PLEASE STOP and READ FIRST 
Prior to writing this evaluation plan, you should have submitted a New Cycle Topic Identification Report AND received CDC’s approval for your new evaluation topic. Please see the CDC Immunization Program Evaluation Guidance (January 31, 2011) for additional details.
 
•	The Immunization Program Operations Manual (IPOM) previously listed ‘required and recommended activities’ for each component; however, the current IPOM lists objectives for each component. Some IPOM chapters list targets in addition to performance measures (aka indicators).  
•	For this Evaluation Plan, grantees may use objectives, performance measures (aka indicators), and targets in the current IPOM; however, please update them, if needed, to follow the definitions and formats provided in the Guide to Immunization Program Evaluation developed in 2007 (e.g. each objective should be ‘SMART’).
•	CDC recommends that grantees complete the Plan in this MS Word template and then copy and paste the content into PAPA when the link is available in April 2011.

NEED HELP WITH THIS PLAN?

CDC Guide to Immunization Program Evaluation (2007 version). It is available at: 
http://www.cdc.gov/vaccines/programs/progeval/default.htm 

CDC Immunization Program Evaluation webpage has many past trainings and sample documents. It is available at:   http://www.cdc.gov/vaccines/programs/progeval/default.htm

Please email IPE@cdc.gov and your Project Officer with any related questions.  

EVALUATION PLAN STARTS HERE

Grantee name: __________________________
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: ________________________

SECTION I: Component and Activity 

1.	Program Component(s) - Specify the component you will be evaluating. This will be prefilled in PAPA based on what you submitted in the New Cycle Topic Identification Report.  
___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. Please specify: ____________________________________________

2.	Please BRIEFLY list and describe which activity within the above component you plan to evaluate. This will be prefilled in PAPA based on what you submitted in the New Cycle Topic Identification Report.  

SECTION II: Stakeholders and Evaluation Team Members

3.	Please complete Table A. Refer to Chapter 1 and Chapter 2 of the Guide to Immunization Program Evaluation for help with this section. Please also list your evaluation team members; however the last column can be left blank for them. 

Person’s Name and job title	Organization/Entity	Roles/Responsibilities in the evaluation	How and when to engage external stakeholders	
Example:
Jane Doe, RN
Nurse Manager
	County X Hospital 	Provide data on post vaccination serologic testing	At quarterly evaluation update meeting via conference call	

				
Add more, if needed.				

SECTION III: Describing the program component/activity
4.	Briefly describe the following aspects (a-d) of the activity you will be evaluating. Refer to Chapter 2 of the Guide to Immunization Program Evaluation for help with this section.

a.	Please select the best option regarding how long your program has been conducting this activity:
___ 5 or more years
___ 1-4 years 
___ Less than 1 year

b.	Background:

c.	Context:

d.	Target population:

5.	Please complete Table B by describing either a) the entire component including the activity you plan to evaluate or b) the specific activity you plan to evaluate. 
Notes:
•	This table should represent the current status of the component or activity, NOT where you would like to be in the future.
•	This table should NOT describe your evaluation-related activities and outcomes, but rather the activity or component you plan to evaluate.  Refer to Appendix E of the Guide to Immunization Program Evaluation for help with this section.

Table B - Program Component or Activity Description (Logic Model Worksheet)
	
Inputs	Activities
Initial               Subsequent	Outputs	Outcomes
Short-/
Mid-term              Long-term	

					

6.	Optional – If you have already created a logic model or prefer to create a logic model in addition to Table 2 (Logic Model Worksheet), please submit it as an attachment (instructions will be provided in PAPA). All headings for submitted logic models should be consistent with Table 2 (i.e. Inputs, Activities, Outputs, and Outcomes). Refer to Chapter 2 of the Guide to Immunization Program Evaluation for help with this section.

