0920-24AA Annual Performance Report (APR) Tool

APR FORM DRAFT

Attachment 3. Annual Performance Report (APR) Tool
Form Approve
OMB No: xxxx-xxxx
Exp. Date: xx-xx-xxxx
Public Reporting burden of this collection of information is estimated at 10 hours, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports
Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA 30333; Attn: PRA (xxxx-xxxx).

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 (February 1, 2024 – August 1, 2024). The required goals and objectives are prefilled
for all recipients. * Goals and objectives shown below may be updated to reflect specific NOFO requirements.
REQUIRED GOALS AND OBJECTIVES
GOAL

OBJECTIVE(S)

Objective 1A. Build internal program capacity to facilitate and monitor the
implementation of prevention programs/policies.
Goal 1: Build Infrastructure
Objective 1B. Conduct/promote training to build capacity of partner
for Sexual Violence Prevention organizations to promote health equity.
Objective 1C. Conduct or leverage an existing primary prevention capacity
assessment with a focus on health equity.
Objective 2A. Develop or enhance an existing state/territory action plan (in
collaboration with SA coalitions, Tribal SA coalitions, and representatives from
underserved communities of the State or Territory) to support state- and
Goal 2. State/Territorial
community-level implementation and sustainability of SV prevention.
Action Plan
Objective 2B. Participate in meaningful engagement with SA coalitions, Tribal
SA coalitions, representatives from underserved communities of the State or
Territory and other collaborators working to prevent SV.
Objective 3A. Identify, implement, and adapt SV prevention strategies that
Goal 3. Implement SV
increase health equity through reduced disparities in targeted SDOH, with a
Prevention Approaches
focus on implementation at the community- and societal-levels

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Goal 4. Data to Action

Objective 4A. Gather and synthesize publicly available state-, territory- and
community-level data to inform SV prevention, track disparities in targeted
SDOH and rates of SV in priority populations, and use this data to select
communities and populations for intervention and to improve programmatic
activities
Objective 4B. Develop and implement an equity-focused evaluation plan (in
collaboration with SA coalitions and Tribal SA coalitions)
Objective 4C. Use program monitoring and evaluation data and other available
data to improve SV prevention strategy implementation

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]

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MILESTONE TABLE

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

Question Instructions/Options
Provide a concise statement of the milestone.
Provide a brief description of activities conducted to
complete the milestone

Expected Milestone Achievement Date
#.# Milestone Status [Choose one from
dropdown]
Please provide reasons for delayed or
discontinued work [3000]

• In Progress (on track)
• Delayed: Please add comments
• Completed
• Discontinued: Please add comments
*only if Milestone Status = Delayed or Discontinued

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 (February 1, 2025 – Jan 31, 2026). 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 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]

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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? [6000]
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 Project 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 in the portal.
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: [Choose one from dropdown]
•
•
•
•
•
•
•
•
•
•

Description of TTA Request [1000]

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

Timeframe [Choose one from
dropdown]
•
•
•
•
•

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
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Instructions for Recipients
The Challenges, Supports and Accomplishments form collects information about challenges, facilitators, and
successes that your program 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 dropdown for the barrier type.
• The “Other” answer option for barrier type is selected only if the barrier does not fall within the existing
answer options.
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]

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•
•
•
•
•
•
•
•
•
•

Lack of buy-in from
partners
Lack of community
engagement
Insufficient funding or
resources
Inability to
access/collect data
Implementation issues
Evaluation issues
Staffing issues
Lack of skills or capacity
State or local climate
Other (not listed):
Please specify

•
•
•
•
•
•
•

Work Plan
State Action Plan/Strategic
Plan
Prevention Strategies
Data to Action
Evaluation
Sustainability
Capacity Assessment

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.

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Facilitator Type: [Choose one from
dropdown]

•
•
•
•
•
•
•
•
•

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

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

Program Component: [Select all
that apply]

•
•
•
•

Work Plan
State Action Plan/Strategic
Plan
Prevention Strategies
Data to Action
Evaluation
Sustainability

•

Capacity Assessment

•
•

What
resources
were
used
[2000]

Facilitator
Comments:
[500]

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.

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Program Component: [Select all that apply]

•
•
•
•
•
•
•

What key accomplishments related to this NOFO has
your organization/state/territory/tribe achieved
during this reporting period? [6000]

Work Plan
State Action Plan/Strategic Plan
Prevention Strategies
Data to Action
Evaluation
Sustainability
Capacity Assessment

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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
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•
•
•

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 health equity and 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
300 characters

Topic
300 characters

Audience
300 characters

Dates

FORM 4: ACTION PLAN
Instructions for Recipients
The Action Plan form collects information about progress on the Action Plan (e.g., enhancing partnerships, state
violence prevention planning and coordination) during the reporting period (February 2, 2024 – August 2, 2024).
This form has three sections:
A. Progress on Action Plan
B. Progress on Implementing Action Plan
C. Partnerships
SECTION 1: PROGRESS ON ACTION PLAN

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

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

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

CHANGES TO THE ACTION PLAN TABLE

Report on any changes to specific section(s) of the Action Plan changed during the reporting period. Choose each
component of the Action Plan that was changed, describe the change, the reason for the change, and how the
change affects your program’s work.

