Rape Prevention and Education Program Report Tool - word

Att._4a_Program_Report_Tool_041416.docx

Monitoring and Reporting System for Rape Prevention and Education (RPE) Program Awardees

Rape Prevention and Education Program Report Tool - word

OMB: 0920-1130

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Attachment 4a— Program Report Tool Word Version

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OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx


Public reporting burden of this collection of information is estimated to average 8 hours for the initial population of the tool and 3 hours for annual reporting 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 D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).


Rape Prevention and Education (RPE)

Program Report Tool


Before You Begin

The goals of the RPE cooperative agreement (14-1401) are to improve the ability of RPE-funded organizations to use the public health approach and effective prevention principles to implement and evaluate sexual violence prevention strategies. The Program Report Tool will capture key information to monitor progress toward the FOA goals. Sections of this tool relate to the steps in the public health approach, and questions are aligned with primary prevention principles. Information collected through this tool is intended to measure the extent to which FOA goals are met, and to provide RPE awardees with information you can use to plan, implement, and evaluate prevention strategies to prevent sexual violence.


Instructions: Please use this Tool to plan and report on your implementation of prevention strategies. For instructions on completing this tool, definitions and additional information about the questions, please refer to the reporting guidance.


Submission: In addition to uploading it onto grants.gov for your continuation application, please submit the completed Tool with your Annual Performance Report to your Project Officer and {email address}


Technical Tips: You may navigate this Tool by clicking on the navigation menu (shown below) located at the top of each spreadsheet or the tabs at the bottom of the window.


Shape1


Please enter information into the yellow fields. If you enter an invalid character in any field that is not open text, an error message box will pop up.


If you need to add an additional tab to describe a prevention strategy, you may do so at any time by clicking here: [Button: Add Prevention Strategy] [Dynamic spreadsheet that allows adding a new spreadsheet for additional prevention strategy]


Questions and Support: If you have any content-related questions or need assistance, please contact your Project Officer. If you need technical support at any time, please send an email with a detailed description of your need to the following address: {email address}.


*denotes required field


Background

Please complete information about the organization implementing each prevention strategy and the alignment of the prevention strategies to your work plan goals and objectives.


[Navigational Menu of the Sections in this tab]

RPE Awardee Information

RPE awardees, please describe to which goals on your state-level work plan the prevention strategy(s) in this Prevention Strategy Tool aligns.


  1. Which RPE awardee are you reporting about? Select from the drop down menu.* [Drop Down Menu]


Alabama

Hawaii

Massachusetts

New Mexico

South Dakota

District of Columbia

Alaska

Idaho

Michigan

New York

Tennessee

Guam

Arizona

Illinois

Minnesota

North Carolina

Texas

Marianna Island

Arkansas

Indiana

Mississippi

North Dakota

Utah

Puerto Rico

California

Iowa

Missouri

Ohio

Vermont

Virgin Islands

Colorado

Kansas

Montana

Oklahoma

Virginia


Connecticut

Kentucky

Nebraska

Oregon

Washington


Delaware

Louisiana

Nevada

Pennsylvania

West Virginia


Florida

Maine

New Hampshire

Rhode Island

Wisconsin


Georgia

Maryland

New Jersey

South Carolina

Wyoming




  1. For each of the prevention strategy reported in this tool, please indicate which state-level RPE work plan goal(s) the prevention strategy relates to or addresses.*


Prevention Strategy Name

RPE State-level Work Plan Goals

{Prevention Strategy 1}

[Open Text Field]

{Prevention Strategy 2}

[Open Text Field]

{Prevention Strategy ...#}

[Open Text Field]



RPE Sub-Awardee or Implementer Information


  1. What is the name of the implementing organization?* [Open Text Field]

  1. Please select all that best describe the sector of the implementing organization. (Check all that apply)* [Check all that apply field with an open text field for “Other”]


  • Public

  • Child Welfare

  • Housing

  • Minority

  • Private

  • Civic/Volunteer

  • Justice/Law enforcement

  • Public Health

  • Governmental Agency

  • Disability

  • Low Socioeconomic Status

  • Social Services

  • Non-government Agency

  • Faith/Religious

  • Media

  • Transportation

  • Non-profit

  • Education

  • Mental Health

  • Tribal

  • Business

  • Healthcare

  • Military

  • Veteran Status

  • Other, please specify: _______________ [Open Text Field]

  • Other, please specify: _______________ [Open Text Field]

  • Other, please specify: _______________ [Open Text Field]


Overall Budget

  1. What is the total annual RPE budget for the implementing organization?* [Open Numeric Field with two decimals]

$_____.___


  1. How much funding is allocated for the implementation of each prevention strategy? Provide information in dollar amounts.


