TITLE V: COMMUNITY PREVENTION GRANTS 

PROGRAM

COMMUNITY SELF-EVALUATION WORKBOOK

Shay Bilchik, Administrator

Office of Juvenile Justice and Delinquency Prevention

1995

Reprinted 1999
This Workbook was prepared by Caliber Associates, Fairfax, VA for 

The Office of Juvenile Justice and Delinquency Prevention (OJJDP) 

under Contract #OJP-91-C-011.
Title V Delinquency Prevention Program

Community Self-Evaluation Workbook Foreword

FOREWORD

In an ongoing effort to provide resources and technical assistance to State and local service 

providers, the Office of Juvenile Justice and Delinquency Prevention is pleased to make 

available The Title V Delinquency Prevention Program Community Self-Evaluation Workbook to 

assist you in assessing the success of your Delinquency Prevention Program. The Workbook is 

designed to provide information and resource aids on program planning, conducting evaluations, 

tracking programs, describing activities, monitoring risk factor data, performing analyses, and 

measuring outcomes and performance indicators. 

While you are required to collect data for measuring the performance and outcomes of your Title 

V Program, use of the Workbook forms is voluntary. The Workbook, however, is designed to 

simplify the task of evaluating Delinquency Prevention Programs by providing forms and 

instructions for collecting and analyzing data and assessing program performance.

By following the steps contained in the Workbook and completing the enclosed forms, essential 

evaluation information will be collected. Since the Workbook is designed to be a resource, 

consider the evaluation steps and data forms as the minimum amount of information that needs 

to be included in your Title V evaluation. If the Workbook meets your needs, copy the forms 

and use them outright or use them as a basis to tailor an evaluation to meet your specific program 

needs. The Workbook is not a prescriptive evaluation tool but rather one that includes 

instructions and data gathering forms that enable communities to assess their Delinquency 

Prevention Program outcomes. The Office took a basic approach in designing the Workbook in 

order to address the needs of grantees with various levels of program evaluation experience. In 

some cases the stated information may appear obvious, but to someone who is less familiar with 

program evaluation procedures or data collection techniques, the detailed step-by-step 

instructions should prove helpful.

The Office of Juvenile Justice and Delinquency Prevention is pleased to provide The Title V 

Delinquency Prevention Program Community Self-Evaluation Workbook as an evaluation 

assistance guide for local communities. While the Workbook was prepared for the Title V 

Program, it may serve as a valuable evaluation tool for other prevention initiatives as well. The 

Office recognizes the importance of evaluating programs and using the results to provide the best 

possible services to America's children and youth. 

Shay Bilchik

Administrator
Title V Delinquency Prevention Program

Community Self-Evaluation Workbook Table of Contents

TABLE OF CONTENTS

Section Page Number 

INTRODUCTION 

Introduction 1

Inventory of Forms 10

"When Should You Fill Out These Evaluation Forms?" Checklist 13

UNIT 1 THE INITIATIVE

Unit 1 Introduction Unit 1 - 1

Instructions and Form 1-1: Grant and Funding Information Unit 1 - 3

Instructions and Form 1-2: Target Community Description Unit 1 - 6

Instructions and Form 1-3: History and Background Unit 1 - 9

Instructions and Form 1-4: Organizational Structure Unit 1 - 11

Instructions and Form 1-5: Prevention Policy Board (PPB) Members Roster Unit 1 - 16

Instructions and Form 1-6: Summary Table of PPB Representation Unit 1 - 18

Instructions and Form 1-7: PPB Meetings, Actions, and Activities Unit 1 - 20

Instructions and Form 1-8: Vision, Goals, and Objectives Unit 1 - 23

Instructions and Form 1-9: Risk Factors and Program Plan Unit 1 - 26

Instructions and Form 1-10: Title V Budget Summary Unit 1 - 28

Instructions and Form 1-11: Process Reflections Unit 1 - 30

UNIT 2 PROGRAMS AND PROJECTS 

Unit 2 Introduction Unit 2 - 1

Instructions and Form 2-1A: Service Delivery Program Description Unit 2 - 6

Instructions and Form 2-1B: Systems Change Project Description Unit 2 - 11

Instructions and Form 2-2A: Service Delivery Program Implementation Log Unit 2 - 15

Instructions and Form 2-2B: Systems Change Project Implementation Log Unit 2 - 20

Instructions and Form 2-3A: Service Delivery Program Process Assessment Unit 2 - 24

Instructions and Form 2-3B: Systems Change Project Process Assessment Unit 2 - 29

Instructions and Form 2-4A: Service Delivery Program Outcome Assessment Unit 2 - 32

Instructions and Form 2-4B: Systems Change Project Outcome Assessment Unit 2 - 35
Title V Delinquency Prevention Program

Community Self-Evaluation Workbook Table of Contents

Section Page Number 

UNIT 3 RISK FACTOR TRACKING

Unit 3 Introduction Unit 3 - 1

Instructions and Form 3-1: Risk Factors and Indicator Summary Unit 3 - 3

Instructions and Form 3-2: Tracking Risk Factor Indicators Unit 3 - 4

Instructions and Form 3-3: Risk Factor Data Analysis Unit 3 - 9

Instructions and Form 3-4: Tracking Indicators of Juvenile Problem Behaviors Unit 3- 11 

Instructions and Form 3-5: Juvenile Problem Behaviors Data Analysis Unit 3 - 13

Appendix : Risk Factors and Sample Indicators

Title V Delinquency Prevention Program

Community Self-Evaluation Workbook Introduction

1

INTRODUCTION

Congratulations on receiving a Title V Delinquency Prevention Program grant for your 

community! To get to this point, your community already has done a great deal of work. 

You’ve mobilized community leaders, conducted risk and resource assessments, and developed a 

successful application to your State agency to address problems of juvenile delinquency in your 

community with a risk-focused prevention strategy. This Workbook is designed to help you 

“write the history” of your community's Title V Initiative. It provides the tools you need for 

conducting an ongoing assessment of your delinquency prevention strategy. 

The “Introduction” is often the part of a book or document that people skip. In this case, 

however, we urge you not to skip over the next few pages, but instead to read the rest of this 

Introduction because (1) it’s brief, and (2) it contains very important information that will help 

you use this Workbook effectively and get the most out of it, including:

• Why you should conduct an evaluation.

• How the Workbook is organized.

• How to use the Workbook.

• A few key assumptions.

• A few key terms.

Why You Should Conduct an Evaluation of Your Title V Delinquency Prevention Program

There are many reasons for evaluating programs, but for Title V, three stand out:

• At a local level, you need information to guide your program efforts, to help make 

sure you’re on the right course for achieving your community’s objectives.

• At a national level, we still need more information about “what works” to prevent 

juvenile delinquency and keep kids out of trouble.

• At a national and State level, in today's world of scarce resources and tight budgets, 

sound evaluation findings are increasingly important—and sometimes required—to 

secure continued program funding.
Title V Delinquency Prevention Program

Community Self-Evaluation Workbook Introduction

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Despite the bad reputation that “evaluation” and “evaluators” have had in the past (they’re right 

up there with taxes and tax collectors), evaluation doesn’t have to be an unpleasant experience 

and evaluators don't have to be strangers who carry a briefcase and live out of town. In fact, 

done right, conducting an evaluation can be a very revealing and rewarding experience, 

especially for community planners (like yourself) and policy-makers. What’s more, with this 

self-evaluation Workbook, nobody’s doing anything to you; you’re doing this for yourself. The 

information you will record on the forms in this Workbook is designed to help you describe and 

understand what’s happening in your community with respect to delinquency prevention, make 

informed decisions about where you want to go next, help chart the course to get there, and then 

look back on how you fared. The lessons you learn are first and foremost meant to be useful to 

you, but as all of the Title V communities around the country begin to learn valuable lessons 

about what works in preventing juvenile delinquency, these lessons will become valuable to the 

field as a whole.

In any evaluation, the key question you are trying to answer is: Did this program (or service, or 

medicine, or class—whatever you’re doing) make a difference? But you also have to ask, 

“Difference compared to what?” Determining the answer to that question is what the evaluation 

design process is all about. There are several traditional approaches to evaluation that help 

answer the “compared to what?” design question, including: pre/post test designs (where you 

compare the same subject to itself before and after the program); experimental designs (where 

subjects are randomly assigned to different groups that are exposed to different programs); and 

quasi-experimental designs (where different groups are exposed to different programs but the 

assignment is not random). 

The overall evaluation design used in this Workbook is a pre/post test design. That is, through 

the risk and resource assessments you conducted, you took a careful look at conditions in your 

community before you implemented your Title V Initiative. With this Workbook, you have the 

tools you need to track your Title V efforts over time and see how conditions in the community 

change after Title V. In other words, with this evaluation design, you will be comparing your 

community to itself: what it was like (based on certain indicators of problems) before the Title 

V Initiative compared to what it is like in the community in future years, during and after Title 

V. With answers to these questions, “what difference is it making?” and “compared to what?” 

you will have valuable information for guiding your program efforts and for affecting the future 

health and well-being of your community—pretty good reasons for conducting an evaluation!
Title V Delinquency Prevention Program

Community Self-Evaluation Workbook Introduction

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How the Self-Evaluation Workbook is Organized

The Self-Evaluation Workbook is organized in three Units, each with a different focus on your 

Title V effort. As you know, the Title V Delinquency Prevention Program provides 

communities with an overall framework for delinquency prevention—a risk-focused 

approach—and a process for implementing it. 

The chart on the following page provides an overview of the Title V process, beginning with the 

formation of your Prevention Policy Board (PPB) and the initiation of ongoing community 

mobilization activities. With the risk and resource assessments that you conducted you 

identified priority risk factors—those that are most pressing in the community—to focus on, as 

well as gaps in community resources for addressing the priority risk factors. With this 

information, you developed a "vision" for the community, and goals and objectives for achieving 

that vision. From there you developed a Delinquency Prevention Plan and a Title V grant 

application that outlined the specific "promising approaches" you planned to undertake to reduce 

juvenile delinquency in your community. 

In implementing your prevention plan, you may have decided to expand or enhance service 

delivery programs for youth and families in the community (e.g., parenting skills classes, home 

visitation programs, after-school services) or to make other changes in the community or its 

systems that also help prevent juvenile delinquency (e.g., media campaigns, school development 

strategies, or community organizing activities). The nature and number of prevention programs 

and projects will vary from one community to the next depending on community characteristics, 

risk profiles, available resources, and selected prevention strategies. Each program or project 

has specific objectives to bring about changes in the knowledge, skills, attitudes, behaviors or 

expectations of children, youth, and families or to cause changes in the systems, values, and 

norms of the community. Collectively, these changes are expected to result in both enhanced 

protective/resiliency factors and decreased risk factors. Ultimately, the enhancements of 

protective/resiliency factors and reductions in risk factors are expected to lead to reductions in 

delinquency and other juvenile problem behaviors in your community.

The three Units in this Self-Evaluation Workbook relate to different parts of the Title V process 

(as illustrated on the right side of the Title V Process Overview chart) and cover both "process 

evaluation" and "impact evaluation" questions:

Unit 1, The Initiative, will help you to take stock of the community mobilization, 

prevention planning and decision-making, and program implementation efforts that 

occurred before you received the Title V grant award, as well as those that occur during 

the grant 
Title V Delinquency Prevention Program

Community Self-Evaluation Workbook Introduction

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Insert File “intro-a.wpg” here (Presentation file)

Process Overview
Title V Delinquency Prevention Program

Community Self-Evaluation Workbook Introduction

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period. Represented in the top section of the process overview chart, this Unit will help 

address three basic process evaluation questions: "what are we trying to do and why?"; 

"who's doing it?"; and "how are we going about it?"

Unit 2, Programs and Projects, focuses on the various service delivery programs and 

systems change projects that you undertake in your community as part of the overall Title 

V Initiative. Represented in the middle of the process overview chart, this Unit gets at 

both process and outcome evaluation questions related to these Title V programs and 

projects, including: "what did we do?"; "with whom?"; "when?"; "where?"; and "what 

did we accomplish?"

Unit 3, Risk Factor Tracking, is designed to help you evaluate the impact of your Title 

V Initiative as a whole by tracking the changes over time in the indicators of risk and 

prevalence of juvenile problem behaviors in your community. Shown at the bottom of 

the process overview chart, this Unit will help address the important impact evaluation 

question of "what difference is Title V making?"

The diagram below summarizes the Title V self-evaluation framework, which parallels the Title 

V Delinquency Prevention Program process. The diagram illustrates the three Units of the 

Workbook and what they cover. 
Title V Delinquency Prevention Program

Community Self-Evaluation Workbook Introduction

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Each Unit has a set of data collection forms to be completed at various times throughout the 

period of your Title V grant. Each form comes with easy, step-by-step instructions on how and 

when to complete it. In many cases, the instructions also include a boxed area with “Things to 

Think About” as you complete the forms. These Things to Think About are provided to help you 

get the most from the information you’re collecting about your Title V Initiative and to help 

guide your future decisions and prevention plans. 

How To Use The Self-Evaluation Workbook

There are three key questions that need to be addressed to answer the overall question of how to 

use this Workbook: How? When? and Who?

How? For each data collection form in the Workbook there is a “master” form that you 

should make copies from before filling it out. Some forms will only be filled out once 

during the grant period, some will be completed on an ongoing basis, and for others, you 

will need several copies, depending on how many different service delivery programs or 

systems change projects you implement as part of your Title V Initiative. The 

instructions for each form tell you how many copies you will need. 
Title V Delinquency Prevention Program

Community Self-Evaluation Workbook Introduction

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When? For each form in the Workbook, the instructions also tell you when you should 

fill it out. In addition, there is a checklist provided at the end of this introductory section 

called "When You Should Fill Out These Forms" that gives you a broad overview of 

when the various forms should be completed. By using these forms on an ongoing basis, 

the evaluation can be integrated into your Title V planning, management, and 

decision-making processes.

