Form No number No number Progress Monitoring Report

Progress Monitoring Report
This progress monitoring report was designed to enable state programs to provide detailed information on their activities. This
is your opportunity to ensure that CDC understands your state program. The following questions appear in order of the state
recipient activities (core capacities: I–VI). At the end of the instrument, there is additional space available to write about any
other activities that your state was involved in that did not fit into one of the recipient activities.
We are aware that several answers may be "no," "in progress," or "not yet"—that is expected. If an item does not apply to
your circumstances, please feel free to enter "NA" or "nothing to report" into the relevant text box. Each reporting period, you
will be able to update this report. This report has been automated on-line so that you can import your previous answers as
appropriate. Only events that occurred during the most recent period need to be updated. The system is designed to make it
easy for you to update, delete, or add information. We may need to follow up with you on some of the information you provide
(e.g., to highlight success stories, to clarify details).
This progress monitoring report will serve the following purposes:
1.
2.

monitor the activities and progress of funded states in CDC’s Nutrition and Physical Activity Program to Prevent Obesity
and Other Chronic Diseases; and
assist CDC in providing funded states with appropriate technical assistance that will lead to program effectiveness and
improvement.

Please provide updated information covering the period from January 1st, 2007 to June 30th, 2007.
We appreciate your cooperation in this endeavor, and we welcome any feedback on the reporting content and format.
If you have any questions while filling out this form, please feel free to contact us or our contractor, RTI at
1-800-344-1393
, or send e-mail to PMR-help@rti.org.
Form Approved
OMB No.: 0920-0669
Expiration Date: 01/31/2008

Public reporting burden of this collection of information is estimated to average 12 hours per response, 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 E-11,
Atlanta, Georgia 30333; ATTN: PRA (0920-0669).

INTRODUCTION
I1: If you have any questions while filling out this form, please feel free to contact us or our contractor, RTI at
1-800-344-1393
, or send e-mail to PMR-help@rti.org.
Please provide updated information covering the period from January 1st, 2007 to June 30th, 2007.
This section of the report addresses recipient activity #1:
Develop a coordinated nutrition and physical activity program infrastructure.

For a flowchart showing you the flow of questions in this section, click here.

(PDF)

STAFFING
I2: Please complete the following for each staff member with FTE's dedicated to this effort. Reporting on one
staff member at a time, complete the staff member's position and educational qualifications (select all that apply),
the content area of their degree, % time dedicated to this effort, the source paying for the position (select all that
apply and, if there are multiple sources, indicate the % FTE covered by each source), the date he/she started
working on the project (month/year), staff type (permanent/interim), and expertise areas (select all that apply).
Be sure to capture all FTE’s dedicated to this effort in the State Health Department (including contracts).
You must include all FTE dedicated to this effort, even if you reported them in a previous PMR .
NOTE: You will be prompted to add additional FTE's following this screen, if applicable.
Staff Name

Position

If OTHER position, please specify.

Education Qualifications (Check all that apply)

c MPH
d
e
f
g
c Other Master's
d
e
f
g
c RN
d
e
f
g
c RD
d
e
f
g
c Bachelor’s
d
e
f
g
c Associate’s
d
e
f
g
c MD
d
e
f
g
c Doctorate
d
e
f
g
c No post-secondary degree
d
e
f
g
Degree Content Area

c Public Health
d
e
f
g
c Exercise Science
d
e
f
g
c Physical Education
d
e
f
g
c Nutrition
d
e
f
g
c Public Health Nutrition
d
e
f
g
c Other
d
e
f
g
If OTHER Degree Content Area, please specify.

Percent of Time on Project

Source of Funds (Check all that apply)

c Nutrition and Physical Activity Program to Prevent Obesity and Other Chronic Diseases cooperative
d
e
f
g
agreement
c Other CDC funding
d
e
f
g
c State funds
d
e
f
g
c Foundation funds
d
e
f
g

c Other (Please specify)
d
e
f
g
If OTHER source of CDC funding, please specify.

If OTHER source of funds, please specify.

In the most recent funding period:
Percent of salary covered by cooperative agreement

Percent of salary covered by other CDC funding

Percent of salary covered by state funds

Percent of salary covered by foundation funds

Percent of salary covered by other sources

Date Staff Started Working on Project (MM/YYYY)

Staff Type

j Permanent
k
l
m
n
j Interim
k
l
m
n
Expertise Areas (Check all that apply)

c Qualitative &/or quantitative methods
d
e
f
g
c Epidemiology & surveillance
d
e
f
g
c Program evaluation
d
e
f
g
c Health communication
d
e
f
g
c Partnerships and coalition building
d
e
f
g
c Nutrition
d
e
f
g
c Physical activity
d
e
f
g
c Program coordination, management and strategic planning
d
e
f
g
c Social marketing
d
e
f
g
c Other (please specify)
d
e
f
g
If OTHER expertise areas, please specify.

TRAINING
I4: Please select all of the following CDC trainings in which state Nutrition and Physical Activity Program to
Prevent Obesity and Other Chronic Diseases staff participated during the past 6 months.
CDC Trainings

c California Child Obesity Conference: "Protecting the Future of Our Children" in Anaheim January
d
e
f
g
24 - 26, 2007

c Evaluation Workshop: The Big Picture: Getting to the Evaluation of the State Plan May 21-24,
d
e
f
g
2007
c Other CDC Training
d
e
f
g

c None
d
e
f
g

I4g: For California Child Obesity Conference: "Protecting the Future of Our Children" in Anaheim
January 24 - 26, 2007, please provide the position(s) of Nutrition & Physical Activity Program to Prevent
Obesity and Other Chronic Diseases staff who attended, making sure to mark all that apply.
Staff Positions

c Program coordinator
d
e
f
g
c Physical activity coordinator
d
e
f
g
c Nutrition coordinator
d
e
f
g
c Evaluator
d
e
f
g
c Communications coordinator
d
e
f
g
c Epidemiologist
d
e
f
g
c Other (please specify)
d
e
f
g
If OTHER Staff Positions, please specify.

I4h: For Evaluation Workshop: The Big Picture: Getting to the Evaluation of the State Plan May 21-24,
2007, please provide the position(s) of Nutrition & Physical Activity Program to Prevent Obesity and Other
Chronic Diseases staff who attended, making sure to mark all that apply.
Staff Positions

c Program coordinator
d
e
f
g
c Physical activity coordinator
d
e
f
g

c Nutrition coordinator
d
e
f
g
c Evaluator
d
e
f
g

c Communications coordinator
d
e
f
g
c Epidemiologist
d
e
f
g

c Other (please specify)
d
e
f
g
If OTHER Staff Positions, please specify.

I9: Were there any other CDC trainings not previously listed in which state Nutrition & Physical Activity Program
to Prevent Obesity and Other Chronic Diseases staff participated?

j Yes
k
l
m
n

j No
k
l
m
n

I8: Please list the other training event, date attended, and the position(s) of Nutrition & Physical Activity
Program to Prevent Obesity and Other Chronic Diseases staff who attended, making sure to mark all that apply.
Name of Training

Date Attended (MM/YYYY)

Or

c Ongoing Training
d
e
f
g
Staff Positions

c Program coordinator
d
e
f
g
c Physical activity coordinator
d
e
f
g
c Nutrition coordinator
d
e
f
g
c Evaluator
d
e
f
g
c Communications coordinator
d
e
f
g
c Epidemiologist
d
e
f
g
c Other (please specify)
d
e
f
g
If OTHER Staff Positions, please specify.

I10: Other than DNPA-provided training, were any trainings that you attended during this reporting period
particularly useful for building capacity or staff expertise in the major program content areas (e.g., physical
activity, fruits and vegetables, breastfeeding, TV watching, nutrition, social marketing, media advocacy,
evaluation) or obesity prevention and control?

j Yes
k
l
m
n
j No
k
l
m
n

I11: Please indicate which functional/content area(s) (e.g., physical activity, fruits and vegetables,
breastfeeding, TV watching, nutrition, social marketing, media advocacy, evaluation) and briefly describe what
you learned.
Functional/Content Area(s)

Date Attended (MM/YYYY)

Or

c Ongoing Training
d
e
f
g

Describe

I13: What actions were taken based on the training(s) program staff have attended to date (for example,
describe how skills or "take away" messages have been applied or shared with partners)?
Actions

RESOURCES
R1: Please complete the following regarding the Nutrition and Physical Activity Program to Prevent Obesity and
Other Chronic Diseases cooperative agreement expenditures spent during the last 12 months. Provide all cost
components (i.e., include direct and indirect costs) for each of the following 3 expenditure categories: total
expenditures, evaluation/surveillance expenditures, and contracts for program intervention activities (e.g., media,
contracts). You may respond in dollar amounts OR percent of funds spent on each budget category. (The total
does not need to equal 100%.)
Note: Please enter numbers only. For example, $500,000 would be entered as 500000 - no comma, no dollar
sign, and no words.
Total Expenditures

j Dollars
k
l
m
n

j Percent
k
l
m
n

Evaluation/Surveillance

j Dollars
k
l
m
n

j Percent
k
l
m
n

Contracts for Program Intervention Activities

j Dollars
k
l
m
n

j Percent
k
l
m
n

R3: For the five largest contracts in the last 12 months, please describe the contract, and specify the amount,
the title and type of recipient (e.g., local health department, school district, regional health group, local planning
council, outdoor advertising firm), the target audience and the activity.
Contract Title

Type of Recipient

Amount

Age of Target Audience (Check all that apply)

c Infants and toddlers
d
e
f
g
c 3-4 yr.
d
e
f
g
c 5-9 yr.
d
e
f
g
c 10-13 yr.
d
e
f
g
c 14-17 yr.
d
e
f
g
c 18–29 yr.
d
e
f
g
c 30–64 yr.
d
e
f
g
c 65+
d
e
f
g
c All ages
d
e
f
g
c Not applicable
d
e
f
g
If not applicable, please explain.

Activity (Check all that apply)

c Planning
d
e
f
g
c Breastfeeding
d
e
f
g
c Fruit & vegetables
d
e
f
g
c Caloric intake
d
e
f
g
c TV use
d
e
f
g
c Physical activity
d
e
f
g
c Evaluation
d
e
f
g
c Other nutrition activity
d
e
f
g
c Other (Please specify)
d
e
f
g
If OTHER Activity, please specify

R5: Please select all sources of funds outside this CDC-DNPA cooperative agreement that have been obtained in
the most recent reporting period for the state nutrition and physical activity program or the accomplishment of
the state plan.
Non-CDC Sources of Funding

c None
d
e
f
g
c Federal Programs
d
e
f
g
c State Programs
d
e
f
g
c Foundation grants
d
e
f
g
c Contributions from private businesses
d
e
f
g

c Other
d
e
f
g

R6: For federal programs, please provide the name of the funder, approximate amount, and the purpose of
funding.
Name of Federal Program(s) Providing Funding

Amount

Purpose of Funding

c Infrastructure (e.g., staffing)
d
e
f
g

c Planning/programs
d
e
f
g
c Evaluation/surveillance
d
e
f
g

c Other (Please specify)
d
e
f
g
If OTHER purpose, please specify

R8: For state programs, please provide the approximate amount and purpose of funding.
Amount

Purpose of Funding

c Infrastructure (e.g., staffing)
d
e
f
g
c Planning/programs
d
e
f
g

c Evaluation/surveillance
d
e
f
g
c Other (Please specify)
d
e
f
g
If OTHER purpose, please specify

R9: For foundation grants, please provide the approximate amount and purpose of funding.
Amount

Purpose of Funding

c Infrastructure (e.g., staffing)
d
e
f
g

c Planning/programs
d
e
f
g
c Evaluation/surveillance
d
e
f
g
c Other (Please specify)
d
e
f
g
If OTHER purpose, please specify

R10: For contributions from private business, please provide the approximate amount and purpose of
funding.
Amount

Purpose of Funding

c Infrastructure (e.g., staffing)
d
e
f
g
c Planning/programs
d
e
f
g
c Evaluation/surveillance
d
e
f
g
c Other (Please specify)
d
e
f
g
If OTHER purpose, please specify

R12: For this other source of non-CDC funds, please identify the source/program and provide the approximate
amount and purpose of funding.
Source

Amount

Purpose of Funding

c Infrastructure (e.g., staffing)
d
e
f
g
c Planning/programs
d
e
f
g
c Evaluation/surveillance
d
e
f
g
c Other (Please specify)
d
e
f
g
If OTHER Purpose, please specify.

