Work plan instruments

[PHIC] Preventive Health and Health Services Block Grant

Att E_Work Plan Instruments (003)-Updated 081420

OMB: 0920-0106

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Advisory Committee Data Collection Instrument

In this UIC, users will add/edit members of the Advisory Committee and add information about meetings and public hearings. This UIC can be accessed at any time.



Add/Edit A Member

If the user has selected “Edit A Member,” the system displays a list of names to choose which one to edit. Block Grant Coordinators can edit any members of their own Advisory Committee. When a name is chosen, the system opens that entry for editing. If the user has selected “Add A Member,” the system opens a blank form for them to complete. They will complete all the questions for each member of the committee.



  1. Member Name: [Short Text]

  2. Member Title: [Short Text]

  3. Organization Name: [Short Text]

  4. Please select all the relevant constituencies, organizations, or perspectives represented by this member. (check as many as apply) [Multiple selection list with the following options:]

    • Community-based organization

    • Community resident

    • County and/or local health department

    • Minority-related organization

    • Schools of public health

    • Other (please specify below)

  5. [If “Other” is chosen above, answer this question. Otherwise skip to question 6] Other constituencies, organizations, or perspectives represented by this member: [text field, 250 character limit.]

  6. Is this member the chair of the Advisory Committee? [Yes/No] (If no, skip to question 8)

  7. [If “Yes” is chosen above, answer this question. Otherwise skip to question 8] Is this member the Lead Health Official of this jurisdiction? [Yes/No]

  8. Year this member first joined the Advisory Committee: [Year]

  9. Year this member left the Advisory Committee: [Year]

  10. (Optional) Deactivate/Reactivate this Member



Add/Edit A Meeting

Block Grant Coordinators can edit any meetings of their own Advisory Committee in the current or upcoming federal fiscal year. After close-out, the Advisory Committee information for that federal fiscal year can no longer be edited.

If the user has selected “Edit A Meeting,” the system displays a list of previously entered and editable meetings to choose which one to edit. When a name is chosen, the system opens that entry for editing. If the user has selected “Add A Meeting,” the system opens a blank form for them to complete.

  1. Title of Meeting: [Short Text]

  2. Date of Meeting: [date, day/month/year]

  3. Federal Fiscal Year(s) of the Work Plan discussed at this meeting: [date, 4-digit year only] *Allow multiple entries

  4. Type of Meeting: *Choose one

    • Advisory Committee Meeting (skip to question 7)

    • Public Hearing

  1. [If the answer to 4 was “Public Hearing,” answer questions 5 and 6. Otherwise, skip to question 7.] How was the public invited to the Public Hearing? *Select all that apply

    • Email Announcement

    • Flyers

    • Phone Calls

    • Mass Text Message

    • In Person

    • Press Release

    • Website

    • Mailings

    • Radio

    • TV

    • Social Media (e.g. Facebook and Twitter)

    • Other; please specify ________________

  2. How was the draft Work Plan made available for public viewing?

    • Email Announcement

    • Flyers

    • Phone Calls

    • Mass Text Message

    • In Person

    • Press Release

    • Website

    • Mailings

    • Radio

    • TV

    • Social Media (e.g. Facebook and Twitter)

    • Other; please specify ________________

  3. Please select all the committee members who attended this meeting: *Select all that apply [Multiple selection list that is populated by the names of all current active members of the advisory committee for that federal fiscal year]

    • Firstname Lastname 1

    • Firstname Lastname 2…

  4. Did the chair of the Advisory Committee chair this meeting? [Yes/No]

    1. If NO, answer questions 9 & 10

    2. If YES, skip to question 10

  1. [If the answer to 8 was YES, skip to question 10] Who chaired this meeting under delegated authority from the chair of the Advisory Committee? *Choose one [Single Option Selection List that is populated with the names of every member selected in question 5]

    • Firstname Lastname 1

    • Firstname Lastname 2…

  2. Please upload the minutes from this meeting. [File Upload]





Budget Data Collection Instrument

  1. Federal Fiscal Year of this budget: [Auto-populated from Allocation Table UIC]

  2. Recipient: [Auto-Populated from User Profile UIC]

  3. Total Allocation for the current federal fiscal year: [Auto-Populated from Allocation Table UIC] *Auto-populated from Allocation Tale from table field [Recipient Name] Total Allocation. If there is no finalized Allocation Table, the system will give an error.

