BASE -Annual Progress Report

Form Approved
OMB No. 0920-XXXX
Exp. Date xx/xx/20xx
CE 11-1101 Core Violence and Injury Prevention Program (Core VIPP)
Annual Progress Report: BIC Year 4
Awardee:
Award Number:
Instructions: Using the template provided below, verify start and end dates, select progress status, and describe progress during Year 4 toward objectives and
activities submitted in your Year 4 continuation application. You may choose to modify activities for standardized objectives or your state objectives based on
the information you provided in your Year 4 Continuation Application and more current information to better reflect Year 4 activities. Indicate any changes
made to progress report objectives and activities in the related “Progress Description” field and provide a brief justification for the change(s).
Definitions:
 Objective = Specific statements about how to achieve a goal
 Measurement = Description of how all activities specific to the objective will be monitored
 Activity = Specific steps/tasks needed to accomplish objectives
 Start date = Date an activity will begin
 End date = Projected completion date for an activity
 Progress status:
o Not started = Activity is not yet started
o Redirected = Activity redirected to next funding year
o Planning = Planning the implementation and evaluation of the activity
o Ongoing/Implementation = Activity is ongoing and/or being implemented and evaluated
o Complete = Completed implementation and evaluation of the activity
o n/a = Not applicable
•
Description of Progress = Brief but sufficient description of the level of progress achieved for the activity during the reporting period must be entered
(do not just refer to attachments). Please include activity successes for all activities and barriers to progress for activities “not started” or “redirected.”
Public reporting burden of this collection of information is estimated to average 22 hours for the initial population of the tool, and 11 hours for annual reporting for
awardees funded for BASE component. The response includes 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN:
PRA (0920-XXXX).

Base Integration Component (BIC)
Goal 1: Enhance injury and violence prevention program infrastructure
Activity
(500 character limit)

Start and End
Date (mm/dd/yy)

Progress Status

Description of Progress
(1000 character limit)

Objective 1.4: Annually support at least one workforce development activity for key staff or partners, building capacity in the Core Competencies (for a
description of Core Competencies please refer to the FOA, p. 11).
Measurement:
Activity 1.4.1:

Start:

Select One

End:
Activity 1.4.2:

Start:

Select One

End:
Activity 1.4.3:

Start:

Select One

End:
Activity 1.4.4:

Start:

Select One

End:
Activity 1.4.5:

Start:

Select One

End:
Activity 1.4.6:

Start:

Select One

End:
Activity 1.4.7:

Start:

Select One

End:
Objective 1.5: Annually use media and communication strategies to disseminate information related to injury and/or violence prevention.
Measurement:
Activity 1.5.1:

Start:

Select One

End:
Activity 1.5.2:

Start:

Select One

End:
Activity 1.5.3:

Start:

Select One
2

Activity
(500 character limit)

Start and End
Date (mm/dd/yy)

Progress Status

Description of Progress
(1000 character limit)

End:
Activity 1.5.4:

Start:

Select One

End:
Activity 1.5.5:

Start:

Select One

End:
Activity 1.5.6:

Start:

Select One

End:
Activity 1.5.7:

Start:

Select One

End:
Objective 1.6: Annually generate support and resources and/or secure funding to support integrated state violence and injury prevention program activities
(please describe activities related to resources leveraged).
Measurement:
Activity 1.6.1:

Start:

Select One

End:
Activity 1.6.2:

Start:

Select One

End:
Activity 1.6.3:

Start:

Select One

End:
Activity 1.6.4:

Start:

Select One

End:
Activity 1.6.5:

Start:

Select One

End:
Activity 1.6.6:

Start:

Select One

End:
Activity 1.6.7:

Start:

Select One

End:
3

Activity
(500 character limit)

Start and End
Date (mm/dd/yy)

Progress Status

Description of Progress
(1000 character limit)

Objective 1.7: Annually support ICPG by providing funding and resources, and assure access to current information about injury and violence prevention and
control.
Measurement:
Activity 1.7.1:

Start:

Select One

End:
Activity 1.7.2:

Start:

