION PLAN APR FORM DRAFT

Secondary
Setting (if
applicable)

Insert Numeric
Value

Insert Numeric Value

Insert Text

FORM 5-2: COMMUNITY-LEVEL PROGRAM OR POLICY EFFORT IMPLEMENTATION FORM
Instructions for Recipients
The Implementation Form collects information about each community-level program, policy, or practice that
your organization implemented using DELTA AHEAD funding during the reporting period (September 1st – August
31st). One Implementation form submission should be submitted for each program, policy, or practice. This form
has five sections: 1) Description of Program, Policy, or Practice, 2) Changes to Implementation Plan, 3)
Implementation Progress and Activities, 4) Adaptations, and 5) Population of Focus & Reach.
CDC’s Technical Packages provide strategies, approaches, and example programs, policies, and practices based
on the best available evidence. (Initiative specific Implementation requirements).

Strategy

•A strategy is one of the
focus areas from CDC's
Technial Packages that the
cooperative agreement
focuses on.

Approach

•An approach is a specific
way to advance the
strategy.
•Examples include street
outreach and communitynorm change, public
engagement and education
campaigns, family-friendly
work policies, and modifying
the physical and social
environment.

Program, Policy, or
Practice
•A program, policy, or
practice is a specific group
of activities that work
together to achieve the
intended outcome of the
approach.

As you answer questions about the implementation efforts, please reference the table below:

Program, Policy, and Practice Definitions and Examples
Program

Uses set educational/training
(manualized curriculum)
materials with a planned
audience.

Educational sessions,
Staff/Provider trainings.

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Policy

Includes any work done to
create, develop, or put a policy
into practice. Does not include
work done to implement a
recently enacted policy or policy
scans. (Note: Advocacy is not
allowed under NOFO funded
projects.)

Policy recommendations, Policy
training, Policy development.

Practice

Made up of activities or
meetings that do not follow a
set curriculum.

Social media campaign,
environmental scans, Coalition
meetings, Youth group
meetings, Mentoring,
Curriculum development, Hot
Spot Mapping, Community
outreach.

When creating new Implementation submissions, make sure:
• Each program, policy, or practice is reported separately—one implementation submission form for each
program, policy, or practice.
• Any training associated with TA, capacity building, or strategic planning should be reported in other
forms instead of the Implementation Form.
• Report each component of a multicomponent effort in a separate implementation form submission. This
applies if the implementation effort is made up of a combination of program, policy, and/or practice or if
the components are using different strategies and approaches. When providing a name for a component
of a multicomponent strategy, be sure to use the same main name and include “multicomponent:” in the
name. For example: Inspire (Multicomponent)- Workplace Policy; Inspire (Multicomponent)- Hotspot
Mapping.
• The name of your implementation form submission should be the name of the program, policy, or
practice being implemented.
SECTION 1: DESCRIPTION OF IMPLEMENTATION EFFORT

This section collects information about the program, policy, or practice. In this section you will need to provide
the type of implementation (program, policy, or practice), the name of the program, policy, or practice, and the
associated approaches from CDC’s Technical Packages.
Program, Policy, or practice
To enter new program, policy, or practice please first identify the implementation effort as a program, policy, or
practice. Reference the table above or discuss with your PO if you are unsure which category your effort falls into.
Are you implementing a Program, Policy, or Practice? [Choose one from dropdown]
• Program
• Policy
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COMMUNITY ACTION PLAN APR FORM DRAFT

•
•

Practice
Unknown/Unsure

Implementation effort name and description
For this question you will select from a list of programs, policies, and practices from CDC’s Technical Packages.
Make sure your answer does not fall within a listed answer option before choosing “other.”
Program, Policy, or Practice Name: [Choose one from dropdown]
•
•

List of Example Programs, Policies, and Practices from CDC Technical Package(s) most closely
associated with NOFO
Other (not listed): Specify

