I. Document Information
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Name of organization
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Document name/date
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Date reviewed
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Reviewer’s initials
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II. History/Background of the YBCS Intervention
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III. Description of DP11-1111 Activities
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Program Readiness, Oversight and Management
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Description of any details provided regarding communication
plan
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Description of any details provided regarding management plan
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Description of any details provided regarding participation in
meetings/ training
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Conduct needs and resource assessment
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Description of any gaps identified through needs assessment
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Description of actions organization will take to address gaps
identified through needs assessment
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Set priorities based on the needs assessment
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Description of priorities for the intervention
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Description of how reach is calculated
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Establish new or expand existing partnerships
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Description of activities and partner involvement if
appropriate
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Description of the partners engaged
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Description of the types of partnerships formed
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Develop a program plan
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Description of the YBCS target population in terms of age,
race/ethnicity, and geographic location
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Description of goals and objectives, and activities over the 3
year cooperative agreement to achieve desired outcomes
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Description of mechanisms to reach its target population
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Description of the potential impact of activities in addressing
the gaps identified in the needs assessment
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Description of opportunities to engage organizations to enhance
the implementation
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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).
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Implement Develop a program plan
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Description of activities and partner involvement, if
appropriate
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Extent to which interventions are practical and achievable
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Description of how intervention activities link to program
goals
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Extent to which interventions are reaching target audience(s)
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Evaluate and monitor progress
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Description of short term outcomes
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Description of long term outcomes
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Description of data collection and analysis methods used for
evaluation
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Description of how program monitoring data will be used to
improve program delivery
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Develop a Sustainability Plan
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Description of how program plans to sustain the intervention(s)
beyond the funded period
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Description of strategies to leverage additional funding
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Description of how partners will be leveraged to sustain
intervention beyond funded period
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III. Description of Current Intervention Strategies
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a. Intervention Strategies
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Description of activities (and partner involvement if
appropriate) related to the development of educational resources
for YBCS
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Description of activities (and partner involvement if
appropriate) related to the development or promotion of support
service for YBCS
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b. Communication Channels
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Description of how mass media is used to conduct and/or promote
intervention(s)
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Description of how small media is used to conduct and/or
promote intervention(s)
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Description of how social media is used to conduct and/or
promote intervention(s)
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Description of how interpersonal communication is used to
conduct and/or promote intervention(s)
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d. Target Population
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Description of activities tailored for young breast cancer
survivors
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Description of activities tailored for families/caregivers
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Description of activities tailored for healthcare providers
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IV. Additional Notes
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