Att 7a_Document Review Form_9

Document Review Form

I. Document Information
Name of organization
Document name/date
Date reviewed
Reviewer’s initials
II. History/Background of the YBCS Intervention
III. Description of DP11-1111 Activities
Program Readiness, Oversight and Management
Communication Plan	Description of any details provided regarding communication plan
Management Plan	Description of any details provided regarding management plan
Participation in meetings/trainings	Description of any details provided regarding participation in meetings/ training
Conduct needs and resource assessment
Identified gaps	Description of any gaps identified through needs assessment
Proposed actions to fill gaps	Description of actions organization will take to address gaps identified through needs assessment
Set priorities based on the needs assessment
Identification of 3-5 priorities	Description of priorities for the intervention
Reach calculation	Description of how reach is calculated
Establish new or expand existing partnerships	Description of activities and partner involvement if appropriate
Partner names	Description of the partners engaged
Type of partnership (networking, coordination, collaboration)	Description of the types of partnerships formed
Develop a program plan
Target audience	Description of the YBCS target population in terms of age, race/ethnicity, and geographic location
Goals	Description of goals and objectives, and activities over the 3 year cooperative agreement to achieve desired outcomes
Recruitment plan	Description of mechanisms to reach its target population
Potential impact	Description of the potential impact of activities in addressing the gaps identified in the needs assessment
Collaborative opportunities with other organizations	Description of opportunities to engage organizations to enhance the implementation
Methods for data collection	Description of methods for collecting baseline data (baseline data should be collected within 120 days post award) and subsequent time intervals for collecting follow-up data (follow-up data collection will be collected no later than the end of the project period).
Implement Develop a program plan	Description of activities and partner involvement, if appropriate
Quality of interventions/strategies	Extent to which interventions are practical and achievable
Linkages	Description of how intervention activities link to program goals
Reach	Extent to which interventions are reaching target audience(s)
Evaluate and monitor progress
Short term outcomes	Description of short term outcomes
Long term outcomes	Description of long term outcomes
Data collection and analysis methods	Description of data collection and analysis methods used for evaluation
Program improvement strategies	Description of how program monitoring data will be used to improve program delivery
Develop a Sustainability Plan
Plans for sustainability of intervention	Description of how program plans to sustain the intervention(s) beyond the funded period
Funding	Description of strategies to leverage additional funding
Partners	Description of how partners will be leveraged to sustain intervention beyond funded period
III. Description of Current Intervention Strategies
a. Intervention Strategies
Educational Resources	Description of activities (and partner involvement if appropriate) related to the development of educational resources for YBCS
Support Services	Description of activities (and partner involvement if appropriate) related to the development or promotion of support service for YBCS
b. Communication Channels
Mass Media	Description of how mass media is used to conduct and/or promote intervention(s)
Small Media	Description of how small media is used to conduct and/or promote intervention(s)
Social Media	Description of how social media is used to conduct and/or promote intervention(s)
Interpersonal Communication	Description of how interpersonal communication is used to conduct and/or promote intervention(s)
d. Target Population
YBCS	Description of activities tailored for young breast cancer survivors
Families and/or Caregivers	Description of activities tailored for families/caregivers
Healthcare Providers	Description of activities tailored for healthcare providers
IV. Additional Notes