CDC-RFA-PS15-150203CONT17 Guidance FINAL_2.14.17.docx

Centers for Disease Control and Prevention (CDC) Office of Grant Services Instructions for Preparing an Annual Performance Report (APR) Catalog of Federal Domestic Assistance (CFDA): 93.939 Funding Opportunity Announcement (FOA) Number*: CDC-RFA-PS15-150203CONT17

Comprehensive High-Impact HIV Prevention Projects for Community-Based Organizations National Center for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP)

Eligibility:

This award will be a continuation of funds intended only for grantees previously awarded under PS15-1502: Comprehensive High-Impact HIV Prevention Projects for Community-Based Organizations.

Application Submission:

CDC requires grantees to submit their Annual Performance Reports (APR), which serves as the non-competing continuation application, through www.grantsolutions.gov NLT 120 days prior to the end of the budget period.

If you encounter any difficulties submitting your annual performance report through www.grantsolutions.gov, please contact the GrantSolutions helpdesk at 866-577-0771 or email help@grantsolutions.gov prior to the submission deadline. If you need further information regarding the annual performance report process, please contact Rhonda Perry-Colbert, Grants Management Specialist, at (770) 488-2848. For programmatic information, please contact your assigned Prevention Program Branch Project Officer, listed in the CDC Contacts section of the notice of award.

Reports must be submitted by March 24, 2017, 11:59 pm Eastern Standard Time on www.grantsolutions.gov for the reporting period, July 1, 2017 - June 30, 2018. Late or incomplete reports could result in an enforcement action such as a delay in the award or a reduction in funds. CDC will accept requests for a deadline extension on rare occasions and after adequate justification has been provided.

Annual Federal Financial Report Submission The Annual Federal Financial report (FFR) SF-425 is required and must be submitted to your GMS no later than 90 days after the end of the budget period. The FFR for this Budget Period July 1, 2017 - June 30, 2018 is due to the GMS by 09/30/2017. To submit your FFR, login to www.grantsolutions.gov, select “Reports” from the menu bar and then click on Federal Financial Reports.

General Application Packet Tips:

· Properly label each item of the application packet

· Each section should use 1.5 spacing with one-inch margins

· Number all narrative pages only

· Do not exceed 50 pages (Including appendices, excluding budget and supporting documentation)

· Use a 12 point font

Where the instructions on the forms conflict with these instructions, follow these instructions:

1. CDC requires the use of PDF format for ALL attachments.

2. Use of file formats other than PDF may result in the file being unreadable by CDC staff.

Checklist of required contents of application packet:

1. SF-424 Application for Federal Domestic Assistance-Short Organizational Form

2. SF-424A Budget Information-Non-Construction Programs

3. Budget Justification

4. Indirect Cost Rate Agreement

5. Project Narrative

6. Certification *(See Note Below)

7. Assurances *(See Note Below)

*Note: Certifications and Assurances - Non-Construction forms are required to be submitted with APR application. Please go to the following website:

http://wwwn.cdc.gov/grantassurances/Homepage.aspx, to upload the forms. The forms are required for each year of the project and should be updated as necessary.

When you enter the website, click on Download Instructions and Forms and follow the instructions. To upload the completed forms, click on "Submit Documents" in the upper left corner of the screen.

Instructions for accessing and completing required contents of the application package:

a) Go to: www.grantsolutions.gov

b) Access: My Grants List Screen

c) Select: “Apply for Non-Competing Award”

d) Complete: The GrantSolutions Non-Competing Continuation Application Control Checklist

1. SF-424 Application for Federal Domestic Assistance-Short Organizational Form:

Complete all sections:

A. In addition to inserting the legal name of your organization in Block #5a, insert the CDC Award Number provided in the CDC Notice of Award. Failure to provide your award number could cause delay in processing your application.

B. Please insert your organization’s Financial Official information in Block #8.

SPECIAL NOTE: Items 2, 3, and 4 should be attached to the application through the “Mandatory Documents” section of the “Grant Application” page. Select “Other Attachments Form” and attach as a PDF file.

