Form 0920- Annual Performance Report (APR) Tool

APR FORM DRAFT

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).

Attachment 3a. Annual Performance Report (APR) Tool

Recipient:
Reporting Period:
Contact Person:

Form 1: Work plan

Instructions for Recipients:

The Work Plan form collects information about your progress on work plan goals, objectives, and milestones during the reporting period (September 1, 2023 – March 1, 2024). The required goals and objectives are prefilled for all recipients.

Required goals and objectives

Goal	Objective(s)
Goal 1: Build or Improve Surveillance Infrastructure and Capacity	Objective 1.1. Increased capacity to create, use, and disseminate data from a comprehensive ACEs and PCEs surveillance system
	Objective 1.2. Increased state level collection of ACEs and PCEs data through youth-based surveillance
	Objective 1.3. Increased capacity to collect data on the social determinants of health
	Objective 1.3a. Increased capacity to link data on the social determinants of health
	Objective 1.4. Increased access to ACEs and PCEs, risk and protective factors, and social determinants of health data to inform prevention strategies and identify inequities
	Objective 1.5. Increased state-level monitoring of trends in ACEs and PCEs over time, and use of data from youth populations
	Objective 1.6. Increased use of data on health inequities and the social determinants of health to contextualize risk factors for ACEs, and reduce inequities
	Objective 1.7. Increased sustainability of a comprehensive ACEs and PCEs surveillance system
Goal 2. Implement and Sustain ACEs Prevention Strategies	Objective 2.1. Increased partner awareness of existing state prevention strategies and approaches that address ACEs
	Objective 2.2. Increased coordination and collaboration between state agencies and other sectors
	Objective 2.2a. Increased coordination and collaboration between local agencies and other sectors
	Objective 2.3. Increased capacity to implement comprehensive ACEs prevention strategies at the state level
	Objective 2.3a. Increased capacity to implement comprehensive ACEs prevention strategies at the local level
	Objective 2.4. Increased uptake and implementation of comprehensive ACEs prevention strategies at the state level
	Objective 2.4a. Increased uptake and implementation of comprehensive ACEs prevention strategies at the local level
	Objective 2.5. Increased reach of prevention strategies, with a focus on communities with disproportionate needs due to social determinants of health
	Objective 2.6. Increased evidence for population-based approaches to prevent ACEs
Goal 3. Use ACEs/PCEs Data for Action	Objective 3.1. Increased understanding of state surveillance and prevention capacity related to ACEs and PCEs
	Objective 3.2. Increased capacity to use ACEs and PCEs surveillance and evaluation data to identify and tailor ACEs prevention strategies, improve health equity, and the social determinants of health
	Objective 3.3. Increased data dissemination on ACEs and PCEs to state partners, policy-makers, and the public
	Objective 3.3a. Increased data dissemination on ACEs and PCEs to state and local partners, policy-makers, and the public
	Objective 3.4. Increased knowledge about the effectiveness of ACEs prevention strategies to improve health and wellbeing, and reduce inequities
	Objective 3.5. Increased use and translation of surveillance and evaluation data to inform tailored prevention strategy implementation to reduce ACEs and improve health equity and social determinants of health
	Objective 3.6. Increased partner response to the burden of ACEs and PCEs in their state, and public awareness of societal factors that lead to safe, stable, and nurturing relationships and environments

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)
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]

• Not Started

• 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	Question Instructions/Options
#.# Description [100]	Provide a concise statement of the milestone.
#.# Key Activities [700]	Provide a brief description of activities conducted to complete the milestone
#.# Milestone Status [Choose one from dropdown]	In Progress (on track) Delayed: Please add comments Completed Discontinued: Please add comments
Please provide reasons for delayed or discontinued work [3000]	*only if Milestone Status = Delayed or Discontinued
#.# Reporting Year Milestone was Completed [Choose one from dropdown]	Not Yet Complete Year 1 *additional year added each APR

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 (September 1, 2023 – August 31, 2024). 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 or changes to the approach or strategy. [6000]. The CDC Project Officer must approve any changes to the program or policy efforts approved upon award.