Select One

End:
Activity 1.7.3:

Start:

Select One

End:
Activity 1.7.4:

Start:

Select One

End:
Activity 1.7.5:

Start:

Select One

End:
Activity 1.7.6:

Start:

Select One

End:
Activity 1.7.7:

Start:

Select One

End:
Objective 1.8: Annually implement state plan and carry out activities agreed upon with partner organizations and the ICPG (please describe components of state
plan related to Focus Area SMART objectives).
Measurement:
Activity 1.8.1:

Start:

Select One

End:
Activity 1.8.2:

Start:

Select One

End:
Activity 1.8.3:

Start:

Select One

End:
Activity 1.8.4:

Start:

Select One
4

Activity
(500 character limit)

Start and End
Date (mm/dd/yy)

Progress Status

Description of Progress
(1000 character limit)

End:
Activity 1.8.5:

Start:

Select One

End:
Activity 1.8.6:

Start:

Select One

End:
Activity 1.8.7:

Start:

Select One

End:
Objective 1.9: Annually participate in all CDC initiated/sponsored activities related to Core VIPP, including but not limited to, regional networks, annual joint
CDC/Safe States meeting, webinars, regular phone calls, evaluation, and technical assistance.
Measurement:
Activity 1.9.1:

Start:

Select One

End:
Activity 1.9.2:

Start:

Select One

End:
Activity 1.9.3:

Start:

Select One

End:
Activity 1.9.4:

Start:

Select One

End:
Activity 1.9.5:

Start:

Select One

End:
Activity 1.9.6:

Start:

Select One

End:
Activity 1.9.7:

Start:

Select One

End:
Objective 1.A:
Measurement:
5

Activity

Start and End
Date (mm/dd/yy)

Progress Status

(500 character limit)

Activity 1.A.1:

Start:

Select One

Description of Progress
(1000 character limit)

End:
Activity 1.A.2:

Start:

Select One

End:
Activity 1.A.3:

Start:

Select One

End:
Activity 1.A.4:

Start:

Select One

End:
Activity 1.A.5:

Start:

Select One

End:
Activity 1.A.6:

Start:

Select One

End:
Activity 1.A.7:

Start:

Select One

End:
Goal 2: Collect and analyze data
Activity
(500 character limit)

Start and End
Date (mm/dd/yy)

Progress Status

Description of Progress
(1000 character limit)

Objective 2.2: Annually collect, analyze and interpret statewide centralized electronic injury data (emergency department data, hospital discharge data, and
mortality data) and use to prepare required annual data reports (Annual Injury Data Report, Infant and Early Childhood Injury Special Emphasis Report, TBI
Special Emphasis Report).
Measurement:
Activity 2.2.1:

Start:

Select One

End:
Activity 2.2.2:

Start:

Select One

End:
Activity 2.2.3:

Start:

Select One

End:
6

Activity

Start and End
Date (mm/dd/yy)

Progress Status

(500 character limit)

Activity 2.2.4:

Start:

Select One

Description of Progress
(1000 character limit)

End:
Activity 2.2.5:

Start:

Select One

End:
Activity 2.2.6:

Start:

Select One

End:
Activity 2.2.7:

Start:

Select One

End:
Objective 2.4: Annually promote and facilitate the use of injury data to meet the needs of injury prevention control groups and service agencies.
Measurement:
Activity 2.4.1:

Start:

Select One

End:
Activity 2.4.2:

Start:

Select One

End:
Activity 2.4.3:

Start:

Select One

End:
Activity 2.4.4:

Start:

Select One

End:
Activity 2.4.5:

Start:

Select One

End:
Activity 2.4.6:

Start:

Select One

End:
Activity 2.4.7:

Start:

Select One

End:
Objective 2.A:
Measurement:
7

Activity

Start and End
Date (mm/dd/yy)

Progress Status

(500 character limit)

Activity 2.A.1:

Start:

Select One

Description of Progress
(1000 character limit)

End:
Activity 2.A.2:

Start:

Select One

End:
Activity 2.A.3:

Start:

Select One

End:
Activity 2.A.4:

Start:

Select One

End:
Activity 2.A.5:

Start:

Select One

End:
Activity 2.A.6:

Start:

Select One

End:
Activity 2.A.7:

Start:

Select One

End:
Goal 3: Support and evaluate program and policy interventions
Objective 3.5: Annually collect and analyze data to evaluate the effectiveness of intervention programs and policy strategies .
Please use Focus Area SMART Objectives section to report progress. NOTE: This will be reported in the Year 4 APR.
Objective 3.6: Annually provide support for the implementation of at least two program interventions and two policy strategies (i.e. technical assistance,
training/training materials, monitoring fidelity, troubleshooting barriers, etc.).
Measurement:
Activity 3.6.1:

Start:

Select One

End:
Activity 3.6.2:

Start:

Select One

End:
Activity 3.6.3:

Start:

Select One

End:
8

Activity 3.6.4:

Start:

Select One

End:
Activity 3.6.5:

Start:

Select One

End:
Activity 3.6.6:

Start:

Select One

End:
Activity 3.6.7:

Start:

Select One

End:
Objective 3.7: Annually support the evaluation of at least two program interventions and two policy strategies (describe activities related to support of your
evaluation plan).
Measurement:
Activity 3.7.1:

Start:

Select One

End:
Activity 3.7.2:

Start:

Select One

End:
Activity 3.7.3:

Start:

Select One

End:
Activity 3.7.4:

Start:

Select One

End:
Activity 3.7.5:

Start:

Select One

End:
Activity 3.7.6:

Start:

Select One

End:
Activity 3.7.7:

Start:

Select One

End:
Objective 3.A:
Measurement:
Activity 3.A.1:

Start:

Select One
9

End:
Activity 3.A.2:

Start:

Select One

End:
Activity 3.A.3:

Start:

Select One

End:
Activity 3.A.4:

Start:

Select One

End:
Activity 3.A.5:

Start:

Select One

End:
Activity 3.A.6:

Start:

Select One

End:
Activity 3.A.7:

Start:

Select One

End:

Goal 4: Inform policy
Activity
(500 character limit)

Start and End
Date (mm/dd/yy)

Progress Status

Description of Progress
(1000 character limit)

Objective 4.5: Annually use communication science to inform policy in the two priority areas identified by the ICPG policy subgroup (including NCIPC, CDC, and
other communication science tools).
Measurement:
Activity 4.5.1:

Start:

Select One

End:
Activity 4.5.2:

Start:

Select One

End:
Activity 4.5.3:

Start:

Select One

End:
Activity 4.5.4:

Start:

Select One
10

Activity
(500 character limit)

Start and End
Date (mm/dd/yy)

Progress Status

Description of Progress
(1000 character limit)

End:
Activity 4.5.5:

Start:

Select One

End:
Activity 4.5.6:

Start:

Select One

End:
Activity 4.5.7:

Start:

Select One

End:
Objective 4.6: Annually conduct in-state policy in-service activities that engage key partners in developing and/or implementing the state injury and violence
policy agenda/plan (refer to FOA Recipient Activities for specific details).
Measurement:
Activity 4.6.1:

Start:

Select One

End:
Activity 4.6.2:

Start:

Select One

End:
Activity 4.6.3:

Start:

Select One

End:
Activity 4.6.4:

Start:

Select One

End:
Activity 4.6.5:

Start:

Select One

End:
Activity 4.6.6:

Start:

Select One

End:
Activity 4.6.7:

Start:

Select One

End:
Objective 4.7: Annually engage SHD staff in at least three activities that affect policy (refer to FOA Recipient Activities for specific details).
Measurement:
11

Activity

Start and End
Date (mm/dd/yy)

Progress Status

(500 character limit)

Activity 4.7.1:

Start:

Select One

Description of Progress
(1000 character limit)

End:
Activity 4.7.2:

Start:

Select One

End:
Activity 4.7.3:

Start:

Select One

End:
Activity 4.7.4:

Start:

Select One

End:
Activity 4.7.5:

Start:

Select One

End:
Activity 4.7.6:

Start:

