Implementation of an Internet & Paper-Based Uniform Data Set for OMH-funded Activities

Appendix A

Data Items in Modified Uniform Data Set

UNIFORM DATA SET DATA ITEMS

(modifications highlighted)

Organization and Grant Information

DATA ITEM	RESPONSE
Organization Name
Grant Award Year	Before 2000 2000 2001 2002 2003 2004 2005 2006
Address
Phone/Fax
Contact Person/ Phone/Email
Organization Key Code
Organization Type	Faith-Based Organization Health Care Entity Institution of Higher Education: Hispanic-Serving Institution Institution of Higher Education: Historically Black College/University Institution of Higher Education: Other College/University Institution of Higher Education: Tribal College/University Minority-Serving Community-Based Organization: Health Focused Minority-Serving Community-Based Organization: Non-Health Focused National Minority-Serving Organization: Health Focused National Minority-Serving Organization: Non-Health Focused Public Institutions: Federal government agency Public Institutions: Local government agency Public Institutions: State government agency Public Institutions: Tribal Entity/Government Other
Select if reporting for multiple programs
Project Name
Project Director/ Email
Contact Person
Number of Positions (FTE's) Filled Using OMH Funding
Number of OMH-Funded Staff
Number of Consultants
Number of Individuals Paid on a Fee-For-Service Basis (e.g., interpreters paid per interpretation)
Number of New Staff Hired
If new staff were hired, were they:	Career staff Temporary staff
Number of Volunteers
Current Grant Year
Grant Number
Grant Type	Bilingual/Bicultural Service Demonstration Grant Program Community Programs to Improve Minority Health Health Disparities in Minority Health Program HIV/AIDS Cooperative Agreement HIV/AIDS Minority Health Coalition Demonstration Program Minority Health Coalition National Umbrella Cooperative Agreement Program Standard Cooperative Agreement Program State and Territorial Minority HIV/AIDS Demonstration Program State Partnership Grant Program to Improve Minority Health TACD Program for HIV/AIDS Services Other Grant/Contract
Total Annual Budget of Grantee Organization
OMH Funding
What additional funding did you receive to conduct your OMH-funded activities? Federal Funding (amount) State Funding (amount) Local Funding (amount) Private Funding (amount) In-Kind Contributions (amount)
How were your OMH funds distributed across health issues, activities, and demographic categories?	TABLE (for each category, enter)
Health Issues	Select Health Issue/ Enter Percent of Funding Used
Activities	Select Activity Modules/ Enter Percent of Funding Used
Race	Select Race/ Enter Percent of Funding Used
Ethnicity	Select Ethnicity/ Enter Percent of Funding Used
Gender	Select Gender/ Enter Percent of Funding Used
Age	Select Age/ Enter Percent of Funding Used
What other activities does your organization do that are not funded by OMH? (Note: This question only applies to grantees receiving funding through the State Partnership Initiative)	Enter Other Activities Funded and Funding Source
Were you involved with any partnerships or collaborating organizations as an essential part of the project?	TABLE (for each partnership, enter)
Name of Organization
Type of Agreement	Select: informal formal cooperative subcontract other
Type of Organization	Select
Role in Project Activity	Select: referral source provide service other
Postal zip codes where your project conducts its activities
Project Environment	Check all that apply: Urban Suburban Rural US-Mexican Border
Report Information
Project Name
Reporting Period
Report Narrative	TEXT /Attach Document
Activities Conducted	Select Activity Modules (checkbox)

Module 1 - Training and education for health professionals and community stakeholders