Section 2a: Implementation of New or Revised Surveillance Efforts: Describe the planned implementation of surveillance efforts in the next budget period. Explain any requests to change the current surveillance efforts being implemented. [6000]. The CDC Project Officer and Surveillance Officer must approve any changes to the surveillance 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 TTA request in the portal. Please describe the areas or topics for TTA (e.g., program, evaluation, surveillance). This information will help us to understand what types of TTA are needed across recipients 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., TA request, program wide TTA). If TTA is not needed, please explain.

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]	Timeframe [Chose one from dropdown]
Planning Partnerships Communication Policy Specific Strategy or Approach Implementation and/or Adaptation Surveillance Data Evaluation and Data Health Equity Other (not listed): Please specify topic		Submitted TA Request in portal 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: Challenges, Supports and Accomplishments

Instructions for Recipients

The Challenges, Supports and Accomplishments form collects information about challenges, facilitators, and successes that experienced. This form has five sections: 1) Barriers Encountered, 2) Facilitators Encountered, 3) Successes, 4) Technical Assistance and 5) Capacity Building.

• 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 drop-down 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.

Barrier Type: [Choose one from dropdown]	Describe the barrier and how it impacts your program’s work: [2000]	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]
Lack of buy-in from partners Insufficient funding or resources Inability to access/collect data Implementation issues Evaluation issues Staffing issues Inadequate training/technical assistance Other (not listed): Please specify		Work Plan Surveillance: Youth-Based Surveillance: Social Determinants of Health Surveillance, Other (specify) State Action Plan/Strategic Plan Prevention Strategies Data to Action State Evaluation Sustainability

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.

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]	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]
Strong partners Connection to community Access to funding or resources Access to data Strong implementation Strong evaluation Adequate, experienced staff Access to training/technical assistance Other (not listed): Please Specify		Work Plan Surveillance: Youth-Based Surveillance: Social Determinants of Health Surveillance, Other (specify) State Action Plan/Strategic Plan Prevention Strategies Data to Action State Evaluation 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 Table

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. You should enter at least one success for each of the three NOFO goals.

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.

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]
Work Plan Surveillance: Youth-Based Surveillance: Social Determinants of Health Surveillance, Other (specify) State Action Plan/Strategic Plan Prevention Strategies Data to Action State Evaluation Sustainability

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 (5 or more times)

• Sometimes (3-4 times)

• Rarely (1-2 times)

• 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?

• Frequently (5 or more times)

• Sometimes (3-4 times)

• Rarely (1-2 times)

• Never

4. 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

5. 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

6. To what extent has your organizational capacity to build or improve surveillance infrastructure and capacity increased during this reporting period?

• Not at all

• To a small extent

• To a moderate extent

• To a great extent

7. To what extent has your organizational capacity to use data for action, such as tailored prevention strategy implementation to reduce inequities, improved during this reporting period?

• Not at all

• To a small extent

• To a moderate extent

• To a great extent

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

Section 5: Capacity Building

Capacity Building and Training Table

Please list any capacity building, training, and educational activities related to community and societal level primary prevention that you provided within the state during this reporting period. Include activities related to the NOFO as a whole and NOT specific trainings or activities related to the implementation of your selected approaches.

Type of Activity	Topic	Audience	Dates
300 characters	300 characters	300 characters

Form 4: State Action/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 1, 2023 – March 1, 2024). This form has three sections:

A. Progress on State Action/Strategic Plan

B. Progress on Implementing State Action/Strategic Plan

C. Partnerships

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

Section 2: progress on State Action Plan

Please describe any key activities/accomplishments specifically related to implementation of the state action plan/strategic plan. This does not include activities or accomplishments that are specific to your selected approaches or your surveillance infrastructure enhancement. Those will be reported on in other forms.

Key State Action Plan Activities/Accomplishments this Reporting Period (1050 characters)
Type of Accomplishment/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]
Funding Acquisition Training/Capacity Building Partner engagement/convening Implementation planning Surveillance Data to Action Mass Media 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.

Key Activities Planned for Upcoming Year

(500 characters)

1. Insert text

2. Insert text

3. Insert text

4. Insert text

Resources Needed for Implementing State Action Plan Activities in Upcoming Year (700 characters)

Section 3: partnership

This section collects information about all partner organizations you are 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 recipients’ ACEs 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.