Select One

End:
Activity 4.7.7:

Start:

Select One

End:
Objective 4.A:
Measurement:
Activity 4.A.1:

Start:

Select One

End:
Activity 4.A.2:

Start:

Select One

End:
Activity 4.A.3:

Start:

Select One

End:
Activity 4.A.4:

Start:

Select One

End:
Activity 4.A.5:

Start:

Select One

End:
12

Activity

Start and End
Date (mm/dd/yy)

Progress Status

(500 character limit)

Activity 4.A.6:

Start:

Select One

Description of Progress
(1000 character limit)

End:
Activity 4.A.7:

Start:

Select One

End:

Goal 5: Program evaluation
Activity
(500 character limit)

Start and End
Date (mm/dd/yy)

Progress Status

Description of Progress
(1000 character limit)

Objective 5.2: Annually use surveillance findings to guide evaluation of the overall Core VIPP or injury prevention and control program.
Measurement:
Activity 5.2.1:

Start:

Select One

End:
Activity 5.2.2:

Start:

Select One

End:
Activity 5.2.3:

Start:

Select One

End:
Activity 5.2.4:

Start:

Select One

End:
Activity 5.2.5:

Start:

Select One

End:
Activity 5.2.6:

Start:

Select One

End:
Activity 5.2.7:

Start:

Select One

End:
Objective 5.3: Annually use evaluation findings to make broad-level programmatic changes, including a description of how the findings impacted the program.
Measurement:
13

Activity

Start and End
Date (mm/dd/yy)

Progress Status

(500 character limit)

Activity 5.3.1:

Start:

Select One

Description of Progress
(1000 character limit)

End:
Activity 5.3.2:

Start:

Select One

End:
Activity 5.3.3:

Start:

Select One

End:
Activity 5.3.4:

Start:

Select One

End:
Activity 5.3.5:

Start:

Select One

End:
Activity 5.3.6:

Start:

Select One

End:
Activity 5.3.7:

Start:

Select One

End:
Objective 5.A:
Measurement:
Activity 5.A.1:

Start:

Select One

End:
Activity 5.A.2:

Start:

Select One

End:
Activity 5.A.3:

Start:

Select One

End:
Activity 5.A.4:

Start:

Select One

End:
Activity 5.A.5:

Start:

Select One

End:
14

Activity

Start and End
Date (mm/dd/yy)

Progress Status

(500 character limit)

Activity 5.A.6:

Start:

Select One

Description of Progress
(1000 character limit)

End:
Activity 5.A.7:

Start:

Select One

End:

Focus Area SMART Objectives
Instructions:
Using the template provided below, please indicate the focus areas selected for the funding cycle and describe the SMART objectives and related program and
policy strategies for each focus area. Please identify at least one proximal and one distal SMART objective for each focus area and complete the related fields for
each SMART objective in the related “Distal SMART Objectives” and “Supporting Proximal SMART Objectives” tables. Please also indicate at least one program or
policy strategy for each focus area in the “Strategies” table. All text fields are limited to 500 characters.
Focus Area Definitions:
 Focus Area = this list includes the 23 possible focus areas and “other.” Please select only one.
 Other = if other is selected, please specify the focus area category
 Description = brief description of the specific focus area addressed
 New/Revised = if this is a new or revised focus area (compared to Year 1), please check the box
SMART Objective Definitions:
 SMART: Focus area objectives should be Specific, Measurable, Attainable, Reasonable, and Time-bound (SMART) and reflect the desired outcome of the
focus area strategies supported by the grantee. The suggested format for reporting focus area objectives and an explanation of each of the components
are included below:
o __ the __ of __ __ in __ from __ to __ by __ .
 Distal objective = directly related to population morbidity, mortality, disparity, and cost
 Supporting Proximal objective = grounded in science and logically related to population morbidity, mortality, disparity, and cost. These objectives may
include measures of knowledge, attitudes, and behaviors IF supporting evidence exists to indicate a logical relationship to the burden of violence and
injury for the defined focus area.
 New/Revised = if this is a new or revised objective (compared to Year 1), please check the box
 Increase or Decrease = indicate whether or not the goal is to increase or decrease the baseline measurement

