WW Workplan Template Continuation Application Yr 3 FINAL 01.22.15.pdf

WISEWOMAN Work Plan Year 3 Page 1 of 64

Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN): Grantee Work Plan July 1, 2015 – June 30, 2016

Awardee:

Awardee Number:

Work Plan Instructions:

Please use the following template to complete the work plan for the upcoming budget year. Completed templates should be submitted to your CDC Project Officer by the deadline posted on grants.gov. For any questions and/or assistance with completing this work plan please contact your CDC Project Officer.

Grantees should refer to the guidance “Instructions for Preparing an Annual Performance Report (APR), Catalog of Federal Domestic Assistance (CFDA): _93.094, Funding Opportunity Announcement (FOA) Number*: CDC-RFA-DP13-130203/CONT15” for additional information.

The template was created to provide guidance in the work plan development process. The work plan components include:

• 0 - Program Management

• 1 - Domain 1: Epidemiology and Surveillance

• 2 - Domain 2: Environmental Approaches

• 3 - Domain3: Health Systems

• 4 - Domain 4: Community-Clinical Linkages

• 5 - Evaluation

For all of the program components, grantees will be able to provide information on their project goals, annual objectives, and activities. In the Evaluation component, grantees are asked to develop a plan for evaluating three (3) program activities - one of which can be selected by the grantee. This work plan will serve as the baseline during annual performance reporting, when you will be asked for an update on progress made

WISEWOMAN Work Plan Year 3 Page 2 of 64 towards stated goals, objectives and activities. For that reason it will be important to provide information where applicable that is Specific, Measurable, Achievable, Realistic and Time-phased, also known as SMART.

Project Goals:

Project goals are typically broad statements that provide overall direction for the project. The work plan template allows grantees to write in up to three (3) goals per each component listed above with the exception of the Evaluation component. An example may be to “Maximize the use, collection and analysis of data to ensure that the work of the program is utilized in program planning, analysis, evaluation and surveillance projects.”

Annual Objectives:

Objectives represent the steps a program will take to achieve component-specific goals. Each objective must be related to and contribute directly to the accomplishment of the stated goals. In addition to the pre-populated objectives required by the program, grantees have the option to write in additional objectives. For each objective the grantee should indicate the person responsible and accountable for completing the objective, as well as the plan for monitoring the objective.

Planned Activities:

Activities describe what a grantee plans to do to bring about the intended objectives for the project, such as trainings, educational sessions, surveying, etc. There is a maximum of six activities for the Program Management and Domains 1 and 2, and nine activities for Domains 3 and 4.

A grantee is able to have less than the maximum allotted activities. For each activity the grantee should provide the start and end dates, as well as list any collaborating partners if applicable. The drop-down list of collaborating partners is specific to each domain. If a partner is not listed, the grantee may select “Other”.

Spell Check: Before submitting the completed work plan to your Project Officer, please run a spell check by clicking the button below.

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WISEWOMAN Work Plan Year 3 Page 3 of 64

Program Management Goals

Goal 1:

Goal 2:

Goal 3:

Annual Objective 0.1: Ensure that the staff number is adequate and appropriately skilled to conduct successful program implementation.

Person Responsible:

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Timeframe Activity 0.1.1: Start: Select Date

End: Select Date Activity 0.1.2: Start: Select Date

End: Select Date Activity 0.1.3: Start: Select Date

End: Select Date Activity 0.1.4: Start: Select Date

End: Select Date Activity 0.1.5: Start: Select Date

End: Select Date Activity 0.1.6: Start: Select Date

End: Select Date

WISEWOMAN Work Plan Year 3 Page 4 of 64

Annual Objective 0.2: 100% of internal WISEWOMAN personnel develop and maintain skills needed for successful program implementation through participation in professional development opportunities.