DATA ITEM	RESPONSE
Section I: Number of Individuals Trained and Sessions Conducted
Table 1-1: Number of Individuals Served and Demographics	Demographic Characteristics of Individuals Served
Section II: Number of Sessions Conducted
Type of Training	Cultural Competence Disease Management/Health Information Interpretation Language Health Disparities Education and Outreach Training Data and Evaluation Planning Other (specify)
Number of Sessions
Total Served in All Sessions
Length of Each Session in Hours
Evaluated?	Yes/No
Section III: Additional Training Information
What were the training topics?
Who attended your training/education sessions? (e.g., health care providers, community leaders, CBO staff member, etc…)
Section IV: Short-term Outcomes of Training and Education
For those trainings where trainee outcome was evaluated
Was it with	Pre and post-test Post-test only
What was evaluated (check all that apply)?	Attitudes Practices Knowledge Satisfaction Other
If Pre and Post Tests	TABLE (for each type of training, enter)
Type of Training	Cultural Competence Disease Management/Health Information Interpretation Language Health Disparities Education and Outreach Training Data and Evaluation Planning Other (specify)
Number of People who took Pre Tests
Number of People who took Post Tests
Number with Increase In Score from Pre- to Post-Test
Section V: Qualitative Impacts
Please describe how your trainings have impacted on three sample trainees. To fill out this section, you can draw from evaluation responses, conversations with or observations of trainees, your own notes, or your experience with trainees

Module 2 - Language interpretation

DATA ITEM	RESPONSE
Section I: Number of Individuals Served
Table 2-1: Number of Individuals Served and Demographics	Demographic Characteristics of Individuals Served
Section II: Sessions Conducted and Short-term Outcomes
1. Please enter the total number of interpretations provided by language and the percentage of clients that received a follow-up health/medical referral or assessment as a result of language interpretation.	TABLE (for each language, enter)
Language	Select from list
Total Interpretations
Total Clients Served
Total Providers Served
Number Receiving Referral/Assessment
2. How many clients accessed services as a result of your language interpretation services?
3. What was the average duration of each session of language interpretation?	hour(s)
4. What was the average amount of preparation or other additional time (e.g., transportation time, waiting room time, etc.) per session?	hour(s)
5. Did you translate any materials as part of the service you provided?	Yes/No
For each language, enter total number of materials
6. Please list the kinds of materials you translated
7. Did you provide any simultaneous translation for group sessions or meetings?	Yes/No
If yes, for each language, enter:
Number of Sessions
Approximate Number of People Per Session
Section III: Qualitative Impacts
1. Please describe how the interpretations you provide have impacted on three sample clients. To fill out this section, you can draw from client evaluation responses, conversations with or observations of clients, notes, or your experience with clients.

Module 3 - Target population health education and outreach

DATA ITEM	RESPONSE
Section I: Number of Individuals Served and Sessions Conducted
Table 3-1: Number of Individuals Served and Demographics	Demographic Characteristics of Individuals Served
Table 3-2: Number of Sessions Conducted	TABLE (For each type of session, enter)
Type of Session	Single Session Individual Education Single Session Group Education Multiple Session Individual Education Multiple Session Group Education
Number Of Sessions
Number Of Sessions Per Course
Number Of Courses Conducted
Evaluated?	Yes/No
Section II: Additional Information
1. What were the education session topics?
For Individual Education
For Group Education
2. During the course of your health education and outreach activities, were any clients given referrals to medical, mental health, or other services?	Yes/No
If yes, how many referrals were given?
How many of these clients accessed services as a result of referrals?
Section III: Health Fairs and Other Events
1. Did you conduct or participate in any health fairs during this reporting period?	Yes/No
If YES, what is the total number of health fairs conducted/participated in?
	TABLE (for each health fair enter)
Target Population
Health Issue(s)
Approximate Number Served
Date: (MM/DD/YYYY)
2. Did you conduct or participate in any type of educational event other than those reported above (examples, performing arts, rallies, walks/runs, benefit events)?	Yes/No
If YES, what is the total number of other events conducted/participated in?
	TABLE (for each other event enter)
Event Type
Target Population
Health Issue(s)
Approximate Number Served
Date: (MM/DD/YYYY)
Section IV: Short-term Outcomes of Health Education and Outreach
For those education sessions where trainee outcome was evaluated
Was it with	Pre and post-test Post-test only
What was evaluated (check all that apply)?	Attitudes Practices Knowledge Satisfaction Other
If Pre and Post Tests	TABLE (for each type of training, enter)
Type of Education	Single Session Individual Education Single Session Group Education Multiple Session Individual Education Multiple Session Group Education
Number of People who took Pre-Tests
Number of People who took Post-Tests
Number with Increase In Score from Pre- to Post-Test
Section V: Qualitative Impacts
1. Please describe how your health education and outreach activities have impacted on three sample clients. To fill out this section, you can draw from evaluation responses, conversations with or observations of clients or members of the target population, your own notes, or your experience with clients.

