Annual Progress Report Worksheet

Form Approved

OMB #: 0920-0106

Expiration: 2/29/2024

Attachment G: Annual Progress Report Worksheet

Instructions: Complete this form for each program listed in the work plan.

Note: fields in gray that include the note [Auto-populated from...] will be automatically filled in based on the information in the work plan.

Program Report Table

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

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

3. Work Plan Name: [Auto-populated from Program Information Data Table > Work Plan Name]

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

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

6. Program Fiscal Year: [Auto-populated from Program Information Data Table > Fiscal Year]

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

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

• Yes

• No

9. If you used PHHS Block Grant funding to gain additional support for this program during this federal fiscal year, 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 [Short Text]

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

    1. No

    2. Yes, monetary support

    3. Yes, non-monetary support

    4. Yes, both monetary and non-monetary support

11. Would you like to highlight this program as a success story? *Choose One

    1. Yes

    2. No

12. (Required if you answered Yes to Q1) 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. Yes

    2. No

14. Please briefly describe the products created from PHHS Block Grant funds and provide any links to access the products: [Short Text]

Key Challenges

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

18. What did you learn about the innovative approaches or promising practices you used? Please enter N/A if you selected "Did not use Innovative/Promising Practice": [Text]

19. (Required Final APR) Did you share your findings from the promising practice used? [Yes/No]

20. (Required if you answered Yes to Q19) Please provide links or citations. [Short Text]

21. Final APR Partners: Has the partner information changed? *Choose One

    1. Yes

    2. No

22. (IF YES): CREATE either new Monetary or Non-Monetary Partner

23. Monetary Partner

    1. Program Name: [use search lookup tool]

    2. Monetary Partner Name

    3. Partner Type *choose one

• Local Health Department

• Tribal Health Department/Agency

• Other Local Government

• Local Organization

• Other: Please specify [text]

4. Type of Funding Mechanism Used *choose one

• Grant

• Contract

• Other: Please Specify [Text]

5. Funded Amount (please enter number amount without dollar signs)

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

24. Non-Monetary Partner

    1. Program Name: [use search lookup tool]

    2. Non-Monetary Partner Name

    3. Partner Type *choose one

• Local Health Department

• Tribal Health Department/Agency

• Other Local Government

• Local Organization

• Other, please specify [Short Text]

4. Type of Support (please select all that apply):

• Technical Assistance

• Training

• Resources/Job Aids

• Other: Please specify [text]

Local Support

25. (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. Program Name [use search module to select from list of programs]

    2. Monetary Partner Name: [Short Text]

    3. Partner Type: *choose one

• Local Health Department

• Tribal Health Department/Agency

• Other Local Government

• Local Organization

• Other, please specify [Short Text]

1. Type of Funding Mechanism Used:

• Grant

• Contract

• Other, please specify [Short Text]

1. Funded Amount: [Text]

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

1. 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. Program Name [use search module to select from list of programs]

   2. Partner Name: [Short Text]

   3. Partner Type: *choose one

• Local Health Department

• Tribal Health Department/Agency

• Other Local Government

• Local Organization

• Other, please specify ____________

4. Type of Support *Select all that apply

• Technical Assistance

• Training

• Resources/Job Aids

• Other (please specify) ____________

Objectives and Activities Report Table

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

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

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

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

31. Achieved so Far: [Number]

32. Met/Not Met: *Choose one

33. (Optional) If interim target was not met, enter amount below target. [number]

34. If interim target was not met, what are the key factors that contributed to the target not being met? [Text]

35. If the interim target was not met, what are you planning to do to get the program back on target to meet your final target? [Text]

36. 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)

37. 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]]

38. Achieved: [Number]

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

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

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

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

43. If the target was not met by Interim APR, what did you do to get the program back on track? (if not applicable, enter N/A): [Text]

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

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

Activities

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

47. Program Name: [use search lookup tool]

48. Status: *Choose one

• Met

• Not Met

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

49. Please provide a one-sentence explanation if cancelled: [Text]

50. Summary of Outcome: [Text]

51. Click Save in the blue box to close the activity. Complete all additional activities within the objective. Once all the activities have been completed, click Submit at the bottom of the objectives page to save your work and move on to the next objective. Complete steps 1-10 (above) for each objective.

CDC estimates the average public reporting burden for this collection of information as 11 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 Reports Clearance Officer; 1600 Clifton Road NE, HS 21-8, Atlanta, Georgia 30333 ATTN: PRA (0920-0106)