Person Responsible:

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Timeframe

Activity 0.2.1: Start: Select Date

End: Select Date Activity 0.2.2: Start: Select Date

End: Select Date Activity 0.2.3: Start: Select Date

End: Select Date Activity 0.2.4: Start: Select Date

End: Select Date Activity 0.2.5: Start: Select Date

End: Select Date Activity 0.2.6: Start: Select Date

Annual Objective 0.3: Ensure that WISEWOMAN providers and coaching staff have needed skills for effective program implementation by providing professional development.

Person Responsible:

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

WISEWOMAN Work Plan Year 3 Page 5 of 64

Frequency of Monitoring: Select Frequency

Planned Activities Timeframe Activity 0.3.1: Start: Select Date

End: Select Date Activity 0.3.2: Start: Select Date

End: Select Date Activity 0.3.3: Start: Select Date

End: Select Date Activity 0.3.4: Start: Select Date

End: Select Date Activity 0.3.5: Start: Select Date

End: Select Date Activity 0.3.6: Start: Select Date

Annual Objective 0.4: Adhere to all fiscal requirements of WISEWOMAN (e.g., match, Federal Financial Report, accurate budget).

Person Responsible:

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Timeframe Activity 0.4.1: Start: Select Date

End: Select Date Activity 0.4.2: Start: Select Date

Activity 0.4.3: Start: Select Date

WISEWOMAN Work Plan Year 3 Page 6 of 64

Planned Activities Timeframe

End: Select Date Activity 0.4.4: Start: Select Date

End: Select Date Activity 0.4.5: Start: Select Date

End: Select Date Activity 0.4.6: Start: Select Date

Annual Objective 0.5: 100% of contracts are executed in a timely manner and monitored.

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Timeframe Activity 0.5.1: Start: Select Date

End: Select Date Activity 0.5.2: Start: Select Date

End: Select Date Activity 0.5.3: Start: Select Date

End: Select Date Activity 0.5.4: Start: Select Date

End: Select Date Activity 0.5.5: Start: Select Date

Activity 0.5.6: Start: Select Date

WISEWOMAN Work Plan Year 3 Page 7 of 64

Planned Activities Timeframe

Annual Objective 0.6: Conduct quality assurance on all WISEWOMAN activities and revise processes as indicated.

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Timeframe Activity 0.6.1: Start: Select Date

End: Select Date Activity 0.6.2: Start: Select Date

End: Select Date Activity 0.6.3: Start: Select Date

End: Select Date Activity 0.6.4: Start: Select Date

End: Select Date Activity 0.6.5: Start: Select Date

End: Select Date Activity 0.6.6: Start: Select Date

Annual Objective 0.7:

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

WISEWOMAN Work Plan Year 3 Page 8 of 64

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Timeframe Activity 0.7.1: Start: Select Date

End: Select Date Activity 0.7.2: Start: Select Date

End: Select Date Activity 0.7.3: Start: Select Date

End: Select Date Activity 0.7.4: Start: Select Date

End: Select Date Activity 0.7.5: Start: Select Date

End: Select Date Activity 0.7.6: Start: Select Date

WISEWOMAN Work Plan Year 3 Page 9 of 64

Domain 1: Epidemiology and Surveillance: Gather, analyze, and disseminate data and information and conduct evaluation to inform, prioritize, deliver, and monitor programs and population health.

Goals

Goal 1:

Goal 2:

Goal 3:

Annual Objective 1.1: Maintain a data collection system that collects all required MDEs.

Person Responsible:

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 1.1.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 1.1.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 1.1.3: Partner 1: Select One

Partner 2: Select One

Start: Select Date

WISEWOMAN Work Plan Year 3 Page 10 of 64

Planned Activities Select all collaborating partners for each activity Timeframe Partner 3: Select One

Other (if applicable):

Activity 1.1.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 1.1.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 1.1.6: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Annual Objective 1.2: Submit minimum data element files on schedule and with no more than a 5% error rate. [PERFORMANCE MEASURE]

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 1.2.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

WISEWOMAN Work Plan Year 3 Page 11 of 64

Other (if applicable):

Activity 1.2.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 1.2.3: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 1.2.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 1.2.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 1.2.6: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Annual Objective 1.3: Use data reports for programmatic quality improvement.