Who? Although we recommend that one person should have overall responsibility for 

ensuring that all of the forms in the Workbook are completed (for example, the chair of 

the PPB, a representative of the unit of local government that received the Title V grant, 

or your designated lead evaluator), you probably will want to assign the task of 

completing the various forms in the Workbook to different people who are involved in 

your Title V Initiative. There are plenty of forms to go around, and different people will 

have different levels of involvement and familiarity with the various aspects of your 

Initiative. (This is especially true for the forms in Unit 2, and is discussed further in that 

section.)
Title V Delinquency Prevention Program

Community Self-Evaluation Workbook Introduction

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As you complete the various forms in each section, store them in a three-ring binder to keep 

everything together. There may also be other information related to your Title V Initiative that 

supports or adds to what you record on these data collection forms (e.g., your Title V grant 

application, grant reports, program brochures, evaluation surveys), which you will want to 

include in the Workbook. Copy these supporting materials and put them in the back of the 

binder as an additional appendix. Think of your Workbook as the “living history” of your Title 

V Initiative!

A Few Key Assumptions About the Workbook’s Design...

The forms in this Workbook—and its overall structure—were designed to be consistent with the 

Title V Delinquency Prevention Program Guidelines (published in the Federal Register, Vol. 59, 

No. 146, Monday, August 1, 1994). These guidelines describe the “risk-focused approach” to 

delinquency prevention as well as the process and requirements for making Title V State and 

local subgrant awards. An important aspect of the Title V process has been the training 

provided to communities around the country to help them prepare their grant applications and 

prevention plans. This training program, Communities That Care, which has been attended by 

hundreds of local communities —perhaps yours among them—also served as a basis for the 

design of many of the data collection forms in this Workbook. But don’t worry! Even if you 

didn’t attend Communities That Care training, or have adopted a different model of risk-focused 

prevention, the information to be collected on these forms is still relevant to your Title V 

Initiative.

Although each State may have adopted somewhat different award requirements or processes, the 

following key assumptions about the users of this Self-Evaluation Workbook underlie its design:

• That the State has awarded your community a Title V grant, which you have matched 

with 50% of the amount of the grant (cash or in-kind).

• That you have designated or formed a Prevention Policy Board (PPB) with 15 to 21 

members from your community that will have general oversight responsibility for 

implementation of the Title V grant activities.

• That you have completed a risk and resource assessment for your target community.

• That you have developed a three-year prevention plan for your community which 

included the identification of the priority risk factor(s) to be addressed.

• That you identified, implemented, or expanded one or more individual programs or 

projects to address your community's priority risk factors.
Title V Delinquency Prevention Program

Community Self-Evaluation Workbook Introduction

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These core assumptions, drawn from the Program Guidelines, provide the overall framework for 

the Workbook data collection forms. Although the specific characteristics of each State's Title V 

Delinquency Prevention Program may vary somewhat—and you may have to tailor your 

responses to some items on some forms—these overall Title V features should be applicable to 

most, if not all, local Initiatives. If any of these assumptions are not true for your community, 

you may want to review your State’s Title V requirements, contact your Juvenile Justice 

Specialist, or plan to address them in the early stages of your Title V grant period.

A Few Key Terms Used in the Workbook...

Title V Title V refers to the new program authorized in Title V of the 1992 amendments to the 

Juvenile Justice and Delinquency Prevention Act which provides for “Incentive Grants for Local 

Delinquency Prevention Programs.” More specific guidelines for implementing the Title V 

Program are outlined in the Title V Delinquency Prevention Program Guidelines (published in the 

Federal Register, Vol. 59, No. 146, August 1, 1994).

The Initiative This term refers to your overall Title V prevention effort. The term 

“initiative” is used in reference to “new ideas or methods” and to signify the full range of 

prevention activities you plan to undertake with your Title V grant.

Prevention Policy Board (PPB) The Title V Program Guidelines call for the “designation or 

formation of a local Prevention Policy Board” that will “provide general oversight” for Title V 

activities in each community. In your community, the local oversight group may be called 

something different (e.g., the “Juvenile Delinquency Prevention Task Force” or a “Steering 

Committee”), but “PPB” is used throughout the Workbook to signify this required Title V 

oversight body.

Service Delivery Program A service delivery program is a component of the overall Title V 

Initiative that is designed to address priority risk factors or enhance protective factors through the 

provision of services directly to individual clients or participants in the community.

Systems Change Project A systems change project is a component of the overall Title V 

Initiative that has a broader, community-level focus than a service delivery program such as 

public service announcements or efforts to change local ordinances.
Title V Delinquency Prevention Program

Community Self-Evaluation Workbook Introduction

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Risk Factor A risk factor is a condition of the individual, family, or community that research 

has found to be a predictor of juvenile delinquency and other problem behaviors. A list of risk 

factors (and their indicators) is included in the Appendix to this Workbook. 

Risk Factor Indicator For each risk factor, there are “indicators” of its 

existence—quantifiable data that provide information about how widespread a problem the risk 

factor is in a community. These indicators of risk can be found in nationally published statistics 

(like the U.S. Census), in community-level records (such as school attendance records or 

unemployment rates), or can be generated locally (such as a survey of teen drug awareness and 

use). 

Protective Factor A protective factor is a condition or characteristic (e.g., positive 

relationships with adults) that shields or buffers children from problems. (The term "resiliency" 

is sometimes used in the same way.)

A Final Word About Using This Workbook....

The overarching goal and purpose of this Self-Evaluation Workbook is to provide you with a 

useful set of tools for documenting and assessing your community’s Title V Delinquency 

Prevention Program. The data collection forms contained in the Workbook are interrelated and 

are designed to help you evaluate your Title V Program. Consider these forms resource tools 

that can help make your task of evaluating your Title V efforts easier. If you have any questions 

or need assistance in completing any of the forms contained in the Workbook, call your State 

Juvenile Justice Specialist. If further information is needed, call Donna Bownes, Program 

Manager, State Relations and Assistance Division, Office of Juvenile Justice and Delinquency 

Prevention (OJJDP), in Washington, D.C. at (202) 307-5924. 
Title V Delinquency Prevention Program

Community Self-Evaluation Workbook Introduction

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inventory chart
Title V Delinquency Prevention Program

Community Self-Evaluation Workbook Introduction

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inventory chart
Title V Delinquency Prevention Program

Community Self-Evaluation Workbook Introduction

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inventory chart
Title V Delinquency Prevention Program

Community Self-Evaluation Workbook Introduction

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WHEN SHOULD YOU FILL OUT THESE SELF-EVALUATION FORMS?

Within One Month Following the Title V Grant Award:

 1-1 Grant and Funding Information 

 1-2 Target Community Description

 1-3 History and Background

 1-4 Organizational Structure

 1-5 Prevention Policy Board (PPB) Members Roster 

 1-6 Summary Table of PPB Representation

 1-8 Vision, Goals, and Objectives 

 1-9 Risk Factors and Program Plan

 1-10 Title V Budget Summary

Throughout the Title V Grant Period:

 1-5 Prevention Policy Board (PPB) Members Roster 

 1-7 PPB Meetings, Actions, and Activities

Upon Initiating a Program/Project: 

 2-1A Service Delivery Program Description

 2-1B Systems Change Project Description

Throughout Each Component Program/Project Period:

 2-2A Service Delivery Program Implementation Log

 2-2B Systems Change Project Implementation Log
Title V Delinquency Prevention Program

 Checklist of Forms (Continued) Community Self-Evaluation 

Workbook Introduction

15

Upon Completing a Component Program/Project: 

 2-3A Service Delivery Program Process Assessment

 2-3B Systems Change Project Process Assessment

 2-4A Service Delivery Program Outcome Assessment

 2-4B Systems Change Project Outcome Assessment

At the End of the First Year of the Grant Period:

 1-4 Organizational Structure

 3-1 Risk Factors and Indicator Summary

At the End of Each Year of the Grant Period (and beyond*):

 1-6 Summary Table of PPB Representation

 1-10 Title V Budget Summary

 1-11 Process Reflections

 3-2 Tracking Risk Factor Indicators*

 3-3 Risk Factor Data Analysis*

 3-4 Tracking Indicators of Juvenile Problem Behaviors*

 3-5 Juvenile Problem Behaviors Data Analysis*

TITLE V DELINQUENCY PREVENTION PROGRAM

COMMUNITY SELF-EVALUATION WORKBOOK

INVENTORY OF FORMS 

FORM 

NUMBER FORM NAME KEY FEATURES WHEN TO USE

NUMBER 

OF PAGES COPIES NEEDED

UNIT I - THE INITIATIVE

1-1 Grant and Funding Information Summary of basic information identifying the Title V 

grant recipient and prevention resources

Within one month following Title V 

grant award

1 Single

1-2 Target Community Description Snap-shot of community characteristics, geographic 

boundaries, and demographics

Within one month following Title V 

grant award

1 Single

1-3 History and Background Narrative account of the prior history of prevention 

initiatives in your community leading up to the 

Title V grant

Within one month following Title V 

grant award

1 Single

1-4 Organizational Structure Description and diagram of the roles and relationships 

of the various agencies and individuals involved in the 

Title V Initiative

Within one month following Title V 

grant award and at the end of the 

first year

6 Multiple

1-5 Prevention Policy Board (PPB) 

Members Roster

List of Prevention Policy Board members and their 

affiliations

Within one month following Title V 

grant award and after the departure 

or addition of any PPB member

3 Single

1-6 Summary Table of PPB 

Representation

Tally of Prevention Policy Board member 

participation and representation over time

Within one month following Title V 

grant award and at the end of each 

year of the grant period

1 Single

1-7 PPB Meetings, Actions, 

and Activities

Record or "minutes" of Prevention Policy Board 

meetings, decisions, and activities

During each meeting of the PPB or 

PPB committee

2 Multiple

1-8 Vision, Goals, and Objectives Depiction of the desired future state of your 

community to result from your prevention efforts

Within one month following Title V 

grant award

2 Single

1-9 Risk Factors and Program Plan Outline of programs and projects selected to address 

priority risk factors in your community

Within one month following Title V 

grant award

1 Single
FORM 

NUMBER FORM NAME KEY FEATURES WHEN TO USE

NUMBER 

OF PAGES COPIES NEEDED

1-10 Title V Budget Summary Table of budgeted and actual expenditures Within one month following the 

Title V grant award and at the end of 

the grant period 

1 Single

1-11 Process Reflections Assessment of progress made, barriers encountered, 

and changes planned in community-wide 

implementation process 

At the end of each year of the Title 

V grant period

2 Multiple

UNIT 2 - PREVENTION PROGRAMS AND PROJECTS

2-1A Service Delivery Program 

Description

Overview of the characteristics and desired outcomes 

of component programs 

Upon initiating any Title V service 

delivery program 

3 Multiple

2-1B Systems Change Project 

Description

Overview of the characteristics and desired outcomes 

of component projects 

Upon initiating any Title V systems 

change project 

3 Multiple

2-2A Service Delivery Program 

Implementation Log

Annual record of program steps, activities, and 

services

Throughout each program year 1 Multiple

2-2B Systems Change Project 

Implementation Log

Annual record of project steps, activities, and events Throughout each project period 1 Multiple

2-3A Service Delivery Program 

Process Assessment

Assessment of actual program implementation 

processes as compared to original program plans

At the end of the program period 3 Multiple

2-3B Systems Change Project 

Process Assessment

Assessment of actual project implementation 

processes as compared to original project plans

At the end of the project period 2 Multiple

2-4A Service Delivery Program 

Outcome Assessment

Assessment of progress made in achieving desired 

program outcomes

At the end of the program period 1 Multiple

2-4B Systems Change Project 

Outcome Assessment

Assessment of progress made in achieving desired 

project outcomes

At the end of the project period 1 Multiple

UNIT 3 - RISK FACTOR TRACKING

3-1 Risk Factors and Indicator 

Summary

Outline of priority risk factors in your community and 

relevant indicators of risk levels

At the end of the first year of the 

Title V grant period

1 Single

3-2 Tracking Risk Factor Indicators Table and graph of risk factor indicator data over time At the end of each year after the 2 Multiple
FORM 

NUMBER FORM NAME KEY FEATURES WHEN TO USE

NUMBER 

OF PAGES COPIES NEEDED

Title V grant begins

3-3 Risk Factor Data Analysis Interpretation of risk factor data and trends At the end of each year after the 

Title V grant begins

1 Multiple

3-4 Tracking Indicators of Juvenile 

Problem Behaviors

Table and graph of data related to the occurrence of 

juvenile problem behaviors over time

At the end of each year after the 

Title V grant begins

2 Multiple

3-5 Juvenile Problem Behaviors Data 

Analysis

Interpretation of trends in juvenile problem behaviors At the end of each year after the 

Title V grant begins

1 Multiple
Title V Delinquency Prevention Program

Community Self-Evaluation Instructions

Υνιτ 1 − Παγε 1

UNIT 1 THE INITIATIVE

Unit 1 is entitled The Initiative. The term "Initiative" is used here in reference to "new ideas or 

methods." It signifies the entire undertaking of Title V Delinquency Prevention in your target 

community. "Initiative" refers to your community's ability to begin and follow through with 

your Title V plan. Many factors will affect your ability to sustain an effective Title V Initiative, 

including funding resources, target community characteristics, your goals and objectives, 

organizational structure, leadership, the breadth and depth of community involvement, 

collaboration between participants, decision-making processes, and program plans. The Forms 

in this Unit are designed to document these factors and help frame an assessment of their 

contribution to the ultimate effectiveness of your Title V Initiative.

In completing the Forms in Unit 1, your prevention team will address the following broad 

questions:

· Who you are.

· Where you came from.

· How you are organized. 

· Where you are going. 

· What you are doing to get there.

In answering these questions, you will develop a narrative of pertinent information related to the 

background, processes, and direction of your community's Title V Initiative.

Most of the Forms in Unit 1 should be started, and in many cases completed, within one month 

following the Title V award, or soon thereafter. You will find that much of the information 

requested on these Forms can be taken directly from the grant application that you submitted to 

receive Title V funds. In fact, we suggest that you include a copy of your Title V grant 

application as an "appendix" to the Workbook. The grant application not only serves as a ready 

reference now, but it also represents an important document in the project's initial history that 

later can aid others who might use the Workbook as a tool in evaluating your prevention project. 

If your Prevention Policy Board (PPB) operates under a written set of by-laws or policy rules, 

you might also include those in the Workbook appendix.

