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OMB Control Number: 0920-1282
Expiration Date: 06/30/2026
Performance Measures for the Improving Adolescent Health and Well-Being Through School-Based
Surveillance and the What Works in Schools Program: Appendix A
Public reporting burden of this collection of information is estimated to average 15 hours per response per
year, 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 NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-1282).
Contents
Component 1 Work Plan and Work Plan Status Report ............................................................................. 2
Work Plan Details ..................................................................................................................................... 2
Work Plan Status Report Details ............................................................................................................. 3
Component 1 Work Plan .............................................................................................................................. 4
District-Level Data .................................................................................................................................... 4
Strategy 1A - Health Education (HED)...................................................................................................... 5
Health Education Required Activities .................................................................................................. 5
Strategy 1B - Health Services (HS) ........................................................................................................... 7
Health Service Required Activities....................................................................................................... 7
Strategy 1C - Safe and Supportive Environments (SSE) ........................................................................ 10
Safe and Supportive Environments Required Activities ................................................................... 10
Strategy 1D - Family, School, and Community Engagement (ENGAGE) ............................................... 15
Family, School, and Community-Required Activities ........................................................................ 15
District-Level Collaborations .................................................................................................................. 17
Component 1 Work Plan Status Report .................................................................................................... 18
Strategy 1A: Health Education (HED)..................................................................................................... 18
Strategy 1B: Sexual Health Services (HS)............................................................................................... 20
Strategy 1C: Safe and Supportive Environments (SSE) ......................................................................... 23
Strategy 1D: Family, School, and Community Engagement (ENGAGE) ................................................ 28
Collaboration and Partnership............................................................................................................... 30
Component 1 Work Plan and Work Plan Status Report
Work Plan Details
You will use this Work Plan to plan annual activities across Component 1 Strategies 1A – 1D. The work
plan serves as a forecasting process. It shows the following:
•
•
•
Proposed activities and who will complete them
For which audience
To what extent implemented
You will update this document annually with your proposed activities for the program year. You will use
this document during your monthly calls with your program consultant. It will help:
• Guide discussion around progress
•
•
Identify possible barriers to implementation
Identify technical assistance needs
Consider this work plan your comprehensive roadmap for the year. It will provide direction and support
as you plan for staffing needs, resource allocation, and leadership support.
You will need the following information to complete the Work Plan:
•
•
•
•
•
•
•
Data sources used to track progress for each required strategy.
District-level data (total number of schools, staff members, etc.)
School-level data (total number of school-based health centers (SBHCs), total number of
instructional support staff, total number of students, total number of GSAs, etc.)
Detailed description of activities that will take place in the program year to accomplish each
required activity.
Job title or role of the person responsible for completing the required activity.
Forecasting Data for the upcoming program year: All reported data will be estimated values for
the upcoming program year. The estimated reported data will be used to track progress over
time.
Details regarding any forms of anticipated collaboration that will impact the strategy activity.
Work Plan Status Report Details
You will use this Work Plan Status Report (WPSR) to capture completed activities twice a year. The work
plan status report serves as a bi-annual report to document accomplishments. It shows the following:
• Required Activity Progress and Reach
• Target Audience
• Facilitators and Barriers
You will submit this report bi-annually on April 1 and October 1st. The Work Plan Status Report will be
used during your monthly calls with your program consultant and will help:
• Guide Discussion around Progress
• Identify Possible Barriers to Implementation
• Identify Possible Facilitators Utilized to Overcome Barriers to Implementation
• Identify Technical Assistance Needs
You will need the following information to complete the Work Plan Status Report:
•
•
•
•
•
Detailed description of activities in the program year to accomplish each required activity.
Data sources used to track progress for each required strategy and activity.
District-level data (total number of schools impacted, staff members reached, etc.)
School-level data (total number of school-based health centers (SBHCs) utilized, total number of
instructional support staff reached, total number of students reached, total number of GSAs
utilized, etc.)
