Form 0920-1097 Performance Meas Template

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Overview

Home Page
Benchmarks
Performance Measures

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Sheet 1: Home Page

							Form Approved: 0920-XXXX
							Expiration Date: xx/xx/xxxx
	National Tobacco Control Programs
Performance Measures Template
				Year [X]
			[Choose your state name…]
				The following navigation bar is available on all worksheets
				Click a tab to jump to the corresponding sheet:
	Instructions:
	You may use this template to complete your benchmark and performance measure information for NTCP.
	Please refer to the supplemental guidance document for detailed instructions.
	Notes on Data Entry: All light yellow cells are available for user input.
	Technical Support:
	If you need technical support at any time, please send an email with a detailed description of your need to the following address:
	OSHMISTA@CDC.GOV
	Public reporting burden of this collection of information is estimated to average 5 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 D-74, Atlanta, Georgia 30333; ATTN: PRA [0920-XXXX].

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Sheet 2: Benchmarks

	Benchmarks
	Evidence of state health officer and other senior state health department management involvement in the tobacco control program
	Description	Response
	Describe the involvement of the state health officer and other senior health department management in the tobacco control program.
	Evidence of executed sustainability plan and activities
	Description	Response
	Briefly describe the process used to develop sustainability plan, including how stakeholders were involved.
	Was the Program Sustainability Assessment Tool completed when developing the plan?
	Were at least 50% of stakeholders from outside the state and local health departments? Please explain.
	Evidence that training and technical assistance needs have been assessed and provided by the program to state and local health department staff, coalition members, and partners statewide
	Description	Response
	Have training & TA needs of partners (state and local health department staff, coalition member, and other partners statewide) been assessed in the last year?
	Were identified training & TA needs delivered, and if so, how? Please explain.
	Evidence of use of funding to support environmental, policy, and systems interventions and strategies that are evidence-based and reach populations disproportionately affected by tobacco use, exposure to SHS and tobacco-related diseases
	Description	Response
	How have environmental, policy, and systems interventions reached populations disproportionately affected by tobacco use, exposure to SHS, and tobacco related diseases? (Include data, if available.)
	Evidence of increased community networks and community-based organizations and individuals who have been affected by tobacco use to educate the community’s decision makers and leaders
	Description	Response
	Has there been an increase in community networks, CBOs, and/or individuals who have been affected by tobacco use educating community decision makers and leaders?
	Please explain.
	Evidence of identifying and training tobacco control spokespersons for each Designated Market Area (DMA)
	(Please see the User Guide Appendix for number and type of DMAs by state)
	Description	Response
	How many DMAs have at least one trained tobacco control spokesperson?
	How many trained tobacco control spokesperson(s) are there in total in your state?
	Evidence of monitoring the percentage of public housing authorities with 100% smoke-free indoor air policies
	Describe the total number of Public Housing Authorities (PHAs) in your state, and those that have comprehensive smoke free policies*. Describe the number of units and residents in each. Do not include subsized or other public housing that are not under the authority of a PHA. *A comprehensive smoke free policy prohibits smoking in all indoor areas of all residential buildings under the jurisdiction of the PHA, including individual living units, hallways, and balconies.
	Description	PHAs with comprehensive smoke free policies*	All PHAs in state
	Number of PHAs
	Number of Units
	Number of residents
	Evidence of monitoring the percentage of public mental health and substance abuse facilities with tobacco–free policies for their campuses
	Description	State legislation banning tobacco use?	Percentage covered, if No
	Mental health outpatient facilities
	Mental health residential facilities
	Substance abuse outpatient facilities
	Substance abuse residential facilities
	Regarding program efforts to expand access to evidence-based tobacco cessation treatment, remove barriers, and promote utilization of covered treatment benefits, please respond to the following CDC evaluation questions.
	Description	Did program efforts target these areas?	Did these efforts target Medicaid recipients?	Was this part of any effort with the CDC 6|18 Team?	Describe progress (As appropriate, distinguish between Medicaid and commercial insurance)
	Expanding access to evidence-based cessation treatment
	Removing barriers to covered cessation treatments
	Promoting utilization of covered cessation treatments

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Sheet 3: Performance Measures