WISEWOMAN Work Plan Year 3 Page 12 of 64

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 1.3.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 1.3.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 1.3.3: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 1.3.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 1.3.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 1.3.6: Partner 1: Select One

Partner 2: Select One

WISEWOMAN Work Plan Year 3 Page 13 of 64

Partner 3: Select One

Other (if applicable):

Annual Objective 1.4: Use existing surveillance data to identify cardiovascular risk factors and needs of population to inform program planning.

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 1.4.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 1.4.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 1.4.3: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 1.4.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

WISEWOMAN Work Plan Year 3 Page 14 of 64

Other (if applicable):

Activity 1.4.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 1.4.6: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Annual Objective 1.5:

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 1.5.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 1.5.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

WISEWOMAN Work Plan Year 3 Page 15 of 64

Activity 1.5.3: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 1.5.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 1.5.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 1.5.6: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

WISEWOMAN Work Plan Year 3 Page 16 of 64

Domain 2: Environmental Approaches: Promote health and support and reinforce healthful behaviors (statewide in schools, worksites, and communities).

Goals

Goal 1:

Goal 2:

Goal 3:

Annual Objective 2.1: Update and use community scans findings to support improvements in cardiovascular risk of participants.

Person Responsible:

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 2.1.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 2.1.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 2.1.3: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

WISEWOMAN Work Plan Year 3 Page 17 of 64

Activity 2.1.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 2.1.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 2.1.6: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Annual Objective 2.2: Increase options to reinforce healthful behaviors in the community by partnering with at least 2 organizations.

[PERFORMANCE MEASURE]

Person Responsible:

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 2.2.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

WISEWOMAN Work Plan Year 3 Page 18 of 64

Activity 2.2.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 2.2.3: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 2.2.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 2.2.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 2.2.6: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Annual Objective 2.3:

WISEWOMAN Work Plan Year 3 Page 19 of 64

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 2.3.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 2.3.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 2.3.3: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 2.3.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 2.3.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 2.3.6: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

WISEWOMAN Work Plan Year 3 Page 20 of 64

WISEWOMAN Work Plan Year 3 Page 21 of 64

Domain 3: Health Systems: Improve the effective delivery and use of clinical and other preventive services in order to prevent disease, detect diseases early, and reduce or eliminate risk factors and mitigate or manage complications.

Goals

Goal 1:

Goal 2:

Goal 3:

Annual Objective 3.1: Improve WISEWOMAN providers’ use of systems to optimize control of hypertension.

Person Responsible:

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 3.1.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.1.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.1.3: Partner 1: Select One

Partner 2: Select One

WISEWOMAN Work Plan Year 3 Page 22 of 64

Partner 3: Select One

Other (if applicable):

Activity 3.1.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.1.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.1.6: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.1.7: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.1.8: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.1.9: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

WISEWOMAN Work Plan Year 3 Page 23 of 64

Annual Objective 3.2: Meet or exceed 95% of CDC approved screening goal. [PERFORMANCE MEASURE]

Target # to be Screened:

Person Responsible:

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 3.2.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.2.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.2.3: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.2.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

WISEWOMAN Work Plan Year 3 Page 24 of 64

Other (if applicable):

Activity 3.2.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.2.6: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.2.7: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.2.8: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.2.9: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Annual Objective 3.3: Follow-up with 100% of women with abnormal blood pressure values. [PERFORMANCE MEASURE]

WISEWOMAN Work Plan Year 3 Page 25 of 64

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 3.3.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.3.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.3.3: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.3.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.3.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.3.6: Partner 1: Select One

Partner 2: Select One

WISEWOMAN Work Plan Year 3 Page 26 of 64

Partner 3: Select One

Other (if applicable):