Module 4 - Materials development and dissemination

DATA ITEM	RESPONSE
Section I: Number of Individuals Trained and Sessions Conducted
Table 4-1: Number of Individuals Served and Demographics	Demographic Characteristics of Individuals Served
Table 4-2: Materials Development	TABLE (For each material developed, enter)
Type of Material	Print health educational material Video/Audio health educational material Directory of services or other resources Public service announcement/broadcast Report Curriculum or Training Manual Fact sheet Sample guidelines/instructions Program information and/or application Educational Web site Other
Source	Developed Adapted
Target Audience
Health Issue
Language
Number Developed
If you developed a Web site or disseminated materials on the Web:
How many Web site hits did you have?
How many materials were downloaded from your Web site?
Section II: Qualitative Impacts
1. For each type of material you developed/adapted, please describe how the language and graphics are appropriate for the intended targeted audience and how you determined this.
2. What kinds of organizations and/or individuals received, heard or saw the materials you developed?

Module 5 - Screening and referral

DATA ITEM	RESPONSE
Section I: Number of Individuals Served and Sessions Conducted
Table 5-1: Number of Individuals Served and Demographics	Demographic Characteristics of Individuals Served
Table 5-2: Number of Screenings Conducted	TABLE (for each type of screening, enter)
Type of Screening	Cancer Cardiovascular disease Diabetes HIV Mental health Other Respiratory disease STDs Substance abuse Tuberculosis
Number of Screenings
Screening Site	Clinic Mobile unit
Table 5-3: Number of Referrals Given	TABLE (for each type of referral, enter)
Type of Referral	Further testing Medical services Other
Number of Referrals
Number of Successful Referrals
Section II: Qualitative Impacts
1. Please describe how your work providing screenings and referrals has impacted on three sample clients. To fill out this section, you can draw from client evaluation responses, conversations with or observations of project clients, notes, or your experience with clients.

Module 6 - Case Management

DATA ITEM	RESPONSE
Section I: Number of Individuals Served
Table 6-1: Demographic Characteristics of Individuals	Demographic Characteristics of Individuals Served
Table 6-2: Number and Type of Case Management Contacts (With Clients)
Total Number of Case Management Contacts: In-Person
Total Number of Case Management Contacts: By Telephone
Table 6-3: Number of Clients Receiving Services Through Case Management By Type of Service
Type of Service	Nutrition Transportation Medication Medical Check-up Benefits Counseling Housing Assistance Family Mental Health Counseling Individual Mental Health Counseling Testing/Screening and Counseling Job Placement/Income Support Other
Number of Clients Receiving Services
Section II: Qualitative Impacts
1. Please describe how your case management activities have impacted on three sample clients. To fill out this section, you can draw from (non-confidential) case notes, client evaluation responses, conversations with or observations of clients, other notes, or your experience with clients.

Module 7 - Wellness and exercise activities

DATA ITEM	RESPONSE
Section I: Number of Individuals Served
Table 7-1: Demographic Characteristics of Individuals Served	Demographic Characteristics of Individuals Served
Table 7-2: Number of Sessions Conducted
Type of Class	Diet/Food Exercise Other Stress Reduction
Total Number of Sessions
Average Number of Participants Per Session
How many individuals received individual physical/wellness training?
Section II: Short-term Impacts
1. Were the wellness/exercise participants evaluated using pre-post tests or screenings?	Yes/No
If Yes	TABLE (for each activity enter)
Type of Wellness Activity	Diet/Food Exercise Other Stress Reduction
Evaluation Method	Blood glucose test Blood pressure Cholesterol test Fitness test Weight/BMI Other
Number of People Taking Pre-Test
Number of People Taking Post-Test
Number of People with Improved Score From Pre- to Post-Tests
Section III: Qualitative Impacts
1. Please describe how your wellness activities have impacted on three sample clients. To fill out this section, you can draw from client evaluation responses, conversations with or observations of clients, notes, or your experience with clients.