Please provide a short description of how your organization is implementing this program, policy, or practice:
[500] In a few sentences describe the program, policy, or practice in way that someone who is not familiar with
the effort would understand. This should include what it intends to do, how it’s implemented, where it will occur,
and evidence of effectiveness. Specific activities implemented as part of this program, policy, or practice will be
collected in Section 3.
Approach
The last question in this section is asking for the 1-2 approaches from Violence Prevention in Practice that best
align with the implementation effort.
•

•

•

If you selected a program, policy, or practice name included in the dropdown in the previous section you
may select “N/A – We selected from CDC’s Technical Packages” for this question. All of the named
programs, policies, and practices above are aligned with specific strategies and approaches from CDC’s
Technical packages, and we will fill this in for you later to ensure the correct approach is assigned.
If you selected “Other” as your Program, Policy, or Practice name, please select one or two approaches
that align with your implementation effort. Refer to the Approach Search Tool on Veto Violence to select
the appropriate approaches.
If you are unsure which approach to choose, discuss this with your Project Officer or select
“Unknown/Unsure”.

Please select the Approach for this implementation effort: [Select one or two that apply]
•
•
•

N/A – We selected from CDC’s Technical Packages
List of Approaches from Violence Prevention in Practice most closely associated with NOFO
Unknown/Unsure

SEM Level
Which SEM Level(s) does this Implementation Effort target? [Select all that apply]
•
•

Individual - Prevention strategies at this level promote attitudes, beliefs, and behaviors that prevent
violence. Examples include conflict resolution and life skills training.
Relationship - Prevention strategies here focus on communication, parenting practices, and other bonds
and connections. Examples include parenting and family-focused prevention programs, mentoring, and
peer programs.
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COMMUNITY ACTION PLAN APR FORM DRAFT

Community - Prevention strategies at this level impact the social, economic, and environmental
characteristics of settings. Examples include reducing social isolation; enhancing economic and housing
opportunities; and improving the processes, policies, and settings in schools and workplaces.
Societal - Prevention strategies at this level impact broad societal factors that help create a level of
acceptance or intolerance for violence. Examples include strategies to change social norms that support
violence as an acceptable way to resolve conflicts, state and federal policies that offer economic and
other supports to families, and policies that support early childhood education to help pave the way for
children to achieve lifelong opportunity and well-being.

•

•

SECTION 2: CHANGES TO IMPLEMENTATION PLAN

This section collects information on changes that have been made to the Implementation plan during the
reporting period.
Implementation Plan Status
Were there any changes made to the implementation plan during this reporting period?
• No (Select Save, Validate, and Check in below)
• Yes (Complete table below)
Implementation plan Changes Table
Report on any changes made to the Implementation Plan, referring to your Program’s Implementation Plan
document as appropriate. If you answered No to the question above, you do not need to fill out this table.
When you report on any changes made during the reporting period, make sure to only select the “Other” answer
option for Type of Change if your answer does not fall within the existing answer options.
Type of Change: [Select one from dropdown]

•
•
•
•
•
•
•
•

Describe the Change [1000] Provide a concise
description of the change and the reason for
the change.

Recruitment and Retention
Delivery Method
Setting/Population of Focus
Timeline
Monitoring
Staffing/Implementers
Stakeholder/Partnership
Other: Please Specify

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COMMUNITY ACTION PLAN APR FORM DRAFT

SECTION 3: IMPLEMENTATION PROGRESS AND ACTIVITIES

This section collects information about the progress made on the implementation of the prevention strategy.

Implementation Progress table
This table collects information on the progress made implementing the prevention strategy. Each reporting
period you will need to add new activities started during the reporting period and update the information for
activities from previous reporting periods if anything has changed. When entering new activity, make sure that
each entry is a discrete type of activity that best measures and demonstrates implementation progress. You will
need to enter the Activity Type, a description of the activity, Activity Status, and the Project Year the activity was
completed.

Activity Type: [Select one from
dropdown]

•
•
•
•
•
•
•

Planning
Training/Coaching
Executing
Coordinating
Monitoring
Gathering or Using Data
Other (not listed): specify

Description of
activity: [2000]

Provide a description of
the activity and include
with sufficient detail
what the activity
entailed, who was
involved and if any
resources are needed.