Details regarding any collaborations that impacted the strategy activity.
Component 1 Work Plan
District-Level Data
The following chart will be updated annually as needed. Enter “n/a” if the field is “not applicable” to
your district.
Elementary
Schools (Grades K5)
Total Number of
Schools
Total Number of
Teachers
Total Number of
Instructional Support
Staff
Total Number of
Students
Total Number of
SBHCs
Total Number of
SBHC Staff
Total Number of
School Nurses
Total Number of
School Staff providing
mental and
behavioral
services/support
Total Number of
School Staff providing
sexual health
services/support
Total Number of
GSAs
Total Number of YACs
Total Number of
Parent Groups
Middle Schools
(Grades 6-8)
High Schools
(Grades 9-12)
Total at district
or school-levels
Strategy 1A - Health Education (HED)
Agency Name:
Cooperative Agreement Number:(Automatically Populated)
Program Year:
Describe the data sources you will use to monitor progress within this strategy:
(Please consider local and state data, YRBS, Profiles, PERS, Needs Assessments, Focus Groups, Interviews,
etc.)
Describe the agency and jurisdictional context regarding Health Education, including sexual and mental
health - Please share key considerations:
Any state or district policy limiting or supporting school and community activities.
- State or District Professional Development Requirements.
-
State or District Level access to Health Education and educators.
Curriculum review and selection processes.
Health Education Required Activities
HED1. Develop, implement, and
review a technical assistance
plan. Its goal is to support and
improve teacher's and school
staff’s knowledge, comfort, and
skills for delivering health
education to students in
secondary grades (6 to 12). This
includes sexual and mental
health education.
Associated Performance Measure:
Description of Activity (Provide as much detail as possible to
describe the actions you will complete to accomplish this activity):
HED2. Each year, professional
development is provided for
teachers and school staff,
delivering health education
instructional programs to
students in secondary grades (6
to 12). This includes sexual
health and mental health
education. Prioritize
instructional competencies
needed for culturally responsive
and inclusive education.
Description of Activity (Provide as much detail as possible and
include a list of the HED PD you will offer along with the anticipated
dates for the upcoming year):
Responsible Person(s) (Job Title Only):
(Automatically Populated)
Responsible Person(s) (Job Title Only):
HED2 Forecasting
To forecast and measure your progress, please complete the following questions with your estimated value to be
completed in the upcoming year
Estimated number of Teachers and School Staff at Middle School level reached:
Estimated number of Teachers and School Staff at the High School level reached:
Associated Performance Measure (Automatically Populated)
HED3. Each year, implement a
health education instructional
program for students in grades K
to 12.
Description of Activity (Provide as much detail as possible to
describe the actions you will complete to accomplish this activity.
Ensure you include how each of the suggested Health Education
components were addressed ):
Health education instructional
programs should:
• Align with a district or school
scope and sequence.
• Be culturally responsive and
focused on meeting the needs of
students who have been
marginalized, including students
from racial and ethical minority
groups. These students identify
as LGBTQ+ and students with
intellectual and developmental
disabilities.
• Incorporate sexual and mental
health content.
• Prioritize skills to identify and
access health services.
• Assess student performance.
Responsible Person(s) (Job Title Only):
HED3 Forecasting
To forecast and measure your progress, please complete the following questions with your estimated value to be
completed in the upcoming year
Estimated Number of Elementary (grades k-5)
By (Date):
Schools Reached:
Estimated Number of Middle (grades 6-8) Schools By (Date):
Reached:
Estimated Number of High Schools (grades 9-12)
By (Date):
Reached:
Associated Performance Measure (Automatically Populated)
Strategy 1B - Health Services (HS)
Agency Name:
Cooperative Agreement Number:
Program Year:
Describe the data sources you will use to monitor progress within this strategy. (Please consider local and
state data, YRBS, Profiles, PERS, Needs Assessments, Focus Groups, Interviews, etc.)