Module 8 - Academic support/career preparation

DATA ITEM	RESPONSE
Section I: Number of Individuals Served
Table 8-1: Demographic Characteristics of Individuals Served	Demographic Characteristics of Individuals Served
Table 8-2: Number of Sessions Conducted	TABLE (for each type of session, enter)
Type of Activity	Individual Academic Support (school tutoring) Career Counseling Career Assessment Linkage to Resources Counseling Sessions Group Career Education Job Skills Training Career Mentoring Other (specify)
Total Number of Sessions
Average Number of Participants Per Session
Evaluated?	Yes/No
Table 8-3: Program Information
Type of Activity	Individual Academic Support (school tutoring) Career Counseling Career Assessment Linkage to Resources Counseling Sessions Group Career Education Job Skills Training Career Mentoring Other (specify)
Program Issue Addressed	Workforce Diversity Health Care Careers Other
Education Level of Participants	Elementary High School College Post-Graduate Professional Other
Number of Participants
Number of New Participants Recruited in this Reporting Period
Section II: Short-term Outcomes
Did any participants apply to or gain acceptance into medical school, other health service training programs, or programs in the health sciences?	Yes/No
If yes, how many individuals submitted applications?
How many applicants were accepted?
For those sessions where participant outcome was evaluated:
Was it with	Pre and post-test Post-test only
What was evaluated (check all that apply)?	Attitudes Practices Knowledge Satisfaction Other
If Pre and Post Tests	TABLE (for each type of session, enter)
Type of Activity	Individual Academic Support (school tutoring) Career Counseling Career Assessment Linkage to Resources Counseling Sessions Group Career Education Job Skills Training Career Mentoring Other (specify)
Number of People Who Took Pre-Tests
Number of People Who Took Post-Tests
Number of People Who Took STANDARDIZED Pre-Tests
Number of People Who Took STANDARDIZED Post-Tests
Number of People with Increase in Score From Pre- to Post-Tests
If standardized tests were used, please list the names of the test(s)
Section III: Qualitative Impacts
1. Please describe how your work in academic support/career preparation has impacted on three sample clients. To fill out this section, you can draw from client evaluation responses, feedback from teachers/school personnel, conversations with or observations of clients, notes, or your experience with clients.

Module 9 - Mentoring

DATA ITEM	RESPONSE
Section I: Number of Individuals Served
Table 9-1: Demographic Characteristics of Individuals Served	Demographic Characteristics of Individuals Served
Section II: Additional Information on Mentoring
1. What was the average length of the mentoring relationship (months)?
2. Typically, what was the frequency of face-to-face contact between mentors and mentees? times per week times per month
3. Typically, what was the frequency of telephone contact between mentors and mentees? times per week times per month
4. How many mentors were involved in your project activities?
Section III: Short-term Outcomes Mentoring
For those sessions where participant outcome was evaluated: (If no sessions were evaluated, skip to section III)
Was it with:	Pre and post-test Post-test only
What was evaluated (check all that apply)?	School Performance Bonding to School Prosocial Future Expectations Other
If Pre- and Post-Test
Number of People Who Took Pre- Tests
Number of People Who Took Post- Tests
Number of People Who Took STANDARDIZED Pre-Tests
Number of People Who Took STANDARDIZED Post-Tests
Number of People with Increase in Score From Pre- to Post-Tests
If standardized tests were used, please list the names of the test(s)
Section IV: Qualitative Impacts
1. Please describe how your work providing mentoring has impacted on three sample clients. To fill out this section, you can draw from client evaluation responses, feedback from teachers/school personnel, conversations with or observations of clients, notes, or your experience with clients.

