Kaiser Permanente Santa Clara: Grant Evaluation 2009/10

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2009-2010 FinalProgram Evaluation Report

Please complete the attached Program Evaluation for the goals that were identified in your original proposal.

If you need additional space, please attach extra pages adhering to the required format.

If you have any questions regarding this evaluation report, please contact Debbie Miguel, CommunityBenefit Specialist at .

Date: ______

Contact Information(For questions/comments on this Report)

Agency Name:
Address:
Name: / Title:
Email: / Phone #:
Name of the Program that was funded
Grant Amount received / $
Expended to Date / $
Program Start Date (with this funding)

List Kaiser Permanente employees or physicians involved with this program below:

Name / Title/ Kaiser Permanente Facility / Description of Activities / Hours of contribution

Please sign and submit the completed Program Evaluation Report and supplemental materialsby the deadlinesaddresses provided below:

  • 11-month Final Evaluation Report: August 2, 2010by noon.
  • Email the soft copy in Word format to email addresses below, and mail a hard copy to the mailing address below.

Ashlee Y. Oh, MPA

Community Benefit & Community Health Manager

Kaiser Permanente Santa Clara

Public Affairs Department

19000 Homestead Road, Building 1, Second Floor, Cupertino, CA 95014

Authorized Agency Signature:

Signature / Print Name and Title / Date

Kaiser Permanente Santa Clara: Grant Evaluation 2009/10

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Program Evaluation(Please refer to the proposal that you submitted)

Organization Name
Project Name
Desired Community Result or Impact / Decreased Obesity
Decreased Diabetes
Decreased Asthma
Decreased incidence/prevalence of heart attack or stroke / Decreased hospitalization
Decreased rate of institutionalization
Other: ______
Program Outcomes / Enhanced access to health care
Enhanced physical and nutritional health
Enhanced quality of care & outcomes / Better socio-emotional wellbeing
Other: ______

INSTRUCTION:

  1. Please add more rows if you need to.
  2. Columns titled “Major Activities, Proposed/Projected Outputs and Outcomes” should remain the same (as originally proposed in your proposal) unless there has been a modification to the program. Please refer to your original proposal.

Major Activities / Proposed/Projected Outputs / Mid-Year Report/ Progress / Final Report/ Progress / Proposed/Projected Program Outcomes / Mid-Year Report/ Progress / Final
Report/ Progress / Data Source
Primary efforts, services or activities of your program — what you program does. ¹ / The direct products or deliverables of your program
List target quantity for each.[1] / Was due 1/26/2010 / Due 8/2/2010 / Benefits/changes of clients during/after the program. Show changes in knowledge, skills, behavior, and/or changes in conditions or status.¹ / Was due 1/26/2010 / Due 8/2/2010 / Method of measurement or data source to track outcome
Example: Parent workshops / Example: 5 workshops focused on obesity prevention (100 parents) / Example: Increased % of parents have knowledge of childhood obesity prevention[2] / Example: Pre and post parent surveys

Total Number of Unduplicated Clients Served: ______

Kaiser Permanente Santa Clara: Grant Evaluation 2009/10

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Evaluation Narrative

  1. Have there been any changes to the program as originally proposed in the application? Is the implementation of your program aligned with the proposed plan and timeline?

No, they remain the same.

Yes, there has been a change(s). The changes are listed below as well as the reasons why those changes were necessary.

  1. Please describe the change(s), its reasons, and/or challenges you have experienced as they relate to program implementation.
  1. What is your plan to respond to these challenges?
  1. How can Kaiser Permanente support your program in anticipating or overcoming these challenges?
  1. How satisfied are you in meeting the goal(s)? Pleas check one box and provide comment.

Very satisfied Somewhat satisfied

Very dissatisfied Somewhat dissatisfied

Comment:

  1. In hopes to learn more about your organization and funded program, Kaiser Permanente Santa Clara welcomes the opportunity to do a site visit. Please advise us of key program/activities that we can observe. Please also include preferred location and timeline.
  1. Please share a successful client story(ies) by using the components provided below. It helps us to better understand the program and its profound impact it has on our clients/community. Feel free to tell the story from a client’s or staff’s point of view. Please attach photos if they are available.

a.Name, age, gender, if appropriate

b.How was this client before he/she entered your program (that was funded by Kaiser Permanente Santa Clara)? How was the referred?

c.What services did the client receive from you? Why were these services critical for this client?

d.How was the client affected by these services and your staff?

e.Has the client “graduated” to a better health/life?

f.Quote(s) from staff:

g.Quote(s) from the client:

h.Other

[1] Definition provided by the United Way Silicon Valley.

[2]Adapted from the FIRST 5 Santa Clara County.