2. SF-424A Budget Information and Justification:

A. Complete all applicable sections.

B. Analysis of Remaining Time and Funds

1. Based on the current rate of obligation, if it appears there will be un-obligated funds at the end of the current budget period, provide detailed actions that will be taken to obligate this amount or use the process below to get access to unused funds.

2. If it appears there will be insufficient funds Provide detailed justification of the shortfall List the actions taken to bring the obligations in line with the authorized funding level.

3. Awardees may request up to 75% of anticipated unobligated funds at the end of the current budget period. These funds are estimated because the budget year has not closed and a final FFR cannot be prepared. For budget years that have closed, grantees may request carry over based on the final FFR for that budget period.

4. If use of estimated un-obligated funds is requested in addition to funding for the next year, complete all columns in Section A of SF-424A and submit an interim hardcopy in miscellaneous attachment section and title: “Interim FFR” Federal Financial Report (FFR), Standard Form-425, available on the internet at http://www.whitehouse.gov/omb/grants_forms.

a. The estimated un-obligated balance should be realistic in order to be consistent with the annual FFR to be submitted following the end of the budget period.

C. The proposed budget should be based on the federal funding level stated in the letter from CDC.

D. In a separate narrative, provide a detailed, line-item budget justification of the funding amount requested, including any request to use unobligated funds, to support the activities to be carried out with those funds. Attach in the “Miscellaneous Attachments” section and title it “Budget Narrative” Document needs to be in the PDF format.

E. The budget justification must be prepared in the general form, format, and to the level of detail as described in the CDC Budget Guidance. The sample budget guidance is provided on CDC’s internet at: http://www.cdc.gov/grants/applying/application-resources.html.

F. For any new proposed subcontracts provide the information specified in the Budget Guidance.

G. When non-federal matching is required, provide a line-item list of non-federal contributions including source, amount, and/or value of third party contributions proposed to meet a matching requirement.

3. Indirect Cost Rate Agreement Requirements for development and submission of indirect (F&A) cost rate proposals and cost allocation plans for all grantees are contained in 45 CFR Part 75, Appendices III through VII.

The following instructions apply to Non-Profit Organizations, State/Local Government and Indian Tribe wide Central Service Cost Allocation Plans

A. If indirect costs are requested, include a copy of the current negotiated federal indirect cost rate agreement or a cost allocation plan approval letter for those Grantees under such a plan.

B. Clearly describe the method used to calculate indirect costs. Make sure the method is consistent with the Indirect Cost Rate Agreement.

C. To be entitled to use indirect cost rates, a rate agreement must be in effect at the start of the budget period.

D. If an Indirect Cost Rate Agreement is not in effect, indirect costs may be charged as direct if (1) this practice is consist with the grantee’s/applicant’s approved accounting practices; and (2) if the costs are adequately supported and justified. Please see the Budget Guidelines (http://www.cdc.gov/grants/applying/application-resources.html) for additional information.

E. If applicable, attach in the “Miscellaneous Attachments” section and name document “Indirect Cost Rate Agreement.”

4. Project Narrative: See attached pages for Programmatic guidance and Project Narrative format.

Directions: Please answer the following questions from your Annual Performance Report (APR). Attach to the application through the “Mandatory Documents” section of the “Grant Application” page. Select “Other Attachments Form” and attach as a PDF file.

The Annual Performance Report requires the grantee to report on progress made during the performance period, July 1, 2016 - December 31, 2016 and to report on proposed programmatic activity for the new budget period (Year 3) July 1, 2017 - June 30, 2018.

SECTION I: PROGRAM MODEL & TARGET POPULATION INFORMATION

Approved Primary Target Population Summary

Gender: (Check only one) ☐ Male ☐ Female ☐ Males & Females ☐ Transgender: Male to Female ☐ Transgender: Female to Male ☐ Transgender Persons (Both Male & Female)

☐ Hispanic or Latino ☐ Non-Hispanic or Latino

Race: (Check all that apply) ☐ Black/African American ☐ White ☐ Asian ☐ Native Hawaiian/Pacific Islander ☐ American Indian/Alaskan Native ☐ Other: Click here to enter text.