Module 10 - Parent skills training/family counseling

DATA ITEM	RESPONSE
Section I: Number of Individuals Served
Table 10-1: Number of Individuals Served and Demographics	Demographic Characteristics of Individuals Served
Section II: Number of Sessions Conducted and Other Information
Total Number of Sessions Conducted: Individual Counseling
Total Number of Sessions Conducted: Group Session or Class
1. What was the average duration of the individual counseling? hours per session total sessions per person
2. What was the average duration of the group sessions? hours per session total sessions per person
Section III: Short-term Outcomes of Parent Skills Training/Family Counseling
For those sessions where participant outcome was evaluated: (If no sessions were evaluated, skip to section III)
Was it with:	Pre and post-test Post-test only
What was evaluated (check all that apply)?	Knowledge of Family Management Family Functioning Family Violence Other
If Pre- and Post-Test	TABLE (for each type of activity, enter)
Type of Activity	Group Sessions Individual Counseling Other (specify)
Number of People Who Took Pre- Tests
Number of People Who Took Post- Tests
Number of People Who Took STANDARDIZED Pre
Number of People Who Took STANDARDIZED Post
Number of People with Increase in Score From Pre
If standardized tests were used, please list the names of the test(s)
Section IV: Qualitative Impacts
1. Please describe how your parenting skills training/family counseling activities have impacted on three sample clients. To fill out this section, you can draw from client evaluation responses, (non-confidential) case notes, conversations with or observations of training clients, other notes, or your general experience with clients.

Module 11 - Self-esteem building

DATA ITEM	RESPONSE
Section I: Number of Individuals Served and Sessions Conducted
Table 11-1: Demographic Characteristics of Individuals Served	Demographic Characteristics of Individuals Served
Table 11-2: Total Number of Sessions Conducted by Type of Activity
Individual Sessions (Total)
Group Sessions or Classes (Total)
Evaluated?	Yes/No
1. What (self esteem) curricula were used (if curriculum was developed by project, write "self developed")?
Section II: Short-term Outcomes
For those sessions where participant outcome was evaluated: (If no sessions were evaluated, skip to section III)
Was it with:	Pre and post-test Post-test only
What was evaluated (check all that apply)?	Self-Esteem Self-Efficacy Future Expectations Other
	TABLE (for each type of activity, enter)
Type of Activity	Group Individual Other (specify)
Number of People Who Took Pre- Tests
Number of People Who Took Post- Tests
Number of People Who Took STANDARDIZED Pre- Tests
Number of People Who Took STANDARDIZED POST- Tests
Number of People with Increase in Score From Pre- to Post- Tests
1. If standardized tests are used, please list the name(s) of the test(s)?
Section III: Qualitative Impacts
1. Please describe how your work in self-esteem building has impacted on three sample clients. To fill out this section, you can draw from client evaluation responses, conversations with or observations of project clients, notes, or your experience with clients.

Module 12 - Cultural activities

DATA ITEM	RESPONSE
Section I: Number of Individuals Served
Table 12-1: Demographic Characteristics of Individuals Served	Demographic Characteristics of Individuals Served
Table 12-2: Number of Individuals Served and Type of Activity	TABLE (for each type of activity, enter)
Type of Activity	Experimental/Group Workshop Field Trip/Special Event Other (specify)
Total Number Served
Total Number of Events
Section II: Short-term Outcomes
For those activities where participant outcome was evaluated: (If no sessions were evaluated, skip to section III)
Was it with	Pre and post-test Post-test only
What was evaluated (check all that apply)?	Participant Knowledge of His/Her Culture Participant Knowledge of Cultural Diversity Other
	TABLE (for each type of activity, enter)
Type of Activity	Group Individual Other (specify)
Number of People Who Took Pre- Tests
Number of People Who Took Post- Tests
Number of People Who Took STANDARDIZED Pre- Tests
Number of People Who Took STANDARDIZED POST- Tests
Number of People with Increase in Score From Pre- to Post- Tests
If standardized tests were used, please list the names of the test(s)
Section III: Qualitative Impacts
1. Please describe how your cultural activities have impacted on three sample clients. To fill out this section, you can draw from client evaluation responses, conversations with or observations of project clients, notes, or your experience with clients.