Activity 3.3.7: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.3.8: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.3.9: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Annual Objective 3.4: Deliver quality risk reduction counseling to 100% of women screened. [PERFORMANCE MEASURE]

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 3.4.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

WISEWOMAN Work Plan Year 3 Page 27 of 64

Other (if applicable):

Activity 3.4.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.4.3: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.4.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.4.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.4.6: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.4.7: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

WISEWOMAN Work Plan Year 3 Page 28 of 64

Activity 3.4.8: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.4.9: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Annual Objective 3.5: Assure systems in place for medication access, support and follow-up for WISEWOMAN participants.

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 3.5.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.5.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

Activity 3.5.3: Partner 1: Select One Start: Select Date

WISEWOMAN Work Plan Year 3 Page 29 of 64

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

End: Select Date

Activity 3.5.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.5.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.5.6: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.5.7: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.5.8: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.5.9: Partner 1: Select One

Partner 2: Select One

WISEWOMAN Work Plan Year 3 Page 30 of 64

Annual Objective 3.6: Assure all participants are linked to tailored healthy behavior support options (e.g. LSP/health coaching/tobacco cessation).

Person Responsible:

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 3.6.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.6.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.6.3: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.6.4: Partner 1: Select One

Partner 2: Select One

WISEWOMAN Work Plan Year 3 Page 31 of 64

Partner 3: Select One

Other (if applicable):

Activity 3.6.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.6.6: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.6.7: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.6.8: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.6.9: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Annual Objective 3.7:

WISEWOMAN Work Plan Year 3 Page 32 of 64

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 3.7.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.7.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.7.3: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.7.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.7.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

Activity 3.7.6: Partner 1: Select One Start: Select Date

WISEWOMAN Work Plan Year 3 Page 33 of 64

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

End: Select Date

Activity 3.7.7: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.7.8: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.7.9: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Annual Objective 3.8:

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 3.8.1: Partner 1: Select One

Partner 2: Select One

WISEWOMAN Work Plan Year 3 Page 34 of 64

Partner 3: Select One

Other (if applicable):

Activity 3.8.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.8.3: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.8.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.8.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.8.6: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.8.7: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

WISEWOMAN Work Plan Year 3 Page 35 of 64

Other (if applicable):

Activity 3.8.8: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 3.8.9: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

WISEWOMAN Work Plan Year 3 Page 36 of 64

Domain 4: Community-Clinical Linkages: Ensure that communities support and clinics refer patients to programs that improve management of chronic conditions. Such interventions ensure those with or at high risk for chronic diseases have access to quality community resources to best manage their conditions or disease risk.

Goals

Goal 1:

Goal 2:

Goal 3:

Annual Objective 4.1: Assure approved LSP/coaching programs are implemented with fidelity.

Person Responsible:

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 4.1.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.1.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

Activity 4.1.3: Partner 1: Select One Start: Select Date

WISEWOMAN Work Plan Year 3 Page 37 of 64

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

End: Select Date

Activity 4.1.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.1.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.1.6: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.1.7: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.1.8: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.1.9: Partner 1: Select One

Partner 2: Select One

WISEWOMAN Work Plan Year 3 Page 38 of 64

Annual Objective 4.2: Assure all participants have access to at least one healthy behavior support option.

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 4.2.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.2.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.2.3: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.2.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

WISEWOMAN Work Plan Year 3 Page 39 of 64

Other (if applicable):

Activity 4.2.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.2.6: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.2.7: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.2.8: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.2.9: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Annual Objective 4.3: Assure 80% of WISEWOMAN participants referred to a lifestyle program or health coaching attend at least one session.