  4. Annual Basic Allocation for the current federal fiscal year: [Auto-Populated from Allocation Table UIC] *Auto-populated from Allocation Tale from table field [Recipient Name] Basic Allocation. If there is no finalized Allocation Table, the system will give an error.

  5. Sex Offense Allocation for the current federal fiscal year: [Auto-Populated from Allocation Table UIC] *Auto-populated from the Allocation Table field [Recipient Name] Sex Offense Allocation. If there is no finalized Allocation Table, the system will give an error.

  6. Basic Admin Cost: [Number]

  7. Are you receiving Direct Assistance?

    1. Yes

    2. No (Skip to Question 9)

  8. [If the answer to question 7 was Yes, answer this question. Otherwise skip to question 9] Direct Assistance Amount: [Number]

  9. Sex Offense Admin Cost: [Number]

  10. Remaining Basic Allocations for Programs: [Number] *This is auto-generated by subtracting the Basic Admin Cost from the Annual Basic Allocation for the current federal fiscal year

  11. Remaining Sex Offense Allocations for Programs: [Number] *This is auto-generated by subtracting the Sex Offense Admin Cost from the Sex Offense Allocation for the current federal fiscal year

  12. Would you like to continue funding a previous program funded by PHHS Block Grant in a previous year?

    1. If Yes, answer question 13, skip question 14

    2. If No, skip question 13, answer question 14

  13. [If the answer to question 12 was Yes, answer this question and skip question 14] Select the previous program you wish to continue funding: *choose one

  • Program x

  • Program y…

  • Program z…

  1. [If the answer to question 12 was No, skip question 13 and answer this question] Enter the name of a new program you wish to fund: [Short Text]

Program Allocation Data Table

Once the recipient answers question 13 or 14, this program allocation data table will appear to fill out the information for that program. Once complete, the recipient can choose *Add Another Program* and answer questions 12-18 about each program they plan to fund with PHHS Block Grant funds.

  1. Program Name: [Auto-populated]

  2. Program Manager assigned to this program: *Select one option from list of all users with role Program Manager assigned to this recipient

    1. Lastname, Firstname 1

    2. Lastname, Firstname 2…

  3. Current Year Basic Funds budgeted to this program: [Number]

  4. Current Year Sex Offense Funds budgeted to this program: [Number]

Program Data Collection Instrument

In this UIC, the BG Coordinator or Program Manager will fill out the information for each program funded by the PHHS Block Grant. The Program UIC is connected to several other entities which contains pertinent information about the recipient’s program plan.

Program Information

  1. Program Name: [auto-populated from Program Allocation unit of Budget UIC]

  2. Assigned Program Manager: [auto-populated from Program Allocation unit of Budget UIC]

  3. Federal Fiscal Year: [auto-populated from Budget UIC]

  4. Healthy People 2030 Objective: *Choose one of the Healthy People 2030 Objectives

    • (List of all objectives)

  1. Recipient Health Objective for this Program: *Choose one of the Recipient Health Objectives that were entered into the Recipient Health Objective UIC

    • Recipient Health Objective 1

    • Recipient Health Objective 2

Details about Program Funding

  1. Amount of funding to populations disproportionately affected by the problem: [Number}

  2. Amount of funding to local agencies or organizations: [Number]

  3. Type of supported local agency/organization: *Choose one

    • Local Health Department

    • Tribal Health Department/Agency

    • Other Local Government

    • Local Organization

    • Other, please specify ____________

  4. Were PHHS Block Grant funds used to respond to an emerging need or outbreak as part of the program? [Yes/No]

  5. What was the funding role of the PHHS Block Grant for this program? *Choose one

    • Total source of funding (skip to question 13)

    • Supplement other existing funds

  6. (If the answer to question 10 was “Total Source of Funding”, skip this question, if it was “Supplement other existing funds”, answer this question) What percentage of the funding for this program is PHHS Block Grant funding? [Number (percentage)]

  • Less than 10% - Minimal source of funding

  • 10-49% - Partial source of funding

  • 50-74% - Significant source of funding

  • 75-99% - Primary source of funding

  1. (If the answer to question 10 was “Total Source of Funding”, skip this question, if it was “Supplement other existing funds”, answer this question) What existing funding source(s) will PHHS Block Grant funds supplement?