Risk: (Check all that apply) ☐ High-risk heterosexual ☐ MSM

☐ IDU ☐ IDU

☐ Non-IDU ☐ Non-IDU ☐ Other: Click here to enter text. ☐ Other: Click here to enter text.

☐ Other: Click here to enter text.

Approved Secondary Target Population Summary ☐ Not Applicable

Gender: (Check only one) ☐ Male ☐ Female ☐ Males & Females ☐ Transgender: Male to Female ☐ Transgender: Female to Male ☐ Transgender Persons (Both Male & Female)

☐ Hispanic or Latino ☐ Non-Hispanic or Latino

Race: (Check all that apply) ☐ Black/African American ☐ White ☐ Asian ☐ Native Hawaiian/Pacific Islander ☐ American Indian/Alaskan Native ☐ Other: Click here to enter text.

Risk: (Check all that apply) ☐ High-risk heterosexual ☐ MSM

☐ IDU ☐ IDU

☐ Non-IDU ☐ Non-IDU ☐ Other: Click here to enter text. ☐ Other: Click here to enter text.

☐ Other: Click here to enter text.

STRATEGIES AND ACTIVITIES: Please select the approved program strategies and activities to be conducted under PS15-1502.

Targeted HIV Testing (Required) (Check all that apply) Linkage to Care (Required) (Check all that apply) Medication Adherence Interventions (Check all that apply)

☐ Targeted HIV Testing (Required)

☐ Personalized Cognitive Counseling

(PCC)

☐ Couples HIV Testing and Counseling

(CHTC)

☐ ARTAS

☐ Existing Linkage to Care Program

☐ Both (ARTAS and Existing Linkage to Care Program) ☐ Peer Support ☐ Partnership for Health (Medication Adherence)

☐ HEART

☐ Every Dose Every Day Mobile Application ☐ SMART Couples ☐ Existing Medication Adherence Intervention ☐ Not Applicable

HIV PREVENTION BEHAVIORAL INTERVENTIONS WITH HIV-POSITIVE PERSONS

APPROVED FOR IMPLEMENTATION

☐ Not Applicable ☐ CLEAR ☐ WILLOW

☐ PROMISE

☐ Partnership for Health (Safer Sex) ☐ MPowerment ☐ START ☐ Healthy Relationships

☐ POL ☐ CONNECT

☐ d-Up!

HIV PREVENTION BEHAVIORAL INTERVENTIONS WITH HIGH-RISK HIV-NEGATIVE PERSONS

APPROVED FOR IMPLEMENTATION

☐ Not Applicable

☐VOICES/VOCES

☐ d-Up!

☐ Safe in the City ☐ PROMISE ☐ Sister to Sister ☐ MPowerment ☐ Many Men, Many Voices ☐ POL

SECTION II: PS15-1502 PROGRAM STAFFING, SMART OBJECTIVES, PROPOSED YEAR 3 WORK PLAN

1. Please provide your Year 2 SMART objectives and the progress made towards meeting each objective during the reporting period (July 1, 2016 - December 31, 2016) and the proposed Year 3 (July 1, 2017 - June 30, 2018) SMART objectives. The Year 2 SMART objectives must be the same objectives that were approved by your project officer in the Year 1 Annual Performance Report. The Year 2 SMART objectives must include all required objectives as listed in the work plan template. However, additional SMART objectives may be developed, as appropriate. (Complete Appendix D: PS15-1502 Proposed Year 3 Work Plan)

2. During the reporting period (July 1, 2016 - December 31, 2016), were all program staff hired to implement PS15-1502 strategies and activities (i.e., targeted HIV testing, behavioral interventions)? ☐ Yes ☐ No

a. If no, please provide a detailed plan and timeline for when positions will be filled. Click here to enter text.

3. During the reporting period (July 1, 2016 - December 31, 2016), were all the program staff trained to implement PS15-1502 strategies and activities (i.e., targeted HIV testing, behavioral interventions)? ☐ Yes ☐ No

a. If no, please provide a detailed plan for completion of required training and timeline. Click here to enter text.