Module 13 - Recreational sports

DATA ITEM	RESPONSE
Section I: Number of Individuals Served
Table 13-1: Demographic Characteristics of Individuals Served	Demographic Characteristics of Individuals Served
Total Number of Sessions Conducted by Type
Sports
Other Recreational
Section II: Short-term Outcomes
For those activities where participant outcome was evaluated: (If no sessions were evaluated, skip to section III)
Was it with	Pre and post-test Post-test only
What was evaluated (check all that apply)?	Self-Reported Involvement in Risk Behavior Other
If Pre- and Post-Tests,	TABLE (for each type of activity, enter)
Type of Activity	Sports Other Recreational
Number of People Who Took Pre- Tests
Number of People Who Took Post- Tests
Number of People Who Took STANDARDIZED Pre- Tests
Number of People Who Took STANDARDIZED POST- Tests
Number of People with Increase in Score From Pre- to Post- Tests
If standardized tests were used, please list the names of the test(s)

Module 14 - Crisis Intervention

DATA ITEM	RESPONSE
Section I: Number of Individuals Served
Table 14-1: Demographic Characteristics of Individuals Served	Demographic Characteristics of Individuals Served
Table 14-2: Number of Interventions	TABLE (for each type of intervention, enter)
Type of Intervention	Conflict Mediation Emergency Language Interpretation Housing (e.g., related to utilities, evictions) Legal Medical Other (please specify) Transportation
Total Number of Interventions by Type
Average Number of Participants Per Intervention
Section II: Short Term Outcomes	TABLE (for each type of intervention, enter)
Type of Intervention	Conflict Mediation Emergency Language Interpretation Housing (e.g., related to utilities, evictions) Legal Medical Other (please specify) Transportation
Number of Situations Resolved
Number of Situations Unresolved
Section III: Qualitative Impacts
1. Please describe how your work in crisis intervention has impacted on three sample clients. To fill out this section, you can draw from project client responses, conversations with or observations of clients, incident reports or notes, or your general experience with clients.

Module 15 - Conference planning and management

DATA ITEM	RESPONSE
If you have more than one contract for this activity, a separate module should be filled out for each contract. Are you are filling out more than one Module 15?	Yes/No
IF YES: Which one is this?	1 2 3 4 5
If Other, please list number:
What is the role of conferences/meetings with respect to your OMH contract, cooperative agreement, or grant?
For your OMH project, were you supposed to conduct (check one):	One conference/meeting One conference/meeting and evaluation More than one conference/meeting (number) More than one conference/meeting and evaluations (number)
As your only task, or as part of other project activities?	Only task Part of other activities
Please describe:
Section I: Number of Individuals Served and Sessions Conducted
Table 15-1: Number of Individuals Served and Demographics	Demographic Characteristics of Individuals Served
Table 15-2: Number Served by Type of Event	TABLE (for each type of event, enter)
Type of Event	Conference Expert or other panel Meeting Other
Total Number Attending all Events
Section II: Additional Conferences/Meetings Information
Table 15-3: Conference/Meeting Chronology and Type of Event
1. Please complete the following table for all conferences/meetings conducted (as part of your OMH contract, cooperative agreement or grant) during this reporting period	TABLE (for each event, enter)
Duration in Days
Conference Name
Date
Target Population
Health Issues
Type of Event	Conference Expert or other panel Meeting Other
Table 15-4: Number of Materials Developed/Disseminated (at Conferences/Meetings)	TABLE (for each material, enter)
Conference Name
Date
Type of Material
Number Developed	Brochure/Pamphlet Fact sheet Meeting packet Notebook Other
Total Number Distributed
1. Conference/Meeting Purpose and Topics Please identify the primary purpose of each conference/meeting and list the major topics presented by event	TABLE (for each event, enter)
Conference Name	Present information/education Promote organizational linkages and networking Planning and strategy Other
Primary Purpose
Topic
2. Conference/Meeting Collaborations Please complete the following table for the same events listed above. On this table, we are asking for information concerning partners or collaborators you may have had in conducting the conferences/meetings.	TABLE (for each event, enter)
Table 15-5: Conference/Meeting Collaborations
Conference Name
Collaboration?	Yes/No
Number of Partners
Type of Organizations	Select An Organization Type
Nature of Collaborations	Funding Materials Staff or volunteers Speakers/presenters Meeting space Meals Logistics assistance Other
Section III: Evaluation of Conferences/Meetings
1. Please complete the following table for the same events listed above. On this table, we are asking for information concerning evaluations you conducted for each conference/meeting	TABLE (for each event, enter)
Table 15-6: Evaluation
Conference Name
Evaluated?	Yes/No
Type of Evaluation	Satisfaction (with conference/meeting) Knowledge or skill gain Change in behavior or practices Other (please specify)
Conduct Follow up?	Yes/No
Type of Follow up	Change in behavior or practices Knowledge or skill gain Other
Follow up Method	Mail survey Other Telephone survey
Section IV: Qualitative Impacts
1. Please describe how your work in conference planning and management has impacted on three sample clients. To fill out this section, you can draw from client evaluation responses, feedback from event attendees, conversations with or observations of clients, notes, or your experience with clients.