Activity Status: [Select one
from dropdown]

•
•
•
•

In Progress (on track)
Delayed
Completed
Discontinued

Project Year
Completed: [Select one
from dropdown]

•
•

Not Yet Complete
Year X

Additional years added as
appropriate

Implementation Progress Checkbox
Please click the checkbox at the bottom of this section to confirm that you have added any new activities from
the reporting period and have also updated any information that has changed for previously entered activities.

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COMMUNITY ACTION PLAN APR FORM DRAFT

Have you added any new activities from this reporting period and updated the activity status for existing
activities in the table above? [Tick checkbox to confirm]
SECTION 4: ADAPTATIONS

This section collects information about the adaptations made to the program, policy, or practice. For resources
on using essential elements to track adaptations, see https://vetoviolence.cdc.gov/apps/adaptation-guidance/.
Adaptation Table
This table collects information on any adaptations made to the essential elements of the prevention strategy.
Each reporting period you will need to add new adaptations started during the reporting period and update the
information for adaptations from previous reporting periods if anything has changed. If an adaptation is no
longer being implemented during this reporting period, please delete that row from the table.

Type of Adaptation:
[Choose one from
dropdown]

•
•
•
•
•
•

•

•

Added content
Deleted content
Changed sequence
Modified delivery
or methods
Added or deleted
policy component
Modified an
environmental
design element
Changed the type
of recommended
implementer
Other (not listed):
specify

Adaptation
Description
[1000]

Describe in
adequate detail
what change was
made to the design
and
implementation of
the effort. What
essential what,
how, and who is
changed? How is it
changed?

Reason for Adaptation:
[Choose one from
dropdown]

•
•
•
•

•
•
•
•
•

To increase participation
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
To address shared risk and
protective factors
To address multiple forms
of violence
To address racial inequity
To address social
determinants of health
Other (not listed): specify

What
resources are
needed for
this
adaption?
(700
characters)

How was this
adaptation evaluated
and what was the
impact of the
adaptation? [2000]

Describe the impact this
adaptation has had on the
prevention effort including
the impact on the
implementers of the effort
and the population
targeted by the effort.

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COMMUNITY ACTION PLAN APR FORM DRAFT

Adaptation Checkbox
Please click the checkbox at the bottom of this section to confirm that you have added any new adaptations from
the reporting period, have updated any information that has changed for previously entered adaptations, and
have deleted any discontinued adaptations.
Have you added any new adaptations from the reporting period, updated any information that has changed
for previously entered adaptations, and deleted any discontinued adaptations in the table above? [Tick
checkbox to confirm]
SECTION 5: POPULATION OF FOCUS AND REACH

Population of Focus
Provide a narrative description of the population or setting of focus for this implementation effort. [2000]
Why was this population or setting selected and how is the implementation effort appropriate for the
selected population or setting? [ 2000] Provide reasons and data sources that were used for selecting the
population and setting of focus for this prevention effort. Also provide reasons and data sources that were used
to show that the selected program, policy, or practice will be effective for reaching these populations.
Population Groups
Is there a specific community or population you are focusing on? [Chose one from dropdown]
•
•

No Specific Community or Population (Skip to Reach tables below)
Specific Community or Population (Check all that apply below)

If your program is focusing on a specific population, please select all that are applicable from below. Only select
other if your answer does not fall within the existing options.
Racial/ethnic groups [Select all that apply]
•
•
•
•
•
•
•
•
•

Black/African American
Asian
Arabic/North African
Pacific Islander
American Indian/Alaskan Native Peoples
Hispanic/Latinx
White
Mixed race persons
Other: Please Specify

Non-citizen groups: [Select all that apply]
•
•
•
•
•

Immigrants
Migrant workers
Refugees
Asylum seekers
Undocumented status

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COMMUNITY ACTION PLAN APR FORM DRAFT

•

Other: Please Specify

Age groups: [Select all that apply]
•
•
•
•
•
•
•

Infants (0-2)
Young children (2-10)
Youth (11-17)
Young adults (18-24)
Adults (25+)
Older adults (65+)
Other: Please Specify