Name of Partner Organization	Primary Sector	Role of Partner	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 Community-level Partner	SAP Priority Area (if state-level partner)
	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)	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)		New, acquired during this reporting period Existing partner Re-engaged partner Increased engagement No longer a partner	State Community Both

Form 5: implementation

Instructions for Recipients

The Implementation Form collects information about each state-level program, policy, or practice that your organization implemented using Essentials for Childhood: Preventing ACEs Through Data to Action funding during the reporting period (September 1, 2023 – March 1, 2024). 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 and CDC’s Preventing Adverse Childhood Experiences: Leveraging the Best Available Evidence resource tool to provide strategies, approaches, and example programs, policies, and practices based on the best available evidence. (Initiative specific Implementation requirements).

As you answer questions about the prevention approach 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 inform, assist in development, or put a policy into practice (i.e., Child Income Tax Credits) . 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 Preventing Adverse Childhood Experiences: Leveraging the Best Available Evidence resource tool.

Program, Policy, or Practice

Indicate which of the following aspects you are implementing as part of your implementation effort? [Select All]

• Program

• Policy

• Practice

• Unknown/Unsure

Implementation effort name and description

Program, Policy, or Practice Name:

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

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

• Strengthening household financial security

• Family-friendly work policies

• Public education campaigns

• Approaches to reduce parents’ use of corporal punishment

• Bystander approaches

• Men and boys as allies in prevention

• Early childhood home visitation

• High-quality childcare

• Preschool enrichment with family engagement

• Social-emotional learning

• Safe dating and healthy relationship skill programs

• Parenting skills and family relationship approaches

• Mentoring programs

• After-school programs

• Other

• 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.

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 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.

Activity Type: [Select one from dropdown]	Description of Activity: [2000]	Activity Status: [Select one from dropdown]	Project Year Completed: [Select one from dropdown]
Planning Training/Coaching Executing Coordinating Monitoring Collecting and using data to improve implementation Other (not listed): specify	Provide a description of the activity and include with sufficient detail what the activity entailed, who was involved and if any resources are needed.	In Progress (on track) Delayed Completed Discontinued	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.

Type of Adaptation: [Choose one from dropdown]	Adaptation Description [1000]	Reason for Adaptation: [Choose one from dropdown]	What resources are needed for this adaption? (700 characters)	How was this adaptation evaluated and what was the impact of the adaptation? [2000]
Added content Deleted content Changed sequence Modified population of focus Modified delivery or methods Added or deleted policy component Modified an environmental design element Changed the type of recommended implementer Other (not listed): specify	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?	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 Used data to inform tailored implementation Other (not listed): specify		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.

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

• 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

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

Individual Reach table

This table collects information on the number of individuals reached as part of prevention strategies 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	Number of Total Individuals Reached Since Start of NOFO	Reach Type [Choose one from dropdown]	Progress Notes (2000 characters)
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	Insert Numeric Value	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 as part of prevention strategies during the reporting period. Enter a new row for each type of setting reached.

Type	Setting [Select one]	Name of Setting	Description (1000 characters)	Year 5 Target for Settings	Number of Settings Reached this Reporting Period	Progress Notes (2000 characters)
Primary Setting	Community County Territory State NGO CBO Business Faith-based Organization Elementary School Middle School High School College/University Bar Other: Please Specify		Insert Text	Insert Numeric Value	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)	Insert Text
Secondary Setting (if applicable)				Insert Numeric Value	Insert Numeric Value	Insert Text

Form 6: Evaluation

Instructions for Recipients

The Evaluation Form collects information about state-level evaluation and progress on evaluation activities conducted during the reporting period (September 1, 2023 – March 1, 2024). Information from the recipient 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]
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

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/Q8: How has the recipient achieved the overall goals and objectives of the NOFO and achieved the short term and intermediate outcomes in their logic model?

• Q2: How has the recipient leveraged multi-sector partnerships and resources among state agencies (additional funding at the local level) and other sectors to prevent ACEs, including forming sustainable systems and partnerships, and realigning/focusing/mobilizing resources to prevent ACEs?

• Q3: In what ways has the recipient built or enhanced their state-level surveillance system to monitor ACEs, PCEs, and the social determinants of health?

• Q4: How has the recipient integrated and addressed racial and health inequities and social determinants of health in preventing ACEs?