Prevention Strategy Name

Amount allocated in $

{Prevention Strategy 1}

[Open Numeric Field with two decimals]

{Prevention Strategy 2}

[Open Numeric Field with two decimals]

{Prevention Strategy ...#}

[Open Numeric Field with two decimals]


Budget Related to Evaluation

  1. Are funds allocated to evaluate the prevention strategy(s)?* [Closed Options]

  • Yes, funds are allocated for evaluation for each prevention strategy. [Answer Q7a]

  • Yes, funds are allocated for evaluation, but only at the implementing organization level. [Skip to Q7b]

  • No, funds are not allocated at all for evaluation. [Skip to Q8]

  • Not applicable, evaluation is only being implemented at the state. [Skip to Q8]


    1. How much funding is allocated for the evaluation for each prevention strategy? Provide information in dollar amounts.


Prevention Strategy Name

Amount allocated in $

{Prevention Strategy 1}

[Open Numeric Field with two decimals]

{Prevention Strategy 2}

[Open Numeric Field with two decimals]

{Prevention Strategy ...#}

[Open Numeric Field with two decimals]



    1. How much funding is allocated for evaluation? Provide information in dollar amounts. [Open Numeric Field with two decimals]

$_____.___


  1. Provide any additional information or elaborate on any of the above questions as needed. [Open Text Field]


Prevention Strategy #


[Navigational Menu of the Sections in this tab]


Prevention Strategy Description

One of the effective prevention principle is that prevention strategy should be based on the best available evidence (See CDC’s Understanding Evidence for more information about levels of evidence). At a minimum, prevention strategies should have an articulated theory base to address modifiable risk and protective factors related to sexual violence.


  1. What is the prevention strategy you are implementing?* [Drop Down Menu]

  • Bringing in the Bystander

  • Coaching Boys into Men

  • Fourth R

  • Green Dot

  • Safer Choices

  • Safe Dates

  • Second Step

  • Shifting-Boundaries

  • Other, please specify the name of the prevention strategy: _______________ [Open Text Field]


  1. Describe your prevention strategy. Use the following questions to help you describe the strategy. What are the goals of the prevention strategy? What does it aim to change? What methods are used to affect that change (e.g., potential impact)? What are the components and activities of the prevention (e.g., theory of change, roadmap, or logic)? What are the key messages or topics of the strategy?* [Open Text Field]


Prevention Strategy Characteristics

This section asks about the prevention strategy selected to implement to address sexual violence problems in the selected target population, and the “how” or approach used to address the defined sexual violence problems.


  1. Which of the following strategies from the RPE Cooperative Agreement (14-1401) does this prevention strategy relate to? According to the Violence against Women Act of 1994 (VAWA), allotments of RPE funds may only be used for seven permitted uses (first seven listed).* [Drop Down Menu]

  • Educational seminars

  • Operation of hotlines

  • Training programs for professionals

  • Preparation of informational materials

  • Training programs for students and campus personnel designed to reduce the incidence of sexual assault at colleges and universities

  • Education to increase awareness about drugs and alcohol used to facilitate rape or sexual assault; and

  • Other efforts to increase awareness of the facts about or to help prevent sexual assault, including efforts to raise awareness in under-served communities and awareness among people with disabilities as defined in Section 3 of the Americans with Disabilities Act of 1990 (42 U.S.C. Section 12102)

  • Community Change Strategy [If selected, choose one of the sub-group below]

    • Community mobilization

    • Coalition building

    • Policy education

    • Social norms change

  • Capacity Building, please specify: ________________ [Open Text Field]

  • Not Applicable, please specify: ________________ [Open Text Field]


If Other, Capacity Building, or Not Applicable please specify the name of the prevention strategy ________

[Open Text Field]


  1. What sources of information or data did you use to inform your selection of the prevention strategy and determine that it may be effective in changing sexual violence-related outcomes and/or address identified risk and protective factors? (Check all that apply).* [Check all that apply field with an open text field for “Other”]

  • Needs assessment

  • Capacity or assets assessment

  • Environmental scan

  • Strategy theory or Logic model

  • Evaluation report

  • Literature review

  • Other, please specify: __________________ [Open Text Field]

  • Other, please specify: __________________ [Open Text Field]

  • Other, please specify: __________________ [Open Text Field]


  1. Provide any additional information or elaborate on any of the above as needed. [Open Text Field]


Prevention Strategy Selection

This section asks about the extent to which a public health approach was used in selecting the prevention strategy.