PARTNERS
C1: If you have any questions while filling out this form, please feel free to contact us or our contractor, RTI at
1-800-344-1393
, or send e-mail to PMR-help@rti.org.

Please provide updated information covering the period from January 1st, 2007 to June 30th, 2007.
This section of the report addresses recipient activity #2:
Collaboration and coordination with state and local government and private partners,
including members of the population, throughout the planning process.

For a flowchart showing you the flow of questions in this section, click here.

(PDF)

C2: Please provide information about state and local partnerships to coordinate obesity prevention efforts,
especially state programs in cardiovascular health, cancer, diabetes, etc. Provide your 3 most important partners
(by organization – not individuals) for each of the following categories:
l
l
l
l
l
l
l
l
l
l
l

governmental health agencies (federal, state, or local);
voluntary agencies/community-based organizations;
health care;
private sector businesses;
organizations focusing on health disparities (e.g., rural, racial/ethnic, aging);
state/local departments of education;
universities, medical schools or schools of public health;
nutrition organizations;
physical activity organizations;
professional organizations;
other types of organizations (e.g., non-profits, coalitions).

Please list each partner once. Some partners could fall into more than one category -- please select the one
category that suits the partner best.

C3: Please provide your three most important partners (by organization—not individuals) for governmental
health agencies (federal, state, or local). Use the check boxes to indicate how each partner contributed to
the state plan or program during the past 6 months (i.e., not every partner will be included every 6-month
reporting period). In addition, please indicate whether the partnership was pre-existing before this funding period
or is a new partnership (i.e., the partner was added during the funding period). Finally, please indicate whether
there is a Memorandum of Understanding (MOU) with the organization.
Partner

New Partner?

j Yes
k
l
m
n

j No
k
l
m
n

Participate in Planning?

j Yes
k
l
m
n

j No
k
l
m
n

Implement Intervention?

j Yes
k
l
m
n

j No
k
l
m
n

Work toward state plan objectives?

j Yes
k
l
m
n

j No
k
l
m
n

Co-lead workgroups/coalitions/task forces/committees?

j Yes
k
l
m
n

j No
k
l
m
n

Other?

j Yes
k
l
m
n

j No
k
l
m
n

If OTHER, please specify:

In-Kind Staff Time?

j Yes
k
l
m
n

j No
k
l
m
n

Staff Time Paid by Nutrition and Physical Activity Program to
Prevent Obesity and Other Chronic Diseases initiative?

j Yes
k
l
m
n

j No
k
l
m
n

Money?

j Yes
k
l
m
n

j No
k
l
m
n

Co-sponsor Event?

j Yes
k
l
m
n

j No
k
l
m
n

Is there an MOU in place?

j Yes
k
l
m
n

j No
k
l
m
n

C5: Please provide your three most important partners (by organization—not individuals) for voluntary
agencies/community-based organizations. Use the check boxes to indicate how each partner contributed to
the state plan or program within the past 6 months (i.e., not every partner will be included every 6 -month
reporting period). In addition, please indicate whether the partnership was pre-existing before this funding period
or is a new partner (i.e., the partner was added during the funding period). Finally, please indicate whether there
is a Memorandum of Understanding (MOU) with the organization.
Partner

New Partner?

j Yes
k
l
m
n

j No
k
l
m
n

Participate in Planning?

j Yes
k
l
m
n

j No
k
l
m
n

Implement Intervention?

j Yes
k
l
m
n

j No
k
l
m
n

Work toward state plan objectives?

j Yes
k
l
m
n

j No
k
l
m
n

Co-lead workgroups/coalitions/task forces/committees?

j Yes
k
l
m
n

j No
k
l
m
n

Other?

j Yes
k
l
m
n

j No
k
l
m
n

In-Kind Staff Time?

j Yes
k
l
m
n

j No
k
l
m
n

Staff Time Paid by Nutrition and Physical Activity Program to
Prevent Obesity and Other Chronic Diseases initiative?

j Yes
k
l
m
n

j No
k
l
m
n

Money?

j Yes
k
l
m
n

j No
k
l
m
n

Co-sponsor Event?

j Yes
k
l
m
n

j No
k
l
m
n

Is there an MOU in place?

j Yes
k
l
m
n

j No
k
l
m
n

If OTHER, please specify:

C7: Please provide your three most important partners (by organization—not individuals) for health care. Use

the check boxes to indicate how each partner contributed to the state plan or program within the past 6 months
(i.e., not every partner will be included every 6-month reporting period). In addition, please indicate whether the
partnership was pre-existing before this funding period or is a new partner (i.e., the partner was added during the
funding period). Finally, please indicate whether there is a Memorandum of Understanding (MOU) with the
organization.
Partner

New Partner?

j Yes
k
l
m
n

j No
k
l
m
n

Participate in Planning?

j Yes
k
l
m
n

j No
k
l
m
n

Implement Intervention?

j Yes
k
l
m
n

j No
k
l
m
n

Work toward state plan objectives?

j Yes
k
l
m
n

j No
k
l
m
n

Co-lead workgroups/coalitions/task forces/committees?

j Yes
k
l
m
n

j No
k
l
m
n

Other?

j Yes
k
l
m
n

j No
k
l
m
n

In-Kind Staff Time?

j Yes
k
l
m
n

j No
k
l
m
n

Staff Time Paid by Nutrition and Physical Activity Program to
Prevent Obesity and Other Chronic Diseases initiative?

j Yes
k
l
m
n

j No
k
l
m
n

Money?

j Yes
k
l
m
n

j No
k
l
m
n

Co-sponsor Event?

j Yes
k
l
m
n

j No
k
l
m
n

Is there an MOU in place?

j Yes
k
l
m
n

j No
k
l
m
n

If OTHER, please specify:

C9: Please provide your three most important partners (by organization—not individuals) for private sector
businesses. Use the check boxes to indicate how each partner contributed to the state plan or program within
the past 6 months (i.e., not every partner will be included every 6-month reporting period). In addition, please
indicate whether the partnership was pre-existing before this funding period or is a new partner (i.e., the partner
was added during the funding period). Finally, please indicate whether there is a Memorandum of Understanding
(MOU) with the organization.
Partner

New Partner?

j Yes
k
l
m
n

j No
k
l
m
n

Participate in Planning?

j Yes
k
l
m
n

j No
k
l
m
n

Implement Intervention?

j Yes
k
l
m
n

j No
k
l
m
n

Work toward state plan objectives?

j Yes
k
l
m
n

j No
k
l
m
n

Co-lead workgroups/coalitions/task forces/committees?

j Yes
k
l
m
n

j No
k
l
m
n

Other?

j Yes
k
l
m
n

j No
k
l
m
n

If OTHER, please specify:

In-Kind Staff Time?

j Yes
k
l
m
n

j No
k
l
m
n

Staff Time Paid by Nutrition and Physical Activity Program to
Prevent Obesity and Other Chronic Diseases initiative?

j Yes
k
l
m
n

j No
k
l
m
n

Money?

j Yes
k
l
m
n

j No
k
l
m
n

Co-sponsor Event?

j Yes
k
l
m
n

j No
k
l
m
n

Is there an MOU in place?

j Yes
k
l
m
n

j No
k
l
m
n

C11: Please provide your three most important partners (by organization—not individuals) for organizations
focusing on health disparities (e.g., rural, racial/ethnic, aging). Use the check boxes to indicate how each
partner contributed to the state plan or program within the past 6 months (i.e., not every partner will be included
every 6-month reporting period). In addition, please indicate whether the partnership was pre-existing before this
funding period or is a new partner (i.e., the partner was added during the funding period). Finally, please indicate
whether there is a Memorandum of Understanding (MOU) with the organization.
Partner

New Partner?

j Yes
k
l
m
n

j No
k
l
m
n

Participate in Planning?

j Yes
k
l
m
n

j No
k
l
m
n

Implement Intervention?

j Yes
k
l
m
n

j No
k
l
m
n

Work toward state plan objectives?

j Yes
k
l
m
n

j No
k
l
m
n

Co-lead workgroups/coalitions/task forces/committees?

j Yes
k
l
m
n

j No
k
l
m
n

Other?

j Yes
k
l
m
n

j No
k
l
m
n

In-Kind Staff Time?

j Yes
k
l
m
n

j No
k
l
m
n

Staff Time Paid by Nutrition and Physical Activity Program to
Prevent Obesity and Other Chronic Diseases initiative?

j Yes
k
l
m
n

j No
k
l
m
n

Money?

j Yes
k
l
m
n

j No
k
l
m
n

Co-sponsor Event?

j Yes
k
l
m
n

j No
k
l
m
n

Is there an MOU in place?

j Yes
k
l
m
n

j No
k
l
m
n

If OTHER, please specify:

C13: Please provide your three most important partners (by organization—not individuals) for state/local
departments of education. Use the check boxes to indicate how each partner contributed to the state plan or
program within the past 6 months (i.e., not every partner will be included every 6 -month reporting period). In
addition, please indicate whether the partnership was pre -existing before this funding period or is a new partner
(i.e., the partner was added during the funding period). Finally, please indicate whether there is a Memorandum
of Understanding (MOU) with the organization.
Partner

New Partner?

j Yes
k
l
m
n

j No
k
l
m
n

Participate in Planning?

j Yes
k
l
m
n

j No
k
l
m
n

Implement Intervention?

j Yes
k
l
m
n

j No
k
l
m
n

Work toward state plan objectives?

j Yes
k
l
m
n

j No
k
l
m
n

Co-lead workgroups/coalitions/task forces/committees?

j Yes
k
l
m
n

j No
k
l
m
n

Other?

j Yes
k
l
m
n

j No
k
l
m
n

In-Kind Staff Time?

j Yes
k
l
m
n

j No
k
l
m
n

Staff Time Paid by Nutrition & Physical Activity Program to
Prevent Obesity and Other Chronic Diseases initiative?

j Yes
k
l
m
n

j No
k
l
m
n

Money?

j Yes
k
l
m
n

j No
k
l
m
n

Co-sponsor Event?

j Yes
k
l
m
n

j No
k
l
m
n

Is there an MOU in place?