Describe the agency and jurisdictional context regarding Health Services - Please share key
considerations:
Any state or district policy or rule limiting activities within schools and communities.
- Any state or district policy or rule supporting activities within schools and communities. (e.g., CAP).
Health Service Required Activities
HS1. Each year, assess district
Description of Activity (Provide as much detail as possible to
and school capacity,
describe the actions you will complete to accomplish this activity):
infrastructure, and partnerships.
The assessment reviews the
ability to implement activities
that increase student access to
youth-friendly and inclusive
sexual, behavioral, and mental
health services.
Responsible Person(s) (Job Title Only):
Associated Performance Measure (Automatically Populated)
HS2. Build partnerships with
healthcare providers. The goal is
to support student access to
youth-friendly and inclusive
sexual, behavioral, and mental
health services.
Description of Activity (Provide as much detail as possible to
describe the actions you will complete to accomplish this activity):
Responsible Person(s) (Job Title Only):
HS2 Forecasting
To forecast and measure your progress, please complete the following questions with your estimated value to be
completed in the upcoming year
Estimated Number of Partnerships with Sexual
By (Date):
Health Providers Formed:
Estimated Number of Partnerships with
By (Date):
Behavioral Health Providers Formed:
Estimated Number of Partnerships with Mental
By (Date):
Health Providers Formed:
Associated Performance Measure (Automatically Populated)
HS3. Provide annual professional
development to help staff
support student access to health
services, specifically sexual,
behavioral, and mental health
services. Each year, you must
provide professional
development to both:
Description of Activity (Provide as much detail as possible and
include a list of the HS PD you will offer along with the anticipated
dates for the upcoming year):
Responsible Person(s) (Job Title Only):
• Staff who provide health
services
• Other school staff
HS3 Forecasting
To forecast and measure your progress, please complete the following questions with your estimated value to be
completed in the upcoming year
Estimated Number of Middle School Staff who
By (Date):
provide health services Reached:
Estimated Number of High Schools Staff who
By (Date):
provide health services Reached:
Associated Performance Measure (Automatically Populated)
HS4. Implement or enhance
school-based activities that
increase access to services. The
goal is to increase student
access to youth-friendly and
inclusive school- and
community-based sexual,
behavioral, and mental health
services. Activities must include
at least one of the following:
•
HS4_A: Create a referral
system to link students to
sexual, behavioral, and
mental health services.
Description of Activity (Provide as much detail as possible to
describe the actions you will complete to accomplish this activity):
- Include which requirement (HS4_A – HS4_C) is included in the
activity.
Responsible Person(s) (Job Title Only):
•
•
HS4_B: Provide schoolbased sexual, behavioral,
and mental health services
to students. For example,
STI screening, making
condoms available, schoolbased counseling, and
mental health support.
HS4_C: Provide schoolbased health center
services that support
sexual, behavioral, and
mental health services for
students.
HS4 Forecasting
To forecast and measure your progress, please complete the following questions with your estimated value to be
completed in the upcoming year
Estimated Number of Middle School Activities
By (Date):
Implemented or Enhanced:
Estimated Number of High School Activities
By (Date):
Implemented or Enhanced:
Associated Performance Measure (Automatically Populated)
Strategy 1C - Safe and Supportive Environments (SSE)
Agency Name:
Cooperative Agreement Number:
Program Year:
Describe the data sources you will use to monitor progress within this strategy. (Please consider local and
state data, YRBS, Profiles, PERS, Needs Assessments, Focus Groups, Interviews, etc.)
Describe the agency and jurisdictional context regarding Safe and Supportive Environments - Please
share key considerations:
Any state or district policy or rule limiting activities within schools and communities.
- Any state or district policy or rule supporting activities within schools and communities. (e.g., CAP).
-
Identified collaborations/partnerships that will support marginalized groups.