Unit 1 has 11 different Forms, listed in the box on the following page. These Forms should be 

filled out by someone (or several persons) familiar with the history of your community's Title V 

Initiative, the formation of the PPB, and current PPB activities. Remember, the more 

information that is collected and recorded, the more useful the results will be to you. 
Title V Delinquency Prevention Program

Community Self-Evaluation Instructions

Υνιτ 1 − Παγε 2

UNIT 1 FORMS

1-1 Grant and Funding Information 

1-2 Target Community Description

1-3 History and Background

1-4 Organizational Structure

1-5 Prevention Policy Board (PPB) Members Roster 

1-6 Summary Table of PPB Representation

1-7 PPB Meetings, Actions, and Activities

1-8 Vision, Goals, and Objectives 

1-9 Risk Factors and Program Plan

1-10 Title V Budget Summary 

1-11 Process Reflections 
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FORM 1-1: GRANT AND FUNDING INFORMATION

WHEN TO USE:WITHIN ONE MONTH FOLLOWING TITLE V GRANT AWARD

KEY FEATURES: SUMMARY OF IDENTIFYING AND FUNDING DATA

This Form collects basic information about you, the Title V grant recipient, and the prevention 

funding you received.

BEFORE YOU BEGIN:

 Do not write on the original Form. Make copies of Form 1-1. You will need one 

copy of this Form for each separate Title V grant awarded to your community.

 Get a copy of your Title V grant application and the grant award document you received 

from the State. Most of the information required for Form 1-1 can be found in these 

two sources. 

1. Title V Target Community

A. Community Name Fill in the name of the target community for which Title V grant 

funds will be used. Use the same community name that was written in your grant 

application. 

B. State Provide the two letter State abbreviation for your State.

2. Title V Grant Information

A. Grant Recipient Name the unit of general local government (e.g., city, county, township, 

borough, parish, tribe) that is the official recipient of the Title V grant award. 

B. Address Provide the address, including the office number, street, city, State, and zip 

code of the grant recipient described above. 

C. Point of Contact Indicate the name and title of a point of contact at the grant recipient 

organization. This person should hold responsibility for administering Title V funds. 

D. Phone Number and Fax Number List the phone number (P) and the fax number (F) of 

the point of contact. Include the area code. 
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E. State Award Number Indicate the unique identifying number assigned by the State 

Agency to your grant project. 

F. Date Awarded Enter the date the State Agency awarded the grant to your community. 

G. Total Award Amount List the total dollar amount of Title V funds awarded from the 

State to your community for the duration of the grant. Do not include matching 

resources in this space.

H. Funding Period Enter the beginning and ending dates for the funding period of your 

grant. This funding period may range from 12 to 36 months. If your community 

submitted a single application and received a 3-year grant, then complete one copy of 

Form 1-1 and enter a funding period reflecting 36 months. If your community was 

required to submit a new application each year and was awarded three separate Title V 

grants, then complete three copies of Form 1-1, each with a 12-month funding period.

3. Matching Resources for Title V Grant

The terms of the Title V grant require a 50-percent match of resources, either in cash or 

in kind, and the State or the unit of general local government are responsible for 

providing the match. Describe your community's matching resources in Table 3. 

Attach an additional page if you have more than five sources of matching funds. 

A. Source List the name of each provider of matching resources. The source may be a 

State agency or unit of general local government. Be specific in identifying the funding 

source (e.g., State Department of Juvenile Justice Formula Grants Program, County 

Government At-Risk Youth Program). 

B. Type Describe the resource or service provided. Resource types may include: cash, 

staff time, office space, equipment, transportation, professional services, etc.

C. Value Provide the dollar amount of each cash award and the estimated value of the goods 

and services received for each in-kind contribution. Enter the total value of matching 

resources in the bottom row. (This total should equal at least 50 percent of your total 

 Title V grant.)

D. Period List the beginning and end dates of the funding period for the matching resource. 

4. Other Non-Title V Funding Sources for Prevention Activities in the Target Community
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In addition to the Title V grants and matching resources, many communities may also be 

recipients of other Federal, State, local, or private funding that supports interagency 

planning, coordination, and service delivery for prevention programs. Examples of 

non-Title V funding sources include: U.S. Department of Health and Human Services: 

Family Preservation and Support Services; CSAP Community Partnership Grants; 

Department of Education: Drug Free Schools Program; Metropolitan Life Foundation; 

XYZ Corporation Community Development Campaign. Using the same instructions 

explained above for Table 3, list other significant prevention funding sources in your 

community, along with the resource type, value, and period. Be as specific as possible. 

Keep in mind that only funds or in-kind resources from the State or unit of general local 

government may qualify as match funding under Title V. But in order to understand 

your full prevention picture, it is also important to identify what other resources are 

available for prevention activities in your community.

You may receive outside funding before or after the award of the Title V grant. If, 

during the course of the Title V grant period, additional prevention funding is awarded to 

the target community, be sure to add the relevant information to the table. (Attach an 

additional page if you have more than three sources of non-Title V funding sources.)

5. Additional Grant or Resource Information

Use this space or attach extra pages to provide any additional information, special 

circumstances, or other comments related to your grant award and other prevention 

funding resources in your community.
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FORM 1-2: TARGET COMMUNITY DESCRIPTION

WHEN TO USE:WITHIN ONE MONTH FOLLOWING TITLE V GRANT AWARD

KEY FEATURES: COMMUNITY BOUNDARIES AND DEMOGRAPHICS

This Form provides a "snap-shot" of the geographic location and demographic make-up of your 

Title V target community. 

1. Geographic Location and Definition of Target Community

A. Community Name Enter the name of your target community, neighborhood, county, 

city, school district, etc. 

B. State Provide the two letter State abbreviation for your State.

C. Geographic Boundaries of Target Community Identify the specific geographic 

boundaries of your target community. Specify whether the community is defined by the 

boundaries of a neighborhood, school district, county, township, city, tribe, or other 

jurisdiction.

D. Counties or Townships Within Community Boundaries List all of the counties or 

townships that fall entirely or partially within your target community boundaries.

E. School District(s) Within Community Boundaries List all of the school districts that 

fall entirely or partially within your target community boundaries.

2. Target Community Profile

A. Community Setting Classify your target community as urban, suburban, rural, or mixed 

by placing a check in the appropriate box.

B. Total Community Population Using the most recent data available, enter the total 

number of residents in your target community and write the year to which the population 

number refers.

C. Median Annual Household Income Level Indicate the median annual income for 

households in your target community and write the year to which the income data refer. 

The median level is the dollar amount which divides the income distribution into two 

equal groups (half with income above the median, half with income below it).
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D. Brief Community Description Briefly describe some of the primary economic, social, 

or demographic characteristics of your target community. This description may include 

comments on the current economic conditions of the community, principal racial or 

socioeconomic groups who live in the target community, dominant cultural norms or 

values of community members, geographic features, major employers, recent trends, or 

other factors that help define your target community. (Attach an additional sheet if 

necessary.)

3. Youth Profile for the Target Community

A. Number of Children Under Age 18 Using the most current data available, enter the 

number of children in each age range listed. Sum the numbers for each group to show 

the total number of children in the target community. Calculate the percentage of 

children under age 18 relative to the total community population recorded in 2B (that is, 

divide the total number of children entered in Item 3A by the community population 

number entered in Item 2B). At the bottom of the box, indicate the year to which the 

data refer. If the numbers are estimates, write "estimate."

B. Percentage of Children Under Age 18 by Ethnic/Racial Background For each 

ethnic/racial group listed, calculate the percentage of total children in the target 

community of that ancestry or origin. At the bottom of the box, indicate the year to 

which the data refer. If the numbers are estimates, write "estimate."

C. Percentage of Children Under Age 18 by Gender Indicate the percentage of male and 

female children in the target community. At the bottom of the box, indicate the year to 

which the data refer. If the numbers are estimates, write "estimate."

Possible Sources of Information for Completing 

Form 1-2: 

· U.S. Census Data

· Reference librarian

· State University Data Center

· Local Government

· Kids Count Data Book (Annie E. Casey Foundation)

· State Juvenile Justice Specialist

· Chamber of Commerce

· School District
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Things to Think About When Completing Form 1-2: 

· Is your target community well defined? Do you know exactly where 

you're focusing your Title V resources? 

· Is your target community of a manageable size to support the 

implementation and evaluation of a risk-based prevention program? 

· Have you gained the cooperation of all of the potentially important 

government entities within the boundaries of your target community 

(e.g., the school districts, town, county, and tribal governments)? 

· How do community characteristics influence your prevention efforts and 

affect the provision of services to families and youth in the target 

community? 

· Have you involved in the Title V Initiative the major racial, cultural, and 

socio-economic groups who live in your target community? 
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FORM 1-3: HISTORY AND BACKGROUND

WHEN TO USE:WITHIN ONE MONTH FOLLOWING TITLE V GRANT AWARD

KEY FEATURES: NARRATIVE OF WHERE YOU HAVE BEEN

Use this Form to provide a narrative account of the background of your Prevention Initiative and 

Prevention Policy Board (PPB).

History and Background of Prevention Initiatives in the Target Community Before This 

Title V Grant

Briefly describe the history of prevention initiatives in your community leading up to the 

Title V grant. Important aspects may include:

· Previous experiences with delinquency prevention activities, including what was 

done, for how long, what was the budget, and what was the outcome.

· What were the evaluation findings from previous prevention efforts.

· Which programs and services for families and youth were successful in the past 

and which were not successful.

• What other community coalitions or interagency task forces focus specifically on 

youth issues.

· Who initiated delinquency prevention efforts in the community and how others 

were brought on board.

· How collaboration and coordination among different community groups was 

achieved.

· How key leaders and PPB members were brought together to conduct policy 

planning for youth issues.

Your narrative should also describe how previous community efforts relate to the current 

Title V Initiative.

Look carefully at the history of prevention in your community and be candid in writing 

your background statement. This Form is an opportunity to get down in writing the 
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outside factors that may have played an important part in the formation of the current 

Initiative, but which are not captured on other evaluation Forms. Examine what has been 

tried in the past, looking at both that which has been successful and that which has been 

less-than-successful. Think about what has facilitated or obstructed success in past 

efforts. Try to get at what makes the Title V Initiative different from previous prevention 

efforts. This account of your history and background can serve as a record of where the 

community has been and is now, which is essential to assessing progress in the future.
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FORM 1-4: ORGANIZATIONAL STRUCTURE

WHEN TO USE:WITHIN ONE MONTH FOLLOWING THE TITLE V GRANT AWARD 

AND AT THE END OF THE FIRST PROGRAM YEAR

KEY FEATURES: DIAGRAM OF ORGANIZATIONAL STRUCTURE

This Form asks you to describe and draw a diagram of the roles and relationships of the various 

players on the Prevention Policy Board (PPB) and the agencies, organizations, and groups 

involved in the Title V Initiative. Form 1-4 focuses on the internal organizational structure of 

the PPB as well as its external relationships with other community organizations. Form 1-5 will 

collect information on the names and affiliations of the individual members of the PPB.

1. Prevention Policy Board (PPB) Fiscal Agent and Sponsoring Organization

A. Unit of General Local Government Enter the name of the unit of general local 

government (e.g., city, county, township, borough, parish, tribe) that is the official 

recipient and fiscal agent of the Title V grant award. This should be the same unit of 

general local government named on Form 1-1, Item 2-A. (The Title V guidelines require 

a single unit of general local government to serve as the grant recipient, although 

planning of the Title V Initiative is the responsibility of the Prevention Policy Board with 

representatives from multiple organizations.)

B. Name of PPB Sponsoring Organization Identify the specific local agency or entity 

that has responsibility for support of the PPB.

C. Type of Organization Check the appropriate box to identify whether the sponsoring 

organization is a private non-profit organization, government or public agency, private 

business, or other.

2. PPB Leadership Structure

A. Position Title List the leadership positions and titles of the officers of your PPB (e.g., 

chairperson, vice-chairperson, secretary). If your PPB has more than 5 leadership 

positions, continue listing them on an additional sheet of paper.

B. Role For each position listed, describe its role or function on the PPB.

3. Paid Title V PPB Staff 
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A. Number of Full-Time Staff Enter the number of PPB staff— e.g., prevention 

coordinators, outreach workers, or PPB support staff— who are paid through Title V 

funds (State grant or matching funds) and work 35 hours or more per week. Do not 

include here staff members who provide direct services to youth under Title V-supported 

programs (e.g., parent trainers, peer counselors, teachers). 

B. Number of Part-Time Staff Enter the number of PPB staff— e.g., prevention 

coordinators, outreach workers, or PPB support staff— who are paid through Title V 

funds (State grant or matching funds) and work less than 35 hours per week. Do not 

include here staff members who provide direct services to youth under Title V-supported 

programs (e.g., parent trainers, peer counselors, teachers). 

4. PPB Standing Committees

A. Committee Name List the names of the various standing committees or sub-committees 

of the PPB. Examples of committees might include publicity, fundraising or 

development, policy, community outreach, and program evaluation. In this table, list 

permanent, standing committees formed to last the life of the PPB (temporary committees 

or special task forces formed for specific activities are covered below in Item 5). If your 

PPB has more than 8 standing committees, continue listing them on an additional sheet of 

paper. 

B. Role For each committee listed, describe its role or function in the Title V Initiative. 

5. PPB Special Task Forces 

A. Special Task Force Name List the names of special task forces and temporary working 

groups of the PPB (e.g., media campaign task force, parent involvement task force, 

school intervention working group). Unlike the standing committees, these "task 

forces," as the term is used here, are created for specific tasks or projects and are then 

disbanded after the specific task is completed. Be sure to update your PPB Special Task 

Forces Table on an on-going basis as new task forces are formed. If your PPB forms 

more than 8 special task forces, continue listing them on an additional sheet of paper. 

B. Role For each special task force listed, describe its role or function in the Title V 

Initiative.

C. Date Formed Enter the date the task force was formed.

D. Date Disbanded Enter the date the task force was disbanded or terminated.
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6. Community Agencies, Organizations and Groups Involved in the Title V Initiative

A. Agency, Organization, or Group Name In addition to the individuals who serve on the 

PPB, there will be local agencies, organizations, and groups involved in the Title V 

Initiative, such as school districts, local universities, county governments, police 

departments, parent groups, community organizations, or social service agencies. List 

the names of these agencies, organizations, and groups affiliated with the Title V 

Initiative. If your PPB is working with more than 10 different organizations, continue 

listing them on an additional sheet of paper.