j Yes
k
l
m
n

j No
k
l
m
n

If OTHER, please specify:

C15: Please provide your three most important partners (by organization—not individuals) for universities,
medical schools or schools of public health. Use the check boxes to indicate how each partner contributed to
the state plan or program within the past 6 months (i.e., not every partner will be included every 6 -month
reporting period). In addition, please indicate whether the partnership was pre-existing before this funding period
or is a new partner (i.e., the partner was added during the funding period). Finally, please indicate whether there
is a Memorandum of Understanding (MOU) with the organization.
Partner

New Partner?

j Yes
k
l
m
n

j No
k
l
m
n

Participate in Planning?

j Yes
k
l
m
n

j No
k
l
m
n

Implement Intervention?

j Yes
k
l
m
n

j No
k
l
m
n

Work toward state plan objectives?

j Yes
k
l
m
n

j No
k
l
m
n

Co-lead workgroups/coalitions/task forces/committees?

j Yes
k
l
m
n

j No
k
l
m
n

Other?

j Yes
k
l
m
n

j No
k
l
m
n

In-Kind Staff Time?

j Yes
k
l
m
n

j No
k
l
m
n

Staff Time Paid by Nutrition and Physical Activity Program to
Prevent Obesity and Other Chronic Diseases initiative?

j Yes
k
l
m
n

j No
k
l
m
n

Money?

j Yes
k
l
m
n

j No
k
l
m
n

Co-sponsor Event?

j Yes
k
l
m
n

j No
k
l
m
n

Is there an MOU in place?

j Yes
k
l
m
n

j No
k
l
m
n

If OTHER, please specify:

C17: Please provide your three most important partners (by organization—not individuals) for nutrition
organizations. Use the check boxes to indicate how each partner contributed to the state plan or program within
the past 6 months (i.e., not every partner will be included every 6-month reporting period). In addition, please
indicate whether the partnership was pre-existing before this funding period or is a new partner (i.e., the partner
was added during the funding period). Finally, please indicate whether there is a Memorandum of Understanding
(MOU) with the organization.
Partner

New Partner?

j Yes
k
l
m
n

j No
k
l
m
n

Participate in Planning?

j Yes
k
l
m
n

j No
k
l
m
n

Implement Intervention?

j Yes
k
l
m
n

j No
k
l
m
n

Work toward state plan objectives?

j Yes
k
l
m
n

j No
k
l
m
n

Co-lead workgroups/coalitions/task forces/committees?

j Yes
k
l
m
n

j No
k
l
m
n

Other?

j Yes
k
l
m
n

j No
k
l
m
n

In-Kind Staff Time?

j Yes
k
l
m
n

j No
k
l
m
n

Staff Time Paid by Nutrition and Physical Activity Program to
Prevent Obesity and Other Chronic Diseases initiative?

j Yes
k
l
m
n

j No
k
l
m
n

Money?

j Yes
k
l
m
n

j No
k
l
m
n

Co-sponsor Event?

j Yes
k
l
m
n

j No
k
l
m
n

Is there an MOU in place?

j Yes
k
l
m
n

j No
k
l
m
n

If OTHER, please specify:

C19: Please provide your three most important partners (by organization—not individuals) for physical activity
organizations. Use the check boxes to indicate how each partner contributed to the state plan or program within
the past 6 months (i.e., not every partner will be included every 6-month reporting period). In addition, please
indicate whether the partnership was pre-existing before this funding period or is a new partner (i.e., the partner
was added during the funding period). Finally, please indicate whether there is a Memorandum of Understanding
(MOU) with the organization.
Partner

New Partner?

j Yes
k
l
m
n

j No
k
l
m
n

Participate in Planning?

j Yes
k
l
m
n

j No
k
l
m
n

Implement Intervention?

j Yes
k
l
m
n

j No
k
l
m
n

Work toward state plan objectives?

j Yes
k
l
m
n

j No
k
l
m
n

Co-lead workgroups/coalitions/task forces/committees?

j Yes
k
l
m
n

j No
k
l
m
n

Other?

j Yes
k
l
m
n

j No
k
l
m
n

In-Kind Staff Time?

j Yes
k
l
m
n

j No
k
l
m
n

Staff Time Paid by Nutrition and Physical Activity Program to
Prevent Obesity and Other Chronic Diseases initiative?

j Yes
k
l
m
n

j No
k
l
m
n

Money?

j Yes
k
l
m
n

j No
k
l
m
n

Co-sponsor Event?

j Yes
k
l
m
n

j No
k
l
m
n

Is there an MOU in place?

j Yes
k
l
m
n

j No
k
l
m
n

If OTHER, please specify:

C21: Please provide your most important partners (by organization—not individuals) for professional
organizations. Use the check boxes to indicate how each partner contributed to the state plan or program within
the past 6 months (i.e., not every partner will be included every 6-month reporting period). In addition, please
indicate whether the partnership was pre-existing before this funding period or is a new partner (i.e., the partner
was added during the funding period). Finally, please indicate whether there is a Memorandum of Understanding
(MOU) with the organization.
Partner

New Partner?

j Yes
k
l
m
n

j No
k
l
m
n

Participate in Planning?

j Yes
k
l
m
n

j No
k
l
m
n

Implement Intervention?

j Yes
k
l
m
n

j No
k
l
m
n

Work toward state plan objectives?

j Yes
k
l
m
n

j No
k
l
m
n

Co-lead workgroups/coalitions/task forces/committees?

j Yes
k
l
m
n

j No
k
l
m
n

Other?

j Yes
k
l
m
n

j No
k
l
m
n

In-Kind Staff Time?

j Yes
k
l
m
n

j No
k
l
m
n

Staff Time Paid by Nutrition and Physical Activity Program to
Prevent Obesity and Other Chronic Diseases initiative?

j Yes
k
l
m
n

j No
k
l
m
n

Money?

j Yes
k
l
m
n

j No
k
l
m
n

Co-sponsor Event?

j Yes
k
l
m
n

j No
k
l
m
n

Is there an MOU in place?

j Yes
k
l
m
n

j No
k
l
m
n

If OTHER, please specify:

C23: Are there other types of organization (e.g., non-profits, coalitions) partners you'd like to list?

j Yes
k
l
m
n
j No
k
l
m
n

C24: Please provide your three most important partners (by organization—not individuals) for other types of
organizations (e.g., non-profits, coalitions). Use the check boxes to indicate how each partner contributed to
the state plan or program within the past 6 months (i.e., not every partner will be included every 6 -month
reporting period). In addition, please indicate whether the partnership was pre-existing before this funding period
or is a new partner (i.e., the partner was added during the funding period). Finally, please indicate whether there
is a Memorandum of Understanding (MOU) with the organization.
Partner (add each one seperately)

New Partner?

j Yes
k
l
m
n

j No
k
l
m
n

Participate in Planning?

j Yes
k
l
m
n

j No
k
l
m
n

Implement Intervention?

j Yes
k
l
m
n

j No
k
l
m
n

Work toward state plan objectives?

j Yes
k
l
m
n

j No
k
l
m
n

Co-lead workgroups/coalitions/task forces/committees?

j Yes
k
l
m
n

j No
k
l
m
n

Other?

j Yes
k
l
m
n

j No
k
l
m
n

In-Kind Staff Time?

j Yes
k
l
m
n

j No
k
l
m
n

Staff Time Paid by Nutrition and Physical Activity Program to
Prevent Obesity and Other Chronic Diseases initiative?

j Yes
k
l
m
n

j No
k
l
m
n

If OTHER, please specify:

Money?

j Yes
k
l
m
n

j No
k
l
m
n

Co-sponsor Event?

j Yes
k
l
m
n

j No
k
l
m
n

Is there an MOU in place?

j Yes
k
l
m
n

j No
k
l
m
n

C26: Were any new coalitions/task forces/committees/work groups related to the Nutrition & Physical Activity
Program to Prevent Obesity and Other Chronic Diseases initiative (i.e., groups formally organized to address a
specific issue, topic, or program objective in order to move forward) established during this reporting period?
(Examples include evaluation advisory boards, evaluation task forces, surveillance task forces, task force on
funding & resources, task force on older adults, task force on school-aged children.)

j Yes
k
l
m
n
j No
k
l
m
n

C27: Please provide the name of the group/organization and its purpose.
Name

Purpose

C29: Please provide the 3 main activities that existing coalitions/task forces/committees/work groups conducted
in this reporting period. (Briefly describe new efforts of the group, progress on current efforts, and
accomplishments.)
Coalition or Group Name

Activities

C30: Were any coalitions/task forces/committees/work groups disbanded during this reporting period? This
includes any organizations that are no longer partners.

j Yes
k
l
m
n
j No
k
l
m
n

C31: Please provide the names of the coalitions/task forces/committees/work groups that were disbanded during
this reporting period. This includes any organizations that are no longer partners.
Disbanded Organizations

C32: Please give at least one example of a successful collaboration with an internal partner (i.e., within state
health department) in the development, use and/or implementation of the state plan.
Example

C33: Please give at least one example of successful collaboration with an external partner (i.e., partners other
than state health department) in the development, use and/or implementation of the state plan.
Example

C34: Please briefly describe any lessons learned through working with internal partners (i.e., state
government), including the issues that arose and how they were addressed.
Lessons Learned

C35: Please briefly describe any lessons learned through working with external partners (i.e., other than state
government), including the issues that arose and how they were addressed.
Lessons Learned

C36: Do you have one or more “champions” external to the DOH that helped move the obesity prevention and
control program forward?

j Yes
k
l
m
n
j No
k
l
m
n

C37: Please list the "champion" organization and describe their actions taken on behalf of the state program
during this report period.
Organization

Actions

PLANNING
PL1: If you have any questions while filling out this form, please feel free to contact us or our contractor, RTI at
1-800-344-1393
, or send e-mail to PMR-help@rti.org.
Please provide updated information covering the period January 1st, 2007 to June 30th, 2007.
This section of the report addresses recipient activity #3:
Conduct a planning process that leads to a comprehensive nutrition and physical activity
plan to prevent and control obesity and other chronic diseases, and start to implement
the plan.

For a flowchart showing you the flow of questions in this section, click here.

(PDF)

PL3: Has a state plan for nutrition and physical activity been produced during the past 6 months?
State Plan Status

j Not yet
k
l
m
n

j Yes, draft completed
k
l
m
n
j Draft undergoing CDC review
k
l
m
n

j In progress
k
l
m
n
j State plan in effect
k
l
m
n

PL4: Please briefly describe the status of your state plan for nutrition and physical activity.
Status

PL5: Please submit two copies of this report, if it has not been submitted previously. Please provide the title,
publication date and whom it was distributed to.
Title

Publication Date (MM/YYYY)

Distributed To

PL9: Was the state plan revised during this reporting period? If so, please briefly describe the status of the
revision, and note when it was (or will be) shared with CDC.

j Yes
k
l
m
n
j No
k
l
m
n
Status

PL10: Did you use the State Plan Index (SPI) to guide the development or the revision of your state plan? If so,
please describe.

j Yes
k
l
m
n
j No
k
l
m
n
Description

PL11: Did your state involve members of the general state population in developing the state plan?

j Yes
k
l
m
n
j No
k
l
m
n

PL12: Please select from the following choices those activities your state conducted to include and involve
members of the general state population in developing the state plan.
Planning Activities

c Town hall meetings
d
e
f
g
c Hearings
d
e
f
g

c Focus groups about the state planning process or plan (do not include “intervention” related focus
d
e
f
g
groups)

c Written comments
d
e
f
g
c Other
d
e
f
g
If OTHER Activities, please specify.