SECTION III: PROGRAM PROMOTION, OUTREACH AND RECRUITMENT

1. Describe the composition of the Community/Consumer Advisory Board (CAB) during the reporting period (July 1, 2016 - December 31, 2016) (i.e., 75% of CAB members must be representative of the target population(s), include CAB involvement in PS15-1502 program, any changes)? Click here to enter text.

2. Describe how your organization used various program promotion, outreach and recruitment strategies (e.g., use of social network strategy, internet outreach, social media, etc.) to actively promote your program during the reporting period (July 1, 2016 - December 31, 2016). Click here to enter text.

3. Describe new and/or innovative recruitment strategies that will be implemented in Year 3 (July 1, 2017 - June 30, 2018). Click here to enter text.

4. Did your organization utilize client incentives (i.e., monetary and/or non-monetary) to recruit and retain persons for your strategies and activities (i.e., targeted testing, linkage, behavioral interventions)? ☐ Yes ☐ No

a. If yes, please describe the type and value of incentives provided. Click here to enter text.

5. Will there be changes to the incentives your organization utilizes to support the strategies and activities during Year 3? ☐ Yes ☐ No

a. If yes, please describe the new incentives that will be provided. Click here to enter text.

6. Describe successes, challenges, and/or barriers experienced with implementing your program promotion, outreach and recruitment strategies, and how lessons learned will inform future program activities.

Successes: Click here to enter text.

Challenges/Barriers: Click here to enter text.

Lessons Learned: Click here to enter text.

SECTION IV: TARGETED HIV TESTING

1. Your organization is required to meet or exceed each of the established Year 2 targeted HIV testing objectives. If your organization is not expected to meet this objective by the end of the project period (July 1, 2016 - June 30, 2017), what adjustments will your organization make to meet the established objectives? Click here to enter text.

2. Is the CLIA waiver under which your targeted HIV testing program component operates current?

☐ Yes ☐ No

a. If yes, provide the CLIA waiver renewal date? Click here to enter text.

b. If no, please explain. Click here to enter text.

3. Describe the venue(s) where the targeted HIV testing was conducted during the reporting period (July 1, 2016 - December 31, 2016) (e.g., mobile unit, bars, non-clinical, clinical, etc.). Click here to enter text.

a. How do you implement targeted testing in a clinical setting? Please check Not Applicable if not conducting targeted testing in a clinical setting. Not Applicable ☐ Click here to enter text.

b. Does your organization propose to change the venue(s) where targeted HIV testing is conducted in Year 3 (July 1, 2017 - June 30, 2018)? ☐ Yes ☐ No

c. If yes, please describe the venue(s) where HIV testing will be conducted. Click here to enter text.

4. Please describe the process your organization utilizes to confirm that a person is newly diagnosed with HIV infection. Click here to enter text.

5. Provide information for the following targeted HIV testing and linkage to HIV medical care activities conducted during the reporting period (July 1, 2016 - December 31, 2016). Please provide the information below for each target population served. The table must be completed for your organization and any partner organizations/subcontractor(s) that your organization currently works with to provide targeted HIV testing. (See Supplemental Instructions for PS15-1502 Annual Performance Report (APR) for guidance on completing Appendix Table A1.b) **Please note – The total number of persons tested should only be counted once per test event. For example, a client who received a preliminary HIV- positive test result and a confirmatory test result should only be counted once toward the total number of persons tested. Total number of persons tested = number of persons who tested HIV-negative + number of persons who tested preliminary HIV-positive.