Groups with disabilities/health risks: [Select all that apply]
•
•
•
•
•
•

Intellectual/developmental disabilities
Mobility/ambulatory disabilities
People with disabilities (general)
Substance use
Mental illness
Other: Please Specify

Gender groups: [Select all that apply]
•
•
•
•
•

Men
Women
Non-binary
Transgender
Other: Please Specify

Sexual orientation groups: [Select all that apply]
•
•
•
•
•
•

Gay/lesbian
Straight (heterosexual)
Queer
Bisexual
Pansexual
Other: Please Specify

Economically disadvantaged groups: [Select all that apply]
•
•
•
•

Experiencing homelessness
Experiencing poverty
Receiving government aid
Other: Please Specify

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COMMUNITY ACTION PLAN APR FORM DRAFT

Geographical groups: [Select all that apply]
•
•
•
•
•
•

Tribal
Rural
Urban
Low-income neighborhoods
Suburban
Other: Please Specify

Other Groups: [Select all that apply]
•
•
•
•
•
•
•
•
•
•
•

Foster youth
Single parents
Incarcerated or formerly incarcerated
Veterans
Military (active)
Victims of crimes/violence
Perpetrators of crimes/violence
Gang members
Students
Non-English speaking
Other Population(s) not listed above and not belonging to any grouping above: Please specify

Page 36

COMMUNITY ACTION PLAN APR FORM DRAFT

Individual Reach table
This table collects information on the number of individuals reached during the reporting period. Enter a new row
for each specific population reached.
Description
of
Population
[1000]

Year 5
Target for
Individuals

Number of Individuals
Reached This Reporting
Period

Describe the
population that
you are
reaching.

Insert Numeric
Value

List the number of individuals
reached during the reporting
period across all settings (primary
and secondary) that began
implementation by the end of the
reporting period. This should
include number of individuals
reached and should not include
individuals that you anticipate
reaching in the future.
•Data are missing (program
unable to collect this reporting
period)
• Data are not applicable
(program does not collect)Value

Number of
Total
Individuals
Reached
Since Start of
NOFO
Insert Numeric
Value

Reach Type [Choose one
from dropdown]

Progress
Notes
(2000
characters)

Individuals reached can be
described in terms of Primary Reach
– that is individuals directly
impacted by the prevention
strategy (e.g., employees, parents,
youth serving providers, students);
and Secondary Reach – which is an
estimate of individuals with
potential exposure to the
prevention strategy, but not
necessarily directed at them (e.g.,
community members).
•Primary
•Secondary

Insert Text

Setting Reach table
This section collects information on the number of settings reached during the reporting period. Enter a new row
for each type of setting reached.
Type
Primary Setting

Setting [Select one]

•
•
•
•

Community
County
Territory
State
NGO
CBO
Business
Faith-based
Organization
Elementary
School
Middle School
High School
College/University
Bar

•

Other: Please

•
•
•
•
•
•
•
•
•

Specify
Att. 3 – APR Tool

Description
(1000 characters)

Year 5 Target
for Settings

Insert Text

Insert Numeric
Value

Number of Settings
Reached this Reporting
Period
Insert Numeric Value

List the number of settings
in which implementation
has begun as of the end of
the reporting period. This
should include actual
number of settings where
implementation has started
and should not include any
projected data.
•

•

Data are missing
(program unable to
collect this reporting
period)
Data are not applicable
(program does not
collect)

Progress Notes
(2000
characters)
Insert Text

COMMUNITY ACTION PLAN APR FORM DRAFT

Secondary
Setting (if
applicable)

Insert Numeric
Value

Insert Numeric Value

Insert Text

FORM 6-1: NOFO EVALUATION : STATE EVALUATION
Instructions for Recipients
The Evaluation Form collects information about state-level evaluation and progress on evaluation activities
conducted during the reporting period (September 1st – August 31st). Information from the state evaluation plan
will be reported here. This form has three sections: 1) Evaluation Plan, 2) Progress on Addressing Evaluation
Questions, and 3) Outcomes & Indicators.
SECTION 1: EVALUATION PLAN