PL13: Summarize the main feedback or recommendations resulting from the town hall meetings.
Feedback or Recommendations

PL14: Summarize the main feedback or recommendations resulting from the hearings.
Feedback or Recommendations

PL16: Summarize the main feedback or recommendations resulting from the focus groups about the state
planning process or plan.
Feedback or Recommendations

PL17: Summarize the main feedback or recommendations resulting from the solicited written comments.
Feedback or Recommendations

PL19: Was there another activity not covered earlier that you would like to report?

j Yes
k
l
m
n

j No
k
l
m
n

PL20: Identify the activity and summarize the main feedback or recommendations resulting from this activity.
Activity

Feedback or Recommendations

PL21: In about 150 words or less, tell us about what you’ve done as part of the state planning process to
understand your target populations as part of the State Planning Process. This can include the processes or
methods, sources of information, organizations consulted, and so on.
Description

PL22: Did you use the Guide to Community Preventive Services (i.e., the Community Guide, found at

www.thecommunityguide.org) to guide the plan and/or identify evidence-based interventions? If so, please
describe.

j No
k
l
m
n
j Not yet, but planning to use it
k
l
m
n
j Yes
k
l
m
n
Describe

PL23: Is the logic model for the overall state plan developed? If so, please provide the date of completion.

j Yes
k
l
m
n

j No
k
l
m
n
Date Completed (MM/YYYY)

PL24: We want the PMR to capture all your state plan objectives. Since your objectives probably won't change a
great deal once they are developed as part of the state planning process, you won't need to enter them every
reporting period.
Please briefly state an objective contained in the plan. Remember that objectives are supposed to be specific,
measurable, achievable, relevant, and time-bound (SMART). We will refer to these objectives again later in this
progress report.
Objective (Please describe only one)

Responsible Party

PL26: Please describe any actions your state took as part of the state planning process to assess existing obesity
prevention and control efforts.
Actions

PL27: Please describe any other actions taken (not described previously) to assess gaps in service and/or
opportunities for additional service.
Actions

PL28: Please describe any other actions taken (not described previously) to assess barriers to service .
Actions

PL30: Please describe an example of how utilizing the social-ecologic model has been particularly helpful in
preparing your state plan —in its development or its implementation —(e.g., selection of target populations, data
sources, partners, etc.). In your example, describe the elements that address each of the relevant levels of a
social-ecologic model:
1.
2.
3.
4.

Societal/Media level (e.g., media advocacy, social marketing media campaigns, public education initiatives,
website development, advertising/event sponsorships);
Community level (e.g., coordinated referral system, neighborhood organizations or groups, community
events);
Organizational level (e.g., schools, worksites, health care providers/organizations);
Interpersonal level (e.g., families, parents, caregivers, significant others);

5.

Personal level (e.g., increase awareness, knowledge, attitudes).
Societal/Media level

Community level

Organizational level

Interpersonal level

Personal level

POLICY
PO1: If you have any questions while filling out this form, please feel free to contact us or our contractor, RTI at
1-800-344-1393
, or send e-mail to PMR-help@rti.org.
Please provide updated information covering the period January 1st, 2007 to June 30th, 2007.

This next series of questions asks you to describe any POLICIES, LEGISLATIVE ACTS, or ENVIRONMENTAL
CHANGES that were initiated, modified or enforced as a result of the state planning process during the past 6
months. Please do not provide the same answer in more than one place.
Policy is defined as those laws, regulations, formal, and informal rules and understandings that are adopted on a
collective basis to guide individual and collective behavior. Environmental change may result from either policy or
legislation, but there is no need to repeat the same information for the question about environmental change. Use
the final question in this series on policies to cover any environmental change that may have occurred unrelated
to policy or legislation. Please include changes on the state, regional, or local levels, as appropriate.
For a flowchart showing you the flow of questions in this section, click here.

(PDF)

PO3: Were there any policy changes affecting overweight/obesity (e.g., nutrition, physical activity, TV watching,
breastfeeding) initiated, modified, or enforced in your state during this reporting period? {NOTE: A policy is
defined as those regulations, formal, and informal rules and understandings that are adopted on a collective basis
to guide individual and collective behavior.}
NOTE: Legislative acts involving policy and environmental changes should only be included in the legislative
section (PO11).

j Yes
k
l
m
n
j Not during this reporting period
k
l
m
n
If yes, how many?

PO5: The next couple of questions will be asked regarding each policy affecting overweight/obesity that was
initiated or modified in the last 6 months one at a time. Please briefly describe the policy.
Name

Describe

Was this policy initiated locally or at the state level?

j Local
k
l
m
n
j State
k
l
m
n
Was this policy enacted?

j Yes
k
l
m
n
j Not during this reporting period
k
l
m
n

PO11: Were any legislative acts or local ordinances affecting overweight/obesity (e.g., nutrition, physical
activity, TV watching, breastfeeding) initiated, modified, or enforced during this reporting period? {NOTE: A
legislative act is defined as a formal legal action taken by local or state government. Examples include line items
in the state budget to include obesity funding, bills supporting breastfeeding, bills supporting physical activity and
proper nutrition in schools, etc.}

j Yes
k
l
m
n
j Not during this reporting period
k
l
m
n
If yes, how many?

PO13: The next couple of questions will be asked regarding each legislative act or local ordinance initiated or
modified in the past 6 months one at a time. Please briefly describe the legislative act or local ordinance.
Name

Senate or House Number

Describe

Was this legislation or local ordinance initiated locally or at the state level?

j Local
k
l
m
n
j State
k
l
m
n
Was this legislation or local ordinance enacted in your state?

j Yes
k
l
m
n
j No
k
l
m
n

PO19: Did your state implement any other environmental changes (environmental interventions that alter or
control the legal, social, economic, and physical environment) affecting overweight/obesity (e.g., nutrition,
physical activity, TV watching, breastfeeding)? {NOTE: Examples include Rails to Trails programs, the closing of a
dangerous street located near a school property, zoning/planning for parks and other recreational areas, etc.}
NOTE: Legislative acts involving policy and environmental changes should only be included in the legislative
section (PO11).

j Yes
k
l
m
n

j Not during this reporting period
k
l
m
n
If yes, how many?

PO21: The next couple of questions will be asked regarding each environmental change initiated affecting
overweight/obesity one at a time. Please briefly describe the environmental change.
Name

Describe

Was this environmental change initiated locally or at the state level?

j Local
k
l
m
n
j State
k
l
m
n
Was this environmental change implemented?

j Yes
k
l
m
n
j Not during this reporting period
k
l
m
n

DATA SOURCES
DS1: If you have any questions while filling out this form, please feel free to contact us or our contractor, RTI at
1-800-344-1393
, or send e-mail to PMR-help@rti.org.
Please provide updated information covering the period January 1st, 2007 to June 30th, 2007.
This section of the report addresses recipient activity #4:
Identify and assess data sources to define and monitor the burden of obesity.

These next series of questions ask you to identify the data sources your state is using to monitor the burden of
obesity and other chronic diseases as well as to monitor the trends in nutrition and physical activity as they relate
to obesity and other chronic diseases in your state. If the data source you are using is not listed, please briefly
describe it in the text box when provided. Please report on the sources used during the past reporting period.
Note: we are interested in data from surveillance systems - ongoing systems that are in -place and sustainable
over time.
For a flowchart showing you the flow of questions in this section, click here.

(PDF)

DS3: Did your state use data sources to monitor (a) the burden of obesity and other chronic diseases, (b)

physical activity trends, or (c) nutrition trends as related to obesity and other chronic diseases?

j Yes
k
l
m
n

j No
k
l
m
n

DS4: Indicate the data sources your state uses for monitoring over time. (Check all that apply.)
Note: On the following screens we will ask you some additional questions about each data source you have been
using.
Data Sources

c Behavioral Risk Factor Surveillance System
d
e
f
g
c Youth Risk Behavior Surveillance System
d
e
f
g
c Pediatric Nutrition Surveillance System
d
e
f
g
c Pregnancy Nutrition Surveillance System
d
e
f
g
c Pregnancy Risk Assessment Monitoring System (PRAMS)
d
e
f
g
c State developed surveillance system(s) or surveys
d
e
f
g
c Youth Tobacco Survey
d
e
f
g

DS5: Indicate the variables from the Behavioral Risk Factor Surveillance System (BRFSS) your state uses
for monitoring over time. (Check all that apply.)
BRFSS variables

c height and weight
d
e
f
g

c physical activity
d
e
f
g
c fruits and vegetables
d
e
f
g

c weight control
d
e
f
g
c other (Please specify)
d
e
f
g
If other BRFSS variables, please specify.

What is the most recent year of data you used?

DS8: Indicate the variables from Youth Risk Behavior Surveillance System your state uses for monitoring
over time. (Check all that apply.)
YRBSS Variables

c height and weight
d
e
f
g

c physical activity
d
e
f
g
c fruits and vegetables
d
e
f
g

c weight control
d
e
f
g
c TV watching
d
e
f
g

c other (Please specify)
d
e
f
g
If OTHER YRBSS Variables, please specify.

What is the most recent year of data you used?

DS11: Indicate the variables from Pediatric Nutrition Surveillance System your state uses for monitoring
over time. (Check all that apply.)
PedNSS Variables

c height and weight
d
e
f
g

c breastfeeding
d
e
f
g
c other
d
e
f
g
What is the most recent year of data you used?

DS14: Indicate the variables from Pregnancy Nutrition Surveillance System your state uses for monitoring
over time. (Check all that apply.)
PNSS Variables

c height and weight
d
e
f
g
c breastfeeding
d
e
f
g

c other
d
e
f
g
What is the most recent year of data you used?

DS17: Indicate the variables from Pregnancy Risk Assessment Monitoring System (PRAMS) your state
uses for monitoring over time. (Check all that apply.)
PRAMS Variables

c breastfeeding
d
e
f
g
c other (Please specify)
d
e
f
g
If OTHER PRAMS Variables, please specify.

What is the most recent year of data you used?

DS21: Indicate the variables from Youth Tobacco Survey your state uses for monitoring over time. (Check all
that apply.)
YTS Variables

c height and weight
d
e
f
g

c physical activity
d
e
f
g
c nutrition
d
e
f
g
c other (Please specify)
d
e
f
g
If OTHER YTS Variables, please specify.

What is the most recent year of data you used?

DS18: Indicate the variables from State developed surveillance system(s) or surveys your state uses for
monitoring over time. (Check all that apply.)
State Variables

c BMI
d
e
f
g
c physical activity
d
e
f
g
c nutrition
d
e
f
g
c other (Please specify)
d
e
f
g
If OTHER State Variables, please specify.

What is the most recent year of data you used?

Name of the State System/Survey

DS19: Please indicate how BMI was collected.

j Self-reported height and weight
k
l
m
n
j Measured height and weight by a trained anthropometrist
k
l
m
n

DS24: Is there another data source/system you would like to report?

j Yes
k
l
m
n
j No
k
l
m
n

DS25: Identify the data source/system and indicate the variables your state uses for monitoring over time.
(Check all that apply.)
Data Source

Variables

c height and weight
d
e
f
g

c physical activity
d
e
f
g
c nutrition
d
e
f
g

c other (Please specify)
d
e
f
g
If OTHER data source variables, please specify.