During the reporting period, July 1, 2016 - December 31, 2016, provide the below information in Appendix Tables A1.a, Al.b:

a. Target population(s), include race/ethnicity, gender, age group and transmission risk

b. Type of HIV test used for each target population (e.g., OraQuick Advance, OraSure, whole blood, etc.)

c. Total number of persons tested

d. Total number of persons testing HIV-negative

e. Total number of newly diagnosed HIV-positive persons by target population

f. Total number of previously diagnosed HIV-positive persons by target population

g. Total number of newly diagnosed, HIV-positive persons

h. Newly diagnosed HIV positivity rate (%) (i.e., Total number of newly diagnosed HIV-positive persons /Total number of persons tested)

i. Total number of newly diagnosed HIV-positive persons linked to HIV medical care

j. Total number of previously diagnosed, HIV-positive persons

k. Total number of previously diagnosed, HIV-positive persons not currently receiving HIV medical care

l. Total number of previously diagnosed, (out-of-care) HIV-positive persons linked or re-engaged into HIV medical care

Personalized Cognitive Counseling (PCC) Please complete this section if your organization is funded to conduct Personalized Cognitive Counseling (PCC) under PS15-1502. If your organization is not funded to conduct PCC, please check Not Applicable and skip to Couples HIV Testing and Counseling. Not Applicable ☐

6. Did your organization conduct Personalized Cognitive Counseling during the reporting period (July 1, 2016 - December 31, 2016)? ☐ Yes ☐ No

a. If yes, please provide the number of repeat testers and total number of repeat testers receiving Personalized Cognitive Counseling: (Complete Appendix Table A2)

Couples HIV Testing and Counseling (CHTC) Please complete this section if your organization is funded to conduct Couples HIV Testing and Counseling (CHTC) under PS15-1502. If your organization is not funded to conduct CHTC, please check Not Applicable and skip to Question 8. Not Applicable ☐

7. Did your organization conduct Couples HIV Testing and Counseling during the reporting period (July 1, 2016 - December 31, 2016)? ☐ Yes ☐ No

a. If yes, please provide the number of couples tested for each couple test result type (i.e., concordant high - risk HIV - negative, concordant HIV-positive, discordant): (Complete Appendix Table A3)

8. Describe successes, challenges, and/or barriers experienced with implementing your targeted HIV testing program component, including personalized cognitive counseling or couples HIV testing and counseling, if applicable, and how lessons learned will inform future program activities.

Successes: Click here to enter text.

Challenges/Barriers: Click here to enter text.

Lessons Learned: Click here to enter text.

Integrated Screening Activities Note: PS15-1502 supports and promotes the collaboration between HIV, STD, viral hepatitis, and/or TB programs via the provision of integrated screening activities delivered in conjunction with HIV testing.

9. Describe your organization’s process for integrating STD, viral hepatitis, and/or TB screening activities into your PS15-1502 program. Click here to enter text.

10. Describe successes, challenges, and/or barriers experienced while implementing your organization’s integrated screening activities and the lessons learned to address the challenges and inform future program activities.

Successes: Click here to enter text.

Challenges/Barriers: Click here to enter text.

Lessons Learned: Click here to enter text.

11. If applicable, describe the proposed changes that will be made to your organization’s Year 3 (July 1, 2017 - June 30, 2018) integrated screening activities. Click here to enter text.

Please complete this question if your organization is conducting integrated screening with PS15-1502 funds. If your organization is not using PS15-1502 funds to implement integrated screening, please check Not Applicable and skip to Section V. Not Applicable ☐

12. Provide information for the following integrated screening activities:

(Complete Appendix Table A4)

a. Total number of persons screened:

i. STDs (e.g., syphilis, chlamydial infection, gonorrhea)

ii. Viral hepatitis

iii. TB

b. Total number of persons referred to care and treatment/vaccination services for:

i. STDs (e.g., syphilis, chlamydial infection, gonorrhea)

ii. Viral hepatitis

iii. TB

SECTION V: COMPREHENSIVE HIV PREVENTION FOR HIV-POSITIVE PERSONS and HIGH-RISK HIV-NEGATIVE PERSONS

Partner Services

1. Please describe the process your organization utilized to refer newly diagnosed persons with HIV infection to Partner Services, in accordance with state and local regulations during the reporting period (July 1, 2016 - December 31, 2016). Click here to enter text.