B. Role For each agency, organization, or group listed, describe its role in the Title V 

Initiative (e.g., evaluation support, site for after-school program, counseling services for 

at-risk youth). Note that different sections of the same agency may have different roles 

and should be listed separately. For example, the Director's office of the local child 

welfare agency might be the sponsoring organization, while the case workers in the same 

agency might provide direct services to the target population in a program directed by the 

PPB.

7. Diagram of PPB Structure at Grant Start-Up

Draw a simple chart of your PPB organizational structure to show graphically the 

relationships between the general membership and the officers, paid staff, and committees, 

which you listed in sections 2, 3 and 4. By looking at the organizational diagram, an 

outsider should be able to understand the basic set-up of the PPB. 

The diagram on the next page shows a sample PPB organizational structure. This is just 

one example; every PPB may be organized differently.
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Sample Diagram: 

Form 1-4 Diagram of 

PPB Structure

8. Diagram of PPB Structure at End of First Year

At the end of the first year of the grant period, repeat the instructions explained above in 

section 7, showing the PPB organizational structure at the end of the year. Observe how 

the PPB organizational structure has evolved and changed over the first year of the grant. 

9. Diagram of Title V Initiative Organizational Structure at Grant Start-Up

Draw a simple chart of your overall Title V Initiative organizational structure to 

graphically show the relationships between the PPB and the other organizations, agencies, 

and groups that you listed in section 6. Use solid lines to show direct relationships and 

dashed lines to indicate indirect relationships. By looking at the organizational diagram, 

an outsider should be able to understand the basic set-up of the players involved in your 

Title V Initiative. 

On the next page is a sample diagram of a Title V organizational structure. This is just 

one example; every Initiative may be organized differently. 
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Sample Diagram: Form 1-4 Diagram of Title V Organizational Structure 

10. Diagram of Title V Initiative Organizational Structure at End of First Year 

At the end of the first year of the grant period, repeat the instructions explained above in 

section 9, showing the Title V organizational structure at the end of the year. Observe 

how the organizational structure has evolved and changed over the first year of the grant. 
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Things to Think About When Completing Form 1-4: 

· Has your community clearly defined the organizational structure of your PPB? 

· Have leadership roles been clearly established? How?

· Has your community clearly delineated roles and responsibilities for the various 

organizations and groups involved in the Title V Initiative? 

· Are all of the major players in your community's Title V Initiative represented in 

the organizational diagram?

· Does your organizational structure facilitate the achievement of your goals and 

objectives? If no, why not? 

· Has your organizational structure changed over time? What has changed? Why? 

· What are the implications of these changes on your ability to function effectively? 

FORM 1-5: PREVENTION POLICY BOARD (PPB) MEMBERS ROSTER

WHEN TO USE:WITHIN ONE MONTH FOLLOWING THE TITLE V GRANT AWARD 

AND AFTER THE DEPARTURE OR ADDITION OF A PPB 

MEMBER 

KEY FEATURES: ROSTER OF PPB MEMBERS

This roster records information about the members of your community's Prevention Policy Board 

(PPB). Following the award of your Title V Grant, you should complete this roster to document 

the initial composition of the Board. Continue to update the roster as members leave and new 

members join the PPB.

A. Number (No.) On the first two pages of the PPB roster, the rows in Column A are 

numbered from 1 to 21 to capture information on up to 21 PPB members. Column A of 

the third page is blank (i.e., not numbered). If your PPB has more than 21 PPB members 

over the life of the Title V grant, make a copy of the third page and add consecutive 

numbers in Column A for each additional member as necessary. 

 The Title V Guidelines specify that "your PPB should consist of no fewer than 

15 and no more than 21 members from the community, representing a 
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balance of public agencies, private nonprofit organizations serving 

children, youth and families, and business and industry." While you 

should not have more than 21 members on your PPB at any given time, 

you may have more than 21 different members over the grant period if 

some of the original members leave and are replaced with new 

members. 

B. Name Enter the first and last name of each PPB member.

C. Title Provide the member's position/title within the organization he or she represents. 

D. Organization List the name of the agency, organization, or company the member 

represents. 

E. Community Sector From the table below, identify the one community sector which 

best describes the member's organization and write that sector code in Column E. 

Community Sector Code Community Sector Code

Justice System/Courts (e.g., Juvenile Court, DA's Office) JS Media (e.g., TV or Radio Station) MD

Law Enforcement (e.g., Police or Sheriffs Departments) LW Business (e.g., Private Company) BS

Education (e.g., Pre-School, Elementary or High School) ED Local Government (e.g., Mayor's Office) GV

Youth Serving Organizations (e.g., YMCA, Boys Club) YS Cultural/Ethnic Groups (e.g., NAACP) CU

Child Welfare Agencies (e.g., Dept. of Children and Families) CW Existing Task Force (e.g., Prevention 2000) TF

Religious Organizations (e.g., Church or Synagogue) RL Senior Citizens (e.g., AARP, Senior Center) SR

Health Services (e.g., Health Department, Hospitals) HT Youth Members (Persons under age 21) YM

Prevention/Treatment Providers (e.g., Mental Health Center) PR Parents (Parent of Youth) PT

Civic/Volunteer Organizations (e.g., Lions Club, Junior League) CV Other OT

F. Organization (Org.) Type In Column F, write the appropriate organization type code 

from the table below to indicate whether the PPB member represents a public agency, 

private non-profit organization, or a private for-profit business. Use the code "CTZ" if 

the member is a citizen of the community, not affiliated with any particular organization.
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Organization Type Code

Public Agency PUB

Private Non-Profit Organization PNP

Private For-Profit Business BUS

Private Citizen CTZ

G. Start Date Enter the date the member joined the board.

H. Stop Date For those members who leave the PPB, indicate the date of their departure. 

Not all members will have a stop date.

I. Name of Replacement For those members who leave the PPB, list the name of their 

replacement in the final column. Then, add the new member to the next available line 

on the roster and fill in the requested information. 
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FORM 1-6: SUMMARY TABLE OF PPB REPRESENTATION

WHEN TO USE:WITHIN ONE MONTH FOLLOWING THE TITLE V GRANT AWARD 

AND AT THE END OF EACH YEAR OF THE GRANT PERIOD

KEY FEATURES: TABLE OF PPB PARTICIPATION AND REPRESENTATION

This Form will summarize information from Form 1-5 and be used to assess board stability, 

community representation, and organizational balance. The Form is designed to provide a 

"snap-shot" of the Prevention Policy Board (PPB) at four distinct points in time: grant start and 

at the end of each of the 3 years.

 Using the PPB Members Roster (Form 1-5), complete the first Column ("Grant 

Start") of the Summary PPB Table to show PPB member representation 

at the beginning of the Title V Initiative. At the end of each project year, 

complete the next Column of the table ("Year 1 End," "Year 2 End," and 

"Year 3 End"). If there have been no departures from or additions to the 

PPB over the year(s), there will be no differences between Summary 

Table columns.

A. Total Number of Board Members on PPB Enter the total number of participating 

members on the board at the beginning of the grant and then at the end of each project 

year. At year end, count only those members who are still on the board. Do not include 

board members who participated at the beginning of the year but then left the board.

B. Number of Members Who Departed the PPB Provide the number of members who 

left the board during the specified year. The number will be "0" at Grant Start.

C. Number of New Members Enter the number of people who joined your PPB as "new 

members" during the year. (At Grant Start they will all be new members.)

D. Total Number of PPB Meetings Held Enter the total number of meetings of the full 

PPB held during the year. 

E. Average Number of Members at PPB Meetings Calculate the average number of PPB 

members who attended the PPB meetings reflected in Item D.

F. Number of Members from Each Community Sector For each community sector 

listed in section F, record the number of participating PPB members (refer to Column E 
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of Form 1-5.) Write the total number for each sector in the appropriate row of Form 1-6. 

At the end of each grant year, include only active board members and exclude those 

members who departed the PPB during the year. 

G. Number of Members from Each Organization Type For each type of organization 

listed in section G, record the number of PPB members (refer to Column F of Form 1-5.) 

Write the total number for each organization type in the appropriate row of Form 1-6. 

At the end of each grant year, include only active board members and exclude those 

members who departed the PPB during the year. 

Things to Think About When Completing Forms 1-5 and 1-6: 

· Does your PPB consist of 15 to 21 members, as specified in the Title V Federal Guidelines? 

· Are community youth and parents involved in the PPB? 

· Is there representation on the PPB by public agencies, private non-profit organizations 

serving youth and families, and for-profit businesses?

· Does your overall membership reflect the racial, ethnic, and cultural composition of the 

community's youth population? 

· Are there major community sectors that are not represented on your PPB? Are there 

community sectors that are overly represented on your PPB? 

· How many community key leaders (e.g., city council member, police chief, school 

superintendent, etc.) are members of the PPB?

· Over the grant period, has your PPB membership remained relatively stable or experienced 

high turnover? 

· If turnover has been high, what do you attribute this to? 

· Have departures of PPB members affected project implementation? 

· How are new members recruited and selected? Does the process work?

· What steps have been taken to facilitate the transition of new members onto the PPB? 

What training is provided to new members?

· Should new recruitment efforts be implemented for the continuation of the project? Who 

should be recruited to the PPB? 
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FORM 1-7: PPB MEETINGS, ACTIONS, AND ACTIVITIES

WHEN TO USE:DURING EACH MEETING OF THE PPB OR ITS COMMITTEES

KEY FEATURES: RECORD OF PPB MEETINGS AND DECISIONS

This Form will serve as a log of the issues discussed and decisions made at Prevention Policy 

Board (PPB) meetings. Planned actions will be recorded at each meeting and then the status of 

each action will be reviewed at the next meeting(s). Consider using Form 1-7 for recording the 

minutes of all PPB meetings!

 Do not write on this Form. Make additional copies of both pages of Form 1-7. You 

will need one copy of the Form to document each PPB meeting. 

 

 Sections 1 through 4 are to be completed during each PPB meeting. 

Section 5 will be completed at the following meeting(s). 

1. Meeting Information

A. Date Provide the date of the meeting. 

B. Time Provide the time the meeting started and the time it ended.

C. Location Provide the meeting site.

2. Participants

A. Meeting Group Indicate whether the meeting was held for the entire PPB or a 

committee, subcommittee, task force, or working group of the PPB. If applicable, 

specify the name of the sub-group. 

B. Names of Participants Record the names of all persons attending the meeting. 

3. Major Issues Discussed or Activities Conducted

Briefly summarize the principal topics discussed, activities conducted, or problems 

addressed during the meeting. If additional space is necessary, attach a separate sheet. 

4. Key Decisions Made at Today's Meeting 
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A. Action to be Taken List the actions and activities that board members have agreed to 

undertake based on the issues discussed. Be specific. Try to link the actions to the 

issues and topics listed in section 3. Examples of possible actions: Contact the local 

radio station to schedule dates for upcoming media campaign; Hold a sub-committee 

meeting to assess the progress of a parenting education class; Collect current risk 

indicator data from the District Attorney's Office; Establish a task force to organize a 

community forum on youth violence. 

B. Who is Responsible Name the person(s) who will be responsible for completing the 

action. 

C. Target Date List the date by which the action is intended to be completed. 

 At your next meeting, complete section 5 of Form 1-7 for the previous meeting(s). 

This is similar to addressing "old business." 

5. Progress Since the Last Meeting

D. Status Code From the box below, choose and enter the appropriate status code to 

indicate whether the action was completed by the target date, was completed behind 

schedule, is in progress, or was never initiated. Change status codes as necessary to 

reflect progress. Incorporate the status of actions from previous meetings into the 

agenda for the current meeting. 

Status Code 

Completed by target date C 

Completed behind schedule CB

In progress, not yet complete IP

No action taken NA

E. Actual Completion Date Enter the date the action was actually completed. If no 

action has been taken (NA) or the activity is still in progress (IP), then leave the box 

blank until completion. 
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Things to Think About When Completing Form 1-7: 

· Are PPB meetings being held on a regular basis? 

· Are most PPB members attending meetings regularly and actively participating?

· In general, is the level of participation balanced among the members? (That is, 

are one or two people doing all the work or is the level of participation 

distributed fairly evenly among the members?) 

· Do PPB members regularly receive meeting minutes, notices, and other 

communications? 

· Are there appropriate rules and procedures to facilitate smooth meeting 

dynamics? 

· Are there adequate decision-making and conflict resolution processes in place?

· Are actions and activities generally completed as planned? If not, what needs to 

be done? 

· Are realistic schedules being set?

· Is adequate time being spent by the PPB in oversight of the Title V Initiative?
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FORM 1-8: VISION, GOALS, AND OBJECTIVES

WHEN TO USE:WITHIN ONE MONTH FOLLOWING TITLE V GRANT AWARD

KEY FEATURES: NARRATIVE OF WHERE YOU'RE GOING

This Form captures the overall vision and goals of your Title V Initiative. Clarifying the 

specific intentions of your grant project is critical to shaping the direction of your delinquency 

prevention activities. Moreover, setting measurable goals and objectives is essential to 

evaluating the achievements of your Initiative. Think of it this way: If you don't know where 

you're going, how will you know which way to go, and how will you know when you get there?

 When completing Form 1-8, refer to the prevention strategies, goals, and objectives 

outlined in your Title V grant application.

1. Vision for Target Community

Describe the desired future state of your target community. Think about what you would 

like to see, feel, and experience in the target community. Complete the thought, "Ten 

years from now we would like to see this community...." This vision statement should 

frame the direction you are headed with the Title V Initiative. If necessary, continue 

your vision statement on an additional sheet of paper.

2. Overall Prevention Goals

Now review your vision statement and the priority risk factors you identified for the 

target community and write your overall prevention goals for achieving the vision and 

addressing the risk factors. Your goals should state in general terms what the Prevention 

Policy Board (PPB) hopes to accomplish for this community with the Title V grant. 

Goals will often be expressed as the reduction of juvenile problem behaviors (e.g., to 

prevent juvenile delinquency or to reduce juvenile crime significantly), the reduction of 

risk factors (e.g., to reduce family conflict or to restrict the availability of firearms), or 

the enhancement of protective factors (e.g., to create clear laws and norms which prohibit 

the use of alcohol and drugs by youth, or to promote strong bonds between children and 

pro-social community members).