Module 16 - Linkage-building/community coordination

DATA ITEM	RESPONSE
Section I: Process Information
1. Were you involved with any partnerships or collaborating organizations as an essential part of your OMH project?	Yes/No
If Yes, please describe	TABLE (for each partnership, enter)
Name of Organization
Type of Agreement	Informal Formal Cooperative Agreement Subcontract Other
Type of Organization	Select An Organization Type
Role in Grant Activity	referral source provide service co-sponsor programs/activities planning and/or evaluation other
Total Number of Meetings Conducted with that Organization
Total Number of Activities conducted with that Organization
Section II: Short-term Outcomes of Linkage-building and Community Coordination
1. How many NEW organizations have you formed linkages with over the past reporting period? Please list	TABLE (for each new linkage, enter)
Name of Organization
Type of Agreement	Informal Formal Cooperative Agreement Subcontract Other
Type of Organization	Select type of organization
Role in Grant Activity	referral source provide service co-sponsor programs/activities planning and/or evaluation other
2. Did you form any new coalitions or collaborations in the past reporting period? Please list	TABLE (for each new coalition, enter)
Name of Organization
Type of Agreement	Informal Formal Cooperative Agreement Subcontract Other
Type of Organization	Select type of organization
Role in Grant Activity	referral source provide service co-sponsor programs/activities planning and/or evaluation other
For those coalitions or collaborations you formed or participated in, how many times did they meet?
Were any of these collaborations part of ongoing task forces or committees?	Yes/No
If Yes, How many times did they meet?
Are there plans for this partnership to continue meeting?	Yes/No
If No, did the partnership complete its goals?	Yes/No
Section III: System Change Data
1. As a result of your work on linkage-building/community coordination, were any new polices or procedures implemented at the linked organizations?	Yes/No/N/A
If YES, please describe:
2. As a result of your work on linkage-building/community coordination, has the grantee or partner organization (or their staff) become part of a local/regional coalition, committee, or other policy-related body?	Yes/No
If Yes, please describe	TABLE (for each coalition, enter)
Name of Committee
Description of Task Force/Committee/Coalition
Types of Members
Other Information (IF APPLICABLE)
3. As a result of your work on linkage-building/community coordination did any local providers form task forces, committees, coalitions, or other groups in order to address health services provided to the target population(s)?	Yes/No
If YES, please describe	TABLE (for each task force, enter)
Name of Provider
Description of Task Force/Committee/Coalition
Types of Members
Other Information (IF APPLICABLE)
4. As a result of your work on linkage-building/community coordination, did any community organizations collaborate to increase services, obtain funds, or engage in other collaborative activities?	Yes/No/N/A
If YES, please describe
5. As a result of your work on linkage-building/community coordination, did the city, county or state initiate any changes in legislation or regulations regarding access to health care by your target community/ies?	Yes/No/N/A
If YES, please describe
6. As a result of your work on linkage-building/community coordination, did the city, county or state draft any policy statements or guidelines regarding access to health care by your target community/ies?	Yes/No/N/A
If YES, please describe:
Section IV: Qualitative Impacts
Please describe how your work in linkage building/community coordination has impacted on three sample clients (either individuals or organizations). To fill out this section you can draw from project client evaluation responses, conversations with or observations of clients, notes, or your general experience with clients