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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/Tribal
collaboration
• Resources/Funding
• Training/Technical
Assistance
• Sustainability
• Health Equity
• Data Use/Sources
• Capacity Assessment
• Other (not listed): Specify

SECTION 2: PROGRESS AND PLANNED ACTIVITIES FOR ACTION PLAN
Please describe any key activities/accomplishments specifically related to implementation of the Action Plan. This
does not include activities or accomplishments that are specific to your selected approaches. Those will be
reported on in other forms.
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]

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•
•
•
•
•
•
•
•
•
•

Funding Acquisition
Training/Capacity Building
Community engagement
Partner 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 reduce health inequities by
addressing social determinants of health that impact violence that are prioritized for your state-, community-,
and tribal-level activities.

ACTION PLAN KEY ACTIVITIES FOR UPCOMING YEAR TABLE

Describe key planned Action Plan activities in the next budget period (February 1, 2025 – January 31, 2026)
(700 characters)

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

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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’ Rape Prevention and Education 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, community-level, and tribal partners.

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Name of
Partner
Organization

Primary Sector

•
•
•
•

•

•
•
•
•
•
•
•

•

•
•

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

Role of Partner

•
•
•
•
•
•
•
•
•
•
•

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

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

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

•

•
•
•
•

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

State-,
Community-, or
Tribal-level
Partner [Select
all that apply]

•
•
•

State
Community
Tribal

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FORM 5: IMPLEMENTATION
Instructions for Recipients
The Implementation Form collects information about each state-level program, policy, or practice that your
organization implemented using Rape Prevention and Education program funding during the reporting period
(February 1, 2024 – August 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.

Strategy

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

Program, Policy, or
Practice

Approach

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

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

As you answer questions about the 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.

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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. If you are implementing a program, practice or
policy in multiple settings you will complete one implementation submission form fand provide details
about separate implementations in the Section 5 (Reach).
• If you are implementing a program, policy, or practice across multiple sub-recipients you should submit
one implementation form for that program, policy, or practice and list out sub-recipient specific
activities, adaptations, and reach in those sections.
• Any training associated with TA, capacity building, or strategic planning should be reported in other
forms instead of the Implementation Form.
• 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 VetoViolence Approach Search tool.
Program, Policy, or Practice
Indicate which of the following aspects you are implementing as part of this implementation effort? [Select all
that apply]
• 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.

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

Strengthen household financial security
Family-friendly policies
Improve school climate and safety
Improve organizational environments
Reduce exposure to community-level risks
Modify the physical and social environment
Bystander approaches
Men and boys as allies in prevention
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.

Is this Implementation Effort the continuation of a program, policy, or practice from 19-1902?
•
•

Yes
No

SECTION 2: CHANGES TO IMPLEMENTATION PLAN

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

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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 activities, make sure that
each entry is a discrete type of activity that best measures and demonstrates implementation progress. You will
need to enter the Activity Type, a description of the activity, Activity Status, and the Project Year the activity was
completed.

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Activity Type: [Select one
from dropdown]

•
•
•
•
•
•

•

Planning
Training/Coaching
Executing
Coordinating
Monitoring
Collecting and using data
to improve
implementation
Other (not listed): specify

Description of
Activity:
[2000]
Provide a
description of
the activity and
include with
sufficient detail
what the activity
entailed, who
was involved,
and if any
resources are
needed.

Number of
Sites/Locations
Activity
Implemented at

Activity Status:
[Select one from
dropdown]

Insert numeric value

•
•
•
•

In Progress (on
track)
Delayed
Completed
Discontinued

Project Year
Completed: [Select one
from dropdown]

•
•

Not Yet Complete
Year X

Additional years added as
appropriate

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

SECTION 4: ADAPTATIONS

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

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Type of
Adaptation:
[Choose one from
dropdown]

•
•
•
•

•

•

•

•

•

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

Adaptation
Description
[1000]

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

Number of
Sites/Locations
Adaptation
Implemented At

Reason for
Adaptation: [Choose
one from dropdown]

Insert numeric value

•
•

•

•

•

•
•
•

•

•

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

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

How was this
adaptation
evaluated and
what was the
impact of the
adaptation?
[2000]
Describe the impact
this adaptation has
had on the
prevention effort
including the impact
on the implementers
of the effort and the
population targeted
by the effort.

