0920-24EZ Cooperative Agreement Work Plan Template

Form Approved

OMB 0920-xxxx

Exp. 0x/xx/2027

Cooperative Agreement Work Plan Template

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Section 1. Cooperative Agreement Work plan Component A
Objective 1:	By # days post-award, establish and convene a Regional Coordinating Body
Implementation Timeframe	Start Date: MM/DD/YYYY				End Date: MM/DD/YYYY
	Target date		Responsible Position or Party		Progress or Process Measure(s)		Status
Activity 1:
Activity 2:
Activity 3:
Activity 4:
Activity 5:
Setting	Regional Tribal	State		Territorial		Local
Collaboration and Coordination	Describe collaboration and coordination activities with STLT health departments and officials, health care facilities, and health care coalitions to improve public health preparedness and response.
Health Equity Considerations	Are considerations to increase the likelihood that health equity can be addressed integrated into the decision-making process when developing and convening the regional coordinating body? Yes ☐No ☐Not Applicable If yes to Question 1, how? If no, please explain why not. [Include text here] Has the center considered the burden of social determinants of health on populations with access and functional needs, low socioeconomic status, and communities experiencing racism? Yes ☐No ☐Not Applicable
Objective 2:	By # days post-award, develop a Five-Year Regional Work Plan, FY2025-2030 with priority areas and objectives, and STLT PHPR focus areas
Implementation Timeframe	Start Date: MM/DD/YYYY				End Date: MM/DD/YYYY
	Target date		Responsible Position or Party		Progress or Process Measure(s)		Status
Activity 1:
Activity 2:
Activity 3:
Activity 4:
Activity 5:
Setting	Regional	State		Territorial		Local		Tribal

Collaboration and Coordination	Describe collaboration and coordination activities with applicable STLT health departments and officials, health care facilities, and health care coalitions to improve public health preparedness and response.
Health Equity Considerations	Has the coordinating body considered the evidence base documenting drivers of health disparities and inequities to inform development of the objective? If yes, how? If no, please explain why not. [Include text here] Are considerations for health equity integrated into the decision-making process when developing and framing the focus areas, objectives, and priorities? Yes ☐ No ☐ Not Applicable f yes, how? If no, please explain why not. Has the planning process considered the burden of social determinants of health on populations with access and functional needs, low socioeconomic status, and communities experiencing racism? Yes ☐No ☐Not Applicable Are there known unintended positive or negative impacts of the planning process or plan on health equity? Yes ☐No ☐Not Applicable
Objective 3:	By # days post-award, establish a Steering Committee (may be a subset of the Regional Coordinating Body)
Implementation Timeframe	Start Date: MM/DD/YYYY		End Date: MM/DD/YYYY
	Target date	Responsible Position or Party	Progress or Process Measure(s)	Status
Activity 1:
Activity 2:
Activity 3:
Activity 4:
Activity 5:
Setting	Regional ☐ State ☐ Territorial ☐ Local ☐ Tribal
Collaboration and Coordination	Describe collaboration and coordination activities with applicable state, territorial, local, and tribal health department and officials, health care facilities, and health care coalitions to improve public health preparedness and response.
Health Equity Considerations	Are considerations to increase the likelihood that health equity can be addressed integrated into the decision-making process when developing and convening the Steering Committee? Yes ☐No ☐Not Applicable 2. If yes to Question 1, how? If no, please explain why not. [Include text here]
Objective 4:	By # days post-award, establish and maintain a regional public health preparedness and response center (Year 1, to be maintained in years 2 – 5)

