0920-25BS NCCDPHP_DASH_Component3_Guidance

Form Approved
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 B

Public reporting burden of this collection of information is estimated to average 9 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 3 Work Plan and Work Plan Status Report ............................................................................. 2
Work Plan Details ..................................................................................................................................... 2
Work Plan Status Report Details ............................................................................................................. 2
Component 3 Work Plan .............................................................................................................................. 4
Component 3 Work Plan Status Report ...................................................................................................... 9

Component 3 Work Plan and Work Plan Status Report
Work Plan Details
You will use this Work Plan to plan annual Component 3 surveillance activities. The work plan serves as a
forecasting process. It shows the following:
•
•
•

Proposed activities and who will complete them
Anticipated Start Dates
Anticipated Completion Dates

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.
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.
Anticipated start and completion dates

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 Summary
• 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:
•
•

Data sources used to track progress for each required strategy and activity.
Data sources used to track possible barriers and facilitators.

Component 3 Work Plan
Agency/Organization Name: Click or tap here to enter text.
Timeframe: August 1, 20xx – July 31, 20xx

Grant #: DP00xxxx

Youth Risk Behavior Survey (YRBS)
Establish, implement, and strengthen systematic procedures to collect Youth Risk Behavior Survey (YRBS) data, and report on adolescent health
risk behaviors as outlined in the Handbook for Conducting Youth Risk Behavior Surveys. Please provide information about the YRBS required
activities and the actions you will use to complete these activities, who is responsible, the timeline, and what you will use as the proof of
completion.

0139 Required Activity

1. Establish and maintain a YRBS
coalition to support survey
administration.
2. Develop a state, territorial,
tribal, or local YRBS
questionnaire meeting
specifications outlined in the
Handbook for Conducting Youth
Risk Behavior Surveys.
3. Produce an up-to-date
sampling frame and develop
sampling parameters to support
scientific selection of state,
territorial, tribal, and local
samples that will generate
jurisdiction-wide estimates of at
least all public-school students
in grades 9-12. The sampling

Activity
Number

1.1
1.2
2.1
2.2

3.1

3.2

Description of Activity
Provide as much detail as possible to
describe the actions that will be completed
to accomplish this activity.

Anticipated
Responsible Person(s) Anticipated
Completion
(Job title only)
Start Date
Date

frame and sampling parameters
should meet specifications
outlined in the Handbook for
Conducting Youth Risk Behavior
Surveys.
4. Obtain school agreements
and parental permission for
student participation using
jurisdiction-level requirements
identified before survey
administration begins.
5. Select classes to be surveyed
in the sampled schools based on
the procedures outlined in the
Handbook for Conducting Youth
Risk Behavior Surveys.
6. Conduct the YRBS (in oddnumbered calendar years)
according to survey
administration procedures
outlined in the Handbook for
Conducting Youth Risk Behavior
Surveys.
7. Coordinate with other CDCfunded agencies and
organizations on data collection
for national, state, territorial,
tribal, and local YRBSs
conducted among schools in the
same jurisdiction.
8. Submit all completed answer
sheets or raw data sets and

4.1
4.2

5.1
5.2
6.1

6.2

7.1

7.2

8.1

Submit the Survey Tracking Form at least
every 2 weeks during data collection to the
CDC Survey TA contractor.

appropriate sample
documentation forms as
specified in the Handbook for
Conducting Youth Risk Behavior
Surveys to the CDC Survey TA
contractor for processing.
9. Disseminate YRBS results
through fact sheets, reports,
Web sites, and other products
and then use the results to help
target and improve
interventions, establish funding
priorities, and support
development of policies and
practices to reduce priority
health-risk behaviors among
youth.

8.2

9.1

9.2

Submit to CDC examples of the
materials you disseminate.
Optional Activity:
10.
Tier 1: Add eight (8) traditional
Adverse Childhood Experiences
(ACEs) to your 2025, 2027, and
2029 YRBS questionnaires.
or
Tier 2: Add 16 ACEs and Positive
Childhood Experiences (PCEs) to
your 2025, 2027, and 2029 YRBS
questionnaires.

10.1

10.2

Survey: School Health Profiles (Profiles):
Establish, implement, and strengthen systematic procedures to collect School Health Profiles (Profiles) data, and report on school health policies
and practices as outlined in the Handbook for Conducting School Health Profiles. Please provide information about the Profiles required activities
and the actions you will use to complete these activities, who is responsible, the timeline, and what you will use as the proof of completion.
0139 Required Activity
1. Produce an up-to-date
sampling frame and develop
sampling parameters to support
scientific selection of state,
territorial, tribal, and local
samples that will generate
jurisdiction-wide estimates of at
least all public secondary
schools. The sampling frame and
sampling parameters should
meet specifications outlined in
the Handbook for Conducting
School Health Profiles.
2. Conduct Profiles (in evennumbered calendar years)
according to survey
administration procedures
outlined in the Handbook for
Conducting School Health
Profiles.
3. Follow up with nonresponding
principals and teachers using
pre-established methods (e.g.,
postcards, phone calls, or
emails) over a planned
timeframe to increase Profiles
response rates.