• Q5: In what ways has the recipient enhanced their statewide action plan to implement complementary ACEs prevention strategies (additional funding for implementation at the local level)?

• Q6: What factors are critical to implementing ACEs prevention program strategies?

• Q7. In what ways has the recipient enhanced their ability to use ACEs and PCEs surveillance and evaluation data to inform prevention strategy allocation? In what ways has the recipient enhanced their ability to disseminate and use data to inform partner, policy, or other action?

• Q9: To what extent has the recipient seen a sustainable increase in capacity and activities related to routine monitoring of ACEs and PCEs data among youth? To what extent has the recipient seen a sustainable increase in capacity and activities related to routine monitoring of near real-time surveillance to monitor indicators of ACEs?

• Q10: To what extent has the recipient demonstrated ability to link ACEs and PCEs data to those on the social determinants of health, and utilize these data to inform prevention strategies? (if applicable)

• Q11/12/14: What is the reach/exposure of the NOFO efforts for each goal area?

• Q13: To what extent has the recipient demonstrated use of surveillance and evaluation data to inform prevention strategy allocation and implementation, including to improve health equity?

• Q11: ADDITIONAL RECIPIENT EVALUTION QUESTION (S) (OPTIONAL)

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 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.

Associated Effort(s) (Select all that apply)	Evaluation Questions Addressed [Select all that Apply]	Description of Outcome	Type	Indicator Description [500]	Data Source Type [Select all that apply]	Data Source Name and Description [500]	Indicator Population	Baseline Value	Current Value	Year 5 Target	Change in Outcome since last reporting period	Progress Notes
Goal 1 Goal 2 Goal 3 Other	Questions #1-10	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) Implementation Program/Policy Specific Risk Factor Protective Factor Violence Outcome NOFO Level Other (not listed)	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.	Needs Assessment Surveillance Data Law Enforcement Data Hospital Data Surveys Interviews Focus Groups Administrative Data National Data State-level data Other (not listed): Please Specify			[Enter a Unit and Number] OR N/A [Chose one from dropdown] This value will be entered in Year 1 and will be locked in future APRs. Data are missing (program unable to collect this reporting period) Data are not applicable (program does not collect)	[Enter a Unit and Number] OR N/A [Chose one from dropdown] This should be the most recent known value at the end of the reporting period. e	Insert Numeric Value		Insert Text

Form 7: Data to ACTION

Instructions for Recipients

The Data to Action form collects information about your state-level ACEs and PCEs surveillance activities and data to action efforts achieved during the reporting period (September 1, 2023 – March 1, 2024). This form has six sections: 1) Surveillance and Data to Action Infrastructure Enhancements; 2) Data Collection and Use; 3) Data Dissemination; 4) Other Surveillance and Data to Action Funding; 5) Data Management Plan Changes; and 6) Data to Action and Dissemination Plan Changes.

Section 1: Surveillance and data to action infrastructure enhancements

Enhancements to the Surveillance and Data to Action Infrastructure

Have you built or enhanced your ACEs and PCEs surveillance capacity or your data to action capacity during this reporting period?

• No (Select Save, Validate, and Check in below)

• Yes (Complete table below)

Report on any new components and enhancements specific to your ACEs and PCEs surveillance capacity and infrastructure, as well as your data to action efforts, that were implemented during the reporting period. Choose each component of your surveillance and data to action infrastructure that was established, enhanced, or implemented. Additionally, describe the activity or enhancement, the reason for the activity or enhancement, and how the activity or enhancement affects your program’s work.