  1. Describe the rationale for selecting this prevention strategy to implement. Use the following questions to help you describe the rationale: To what extent does the prevention strategy align with the needs and defined sexual violence problem in the selected target population? How will this strategy achieve the intended outcomes for the selected target population? A later section will ask about the selected target population.* [Open Text Field]


  1. At what level of the Social Ecological Model do you expect change to occur? (Check all that apply)* [Check all that apply field with an open text field for “Other”]

  • Individual

  • Relationship

  • Community

  • Societal

  • Other: Capacity Building

  • Other, please specify: [Open Text Field]




Risk and Protective Factors

This section asks about the “what” or the defined sexual violence problems needing to be addressed.


  1. Which of the following risk factors does this strategy seek to address? (Check all that apply)* [Check all that apply field with an open text field for “Other”]


Individual

Relationship

  • Low education/educational achievement

  • Lack of non-violent problem solving skills

  • Poor behavior/impulse control

  • Prior violent victimization or perpetration

  • Witnessing violence

  • Psychological/mental health problems

  • Substance use

  • Delinquency

  • Empathetic deficits

  • General aggressiveness and acceptance of violence

  • Early sexual initiation

  • Coercive sexual fantasies

  • Preference for impersonal sex and sexual risk-taking

  • Exposure to sexually explicit media

  • Hostility towards women

  • Adherence to traditional gender role norms

  • Hypermasculinity

  • Suicidal behavior

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

  • Social isolation/lack of social support

  • Family environment characterized by physical violence and conflict

  • Childhood history of physical, sexual or emotional abuse

  • Emotionally unsupportive familial environment

  • Poor parent-child relationships, particularly with fathers

  • Association with sexually aggressive, hyper-masculine, or delinquent peers

  • Gang involvement

  • Involvement in a violent or abusive intimate relationship

  • Economic stress

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]


Community

Societal

  • Poverty

  • High unemployment rates/diminished economic opportunities

  • Lack of institutional support from police and judicial system

  • Community violence/general tolerance of violence within community

  • Weak community sanctions against sexual violence perpetrators

  • High alcohol outlet density

  • Poor neighborhood support or cohesion

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

  • Societal norms that support sexual violence

  • Cultural norms that support aggression

  • Societal norms that support male superiority and sexual entitlement

  • Societal norms that maintain women's inferiority and sexual submissiveness

  • Weak health, educational, economic and social laws and policies relating to sexual violence and gender equity

  • Higher levels of crime and other violence

  • Harmful gender norms

  • Media violence

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]





  1. Which of the following protective factors does this strategy seek to address? (Check all that apply)* [Check all that apply field with an open text field for “Other”]


Individual

Relationship

  • Emotional health and connectedness

  • High education/academic achievement

  • Empathy and concern for how one's actions affect others

  • Skills solving problems in non-violent manner

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

  • Family support and connectedness

  • Connection to a caring adult

  • Connection/commitment to school

  • Parental use of reasoning to resolve family conflict

  • Association with prosocial peers

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

Community

Societal

  • Coordination of services among community agencies

  • Access to mental health and substance abuse services

  • Community support and connectedness

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]




Target population

This section asks about the “who” or the entities (e.g., individual, organization, community, or other setting) expected to be affected or to change as a result of the prevention strategy to address the defined sexual violence problems.


  1. Who or what entities will change or be affected as a result of the prevention strategy? (Check all that apply) Specify characteristics of the target population in the question that follows.* [Check all that apply field with an open text field for “Other”]


Individuals

Organizations

Communities

  • Students

  • School

  • School District

  • Pre-School

  • Elementary School

  • Middle School

  • High School

  • Higher Education (University/College)

  • Pre-School

  • Elementary School

  • Middle School

  • High School

  • Higher Education (University/College)

  • Elementary School

  • Middle School

  • High School

  • Higher Education (University/College)

  • Teachers/Professors

  • School Administrators

  • County

  • School Staff

  • Governmental Agency

  • City

  • Policy makers

  • Non-government Agency

  • Census Tract/Zip Code

  • Parents

  • Non-profit

  • Commercial District

  • Healthcare professionals

  • Business

  • Neighborhood

  • Mental health providers

  • Bar

  • Territory Area

  • General public

  • Home

  • Park and Recreational Area

  • Individual with specific characteristics

  • Organizations serving individuals with specific characteristics

  • Communities with specific characteristics

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]





  1. What are the characteristics related to the selected target population described above? (Check all that apply)* [Check all that apply field with an open text field for “Other”]


Gender

Race

Age

  • Male

  • Female

  • Transgender

  • African American or Black

  • American Indian or Alaska Native

  • Asian Indian

  • Chinese

  • Filipino

  • Japanese

  • Korean

  • Vietnamese

  • Native Hawaiian or other Pacific Islander

  • Guamanian or Chamorro

  • Samoan

  • White

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

  • Infants/Toddlers (0–1 yrs)