Description of Activity
Activity Provide as much detail as possible to describe
Number
the actions that will be completed to
accomplish this activity.

1.1

1.2

2.1

2.2
3.1

3.2

Submit the Survey Tracking Form at least every
2 weeks during data collection to the CDC
Survey TA contractor.

Responsible Person(s)
(Job title only)

Anticipated
Start Date

Anticipated
Completion
Date

4. Coordinate with other CDCfunded agencies and
organizations on data collection
for national, state, territorial,
tribal, and local Profiles
conducted among schools in the
same jurisdiction.
5. Submit all completed
questionnaires or raw data sets
and appropriate sample
documentation forms as
specified in the Handbook for
Conducting School Health
Profiles to the CDC Survey TA
contractor for processing.
6. Disseminate Profiles results
through fact sheets, reports,
Web sites, and other products
and then use the results to help
target and improve
interventions, establish funding
priorities, and support
development of policies and
practices to reduce priority
health-risk behaviors among
youth
Submit to CDC examples of the
materials you disseminate.

4.1

4.2

5.1

5.2

6.1

6.2

Component 3 Work Plan Status Report
Agency/Organization Name: Click or tap here to enter text.
Timeframe: ☐ Report #1: August 1, 20xx – January 31, 20xx

Section I:
0139 Required Activity
1. Establish and maintain a YRBS
coalition to support survey
administration.
2. Develop a state, territorial, tribal,
or local YRBS questionnaire meeting
specifications outlined in the
Handbook for Conducting Youth Risk
Behavior Surveys.
3. Produce an up-to-date sampling
frame and develop sampling
parameters to support scientific
selection of state, territorial, tribal,
and local samples that will generate
jurisdiction-wide estimates of at
least all public-school students in
grades 9-12. The sampling frame
and sampling parameters should
meet specifications outlined in the
Handbook for Conducting Youth Risk
Behavior Surveys.
4. Obtain school agreements and
parental permission for student

Grant #: DP00xxxx
☐ Report #2: February 1, 20xx – July 31, 20xx

Youth Risk Behavior Survey (YRBS)
Achievement of
Comment and/or Summarize Requirement Progress
Requirement
Click or tap here to enter text.
☐ Completed
☐ In Progress
☐ Not started
☐ Not Applicable
☐ Completed
☐ In Progress
☐ Not started
☐ Not Applicable

Click or tap here to enter text.

☐ Completed
☐ In Progress
☐ Not started
☐ Not Applicable

Click or tap here to enter text.

☐ Completed
☐ In Progress

Click or tap here to enter text.

participation using jurisdiction-level
requirements identified before
survey administration begins.
5. Select classes to be surveyed in
the sampled schools based on the
procedures outlined in the
Handbook for Conducting Youth Risk
Behavior Surveys.
6. Conduct the YRBS (in oddnumbered calendar years)
according to survey administration
procedures outlined in the
Handbook for Conducting Youth Risk
Behavior Surveys.
Submit the Survey Tracking Form at
least every 2 weeks during data
collection to the CDC Survey TA
contractor.
7. Coordinate with other CDCfunded agencies and organizations
on data collection for national,
state, territorial, tribal, and local
YRBSs conducted among schools in
the same jurisdiction
8. Submit all completed answer
sheets or raw data sets and
appropriate sample documentation
forms as specified in the Handbook
for Conducting Youth Risk Behavior
Surveys to the CDC Survey TA
contractor for processing.
9. Disseminate YRBS results through
fact sheets, reports, Web sites, and
other products and then use the
results to help target and improve

☐ Not started
☐ Not Applicable
☐ Completed
☐ In Progress
☐ Not started
☐ Not Applicable

Click or tap here to enter text.

☐ Completed
☐ In Progress
☐ Not started
☐ Not Applicable

Click or tap here to enter text.

☐ Completed
☐ In Progress
☐ Not started
☐ Not Applicable

Click or tap here to enter text.

☐ Completed
☐ In Progress
☐ Not started
☐ Not Applicable

Click or tap here to enter text.

