Form 0920-24AA Annual Performance Report (APR) Tool

APR FORM DRAFT

Attachment 3. Annual Performance Report (APR) Tool

Form Approve OMB No: 0920-1431 Exp. Date: 04/30/27

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 H21-8, Atlanta, GA 30333; Attn: PRA (0920-1431).

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 (August 1, 2024 – July 31, 2025). 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)
Goal 1: Build Infrastructure for Sexual Violence Prevention	Objective 1A. Continue to build internal program capacity to facilitate and monitor the implementation of prevention programs/policies by acquiring, training, and retaining staff.
	Objective 1B. Conduct/promote training to build capacity of partner organizations to promote optimal level of health for all, and especially for those at greatest risk.
	Objective 1C. Conduct or leverage an existing primary prevention capacity assessment with a focus on optimal level of health for all, and especially for those at greatest risk.
	Objective 1D. Participate in CDC-sponsored programs and activities.
Goal 2. State/Territorial Action Plan	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 community-level implementation and sustainability of SV prevention.
	Objective 2B. Leverage multi-sector partners and resources toward SV prevention.
	Objective 2C. 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.
Goal 3. Implement SV Prevention Approaches	Objective 3A. Identify, implement, and adapt SV prevention strategies that focus on reducing differences in health outcomes across population groups, with a focus on community- and societal-level implementations.

Goal 4. Data to Action	Objective 4A. Gather and synthesize publicly available state-, territory- and community-level data to inform SV prevention, track differences in health outcomes across population groups and conditions that put people at risk, including rates of SV in priority populations, and use this data to select communities and populations for intervention and to improve programmatic activities
	Objective 4B. Utilize state and community-level data to identify and select SV prevention strategies for populations and communities with disproportionately high rates of SV.
	Objective 4C. Develop and implement an 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

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]

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	Question Instructions/Options
#.# Description [100]	Provide a concise statement of the milestone.
#.# Key Activities [700]	Provide a brief description of activities conducted to complete the milestone
Expected Milestone Achievement Date
#.# Milestone Status [Choose one from dropdown]	In Progress (on track) Delayed: Please add comments Completed Discontinued: Please add comments
Please provide reasons for delayed or discontinued work [3000]	*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 2, 2026 – January 31, 2027). 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]

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]	Timeframe [Choose one from dropdown]
Planning Partnerships Communication Policy Specific Strategy or Approach Implementation and/or Adaptation Surveillance Data Evaluation and Data Assures optimal level of health for all, and especially for those at greatest risk Other (not listed): Please specify topic		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

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 drop- down 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]

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.

Facilitator Type: [Choose one from dropdown]	Describe the facilitator and how it impacts your program’s work: [2000]	Program Component: [Select all that apply]	What resources were used [2000]	Facilitator Comments: [500]
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		Work Plan State Action Plan/Strategic Plan Prevention Strategies Data to Action Evaluation Sustainability Capacity Assessment

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.

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

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

   • 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 promoting optimal level of health for all, and especially for those at greatest risk, 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	Topic	Audience	Dates
300 characters	300 characters	300 characters

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 (August 1, 2024 – July 31, 2025). This form has three sections:

1. Progress on Action Plan

2. Progress on Implementing Action Plan

3. 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.

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 Assures optimal health for all, and especially for those at greatest risk 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]

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, 2026 – January 31, 2027) (700 characters)

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

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.

Name of Partner Organization	Primary Sector	Role of Partner	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]	State-, Community-, or Tribal-level Partner [Select all that apply]
	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)	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)		New, acquired during this reporting period Existing partner Re-engaged partner Increased engagement No longer a partner	State Community Tribal

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 (August 1, 2024 – July 31, 2025). 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.

SEM Levels 

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. 

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

• An approach is a specific way to advance the strategy.

• Examples include street outreach and community- norm 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.

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.

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.

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.

Activity Type: [Select one from dropdown]	Description of Activity: [2000]	Number of Sites/Locations Activity Implemented at	Activity Status: [Select one from dropdown]	Project Year Completed: [Select one from dropdown]
Planning Training/Coaching Executing Coordinating Monitoring Collecting and using data to improve implementation Other (not listed): specify	Provide a description of the activity and include with sufficient detail what the activity entailed, who was involved, and if any resources are needed.	Insert numeric value	In Progress (on track) Delayed Completed Discontinued	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.

Type of Adaptation: [Choose one from dropdown]	Adaptation Description [1000]	Number of Sites/Locations Adaptation Implemented At	Reason for Adaptation: [Choose one from dropdown]	What resources are needed for this adaption? (700 characters)	How was this adaptation evaluated and what was the impact of the adaptation? [2000]
Added content Deleted content Changed sequence Modified population of focus Modified	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?	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 inequities To address social determinants of health Used data to inform tailored implementation Other (not listed): specify		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.
delivery or
methods Added or
deleted policy
component Modified an
environmental
design element Changed the
type of
recommended
implementer Other (not
listed): specify

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 populations that your implementation effort is specifically focusing on, not all population groups that are being reached. For example, if you are implementing a program in a school that has people with disabilities, but the program is not specifically focused on reaching that group, you should not select those populations below.

Racial/ethnic groups [Select all that apply]

• Black/African American

• Asian

• Middle Eastern/North African

• Native Hawaiian/Pacific Islander

• American Indian/Alaska Native

• Hispanic/Latino

• White

Non-citizen groups: [Select all that apply]

• Immigrants

• Migrant workers

• Refugees

• Asylum seekers

• 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

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

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

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]	Name of Setting	Setting [Select one]	Geographic Location	Description (1000 characters)	Year 5 Target for Settings	Number of Settings Reached this Reporting Period	Progress Notes (2000 characters)
Insert Text	Insert Text	Community County Frontier Territory State Tribe NGO CBO Business Faith-based Organization Elementary School Middle School High School College/University Bar Other: Please Specify		Insert Text	Insert Numeric Value	Insert Numeric Value 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	Insert Text
						(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)

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 (August 1, 2024 – July 31, 2025). 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

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 optimal health for all, and especially for those at greatest risk?

• 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 optimal health for all, and especially for those at greatest risk 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 2, 2026 – January 31, 2027) (700 characters)

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.

Associate d Effort(s) (Select all that apply)

Evaluatio n Questions Addresse d [Select all that Apply]

Description of Outcome

Type

Indicator Description [500]

Data Source Type [Select all that apply]

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

Goal 1 Goal 2 Goal 3 Goal 4 Other

Questions #1-7

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

Insert Text 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.

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

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

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

Insert Numeri c Value

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

Insert Text

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 (Name)	Data Source Type	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]
	Needs Assessment Surveillance data Police data Hospital data Surveys Interviews Focus groups Administrative data Other (not listed): Specify		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.

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]	Description of Activity [1000]	Core Audience [Select all that pply]	Reach of Efforts [50]
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)		General public State agencies or governmental partners Non-profit or community partners Policymakers Other, specify

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