    • State or local funding

    • Other federal funding (CDC); please specify ___________

    • Other federal funding (non-CDC)

    • Funding from NGO or non-profit organization

    • Funding from for-profit organization

    • Tribal, district (i.e. DC) or territorial funding

    • Other; please specify _________

  2. Role of PHHS Block Grant Funds in Supporting this Program: *Choose one

    • Startup of a new program

    • Maintain existing program (as is)

    • Enhance or expand the program

    • Restore program

Positions Funded by PHHS Block Grant

  1. Are there any positions funded by the PHHS Block Grant? [Yes/No]

    1. If Yes, continue

    2. If No, skip to question 22

User will ‘Add New Position’ and answer the following questions for each position funded with PHHSBG money.

  1. Position Title: [Position Title]

  2. Is this position vacant? [Yes/No]

    1. If Yes, skip questions 17/18 and answer question 19

    2. If No, answer questions 17/18 and skip question 19

  1. (If answer to question 16 is yes, skip this question, if no, answer this question) Staff Name in Position: [Staff Name]

  2. (If answer to question 16 is yes, skip this question, if no, answer this question) Percent of staff member’s time spent working in each area (funded with PHHS Block Grant dollars):

    • Jurisdiction-level: [% Time]

    • Local: [% Time]

    • Other: [% Time]

    • Total: [% Total time funded with PHHSBG dollars]

  3. (If answer to question 16 is yes, answer this question, if no, skip this question) Describe the recruitment/hiring plan to fill the vacant position: [Short Text]

  4. Total Positions in this program Funded by the PHHS Block Grant: [Number]

  5. Number of FTEs in this Program funded by the PHHS Block Grant (this is how many full-time positions your total number of positions is equivalent to; e.g. two 50% positions would equal one FTE): [Number]

Define the Problem this Program will Address

  1. One-sentence summary of the problem this program will address: [Text]

  2. One-paragraph description of the problem this program will address: [Text]

  3. How was the public health problem prioritized? *Select all that apply

    • Conducted, monitored, or updated a jurisdiction health assessment (e.g., state health assessment)

    • Conducted a topic- or program-specific assessment (e.g., tobacco assessment, environmental health assessment)

    • Identified via surveillance systems or other data sources

    • Prioritized within a strategic plan

    • Declared as an emergency within your jurisdiction

    • Governor (or other political leader) established as a priority

    • Legislature established as a priority

    • Tribal government/elected official established as a priority

    • Other (please specify): __________

  1. Describe in one paragraph the key indicator(s) affected by this problem: [Text]

  2. Baseline value of the key indicator described above: [Number]

  3. Data source for key indicator baseline: [Text]

  4. Date key indicator baseline data was last collected: [Date – either year or full date]

Program Strategy

  1. One-sentence program goal: [Short Text]

  2. Is this program specifically addressing a Social Determinant of Health (SDOH)? [Yes/No]

    1. If Yes, continue

    2. If No, skip to question 32

  1. [If answer question 30 was Yes, answer this question, otherwise skip to question 32] Which SDOH are you addressing with this program? *Select all that apply

    • Economic Stability (e.g. poverty, unemployment, food insecurity, housing instability)

    • Education (e.g. low high school graduation rates, low literacy levels, poor early childhood education)

    • Social and Community Context (e.g. discrimination, low civic participation, poor workplace conditions, incarceration)

    • Health and Health Care (e.g. poor access to healthcare, low health insurance coverage, low health literacy)

    • Neighborhood and Built Environment (e.g. poor quality of housing, limited access to transportation, food desert, poor water/air quality, neighborhood crime and violence)

    • Adverse Childhood Experiences (ACEs)