In stating your goals, be careful to describe the desired end and not the means to the end. 

That is, goals should represent the intended results of your Title V Initiative and not the 

programs or activities you will implement to achieve those results. For example, an 

appropriate community goal might state "to promote academic success among third to 
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fifth graders," rather than "to implement school enrichment curriculum and tutoring 

projects in the elementary school." 

3. Prevention Objectives (Related to the Prevention Goals)

Identify the specific operational objectives associated with the goals of your Title V 

Initiative. These objectives should include measurable results related to the indicators of 

risk in your community. State your objectives in concrete terms. Specify who or what 

will change, by how much, and over what period of time. The more specific your 

objectives are, the easier it will be to tell if your Title V Initiative has achieved them. 

(Attach an additional sheet if necessary.)

 Note that Form 1-8 refers to the overall goals and objectives for your Title V Initiative. 

The objectives and desired outcomes of the specific component service delivery 

programs and systems change projects you undertake will be addressed further in Unit 2.

Sample Goals and Objectives

Following are three examples of goals and objectives that might be associated with 

selected priority risk factors in a given community:

Example 1

Risk Factor: Family Management Problems

Goal: To reduce levels of family dysfunction and enhance the parenting skills of 

parents in our target community. 

Objectives: To reverse the increasing trend of reported child abuse to under 300 cases 

by 1999.

To decrease the number of runaway children by 20% over the next 3 

years.

To increase the number of parents who set appropriate rules for their 

children's behavior (as measured by surveys of parents or youth). 
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Example 2 

Risk Factor: Early Initiation of Problem Behavior (Substance Use)

Goals: To foster a community where use of drugs and alcohol by children is not 

considered acceptable behavior. 

To reduce substance use among minors. 

Objectives: To eliminate the use of alcohol and other drugs on school grounds by 

September 1997. 

To reduce juvenile arrests related to alcohol and other drugs to below the 

state-wide average by 1999. 

To reduce the number of junior high students who report having had a 

drink or having used drugs to less than 5% of the school population by 

1999.

Example 3 

Risk Factor: Lack of Commitment to School 

Goal: To have a community where completing high school is valued and 

commitment to school is encouraged for all students. 

Objectives: To raise the average daily attendance rate to over 95% within the next 

three years.

To increase high school completion rates to at or above national averages 

by 1998. 

To increase by 25% the attendance of parents at school parents/teachers 

association meetings by 1997.

To significantly improve most students' attitudes about their school over 

the next three years (as measured by student surveys).

Things to Think About When Completing Form 1-8: 

· Are your goals clear and succinct?

· Are your objectives quantifiable and measurable?

· Are your goals and objectives based on your community's risk assessment? 

· Are your goals and objectives and the timetable established to reach them realistic?

· Are your Title V programs and projects "in sync" with your goals and objectives? 
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FORM 1-9: RISK FACTORS AND PROGRAM PLAN 

WHEN TO USE:WITHIN ONE MONTH FOLLOWING THE TITLE V GRANT AWARD

KEY FEATURES: OUTLINE OF HOW TO ADDRESS RISK FACTORS

This Form will outline your community's prevention plan of promising approaches to address 

priority risk factors in your community. 

 Refer to the section of your Title V grant application that explains your strategy for 

obtaining and coordinating identified resources to address your community's priority 

risk factors.

A. Priority Risk Factors List the priority risk factors that were identified in your community's 

initial risk assessment. Each box should contain only one risk factor.

B. Programs or Projects that Address the Risk Factor For each of the priority risk 

factors, list the names of the service delivery programs or systems change projects that are 

to be implemented, expanded, or enhanced as part of your Title V Initiative. These 

programs or projects may include, but are not limited to: 

· Early childhood education programs.

· Parent training and family support programs.

· School-based programs.

· Classroom management and instructional strategies.

· Community interventions.

· Lobbying efforts.

· Media mobilization.

· Recreation services.

· Tutoring programs.

· Health and mental health services.

· Substance abuse prevention services.

· Youth leadership development activities. 

Note that the same program or project may be listed several times if it addresses more 

than one priority risk factor.
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Sample Table: Form 1-9 Risk Factors and Program Plan

In their Title V Grant Application, the community of Metropolis identified three priority risk 

factors and eight programs/projects to address their priority risk factors. (Note that one of the 

programs—Metropolis Community College Family Life Program— addresses two risk factors 

and is listed twice.)

A. Priority Risk Factors B. Programs or Projects that Address the Risk Factor

1) Family History of the High Risk 

Behavior

a. Metropolis Medical Center's Healthy Pregnancy Program For 

Addicted Mothers 

b. Metropolis Community College Family Life Program 

2) Availability of Drugs a. East Metropolis "Neighborhood Drug Watch" 

b. City Council review of local zoning ordinance for bars 

c. Stricter enforcement by local bars of "carding" of minors

3) Favorable Attitudes Toward Drugs a. WROCK Radio Station Ad Campaign 

b. Metropolis TV Public Service Announcement 

c. Metro Elementary School Drug Information Curriculum 

d. Metropolis Community College Family Life Program 

Things to Think About When Completing Form 1-9: 

· In which domains — community, family, school, or individual/peer — do 

your priority risk factors fall?

· Does your program plan include effective strategies to address each of your 

community's priority risk factors?

· Does your prevention plan address multiple risks with multiple strategies? 
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FORM 1-10: TITLE V BUDGET SUMMARY

WHEN TO USE:WITHIN ONE MONTH FOLLOWING THE TITLE V GRANT AWARD 

AND AT THE END OF THE PERIOD OF PERFORMANCE

KEY FEATURES: TABLE OF BUDGETED AND ACTUAL EXPENDITURES

This Form will summarize the major expenditure categories of your Title V budget and compare 

budgeted to actual expenses. 

 Section 1 of Form 1-10 is to be completed directly after receiving the grant award. 

Refer to the budget statement in your Title V grant application to outline your 

community's planned expenditures of grant funds and matching resources. 

Sections 2 and 3 are to be completed at the end of the grant funding period.

1. Budgeted Expense (What You Planned to Spend)

A. Expenditure Category Using your grant application, list up to 10 major budget 

categories for your Title V grant funds and matching resources. Summary expenditure 

categories might include personnel, training, materials and supplies, equipment, facility 

costs, advertising and promotion, special events, travel, consultants, or other. 

B. Budget Amount ($) For each expenditure category listed, enter the dollar amount 

budgeted in your original grant application for the project's full period of performance. 

Be sure to calculate the total amount at the bottom of Column B. This total amount 

should approximate the sum of the values entered for Total Award Amount (Item 2G on 

Form 1-1) and Total Matching Resources (Item 3C on Form 1-1).

C. Budgeted Percent (%) For each expenditure category, calculate its percentage of the 

total budgeted amount. Together, all of the percentages entered in Column C should 

sum to 100 (see sample budget below).

2. Actual Expense (What Really Was Spent)

D. Actual Amount ($) Enter the actual dollar amount your community spent on each 

expenditure category over the full Title V grant period. At the bottom of the column, 

calculate and enter your total Title V expenditure.

E. Actual Percent (%) For each expenditure category, calculate its percentage of the total

actual expenditure.

3. Budget Notes and Differences Between Budgeted and Actual Expenses
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Briefly note any special circumstances surrounding budgeted or actual expenditures. 

Describe any significant differences between the budgeted and actual expenditures and 

explain, where possible, the reasons for noted variances. 

Sample Table: Form 1-10 Title V Budget Summary

1. Budgeted Expenses

(What You Planned to Spend) 

2. Actual Expenses

 (What Really Was Spent) 

A. Expenditure Category B. Budgeted 

Amount

C. Budgeted 

Percent 

D. Actual

Amount 

E. Actual 

Percent 

1) Personnel (Salaries and 

Benefits) $60,200

 

56 % * $55,200

 45 

% 

2) Materials and Supplies $4,300

 

4 % $4,400

 

4 %

3) Equipment $12,600

 

12 % $12,500

 10 

% 

4) Travel $2,500

 

2 % $2,500

 

2 %

5) Contracts $20,400

 

19 % ** $35,400

 29 

% 

6) Other $8,000

 

7 % $8,000

 

6 %

7) Advertising/Promotion $0

 

0 % *** $5,000

 

4 %

TOTAL $108,000

 100 

% $123,000

 100 

% 
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3. Budget Notes and Differences Between Budgeted and Actual Expenditures

 * Item # 1: Due to low levels of program participation, one less peer group mediator was hired than planned. 

 

** Item # 5: During the grant period, a small grant of $15,000 was obtained from the ABC Foundation to 

support a contract for extra counseling sessions for participating families in our Title V 

Family Program. *** Item #7: We did not originally intend to hold an ad campaign, but after a series of 

incidents in the community,

 the PPB decided to spend $5,000 to buy air time on two local radio stations. 

 

 

 
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FORM 1-11: PROCESS REFLECTIONS

WHEN TO USE:AT THE END OF EACH YEAR OF THE TITLE V GRANT PERIOD

KEY FEATURES: PROCESS ASSESSMENT

At the end of each year of the grant period, use Form 1-11 to assess your progress, barriers 

encountered, and changes planned as they relate to the planning, decision-making, and 

implementation processes of your Title V Initiative. 

 Before addressing the five "reflection questions" on this Form, you may want to review 

the questions posed in the "Things to Think About" boxes for other Forms in Unit 1. 

You also may choose to conduct surveys, telephone or in-person interviews, or focus 

groups of PPB members to collect information on their responses to these questions.

1. To what extent did you achieve what you had hoped to accomplish with your Title V 

Initiative this year? (What did you plan to do that you didn't? What did you do that 

you didn't originally plan to do?) 

Describe how close you are to reaching your goals and objectives for your Title V 

Initiative this year. Explain how your actions and accomplishments differed from your 

plans. Highlight the factors that enabled or inhibited the success of your efforts.

2. What positive progress has your Prevention Policy Board made over the past year? 

Describe the positive strides and achievements of the PPB. In particular, refer to progress 

made in the areas of leadership, internal board dynamics, risk-focused planning, and 

strategic implementation of the Title V Initiative. Also describe how Title V has enabled 

you to leverage, or tap into, other (non-Title V) monies to support prevention in your 

community. Be specific!

3. What barriers or obstacles hindered your progress ? 

Describe any major barriers or obstacles which the PPB has encountered in implementing 

the Title V Initiative. These may include turf battles, undefined organizational structure, 

lack of leadership, ambiguous goals, conflicting community attitudes, recruitment 

difficulties, high PPB member turnover, unbalanced representation of the community on 

the PPB, inadequate conflict resolution processes, fragmentation of efforts, etc. Be 
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specific—and honest! Identifying these problems now will help you resolve them in the 

future.

4. What major changes have occurred over the past year in the program planning, 

decision-making, and implementation processes of your Title V Initiative? Why? 

Describe any significant changes—intentional or unintentional—that have occurred in the 

planning, decision-making, or implementation processes of your Title V Initiative. These 

changes may involve your organizational structure, policies, goals and objectives, PPB 

representation and functioning, resource availability and expenditures, or other factors. 

Where possible, explain why the noted changes were made.

5. What changes in program planning, decision-making and implementation processes 

could improve the effectiveness of your Title V Initiative going forward?

Given the "lessons learned" from your implementation efforts to date, describe what 

changes in program planning, decision-making, and implementation processes you plan to 

enact for going forward. Focus on ways to improve the long-term success of your Title V 

Initiative and community prevention activities.

 Attach additional sheets if necessary.
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1-1 GRANT AND FUNDING INFORMATION

1. Title V Target Community 

A. Community Name: ____________________________________________________________ B. State: _________

2. Title V Grant Information

A. Grant Recipient (Unit of General Local Government): ______________________________________________

B. Address: _______________________________________________________

_______________________________________________________

C. Point of Contact (Name and Title): _______________________________________________________

_______________________________________________________

D. Phone Number and Fax Number: (P) (F) 

 

E. State Award Number: __________________ F. Date Awarded: ____/____/____

G. Total Award Amount: $_________________ H. Funding Period: ____/____/____ to ____/____/_____

3. Matching Resources for Title V Grant

A. Source B. Type C. Value D. Period

1) $ 

2) $ 
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3) $

4) $ 

5) $ 

Total Matching Resources $ 

4. Other Non-Title V Funding Sources for Prevention Activities in the Target Community

A. Source B. Type C. Value D. Period

1) $ 

2) $ 

3) $ 

5. Additional Grant or Resource Information

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

1-2 TARGET COMMUNITY DESCRIPTION

1. Geographic Location and Definition of Target Community

A. Community Name: _________________________________________________________ B. State: _______

C. Geographic Boundaries of Target Community: ____________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________
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D. Counties or Townships Within Community Boundaries: _____________________________________________

____________________________________________________________________________________________________

E. School District(s) Within Community Boundaries: _________________________________________________

_____________________________________________________________________________________________________

2. Target Community Profile

A. Community Setting:  Urban  Rural  Suburban  Mixed

B. Total Community Population: ____________________________________________ (Year: )

C. Median Annual Household Income Level: ____________________________________________ (Year: )

D. Brief Community Description:

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

3. Youth Profile for the Target Community

A. Number of Children Under Age 

18:

0 to 5 ____________

6 to 10 ____________

11 to 13 ____________

14 to 17 ____________

B. Percentage of Children Under Age 18 by 

Ethnic/Racial Background: 

White __________ %

African American __________ %

Hispanic __________ %

Native American __________ %

C. Percentage of Children 

Under Age 18 by Gender:

Male _______ %

Female _______ %

TOTAL 100 % 
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TOTAL ____________

% of Population ____________

(Year: ) 

Asian __________ %

Other __________ %

TOTAL 100 % 

(Year: ) (Year: ) 

1-3 HISTORY AND BACKGROUND

History and Background of Prevention Initiatives in the Target Community Before This Title V Grant

______________________________________________________________________________________________________

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______________________________________________________________________________________________________

______________________________________________________________________________________________________

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______________________________________________________________________________________________________

______________________________________________________________________________________________________

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(Continue on an additional page if necessary)