Training history of GSA Advisors and what resources will be used
Safe and Supportive Environments Required Activities
SSE1. Implement activities each year that support marginalized youth and foster safe and supportive
school environments for all youth.
SSE1.A: In Year 1, designate a
staff person at the district level
to lead and coordinate diversity,
equity, and inclusion activities
with school-level champions.
Description of Activity (Provide as much detail as possible to
describe the actions you will complete to accomplish this activity):
Responsible Person(s) (Job Title Only):
Associated Performance Measure (Automatically Populated)
SSE1.B: Establish or enhance
student-led clubs that support
youth, including youth with
LGBTQ+ identities. These are
often known as Gender and
Sexualities Alliances (GSAs).
Description of Activity (Provide as much detail as possible to
describe the actions you will complete to accomplish this activity):
Responsible Person(s) (Job Title Only):
SSE1.B Forecasting
To forecast and measure your progress, please complete the following questions with your estimated value to be
completed in the upcoming year
Estimated Number of Middle School Clubs
By (Date):
Established or Enhanced:
Estimated Number of High school Clubs
By (Date):
Established or Enhanced:
Associated Performance Measure (Automatically Populated)
SSE1.C: Develop, implement,
improve, and enforce policies
that prohibit harassment based
on a student’s perceived or
actual sexual orientation or
gender identity. These policies
are in addition to federally
mandated policies based on
race, color, national origin,
disability, age, sex (including
gender identity, sexual
orientation, and pregnancy), or
other constitutionally protected
statuses.
Associated Performance Measure
SSE1.D: Identify “safe spaces”
where all youth, including those
with LGBTQ+ identities, can
receive support from
administrators, teachers, or
other school staff. These could
be a counselor’s office,
designated classroom, or
student organization space.
Description of Activity (Provide as much detail as possible to
describe the actions you will complete to accomplish this activity):
Responsible Person(s) (Job Title Only):
(Automatically Populated)
Description of Activity (Provide as much detail as possible to
describe the actions you will complete to accomplish this activity):
Responsible Person(s) (Job Title Only):
SSE1.D Forecasting
To forecast and measure your progress, please complete the following questions with your estimated value to be
completed in the upcoming year
Estimated Number of Safe Spaces Identified in
Middle Schools:
Estimated Number of Safe Spaces Identified in
High Schools:
By (Date):
By (Date):
Associated Performance Measure (Automatically Populated)
SSE2. Each year, provide
professional development to
school staff to foster safe and
supportive school environments.
Professional development topics
should include supporting
youth, including those with
LGBTQ+ identities and racial and
ethnic minority youth,
classroom management, and
mental health awareness and
crisis response.
Description of Activity (Provide as much detail as possible and
include a list of the SSE PD you will offer along with the anticipated
dates for the upcoming year):
Responsible Person(s) (Job Title Only):
SSE2 Forecasting
To forecast and measure your progress, please complete the following questions with your estimated value to be
completed in the upcoming year
Estimated Number of Middle School Staff
Reached:
Estimated Number of High School Staff Reached:
By (Date):
By (Date):
Associated Performance Measure (Automatically Populated)
SSE3. Implement activities to
support school staff’s mental
health and well-being.
Description of Activity (Provide as much detail as possible to
describe the actions you will complete to accomplish this activity):
Responsible Person(s) (Job Title Only):
Associated Performance Measure (Automatically Populated)
SSE4. Implement school-wide practices to support the behavioral and mental health and social and
emotional well-being of students.
SSE4.A: Establish dedicated
time within the school schedule
for students to connect with
teachers and peers. The goal is
to hold structured discussions
that promote social-emotional
well-being and strengthen
relationships. These might
include advisory programs or
periods and morning meetings.