What is the most recent year of data you used?

Is this a state-developed surveillance system established specifically for the Nutrition and
Physical Activity Program to Prevent Obesity and Other Chronic Diseases?

j Yes
k
l
m
n

j No
k
l
m
n

DS27: Is it a state-developed surveillance system established for some other purpose?

j Yes
k
l
m
n
j No
k
l
m
n

DS28: Please indicate the original purpose of the system.
Purpose

DS29: Please indicate how BMI was collected.

c Self-reported height and weight
d
e
f
g
c Measured height and weight by a trained anthropometrist
d
e
f
g

DS31a: In how many different media has your state reported results in the last 6 months?

Please also provide the titles of papers, speeches, etc. that you used to report the results and attach relevant
examples.
NOTE: You may enter more than one title by separating titles with a semi-colon.
Paper Count

Paper Title(s)

Political Speech Count

Political Speech Title(s)

Fact Sheet Count

Fact Sheet Title(s)

Website Count

Website Title(s)

Press Release Count

Press Release Title(s)

Other Count

If OTHER Medium, please specify.

Other Title(s)

DS31b: To whom (audience) and on what topic has your state reported trends within the last 6 months?
Audience (i.e., to whom did you report these results?)

c General population
d
e
f
g

c Advocacy group
d
e
f
g
c Health department
d
e
f
g

c Legislature
d
e
f
g
c Other (Please specify)
d
e
f
g
If OTHER Audience, please specify.

Topics

c none
d
e
f
g

c obesity
d
e
f
g
c physical activity
d
e
f
g

c nutrition
d
e
f
g
c breastfeeding
d
e
f
g

c diabetes
d
e
f
g
c other chronic diseases
d
e
f
g

IMPLEMENTATION
IM1: If you have any questions while filling out this form, please feel free to contact us or our contractor, RTI at
1-800-344-1393
, or send e-mail to PMR-help@rti.org.
Please provide updated information covering the period January 1st, 2007 to June 30th, 2007.
This section of the report addresses recipient activity #5:
Implement an intervention to prevent obesity and other chronic diseases.

For all questions about your intervention(s), please answer as best you can at this point in time. Please feel free
to leave something blank if you are not yet that far along. You will have an opportunity during later progress
reports to add information and indicate if something has changed.
Please respond to the next series of questions for only one intervention at a time. The full series of questions will
be repeated subsequently for each additional intervention, as needed.
We define an intervention operationally as “A prescribed series of activities grounded within a socioecologic
framework with the main purpose of changing and/or influencing existing obesity -, nutrition- and physical
activity-related behaviors and/or practices.” At a minimum, an intervention should contain all of the following
components:
1.
2.
3.
4.
5.
6.
7.

Grounded in theory and applied within the Socio-Ecologic Framework,
Defined purpose with clearly stated goals and objectives,
Expected outcomes (to include BMI/BMI for age when appropriate),
Defined intervention methodology (where, when and how),
Strategy for implementation (to include collaboration with partners),
Identified target population(s) as described in State Plan,
Defined evaluation methodology.

Include pilot projects, interventions that Nutrition and Physical Activity Program to Prevent Obesity and Other
Chronic Diseases funds have contributed to, interventions based on Nutrition and Physical Activity Program to
Prevent Obesity and Other Chronic Diseases-funded ideas/concepts, etc.
Please include any intervention that is still active. An active intervention is one that is still in the field or whose
evaluation is ongoing.
You can find the detailed Nutrition and Physical Activity Program to Prevent Obesity and Other Chronic Diseases definition of an
intervention by clicking here.
New guidelines for how to report multi-component, multi-site interventions can be found by clicking here.
For a flowchart showing you the flow of questions in this section, click here.

(PDF)

IM4: Please provide the name of the intervention and a description of the intervention.
If you click here, you will see an example of the kind of level of detail we are looking for.
Remember: Please answer pertaining to only ONE intervention at a time. You will be prompted to add additional
interventions after providing information regarding the current intervention.
Intervention Name

Describe the purpose and where the intervention will be provided

Description of intervention methodology and strategy for implementation

Please check the intended outcomes of your intervention and briefly describe them in the text box
below.
Intended Outcomes (Check all that apply)

c policy change
d
e
f
g
c environmental change
d
e
f
g

c behavioral change
d
e
f
g
Description of Intended Outcomes

IM5: List the SMART objectives of the intervention.

Objectives

IM6: Which specific objective(s) from your state plan does this intervention address? (Please refer to the
objectives you identified previously in the Planning section of this questionnaire. You may copy and paste the
relevant objectives.)
Objective(s)

IM7: Please specify the dates of the intervention's activities:
Start Date (MM/YYYY)

End Date (MM/YYYY)

c Ongoing intervention; no end date
d
e
f
g
Please indicate the developmental stage of your intervention

j Planning
k
l
m
n
j In the field
k
l
m
n
j Concluded, but still conducting evaluation
k
l
m
n
What is the level of cumulative funding to date for the entire intervention?

j none
k
l
m
n
j < $5,000
k
l
m
n

j $5,001-$10,000
k
l
m
n
j $10,001-$50,000
k
l
m
n

j $50,001-$100,000
k
l
m
n
j > $100,000
k
l
m
n
Was this intervention funded through a contract mechanism in your state?

j Yes
k
l
m
n
j No
k
l
m
n

IM8: What specific demographics of the state population are addressed by this intervention? (Check all that
apply.)
Ethnicity

c Hispanic or Latino
d
e
f
g
c Not Hispanic or Latino
d
e
f
g

c General population (no specific ethnic audiences addressed)
d
e
f
g
Race

c White
d
e
f
g

c Black or African American
d
e
f
g
c American Indian or Alaska native
d
e
f
g

c Asian
d
e
f
g
c Native Hawaiian or other Pacific Islander
d
e
f
g

c General population (no specific racial audiences addressed)
d
e
f
g
Gender

c Male
d
e
f
g
c Female
d
e
f
g
Area

c Rural
d
e
f
g
c Urban
d
e
f
g

c Suburban
d
e
f
g
c Low Income
d
e
f
g
Age Group

c < 2 yr.
d
e
f
g
c 2-3 yr.
d
e
f
g
c 4-5 yr.
d
e
f
g
c 6-10 yr.
d
e
f
g
c 11-13 yr.
d
e
f
g
c 14-17 yr.
d
e
f
g

c 18–29 yr.
d
e
f
g
c 30–64 yr.
d
e
f
g

c 65+
d
e
f
g
c All Ages
d
e
f
g

IM9: Please briefly describe how you selected this target population.
Description

IM24: Which of the following principal target areas does this intervention specifically address? (Check all that
apply.)
If you used a strategy other than the ones listed, please name the strategy and describe.
Principal Target Areas

c Increase physical activity
d
e
f
g
c Increase the consumption of fruits and vegetables
d
e
f
g

c Decrease the consumption of sugar sweetened beverages
d
e
f
g
c Increase breastfeeding initiation and duration
d
e
f
g

c Reduce the consumption of high energy dense foods
d
e
f
g
c Decrease television viewing
d
e
f
g

c Other
d
e
f
g
c Other
d
e
f
g
If OTHER, please specify.

If OTHER, please describe.

If OTHER, please specify.

If OTHER, please describe.

IM25: An intervention should be grounded in theory and applied within the Socio -Ecologic Framework [i.e.,
should foster behavior change by mobilizing multiple levels of social structure (individual, interpersonal,
organizational, community, and societal)].
Which of the following theories provides the basis for your intervention? (Check all that apply.)

c The Health Belief Model (HBM) [HBM addresses the individual ’s perceptions of the threat posed by a
d
e
f
g
health problem (susceptibility, severity), the benefits of avoiding the threat, and factors influencing the
decision to act (barriers, cues to action, and self-efficacy.]
c The Stages of Change (Transtheoretical) Model [The Stages of Change Model describes individuals’
d
e
f
g
motivation and readiness to change a behavior.]

c The Theory of Planned Behavior (TPB) [The TPB examines the relations between an individual’s beliefs,
d
e
f
g
attitudes, intentions, behavior, and perceived control over that behavior.]
c The Precaution Adoption Process Model (PAPM) [The PAPM names seven stages in an individual’s
d
e
f
g
journey from awareness to action. It begins with lack of awareness and advances through subsequent
stages of becoming aware, deciding whether or not to act, acting, and maintaining.]
c Social Cognitive Theory (SCT) [The SCT describes a dynamic, ongoing process in which personal
d
e
f
g
factors, environmental factors, and human behavior exert influence upon each other.]
c Community Organization and Other Participatory Models [The Community Organization and Other
d
e
f
g
Participatory Models emphasize community-driven approaches to assessing and solving health and social
problems.]
c Diffusion of Innovations Theory [The Diffusion of Innovations Theory addresses how new ideas,
d
e
f
g
products, and social practices spread within an organization, community, or society, or from one society to
another.]
c Communication Theory [The Communication Theory describes how different types of communication
d
e
f
g
affect health behavior.]
c PRECEDE/PROCEED Planning Model [The PRECEDE/PROCEED Planning Model includes Predisposing,
d
e
f
g
Reinforcing, and Enabling Constructs in Educational/Environmental Diagnosis and Evaluation , and
addresses behavior change within the broader context of organizational, policy, and environmental
factors .]
c Other
d
e
f
g
If other, please specify

Which levels of social structure does this intervention specifically address? (Check all that apply.)
Levels of Social Structure

c Individual (e.g., promote increased awareness, knowledge, and motivation)
d
e
f
g
c Interpersonal (e.g., teach families or enhance their skills needed to make desired changes)
d
e
f
g
c Organizational (e.g., foster a supportive social environment; provide opportunities to practice new
d
e
f
g
skills and behaviors in a safe setting)
c Community (e.g., establish and maintain a supportive physical environment)
d
e
f
g
c Societal/Media (e.g., establish and enforce supportive policies; conduct media campaign)
d
e
f
g

IM26: Briefly describe how this intervention fosters behavior change by mobilizing the Individual level of social
structure (e.g., promote increased awareness, knowledge, and motivation).
Individual level

IM27: Briefly describe how this intervention fosters behavior change by mobilizing the Interpersonal level of
social structure (e.g., teach families or enhance their skills needed to make desired changes).

Interpersonal level

IM28: Briefly describe how this intervention fosters behavior change by mobilizing the Organizational level of
social structure (e.g., foster a supportive social environment; provide opportunities to practice new skills and
behaviors in a safe setting).
Organizational level

IM29: Briefly describe how this intervention fosters behavior change by mobilizing the Community level of
social structure (e.g., establish and maintain a supportive physical environment).
Community level

IM30: Briefly describe how this intervention fosters behavior change by mobilizing the Societal/Media level of
social structure (e.g., establish and enforce supportive policies; conduct media campaign).
Societal/Media level

IM34: Please indicate the places or settings in which you are making your intervention available to your primary
audience. In the questions that follow, we will ask you about the number of locations that are available for each
(e.g., how many communities, how many schools, etc.), and the total number of individuals reached in that
setting.
Setting

c Community-wide
d
e
f
g
c Schools
d
e
f
g
c Families
d
e
f
g
c Hospitals, health facilities
d
e
f
g
c Religious organizations/houses of worship
d
e
f
g
c Childcare centers
d
e
f
g
c Worksites
d
e
f
g
c Other (Please specify)
d
e
f
g
If OTHER Setting, please specify.