15



Count/crude rate/percent/cost = the numeric value of the measure of the burden of violence and injury for the defined focus area. The value reported
should be derived from the most current dataset the grantee has access to at the time of reporting. If reporting a rate, please report a crude rate so we
can better identify the population impact across the program in the form of a count of actual injuries prevented/lives saved.
o Select one = indicate if the numeric value is a count, rate, percent, cost, or TBD (“to be determined” by Year 2 reporting)
o Data Year = indicate the year of data used OR the year range for trend data
o Baseline = the value of the proximal or distal measure for the focus area SMART objectives available to the grantee at the time of annual
reporting for Year 1. When deciding on a baseline measure, please consult the grantee’s epidemiologist to determine the most appropriate
baseline measure for the data available. When deciding on baseline for focus area strategies that began prior to the current funding

cycle, the use of trend data (e.g., rate of increase/decrease over a time period) is recommended over multiple year averages in most
cases. Please consider the frequency of data availability during the project period when using trend data.
o









Goal = the anticipated value of the measure of the burden of violence and injury for the focus area available to the grantee at the “year the end
goal is achieved”
Affected Population Count = The count of the entire subpopulation within the geographic region that is being addressed. Note: This field may not apply
to your proximal objectives.
Data source = source of data for the measure indicated
Sub population = the specific sub-population addressed by the focus area strategies (e.g., children, minorities, youth, older drivers, pedestrians)
Measure = the measure the burden of violence and injury for the defined focus area
Distal:
o Hospitalization data
o Emergency department data
o Vital statistics data
Proximal:
o Knowledge Change : General Awareness
o Attitude Change: Personal view, opinion, or feeling
o Behavior Change: Manner of acting
Geographical Region = the geographic area addressed by the focus area strategies (e.g. statewide, county, city, ZIP code)
Goal Year End = the anticipated year the objective will be achieved

Strategy Definitions:
 Strategy Description = brief description of the related focus area program or policy strategy
 New/Revised = if this is a new or revised strategy (compared to Year 1), please check the box
 Strategy Type= indicate whether the related focus area strategy is focused on policy efforts, program interventions, or both
 Reach = indicate the level of impact anticipated for the strategy. The levels include: state, region/district, county/counties, city, ZIP code, organization.
o Specify = indicate the specific geographic region for the strategy
 Type of Support = indicate how the grantee is supporting the strategy. Please select ALL that apply.
 Progress Status = not started, redirected, planning, ongoing/implementation, complete, n/a (see page 1 for a description of the categories)
16

 Progress Description = Brief description of the level of progress achieved for the strategy during the reporting period. Please include activity successes
and barriers to progress for activities. Fields should reflect progress for all of Year 2. Do not leave blank and include sufficient information.

17

Focus Area 1
Focus Area 1:
Description :

Select One

Other:
New/Revised:
Distal SMART Objectives

Distal Objective 1:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Year 3
Year 4:
Year 5:
Distal Objective 2:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:
Distal Objective 3:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Select One

If other, please
specify:

Select One

If other, please
specify:

Select One

If other, please
specify:

18

Focus Area 1
Supporting Proximal SMART Objectives
Proximal Objective 1:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Year 3
Year 4:
Year 5:
Proximal Objective 2:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:
Proximal Objective 3:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:
Proximal Objective 4:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Select One

If other, please
specify:

Select One

If other, please
specify:

Select One

If other, please
specify:

Affected Population Count:
Data Source:
19

Baseline:
Year 2:

Select One

Subpopulation:
Measure Type:

Year 3
Year 4:
Year 5:
Proximal Objective 5:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Strategy Description

Strategy
Type
Select One

Reach
Select One

New/Revised:
If revised, provide brief
explanation:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Focus Area 1 Strategies
Type of Support

Progress Status

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Select One

If other, please
specify:

Select One

If other, please
specify:

Progress Description

Specify:
Select One
New/Revised:
If revised, provide brief
explanation:

Select One

20

Strategy Description

Strategy
Type

Reach

Focus Area 1 Strategies
Type of Support

Progress Status

Progress Description

Specify:
Select One

Select One

New/Revised:
If revised, provide brief
explanation:

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Specify:
Select One

Select One

New/Revised:
If revised, provide brief
explanation:

Specify:
Select One

Select One

New/Revised:
If revised, provide brief
explanation:

Specify:

21

Strategy Description

Strategy
Type
Select One

Focus Area 1 Strategies
Type of Support

Reach
Select One

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

New/Revised:
If revised, provide brief
explanation:

Progress Status

Progress Description

Select One

Specify:

Focus Area 2
Focus Area 2:
Description :

Select One

Other:
New/Revised:
Distal SMART Objectives

Distal Objective 1:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Year 3
Year 4:
Year 5:
Distal Objective 2:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Year 3

Geographic Region:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Select One

If other, please
specify:

Select One

If other, please
specify:
22

Year 4:
Year 5:
Distal Objective 3:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Select One

If other, please
specify:

Select One

If other, please
specify:

Select One

If other, please
specify:

Focus Area 2
Supporting Proximal SMART Objectives
Proximal Objective 1:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Year 3
Year 4:
Year 5:
Proximal Objective 2:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

23

Proximal Objective 3:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Year 3
Year 4:
Year 5:
Proximal Objective 4:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:
Proximal Objective 5:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Strategy Description

Strategy
Type

Reach

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Focus Area 2 Strategies
Type of Support

Progress Status

Select One

If other, please
specify:

Select One

If other, please
specify:

Select One

If other, please
specify:

Progress Description

24

Strategy Description

Strategy
Type
Select One

Reach
Select One

New/Revised:
If revised, provide brief
explanation:

Focus Area 2 Strategies
Type of Support

Progress Status

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Progress Description

Specify:
Select One

Select One

New/Revised:
If revised, provide brief
explanation:

Specify:
Select One

Select One

New/Revised:
If revised, provide brief
explanation:

Specify:
Select One
New/Revised:
If revised, provide brief
explanation:

Select One

25

Strategy Description

Strategy
Type

Focus Area 2 Strategies
Type of Support

Reach

Progress Status

Progress Description

Specify:
Select One

Select One

New/Revised:
If revised, provide brief
explanation:

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Specify:
Select One

Select One

New/Revised:
If revised, provide brief
explanation:

Specify:

Focus Area 3
Focus Area 3:
Description :

Select One

Other:
New/Revised:
Distal SMART Objectives

Distal Objective 1:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Select One

If other, please
26

specify:
Year 3
Year 4:
Year 5:
Distal Objective 2:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:
Distal Objective 3:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Select One

If other, please
specify:

Select One

If other, please
specify:

Select One

If other, please
specify:

Focus Area 3
Supporting Proximal SMART Objectives
Proximal Objective 1:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Year 3

Geographic Region:
27

Year 4:
Year 5:
Proximal Objective 2:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:
Proximal Objective 3:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:
Proximal Objective 4:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:
Proximal Objective 5:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Select One

If other, please
specify:

Select One

If other, please
specify:

Select One

If other, please
specify:

Affected Population Count:
Data Source:
28

Baseline:
Year 2:

Select One

Subpopulation:
Measure Type:

Year 3
Year 4:
Year 5:

Strategy Description

Select One

If other, please
specify:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Strategy
Type
Select One

Reach
Select One

New/Revised:
If revised, provide brief
explanation:

Focus Area 3 Strategies
Type of Support

Progress Status

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Progress Description

Specify:
Select One

Select One

New/Revised:
If revised, provide brief
explanation:

Specify:
Select One
New/Revised:
If revised, provide brief
explanation:

Select One

29

Strategy Description

Strategy
Type

Reach

Focus Area 3 Strategies
Type of Support

Progress Status

Progress Description

Specify:
Select One

Select One

New/Revised:
If revised, provide brief
explanation:

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Specify:
Select One

Select One

New/Revised:
If revised, provide brief
explanation:

Specify:
Select One

Select One

New/Revised:
If revised, provide brief
explanation:

Specify:

Focus Area 4
Focus Area 4:

Select One

Other:
30

Description :

New/Revised:
Distal SMART Objectives

Distal Objective 1:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Year 3
Year 4:
Year 5:
Distal Objective 2:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:
Distal Objective 3:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Select One

If other, please
specify:

Select One

If other, please
specify:

Select One

If other, please
specify:

Focus Area 4
Supporting Proximal SMART Objectives
31

Proximal Objective 1:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Year 3
Year 4:
Year 5:
Proximal Objective 2:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:
Proximal Objective 3:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:
Proximal Objective 4:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Select One

If other, please
specify:

Select One

If other, please
specify:

Select One

If other, please
specify:

Select One

If other, please
32

specify:
Year 3
Year 4:
Year 5:
Proximal Objective 5:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Strategy Description

Strategy
Type
Select One

Reach
Select One

New/Revised:
If revised, provide brief
explanation:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Focus Area 4 Strategies
Type of Support

Progress Status

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Select One

If other, please
specify:

Progress Description

Specify:
Select One

Select One

New/Revised:
If revised, provide brief
explanation:

Specify:
33

Strategy Description

Strategy
Type

Reach

Select One

Select One

New/Revised:
If revised, provide brief
explanation:

Focus Area 4 Strategies
Type of Support

Progress Status

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Progress Description

Specify:
Select One

Select One

New/Revised:
If revised, provide brief
explanation:

Specify:
Select One

Select One

New/Revised:
If revised, provide brief
explanation:

Specify:

34

Strategy Description

Strategy
Type
Select One

Focus Area 4 Strategies
Type of Support

Reach
Select One

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

New/Revised:
If revised, provide brief
explanation:

Progress Status

Progress Description

Select One

Specify:

Focus Area 5
Focus Area 5:
Description :

Select One

Other:
New/Revised:
Distal SMART Objectives

Distal Objective 1:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Year 3
Year 4:
Year 5:
Distal Objective 2:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Year 3

Geographic Region:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Select One

If other, please
specify:

Select One

If other, please
specify:
35

Year 4:
Year 5:
Distal Objective 3:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Select One

If other, please
specify:

Select One

If other, please
specify:

Select One

If other, please
specify:

Focus Area 5
Supporting Proximal SMART Objectives
Proximal Objective 1:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Year 3
Year 4:
Year 5:
Proximal Objective 2:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

36

Proximal Objective 3:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Year 3
Year 4:
Year 5:
Proximal Objective 4:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:
Proximal Objective 5:
New/Revised:
If revised, provide brief explanation:
Increase or Decrease: Select One
Count/Rate/%/Cost
Data Year
Baseline:
Select One
Year 2:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Year 3
Year 4:
Year 5:

Geographic Region:
Goal count/rate/%/Cost:
Goal Year End:

Strategy Description

Strategy
Type

Reach

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Affected Population Count:
Data Source:
Subpopulation:
Measure Type:

Focus Area 5 Strategies
Type of Support

Progress Status

Select One

If other, please
specify:

Select One

If other, please
specify:

Select One

If other, please
specify:

Progress Description

37

Strategy Description

Strategy
Type
Select One

Reach
Select One

New/Revised:
If revised, provide brief
explanation:

Focus Area 5 Strategies
Type of Support

Progress Status

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Progress Description

Specify:
Select One

Select One

New/Revised:
If revised, provide brief
explanation:

Specify:
Select One

Select One

New/Revised:
If revised, provide brief
explanation:

Specify:
Select One
New/Revised:
If revised, provide brief
explanation:

Select One

38

Strategy Description

Strategy
Type

Reach

Focus Area 5 Strategies
Type of Support

Progress Status

Progress Description

Specify:
Select One

Select One

New/Revised:
If revised, provide brief
explanation:

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Funding
Technical Assistance
Staff Support
Data Support
Lead Agency
Coordinating Agency
Other:

Select One

Specify:
Select One

Select One

New/Revised:
If revised, provide brief
explanation:

Specify:

39