Enhancements to the Surveillance and Data to Action Infrastructure Table

Surveillance Infrastructure Activity: [Choose the most appropriate category for the enhancement activity conducted from the dropdown]	Surveillance Infrastructure Enhancement: [Choose the most appropriate category for this from dropdown]	Description of Activity and/or Enhancement: [1000]	Describe the reason for the activity and/or enhancement and how it will impact your overall work: [1000]
Built or improved ACEs and PCEs surveillance infrastructure and data collection capacity Collected or gathered state-level youth-based data on ACEs, PCEs, and related risk and broader protective factors Shared state-level YRBS or other local equivalent survey data to facilitate CDC’s provision of technical assistance in support of data to action efforts Used data on the social determinants of health Synthesized and used near real-time ACEs and PCEs data, and related risk and protective factor data, including from across systems to inform prevention strategies [ENHANCED FUNDING RECIPIENTS ONLY] Synthesized and used syndromic surveillance (near-real time) data to track ACEs and PCEs, and related risk and protective factor data from across systems to inform prevention strategies [ENHANCED FUNDING RECIPIENTS ONLY] Link social determinants of health data with youth-based ACEs and PCEs data Conducted or updated ACEs & PCEs capacity assessments for surveillance and state-wide prevention strategies Utilized surveillance and program evaluation findings to tailor and improve strategy implementation at the state level, with a focus on improving health equity [ENHANCED FUNDING RECIPIENTS ONLY] Utilized surveillance and program evaluation findings to tailor and improve strategy implementation at the local level, with a focus on improving health equity Implemented aspects of a data to action dissemination plan to translate state ACEs, PCEs, and associated risk and protective factor data Conducted an interim process and outcome evaluation of program activities related to ACEs surveillance and prevention [ENHANCED FUNDING RECIPIENTS ONLY] Conducted an interim process and outcome evaluation of program activities related to ACEs surveillance and prevention using linked data	Acquired staff to enhance a surveillance system Developed/leveraged multi-sector partnerships or resources Improved or expanded an existing infrastructure and data collection system Used or obtained state, territorial, or tribal state-level jurisdiction-wide survey of adolescents to collect ACEs and PCEs data Have (or identified the ability to include and/or access) core ACEs data elements Have (or identified the ability to include and/or access) core PCEs data elements Shared state-level YRBS or other local equivalent survey data with CDC Selected social determinants of health indicators relevant to ACEs prevention and intervention strategy selection, in collaboration with CDC Used data to more effectively monitor social and structural inequities related to social determinants of health Utilized state level youth-based ACEs and PCEs surveillance infrastructure to inform selection, implementation, and delivery of prevention strategies Generated, triangulated, and utilized different forms of data to tailor prevention, intervention, and evaluation efforts Used indicators of ACEs from near-real time data to increase use of timely data to aide in prevention and intervention planning [ENHANCED FUNDING RECIPIENTS] Leveraged syndromic surveillance data using standard CDC definitions to track ACEs indicators [ENHANCED FUNDING RECIPIENTS] Linked social determinants of health and ACEs and PCEs surveillance data to inform prevention strategy selection, alteration, and effectiveness [ENHANCED FUNDING RECIPIENTS] Reported to CDC on data linkage challenges and successes and ways that our linked data will be used to inform prevention strategies Conducted or updated ACEs and PCEs capacity assessments for surveillance or state-wide prevention strategies Used information from the surveillance capacity assessment to develop recommendations for building or enhancing the surveillance system Used surveillance and program evaluation findings to tailor and improve strategy implementation at the state-level, with a focus on health inequity Implemented aspects of the data to action plan Conducted an interim process and outcome evaluation of program activities related to ACEs surveillance and prevention at the state level [ENHANCED FUNDING RECIPIENTS ONLY] Conducted an interim process and outcome evaluation of program activities related to ACEs surveillance and prevention at the local level [ENHANCED FUNDING RECIPIENTS ONLY] Conducted an interim process and outcome evaluation of program activities using linked youth-based surveillance and social determinants of health data Other (please specify)

Section 2: Data collection and USE

This section collects information about the progress you have made in the collection, analysis, and use of ACEs and PCEs data, data on the social determinants of health, and data on shared risk and protective factors. To best mirror the types of data that are often available and used for prevention and intervention purposes, there are three tables that align with broad types of data that may be used by your program.

The first table should be used to provide data on ACEs, PCEs, and broader risk and protective factors that are contained within survey data sources. The second table should be used to provide data on social determinants of health indices. The third table should be used to provide data on additionally identified data sources, including but not limited to data from syndromic surveillance, other hospital records (e.g., hospital discharge data; electronic health record data), administrative data from the child welfare system, substance misuse and mental health services resources or law enforcement records, or data from crisis or service hotlines.

Please add ONE row for each data source AND data collection year. For example, if you have data from the Youth Risk Behavior Survey from 2021 and 2023, please add two rows: one row for the 2021 YRBS and one row for the 2023 YRBS.

