Immunization Program Evaluation Plan Template
June 2008

Grantee:__________________________
This form completed by: _____________________	Title:________________________
Evaluation Lead Name:______________________	Title:________________________
Evaluation Lead Phone #:___________________________
Evaluation Lead Email:_____________________________
Projected start date for implementing this evaluation plan:_______________________
Projected end date for implementing this evaluation plan:________________________

A. Program Component(s) - Specify the component you will be evaluating. 

___Adolescent vaccination	___Population Assessment
___Adult vaccination		___AFIX (Provider Quality Assurance)
___Education/training		___Surveillance
___IIS				___Vaccine management and accountability
___Perinatal hepatitis B        	___Women Infants and Children Program

___Other	If checked, please specify: ____________________________________________

B. Please BRIEFLY list which activity or activities within the above component you plan on evaluating. 

C. Evaluation Goal(s) - State the goal(s) related to the component/activity you have chosen. Refer to Chapter 2, Page 11 of the Guide to Immunization Program Evaluation for help with this section.

D. Stakeholders - Fill out the table below. Note: This table is a combination of Tables 1 and 2 in the Guide; therefore, it should include members of the evaluation team. Refer to Chapter 1, Pages 7-10 and Chapter 2, Page 12 of the Guide to Immunization Program Evaluation for help with this section. 

Tables 1 and 2: Stakeholder Assessment and Engagement

Group Name OR Person’s Name and job title:

Interests in or perspectives about the evaluation:

Roles in the evaluation:

Responsibilities in the evaluation:

How and when to engage

(end table)

E. 	Describing the program component/activity.  Briefly describe the following aspects of the component/activity you are evaluating. Note: Please provide a more detailed description if the activity you are evaluating is new or not well established (e.g. activities related to adolescent vaccinations). Refer to Chapter 2, Pages 13-14 of the Guide to Immunization Program Evaluation for help with this section.

Background:

Context:

Stage of Development:

Target population:

Objectives:

F. Fill out the table below. You may choose to describe the entire component or the specific activity or activities within the component that you are evaluating. Note: This table should represent the current status of the component or activity NOT where you would like to be in the future. Refer to Chapter 2, Pages 15-17 of the Guide to Immunization Program Evaluation for help with this section.

Table 3: Program Component/Activity Description

Inputs
Activities:
Initial :    
Subsequent:
Outputs:
Outcomes:
Short/Mid-term: 
(end table)

G. Optional – If you have created a logic model in addition to Table 3, please submit your logic model as an attachment (instructions will be provided in PAPA). Refer to Chapter 2, Page 17 of the Guide to Immunization Program Evaluation for help with this section.

H. Focusing the evaluation and Data Collection and Analysis - Fill out the table below. Note: The number of questions and indicators per question can vary. For each indicator, you need to develop a target and BRIEFLY list/describe the data sources and the method, timeline and person responsible for data collection and analysis. Refer to Chapter 2, Pages 18-29 of the Guide to Immunization Program Evaluation for help with this section.

Table 8: Data Collection and Analysis

	

Table 8: Data Collection and Analysis

Evaluation Question #1:

INDICATOR(S) Indicator 1
TARGET(S):	
DATA SOURCE(S):	
DATA COLLECTION: Method: 
Timeline: 
Person Responsible: 	
ANALYSIS :Method: 
Timeline: 
Person Responsible: 	

INDICATOR(S) Indicator 2
TARGET(S):	
DATA SOURCE(S):	
DATA COLLECTION: Method: 
Timeline: 
Person Responsible: 	
ANALYSIS :Method: 
Timeline: 
Person Responsible: 	

Evaluation Question #2:

INDICATOR(S) Indicator 1
TARGET(S):	
DATA SOURCE(S):	
DATA COLLECTION: Method: 
Timeline: 
Person Responsible: 	
ANALYSIS :Method: 
Timeline: 
Person Responsible: 	

INDICATOR(S) Indicator 2
TARGET(S):	
DATA SOURCE(S):	
DATA COLLECTION: Method: 
Timeline: 
Person Responsible: 	
ANALYSIS :Method: 
Timeline: 
Person Responsible: 	

Evaluation Question #3:

INDICATOR(S) Indicator 1
TARGET(S):	
DATA SOURCE(S):	
DATA COLLECTION: Method: 
Timeline: 
Person Responsible: 	
ANALYSIS :Method: 
Timeline: 
Person Responsible: 	

INDICATOR(S) Indicator 2
TARGET(S):	
DATA SOURCE(S):	
DATA COLLECTION: Method: 
Timeline: 
Person Responsible: 	
ANALYSIS :Method: 
Timeline: 
Person Responsible: 	
(end table)

I.	Ensuring use and sharing lessons learned - Fill out the table below. Note: We understand that this portion of your evaluation will occur in the distant future but please provide your best estimate. Refer to Chapter 2, Page 30-31 of the Guide to Immunization Program Evaluation for help with this section.

Table 9: Disseminating Findings

TARGET PERSON OR GROUP’S NAME:
TARGET’S EVALUATION USE(S):						
DISSEMINATION ITEMS AND METHODS	
TIMELINE FOR DISSEMINATION
PERSON RESPONSIBLE
(end table)

END EVALUATION PLAN

This document can be found on the CDC website at:
http://www.cdc.gov/vaccines/programs/progeval/downloads/ipe_eval_plan_template_06-2008.rtf