Implementation Timeframe	Start Date: MM/DD/YYYY		End Date: MM/DD/YYYY
	Target date	Responsible Position or Party	Progress or Process Measure(s)	Status
Activity 1:
Activity 2:
Activity 3:
Activity 4:
Activity 5:
Setting	Regional ☐ State ☐ Territorial ☐ Local ☐ Tribal
Collaboration and Coordination	Describe collaboration and coordination activities with applicable state, territorial, local, and tribal health department and officials, health care facilities, and health care coalitions to improve public health preparedness and response.
Health Equity Considerations	Are considerations to increase the likelihood that health equity can be addressed integrated into the decision-making process when developing and convening the staffing and operations of the regional center? Yes ☐No ☐Not Applicable 2. If yes to Question 1, how? If no, please explain why not. [Include text here]
Objective 5:	By # days post-award, develop, implement, and evaluate activities to meet objectives in the Five-Year Regional Work Plan, FY2025-2030. The Five-Year Regional Work Plan will include focus areas, partners, roles, and resources needed to accomplish the plan’s objectives.
Implementation Timeframe	Start Date: MM/DD/YYYY		End Date: MM/DD/YYYY
	Target date	Responsible Position or Party	Progress or Process Measure(s)	Status
Activity 1:
Activity 2:
Activity 3:
Activity 4:
Activity 5:
Activity 6:
Activity 7:
Activity 8:
Setting	Regional ☐ State ☐ Territorial ☐ Local ☐ Tribal
Collaboration and Coordination	Describe collaboration and coordination activities with applicable state, territorial, local, and tribal health department and officials, health care facilities, and health care coalitions to improve public health preparedness and response.

Health Equity Considerations

Are considerations to increase the likelihood that health equity can be addressed integrated into the decision-making process when developing and convening the staffing and operations of the regional center? Yes ☐No ☐Not Applicable 2. If yes to Question 1, how? If no, please explain why not. [Include text here]

Section 1. Cooperative Agreement Work plan Component B
Objective 1:	By # days post-award, establish a Steering Committee (may be a subset of the Regional Coordinating Body)
Implementation Timeframe	Start Date: MM/DD/YYYY		End Date: MM/DD/YYYY
	Target date	Responsible Position or Party	Progress or Process Measure(s)	Status
Activity 1:
Activity 2:
Activity 3:
Activity 4:
Activity 5:
Setting	Regional ☐ State ☐ Territorial ☐ Local ☐ Tribal
Collaboration and Coordination	Describe collaboration and coordination activities with applicable state, territorial, local, and tribal health department and officials, health care facilities, and health care coalitions to improve public health preparedness and response.
Health Equity Considerations	Are considerations to increase the likelihood that health equity can be addressed integrated into the decision-making process when developing and convening the Steering Committee? Yes ☐No ☐Not Applicable 2. If yes to Question 1, how? If no, please explain why not. [Include text here]
Objective 2:	By # days post-award, establish and maintain a regional public health preparedness and response center (Year 1, to be maintained in years 2 – 5)
Implementation Timeframe	Start Date: MM/DD/YYYY		End Date: MM/DD/YYYY
	Target date	Responsible Position or Party	Progress or Process Measure(s)	Status
Activity 1:
Activity 2:
Activity 3:
Activity 4:
Activity 5:

Setting	Regional ☐ State ☐ Territorial ☐ Local ☐ Tribal
Collaboration and Coordination	Describe collaboration and coordination activities with applicable state, territorial, local, and tribal health department and officials, health care facilities, and health care coalitions to improve public health preparedness and response.
Health Equity Considerations	Are considerations to increase the likelihood that health equity can be addressed integrated into the decision-making process when developing and convening the staffing and operations of the regional center? Yes ☐No ☐Not Applicable 2. If yes to Question 1, how? If no, please explain why not. [Include text here]
Objective 3:	By # days post-award, develop, implement, and evaluate activities to meet objectives in the Five-Year Regional Work Plan, FY2024 – 2029. The Five-Year Regional Work Plan will include focus areas, partners, roles, and resources needed to accomplish the plan’s objectives.
Implementation Timeframe	Start Date: MM/DD/YYYY		End Date: MM/DD/YYYY
	Target date	Responsible Position or Party	Progress or Process Measure(s)	Status
Activity 1:
Activity 2:
Activity 3:
Activity 4:
Activity 5:
Activity 6:
Activity 7:
Activity 8:
Setting	Regional ☐ State ☐ Territorial ☐ Local ☐ Tribal
Collaboration and Coordination	Describe collaboration and coordination activities with applicable STLT health departments and officials, health care facilities, and health care coalitions to improve public health preparedness and response.
Health Equity Considerations	Are considerations to increase the likelihood that health equity can be addressed integrated into the decision-making process when developing and convening the staffing and operations of the regional center? Yes ☐No ☐Not Applicable 2. If yes to Question 1, how? If no, please explain why not. [Include text here]