Description of Activity (Provide as much detail as possible to
describe the actions you will complete to accomplish this activity):
Responsible Person(s) (Job Title Only):
SSE4.A Forecasting
To forecast and measure your progress, please complete the following questions with your estimated value to be
completed in the upcoming year
Estimated Number of Middle Schools Reached:
By (Date):
Estimated Number of High Schools Reached:
By (Date):
Associated Performance Measure (Automatically Populated)
SSE4.B: Implement schoolwide
positive behavioral interventions
and support for student and
teacher well-being.
This includes:
•
Setting positive
behavioral
expectations for
students
•
Teaching academic
and social behaviors
that students need
to meet school
expectations
•
Defining behaviors
that negatively
affect school
environments
•
Using positive
disciplinary
practices to respond
to negative
behaviors
Description of Activity (Provide as much detail as possible to
describe the actions you will complete to accomplish this activity):
Responsible Person(s) (Job Title Only):
SSE4.B Forecasting
To forecast and measure your progress, please complete the following questions with your estimated value to be
completed in the upcoming year
Estimated Number of Middle Schools Reached:
By (Date):
Estimated Number of High Schools Reached:
By (Date):
Associated Performance Measure (Automatically Populated)
SSE5. Implement positive youth
development approaches.
Specifically, provide school-
Description of Activity (Provide as much detail as possible to
describe the actions you will complete to accomplish this activity):
based mentoring, service
learning, or other positive youth
development programs or
connect students to communitybased programs.
Responsible Person(s) (Job Title Only):
SSE5 Forecasting
To forecast and measure your progress, please complete the following questions with your estimated value to be
completed in the upcoming year
Estimated Number of Middle Schools Reached:
By (Date):
Estimated Number of High Schools Reached:
By (Date):
Associated Performance Measure (Automatically Populated)
Strategy 1D - Family, School, and Community Engagement (ENGAGE)
Agency Name:
Cooperative Agreement Number:
Program Year:
Describe the data sources you will use to monitor progress within this strategy. (Please consider local and
state data, YRBS, Profiles, PERS, Needs Assessments, Focus Groups, Interviews, etc.)
Describe the agency and jurisdictional context regarding family, school, and community engagementPlease share critical considerations:
- any policies or rules that may limit activities within schools and communities
-
SHAC structure, meeting frequency, estimated involvement
Existing parent groups and parent communications
Family, School, and Community-Required Activities
ENGAGE1. Establish and
maintain a SHAC or similar
council or team. It must include
representation from students,
school staff, parents, and
community members. The goal
is to allow them to regularly
provide district or school-level
guidance to support and
improve health-related policies,
programs, and practices.
Associated Performance Measure
ENGAGE2. Establish and
maintain interdepartmental
collaborations across the school
district. The goal is to help
implement district or schoollevel activities that support and
improve school health policies,
programs, and practices.
Description of Activity (Provide as much detail as possible to
describe the actions you will complete to accomplish this activity):
Responsible Person(s) (Job Title Only):
(Automatically Populated)
Description of Activity (Provide as much detail as possible to
describe the actions you will complete to accomplish this activity):
Responsible Person(s) (Job Title Only):
Associated Performance Measure (Automatically Populated)
ENGAGE3. Implement family,
school, and community
engagement strategies. The goal
is to engage parents, caregivers,
guardians, and community
members in health education,
health services, and safe and
supportive environment
activities.
Description of Activity (Provide as much detail as possible to
describe the actions you will complete to accomplish this activity):
Responsible Person(s) (Job Title Only):
Such strategies might include:
• Providing seminars,
workshops, and information
• Providing opportunities for
feedback on program
activities
• Leveraging school and
community resources
Associated Performance Measure (Automatically Populated)
ENGAGE4. Implement youth
engagement strategies. The goal
is actively engaging students in
health education, health
services, and safe and
supportive environment
activities. Strategies should
create space for youth to share
their ideas.
Description of Activity (Provide as much detail as possible to
describe the actions you will complete to accomplish this activity):
- Include how marginalized populations will be actively
engaged.
