CSPECE Quantitative Form

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Attachment 4g. CSPECE Quantitative Form

CSPECE Quantitative Form
ATSDR estimates the average public reporting burden for this collection of information as 15 minutes per response,
including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining
the data/information 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 Information Collection Review Office, 1600
Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0923-0057).

General Instructions: Complete all applicable fields in "Capacity" and "Programmatic Measures" tabs. Detailed
instructions can be found in the "CSPECE Reporting Forms Guidance" document. Reporting measures and
information to be completed should be applicable to most programs, however, due to the variations in CSPECE
programs, a few fields may not be applicable to your program. Fields left blank will be assumed to have no
associated activities completed during the reporting period and/or not applicable to your program. Refer to your
work plan and Evaluation and Performance Measurement Plan to assure you are completing as many relevant fields
as possible for the activities specified to be completed during the reporting period, and addressing justification for
any incomplete activities in your Annual Performance Report (APR) narrative.

Basics
Please provide the following information for this report:
State:
Reporting Period:
POC Name:
POC Email:

Partnerships (Entities that receive no direct ATSDR funding, but are involved in CSPECE plann
programming)
Provide a list of your program's partners and information as it relates to their role and contributions to your program.
Partner Name

Partner Category (select all that
apply)

Example: Licensing Agency ABC

Licensing

Attachment 4g. CSPECE Quantitative Form

tive Form
Form Approved
OMB No. 0923-0057
Exp. Date 10/31/2026

ammatic Measures" tabs. Detailed
ent. Reporting measures and
er, due to the variations in CSPECE
nk will be assumed to have no
cable to your program. Refer to your
are completing as many relevant fields
eriod, and addressing justification for
.

g, but are involved in CSPECE planning or

role and contributions to your program.
Program role (select all that
apply)
Landscape assessment, Data
identification, Outreach,
Screening

Jurisdiction

State

CSPECE Reporting Form
Form Approved
OMB No. 0923-0057
Exp. Date 10/31/2026

ATSDR estimates the average public reporting burden for this collection of information as 15 minutes per response, including the time for reviewing instructions, searching existing
data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, MS H218, Atlanta, Georgia 30333; ATTN: PRA (0923-0053).

General Instructions: Complete all applicable fields in "Capacity" and "Programmatic Measures" tabs. Detailed instructions can be found in the
"CSPECE Reporting Forms Guidance" document. Reporting measures and information to be completed should be applicable to most programs,
however, due to the variations in CSPECE programs, a few fields may not be applicable to your program. Fields left blank will be assumed to have
no associated activities completed during the reporting period and/or not applicable to your program. Refer to your work plan and Evaluation and
Performance Measurement Plan to assure you are completing as many relevant fields as possible for the activities specified to be completed
during the reporting period, and addressing justification for any incomplete activities in your Annual Performance Report narrative.

RP1=Reporting Period 1, Annual Performance Report (Fall of 2023)
RP2=Reporting Period 2, Annual Performance Report (Fall of 2024)
RP3=Reporting Period 3, Annual Performance Report (Fall of 2025)
RP3=Reporting Period 4, Annual Performance Report (Fall of 2026)
RPF=Reporting Period 5, Final Report (March 2028)

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Education Measures: Training and Direct Education

Example (Reporting Period 1): Environmental Hazards and your ECE
Example (Reporting Period 3): CSPECE 101

N/A

N/A
0

# children estimated to be
reached

Training/educational intervention name

# of people educated

# of trainings delivered

Provide details on the trainings and direct education your program provided and the outputs of that education. This section should only
include direct education, which is education in which the participant is expected to be actively engaged and should be delivered by an
instructor. This can be formal trainings or one-on-one education/consultations.

N/A
0

Delivery
Method

Target audience

Online
0 In-person

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Describe any estimation methods used in this section:

Education Measures: Materials, Indirect Education, and Outreach
Provide results on the number of education-related measures below:
Measures:

RP1

RP2

RP3

RP4

RPF

Number of hard copy materials created for outreach and education (e.g. fact
sheets, flyers, pamphlets, brochures, paper newsletters etc.)
Number of electronic materials created for outreach and education (e.g.
outreach materials such as email and electronic listserv/mass mailings, email
newsletters, webpage, videos)
Number of materials created to build program infrastructure (SOPs, guidance
manual, screening tools, webpage, etc.)
Number of people reached through hard copy material distribution
Number of people reached through electronic material distribution
Number of referrals to your program for education
Describe any estimation methods used in this section:

Policy, Systems, Environment (PSE) Measures
Provide results on the number of policy, systems, and or/environmental changes below. The narrative should include a qualitative description of these
changes.
Performance Measures:
RP1
RP2
RP3
RPF
RP4

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Number of PSE changes to support exposure prevention in ECEs
Number of total children estimated to be reached by PSE changes

Screening and Response Measures
Provide the results for all applicable performance measures for your program for the applicable reporting period:
Performance Measures:

RP1

RP2

RP3 RP4

RPF

Number of new licensed ECE programs opened in your state
Number of referrals to your program for screening
Number of estimated children at those referred sites above
Total: Number of sites referred to your program where potentially harmful
exposures were occurring
Number of ECE programs that accepted changes because of identified issues
Number of ECE programs that implemented recommended changes because of
identified issues
Percentage of ECE programs that implemented recommended changes for a
problematic site
Number of total children estimated to be reached by screening and response
activities
Describe any estimation methods used in this section:

STATE-SPECIFIC PERFORMANCE MEASURES
Provide results on any measures that your program is tracking that are not included above:
Performance Measures:

RP1

RP2

RP3

RP4

RPF

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Insert more lines, if needed (right click on applicable row and select "insert")
Describe any estimation methods used in this section:

END

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