Immunization Program Evaluation 
 	2008 Evaluation Plan Review and Feedback Form
 Updated July 30, 2008 

Grantee State/City Name:
ISD Reviewer (s) Name (s)
Review Date:
Component: Activity:

Implementation Start Date (check one)
_____Provided; No revision recommended
_____Provided; Recommend it be delayed (specify under comments)
_____Provided; Recommend it be moved up (specify under comments)
_____Not provided 

Comments:______________________________________________________________

Implementation End Date (check one)
_____Provided; No revision recommended
_____Provided; Recommend it be delayed (specify under comments)
_____Provided; Recommend it be moved up (specify under comments)
_____Not provided 

Comments:______________________________________________________________

B. Activity (ies) (check one)
_____Provided; No revision recommended
_____Provided; Revision recommended (specify under comments)
_____Not provided	

Comments:_____________________________________________________________

 C. Goal(s) (check one)
_____Provided; No revision recommended
_____Provided; Revision recommended (specify under comments)
_____Not provided

Comments:______________________________________________________________

D. Stakeholders 
_____Provided; No revision recommended
_____Provided; Revision recommended (check all that apply)
_____DOES NOT include staff at the program (i.e. “evaluation team”)
_____All cells for each stakeholder are NOT completed
_____Not provided

Comments:______________________________________________________________

E. Component/Activity Description

E1. Background  (check one)
_____Provided; No revision recommended
_____Provided; Revision recommended (specify under comments)
_____Not provided

Comments:______________________________________________________________

E2. Context (check one)
_____Provided; No revision recommended
_____Provided; Revision recommended (specify under comments)
_____Not provided

Comments:______________________________________________________________

E3. Stage of Development (check one)
_____Provided; No revision recommended
_____Provided; Revision recommended (specify under comments)
_____Not provided

Comments:______________________________________________________________

E4. Target population (check one)
_____Provided; No revision recommended
_____Provided; Revision recommended (specify under comments)
_____Not provided

Comments:______________________________________________________________

E5. Objectives
_____Provided; No revision recommended
_____Provided; Revision recommended (check all that apply)
_____One or more objectives are NOT SMART (Specific, Measurable, Achievable, Realistic, Time-bound)
_____One or more objectives DO NOT relate to the goal(s)
_____Not provided

Comments:______________________________________________________________

F. Table 3 – Program component/activity description
_____Provided; No revision recommended
_____Provided; Revision recommended (check all that apply)
_____DOES NOT reflect current status of component/activity
_____One or more columns are NOT completed
_____Inputs DO NOT meet definition (as defined in the Guide to IPE)
_____Activities DO NOT meet definition (as defined in the Guide to IPE)
_____Outputs DO NOT meet definition (as defined in the Guide to IPE)
_____Outcomes DO NOT meet definition (as defined in the Guide to IPE)
_____Not provided

Comments:______________________________________________________________

G. Logic Model (*Optional for the 2008 plan.)
_____Provided; No revision recommended
_____Provided; Revision recommended (check all that apply)
_____DOES NOT reflect current status of component/activity 
_____Content IS NOT similar to Table 3
_____Not provided

Comments:______________________________________________________________

H. Table 8 - Data Collection and Analysis
_____Provided; No revision recommended
_____Provided; Revision recommended (check all that apply)
_____One or more questions DO NOT have at least one indicator
_____One or more indicators DO NOT have a target, data source, data collection and analysis items
_____One or more indicators DO NOT relate to their question
_____Data collection and analysis methodology for one or more indicators NEEDS to be revised
_____Timeline for data collection and analysis for one or more indicators NEEDS to be revised
_____Not provided

Comments:______________________________________________________________

I. Table 9 - Disseminating Findings
_____Provided; No revision recommended
_____Provided; Revision recommended (check all that apply)
_____DOES NOT include staff at the program (i.e. “evaluation team”)
_____DOES NOT include all the stakeholders (Table 1 and 2)
_____All cells for each target ARE NOT completed
_____Not provided

Comments:______________________________________________________________ 

This document can be found on the CDC website at:
http://www.cdc.gov/vaccines/programs/progeval/downloads/eval-prf-form-2008.rtf