Responsible Person(s) (Job Title Only):
They might include:
• Implementing school-wide,
student-planned marketing
campaigns
• Creating district-wide youth
advisory councils (YACs)
Associated Performance Measure (Automatically Populated)
District-Level Collaborations
The following chart will be updated annually as new collaborations are formed.
Please include a brief description of the collaboration and the required activity
Name of
Group/Organization: it is associated with.
Please select what
content areas will
be addressed with
this collaboration:
Describe how this collaboration will support the district’s capacity to address
health equity. (Does it represent or serve a marginalized population identified by
the recipient?)
(Select All That
Apply)
What are the possible outcomes and/or benefits of collaboration to your
organization (monetary, policy implementation, training, health equity, etc.)?
** Recipient will be able to add more collaborations
Component 1 Work Plan Status Report
Site Name
Grant Number
Reporting Period
(Auto-populated)
(Auto-populated)
(Auto-populated)
Strategy 1A: Health Education (HED)
Strategy 1A: Health Education (HED)
Required HED1. Develop, implement, and
review a technical assistance plan. Its goal is
to support and improve teacher and school
staff’s knowledge, comfort, and skills for
delivering health education to students in
secondary grades (6 to 12). This includes
sexual and mental health education.
Required HED2. Each year, provide
professional development for teachers and
school staff, delivering health education
instructional programs to students in
secondary grades (6 to 12). This includes
sexual health and mental health education.
Prioritize instructional competencies needed
Status of
Completion
☐ Completed
☐ In Progress
☐ Not started
☐ Completed
☐ In Progress
☐ Not started
Summarize Progress made in accomplishing
activities below (Please include a
description of what activities were
completed, the intervention/program used,
the Target Audience (student, grade level,
Teacher, Social Worker, Parents, etc.), and
the potential impact of the activity. )
Number Reached
(Estimate)
Click or tap here to enter text.
Click or tap here to enter text.
# of teachers and school staff at the middle
school level reached:
# of teachers and school staff at high school
level reached:
for culturally responsive and inclusive
education.
Required HED3. Each year, implement a
health education instructional program for
students in grades K to 12. Health education
instructional programs should:
◦Align with a district or school scope and
sequence
◦Be culturally responsive, inclusive,
developmentally appropriate, and focused on
meeting the needs of students who have been
marginalized, including students from racial
and ethnic minority groups, students who
identify as LGBTQ+, and students with
intellectual and developmental disabilities
◦Incorporate sexual and mental health
content
◦Prioritize skills to identify and access health
services
◦Assess student performance
☐ Completed
☐ In Progress
☐ Not started
Click or tap here to enter text.
# of Elementary Schools (K-5) reached:
# of Middle Schools (6-8) reached:
# of High Schools (9-12) reached:
Additional HED Activities/Successes/Challenges: Please describe any additional activities beyond those required by the Cooperative Agreement and any
additional successes and/or challenges.
Click or tap here to enter text.
Strategy 1B: Sexual Health Services (HS)
Strategy 1B: Sexual Health
Services (HS)
Required HS1. Each year,
assess district and school
capacity, infrastructure, and
partnerships. The
assessment reviews the
ability to implement
activities that increase
student access to youthfriendly and inclusive sexual,
behavioral, and mental
health services.
Required HS2. Build
partnerships with healthcare
providers. The goal is to
support student access to
youth-friendly and inclusive
sexual, behavioral, and
mental health services.
Status of
Completion
Summarize Progress made in accomplishing activities below (Please
include a description of what activities were completed, the
intervention/program used, the Target Audience (student, grade level,
Teacher, Social Worker, Parents, etc.), and the potential impact of the
activity. )
☐ Completed
☐ In Progress
☐ Not
started
Click or tap here to enter text.
☐ Completed
☐ In Progress
☐ Not
started
Click or tap here to enter text.