Data Collection and Tracking Table: ACEs, PCEs, and Broader Risk and Protective Factors in Survey Data

Data Source [Add one row for each data source by year]	Data Collection Year [Select one]	Please select which geographic areas analyses can be conducted at [select all that apply]	Variable Concept Collected [Select all that apply]	Were data collected or accessed in this reporting period?	Were data analyzed in this reporting period?	Were data used and disseminated in this reporting period? (Note: If yes, details about data use and dissemination will be provided in other sections of this form)
Youth Risk Behavior Survey Other youth-based surveillance system (specify) National Survey of Children’s Health Behavioral Risk Factor Surveillance System Pregnancy Risk Factor Surveillance System Other adult health survey (specify) Other survey data collection (please specify)	Prior to 2021 (specify) 2021 2022 2023 2024 2025 2026 2027 2028	State Region within state County City Census tract Other (specify)	Age Gender Race and ethnicity Sexual or gender identity Disability Socio-economic status Educational attainment Lifetime emotional abuse Past-year emotional abuse Lifetime physical abuse Past-year physical abuse Lifetime sexual abuse Lifetime physical neglect Lifetime witnessed intimate partner violence Lifetime household or parent substance misuse Lifetime household or parent mental illness Lifetime household or parent incarceration Racial or ethnic discrimination Sexual minority discrimination Gender discrimination Weight discrimination Disability-based discrimination Witnessed community violence Victim of bullying Victim of peer violence Victim of other form of sexual violence Victim of partner violence Victim of community violence Experienced housing instability or homelessness Experienced food insecurity Experienced basic needs instability Parent or caregiver death Parent or caregiver divorce or separation Feeling able to talk to family or other adults about feelings Family stands by you in difficult times Felt safe and protected by an adult in your home Had at least two non-parental adults who took an interest in you Feeling supported by friends Feeling a sense of belonging at school Parental monitoring Feeling safe at school Living in a supportive or connected neighborhood Living in a safe neighborhood Participated in school, extra-curricular, or community activities or traditions Other (please specify)	Yes No	Yes No	Yes No

Data Collection and Tracking Table: Social determinants of health indices

Data Source [Add one row for each data source by year]	Data Collection Year [Select one]	Please select which geographic areas analyses can be conducted at [select all that apply]	Variable Concept Collected [Please describe each measure used within the index, 1000]	Were data collected or accessed in this reporting period?	Were data analyzed in this reporting period?	Were data used and disseminated in this reporting period? (Note: If yes, details about data use and dissemination will be provided in other sections of this form)
County Health Rankings Child Opportunity Index 2.0 American Community Survey Annie E. Casey Kids Count Data Center Other social determinants of health index (specify)	Prior to 2021 (specify) 2021 2022 2023 2024 2025 2026 2027 2028	State Region within state County City Census tract Other (specify)		Yes No	Yes No	Yes No

Data Collection and Tracking Table: Administrative Medical, Social Service, Law Enforcement, or Hotline Data

Data Source [Add one row for each data source by year]	Data Collection Year [Select one]	Please select which geographic areas analyses can be conducted at [select all that apply]	Variable Concept Collected [Select all that apply]	Were data collected or accessed in this reporting period?	Were data analyzed in this reporting period?	Were data used and disseminated in this reporting period? (Note: If yes, details about data use and dissemination will be provided in other sections of this form)
Syndromic surveillance Electronic health record (EHR) Hospital discharge data Hotline (specify) Child welfare data Substance misuse or mental health service records Law enforcement records Other administrative data sources (specify)	Prior to 2021 (specify) 2021 2022 2023 2024 2025 2026 2027 2028	State Region within state County City Census tract Other (specify)	Age Gender Race and ethnicity Sexual or gender identity Disability Socio-economic status Educational attainment Public or private insurance Medical record for child abuse or neglect Medical record for other sexual violence (child) Medical record for dating violence (child) Medical record for firearm injury (child) Medical record for mental health condition (adult) Medical record for suicidal ideation or attempt (adult) Medical record for drug overdose (adult) Medical record for alcohol misuse (adult) Medical record for intimate partner violence (adult) Medical record for sexual violence (adult) Medical record for firearm injury (adult) Medical record for mental health condition (child) Medical record for suicidal ideation or attempt (child) Medical record for drug overdose (child) Medical record for alcohol misuse (child) Crisis service call volume (specify) Service support call volume (specify) Substantiated child abuse or neglect case records Reported child abuse or neglect case records Mental health service referral or use records Substance misuse treatment referral or use records Police records for arrests Police records for victimization Other (please specify)	Yes No	Yes No	Yes No

Additional Data Access and Use

Please add any additional data sources that you are accessing and/or using that you have not included above or in the evaluation section.

