Annual Progress Report Instruments

Annual Progress Report Data Collection Instrument

Program Report Table

1. Program Name: [Auto-populated from Program Information Data Table > Program Name]

2. Healthy People 2030 Objective: [Auto-populated from Program Information Data Table > Healthy People 2030 Objective]

3. Recipient Health Objective: [Auto-populated from Program Information Data Table > Recipient Health Objective]

4. Program Goal: [Auto-populated from Program Strategy > Program Goal]

5. Program Strategy: [Auto-populated from Program Strategy > Summary of Program Strategy]

6. Evaluation Methodology: [Auto-populated from Program Strategy > Evaluation Methodology]

7. Primary Strategic Partners: [Auto-populated from Program Strategy > Primary Strategic Partners]

8. Program Setting: [Auto-populated from Program Strategy > Primary Strategic Partners]

9. Did you use PHHS Block Grant funding to gain additional support for this program during this federal fiscal year? *Choose one

• Yes

• No (Skip to question 11)

10. (If answer to question 9 was No, skip this question) What best describes the additional support you received? *Select all that apply

• The Block Grant provided seed funding (e.g., to do a pilot of a promising program)

• We blended Block Grant funding with funding from other sources

• Block Grant funding enabled us to receive matching funds from another source

• We received in-kind support from another source (e.g., resources, staffing)

• We gained increased buy-in or leadership support for the program

• Block Grant funds were leveraged with resources from other organizations to contribute to jurisdiction-wide priority

• Other, please specify_______________

11. Would you like to highlight this program as a success story? [Yes/No]

    1. If Yes, answer question 12

    2. If No, skip to question 13

12. (If answer to question 11 was No, skip this question) Please describe why you chose to highlight this program: [Short Text]

13. Were there any products (publications, conferences etc.) that came from activities funded by PHHS Block Grant money? [Yes/No]

    1. If Yes, answer question 14

    2. If No, skip to question 15

14. (If answer to question 13 was No, skip this question) Please briefly describe the products created from PHHS Block Grant funds and provide any links to access the products: [Short Text]

Lessons Learned

15. What were the key challenges or barriers to success that you experienced to date in this program this year? [Text]

16. What strategies did you use to address those challenges or barriers? [Text]

17. If you used innovative approaches/promising practices in this program, did they meet your criteria for success? *Choose one

• Yes

• No

• Did Not Use Innovative/Promising Practices (Skip to question 21)

18. (If answer to question 17 was “Did Not Use Innovative/Promising Practice” skip this question) What did you learn about the innovative approaches or promising practices you used? [Text]

19. (Optional - If answer to question 17 was “Did Not Use Innovative/Promising Practice” skip this question) Did you share your findings from the promising practice used? [Yes/No]

    1. If YES, answer question 20

    2. If NO, skip to question 21

20. (If answer to question 17 was “Did Not Use Innovative/Promising Practice” skip this question AND if answer to question 19 was No, skip this question) (Optional) How did you share your findings? Please provide links or citations. [Short Text]

Local Support

21. Did you provide support (monetary or non-monetary) to any local agencies or organizations?

• No (Skip to question 24)

• Yes, monetary support (Answer question 22, skip question 23)

• Yes, non-monetary support (Skip question 22, answer question 23)

• Yes, both monetary and non-monetary support (Answer questions 22 and 23)

22. (If answer to question 21 was “Yes, monetary support” or “Yes, both monetary and non-monetary support” answer this question, otherwise skip) Please list the local agencies/organizations you provided with MONETARY support. [First line on table will appear by default and be followed by a button/option to Add Another] [They will complete the following questions for each partner]

    1. Partner Name: [Short Text]

    2. Partner Type: *choose one

• Local Health Department

• Tribal Health Department/Agency

• Other Local Government

• Local Organization

• Other, please specify ____________

1. Type of Funding Mechanism Used:

• Grant

• Contract

• Other, please specify______________

1. Funded Amount: [Currency]

2. Purpose of Funds (e.g. to host an event, given as a grant): [Short Text]

1. (If answer to question 21 was “Yes, non-monetary support” or “Yes, both monetary and non-monetary support” answer this question, otherwise skip) Please list the local agencies/organizations you provided with NON-MONETARY support [First line on table will appear by default and be followed by a button/option to Add Another] [They will complete the following questions for each partner]

   1. Partner Name: [Short Text]

   2. Partner Type: *choose one

      • Local Health Department

      • Tribal Health Department/Agency

      • Other Local Government

      • Local Organization

      • Other, please specify ____________

   3. Type of Support *Select all that apply

• Technical Assistance

• Training

• Resources/Job Aids

• Other (please specify) ____________

Objectives and Activities Report Table

24. Program SMART Objective Name: [Auto-populated from Objectives & Activities > Objective Information > Program SMART Objective Name]

25. Type of Intervention: [Auto-populated from Objective Information > Evidence-based or innovative/promising practice]

26. Selection Rationale: [Auto-populated: IF EVIDENCE-BASED from Objectives & Activities > Objective information > Evidence Source for Intervention OR IF INNOVATIVE/PROMISING from Objectives & Activities > Objective Information > Rationale for Innovative / Promising Practice]

27. Program SMART Objective: [Auto-populated from Objectives & Activities > Objective Information> Program SMART Objective]

28. Baseline: [Auto-populated from Objectives & Activities > Objective Information> baseline value]

(If report type is APR – answer this set of questions)

29. Interim Target: [Auto-populated from Objectives & Activities > Objective Information, in the format: Your interim target was [Interim Target Value] [unit of measurement]s [item to be measured]]

30. Achieved so Far: [Number]

31. Met/Not Met: [Auto-populated based on the number entered]

32. Distance from Target: [Auto-populated, calculated in system]

33. (IF NOT MET) What are the key factors that contributed to the target not being met? [Text]

34. (IF NOT MET) What are you planning to do to get the program back on target to meet your final target? [Text]

35. One-sentence summary of results towards this Program SMART Objective: [Short Text]

36. One-paragraph description of results towards this Program SMART Objective: [Short Text]

(If report type is Final Progress Report – answer this set of questions)

36. Final Target: [Auto-populated from Objectives & Activities > Objective Information, in the format: Your final target was [final Target Value] [unit of measurement]s [item to be measured]]

37. Achieved: [Number]

38. Met/Not Met: [Auto-populated based on the number entered]

39. Distance from Target: [Auto-populated, calculated in system]

40. (IF NOT MET) What are the key factors that contributed to the target not being met? [Text]

41. (IF NOT MET) What are you planning to do to address these factors in the future? [Text]

42. One-sentence summary of results towards this Program SMART Objective: [Short Text]

43. One-paragraph description of results towards this Program SMART Objective: [Short Text]

Activities

44. Activity: [Auto-populated from Objectives & Activities > Activity Information> Activity Name]

45. (IF REPORT IS APR) Status: *Choose one

• On track to meet target

• At risk of not meeting target

• Canceled *If selected, answer follow-up that will pop-up

  1. Please provide a one-sentence explanation: [Text]

46. (IF REPORT IS FINAL PROGRESS) Status: *Choose one

• Complete

• Not Complete

• Canceled *If selected, answer follow-up that will pop-up

  1. Please provide a one-sentence explanation: [Text]

47. (IF REPORT IS APR) Summary of Activity Status: [Text]

48. (IF REPORT IS Final Progress Report) Summary of Outcome: [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 (0920-0106).