Medication Adherence Please complete this section if your organization is funded to conduct a medication adherence intervention under PS15-1502. If your organization is not funded to conduct a medication adherence intervention, please check Not Applicable. Not Applicable ☐

2. Provide the following information as it relates to either an existing medication adherence program or CDC - approved medication adherence intervention for HIV-positive persons during the reporting period (July 1, 2016 - December 31, 2016)?

a. Total number of HIV-positive persons (previously and newly diagnosed) enrolled in a medication adherence program? (Complete Appendix Table B1)

Linkage and Referrals

3. Describe your organization’s processes during the reporting period (July 1, 2016 - December 31, 2016) for linking, providing, and/or referring HIV-positive persons to the following:

Click here to enter text.

· HIV medical care and treatment

· Partner Services (PS)

· Medication adherence services, as appropriate

· HIP behavioral intervention(s)

· Prevention and essential support services (See examples listed below)

Prevention and Essential Support Services for HIV-Positive Persons

i. Insurance navigation and enrollment

ii. Screening and treatment for STDs, viral hepatitis, and/or TB, as recommended by CDC

iii. Mental health counseling and services

iv. Substance abuse treatment and services

v. Housing

vi. Transportation services (to and from HIV prevention and medical care appointments)

vii. Employment services

viii. Basic education continuation and completion services

ix. Sex education, including HIV education (e.g., risk reduction programs, school-based HIV prevention providers)

x. Other

4. Provide the following information as it relates to the targeted HIV testing referrals for HIV-positive persons during the reporting period (July 1, 2016 - December 31, 2016). Examples of prevention and essential support services are listed above. (Complete Appendix Table B2)

a. Total number of HIV-positive persons (newly and previously diagnosed) referred to HIV prevention and essential support services

b. Total number of HIV-positive persons provided/referred to each prevention and essential support service

c. Total number of HIV-positive persons who accessed each HIV prevention and essential support service, if data are available.

5. Describe your organization’s processes during the reporting period (July 1, 2016 - December 31, 2016) for referring high-risk HIV-negative persons to the following appropriate prevention and essential support services (See examples listed below): Click here to enter text.

· Screening and treatment for STDs, viral hepatitis, and/or TB, as recommended by CDC

· Pre-exposure prophylaxis, as appropriate (PrEP)

· Non-occupational post-exposure prophylaxis, as appropriate (nPEP)

Prevention and Essential Support Services for High-Risk HIV-Negative Persons

i. Insurance navigation and enrollment

ii. Mental health counseling and services

iii. Substance abuse treatment and services

iv. Housing

v. Transportation services (to and from HIV prevention and medical care appointments)

vi. Employment services

vii. Basic education continuation and completion services

viii. Sex education, including HIV education (e.g., risk reduction programs, school-based HIV prevention providers)

ix. HIP interventions and services that will have the greatest impact on reducing HIV infections

x. Other

6. Provide the following information as it relates to HIV testing referrals for high-risk HIV-negative persons during the reporting period (July 1, 2016 - December 31, 2016). (Complete Appendix Table B3)

a. Total number of high-risk HIV-negative persons referred to HIV prevention and essential support services

b. Total number of high-risk HIV-negative persons provided/referred to each prevention and essential support service

c. Total number of high-risk HIV-negative persons who accessed each HIV prevention and essential support service, if data are available.

7. Describe in detail, your organization’s process for:

a. Ensuring that all persons, both HIV-positives and high-risk HIV-negatives, who are enrolled in behavioral strategies and activities receive the appropriate referrals to prevention and essential support services. Click here to enter text.

b. Tracking referrals to prevention and essential support services for all persons enrolled in behavioral strategies and activities. Click here to enter text.

8. If your organization does not have an established referral process for persons enrolled in behavioral strategies and activities, please explain any challenges and/or barriers experienced. Click here to enter text.

9. Does your organization plan to change their process in Year 3 (July 1, 2017 - June 30, 2018) for:

a. Ensuring appropriate referrals are provided for all persons enrolled in behavioral strategies and activities? ☐ Yes ☐ No

i. If yes, please describe. Click here to enter text.

b. Tracking referrals to prevention and essential support services for all persons enrolled in behavioral strategies and activities? ☐ Yes ☐ No

i. If yes, please describe. Click here to enter text.

