Title Page
Make sure to include: County Name, Coalition Name, Date, and Name of Report
Understanding this Template:
Notations made in purple provide guidelines for individual sections.
Text in black indicates information that can be included as provided material for the report.
Introduction
Include here brief context for the report, including community overview, the risk and protective factors of priority focus, and programs implemented to address these factors.
The community context overview should include brief history of the coalition (when it was started, its mission/vision, and the overall plans for the next year. This should be accomplished in 1-2 paragraphs.
Risk factors are characteristics of community, family, school, and individual/peer group environments that can increase the likelihood of negative behaviors including drug use, delinquency, teen pregnancy, school dropout, violence, and depression/anxiety. For example, children who have little attachment to the neighborhoods in which they live or children who live in areas with high crime rates (elevated risk factors of low community attachment and neighborhood disorganization under the community domain) are more likely to exhibit problem behaviors of substance abuse, delinquency, and violence. Protective factors are community, family, school, and individual/peer group environments that have a positive influence and “protect” or “buffer” against the negative influences associated with risk factors. Though closely related, protective factors are not the opposite of risk factors, but rather reduce the effects of existing risk factors.
At this point, detail the priority risk and protective factors identified for your community. Include how/why they were identified (i.e., high risk/low protection as a result from the 2013 ATOD youth survey, numbers from law enforcement, health scores, etc.), and if they’ve changed from past priorities. Community risk and protective factors of priority may have changed since originally receiving the grant; if your numbers have changed your focus (as identified in the most recent community assessment), note the change here.
Use the next paragraphs to explain what programs, policies, and practices have been chosen to address the priority risk and protective factors mentioned above. Give a brief (2-3 sentences) description of the program. This Introduction section should be approximately 1-2 pages. Most of the contents can likely come from past reports submitted, but please review and edit them so they flow smoothly.
Plan Amendments
Your coalition may have come to realize the need to add or remove strategies from the originally approved implementation/community action plan. These amendments may be the addition of evidence-based strategies based on new data revealing a need in the community (from the Community Assessment), the removal of a strategy due to a lack of community support or feasibility, or just the need for a midcourse adjustment. While amendments can be filed at any time, they are easily able to be incorporated into this section (as needed) in preparing for the upcoming fiscal year.
If you’re applying for an amendment provide the following information:
Narrative justifying the adjustment and describing the details of the strategy(ies) including target audience, evidence of effectiveness, and dose/duration (e.g., number of sessions).
Logic model highlighting the community-level needs assessment data related to the selection of the strategy (refer to the Community-Level Outcome Evaluation section of your report).
CONSEQUENCE(S) / BEHAVIOR(S) / DETERMINANT(S) / STRATEGY(IES)Legal
Health
Social
Financial
Evaluation logic model highlighting the sources of data that will be utilized to measure change among participants, and how data will be collected.
CONSEQUENCE(S) / BEHAVIOR(S) / DETERMINANT(S) / STRATEGY(IES)Legal
Health
Social
Financial
Work Plan
Using the chart below, outline the major tasks that are needed to plan, implement, and evaluate the prevention efforts in the coming year. Use the different quarters to indicate what quarter each task should be started (S) and finished (F). If the goal should be started and finished in one quarter, indicate this (S/F). Setting a start and ideal completion date is especially important if you’re adding a new program. Please feel free to refer to your grant timelines and deliverables to ensure minimum requirements are included, but also make sure you include items not required by DMHA, but necessary for a successful year of implementation. An example is provided below.
Task or Goal / Quarter1 / 2 / 3 / 4
Recruit 20 participants for Strengthening Families Program cohorts. / S / F / S / F
Train 4 Strengthening Families Program Facilitators / S / F
Hold Strengthening Families Program (two cohorts) / S/F / S/F
Budget
Respondent Name: ______
Twelve Month Figures (100%)
AMOUNT REQUESTED
Personnel1) Staff Salaries
2) Staff Fringes
Non-Personnel
3) Travel4) Training
5) Equipment
7) Strategy (ies)
8) Other
***************************************** / *********************************
Total Project Costs
Personnel Budget
Staff Position * / (100%)Salary
(a) / (100%)
Fringe
Benefits
(b)** / % of
Time on
Project
(c) / Total
Amount of Salary
Requested
(a x c) / Total
Amount of
Benefits
Requested
(b x c)
TOTAL
Salary and fringes are to be shown as 12 month figures
* Include Job Description for each staff position as attachment
** FRINGE BENEFITS: Include contributions for Social Security, employee insurance, pension plans, etc.
Non-Personnel Budget
Include information on Travel, Training, Materials, Equipment, Consultant Services and other costs associated with each strategy implementation
Reimbursement for travel cannot exceed the allowable state reimbursement rates for travel, per diem and overnight accommodations.
Item Description / Estimated Cost (100%)Total
NOTE: Use additional sheets as needed. (Number each additional page
Budget Narrative
Provide a description of each item listed in all areas of the budget. You should explain how the item supports you scope of work.