☐ Completed
☐ In Progress
☐ Not started
☐ Not Applicable

Click or tap here to enter text.

interventions, establish funding
priorities, and support development
of policies and practices to reduce
priority health-risk behaviors among
youth.
Please provide descriptions of YRBS
data products, including links to any
online products, in the “YRBS
Products” in Section II.
Optional Activity
10.
Tier 1: Add eight (8) traditional
Adverse Childhood Experiences
(ACEs) to your 2025, 2027, and 2029
YRBS questionnaires.
or
Tier 2: Add 16 ACEs and Positive
Childhood Experiences (PCEs) to
your 2025, 2027, and 2029 YRBS
questionnaires.

☐ Completed
☐ In Progress
☐ Not started
☐ Not Applicable

Click or tap here to enter text.

0139 Required Activity
1. Produce an up-to-date sampling
frame and develop sampling
parameters to support scientific
selection of state, territorial, tribal, and
local samples that will generate
jurisdiction-wide estimates of at least
all public secondary schools. The
sampling frame and sampling
parameters should meet specifications
outlined in the Handbook for
Conducting School Health Profiles.
2. Conduct Profiles (in even-numbered
calendar years) according to survey
administration procedures outlined in
the Handbook for Conducting School
Health Profiles.
Submit the Survey Tracking Form at
least every 2 weeks during data
collection to the CDC Survey TA
contractor.
3. Follow up with nonresponding
principals and teachers using preestablished methods (e.g., postcards,
phone calls, or emails) over a planned
timeframe to increase Profiles response
rates.
4. Coordinate with other CDC-funded
agencies and organizations on data
collection for national, state, territorial,
tribal, and local Profiles conducted
among schools in the same jurisdiction.

School Health Profiles (Profiles)
Achievement of
Comment and/or Summarize Requirement Progress
Requirement
Click or tap here to enter text.
☐ Completed
☐ In Progress
☐ Not started
☐ Not Applicable

☐ Completed
☐ In Progress
☐ Not started
☐ Not Applicable

Click or tap here to enter text.

☐ Completed
☐ In Progress
☐ Not started
☐ Not Applicable

Click or tap here to enter text.

☐ Completed
☐ In Progress
☐ Not started
☐ Not Applicable

Click or tap here to enter text.

5. Submit all completed questionnaires
or raw data sets and appropriate
sample documentation forms as
specified in the Handbook for
Conducting School Health Profiles to the
CDC Survey TA contractor for
processing.
6. Disseminate Profiles results through
fact sheets, reports, Web sites, and
other products and then use the results
to help target and improve
interventions, establish funding
priorities, and support development of
policies and practices to reduce priority
health-risk behaviors among youth.
Please provide descriptions of Profiles
data products, including links to any
online products, in the “Profiles
Products” in section II.

☐ Completed
☐ In Progress
☐ Not started
☐ Not Applicable

Click or tap here to enter text.

☐ Completed
☐ In Progress
☐ Not started
☐ Not Applicable

Click or tap here to enter text.

Section II:

YRBS Success: Please share a brief YRBS success during this reporting period (may be bulleted).
Click or tap here to enter text.
YRBS Process Evaluation: Review survey implementation activities from the most recent cycle to identify what went well and what can be
improved in the future to increase the quality of data and institutionalize the YRBS in their jurisdiction. What specific activities worked well during
the recent administration of YRBS in this jurisdiction? What activities did not work well? What will you do differently to increase your chances to
achieve representative data for YRBS in the next cycle?
Click or tap here to enter text.
YRBS products: Please describe any products (websites, publications, fact sheets, infographics, etc.) created using your YRBS results and provide
links to any products available online:
Click or tap here to enter text.

Profiles Success: Please share a brief Profiles success during this reporting period (may be bulleted):
Click or tap here to enter text.
Profiles Process Evaluation: Review survey implementation activities from the most recent cycle to identify what went well and what can be
improved in the future to increase the quality of data and institutionalize the Profiles in their jurisdiction. What specific activities worked well
during the recent administration of YRBS in this jurisdiction? What activities did not work well? What will you do differently to increase your
chances to achieve representative data for Profiles in the next cycle?
Click or tap here to enter text.

Profiles products: Please describe any products (websites, publications, fact sheets, infographics, etc.) created using your Profiles results and
provide links to any products available online:
Click or tap here to enter text.

Leveraged/In-kind Support: Please share all resources that have been leveraged through this reporting period (staffing, supplies, additional
funding, etc.):
Click or tap here to enter text.

Challenges: Please describe any challenges that might affect your ability to achieve annual and reporting-period outcomes or complete the
activities in the work plan.
Click or tap here to enter text.
CDC Program Support to Awardees: Please describe how CDC could help you overcome challenges to achieving annual and project-period
outcomes and completing activities outlined in the work plan.
Click or tap here to enter text.