[PERFORMANCE MEASURE]

WISEWOMAN Work Plan Year 3 Page 40 of 64

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 4.3.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.3.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.3.3: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.3.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.3.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

Activity 4.3.6: Partner 1: Select One Start: Select Date

WISEWOMAN Work Plan Year 3 Page 41 of 64

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

End: Select Date

Activity 4.3.7: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.3.8: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.3.9: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Annual Objective 4.4: Assure 60% of WISEWOMAN participants who participate in a lifestyle program or health coaching complete the program (as defined by approved template). [PERFORMANCE MEASURE]

Person Responsible:

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Activity 4.4.1: Partner 1: Select One Start: Select Date

WISEWOMAN Work Plan Year 3 Page 42 of 64

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

End: Select Date

Activity 4.4.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.4.3: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.4.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.4.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.4.6: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.4.7: Partner 1: Select One

Partner 2: Select One

WISEWOMAN Work Plan Year 3 Page 43 of 64

Partner 3: Select One

Other (if applicable):

Activity 4.4.8: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.4.9: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Annual Objective 4.5: Assure tobacco cessation referral systems to state quit lines and/or community resources are in place and referral outcomes are documented and can be conveyed to CDC and WISEWOMAN providers.

Person Responsible:

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 4.5.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.5.2: Partner 1: Select One

Partner 2: Select One

WISEWOMAN Work Plan Year 3 Page 44 of 64

Partner 3: Select One

Other (if applicable):

Activity 4.5.3: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.5.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.5.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.5.6: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.5.7: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.5.8: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

WISEWOMAN Work Plan Year 3 Page 45 of 64

Other (if applicable):

Activity 4.5.9: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Annual Objective 4.6: Assess uptake of healthy behavior support options to assure WISEWOMAN participants’ needs are met.

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 4.6.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.6.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.6.3: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

WISEWOMAN Work Plan Year 3 Page 46 of 64

Activity 4.6.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.6.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.6.6: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.6.7: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.6.8: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.6.9: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

WISEWOMAN Work Plan Year 3 Page 47 of 64

Annual Objective 4.7: Assure required data follow-up questions are conducted for completed LSP and/or Health Coaching Programs within 4 weeks of completion

Person Responsible:

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 4.7.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.7.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.7.3: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.7.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.7.5: Partner 1: Select One

Partner 2: Select One

WISEWOMAN Work Plan Year 3 Page 48 of 64

Partner 3: Select One

Other (if applicable):

Activity 4.7. 6: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.7.7: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.7.8: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.7.9: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Annual Objective 4.8:

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

WISEWOMAN Work Plan Year 3 Page 49 of 64

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 4.8.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.8.2: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.8.3: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.8.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.8.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.8.6: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

WISEWOMAN Work Plan Year 3 Page 50 of 64

Activity 4.8.7: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.8.8: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.8.9: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Annual Objective 4.9:

Objective Monitoring Plan – Describe below the plan for monitoring the progress of the objective.

How will the objective be monitored?:

Data Source:

Frequency of Monitoring: Select Frequency

Planned Activities Select all collaborating partners for each activity Timeframe Activity 4.9.1: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

Activity 4.9.2: Partner 1: Select One Start: Select Date

WISEWOMAN Work Plan Year 3 Page 51 of 64

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

End: Select Date

Activity 4.9.3: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.9.4: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.9.5: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.9.6: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date

End: Select Date

Activity 4.9.7: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

Start: Select Date End: Select Date

Activity 4.9.8: Partner 1: Select One

Partner 2: Select One

WISEWOMAN Work Plan Year 3 Page 52 of 64

Partner 3: Select One

Other (if applicable):

Activity 4.9.9: Partner 1: Select One

Partner 2: Select One

Partner 3: Select One

Other (if applicable):

WISEWOMAN Work Plan Year 3 Page 53 of 64

Grantee Evaluation Plan Grantees should complete the evaluation plan template below for each of the following: 1) uncontrolled hypertension, 2) Health Coaching and/or Lifestyle Program, and 3) evaluation area of your choosing. A fourth evaluation area is optional.