SECTION IV:  Focusing the evaluation and Data Collection and Analysis 

7.	Please complete Table C. 
NOTES:
•	The Immunization Program Operations Manual (IPOM) previously listed ‘required and recommended activities’ for each component; however, the current IPOM lists objectives for each component. Some IPOM chapters list targets in addition to performance measures (aka indicators).  
•	For this Evaluation Plan, you may use objectives, performance measures (aka indicators), and targets in the current IPOM; however, please update them, if needed, to follow the definitions and formats provided in the Guide to Immunization Program Evaluation developed in 2007 (e.g. each objective should be ‘SMART’).
•	Each evaluation question should be associated with a ‘SMART’ objective(s) and one or more indicators (i.e. the number of objectives and indicators per question can vary). 
•	BRIEFLY list/describe the data sources and the method, timeline and person responsible for data collection and analysis. 
•	An example objective, questions and indicators are included below. 

Table C: Data Collection and Analysis
	
‘SMART’ Objective(s) being evaluated: 
Example: During the five-year grant cycle assess policies and pre-printed orders used by delivery hospitals.  
	
Evaluation Question #1:
Example: What proportion of delivery hospitals have policies and pre-printed orders for review of maternal records for HBsAg results and testing for HBsAg when appropriate?
	
INDICATORS	TARGETS	
DATA SOURCES
	DATA COLLECTION
ACTIVITIES	ANALYSES
	
Indicator 1
Example: 
Proportion of delivery hospitals with policies 	100% of delivery hospitals have policies 	Infection control nurse	Method: Hospital survey
Timeline: Jun-Aug 2011
Person Responsible: Hep B coordinator	Method: Frequencies
Timeline: Sept-Nov 2011
Person Responsible: Hep B coordinator
	
Indicator 2 
Example: 
Proportion of delivery hospitals with pre-printed orders.  
	100% of delivery hospitals have pre-printed orders	Infection control nurse	Method: Hospital survey Timeline: Jun-Aug 2011
Person Responsible: Hep B coordinator	Method: Frequencies Timeline: Sept-Nov 2011
Person Responsible: Hep B coordinator	
IPOM Objective(s) being evaluated:  Example: During the five-year grant cycle assess policies and pre-printed orders used by delivery hospitals.  
	
Evaluation Question #2: Example: What are the barriers and facilitators to using pre-printed orders for testing for HBsAg when appropriate?
	
INDICATORS	TARGETS	DATA SOURCES	DATA COLLECTION
ACTIVITIES	ANALYSES	
Indicator 1
Example: 
Barriers and facilitators related to pre-printed orders 	100% of delivery hospitals provide barriers and facilitators	Infection control nurses and/or administrators	Method: Interviews 
Timeline: Sep-Oct 2011
Person Responsible: Hep B coordinator	Method: Frequencies, themes  
Timeline: Sept-Nov 2011
Person Responsible: Hep B coordinator	
Indicator 2
Add more, if needed.			Method: 
Timeline: 
Person Responsible: 	Method: 
Timeline: 
Person Responsible:	
Evaluation Question #3: Add more, if needed.	
Indicator(s)
Add more, if needed.			Method: 
Timeline: 
Person Responsible: 	Method: 
Timeline: 
Person Responsible:	

SECTION V: Ensuring use and sharing lessons learned 
8.	Please complete Table D. We understand that this portion of your evaluation will occur in the distant future but please provide your best estimate. Refer to Chapter 2 of the Guide to Immunization Program Evaluation for help with this section.

Table D: Dissemination of Evaluation Findings	
PERSON OR   
   GROUP’S 
      NAME	DISSEMINATION 
    ITEMS AND 
     METHODS 	TIMELINE FOR
DISSEMINATION	PROPOSED USE 
OF FINDINGS	EVALUATION TEAM MEMBER  RESPONSIBLE FOR
DISSEMINATION	
Example: Immunization Coalition	Final Report via email	End of evaluation (projected date: May 2012)	Inform their education and outreach activities	Evaluation team lead	

Add more, if needed.

END EVALUATION PLAN

This document can  be found on the CDC web site at: http://www.cdc.gov/vaccines/programs/progeval/downloads/eval-plan-template.rtf