Number Reached
# of Partnerships with
Sexual Health Providers
Formed:
# of Partnerships with
Behavioral Health
Providers Formed:
# of Partnerships with
Mental Health Providers
Formed:
Required HS3. Provide
annual professional
development to help staff
support student access to
health services, specifically
sexual, behavioral, and
mental health services. Each
year, you must provide
professional development to
both: Staff who provide
health services, and other
school staff.
Required HS4. Implement or
enhance school-based
activities that increase
access to services. Activities
must include at least one of
the following:
•
•
HS4.A: Create a
referral system to
link students to
sexual, behavioral,
and mental health
services.
HS4.B: Provide
school-based sexual,
behavioral, and
mental health
services to students.
For example, STI
☐ Completed
☐ In Progress
☐ Not
started
Click or tap here to enter text.
☐ Completed
☐ In Progress
☐ Not
started
Click or tap here to enter text.
# of Middle School Staff
who provide health
services Reached:
# of High school staff
who provide health
services Reached:
# of Middle School
Activities
Implemented or
Enhanced:
# of High School
Activities
Implemented or
Enhanced:
•
screening, making
condoms available,
school-based
counseling, and
mental health
support.
HS4.C: Provide
school-based health
center services that
support sexual,
behavioral, and
mental health
services for students.
Additional HS Activities/Successes/Challenges: Please describe any additional activities beyond those required by the Cooperative Agreement and any
additional successes and/or challenges.
Click or tap here to enter text.
Strategy 1C: Safe and Supportive Environments (SSE)
Strategy 1C: Safe and
Supportive Environments
(SSE)
Status of
Completion
Summarize Progress made in accomplishing activities below (Please include
a description of what activities were completed, the intervention/program
used, the Target Audience (student, grade level, Teacher, Social Worker,
Parents, etc.), and the potential impact of the activity. )
Number Reached
SSE1: Implement activities each year that support marginalized youth and foster safe and supportive school environments for all youth.
SSE1.A: In Year 1,
designate a staff person at
the district level to lead
and coordinate diversity,
equity, and inclusion
activities with school-level
champions.
SSE1.B: Establish or
enhance student-led clubs
that support youth,
including youth with
LGBTQ+ identities. These
are often known as Gender
and Sexualities Alliances
(GSAs).
SSE1.C: Develop,
implement, improve, and
enforce policies that
prohibit harassment based
on a student’s perceived or
☐ Completed
☐ In Progress
☐ Not started
☐ Completed
☐ In Progress
☐ Not started
☐ Completed
☐ In Progress
☐ Not started
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
# of Middle School Clubs
that were established or
enhanced:
# of High School Clubs that
were established or
enhanced:
actual sexual orientation
or gender identity. These
policies are in addition to
federally mandated
policies based on race,
color, national origin,
disability, age, sex
(including gender identity,
sexual orientation, and
pregnancy), or other
constitutionally protected
statuses.
SSE1.D: Identify “safe
spaces” where all youth,
including those with
LGBTQ+ identities, can
☐ Completed
receive support from
☐ In Progress
administrators, teachers,
☐ Not started
or other school staff. These
could be a counselor’s
office, designated
classroom, or student
organization space.
Required SSE2. Each year,
provide professional
development to school staff
on fostering safe and
supportive school
environments. Professional
☐ Completed
☐ In Progress
☐ Not started
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# of Safe Spaces Identified
in Middle Schools:
# of Safe Spaces identified in
High Schools:
# of Middle School Staff
reached:
# of High School Staff
reached:
development topics should
consist of:
• supporting youth
including those with
LGBTQ+ identities
and racial and ethnic
minority youth
• classroom
management, and
• mental health
awareness and crisis
response.
Required SSE3. Implement
activities to support school
staff’s mental health and
well-being.
☐ Completed
☐ In Progress
☐ Not started
SSE4: Implement school-wide practices to support the behavioral and mental health and social and emotional well-being of students.