Evaluation Area 1: Evaluation of efforts to address uncontrolled hypertension.

Note: According to the WISEWOMAN Technical Assistance Guidance document, grantees should work with their health care providers to establish standard protocols for follow-up of uncontrolled hypertension. The protocol will vary depending on the capacity of the health care facility, but at a minimum should include medication counseling. The protocol may include team-based care with pharmacists, nutritionists, nurse educators, community health workers or others. It may include use of electronic reporting and tracking of blood pressure trends, and self-measured blood pressure monitoring among other strategies. The aim is to help health care providers establish or strengthen practical methods to track and improve control of hypertension.

Brief Overview of Evaluation Area 1: Provide a brief description of what you plan to evaluate (i.e. intervention, activity component, and any contextual factors to address).

1a. Evaluation Question: Evaluation Type: Select One Person Responsible:

Indicator(s) A specific, observable, and measurable characteristic or change that shows progress toward achieving a specified outcome.

Source(s):

Select a source for each indictor.

Method:

How you will collect the data for this indicator?

Timing:

When you will collect the data for this indicator (i.e., start-end date and frequency)?

Select One Select One Select One

Data Analysis:

1b. Evaluation Question: Evaluation Type: Select One Person Responsible:

Indicator(s) A specific, observable, and measurable characteristic or change that shows progress toward achieving a specified outcome.

Source(s):

Select a source for each indictor.

Method:

How you will collect the data for this indicator?

Timing:

When you will collect the data for this indicator (i.e., start-end date and frequency)?

WISEWOMAN Work Plan Year 3 Page 54 of 64

Select One Select One Select One

Data Analysis:

1c. Evaluation Question: Evaluation Type: Select One Person Responsible:

Indicator(s) A specific, observable, and measurable characteristic or change that shows progress toward achieving a specified outcome.

Source(s):

Select a source for each indictor.

Method:

How you will collect the data for this indicator?

Timing:

When you will collect the data for this indicator (i.e., start-end date and frequency)?

Select One Select One Select One

Data Analysis:

1d. Evaluation Question: Evaluation Type: Select One Person Responsible:

Indicator(s) A specific, observable, and measurable characteristic or change that shows progress toward achieving a specified outcome.

Source(s):

Select a source for each indictor.

Method:

How you will collect the data for this indicator?

Timing:

When you will collect the data for this indicator (i.e., start-end date and frequency)?

Select One Select One Select One

Data Analysis:

1e. Evaluation Question: Evaluation Type: Select One Person Responsible:

WISEWOMAN Work Plan Year 3 Page 55 of 64

A specific, observable, and measurable characteristic or change that shows progress toward achieving a specified outcome.

Source(s):

Select a source for each indictor.

Method:

How you will collect the data for this indicator?

Timing:

When you will collect the data for this indicator (i.e., start-end date and frequency)?

Select One Select One Select One

Data Analysis:

1f. Focus the Evaluation Design for Evaluation Area 1: Describe the purpose of the evaluation, how you plan to use results for program improvement, and the process used for developing your evaluation questions.

1g. Evaluation Stakeholders and Primary Intended Users of the Evaluation for Evaluation Area 1: Describe individuals who have a stake in the evaluation and who will use the evaluation results.

Please include a brief description of how you have engaged the evaluation stakeholders.

1h. Communication/Dissemination Plan for Evaluation Area 1:

Describe your plans for communicating/disseminating your findings (i.e., distribution products, channels, and timeline) and the ways in which this evaluation will be used in your overall program.

Annual Evaluation Objective for Evaluation Area 1:

Planned Evaluation Activities List below the planned evaluation activities for the coming year Timeframe

Activity 5.1.1: Start: Select Date

End: Select Date

Activity 5.1.2: Start: Select Date

WISEWOMAN Work Plan Year 3 Page 56 of 64

Activity 5.1.3: Start: Select Date

End: Select Date

Evaluation Area 2: Evaluation of the…