Changes to the Evaluation Plan
Were there any changes to the evaluation plan during this reporting period?
No (Select Save, Validate, and Check in below)
Yes (Complete table below)

•
•

Changes to the Evaluation plan table
Report on any changes to specific section(s) of the evaluation plan changed during the reporting period. Choose
each component of the Evaluation Plan that was changed, describe the change, the reason for the change, and
how the change affects your program’s work.
Evaluation Plan Change: [Choose one
from dropdown]

•
•
•
•
•
•
•
•

Evaluation Design
Evaluation Question
Data Analysis, Synthesis, and
Interpretation
Data Collection
Method/Source
Outcomes and Indicators
Translation, Communication,
and Dissemination
Evaluation Team
Other (not listed): Specify

Att. 3 – APR Tool

Description of change: [1000]

Describe the reason for the change
and how it will impact your overall
work: [1000]

COMMUNITY ACTION PLAN APR FORM DRAFT

SECTION 2: PROGRESS ON ADDRESSING EVALUATION QUESTIONS

Evaluation Questions Table
This section collects information about the progress your program has made on the evaluation questions.
Required evaluation questions are included below, and you may add # additional evaluation questions specific to
your program (optional). For each question provide a summary of findings, including any qualitative results.
Quantitative results will be collected in the next section: Outcomes & Indicators.
Evaluation Question
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Q1: To what extent has the Coalition accomplished the short term and intermediate outcomes in the
NOFO Logic Model?
Q2: To what extent did the Coalition achieve high quality implementation of community and societal
level primary prevention PPEs based on the best available evidence during the period of performance?
Q3: To what extent was there an increase in statewide capacity to implement, evaluate and sustain
primary prevention of IPV?
Q4: What factors are critical to implementing and sustaining community and societal level primary
prevention approach to prevent IPV?
Q5: To what extent did the Coalition achieve alignment of state and local level PPE implementation?
Q6: To what extent was the Coalition able to address SDoH and health equity and they relate to IPV into
their state-level planning, implementation, and evaluation?
Q7:
Q8:
Q9:
Q10:
Q11:
Q12:
Q13:
Q14:
Q15:

Summary of Findings (include any qualitative results) [2000] Provide a summary of the progress your
organization has made in relation to the evaluation question. You may also summarize any qualitative results
you have collected related to the evaluation question.
Planned Evaluation Activities in Next Reporting Period: Please provide a general description of evaluation
activities planned for the next reporting period. [2250]
SECTION 3: OUTCOMES AND INDICATORS

This section collects data on the indicators you are using to measure your selected outcomes.
Outcome and Indicator Table
Only enter one outcome per row. If an outcome has more than one indicator, add a row for each indicator. Data
entered in this table will be pulled forward each APR and you will only need to update the Current Value in future
APRs. For this NOFO, recipients may be assessing numerous outcomes. However, for the purpose of reporting in
Att. 3 – APR Tool

COMMUNITY ACTION PLAN APR FORM DRAFT

the partners portal, we ask that you enter a maximum of 30 outcomes with up to 5 indicators per outcome. To
help streamline your efforts, we recommend entering 20 of the most relevant, high-priority outcomes each with
1-3 indicators. Recipients can continue to assess other outcomes, but report on the high-priority ones annually.
SEM Level [Select all that apply] (guidance below will be visible when users hover over the field)
•

•

•
•

Individual – biological and personal history factors that increase or decrease the likelihood of becoming a
victim or perpetrator of violence. Factors may include age, education, income, substance use, and history
of abuse.
Relationship – close relationships that may increase or decrease the risk of experiencing violence as a
victim or perpetrator. A person’s closest social circle — peers, partners, and family members — influence
their behavior and shape their experience.
Community - local settings and characteristics associated with becoming victims or perpetrators of
violence. Settings include neighborhoods, schools, and workplaces.
Societal - broad societal factors that help create a level of acceptance or intolerance for violence. It also
includes the health, economic, educational, and social policies that help to maintain economic or social
inequalities between groups in society.