IM34a: Please indicate the number of communities in which you are making your intervention available to your
primary audience (the count) and the total number of individuals reached in that community.
Community Count

Individuals Reached

IM34b: Please indicate the number of schools in which you are making your intervention available to your
primary audience (the count) and the total number of individuals reached in those schools.
School Count

Individuals Reached

IM34d: Please indicate the number of family settings in which you are making your intervention available to
your primary audience (the count) and the total number of individuals reached in those settings.
Family Count

Individuals Reached

IM34e: Please indicate the number of hospital settings in which you are making your intervention available to
your primary audience (the count) and the total number of individuals reached in those hospital settings.
Hospital Count

Individuals Reached

IM34f: Please indicate the number of places of worship in which you are making your intervention available to
your primary audience (the count) and the total number of individuals reached in those places of worship.
Worship Count

Individuals Reached

IM34g: Please indicate the number of childcare settings in which you are making your intervention available to
your primary audience (the count) and the total number of individuals reached in those childcare settings.
Childcare Center Count

Individuals Reached

IM34c: Please indicate the number of worksites in which you are making your intervention available to your
primary audience (the count) and the total number of individuals reached in those worksites.
Worksite Count

Individuals Reached

IM34h: Please indicate the number of other places or settings in which you are making your intervention
available to your primary audience (the count) and the total number of individuals reached in those other
settings.
Other Count

Individuals Reached

IM35: Please describe any barriers that have been encountered with regard to implementing the intervention.
Describe

IM36: Please describe the solutions that were developed to overcome these barriers.
Describe

IM38a: Did your worksite activities fit the definition of the worksite-based multi-component nutrition and
physical activity strategies? [The Obesity Chapter of the Guide to Community Preventive Services found sufficient
evidence of the effectiveness of multi-component intervention programs to prevent obesity in the worksite
setting.]

j Yes
k
l
m
n

j No
k
l
m
n

IM38b: Please indicate which, if any, of the following promising practices from the CDC Community Guide and
other CDC efforts were included in the worksite intervention.

c Enhanced access to physical activity such as developing walking trails or building
d
e
f
g
fitness centers at the worksite, combined with health education [Definitions: Enhanced access
to physical activity strategies in combination with health education are interventions that enable or

facilitate access to programs, workshops, classes, and other resources in a worksite setting for
physical activity. Such strategies included development of walking trails, building of fitness center at
the worksite, par course, etc]

c Multi-component educational interventions which incorporated exercise prescriptions,
d
e
f
g
nutrition prescriptions, and/or small media in addition to health education sessions
[Definitions: Multi-component educational interventions are aimed at provision of information, with
the curriculum/modules addressing health promotion programs (e.g., healthy lifestyles, physical
activity, nutrition) and risk reduction programs (e.g., weight management, cardiovascular (CVD)
risks, diabetes risks, etc.). Health education sessions can be considered mild, moderate or intensive.
In addition to health education sessions, these studies incorporated components such as 1) exercise
prescription, 2) nutrition prescription, and 3) small media. It was a challenge to evaluate multi component educational interventions. These interventions were evaluated together because it was not
possible to separate out health education alone from other components.]

c Exercise prescriptions alone [Definitions: Exercise prescription involves a planned or
d
e
f
g
structured physical activity regimen given to an individual or group with specific recommendations on
the frequency, intensity, and type of exercise.]
c Weight loss competitions [Definitions: Weight-loss competitions and Incentive-based
d
e
f
g
Interventions are competitions and incentives consist of rewards for weight loss and/or behavior
change such as increase physical activity or improve nutrition. The rewards can be in-kind, financial,
or the honor/pride of winning. The incentives can vary in size and types and can be used for
screening, enrollment, compliance (staying in the program), completion of the program, and /or
maintenance of the changes after the interventions.
c Behavioral interventions without incentives [Definitions: Behavioral interventions teach
d
e
f
g
behavioral management skills, modeling or demonstration, participatory skill development, individual
benchmarking (i.e., goal-setting and achievement), providing feedback and building social for
behavioral patterns.

c Behavioral interventions with incentives [Definitions: These programs teach participants
d
e
f
g
specific behavioral skills that enable them to incorporate physical activity and improve their nutrition
through modeling or demonstration, participatory skill development, individual benchmarking (i.e.,
goal-setting and achievement), feedback and building social for behavioral patterns. These behavior
changes following those interventions are not rewarded by incentives.]

IM38c: In less than 100 words please specifically describe how your activities fit the definition.
Enhanced access to physical activity such as developing walking trails or building fitness centers at the worksite,
combined with health education [Definitions: Enhanced access to physical activity strategies in combination with
health education are interventions that enable or facilitate access to programs, workshops, classes, and other
resources in a worksite setting for physical activity. Such strategies included development of walking trails,
building of fitness center at the worksite, par course, etc]
Describe

IM38d: In less than 100 words please specifically describe how your activities fit the definition.
Multi-component educational interventions which incorporated exercise prescriptions, nutrition
prescriptions, and/or small media in addition to health education sessions [Definitions: Multi-component
educational interventions are aimed at provision of information, with the curriculum/modules addressing health
promotion programs (e.g., healthy lifestyles, physical activity, nutrition) and risk reduction programs (e.g., weight
management, cardiovascular (CVD) risks, diabetes risks, etc.). Health education sessions can be considered mild,
moderate or intensive. In addition to health education sessions, these studies incorporated components such as

1) exercise prescription, 2) nutrition prescription, and 3) small media. It was a challenge to evaluate multi component educational interventions. These interventions were evaluated together because it was not possible to
separate out health education alone from other components.]
Describe

IM38e: In less than 100 words please specifically describe how your activities fit the definition.
Exercise prescriptions alone [Definitions: Exercise prescription involves a planned or structured physical
activity regimen given to an individual or group with specific recommendations on the frequency, intensity, and
type of exercise.]
Describe

IM38f: In less than 100 words please specifically describe how your activities fit the definition.
Weight loss competitions [Definitions: Weight-loss competitions and Incentive-based Interventions are
competitions and incentives consist of rewards for weight loss and/or behavior change such as increase physical
activity or improve nutrition. The rewards can be in-kind, financial, or the honor/pride of winning. The incentives
can vary in size and types and can be used for screening, enrollment, compliance (staying in the program),
completion of the program, and /or maintenance of the changes after the interventions. These interventions do
not include teaching behavioral management skills, modeling or demonstration, participatory skill development,
individual benchmarking (i.e., goal-setting and achievement) and providing feedback.]
Describe

IM38g: In less than 100 words please specifically describe how your activities fit the definition.
Behavioral interventions without incentives [Definitions: Behavioral interventions teach behavioral

management skills, modeling or demonstration, participatory skill development, individual benchmarking (i.e.,
goal-setting and achievement), providing feedback and building social for behavioral patterns. Such interventions
are complemented by in-kind or financial incentives, typically given for participation and/or completion of the
program.]
Describe

IM38h: In less than 100 words please specifically describe how your activities fit the definition.
Behavioral interventions with incentives [Definitions: These programs teach participants specific behavioral
skills that enable them to incorporate physical activity and improve their nutrition through modeling or
demonstration, participatory skill development, individual benchmarking (i.e., goal-setting and achievement),
feedback and building social for behavioral patterns. These behavior changes following those interventions are not
rewarded by incentives.]
Describe

IM39: Please indicate which, if any, of the following recommended strategies from CDC's Increasing Physical
Activity: A Report on Recommendations of the Task Force on Community Preventive Services were included in the
intervention.

c Community-wide campaigns [definition: large-scale, highly visible, multi-component
d
e
f
g
campaigns direct their messages to large audiences using a variety of approaches, including
television, radio, newspapers, movie theaters, billboards, and mailings.]
c Individually adapted health behavior change programs [definition: These programs are
d
e
f
g
tailored to a person’s specific interests or readiness to make a change in physical activity habits.
Teaching behavioral skills such as goal setting, building social support, self-rewards, problem solving,
and relapse prevention all assist individuals in learning to incorporate physical activity into their daily
routines.]
c School-based PE [definition: This approach seeks to modify school curricula and policies, and to
d
e
f
g
increase the amount of time students spend in moderate to vigorous activity while in physical
education class. Schools can accomplish this either by increasing the amount of time spent in PE
class, or by increasing students’ activity levels during PE classes.]
c Social support interventions in community settings [definition: The goal of this approach is
d
e
f
g
to increase physical activity by creating or strengthening social networks. Examples include exercise
buddies, exercise contracts, and walking groups.]
c Creation of or enhanced access to places for physical activity combined with
d
e
f
g
informational outreach activities [definition: This approach ensures that the physical environment
is conducive to physical activity, such that places where people can be physically active are readily
available, accessible, and acceptable. Examples would include attractive sidewalks, stairwells, walking
or biking trails, and exercise facilities in communities or in the workplace. Informational outreach

strives to make people aware of available resources, encourages them to take local action, or
provides training, seminars, counseling, or risk screening so that resources are well used. The goal is
to improve quality of life and achieve livable communities.

c Point-of-decision prompts [definition: Motivational information is provided at the place where
d
e
f
g
an individual is likely to be making a choice of action. For example, by locating signs close to
elevators and escalators, people are encouraged to use safe and accessible stairs as a physically
active alternative to passive transport.
c Community-scale urban design and land use policies and practices [definition: Urban
d
e
f
g
design and land use policies that support physical activity in small geographic areas, generally several
square kilometers in area or more.]
c Street-scale urban design and land use policies and practices [definition: Urban design
d
e
f
g
and land use policies that support physical activity in small geographic area, generally limited to a
few blocks.]
c Not Applicable (If a different physical activity strategy was used, please note in IM102)
d
e
f
g

IM40: In less than 100 words please specifically describe how your activities fit the definition.
Community-wide campaigns [definition: large-scale, highly visible, multi-component campaigns direct their
messages to large audiences using a variety of approaches, including television, radio, newspapers, movie
theaters, billboards, and mailings.]
Describe

IM42: In less than 100 words please specifically describe how your activities fit the definition.
Individually adapted health behavior change programs [definition: These programs are tailored to a
person’s specific interests or readiness to make a change in physical activity habits. Teaching behavioral skills
such as goal setting, building social support, self-rewards, problem solving, and relapse prevention all assist
individuals in learning to incorporate physical activity into their daily routines.]
Describe

IM44: In less than 100 words please specifically describe how your activities fit the definition.
School-based PE [definition: This approach seeks to modify school curricula and policies, and to increase the

amount of time students spend in moderate to vigorous activity while in physical education class. Schools can
accomplish this either by increasing the amount of time spent in PE class, or by increasing students ’ activity levels
during PE classes.]
Describe

IM46: In less than 100 words please specifically describe how your activities fit the definition.
Social support interventions in community settings [definition: The goal of this approach is to increase
physical activity by creating or strengthening social networks. Examples include exercise buddies, exercise
contracts, and walking groups.]
Describe