1-4 ORGANIZATIONAL STRUCTURE

1. Prevention Policy Board (PPB) Fiscal Agent and Sponsoring Organization

A. Unit of General Local Government: __________________________________________________________

B. Name of PPB Sponsoring Organization: __________________________________________________________
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C. Type of Organization: 

 Private Non-Profit Organization 

 Government/Public Agency

 Private Business

 Other (Specify: __________________________________________ )

2. PPB Leadership Structure

A. Position Title B. Role

1)

2)

3)

4)

5)

3. Paid Title V PPB Staff 

A. Number of Full-Time Staff ________ B. Number of Part-Time Staff ________

4. PPB Standing Committees

A. Committee Name B. Role 
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1)

2)

3)

4)

5)

6)

7)

8)

5. PPB Special Task Forces

A. Special Task Force Name B. Role C. Date

 Formed

D. Date

 

Disbanded 

1)

2)

3)

4)

5)

6)
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7)

8)

6. Community Agencies, Organizations and Groups Involved in the Title V Initiative 

A. Agency, Organization, or Group Name B. Role 

1)

2)

3)

4)

5)

6)

7)

8)

9)

10)
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7. Diagram of PPB Structure at Grant Start-Up
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8. Diagram of PPB Organizational Structure at End of First Year 
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9. Diagram of Title V Initiative Organizational Structure at Grant Start-Up
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10. Diagram of Title V Initiative Organizational Structure at End of First Year
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1-6 SUMMARY TABLE OF PPB REPRESENTATION

1) GRANT 

START

2) YEAR 1 

END 

3) YEAR 2 

END 

4) YEAR 3 

END 

A. Total Number of Board Members on PPB

B. Number of Members Who Departed the PPB 0 

C. Number of New Members

D. Total Number of PPB Meetings Held

E. Average Number of Members at PPB Meetings

F. Number of Members from Each Community Sector:

 Justice System/Courts (JS)

 Law Enforcement (LW)

 Education (ED) 

 Youth Serving Organizations (YS)

 Child Welfare Agencies (CW)

 Religious Organizations (RL)

 Health Services (HT)

 Prevention/Treatment Providers (PR)

 Civic/Volunteer Organizations (CV)
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 Media (MD)

 Business (BS)

 Local Government (GV)

 Cultural/Ethnic Groups (CU) 

 Existing Prevention Task Force (TF)

 Senior Citizens (SR)

 Youth Members (YM)

 Parents (PT)

 Other (OT)

G. Number of Members from Each Organization Type:

 Public Agencies (PUB)

 Private Non-Profit Organization (PNP)

 Private For-Profit Business (BUS)

 Private Citizen (CTZ)

1-7 PPB MEETINGS, ACTIONS, AND ACTIVITIES

1. Meeting Information

A. Date: ____/____/____ B. Time: _________ to __________

C. Location: ______________________________________
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2. Participants

A. Meeting Group:

 Full PPB  PPB Committee or Task Force (Specify:_______________________________________ )

B. Names of Participants:

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

______________________ ______________________ ______________________ ______________________

3. Major Issues Discussed or Activities Conducted

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

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_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

(Continue on an additional page if necessary)

1-8 VISION, GOALS, AND OBJECTIVES

1. Vision for Target Community

"Ten years from now we would like to see this community...."

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_______________________________________________________________________________________________________

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2. Overall Prevention Goals

1)___________________________________________________________________________________________________

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____________________________________________________________________________________________________

2)____________________________________________________________________________________________________

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_____________________________________________________________________________________________________

3)_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

3. Prevention Objectives (Related to the Prevention Goals)

1)____________________________________________________________________________________________________

____________________________________________________________________________________________________

2)____________________________________________________________________________________________________

____________________________________________________________________________________________________

3)____________________________________________________________________________________________________

____________________________________________________________________________________________________

4)____________________________________________________________________________________________________

__________________________________________________________________________________________________

5)____________________________________________________________________________________________________

____________________________________________________________________________________________________

6)____________________________________________________________________________________________________

____________________________________________________________________________________________________

7)____________________________________________________________________________________________________

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8)____________________________________________________________________________________________________

____________________________________________________________________________________________________

(Continue on an additional page if necessary)
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1-9 RISK FACTORS AND PROGRAM PLAN

A. Priority Risk Factors B. Programs or Projects that Address the Risk Factor

1) a.

b.

c.

d.

e.

2) a.

b.

c.

d.

e.

3) a.

b.

c.

d.
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e.

4) a.

b.

c.

d.

e.

5) a.

b.

c.

d.

e.

1-10 TITLE V BUDGET SUMMARY

1. Budgeted Expenses

(What You Planned to Spend) 

2. Actual Expenses

 (What Really Was Spent) 

A. Expenditure Category B. Budgeted 

Amount

C. Budgeted 

Percent 

D. Actual

Amount 

E. Actual 

Percent 

1) $ 

 

 $ 

 
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2) $ 

 

 $ 

 3) $ 

 

 $ 

 4) $ 

 

 $ 

 5) $ 

 

 $ 

 6) $ 

 

 $ 

 7) $ 

 

 $ 

 8) $ 

 

 $ 

 9) $ 

 

 $ 

 10) $ 

 

 $ 

 TOTAL $ 100 $ 100 

 

3. Budget Notes and Differences Between Budgeted and Actual Expenses

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_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

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_______________________________________________________________________________________________________

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(Continue on an additional page if necessary)

1-11 PROCESS REFLECTIONS
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1. To what extent did you achieve what you had hoped to accomplish with your Title V Initiative this year? (What 

did you plan to do that you didn't? What did you do that you didn't originally plan to do?) 

__________________________________________________________________________________________________

_________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

2. What positive progress has your Prevention Policy Board made over the past year?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

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3. What barriers or obstacles hindered your progress?
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__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

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__________________________________________________________________________________________________

4. What major changes have occurred over the past year in the program planning, decision-making and 

implementation processes of your Title V Initiative? Why? 

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

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5. What changes in program planning, decision-making, and implementation processes could improve the 
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effectiveness of your Title V Initiative going forward?

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(Continue on an additional page if necessary)
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1-5 PREVENTION POLICY BOARD (PPB) MEMBERS

ROSTER

A. No. B. Name C. Title D. Organization E. Community 

Sector 

F. Org.

Type

G. Start

Date 

H. Stop 

Date 

I. Name of

Replacement 

1)

2)

3)

4)

5)

6)

7)
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A. No. B. Name C. Title D. Organization E. Community 

Sector 

F. Org.

Type

G. Start

Date 

H. Stop 

Date 

I. Name of

Replacement 

8)

9)

10)

11)

12)

13)

14)

15)

16)
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A. No. B. Name C. Title D. Organization E. Community 

Sector 

F. Org.

Type

G. Start

Date 

H. Stop 

Date 

I. Name of

Replacement 

17)

18)

19)

20)

21)

 The Title V Guidelines specify that your Prevention Policy Board should consist of no fewer than 15 and no more than 21 members from the community. While you 

should not have more than 21 members on your PPB at any given time, you may have more than 21 different members over the grant period if some of the original 

members leave and are replaced with new members. Use the table on the following page and add consecutive numbers in column A for each new member as 

necessary.

A. No. B. Name C. Title D. Organization E. Community 

Sector 

F. Org.

Type

G. Start

Date 

H. Stop 

Date 

I. Name of

Replacement 
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A. No. B. Name C. Title D. Organization E. Community 

Sector 

F. Org.

Type

G. Start

Date 

H. Stop 

Date 

I. Name of

Replacement 
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A. No. B. Name C. Title D. Organization E. Community 

Sector 

F. Org.

Type

G. Start

Date 

H. Stop 

Date 

I. Name of

Replacement 

4. Key Decisions Made At Today's Meeting (Date: ______________ ) 5. Progress Since the Last Meeting

A. Actions to be Taken (Be Specific) B. Who is Responsible C. Target 

Date 

D. Status Code E. Actual 

Completion 

Date 

1) 

2)
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3)

4)

5)

6)

7)

8)

↑
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 Status Codes: C = Completed by target date CB = Completed behind schedule IP =In progress, not yet complete NA=No action taken
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UNIT 2 PROGRAMS AND PROJECTS

Unit 2 of the Community Self-Evaluation Workbook focuses on the various service delivery 

programs and systems change projects that you implement in your community as part of the 

overall Title V Initiative. It is designed to look at each program and project separately and 

assess each one in terms of its own objectives.

Programs and Projects

Before proceeding further, it is important to clarify two key terms as they are used in this Unit: 

service delivery program (program) and systems change project (project). 

· A service delivery program is a component of the overall Title V Initiative that is 

designed to provide services directly to clients or participants in the community. 

Examples of "service delivery programs" would include parent training programs, 

counseling for youth, mentoring programs for teens, tutoring programs for students, home 

visitor services for new parents, school-based recreational services, etc. In service 

delivery programs, individual youth or families will have direct contact with a service 

provider and receive individual benefit from participating in the program. 

· A systems change project is a component of the overall Title V Initiative that has broader 

community-level implications. Projects are designed to bring about system-level change 

rather than changes in individuals. Examples of Title V "systems change projects" would 

include community organizing, media campaigns, lobbying efforts, information 

dissemination, community policing, school development strategies, etc. Systems change 

projects may be a one-time event (e.g., obtaining signatures for a petition) or a series of 

events (e.g., an ongoing lobbying effort to change a local ordinance) designed to achieve 

one of your Title V prevention goals. 

In your Title V Prevention Plan, your Prevention Policy Board (PPB) may have decided to focus 

solely on one or the other, or some combination of service delivery programs and systems 

change projects. These are the things you entered on Form 1-9, Risk Factors and 

Program Plan, when you listed the various programs and projects in your Title V 

Delinquency Prevention Plan to address the priority risk factors in your community. 
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The Metropolis example, provided in Unit 1 with Form 1-9, is presented below with service 

delivery programs and systems change projects identified appropriately. In their Title V grant 

application, Metropolis selected two service delivery programs and six systems change projects 

to address the three priority risk factors in their community. (Note that one program, the 

Metropolis Community College Family Life Program, addresses two risk factors.)

Sample Table: Service Delivery Program/Systems Change Project Distinction

A. Priority Risk 

Factors

B. Programs or Projects that Address the 

Risk Factor

Service Delivery Program/

Systems Change Project

1) Family 

History of the 

High Risk 

Behavior

a. Metropolis Medical Center's Healthy Pregnancy 

Program For Addicted Mothers 

b. Metropolis Community College Family Life Program

a. Service Delivery Program

b. Service Delivery Program

2) Availability of 

Drugs

a. East Metropolis "Neighborhood Drug Watch"

b. City Council review of local zoning ordinance for bars

c. Stricter enforcement by local bars of "carding" of 

minors

a. Systems Change Project

b. Systems Change Project

c. Systems Change Project

3) Favorable 

Attitudes 

Toward Drugs

a. WROCK Radio Station Ad Campaign

b. Metropolis TV Public Service Announcement

c. Metro Elementary School Drug Information 

Curriculum 

d. Metropolis Community College Family Life Program

a. Systems Change Project

b. Systems Change Project

c. Systems Change Project

d. Service Delivery Program

While service delivery programs and systems change projects both have the ultimate goal of 

reducing delinquency and improving the overall quality of life in the community, their focus and 

processes are different, and so to capture them accurately in the evaluation, the Forms they 

require also are somewhat different. Unit 2, therefore, has two sets of Forms, listed in the box 

on the following page. One set, labeled A, is to be used for the service delivery programs you 

implement as part of your Title V Initiative, and the other, labeled B, for systems change 

projects. 

For each service delivery program and systems change project you listed on Form 1-9 (as well as 

any others you may decide to undertake in the future), you will fill out a complete set of the four 

Forms—either service delivery program or systems change project—in this Unit. In the 

Metropolis example, they would complete two sets of Unit 2 A Forms for service delivery 

programs and six sets of Unit 2 B Forms for systems change projects. (Note that while the 

Metropolis Community College Family Life Program is listed twice in the table because it 

addresses two risk factors, it would require only one set of program forms.) 
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If you’re not sure whether the particular Title V activity you’re planning to implement is a 

service delivery program or a systems change project, and therefore which set of Forms to use, 

start with service delivery program Form 2-1A Service Delivery Program Description. Think 

about the specific individuals or group of individuals who would receive program services

directly, and how many hours of the program service they would receive. If you can’t easily 

answer these questions, it’s probably a systems change project, and you should use Forms 2-1B 

to 2-4B.

UNIT 2 FORMS*

Service Delivery Programs

2-1A Service Delivery Program Description

2-2A Service Delivery Program Implementation Log

2-3A Service Delivery Program Process Assessment

2-4A Service Delivery Program Outcome Assessment

Systems Change Projects

2-1B Systems Change Project Description 

2-2B Systems Change Project Implementation Log

2-3B Systems Change Project Process Assessment

2-4B Systems Change Project Outcome Assessment

Who Should Complete the Forms in Unit 2? 

Someone who is very familiar with the respective Title V program(s) or project(s) should 

complete the Forms in Unit 2. In most cases, no one person will have to complete all of these 

Forms for every service delivery program or systems change project you implement. Each set, 

as appropriate, should be completed by someone who knows the program or project well and can 

provide detailed, accurate information about it. 

* Many of the Forms in Unit 2 are adapted from worksheets found in Linney, J.A. & Wandersman, A. (1991). 

Prevention Plus III: Assessing Alcohol and Other Drug Prevention Programs at the School and Community 

Level. U.S. Department of Health and Human Services, Office for Substance Abuse Prevention.

Because different communities across the country will undertake many different types of 

activities to help address their specific juvenile problems and risk factors, there may be some 

items on these Forms that don’t apply to your specific Title V programs or projects. Try to 
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provide as much information as possible about them, but if something doesn’t seem to apply, 

write “NA” for Not Applicable.

A Final Word About the Purpose and Forms of Unit 2...