Att. 3 – APR Tool

COMMUNITY ACTION PLAN APR FORM DRAFT
Associated Effort(s)
(Select all that apply)

NOFO Evaluation
State-level PPE1
State-level PPE2

Evaluatio
n
Question
s
Addresse
d [Select
all that
Apply]
Questions
#1-15

Att. 3 – APR Tool

Description
of Outcome

Type

SEM Level

Indicator
Description
[500]

Data Source
Type [Select
all that apply]

Describe the
outcome that
is being
measured. As a
reminder,
outcome
statements
typically
include
directionality
(increase,
decrease,
maintain),
what will
change
(specific
outcome) and
for whom
(target
population).

Select one (1)

Select one (1)
• Individual
• Relationship
• Community
• Societal

Insert Text

• Needs
Assessment
• Surveillance
Data
• Law
Enforcement
Data
• Hospital Data
• Surveys
• Interviews
• Focus Groups
• Administrativ
e Data
• National Data
• State-level
data
• Other (not
listed): Please
Specify

• Implementatio
n/Process
• Risk Factor
• Protective
Factor
• Violence
Outcome
• Other (not
listed)

Define the
indicator being
used to
measure the
outcome. As a
reminder, an
indicator is a
documentable
or measurable
piece of
information,
from a specific
data source,
used to
determine if
the outcome
was achieved.
Also describe
what level of
disaggregation
you collect this
indicator at.

Data
Source
Name
and
Descripti
on [500]

Indicator
Populati
on

Baselin
e
Value

Curren
t Value

Year 5
Target

[Enter a
Unit
and
Number
] OR
N/A
[Chose
one
from
dropdo
wn]
This
value
will be
entered
in Year
1 and
will be
locked
in
future
APRs.

[Enter
a Unit
and
Number
] OR
N/A
[Chose
one
from
dropdo
wn]
This
should
be the
most
recent
known
value at
the end
of the
reportin
g
period.
e

Insert
Numeric
Value

Data
are
missing
(progra
m
unable
to
collect
this
reportin
g
period)

Chang
Outco
since
repor
perio

COMMUNITY ACTION PLAN APR FORM DRAFT
Associated Effort(s)
(Select all that apply)

Evaluatio
n
Question
s
Addresse
d [Select
all that
Apply]

Description
of Outcome

Type

SEM Level

Indicator
Description
[500]

Data Source
Type [Select
all that apply]

Data
Source
Name
and
Descripti
on [500]

Indicator
Populati
on

Baselin
e
Value

Data
are not
applica
ble
(progra
m does
not
collect)

Att. 3 – APR Tool

Curren
t Value

Year 5
Target

Chang
Outco
since
repor
perio

COMMUNITY ACTION PLAN APR FORM DRAFT

FORM 6-2: COMMUNITY-LEVEL EVALUATION FORM
Instructions for Recipients
The Evaluation Form collects information about community-level evaluation and progress on evaluation activities
conducted during the reporting period (September 1st – August 31st). Information from the Community Action
Plan evaluation plan will be reported here. This form has three sections: 1) Evaluation Plan, 2) Progress on
Addressing Evaluation Questions, and 3) Outcomes & Indicators.
SECTION 1: EVALUATION PLAN

Changes to the Evaluation Plan
Were there any changes to the evaluation plan during this reporting period?
No (Select Save, Validate, and Check in below)
Yes (Complete table below)

•
•

Changes to the Evaluation plan table
Report on any changes to specific section(s) of the evaluation plan changed during the reporting period. Choose
each component of the Evaluation Plan that was changed, describe the change, the reason for the change, and
how the change affects your program’s work.
Evaluation Plan Change:
[Choose one from
dropdown]
•
•
•

•
•
•

•
•

Description of change:
[1000]

Describe the reason for the
change and how it will
impact your overall work:
[1000]

Notes

Evaluation Design
Evaluation
Question
Data Analysis,
Synthesis, and
Interpretation
Data Collection
Method/Source
Outcomes and
Indicators
Translation,
Communication,
and Dissemination
Evaluation Team
Other (not listed):
Specify

