CSPECE Quantitative Form

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Overview

Capacity
Programmatic Measures

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Sheet 1: Capacity

Attachment 4g. CSPECE Quantitative Form
CSPECE Quantitative Form									END
ATSDR estimates the average public reporting burden for this collection of information as 15 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-0057).
General Instructions: Complete all applicable fields in "Capacity" and "Programmatic Measures" tabs. Detailed instructions can be found in the "CSPECE Reporting Forms Guidance" document. Reporting measures and information to be completed should be applicable to most programs, however, due to the variations in CSPECE programs, a few fields may not be applicable to your program. Fields left blank will be assumed to have no associated activities completed during the reporting period and/or not applicable to your program. Refer to your work plan and Evaluation and Performance Measurement Plan to assure you are completing as many relevant fields as possible for the activities specified to be completed during the reporting period, and addressing justification for any incomplete activities in your Annual Performance Report (APR) narrative.
RP1=Reporting Period 1, December 2020	Basics
RP2=Reporting Period 2, December 2021	Please provide the following information for this report:
RP3=Reporting Period 3, December 2022	State:
RPF=Reporting Period Final, March 2022	Reporting Period:
	POC Name:
	POC Email:
	Phase
	Please indicate which phase(s) you were in during the reporting period. If you completed activities in multiple phases, please select ALL applicable phases for the reporting period.
	Reporting Period 1 Phase(s):
	Reporting Period 2 Phase(s):
	Reporting Period 3 Phase(s):
	Final Report Period Phase(s):
Partnerships (Entities that receive no direct ATSDR funding, but are involved in CSPECE planning or programming)
Provide a list of your program's partners and information as it relates to their role and contributions to your program.
Partner Name	Partner Category (select all that apply)	Program role (select all that apply)	Advisory Committee Member	Partnership Confirmation	Jurisdiction	Partner in RP1?	Partner in RP2?	Partner in RP3?	Partner in RPF?
Example: Licensing Agency ABC	Licensing	Landscape assessment, Data identification, Outreach	Yes	Email confirmation	State	Yes	Yes	Yes	Yes
Data
Provide the data sources identified for inclusion in screening, identifying ECEs, or describing the landscape of your state.
Data Source Name/Title	Data Category (select all that apply)	Data Use (select all that apply)	Data Source Agency	Data Source in RP1?	Data Source in RP2?	Data Source in RP3?	Data Source in RPF?
Example: EPA National Emissions Inventory Data	Air	Screening	EPA	No	No	Yes	Yes
Training/Education Sessions that APPLETREE staff completed
Please provide information on the trainings or education sessions that APPLETREE staff have attended that are relevant to CSPECE.
Training name	Purpose (1 sentence max)	Training Source	Nationally available?	Length in hours	# staff trained	Date Completed	URL to access training information
Example: Fundamentals of GIS	Learn basics of mapping	Coursera	Yes	20	1	3/01/19-3/31/19	https://www.coursera.org/learn/gis?specialization=gis
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Sheet 2: Programmatic Measures

CSPECE Reporting Form

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ATSDR estimates the average public reporting burden for this collection of information as 15 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-xxxx).

General Instructions: Complete all applicable fields in "Capacity" and "Programmatic Measures" tabs. Detailed instructions can be found in the "CSPECE Reporting Forms Guidance" document. Reporting measures and information to be completed should be applicable to most programs, however, due to the variations in CSPECE programs, a few fields may not be applicable to your program. Fields left blank will be assumed to have no associated activities completed during the reporting period and/or not applicable to your program. Refer to your work plan and Evaluation and Performance Measurement Plan to assure you are completing as many relevant fields as possible for the activities specified to be completed during the reporting period, and addressing justification for any incomplete activities in your Annual Report narrative.

RP1=Reporting Period 1, December 2020

RP2=Reporting Period 2, December 2021

RP3=Reporting Period 3, December 2022

RPF=Reporting Period Final, March 2022

Education Measures: Training and Direct Education

Provide details on the trainings and direct education your program provided and the outputs of that education. This section should only include direct education, which is education in which the participant is expected to be actively engaged and should be delivered by an instructor. This can be formal trainings or one-on-one education/consultations.

RP1

RP2

RP3

RPF

Complete in Reporting Period 1 and Update as Necessary

Training/educational intervention name

# of trainings delivered

# of people educated

# children estimated to be reached

# of trainings delivered

# of people educated

# children estimated to be reached

# of trainings delivered

# of people educated

# children estimated to be reached

# of trainings delivered

# of people educated

# children estimated to be reached

Delivery Method

Implementation Stage

Target audience(s) (select all that apply)

Specify "other" target audience, if applicable:

Organization delivering the training

Intervention topic(s)

Who developed this training?

Example (Reporting Period 1): Environmental Hazards and your ECE

N/A

N/A

N/A

Online

Planning

Licensing/Inspection--State

N/a

Licensing agency

Understanding and using screening form

APPLETREE staff/team

Example (Reporting Period 3): CSPECE 101

0

0

0

2

50

750

3

100

1500

0

0

0

In-person

Implementation (0-<3 yrs)

Childcare providers

N/a

Non-profit partner ABC

Potential hazards common to ECEs

APPLETREE staff/team

Describe any estimation methods used in this section:

Education Measures: Materials, Indirect Education, and Outreach

Provide results on the number of education-related measures below:

Measures:

RP1

RP2

RP3

RPF

Number of hard copy materials created for outreach and education (e.g. fact sheets, flyers, pamphlets, brochures, paper newsletters etc.)

Number of electronic materials created for outreach and education (e.g. outreach materials such as email and electronic listserv/mass mailings, email newsletters, webpage, videos)

Number of materials created to build program infrastructure (SOPs, guidance manual, screening tools, webpage, etc.)

Number of people reached through hard copy material distribution

Number of people reached through electronic material distribution

Number of referrals to your program for education

Describe any estimation methods used in this section:

Policy, Systems, Environment (PSE) Measures

Provide results on the number of policy, systems, and or/environmental changes below. The narrative should include a qualitative description of these changes.

Performance Measures:

RP1

RP2

RP3

RPF

Number of PSE changes to support exposure prevention in ECEs

Number of total children estimated to be reached by PSE changes

Screening and Response Measures

Provide the results for all applicable performance measures for your program for the applicable reporting period:

Performance Measures:

RP1

RP2

RP3

RPF

Number of new licensed ECE programs opened in your state

Number of referrals to your program for screening

Number of estimated children at those referred sites above

Total: Number of sites referred to your program where potentially harmful exposures were occurring by pathway

Air: Number of referred sites with potential concern about air.

Water: Number of referred sites with potential concern about water.

Soil: Number of referred sites with potential concern about soil.

Other pathway: Number of referred sites with potential concern about another exposure pathway

Total: Number of sites screened

Air: Number of sites screened with potential concern about air.

Water: Number of sites screened with potential concern about water.

Soil: Number of sites screened with potential concern about soil.

Other pathway: Number of sites screened with potential concern about another exposure pathway

Number of ECE programs that accepted changes because of identified issues

Number of ECE programs that implemented recommended changes because of identified issues

Percentage of ECE programs that implemented recommended changes for a problematic site

Number of total children estimated to be reached by screening and response activities

Describe any estimation methods used in this section:

STATE-SPECIFIC PERFORMANCE MEASURES

Provide results on any measures that your program is tracking that are not included above:

Performance Measures:

RP1

RP2

RP3

RPF

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Describe any estimation methods used in this section:

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