  2. One-paragraph summary of program strategy: [Text]

  3. List of primary strategic partners: [Text]

  4. (OPTIONAL) Planned non-monetary support to local agencies or organizations: *Select all that apply

    • Technical Assistance

    • Training

    • Resources/Job Aids

    • Other (please specify) ____________

  1. One-paragraph summary of evaluation methodology: [Text]

  2. Program Setting(s): *Select all that apply

    • Business, corporation or industry

    • Child care center

    • Community based organization

    • Faith based organization

    • Home

    • Local health department

    • Medical or clinical site

    • Parks or playgrounds

    • Rape crisis center

    • Schools or school district

    • Senior residence or center

    • State health department

    • Tribal nation or area

    • University or college

    • Work site

    • Other, please specify___________________

Target Population of Program

In the target population section, only answer the questions that apply to your overall target population of the Program. You will be able to specify your target population to each Program SMART Objective in the Objectives and Activities UIC.

  1. Target population data source (Include Date): [Short Text]

  2. Number of people served: [Number]

  3. Ethnicity:

    • Hispanic or Latino

    • Not Hispanic or Latino

  1. Race: *Select all that apply

    • American Indian or Alaskan Native

    • Asian

    • Black or African American

    • Native Hawaiian or Other Pacific Islander

    • White

  2. Age: *Select all that apply

    • Under 1 year

    • 1 - 4 years

    • 5 - 14 years

    • 15 - 24 years

    • 25 - 34 years

    • 35 - 44 years

    • 45 – 54 years

    • 55 - 64 years

    • 65 – 74 years

    • 75 – 84 years

    • 85 years and older

  3. Sexual Orientation: *Select all that apply

    • Gay (lesbian or gay)

    • Straight, this is not gay (or lesbian or gay)

    • Bisexual

    • Something else

    • I don’t know the answer

  1. Gender Identity: *Select all that apply

    • Male

    • Female

    • Transgender

    • None of these

  2. Geography: *Choose one

    • Rural

    • Urban

    • Both

  1. Location (e.g. close to a factory, specific zip code, county): [Short Text]

  2. Occupation: [Short Text]

  3. Educational Attainment: *Select all that apply

    • Some High School

    • High School Diploma

    • Some College

    • College Degree

    • Graduate Degree

  4. Health Insurance Status: *Select all that apply

    • Uninsured

    • Medicaid

    • Medicare

    • Private Health Insurance

    • Affordable Care Act Plan

    • Other, please specify ______________

  5. Primarily Low Income: *Choose one

    • Yes

    • No

  1. Are members of this target population disproportionately affected by the problem? [Yes/No]

    1. If Yes, answer question 51

    2. If No, complete

  1. (If answer to question 40 was Yes, answer this question, otherwise skip) Is the entire target population disproportionately affected by the Problem, or only part? *Choose one

    • All

    • Part (Present a disparate population form that contains the same fields as the target population)





Objectives and Activities Data Collection Instrument

The Block Grant Coordinator or Program Manager will fill in the following information about Program SMART Objectives and Activities for each program funded by the PHHS Block Grant. The Objective and Activity UIC is connected to several other entities which contains pertinent information about the recipient’s program plan.

Program Information

  1. Name of Program SMART Objective (this is the SMART Objective at the program level): [Text]

  2. Is the problem for this objective the same as the problem for the program as a whole, or is it a subset of the larger problem?

    • The problem is the same (Skip to question 9 - SMART Objective)

    • This Program SMART Objective focuses on a subset of the larger problem (Answer questions 3-8)

  3. Please provide a one-sentence summary of the problem for this objective: [Text]

  4. Please provide a one-paragraph description of the problem for this objective: [Text]

  5. Describe in one paragraph the key indicator(s) affected by this problem: [Text]

  6. Baseline value for the key indicator described above: [Number]

  7. Data source for key indicator baseline: [Text]

  8. Date key indicator baseline data was last collected: [Date – can be full date or just year]

  9. Program SMART Objective: [Text]

Intervention Information

  1. One-sentence summary of intervention: [Text]

  2. One-paragraph description of intervention: [Text]

  3. Is this an evidence-based intervention, or an innovative/promising practice? *Choose one

    • Evidence-Based Intervention

    • Innovative/Promising Practice (Skip question 13)