Module 17 – Technical assistance and organizational capacity building

DATA ITEM	RESPONSE
Section I: Number of Individuals Served and Sessions Conducted
Table 17-1: Number of Individuals Served	Demographic Characteristics of Individuals Served
Table 17-2: Organizations Served and TA Provided	TABLE (for each organization, enter)
Name of Organization
Type of Organization	Select An Organization Type
New / Existing	Existing New
TA Provided	Staff received health issue training Staff received program skills training Staff received training in fundraising Staff received leadership training Staff received MIS training Staff received fiscal management training Recommendations for new policies Staffing Recommendations for new technology or systems Board development Strategic planning for internal improvement Program planning and implementation Evaluation Other
Target Population
Table 17-3: Number of Activities Conducted	TABLE (for each organization, enter)
Type of Activity (TA)	Staff received health issue training Staff received program skills training Staff received training in fundraising Staff received leadership training Staff received MIS training Staff received fiscal management training Recommendations for new policies New staff hired Recommendations for new technology or systems Board development Strategic planning for internal improvement Planning Evaluation Other
Number of Times Activity Provided
Total Number Served
Section II: Short-Term Outcomes
1) As a result of your work on organizational capacity building: Were any new polices or procedures developed at client organizations?	Yes/No N/A
If YES, please describe
2. As a result of your work in this activity, were any new programs (e.g., HIV/AIDS education) implemented?	Yes/No
If YES, please describe
3. As a result of your work in this activity, were any new funding applications submitted (by client organizations)?	Yes/No N/A
If YES, please describe?	TABLE (for each funding source, enter)
Funding Source	Federal Government State/Local Government Private Foundation Other
Number of Applications Submitted
Number of Applications Funded
4. As a result of your work in this activity, were any new technologies or systems implemented?	Yes/No N/A
If YES, please describe.
Section III: Qualitative Impacts
Please describe three case examples of how your work in technical assistance and organizational capacity building has impacted on different, sample organizations, noting their situation and capacity before and after your assistance. To fill out this section you can draw from project client evaluation responses, conversations with or observations of clients, notes, or your general experience with clients.

Module 18 - Resource coordination

DATA ITEM	RESPONSE
Section I: Resources Provided to Organizations
Table 18-1: Resources Provided to Organizations		TABLE (for each activity, enter)
Organization Name
Organization Type		Select An Organization Type
Funding		Yes/No
Materials		Yes/No
Technology or Equipment		Yes/No
People		Yes/No
Other		Yes/No
1. Did you provide mini-grants to organizations as a project activity?		Yes/No
If Yes, please describe the recipient organization and the purpose of the grant in the space below.
2. Did you develop/maintain a Web site for the purpose of making information available to community organizations?		Yes/No
If Yes, please describe the Web site in the space below.

Module 19 – Planning and evaluation

DATA ITEM	RESPONSE
Section I: Basic Information on Planning and Evaluation
1. Which of the following methodologies were employed in your planning and evaluation activities (check all that apply)?	Focus groups Obtaining local health data Meetings Local/State reports Interviews with key informants Surveys Newspaper/media review Literature searches Other (Specify)
2. Did your planning and evaluation activities address specific health conditions?	Yes/No
If YES, which health conditions were addressed?
3. Did your planning and evaluation activities address specific populations?	Yes/No
If YES, which populations were addressed?
4. Which of the following areas were covered in your planning and evaluation activities? (Check all that apply)?	Barriers to accessing health care for target population Target population (health) behavior Cultural/linguistic training needs for area health provider/staff Target population health status Existence of culturally appropriate health education materials Target population knowledge/awareness Existence of culturally/linguistically competent health services Other (Specify)
4. What were the main findings or results of your planning and evaluation activities? Please summarize, but include all key findings.
5. Were data collected for planning purposes or to target resources?	Yes/No
If yes, please describe.
6. Did you implement any changes in the data collection (such as collecting new kinds of data or enhancing data technology) to improve internal data systems?	Yes/No
If yes, please describe.
7. Does your project address gaps or problems identified through your planning and evaluation activities?	Yes/No
If yes, please describe
8. Did you evaluate efforts funded under your grant?	Yes/No
If yes, please describe.
8a. Were your evaluation criteria related to goals or other targets in your strategic plan?	Yes/No
If yes, please describe.