The Forms in Unit 2 are designed to help you capture very important information about the 

implementation of your Title V Initiative: what you did, how you did it, and how much of it you 

did. They also provide you with a framework to help think about the objectives and outcomes 

of your various programs and projects: how you define success and how you will know if 

you’ve achieved it. The Forms in this Unit, however, do not provide the tools you need to 

conduct formal outcome evaluations of each of your various Title V activities. Outcome 

evaluations are concerned with measuring the immediate effects of programs on those who 

receive the service. Outcome evaluations must be closely linked to program objectives, and 

these will, of course, vary greatly depending on the types of service delivery programs (or 

systems change projects) that you decide to offer. For example, if one of your programs is 

parenting effectiveness training and another is mentoring at-risk youth, these two programs will 

have different objectives and different outcome measures. While you may choose to conduct 

more in-depth and sophisticated outcome evaluations of some or all of your individual Title V 

service delivery programs or systems change projects, such evaluations will require more 

detailed consideration of the appropriate evaluation design and measurement tools to be 

used—beyond what is included in these Unit 2 Forms. On the following page is a list of several 

additional resources that you may find useful in designing more program-specific outcome 

evaluations. 

Unit 2 Reminders

 Do not write on the original Forms in this Unit. Make 

one copy of the appropriate set of Forms for each

service delivery program and each systems change 

project that is part of your overall Title V Initiative 

(see Form 1-9).

 Delegate responsibility for completing each set of Forms 
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to someone who is familiar with the service delivery 

program or systems change project and can 

complete them accurately and objectively.

 Include as much information as you can. If some 

questions or sections do not seem to apply to a given 

service delivery program or systems change project, 

write “NA” for Not Applicable.

Program/Project Evaluation Resources 

 Community Research Associates, Inc.. (1989) Evaluating Juvenile Justice Programs: A 

Design Monograph for State Planners. CRA's Monograph for State Planners is an 

evaluation planning guide for juvenile justice systems. Contact: Community Research 

Associates, 41E University, Suite 3A, Champaign, IL 61820; 217-398-3120.

 Developmental Research and Programs, Inc. (1995) Communities That Care (CTC) 

Youth Survey. CTC's Youth Survey is a validated instrument that measures risk and 

protective factors among sixth through twelfth-grade students. For more information 

about this survey, as well as other CTC community prevention program implementation 

and evaluation resources, contact: Developmental Research and Programs, Inc. (DRP), 

130 Nickerson, Suite 107, Seattle, WA 98109; 1-800-736-2630.

 Gottfredson, D., Fink, C., Harmon, M., Lopes, J. & Gottfredson, G. (1993) 

Compendium of Instruments to Measure Drug Use and Risk Factors for Drug Use. 

Institute of Criminal Justice and Criminology, University of Maryland. Compendium of 

Instruments to Measure Drug Use and Risk Factors for Drug Involvement describes and 

assesses a variety of validated instruments that could be used in evaluations of drug use 

prevention programs. Contact: Institute of Criminal Justice and Criminology, 

University of Maryland; 301-405-4699.

 Hawkins, D. & Nederhood, B. (1987) Handbook for Evaluating Drug and Alcohol 
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Prevention Programs. Staff/Team Evaluation of Prevention Programs (STEPP). U.S. 

Department of Health and Human Services, Office for Substance Abuse Prevention. The 

STEPP Handbook provides instruments and activities for determining program 

effectiveness, as well as documenting and monitoring the provision of services. Contact: 

National Clearinghouse for Alcohol and Drug Information (NCADI), P.O. Box 2345, 

Rockville, MD 20847-2345; 1-800-729-6686.

 Kumpfer, K., Shur, G., Ross, J., Bunnell, K., Librett, J. & Millward, A. (1993) 

Measurements in Prevention: A Manual on Selecting and Using Instruments To Evaluate 

Prevention Programs. U.S. Department of Health and Human Services, Center for 

Substance Abuse Prevention. Measurements in Prevention is a large of compendium aimed at helping 

readers select appropriate instruments to evaluate substance abuse and other prevention programs. Contact: 

National Clearinghouse for Alcohol and Drug Information (NCADI), P.O. Box 2345, Rockville, MD 

20847-2345; 1-800-729-6686.

 Linney, J.A. & Wandersman, A. (1991) Prevention Plus III: Assessing Alcohol and Other Drug Prevention 

Programs at the School and Community Level. U.S. Department of Health and Human Services, Office for 

Substance Abuse Prevention. Prevention Plus III presents tools and techniques for a four step program 

assessment process and also includes survey instruments that can be used to measure program outcomes and 

impacts. Contact: National Clearinghouse for Alcohol and Drug Information (NCADI), P.O. Box 2345, 

Rockville, MD 20847-2345; 1-800-729-6686.

 Muraskin, L. (1993) Understanding Evaluation: The Way to Better Prevention Programs. Prepared by 

Westat, Inc. for the U.S. Department of Education (1993). Understanding Evaluation describes the why and 

how of program evaluation. Contact: National Clearinghouse for Alcohol and Drug Information (NCADI), P.O. 

Box 2345, Rockville, MD 20847-2345; 1-800-729-6686.

 The National Crime Prevention Council. (1986) What, Me Evaluate? A Basic Evaluation Guide for Citizen 

Crime Prevention Programs. What, Me Evaluate? outlines in easy-to-understand language the steps to 

conducting basic evaluations of crime prevention programs. Contact: National Crime Prevention Council, 723 

15th Street, NW, Suite 540, Washington, D.C. 20005; 202-393-7141.

 Sage Publications. (1987) Program Evaluation Kit, Second Edition. The Sage Publications Program 

Evaluation Kit contains nine volumes of practical, field-tested, step-by-step guides that can aid practitioners in 

planning and conducting evaluations. Contact: Sage Publications, Inc., P.O. Box 508, Thousand Oaks, CA, 

91359-9924; 

805- 499-9774.

FORM 2-1A: SERVICE DELIVERY PROGRAM DESCRIPTION

WHEN TO USE:UPON INITIATING A TITLE V SERVICE DELIVERY PROGRAM 

KEY FEATURES: CHARACTERISTICS OF THE PROGRAM

This Form provides a general description of a community service delivery program. It answers 

several fundamental process evaluation questions, including: what? why? where? when? who? 

for whom? and if successful, what happens?
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BEFORE YOU BEGIN:

Do not write on the original Form. Make additional copies of the three pages of Form 

2-1A. You will need one full set for each service delivery program that is part of your 

Title V Initiative. 

Remember to use Form 2-1A for Title V service delivery programs and Form 2-1B for Title V 

systems change projects. Refer to the Unit 2 introduction for a description of the 

difference between service delivery programs and systems change projects. 

1. Program Overview (What?) 

A. Program Name Fill in the name or title of the service delivery program.

B. Lead Organization(s) Write the name of the organization(s) or agencies with primary 

responsibility for implementing the program. For example, if the school board and the 

NAACP are cooperating to run a Title V mentoring program to keep kids in school, write 

the names of both organizations. 

C. Planned Program Period Write the beginning and ending dates of the program cycle 

that the Prevention Policy Board has selected for this program to be part of the Title V 

Initiative. If the program period is on-going or does not have a scheduled end date, write 

"indefinite" next to the date space. Use item "E," Brief Program Description, to add any 

additional information related to the program period (e.g., the program is a continuation 

or extension of a pre-existing community program).

D. Amount of Direct Funding for This Program From Title V Enter the total dollar 

amount of funding (or the dollar value of in-kind resources) received by this program 

through Title V (including both grant and matching funds). 

E. Brief Program Description Write a brief description of the program, summarizing its 

purpose and process. Describe the program as if you were explaining it to an outside 

reader. To provide additional background information on your program, you may attach 

relevant program brochures or fact sheets as part of the Workbook appendix. 

Sample: Form 2-1A Brief Program Description 

 

The Apple Program for Toddlers is a full-day early childhood education program operated 

under the auspices of the county office for family and children services. The Apple 
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Program is dedicated to supporting the developmental, cognitive, and emotional 

development of at-risk two year olds. The Program pays particular attention to the 

development of language skills. The center-based program is an extension of the Apple 

Pre-School Program, which has served over 200 three and four year olds in the community 

since 1990. 

2. Objectives and Desired Outcomes (Why?)

What are the objectives and desired outcomes of this program? What do you hope 

to accomplish? What protective/resiliency factors will be enhanced by this 

program? Describe the specific objectives and desired outcomes of the program. To 

complete this section, finish this set of statements: "After completing this program or 

being involved in it, participants will..., should know how to..., be able to..., or 

understand..." Desired outcomes will include the changes in knowledge, attitudes, skills, 

behaviors, expectations or emotional status that the program or activity is designed to bring 

about in individuals, families, or community groups. Achieving these desired outcomes 

should support the achievement of the overall Title V goals and objectives established by 

your community's PPB and recorded on Form 1-8. Examples of desired outcomes of a 

Title V service delivery program might include:

· Enhanced parents' understanding of effective parent/child communication strategies.

· Increased children's knowledge of the effects and danger of alcohol.

· Enhanced bonding of students to teachers. 

· Decreased specific behavioral problems in pre-school children. 

· Increased participation of teens in after-school recreation programs.

· Improved clients' job skills and employment prospects.

· Increased teachers' use of pro-active classroom management strategies.

 As illustrated in these examples, desired outcomes should be attainable, measurable, and 

within the control of the program itself. 

3. Operations (Where? When?)

A. Program Site/Setting Write the primary location of the program (e.g., school, church, 

summer camp, program center).

B. Hours of Operation Indicate the days of the week and hours of the day that the 

program typically operates. For some service delivery programs, the hours of 

operation will be very well defined, e.g., "Monday through Thursday from 9 am to 6 pm 

and Saturdays from 11 am to 3 pm." For other programs, however, hours of operation 

will be less specific. For example, a tutoring program may operate "after-school and 
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weekends as worked out between individual tutors and students."

4. Program Staff (Who?) 

A. General Description of Program Staff Provide a brief description of program staff. 

List the positions and/or relevant background of staff members (names are not 

necessary). For example, staff of a home visiting program for new parents might 

include: a program administrator who has responsibility for program management and 

general oversight, three social workers who conduct the home visits, a registered nurse 

who provides health care consultation, a secretary/receptionist who provides support and 

administrative services, and several unpaid high-school interns who accompany staff on 

home visits. 

B. Number of Program Staff Write the number of staff who contribute to the program in 

each of the following areas: managers, service providers, administrative/clerical staff, 

volunteers, and others. Distinguish full-time and part-time staff by marking them in the 

appropriate columns provided. Full-time staff work 35 or more hours per week; 

Part-time staff work less than 35 hours per week. In the home visiting program 

described above in Item 4A, the program staff includes: 1 full-time manager (the 

program administrator), 3 full-time service providers (the social workers), 1 part-time 

service provider (the registered nurse), 1 part-time clerical staff (the 

secretary/receptionist) and 6 part-time volunteers (the high-school students). 

C. Special Training Needed By Staff to Provide Services In the columns provided, list the 

type(s) of training needed by staff to properly provide services in your program, the 

position of staff needing this training, and the dates this training was (or will be) 

provided. Examples of special training include: Child Development Associate (CDA) 

training for early childhood teachers; conflict resolution training for peer mediators; 

"Issues in Substance Abuse" training for service providers.

5. Specific Program Services and Activities (What Goes On?) 

A. Services and Activities Describe the specific services provided and activities conducted 

by program staff. A mentoring program sponsored by a local business/school 

partnership might list here: weekly one-on-one tutoring services, monthly group 

recreational activities, and quarterly student visits to observe the workplace. A parent 

training program might specify: weekly parenting classes, mothers' support groups, 

individual and family counseling, monthly home visits, and as-needed information and 

referral services. 

B. Materials and Curriculum Name any specific program materials, curriculum, or 
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models used by the program. For example, Keys to Caregiving Videotape Series,

Parents as Teachers Curriculum, and STAR Model.

6. Population Served (For Whom?) 

A. Program Participants and Service Recipients (Target Population) Describe the 

population(s) intended to participate in program activities or receive program services. 

Selected populations might be characterized by their: location (such as children from a 

school district, citizens within a police precinct, or residents in a public housing 

development), status (e.g., abused children, high-school dropouts, teen moms, families 

living in poverty), race, gender or other shared attributes.

B. Age Range of Target Population(s) If applicable, indicate the age range of the target 

population(s). 

C. Eligibility Requirements (e.g., income level, academic standing, legal status, other) 

Can anyone participate in your program or are there guidelines or selection criteria that 

determine eligibility? Describe any income level requirements, academic standings, 

legal status qualifications, or other eligibility requirements for your program. Examples 

of eligibility requirements for target populations might include: 

· Earning annual household incomes of less than $10,000.

· Being behind grade level for one's age group.

· Maintaining prior arrests.

· Living in a foster home.

· Completing a prerequisite program. 

If there are no eligibility requirements for your program, leave this section blank. 

D. Anticipated Number to be Served Enter the total projected number of program 

participants or service recipients.

7. Measures of Program Success (If Successful, What Happens?)

Describe how you will know that your service delivery program is successful and list 

specific measures or indicators of success. For each of the program objectives and desired 

outcomes listed in Item 2 above, identify potential evidence that will show that the 

outcome was accomplished. These measures or indicators may be collected from a 

variety of sources including existing records or databases (e.g., school attendance records 

or police files), participant surveys, or direct observations. 
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For example, measures of program success for a parenting training program might include: 

· 80% of enrolled parents complete all the training sessions.

· 90% of participating parents receive satisfactory ratings by the program leader for 

their in-class role plays of parent/child interaction.

· A majority of parents score 70% or better on the parenting skills test administered at 

the end of the program.

· Most parents report improvement in their levels of parenting satisfaction and sense 

of competence.

· 50% or more children of participating parents show marked improvement on selected 

child development and behavior indices.

Be as specific as possible in listing your measures of program success.

8. Other Program Notes or Special Circumstances (But...) 

Note any other special circumstances or pre-existing conditions that may affect the service 

delivery program and its potential for success. Describe any elements not included on this 

Form that are important for understanding the program and putting the desired outcomes 

and measures of success into perspective. 
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FORM 2-1B: SYSTEMS CHANGE PROJECT DESCRIPTION

WHEN TO USE: UPON INITIATING A TITLE V SYSTEMS CHANGE PROJECT

KEY FEATURES: CHARACTERISTICS OF THE PROJECT

This Form provides a general description of a systems change project. It answers several 

fundamental process evaluation questions, including: what? why? where? when? who? for 

whom? and if successful, what happens?