SSE4.A: Establish
dedicated time within the
school schedule for
students to connect with
teachers and peers. These
might include advisory
programs or periods and
morning meetings.
SSE4.B: Implement
schoolwide positive
behavioral interventions
☐ Completed
☐ In Progress
☐ Not started
☐ Completed
☐ In Progress
☐ Not started
# of Middle Schools
reached:
# of High Schools reached:
# of Middle Schools
reached:
# of High Schools reached:
and support for student
and teacher well-being.
This includes:
• Setting positive
behavioral
expectations for
students
• Teaching academic
and social behaviors
that students need to
meet school
expectations
• Defining behaviors
that negatively affect
school environments
• Using positive
disciplinary practices
to respond to
negative behaviors
# of Middle School schools
reached:
Required SSE5. Implement
positive youth development
approaches. Specifically,
provide school-based
mentoring, service learning,
or other positive youth
development programs or
connect students to
community-based programs.
☐ Completed
☐ In Progress
☐ Not started
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# of High School schools
reached:
Additional SSE Activities/Successes/Challenges: Please describe any additional activities beyond those required by the Cooperative Agreement and any
additional successes and/or challenges.
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Strategy 1D: Family, School, and Community Engagement (ENGAGE)
Strategy 1D: Family, School, and
Community Engagement
(ENGAGE)
ENGAGE1. Establish and
maintain a SHAC or similar
council or team. It must include
representation from students,
school staff, parents, and
community members. The goal is
to allow them to regularly
provide district or school-level
guidance to support and improve
health-related policies,
programs, and practices.
ENGAGE2. Establish and
maintain interdepartmental
collaborations across the school
district. The goal is to help
implement district or school-level
activities that support and
improve school health policies,
programs, and practices.
ENGAGE3. Implement family,
school, and community
engagement strategies. The goal
is to engage parents, caregivers,
Status of
Completion
Comment and/ or Summarize Progress made in accomplishing
activities below
☐ Completed
☐ In Progress
☐ Not started
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☐ Completed
☐ In Progress
☐ Not started
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☐ Completed
☐ In Progress
☐ Not started
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Number Reached
guardians, and community
members in health education,
health services, and safe and
supportive environment
activities.
Such strategies might include:
• Providing seminars,
workshops, and information
• Providing opportunities for
feedback on program activities
• Leveraging school and
community resources
ENGAGE4. Implement youth
engagement strategies. The
goal is actively engaging
students in health education,
health services, and safe and
supportive environment
activities. Strategies should
create space for youth to
share their ideas.
They might include:
• Implementing school-wide,
student-planned marketing
campaigns
• Creating district-wide youth
advisory councils (YACs)
☐ Completed
☐ In Progress
☐ Not started
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Collaboration and Partnership
Evaluation Activities: Please share any evaluation efforts and updates (i.e., reports, 1-pager, infographics, conference abstracts, developing systems to
capture referrals, technical assistance, etc.) developed during the reporting period:
Click
or tapENGAGE
here to enter
text.
Additional
Activities/Successes/Challenges:
Please describe any additional activities beyond those required by the Cooperative Agreement and any
additional successes and/or challenges.
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Successes: Please describe any additional successes (e.g., identified through evaluation results or lessons learned).
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Challenges: Please describe any challenges that might affect your ability to achieve outcomes, , or complete the activities in the work plan.
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Collaboration and Partnerships: Please describe how your collaborations and partnerships supported the implementation of activities outlined in the
workplan.
CDC Program Support to Awardees: Please describe how CDC could help you overcome challenges to achieving annual and project-period outcomes, and
performance measures, and completing activities outlined in the work plan.
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| File Type | application/pdf |
| Author | Faust Thomas, Loren C. (CDC/NCCDPHP/DASH) |
| File Modified | 2024-12-03 |
| File Created | 2024-12-03 |