SECTION 2: PROGRESS ON ADDRESSING EVALUATION QUESTIONS
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COMMUNITY ACTION PLAN APR FORM DRAFT

Evaluation Questions Table
This section collects information about the progress your program has made on the evaluation questions.
Required evaluation questions are included below, and you may add # additional evaluation questions specific to
your program (optional). For each question provide a summary of findings, including any qualitative results.
Quantitative results will be collected in the next section: Outcomes & Indicators.
Evaluation Question
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Q1: To what extent has the Coalition accomplished outcomes in the CAP logic model?
Q2: To what extent, and how, did the comprehensive PPEs work together to achieve common
outcomes?
Q3: To what extent did the Coalition achieve alignment of state and local level PPE implementation?
Q4: To what extent was the Coalition able to address SDoH and health equity as they relate to IPV into
their community-level planning, implementation, and evaluation?
Q5:
Q6:
Q7:
Q8:
Q9:
Q10:
Q11:
Q12:
Q13:
Q14:
Q15:

Summary of Findings (include any qualitative results) [2000] Provide a summary of the progress your
organization has made in relation to the evaluation question. You may also summarize any qualitative results
you have collected related to the evaluation question.
Planned Evaluation Activities in Next Reporting Period: Please provide a general description of evaluation
activities planned for the next reporting period. [2250]

Page 44

COMMUNITY ACTION PLAN APR FORM DRAFT

SECTION 3: OUTCOMES AND INDICATORS

This section collects data on the indicators you are using to measure your selected outcomes.
Outcome and Indicator Table
Only enter one outcome per row. If an outcome has more than one indicator, add a row for each indicator. Data entered in this table will be
pulled forward each APR and you will only need to update the Current Value in future APRs. For this NOFO, recipients may be assessing numerous
outcomes. However, for the purpose of reporting in the partners portal, we ask that you enter a maximum of 30 outcomes with up to 5 indicators
per outcome. To help streamline your efforts, we recommend entering 20 of the most relevant, high-priority outcomes each with 1-3 indicators.
Recipients can continue to assess other outcomes, but report on the high-priority ones annually.
Associated
Effort(s)
[Select all
that
apply]
Select all that
apply
Community
Evaluation
Communitylevel PPE1
Communitylevel PPE2
Community
level PPE3
Communitylevel PPE4

Evaluation
Questions
Addressed
[Select all
that
Apply]

Questions #115

Description
of Outcome

Type

SEM Level

Indicator
Description
[500]

Data Source
Type [Select
all that
apply]

Describe the
outcome that
is being
measured. As
a reminder,
outcome
statements
typically
include
directionality
(increase,
decrease,
maintain),
what will
change
(specific
outcome) and
for whom
(target
population).

Select one (1)

Select one (1)
• Individual
• Relationship
• Community
• Societal

Insert Text

•

Define the
indicator being
used to measure
the outcome. As
a reminder, an
indicator is a
documentable or
measurable
piece of
information,
from a specific
data source,
used to
determine if the
outcome was
achieved. Also
describe what
level of
disaggregation
you collect this
indicator at.

•

• Implementation/
Process
• Risk Factor
• Protective Factor
• Violence
Outcome

• Other (not listed)

•
•
•
•
•
•
•
•
•

Data
Source
Name and
Description
[500]

Needs
Assessment
Surveillance
Data
Law
Enforcemen
t Data
Hospital
Data
Surveys
Interviews
Focus
Groups
Administrati
ve Data
National
Data
State-level
data
Other (not
listed):
Please
Specify

Page 45

Indicator
Population

Year 5
Target

Current
Value

Insert
Numeric
Value

[Enter a
Unit and
Number]
OR N/A
[Chose
one from
dropdow
n] This
should
be the
most
recent
known
value at
the end
of the
reporting
period.
e

Change
in
Outcome
since last
reportin
g period

Prog
Note

Insert
Text

COMMUNITY ACTION PLAN APR FORM DRAFT

Page 46