  • Infants/Toddlers (2–3 yrs)

  • Children (4–11 yrs)

  • Adolescents (12–17 yrs)

  • Young Adults (18–24 yrs)

  • Adults (25–39 yrs)

  • Adults (40–49 yrs)

  • Older Adults (50–64 yrs)

  • Older Adults (65+ yrs)

Sexual Identity

Other Characteristics

  • Bisexual

  • Gay

  • Heterosexual

  • Lesbian

  • Questioning

  • Disability

  • Faith/Religious

  • Low Socioeconomic Status

  • Minority

  • Tribal

  • Veteran Status

  • Other, please specify: ______ [Open Text Field]

  • Other, please specify: ______ [Open Text Field]

Ethnicity

  • Hispanic or Latino

  • Not Hispanic or Latino


  1. Briefly provide any additional information about the selected target population for this prevention strategy or elaborate on the above as needed. [Open Text Field]


  1. What information or data, and from what sources, did you use to identify and select the target population for this prevention strategy? (Check all that apply).* [Check all that apply field with open text fields]

  • Needs assessment

  • Evaluation/Evaluation report

  • In-depth interviews

  • Surveys

  • Focus groups

  • Police reports

  • Medical examiner files

  • Vital records

  • Hospital charts

  • Registries

  • Population-based surveys

  • Other, please specify: _____________ [Open Text Field]

  • Other, please specify: _____________ [Open Text Field]

  • Other, please specify: _____________ [Open Text Field]






Reach

This section asks about how much of the target population defined above were actually reached and affected.


  1. To what extent does the prevention strategy reach or affect change in the selected target population?* (Reach Impact = Potential or Intended / Actual number of individuals, organizations, or communities affected by or who received the prevention strategy). Complete this for each of your target populations for this prevention strategy. You may use the button below to add as many rows as needed to this table.

Unit of Analysis

Target Population Description

Potential Reach

Actual Reach

Reach Impact

[Drop Down Menu]

  • Individual

  • Organizational

  • Community

[Open Text Field]


[Open Numeric Field]


[Open Numeric Field]


{auto calculation}


[Button: Add Reach Table] [Dynamic Button that allows respondent to add as many rows as they want]


  1. Briefly provide any additional information or elaborate on the above as needed. [Open Text Field]



Information Collection and Evaluation

This section asks about information collection or evaluation activities and use of collected information.


  1. Do you collect information or data on the implementation of the prevention strategy?* [Drop Down Menu]

  • Yes

  • No [Skip to Q17]


16a. What types of information or data do you collect about the implementation of the prevention strategy? [Open Text Field]


16b. What are the sources of information or data that you use? (Check all that apply). [Check all that apply field with an open text field for “Other”]

  • Needs assessment

  • Capacity or assets assessment

  • Environmental scan

  • Strategy theory or Logic model

  • Evaluation report

  • Literature review

  • Administrative records

  • Tracking logs

  • Other, please specify: __________________ [Open Text Field]

  • Other, please specify: __________________ [Open Text Field]

  • Other, please specify: __________________ [Open Text Field]


  1. Do you collect information or data on the outcomes of the prevention strategy?* [Drop Down Menu]

  • Yes

  • No [Skip to Q18]


17a. What types of data or information do you collect about the outcomes of the prevention strategy (e.g., risk/protective factors, knowledge, skills, behaviors, attitudes, victimization, perpetration, practices)? [Open Text Field]


17b. What sources of information or data do you use to measure those outcomes? (Check all that apply). [Check all that apply field with open text fields]

  • Needs assessment

  • Evaluation/Evaluation report

  • In-depth interviews

  • Surveys

  • Focus groups

  • Police reports

  • Medical examiner files

  • Vital records

  • Hospital charts

  • Registries

  • Population-based surveys

  • Other, please specify: _____________ [Open Text Field]

  • Other, please specify: _____________ [Open Text Field]

  • Other, please specify: _____________ [Open Text Field]


  1. Do you use information or data that you collect for program improvement?* [Drop Down Menu]

  • Yes

  • No [Skip to Q19]


18a. How do you use information or data you collect? [Open Text Field]


  1. Do you disseminate information (e.g., impact) or lessons learned about the prevention strategy?* [Drop Down Menu]

  • Yes

  • No [Completed]


19a. What information or lessons learned do you share? [Open Text Field]


19b. To whom and how do you disseminate or share the information or lessons learned? [Open Text Field]



Attachment 4a— Program Report Tool Word Version 18

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorPari Chowdhary
File Modified0000-00-00
File Created2021-01-22

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