IM48: In less than 100 words please specifically describe how your activities fit the definition.
Creation of or enhanced access to places for physical activity combined with informational outreach
activities [definition: This approach ensures that the physical environment is conducive to physical activity, such
that places where people can be physically active are readily available, accessible, and acceptable. Examples
would include attractive sidewalks, stairwells, walking or biking trails, and exercise facilities in communities or in
the workplace. Informational outreach strives to make people aware of available resources, encourages them to
take local action, or provides training, seminars, counseling, or risk screening so that resources are well used. The
goal is to improve quality of life and achieve livable communities.
Describe

IM50: In less than 100 words please specifically describe how your activities fit the definition.
Point-of-decision prompts [definition: Motivational information is provided at the place where an individual is

likely to be making a choice of action. For example, by locating signs close to elevators and escalators, people are
encouraged to use safe and accessible stairs as a physically active alternative to passive transport.
Describe

IM51a: In less than 100 words please specifically describe how your activities fit the definition.
Community-scale urban design and land use policies and practices [definition: Urban design and land use
policies and practices that support physical activity in geographic areas, generally several square kilometers in
area or more.]
Describe

IM51c: In less than 100 words please specifically describe how your activities fit the definition.
Street-scale urban design and land use policies and practices [definition: Urban design and land use
policies that support physical activity in small geographic areas, generally limited to a few blocks.]
Describe

IM52: Please indicate which, if any, of the following recommended strategies from CDC's Breastfeeding -Strategy for Reducing Childhood Overweight and Related Chronic Diseases were included in the intervention.
Please be sure to check only those boxes for which your intervention activities conform to the
definition.

c Breastfeeding education and programs (group/individual) in hospitals [definition:
d
e
f
g
Breastfeeding education refers to the provision of factual or technical information about breastfeeding
in small groups or individually during the prenatal or postpartum period. Breastfeeding education as

defined here is provided in the healthcare setting and may include the use of videos, posters,
pamphlets or other materials.]

c Telephone or in-home breastfeeding support (peer counseling) [definition: Peer
d
e
f
g
counseling refers to the provision of support and/or advice on breastfeeding. This support is usually
provided by mothers who have breastfeeding and other demographics in common with the women
they counsel. They received training as a peer counselor. Peer support may be offered during the
prenatal and/or postpartum period and contacts may be provided via home visit or telephone.]

c Implementation of Ten Steps to Successful Breastfeeding [definition: In 1989, the WHO
d
e
f
g
and UNICEF issued a joint statement entitled Promoting and Supporting Breastfeeding: The Special
Role of Maternity Services. In this document are 10 important steps to successful breastfeeding
intended for application in every facility providing maternity services and care for newborn infants.]
c Training for Health Care Professionals [definition: Training of healthcare professionals refers
d
e
f
g
to the provision of professional training on breastfeeding to physicians, nurses, nutritionists and other
healthcare providers.]

c Prenatal breastfeeding education for women who work [definition: refers to the provision
d
e
f
g
of factual or technical information about breastfeeding in small groups or individually during the
prenatal period targeted specifically to women who will return to work following the birth of their
infants. The education may be provided in the healthcare setting, workplace or community and may
include the use of videos, posters, pamphlets or other materials.]
c Policies providing information on breastfeeding and services that are available for
d
e
f
g
women who work [definition: “Policies” refer to changes in health services and/or personnel support
at the institutional or organizational level within the workplace in favor of breastfeeding and
supportive of continued breastfeeding during employment.]
c Breastfeeding Mothers’ Room on the worksite [definition: Breastfeeding Mothers’ Rooms are
d
e
f
g
private, walled rooms with doors capable of locking, electric outlets, and appropriate seating, etc. for
use by employees who are breastfeeding mothers to express milk for their infants during the work
period.]

c Social marketing and/or media campaigns [definition: Social marketing is the design,
d
e
f
g
implementation, and control of programs seeking to increase the acceptability of a social/health
related idea or practice in a target group(s). It utilizes concepts of market segmentation, consumer
research, idea configuration, communication, facilitation, incentives, and exchange theory to
maximize target group response, in order to improve the personal and societal welfare of the target
audience. The optimal social marketing campaign is tailored to the unique perspective, needs, and
experiences of the target audience, with input from representative members of this group.] Media
campaigns are one venue for social marketing.
c Not Applicable (If a different breastfeeding strategy was used, please note in IM102)
d
e
f
g

IM53: In less than 100 words please specifically describe how your activities fit the definition.
Breastfeeding education and programs (group/individual) in hospitals [definition: Breastfeeding education
refers to the provision of factual or technical information about breastfeeding in small groups or individually
during the prenatal or postpartum period. Breastfeeding education as defined here is provided in the healthcare
setting and may include the use of videos, posters, pamphlets or other materials.]
Describe

IM55: In less than 100 words please specifically describe how your activities fit the definition.

Telephone or in-home breastfeeding support (peer counseling) [definition: Peer counseling refers to the
provision of support and/or advice on breastfeeding. This support is usually provided by mothers who have
breastfeeding and other demographics in common with the women they counsel. They received training as a peer
counselor. Peer support may be offered during the prenatal and/or postpartum period and contacts may be
provided via home visit or telephone.]
Describe

IM57: In less than 100 words please specifically describe how your activities fit the definition.
Implementation of Ten Steps to Successful Breastfeeding [definition: In 1989, the WHO and UNICEF issued
a joint statement entitled Promoting and Supporting Breastfeeding: The Special Role of Maternity Services. In this
document are 10 important steps to successful breastfeeding intended for application in every facility providing
maternity services and care for newborn infants.]
Describe

IM59: In less than 100 words please specifically describe how your activities fit the definition.
Training for Health Care Professionals [definition: Training of healthcare professionals refers to the provision
of professional training on breastfeeding to physicians, nurses, nutritionists and other healthcare providers.]
Describe

IM61: In less than 100 words please specifically describe how your activities fit the definition.
Prenatal breastfeeding education for women who work [definition: refers to the provision of factual or
technical information about breastfeeding in small groups or individually during the prenatal period targeted

specifically to women who will return to work following the birth of their infants. The education may be provided
in the healthcare setting, workplace or community and may include the use of videos, posters, pamphlets or other
materials.]
Describe

IM63: In less than 100 words please specifically describe how your activities fit the definition.
Policies providing information on breastfeeding and services that are available for women who work
[definition: “Policies” refer to changes in health services and/or personnel support at the institutional or
organizational level within the workplace in favor of breastfeeding and supportive of continued breastfeeding
during employment.]
Describe

IM65: In less than 100 words please specifically describe how your activities fit the definition.
Breastfeeding Mothers’ Room on the worksite [definition: Breastfeeding Mothers’ Rooms are private, walled
rooms with doors capable of locking, electric outlets, and appropriate seating, etc. for use by employees who are
breastfeeding mothers to express milk for their infants during the work period.]
Describe

IM67: In less than 100 words please specifically describe how your activities fit the definition.
Social marketing and/or media campaigns [definition: Social marketing is the design, implementation, and
control of programs seeking to increase the acceptability of a social/health related idea or practice in a target
group(s). It utilizes concepts of market segmentation, consumer research, idea configuration, communication,
facilitation, incentives, and exchange theory to maximize target group response, in order to improve the personal

and societal welfare of the target audience. The optimal social marketing campaign is tailored to the unique
perspective, needs, and experiences of the target audience, with input from representative members of this
group.] Media campaigns are one venue for social marketing.
Describe

IM71: Complete this item for all nutrition interventions. Please check which of the following specific components
were included in the intervention, making sure to check only those boxes for which your intervention activities
conform to the definition. The Agency for Healthcare Research and Quality determined the following intervention
characteristics were beneficial for selected dietary changes. Please check which of the following specific
components were included in the intervention, making sure to check only those boxes for which your intervention
activities conform to the definition.

c Social support [definition: Interpersonal relationships are used to assist individuals in adopting
d
e
f
g
or maintaining beneficial dietary behaviors. The goal of this approach is to improve dietary behaviors
by creating or strengthening social networks. Examples include peer counseling and employee
advisory boards.]
c Interactive activities involving food [definition: Delivery of the intervention is provided
d
e
f
g
through individual participation with food, i.e., tasting or cooking.]

c Goal setting [definition: Individuals determine dietary, nutritional, and/or weight goals and, if
d
e
f
g
applicable, monitor their progress and goal attainment.]
c Community-wide campaigns [definition: Large-scale, highly visible, multi-component
d
e
f
g
campaigns direct their messages to large audiences using a variety of approaches, including
television, radio, newspapers, movie theaters, billboards, and mailings.]

c Informational campaigns [definition: Highly visible, multi-component campaigns direct their
d
e
f
g
messages to audiences within a controlled setting using a variety of approaches, including e-mail
announcements, posters, and educational events.]
c Policies [definition: Creation or modification of written policies that govern type, pricing and
d
e
f
g
availability of food. Examples include type of food allowed to be sold for fund-raisers, usage of
vending machines, and pricing of healthy foods.]
c Creation or modification of physical environment [definition: Environments are designed to
d
e
f
g
improve accessibility and acquisition of healthy foods and ease of making healthy dietary choices.
Change of the physical environment is often the result of policy execution.]

c Point-of-decision prompts [definition: Motivational information is provided at the place where
d
e
f
g
an individual is likely to make a choice of action. For example, signs located at a food buffet may
encourage individuals to select healthier menu options.]
c Informational outreach activities [definition: These activities increase awareness of available
d
e
f
g
resources, encourage individuals to take local action, or provide training, seminars, counseling, or risk
screening so that resources are used well.]

c Clinical screening [definition: Individuals are screened for weight, BMI, BMI for age,
d
e
f
g
biochemical or clinical markers of nutritional status, and are provided with results and nutritional
information and, if applicable, physician referral.]
c Not Applicable (If a different nutrition strategy was used, please note in IM102)
d
e
f
g

IM72: In less than 100 words, please describe how your activities fit the definition.
Social support [definition: Interpersonal relationships are used to assist individuals in adopting or maintaining

beneficial dietary behaviors. The goal of this approach is to improve dietary behaviors by creating or
strengthening social networks. Examples include peer counseling and employee advisory boards.]
Describe

IM74: In less than 100 words, please describe how your activities fit the definition.
Interactive activities involving food [definition: Delivery of the intervention is provided through individual
participation with food, i.e., tasting or cooking.]
Describe

IM76: In less than 100 words, please describe how your activities fit the definition.
Goal setting [definition: Individuals determine dietary, nutritional, and/or weight goals and, if applicable,
monitor their progress and goal attainment.]
Describe

IM84: In less than 100 words, please describe how your activities fit the definition.
Community-wide campaigns [definition: Large-scale, highly visible, multi-component campaigns direct their
messages to large audiences using a variety of approaches, including television, radio, newspapers, movie
theaters, billboards, and mailings.]

Describe

IM86: In less than 100 words, please describe how your activities fit the definition.
Informational campaigns [definition: Highly visible, multi-component campaigns direct their messages to
audiences within a controlled setting using a variety of approaches, including e-mail announcements, posters, and
educational events.]
Describe

IM88: In less than 100 words, please describe how your activities fit the definition.
Policies [definition: Creation or modification of written policies that govern type, pricing and availability of food.
Examples include type of food allowed to be sold for fund-raisers, usage of vending machines, and pricing of
healthy foods.]
Describe

IM90: In less than 100 words, please describe how your activities fit the definition.
Creation or modification of physical environment [definition: Environments are designed to improve
accessibility and acquisition of healthy foods and ease of making healthy dietary choices. Change of the physical
environment is often the result of policy execution.]