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APR FORM DRAFT

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

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

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

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

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

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

Immigrants
Migrant workers
Refugees
Asylum seekers
Undocumented status
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•

Other: Please Specify

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

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

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

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

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

Men
Women
Non-binary
Transgender
Other: Please Specify

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

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

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

Experiencing homelessness
Experiencing poverty
Receiving government aid
Other: Please Specify

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

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

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

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

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APR FORM DRAFT

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.
Implementing
Organization
[500]
Insert Text

Name of
Setting

Insert Text

Setting [Select one]

•
•
•
•
•

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

•

Other: Please Specify

•
•
•
•
•
•
•
•
•
•

Geographic
Location

Description
(1000
characters)

Year 5
Target for
Settings

Insert Text

Insert Numeric
Value

Number of
Settings
Reached this
Reporting
Period

Progress
Notes
(2000
characters)

Insert Numeric
Value

Insert Text

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

•

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

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.
Implementing
Organization
[500]

Description
of
Population
[1000]

Year 5
Target for
Individuals
Reached

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)

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APR FORM DRAFT

Insert Text

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)

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

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 (February 1, 2024 – August 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
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APR FORM DRAFT

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 questions shown
below may be updated to reflect specific NOFO requirements.
Evaluation Questions
•
•
•
•
•
•
•
•

Q1. To what extent has the recipient accomplished the short term and intermediate outcomes in the
NOFO logic model?
Q2. To what extent has the recipient increased internal and partner capacity to facilitate/monitor the
implementation of SV prevention strategies and promote health equity?
Q3. To what extent has the recipient leveraged multisector partnerships and resources toward SV
prevention?
Q4. To what extent has the recipient implemented strategies that address SDOH?
Q5. To what extent has the recipient achieved high-quality implementation of SV prevention strategies
that increase health equity at the community- and societal levels?
Q6. To what extent has the recipient increased use of data-driven decision making, as well as
state/territory- and community-level monitoring of trends, related SV prevention and SDOH?
Q7. Which factors are critical for implementing selected prevention strategies and approaches?
Q8. 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.
Describe key planned Evaluation activities in the next budget period (February 1, 2025 – January 31, 2025)
(700 characters)

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APR FORM DRAFT

RESOURCES NEEDED FOR IMPLEMENTING EVALUATION PLAN ACTIVITIES IN UPCOMING YEAR (700
CHARACTERS)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.

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APR FORM DRAFT
Associate
d Effort(s)
(Select all
that
apply)
Goal 1
Goal 2
Goal 3
Goal 4
Other

Evaluatio
n
Questions
Addresse
d [Select
all that
Apply]
Questions
#1-7

Description
of Outcome

Type

Indicator
Description [500]

Data Source
Type [Select all
that apply]

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

Select one (1)

Insert Text

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

• Process
• Program/P
olicy
Specific
• Risk Factor
• Protective
Factor
• Violence
Outcome
• NOFO Level
• Other (not
listed)

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

Data
Source
Name and
Description
[500]

Indicator
Populati
on

Baseline
Value

Current
Value

Year 5
Goal

Change in
Outcome
since last
reporting
period

Progress
Notes

[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.

[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.

Insert
Numeri
c Value

• Moving
Towards
Target
• No
Change
• Moving
Away
From
Target
• Target
Met
• Target
Exceede
d
• Unknow
n

Insert Text

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

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

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APR FORM DRAFT
FORM 7: DATA TO ACTION
Instructions for Recipients
The Data to Action Form collects information about progress on data to action activities conducted during the reporting period (February 2, 2024
– August 2, 2024). This form has two sections: 1) Data Collection and Use, and 2) Data Dissemination.

SECTION 1: DATA COLLECTION AND USE

This section collects information about the progress you have made in the collection, analysis, and use of Sexual Violence data, data on the social
determinants of health, and data on shared risk and protective factors.
Data
Data Access and Use
Data Source Type

Data Source
(Name)

•
•
•
•
•
•
•
•
•

Needs Assessment
Surveillance data
Police data
Hospital data
Surveys
Interviews
Focus groups
Administrative data
Other (not listed):
Specify

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]

• Select population of focus
• Select prevention
strategies/approaches/programs
• Select sub-recipients or
community partners
• Address health disparities
• Inform Action Plan
• Inform program or policy effort
implementation
• Complete Evaluation

SECTION 2: 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.
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APR FORM DRAFT
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]
• Released new or updated data dashboard or
data website
• Released new or updated infographic
• Released new or updated fact sheets
• Released new or updated report
• Published manuscript/scientific publication
• Other (please specify)

Description of Activity [1000]

Core Audience [Select all that
pply]
• General public
• State agencies or governmental
partners
• Non-profit or community
partners
• Policymakers
• Other, specify

Page 30

Reach of Efforts [50]