	Performance Measures
	Best Practice Area
	Mass-Reach Health Communication Interventions
	Number of monthly speaking opportunities by trained tobacco control spokespersons to educate decision-makers, stakeholders, and the public
	*Someone who is knowledgeable about the issues and can speak to the public, media, and interested groups to educate about science, programs and policies to help curb tobacco use. These people could be contractors, local advocates, coalition members
	Description	Response
	How many times did a trained tobacco control spokesperson speak to educate decision-makers, stakeholders, and the public (including media) from [Date] to [Date]?
	Number of paid and earned media efforts targeting populations or areas with high concentrations of smoking prevalence, secondhand smoke exposure, and chronic disease
	Did any media efforts target population(s) or area(s) disproportionately impacted by tobacco use?	Indicate which populations or areas were targeted, using drop down:
	African American
	Asian American, Native Hawaiian, Pacific Islander
	Native American, Native Alaskan
	Hispanic / Latino
	Behavioral Health or Substance Abuse
	LGBT
	Rural
	Urban
	Low SES
	Pregnant Women
	Veteran/Military
	Other (please explain)
	Select the paid media channel(s) used for these targeted efforts, if applicable.	Indicate which paid channels were used, using drop down:
	TV
	Radio
	Internet (paid, not free posts)
	Magazines
	Newspapers
	Billboards
	Other (please explain)
	Which earned media efforts have targeted disparately affected populations or areas (by program or designated spokesperson)?	Indicate which earned media channels were used, using drop down:
	Letters to the Editors/Editorials
	Press Releases
	Interviews
	Other (please explain)
	Types of social media activities used to complement traditional paid and earned media efforts (e.g., social media campaign, posting content) and the reach of social media activities by social media site used (e.g., Facebook, Twitter, YouTube)
	Indicate if the following social media activities that have been used to complement traditional paid and earned media efforts. If yes, describe reach, using quantitative data on number of posts, tweets, retweets, like/follows, or audience information, when available.
	Social media activities	Indicate which social media activities were used using the drop-down:
	Facebook Posts
	Describe Reach using quantitative data on number of posts, tweets, retweets, likes/follows, if available:
	Provide additional details on audience, topic/message or information shared, if available :
	Tweets/Retweets
	Describe Reach using quantitative data on number of posts, tweets, retweets, likes/follows, if available:
	Provide additional details on audience, topic/message or information shared, if available :
	YouTube videos
	Describe Reach using quantitative data on number of posts, tweets, retweets, likes/follows, if available:
	Provide additional details on audience, topic/message or information shared, if available :
	Blogs
	Describe Reach using quantitative data on number of posts, tweets, retweets, likes/follows, if available:
	Provide additional details on audience, topic/message or information shared, if available :
	Buttons or other materials posted on website
	Describe Reach using quantitative data on number of posts, tweets, retweets, likes/follows, if available:
	Provide additional details on audience, topic/message or information shared, if available :
	Other: specify below
	Provide additional details on audience, topic/message or information shared, if available :
	Best Practice Area
	Surveillance and Evaluation
	Number and type of tobacco-related surveys implemented during the funding year (e.g., ATS, YTS), and type of tobacco-related modules implemented (e.g., BRFSS, YRBSS)
	What surveys providing data on tobacco use indicators were implemented in [Year] ? Check all that apply, including those where the program contributed funding to enhance data collection.	Indicate which surveys were implemented by using the drop down:
	Adult Tobacco Survey
	Youth Tobacco Survey
	Youth Risk Behavior Survey
	Other tobacco-related state surveys, Explain:
	Number and type of tobacco-related surveys implemented during the funding year (e.g., ATS, YTS), and type of tobacco-related modules implemented (e.g., BRFSS, YRBSS)
	Description	Response
	Describe any modules (e.g., Secondhand Smoke, Diabetes, mental Health) that were implemented or used, or additional methods (e.g., innovative sampling) that were used to enhance surveillance efforts.
	Number and type of tobacco-related indicators developed and implemented in state surveillance systems during the funding year (e.g., ATS, YTS, BRFSS, YRBSS)
	Are recent state tobacco use adult prevalence rates available for the following populations?	Select the Appropriate Response (Yes/No/NA) for Each Category:
	African American
	American Indian/Alaska Native
	Asian American/Pacific Islander
	Behavioral Health/Substance Abuse
	Hispanic/Latino
	LGBT
	Low SES
	Rural/Urban
	Best Practice Area
	Infrastructure, Administration, and Management
	Percentage of funding (state, CDC, and other) used to meet CDC-recommended funding levels outlined in Best Practices - 2014
	Description	Response
	As of [DATE], how much funding was allocated to the state Tobacco Control Program (including all sources, state, CDC, and other)?
	Number and type of staff positions maintained throughout the entire funding year to support the tobacco control program (e.g., program director, policy coordinator, communications specialist, cessation coordinator, surveillance and evaluation staff, fiscal management systems staff, and administrative staff)
	Description	Response
	How many months has a tobacco program manager/director been in place? (Round up if partial month)
	Indicate how many full-time staff members there are per category:	Enter the number of staff members, using decimals if needed:
	Note: If staff fulfill more than one major role, you may include them in more than one categories, unless their title specifies one area, such as "Cessation specialist"
	Administrative
	Cessation
	Communications
	Disparities
	Fiscal management
	Policy
	Prevention
	Surveillance and Evaluation