Describe

IM92: In less than 100 words, please describe how your activities fit the definition.
Point-of-decision prompts [definition: Motivational information is provided at the place where an individual is
likely to make a choice of action. For example, signs located at a food buffet may encourage individuals to select
healthier menu options.]
Describe

IM94: In less than 100 words, please describe how your activities fit the definition.
Informational outreach activities [definition: These activities increase awareness of available resources,
encourage individuals to take local action, or provide training, seminars, counseling, or risk screening so that
resources are used well.]
Describe

IM96: In less than 100 words, please describe how your activities fit the definition.
Screening [definition: Individuals are screened for weight, BMI, and BMI for age when appropriate, and are
provided with results, nutritional information and, if applicable, physician referral.]

Describe

IM98: Did you use any of the following promising strategies (interventions that we have reason to believe will be
effective; however, they do not appear in the Community Guide as recommended interventions because we don’t
yet have sufficient scientific evidence of their effectiveness)? Please check all that apply.

c Increased fruit and vegetable consumption (e.g. 5 A Day) in diet for weight management
d
e
f
g
c Decreased soft drinks or sweetened beverages in diet for weight management
d
e
f
g
c Paying attention to portion sizes
d
e
f
g
c No promising strategies used
d
e
f
g

IM99: Please describe your use of this promising strategy:
Increased fruit and vegetable consumption in diet for weight management.
Describe

IM100: Please describe your use of this promising strategy:
Decreased soft drinks or sweetened beverages in diet for weight management
Describe

IM101: Please describe your use of this promising strategy:

Paying attention to portion sizes.
Describe

IM102: Were any other intervention strategies used? If so, please describe the intervention strategy and its
source or evidence that it is effective in changing body weight and/or health behavior.

j Yes
k
l
m
n
j No
k
l
m
n
Describe

EV18: Have you developed an evaluation plan for this intervention ? If so, please provide the date of completion.
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window, locate the document you would like to upload on your computer, click "Open" and then click "Upload."
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j No
k
l
m
n

j In Progress
k
l
m
n
j Yes
k
l
m
n
Date Completed (MM/YYYY) if applicable

EV19: Did you use the CDC Framework for Program Evaluation in Public Health to develop the evaluation plan or
conduct evaluations?

j No
k
l
m
n
j Not yet
k
l
m
n

j Yes
k
l
m
n

EV20: If you didn’t use this, what evaluation framework did you use?
Please provide the reference

EV21: Is there a separate logic model related to the evaluation plan for the intervention?
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window, locate the document you would like to upload on your computer, click "Open" and then click "Upload."
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j No
k
l
m
n
j In Progress
k
l
m
n
j Yes
k
l
m
n

EV22: Did stakeholders participate in designing or conducting the evaluation of your intervention(s)?
Stakeholders include those involved, those affected, and primary intended users (e.g., partners, members of the
target population).

j Yes
k
l
m
n

j No
k
l
m
n

EV23: Please check those activities your state specifically conducted to include and involve stakeholders in the
evaluation of the intervention. Check all that apply.
Stakeholder Activities

c Evaluation advisory board
d
e
f
g
c Community advisory group
d
e
f
g
c Focus groups about evaluating the intervention
d
e
f
g
c Solicited written comments
d
e
f
g
c Other (Please specify)
d
e
f
g
If OTHER Activities, please specify.

EV24: Describe the major recommendations with regard to your evaluation advisory board.
Recommendations

EV25: Describe the major recommendations with regard to your community advisory group.
Recommendations

EV26: Describe the major recommendations with regard to focus groups about evaluating the intervention.
Recommendations

EV27: Describe the major recommendations with regard to solicited written comments.
Recommendations

EV28: Describe the major recommendations with regard to other activities where stakeholders participated in

designing or conducting the evaluation of your intervention.
Recommendations

EV29: Please briefly describe in 100 words or less your methods for evaluating the intervention.

EV29a: Has your state started to measure process or implementation indicators from the interventions?

j Not yet
k
l
m
n
j Yes
k
l
m
n

EV29b: Please describe the process or implementation indicator(s) (e.g., number of people reached by the
intervention) and the results of any statistical analyses from the evaluation.
Describe

Results

EV29c: Please list what data sources were used to measure these indicators.
Data Sources

EV30: Has your state started to measure short-term, intermediate, or long-term outcomes from the
interventions?

j Not yet
k
l
m
n
j Yes
k
l
m
n

EV31: Please describe the outcome indicator(s) (e.g., decreased television viewing among high school students
or passing new school vending machine policies) and the results of any analyses from the evaluation.
Please include a description of any baseline data collected.
Describe

Results

EV32: Please list what data sources were used to measure these outcomes.
Data Sources

EV37: Please explain what you have done to ensure that you will be able to detect realistic changes in post intervention outcome measures when compared with pre-intervention measures (e.g., power calculations).
Describe

EV33: Have you reported any evaluation results during the past 6 months, including process or implementation
evaluation results?

j Yes
k
l
m
n
j No
k
l
m
n

EV34: Please list the topic, and to whom (i.e., the audience) and how (i.e., the medium) you reported these
results. Please also provide the title of the paper, speech, etc. that you used to report the results and attach
relevant example(s).
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window, locate the document you would like to upload on your computer, click "Open" and then click "Upload."
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Topic

Audience (i.e., to whom did you report these results?)

c General population
d
e
f
g

c Advocacy group
d
e
f
g
c Health department
d
e
f
g

c Legislature
d
e
f
g
c Other (Please specify)
d
e
f
g
If OTHER Audience, please specify.

Medium (i.e., how did you report these results?)

c Paper/report
d
e
f
g

c Political speech
d
e
f
g
c Fact Sheet
d
e
f
g

c Website
d
e
f
g
c Press release
d
e
f
g

c Other (please specify)
d
e
f
g
If OTHER Medium, please specify.

Title

EV34a: Please describe any progress on the intervention that has not already been reported.
Describe

EVALUATION
EV1: If you have any questions while filling out this form, please feel free to contact us or our contractor, RTI at
1-800-344-1393
, or send e-mail to PMR-help@rti.org.
Please provide updated information covering the period January 1st, 2007 to June 30th, 2007.
This section of the report addresses recipient activity #5:
Evaluate progress and impact of the State plan and intervention projects.
It includes a set of questions about monitoring state plan objectives, followed by some questions about evaluation
of interventions.
For a flowchart showing you the flow of questions in this section, click here.

(PDF)

EV3: Have you developed a plan for monitoring the implementation of the state plan objectives? If so, please
provide the date of completion.
To upload an attachment, click "Upload Attachment" and then click the "browse" button. Using the pop-up

window, locate the document you would like to upload on your computer, click "Open" and then click "Upload."
You may view all uploaded attachments by going to the document repository on the main page.
Upload Attachment

j No
k
l
m
n

j In Progress
k
l
m
n
j Yes
k
l
m
n
Date Completed (MM/YYYY) if applicable

EV14: Please briefly describe in 100 words or less how you are monitoring your implementation of the state plan
objectives.

EV15: For each of the state objectives you identified earlier in this instrument, please list the indicator(s) you are
using to track progress toward that objective. One full screen will be devoted to each individual objective;
therefore please list the indicator for each objective one at a time. Indicators may be implementation indicators or
outcome indicators from the interventions.
Implementation indicators are the direct products of program activities, often measured in terms of the amount of
work accomplished, such as the number of clients served or sessions held.
Outcome indicators refer to the results, impacts or effects of your program activities, and may be short-term,
intermediate, or long-term.
Please also supply the party responsible for accomplishing each objective (e.g., a partner, an academic institution,
or the DOH).
NOTE: For each objective, you need to click "edit" so that you can address who is responsible and provide results
to date.
Party Responsible

Implementation Indicator(s)

Outcome Indicator(s)

Results To Date

EV17: Please identify the intervention(s) you are evaluating.

c Sample 1
d
e
f
g

c Sample 2
d
e
f
g
c Sample 3
d
e
f
g

c Sample 4
d
e
f
g

OTHER ACCOMPLISHMENTS
SIntro: If you have any questions while filling out this form, please feel free to contact us or our contractor, RTI
1-800-344-1393
at
, or send e-mail to PMR-help@rti.org.
Please provide updated information covering the period ::REPORTPERIOD::.
We recognize that you have been involved in several activities that you may not have reported yet. Please use
this section as an opportunity to highlight any such activities. We have provided some examples below of the
types of activities that do not meet our definition of an intervention, but are still important activities for you to
report.
Building Community Coalitions to Promote Nutrition and Physical Activity - Skill-Building Workshops:
These workshops are designed to train communities interested in creating a community coalition or collaborative
to promote nutrition and physical activity for obesity prevention. The main components of the training include the
following: identifying and bringing together stakeholders; community assessment; strategic and action planning;
evaluation; and coalition sustainability.
Getting Kids Physically Active: The purpose of this program is to provide training on evidence based practices
to improve the quality of physical education offered to children ages K -8 across the State, through private and
public programs. The training is provided to various organizations across the State (e.g. summer feeding
programs, camps, church leagues, schools, etc.). The trainings are comprised of 1) a 35 minute PowerPoint
presentation indicating the major parts of the training, addressing behavioral problems, and bringing the
participants up to an even playing field and 2) a 2.5 hours hands-on training introducing games and techniques to
be used in any setting where children are involved in physical activity.
License to Breastfeed Wallet Cards: The aims of this program are to increase breastfeeding rates and improve
short and long term health of maternal/infant health in the AME congregations. The state provides a wallet card

that invokes the state law reinforcing women's legal right to breastfeed.
For a flowchart showing you the flow of questions in this section, click here.

(PDF)

IM110: Are you funded as a basic implementation state?

j Yes
k
l
m
n
j No
k
l
m
n

IM111: In regard to collaboration with partners on secondary prevention strategies, please describe any
secondary prevention programs in place (i.e., treatment of obesity), in less than 250 words. At a minimum,
please specify the target population and intended outcomes, as well as any results if available.
Describe

EV38: Please describe any resources and/or training that you (the state DOH) developed that other states could
use as a part of their obesity prevention programs in the last 6 months (in 250 words or less).
Describe

EV39: Briefly describe how the State DOH assisted with disseminating the resources/training in the last 6
months (in 250 words or less).

Describe

S1: Please use this space to tell us about any thing that has occurred during this reporting period that you don’t
feel you had the chance to address under a specific recipient activity. You may upload attachments if you find
them relevant.
To upload an attachment, click "Upload Attachment" and then click the "browse" button. Using the pop-up
window, locate the document you would like to upload on your computer, click "Open" and then click "Upload."
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Upload Attachment
Comments

S2: Please briefly describe your five most significant accomplishments in the last 6 months. This would include
products or accomplishments of the state program, partners, mini-grant recipients, etc. Consider this an
opportunity to highlight the results of your efforts.
Accomplishments

S3: Please describe what you consider the most important success of your program to date.

Describe

S4: We welcome your comments and suggestions for improving this progress report.
Suggestions