10. Describe successes, challenges, and/or barriers experienced with linking and/or referring HIV-positive persons to HIV medical care and appropriate prevention and essential support services during the reporting period (July 1, 2016 - December 31, 2016).

Successes: Click here to enter text.

Challenges/Barriers: Click here to enter text.

11. Describe successes, challenges, and/or barriers experienced with referring high-risk HIV-negative persons to appropriate prevention and essential support services during the reporting period (July 1, 2016 - December 31, 2016).

Successes: Click here to enter text.

Challenges/Barriers: Click here to enter text.

12. Has your organization established new MOA/MOUs with other organizations to ensure client referrals for the PS15-1502 program since the Year 2 reporting period (July 1, 2016 - June 30, 2017)? ☐ Yes ☐ No

a. If new MOA/MOUs have been established since the Year 2 reporting period (July 1, 2016 - June 30, 2017), please list the organizations and attach copies of the MOA/MOUs to the APR. Click here to enter text.

High-Impact Prevention Behavioral Interventions

1. If established Year 2 strategies and activities objectives are not on target to be met by the end of the project period (July 1, 2016 - June 30, 2017), what adjustments will your organization make to meet the established objectives? Click here to enter text.

2. Provide information for the following strategies and activities for each target population for which your organization is funded. (Complete Appendix Tables B4.a and B4.b)

Note: Individual Level Interventions (ILI) – CLEAR, Partnership for Health, START, Sister to Sister; Group Level Interventions (GLI) – Connect, Healthy Relationships, 3MV, VOICES/VOCES, Willow, Safe in the City; Community Level Interventions (CLI) – PROMISE, d-Up!, MPowerment, POL

a. List the high-impact prevention behavioral intervention being implemented

b. Target population include race/ethnicity, gender, age, and transmission risk

c. Recruitment venues/locations

d. Total number of persons enrolled in the intervention (ILI and GLI only)

e. Total number of persons that completed the intervention (ILI and GLI only)

f. Total number of waves/cycles, etc. completed (GLI only)

g. Total number of persons from the target population/community that completed M groups(CLI only)

h. Total number of peer advocates/opinion leaders/core group members who completed training (CLI only)

i. Total number of risk reduction conversations (informal, outreach, one-on-one) that occurred (CLI only)

j. Total number of risk reduction messaging/educational materials distributed in media campaigns (CLI only)

k. Total number of formal outreach/social events conducted (CLI only)

3. Describe successes, challenges, and/or barriers experienced while implementing your organization’s strategies and activities funded in year 2 and any lessons learned.

SECTION VI: CONDOM DISTRIBUTION

1. Describe the structure of your organization’s condom distribution program component, whether or not PS15-1502 funds are used. Click here to enter text.

a. If condoms were not purchased with PS15-1502 funds, please indicate your funding source. Click here to enter text.

2. If established condom distribution objectives are not on target to be met by the end of the project period (July 1, 2016 - June 30, 2017), what adjustments will your organization make to meet the established objectives? Click here to enter text.

3. Provide information for the condom distribution component of your organization’s PS15-1502 program: (Complete Appendix Table C1)

a. Total number of condoms purchased with PS15-1502 funds, if applicable

b. Total number of condoms distributed through program activities for HIV-positive persons

c. Total number of condoms distributed through program activities for high-risk HIV-negative persons and persons with unknown HIV status

d. Type of venues where condoms were distributed

e. Total number of condoms distributed through PS15-1502 program activities

SECTION VII: MONITORING AND EVALUATION REQUIREMENTS (M&E)

1. Describe your organization’s monitoring & evaluation, data collection & reporting, and quality assurance activities that were implemented during the reporting period (July 1, 2016 - December 31, 2016). Click here to enter text.

2. Describe successes, challenges, and/or barriers experienced with your organization’s monitoring & evaluation, data collection & reporting, and quality assurance activities including EvaluationWeb during the reporting period and the lessons learned to address the challenges and inform future M&E efforts.

