Partnerships for Success (PFS) Community-Level Instrument Revised (CLI-R) Question 33 Worksheet

Partnerships for Success (PFS) Community-Level Instrument—Revised (CLI-R) Question 33 Worksheet

33a. Intervention name / 33b. Service Type / 33c. Service Type name / 33d. Date started / 33e. CSAP strategy type / 33f. Institute of Medicine (IOM) category / 33g. Intervention targets /
Select the name of each prevention intervention you are implementing, or select “other” and write in the name / Select the service type for each major set of services or activities you are implementing for this intervention, or select “other” and write in the name. Many strategies may consist of only one service type. / Write in the name of the specific set of services or activities that you implemented as part of your intervention. In many cases, this will be the same as the intervention name. / Date you began funding this intervention service type through your PFS initiative
(MM/YYYY) / Select the CSAP strategy type that best describes this intervention service type / Select the IOM category for this intervention service type / Select the option that best describes the targets of this intervention service type
Choose an item.
Specify Other: / Choose an item.
Specify Other: / Click here to enter a date. / Choose an item. / Choose an item. / Choose an item.
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Specify Other: / Choose an item.
Specify Other: / Click here to enter a date. / Choose an item. / Choose an item. / Choose an item.
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Specify Other: / Choose an item.
Specify Other: / Click here to enter a date. / Choose an item. / Choose an item. / Choose an item.
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Specify Other: / Choose an item.
Specify Other: / Click here to enter a date. / Choose an item. / Choose an item. / Choose an item.
Choose an item.
Specify Other: / Choose an item.
Specify Other: / Click here to enter a date. / Choose an item. / Choose an item. / Choose an item.
Choose an item.
Specify Other: / Choose an item.
Specify Other: / Click here to enter a date. / Choose an item. / Choose an item. / Choose an item.
Choose an item.
Specify Other: / Choose an item.
Specify Other: / Click here to enter a date. / Choose an item. / Choose an item. / Choose an item.
Choose an item.
Specify Other: / Choose an item.
Specify Other: / Click here to enter a date. / Choose an item. / Choose an item. / Choose an item.
Choose an item.
Specify Other: / Choose an item.
Specify Other: / Click here to enter a date. / Choose an item. / Choose an item. / Choose an item.
Choose an item.
Specify Other: / Choose an item.
Specify Other: / Click here to enter a date. / Choose an item. / Choose an item. / Choose an item.
Choose an item.
Specify Other: / Choose an item.
Specify Other: / Click here to enter a date. / Choose an item. / Choose an item. / Choose an item.

May 2015Partnerships for Success