Immunization Program Evaluation Plan Template

Please include the following sections in your evaluation plan. You will need to use the “Guide to Immunization Program Evaluation for Grantees”^1 for descriptions, details, and tables related to the sections below.

1.	Program Component
Specify the component you have chosen.

2.	Evaluation Goal(s) 
State the goal(s) related to the component you have chosen. 

3.	Evaluation Team
Fill out and include Table 1, “Evaluation Team Roles and Responsibilities” (Appendix B, page 34) 
or list and briefly describe each member’s title, role and responsibilities.

4.	Stakeholders
Fill out and include Table 2, “Stakeholder Assessment and Engagement” (Appendix C, page 35) 
or list and briefly describe each stakeholder including each person/group’s: name, job title, interest/perspective, role, and how and when you engaged (or plan to engage) the stakeholder.

5.	Describing the program component
a.	Briefly describe the component including the following sections: background, context, stage of development and target population.
b.	List the objective(s) related to the component you have chosen.
c.	Fill out and include Table 3, “Program Component Description” (Appendix D, page 36) 
or you can provide a list of each of the following:  inputs, activities, outputs, outcomes.
d.	Optional: Attach the program component’s logic model

6.	Focusing the evaluation and Data Collection and Analysis
Fill out and include Table 8, “Data Collection and Analysis” (Appendix K, page 43) 
or list and briefly describe the following: evaluation questions, the related indicators and targets, the data sources and methods and when and by whom data will be collected and analyzed.

7.	Ensuring use and sharing lessons learned
Fill out and include Table 9, “Disseminating Findings” (Appendix L, page 44) 
or list and briefly describe with whom you will share the findings of the evaluation, how these findings will be useful to them and what methods (and format) you will use to share these findings.

^1Available at the Immunization Program Evaluation Website http://www.cdc.gov/vaccines/programs/progeval/

This document can be found on the CDC website at: http://www.cdc.gov/vaccines/programs/progeval/downloads/ipe_eval_plan_template_11-2007.rtf