  1. (If answer to question 12 was “Innovative/Promising Practice, skip this question) Evidence Source for Intervention: *Select all that apply

    • Best Practice Initiative (U.S. Department of Health and Human Services)

    • Guide to Clinical Preventive Services (Task Force on Community Preventive Services)

    • MMWR Recommendations and Reports (Centers for Disease Control and Prevention)

    • Model Practices Database (National Association of City and County Health Officials)

    • National Guideline Clearinghouse (Agency for Healthcare Research and Quality)

    • Promising Practices Network (RAND Corporation)

    • Other (describe) ________________________

  1. Rationale for choosing the intervention: [Text]

  2. Item to be Measured: [Short Text]

  3. Unit of Measurement: [Short Text]

  4. Baseline value for the item to be measured: [Number]

  5. Data source for baseline value: [Text

  6. Date baseline was last collected: [Date]

  7. Interim target value to be achieved by the Annual Progress Report: [Number]

  8. Final target value to be achieved by the Final Progress Report: [Number]



Target Population of Program

In the target population section, only answer the questions that apply to your target population of the Program SMART Objective.

  1. Is the Target Population of this Program SMART Objective the same as the Target Population of the Program or a subset of the Program Target Population?

    • Same as the Program (Skip to question 36)

    • Sub-set of the Program (Answer questions 23-35)

  2. Target Population Data Source (Include Date): [Short Text]

  3. Number of People Served: [Number]

  4. Ethnicity:

    • Hispanic or Latino

    • Not Hispanic or Latino

  1. Race: *Select all that apply

    • American Indian or Alaskan Native

    • Asian

    • Black or African American

    • Native Hawaiian or Other Pacific Islander

    • White

  1. Age: *Select all that apply

    • Under 1 year

    • 1 - 4 years

    • 5 - 14 years

    • 15 - 24 years

    • 25 - 34 years

    • 35 - 44 years

    • 45 – 54 years

    • 55 - 64 years

    • 65 – 74 years

    • 75 – 84 years

    • 85 years and older

  1. Sexual Orientation: *Select all that apply

    • Straight, this is not gay (or lesbian or gay)

    • Gay (lesbian or gay); Bisexual

    • Something else; please specify_______________

  1. Gender Identity: *Select all that apply

    • Female

    • Male

    • Transgender

    • Additional gender category (or other); please specify ______________

  1. Geography: *Choose one

    • Rural

    • Urban

    • Both

  1. Location (e.g. close to a factory, specific zip code, county): [Short Text]

  2. Occupation: [Short Text]

  3. Educational Attainment: *Select all that apply

    • Some High School

    • High School Diploma

    • Some College

    • College Degree

    • Graduate Degree

  4. Health Insurance Status:

    • Uninsured

    • Medicaid

    • Medicare

    • Private Health Insurance

    • Affordable Care Act Plan

    • Other, please specify ______________

  5. Primarily Low Income: *Choose one

    • Yes

    • No

  1. Are any members of this target population disproportionately affected by the Problem described above?

    • Yes

    • No (Skip question to 38)

  1. Does the entire target population experience health disparities, or only part? *Choose one

    • All

    • Part (Present a disparate population form that contains the same fields as the target population)



Activities

Recipients will add multiple activities for each Program SMART Objective. They will push “Add New Activity” and answer questions 38-44 for each activity.

  1. Activity Title: [Activity Title]

  2. One-sentence summary of the Activity: [Short Text]

  3. One-paragraph description of the Activity: [Text]

  4. Does the activity include the collection, generation, or analysis of data? [Yes/No]

  5. Does the data collection involve public health data? [Yes/No]

    • If Yes, you will need to complete and upload a DMP

    • If No, you will be contacted by your PO to provide additional information about the data collection by x date.

  6. (If YES to question 42) Upload DMP file: [File Upload]

  7. (Optional) Additional information about the activity: [Text]







CDC estimates the average public reporting burden for this collection of information as 12 hours per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0879).


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