Data Source (Name)	Data Source Type	Description of Data Source [500]	Use of Data	Describe Use [500]	Describe any barriers or challenges your program encountered in accessing this data source: [500]
	Needs Assessment Surveillance data Police data Hospital data Surveys Interviews Focus groups Administrative data Other (not listed): Specify		Select population of focus Select prevention strategies/approaches/programs Select sub-recipients or community partners Address health disparities Inform State Action Plan Inform program or policy effort implementation Complete Evaluation

Section 3: Data dissemination

This section collects data on efforts you have made to disseminate data to partners, the public, the media, or policymakers during the reporting period, in alignment with your data dissemination plan. Please report on completed efforts (i.e., dashboards, infographics, fact sheets, or other data tools that were released – not in development – during the reporting period). Progress on activities in development can be listed in Section 1.

Choose which data dissemination activity was conducted and provide a description of the activity, the core audience, and the potential reach.

Data Dissemination Table

Data Dissemination Activity [Choose the most appropriate category for this activity]	Description of Activity [1000]	Core Audience [Select all that pply]	Reach of Efforts [50]
Released new or updated data dashboard or data website Released new or updated infographic Released new or updated fact sheets (state-level) Released new or updated fact sheets (local-level) Other (please specify)		General public State agencies or governmental partners Non-profit or community partners Policymakers Other, specify

Section 4: other surveillance OR DATA TO ACTION funding

This section collects data on additional funding support for your comprehensive ACEs and PCEs surveillance system or funds that support data dissemination or data to action efforts during the reporting period.

Have you leveraged other sources of funding to support your comprehensive ACEs and PCEs surveillance system during this reporting period? No (Select Save, Validate, and Check in below)

• Yes (Complete table below)

Additional Surveillance and Data to Action Data Funding Table

Additional Funding Received [If YES, please describe any additional funding leveraged.] [1000]	Additional Surveillance Data Funding Notes [Provide any additional information related ACEs data and funding. If none, indicate N/A] [1000]

Section 5: Modifications to data management plan

This section collects data on any changes or updates that have been made to your data management plan during the performance period.

Have you modified your data management plan during this reporting period? No (Select Save, Validate, and Check in below)

• Yes (Complete table below, and upload your updated Data Management Plan)

Data Management Plan Modifications Table

What type of modification was made to your Data Management Plan during this reporting period? [Select All that apply]

Describe any updates to your data management plan [1000]

Adding or removing collected or generated data Standards to be used for the collected or generated data, including plans for data management/organization (e.g., dashboard, data systems) Mechanisms for or limitations to providing access to and sharing of the data Use of data standards that ensure all released data have appropriate documentation that describes the method of collection, what the data represent, and potential limitations for use Plans for archiving and long-term preservation of the data Other (please specify)

Section 6: Modifications to Data Dissemination and Data to Action PlaN

This section collects data on changes or updates that were made to your data to action and dissemination plan during the performance period.

Data Dissemination and Data to Action Plan Modifications Table

Have you modified your data dissemination and data to action plan during this reporting period?

• No (Select Save, Validate, and Check in below)

• Yes (Complete table below, and upload your updated Data Dissemination and Data to Action Plan)

What type of modification was made to your data dissemination and data to action plan during this reporting period? [Select all that apply]	Describe any updates to your data dissemination and data to action plan, with an emphasis on plans for the coming reporting period. [1000]
Updated dissemination and data to action plan Synthesized data to tailor implementation of prevention strategies (state-level) Synthesized data to tailor implementation of prevention strategies (ENHANCED ONLY: local-level) Disseminated data: data dashboard or website Disseminated data: infographic Disseminated data: fact sheets Other (please specify)

Page 12