Successes: Click here to enter text.

Challenges/Barriers: Click here to enter text.

Lessons Learned: Click here to enter text.

3. Please describe proposed changes to your monitoring & evaluation, data collection & reporting, and quality assurance activities for Year 3 (July 1, 2017 - June 30, 2018). Click here to enter text.

4. As part of your organization’s HIV prevention program data security and confidentiality requirements, community-based organizations (CBOs) funded by PS15-1502 should comply with the National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention’s (NCHHSTP) Data Security and Confidentiality Guidelines for HIV, Viral Hepatitis, Sexually Transmitted Disease, and Tuberculosis Programs (2011). All standards included in the NCHHSTP Data Security and Confidentiality Guidelines should be implemented for HIV prevention grantees funded by FOA PS15-1502, unless otherwise justified. A separate memorandum of understanding (MOU) and rules of behavior (ROB) for data security and confidentiality will no longer need to be submitted for 2015. Rather, a “Certification of Compliance” (see Appendix E) must be signed by an overall responsible party or parties (OPR) and submitted annually to the PPB Project Officer at the same time the APR is submitted to the Office of Grant Services. For information on the new data security guidelines, please refer to http://www.cdc.gov/nchhstp/programintegration/docs/PCSIDataSecurityGuidelines.pdf.

NOTE: The “Certification of Compliance” must be signed and emailed to the PS15-1502@cdc.gov mailbox with a courtesy copy to your PPB Project Officer.

SECTION VIII: HIV AND ORGANIZATIONAL PLANNING

1. Describe the HIV Planning Group (HPG) activities your organization was involved in during the reporting period (July 1, 2016 - December 31, 2016). Click here to enter text.

2. If your organization did not participate in HPG activities, describe the changes that will be made to support increased participation in HPG activities. Click here to enter text.

SECTION IX: KEY PERSONNEL/BOARD GOVERNANCE

1. Describe any key organizational changes that occurred during the reporting period (July 1, 2016 - December 31, 2016). Key changes include, but are not limited to, changes in board composition, key staff (e.g., administrative [Executive Director] and program [Program Manager]), and organization location. If no changes were made, please state “no changes made.” Click here to enter text.

2. Did the organization’s Board of Directors meet on a regular basis during the reporting period (July 1, 2016 - December 31, 2016)? ☐ Yes ☐ No

a. If yes, what is the meeting frequency of the full Board of Directors? Click here to enter text.

b. If no, please explain. Click here to enter text.

c. Describe the Board of Directors involvement with the progress of the PS15-1502 program.

SECTION X: CAPACITY BUILDING ASSISTANCE (CBA)/TECHNICAL ASSISTANCE (TA)

1. Did your organization access CBA and/or TA services during the reporting period (July 1, 2016 - December 31, 2016)? ☐ Yes ☐ No

a. If yes, please provide the following:

i. Type of CBA and/or TA received: Click here to enter text.

ii. Were you satisfied with the CBA/TA provided? ☐ Yes ☐ No

a. If no, please explain (be specific): Click here to enter text.

2. List any CBA/TA accessed or requested for the remainder of the reporting period (January 1, 2017 - June 30, 2017). Click here to enter text.

SECTION XI: GENERAL COMMENTS

1. Please describe any best practices or lessons learned that were implemented during the reporting period that have not already been previously discussed. Click here to enter text.

2. Please provide any additional information regarding your PS15-1502 funded program that you think is important for CDC to know. Click here to enter text.

SECTION XII: ASSURANCES OF COMPLIANCE

1. Does your organization have a disclaimer notice posted on your website regarding the content material?

☐ Yes ☐ No Submit the completed forms for all materials used or proposed for use during the reporting period of July 1, 2016 - December 31, 2016. Attach the following Assurance of Compliance Forms to the application through the “Mandatory Documents” section of the “Grant Application” page. Select “Other Attachments Form” and attach as a PDF file. (See Appendix F for template).

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