BEFORE YOU BEGIN:

Do not write on the original Form. Make additional copies of the three pages of Form 

2-1B. You will need one full set for each systems change project that is part of your Title V 

Initiative. 

Remember to use Form 2-1B for Title V systems change projects and Form 2-1A for Title V 

service delivery programs. Refer to the Unit 2 introduction for a description of the 

difference between service delivery programs and systems change projects. 

Title V projects will vary greatly in nature and characteristics. As such, not every systems 

change project will be able to answer every question on this Form. Write "NA" for those 

questions that are not applicable.

1. Project Overview (What?)

A. Project Name Fill in the name or title of the systems change project.

B. Lead Organization(s) Write the name of the organization(s) or agencies with primary 

responsibility for implementing the project. 

C. Planned Project Period Write the beginning and ending dates of the project cycle that 

the Prevention Policy Board has selected for this project to be part of the Title V 

Initiative. If the project period is on-going or does not have a scheduled end date, write 

"indefinite" next to the date space. Use item "E," Brief Project Description, to add any 

additional information related to the project period (e.g., the project is an extension of a 

pre-existing project).

D. Amount of Direct Funding for This Project From Title V Enter the total dollar amount 

of funding (or the dollar value of in-kind resources) received by this project through Title 

V (including both grant and matching funds). 
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E. Brief Project Description Write a brief description of the project, summarizing its 

purpose and process. Describe the project as if you were explaining it to an outside 

reader. To provide additional background information on your project, you may attach 

relevant project brochures or fact sheets as part of the Workbook appendix. 

Sample: Form 2-1B Brief Project Description 

The "Parents as Partners Campaign" is a new initiative of the Calvert County School 

System aimed at increasing parent involvement in their children's education. During the 

month of September, parents will be encouraged to join the PTA of their child's school 

through public service announcements on the local radio station, notices posted 

throughout the community, and flyers sent home with each student. A special 

open-school night event will be held to bring parents, teachers, and administrators 

together to discuss ways in which parents can play an active and meaningful role in the 

planning and implementation of school policies. 

2. Objectives and Desired Outcomes (Why?) 

What are the objectives and desired outcomes of this systems change project? 

What do you hope to accomplish? What protective/resiliency factors will be 

enhanced?

Describe the objectives and desired outcomes of the systems change project. To 

complete this section, finish this set of statements: "After completing this systems 

change project, community members will..., should know how to..., be able to..., or 

understand..." Desired outcomes will include the changes that the systems change 

project or activity is designed to bring about in the broader community or community 

systems. These changes should support the overall Title V goals and objectives 

established by your community's PPB. Examples of desired outcomes for systems 

change projects might include:

· Reclaimed and cleaned-up a neighborhood park, which had become a popular 

spot for drug activity.

· Enacted new school policies with clear consequences for carrying firearms. 

· Increased community awareness of the problems of drug abuse and the 

availability of community service delivery programs through the use of media 

campaigns. 

· Increased student resistance to gang involvement. 

· Eliminated billboards advertising cigarettes and alcohol within a five mile 

radius of the town's schools. 

· Limited the sale of alcohol to minors by community bars.

Desired outcomes for most systems change projects will be related to group and 
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system-level changes rather than changes in particular individuals. 

3. Operations (Where? When?)

A. Project Site/Setting Write the primary setting of the systems change project (e.g., 

neighborhood, school, police precinct, entire community).

B. Schedule (if applicable) Where appropriate, note the days and hours that the project 

will be in operation. For example, a public service announcement might run every night 

between 10 p.m. and 11 p.m. or a neighborhood mobilization meeting might be convened 

for 3 hours on a particular afternoon. Write "NA" if there are no specific operating 

hours for your project.

4. Project Staff (Who?) 

General Description of Project Staff or Organizers Provide a brief description of 

project staff or principal organizers. List the positions and or relevant background of 

staff members (names are not necessary). For example, in the "Parents as Partners 

Campaign" project described above, a school principal may provide broad oversight for 

the project, four teachers may be charged with the development and distribution of 

publicity notices and flyers, and two parent organizers may lead on-going mobilization 

and monitoring efforts.

5. Specific Project Events and Activities (What Goes On?) 

Describe the specific events and activities to be implemented as part of this project. 

These might include, for example: policy reviews, curriculum development, recruitment 

drives, community meetings, alcohol-free graduation celebrations, public service 

announcements, school assemblies, dissemination of bumper stickers, special 

performances, etc. 

6. Target Audience(s), Community Population(s), or System(s) Served (For Whom?) 

Describe the target audience(s), population(s) or system(s) expected to be affected by 

project services. These may be defined groups (such as residents who live in a particular 

housing development or schools within a particular school system) or the broader 

community.
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7. Measures of Project Success (If Successful, What Happens?)

Describe how you will know that the project is successful and list specific measures or 

indicators of success. For each of the desired outcomes listed in Item 2 above, identify 

potential evidence that will show that the outcome was accomplished. For a prevention 

media campaign, for example, measures of project success might include: 

· Count of PSA presentations from a TV station log.

· Count of print advertisements in community newspapers.

· Count of cars with bumper stickers along a busy intersection.

· Survey of resident attitudes about alcohol and drug use and dangers.

· Survey of resident knowledge of community alcohol and drug prevention and 

intervention programs.

· Reported use of alcohol and drugs among community youth.

Measures of project success should be tailored to meet the goals and characteristics of the 

project. Be as specific as possible when answering the question, "How will we know if 

this systems change project has been successful?"

8. Other Project Notes or Special Circumstances (But...) 

Note any other circumstances or pre-existing conditions that may affect the systems 

change project and its potential for success. Describe any elements not included on this 

Form that are important for understanding the project and putting the desired outcomes 

and measures of success into perspective. 
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FORM 2-2A: SERVICE DELIVERY PROGRAM IMPLEMENTATION LOG 

WHEN TO USE:THROUGHOUT EACH PROGRAM YEAR 

KEY FEATURES: SUMMARY OF PROGRAM COMPONENTS

Every service delivery program can be broken down into a series of separate components (i.e., 

steps, activities, and services) that make up the work of the program and produce program 

outcomes. With this Form you will keep an annual log of these program components. This 

Form is not meant to substitute for whatever detailed records (e.g., attendance records or client 

case records) that you will keep as a regular part of your program management practices. The 

Form is a tool for summarizing your program records.

BEFORE YOU BEGIN:

 Do not write on the original Form. Make additional copies of Form 2-2A. Each 

year, you will need to complete Form 2-2A for each on-going service delivery program

that is part of your Title V Initiative. If an individual program has many component 

parts, you may need multiple copies of the Form each year.

 Remember to use Form 2-2A for Title V service delivery programs and Form 2-2B for 

Title V systems change projects. Refer to the Unit 2 introduction for a description of 

the difference between service delivery programs and systems change projects. 

 To guide you through the completion of Form 2-3A, a Sample Implementation Log for 

the Metropolis Community College Family Life Program is included on page 19. As 

you read the instructions, follow along with the Sample Log — it will be easier to 

understand! 

1. Program and Year

A. Program Name Enter the name or title of your service delivery program.

B. Year Enter the year for which you are completing this log. Remember, you need to 

complete one Service Delivery Program Implementation Log for each year of the 

program period. (If your program begins in September 1995, leave the months from 

January to August blank in 1995 and start a new log for January 1996.)

2. Implementation Log
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A. Program Components In the left-hand column of the table, fill in the various steps, 

activities and services that make up the program. Begin with the important preparatory 

steps that laid the foundation for achieving desired outcomes (such as recruiting 

volunteers or training service providers), then list the activities related to the desired 

program outcomes (such as counseling sessions with clients or after-school sports 

services for teens). Your program may actually be composed of many, many small 

tasks. Try to group smaller tasks together and list only the most significant steps, 

activities, and services. Be as specific as possible in your brief description of each 

program component.

Number each program component sequentially. If you have more than six components 

during a given year, you will need to copy additional Forms for the same year. (If the 

component continues into a new year, use the same identifier number each year.)

Use the list below for ideas to get you started. This list may not include all of the steps, 

services or activities that your program actually implemented, but it will give you an idea 

of the kinds of things to include.

Examples of Program Components

· Train staff or volunteers

· Develop curricula

· Circulate flyers or brochures

· Perform client needs assessments

· Hold classes for participants

· Provide health screenings

· Give presentations or lectures

· Hold socials or ceremonies

· Conduct workshops 

· Make mentoring matches

· Sponsor sports programs

· Hold field trips

· Attend cultural events

· Sponsor job training sessions

· Provide direct services for clients 

· Visit families at home

In the Metropolis example... The first major activity of the Metropolis Community 

College Family Life Program was to provide training for trainers in early January, 1995. 

Throughout the year, subsequent program activities and services for Metropolis parents 

and families included: parent training classes, home visits, family dinners, a special 

lecture, and a winter holiday family celebration.

B. Number Served/Participating Per Month (Unshaded Top Box) For each of the 

program components listed in the first column, write the number served or number 
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participating in that program component in the top unshaded box under each month of the 

year. This number may represent teachers trained, families served, youth counseled, 

volunteers recruited, or another participant unit of the specific component. Note that this 

monthly number served may count individual participants multiple times if they received 

services or had contact with the program more than one time during that month. Enter 0 

under months where the specific program component did not take place.

In the Metropolis example... There was a Training for Trainers Session held in January. 

Since 2 parent trainers received one day of training, the number 2 is written in the top 

box under "Jan" and 0's are entered for the remaining months. The second component 

activity was Parent Training Classes (item 2). They were held twice per month with 

varying participation rates among the 18 enrolled parents: during January, 18 parents 

attended the first session and 16 attended the second for a total participation of 34 parents 

for the month; in February, 6 parents attended the first session and 4 attended the second 

class for a total participation of 10 parents for the month. Home visits (item 3) also were 

conducted as part of the Family Life Program. Home visits were conducted in 10 homes 

in January, 9 in February, and 12 in March. And so on throughout the year. 

C. Average Session Time in Hours (Shaded Bottom Box) For each of the program 

components listed in the first column, write the average number of hours that services 

were provided or activities were conducted in the bottom shaded box under each month 

of the year. Round actual times to increments of quarter hours. If there were several 

sessions or activities of varying lengths of time during the month, enter the average time 

spent. For example, if three youth received counseling sessions of 1 hour, 3/4 hour, 1 

1/4 hours, respectively, then the average time entered would be 1 hour. 

In the Metropolis example... Parent Training Classes (item 2) were conducted twice per 

month for 2 hours per class, totaling 4 hours per month. In August, 1 two-hour class was 

canceled, so only 2 hours are entered.

D. Total Served and Unit Enter the total number of unduplicated participants served during 

the year. That is to say, enter the total number of individuals, families, or groups served, 

regardless of the number of contacts each made with the program during the year. Let's 

say, for example, that Joe, Terence, and Camile attend a job training workshop in 

February and Joe, Terence, and Sandy attend a second workshop in March. The total 

unduplicated number served for the job training program would be four people (Joe, 

Terence, Camile, and Sandy). Be sure to specify the unit (students, parents, families, 

volunteers, community members, etc.). This unit should be the same unit that is used for 

the numbers entered in B, Number Served/Participating Per Month. 
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In the Metropolis example... A total of 18 parents from 11 families were enrolled in the 

program. Over the course of the year, different numbers of parents attended each Parent 

Training Class (item 2), but all 18 of the parents attended 1 or more of the classes and so 

18 Parents is entered in column D. Similarly, the 4 Family Dinners (item 4) were 

attended by 8, 6, 7 and 8 families respectively with some of the same families attending 

more than one dinner and the total number of different families served was 9.

E. Notes and Explanations Enter any special notes or brief explanations that clarify the 

program component or explain unusual levels of participation. 

In the Metropolis example... The Family Life Program's February Parent Training Class 

experienced low turnout rates because of bad snow storms, which are noted in the last 

column. 
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INSERT EXAMPLE
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FORM 2-2B: SYSTEMS CHANGE PROJECT IMPLEMENTATION LOG 

WHEN TO USE:THROUGHOUT EACH PROJECT PERIOD

KEY FEATURES: SUMMARY OF PROJECT ACTIVITIES/STEPS/EVENTS

Like service delivery programs, systems change projects can be broken down into a series of 

separate steps, activities, and events that make up the work of the project and produce the 

project's outcomes. With this Form you will keep a log of these project components over the 

project period.

BEFORE YOU BEGIN:

 Do not write on the original Form. Make additional copies of Form 2-2B. You will 

need to complete Form 2-2B for each systems change project that is part of your Title V 

Initiative. If an individual project has many components, you may need multiple 

copies of the Form for the same project.

 Remember to use Form 2-2B for Title V systems change projects and Form 2-2A for 

Title V service delivery programs. Refer to the Unit 2 introduction for a description of 

the difference between service delivery programs and systems change projects. 

 To guide you through the completion of Form 2-2B, a Sample Systems Change Project 

Implementation Log for the Metropolis Carding Campaign is included on page 23. As 

you read the instructions, follow along with the Sample Log — it will be easier to 

understand!

1. Project Name Enter the name or title of your systems change project.

2. Implementation Log

A. Project Components In the left-hand column of the table, fill in the various steps, 

activities, and events that make up the project. Begin with the important preparatory 

steps that laid the foundation for achieving desired project outcomes (such as convening 

community meetings or establishing new policy guidelines) and then list any events or 

activities related to the desired outcomes (such as public service announcements, pep 

rallies, or changes in a local ordinance). Your project may actually be composed of 

many, many small tasks. Try to group smaller tasks together and list only the most 

significant steps, activities, and events. Be as specific as possible in your brief 

description of the project components. 
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Number each project component sequentially. If you have more than six components for 

a given project, you will need to copy additional Forms for that project.

Use the list below for ideas to get you started. This list may not include all of the steps, 

events, or activities that your project actually implemented, but it will give you an idea of 

the kinds of things to include.

Examples of Project Components

· Form committee

· Establish policies and guidelines

· Place newspaper or radio ads 

· Hold lectures

· Mobilize community groups

· Sign petitions

· Sponsor cultural events

· Organize street fairs

· Hold community service activities

· Develop curricula

· Plan ceremonies

· Change legal standards

In the Metropolis example... The Metropolis Carding Campaign consisted of the 

following components: drafting a campaign plan, presenting the campaign plan at a 

kick-off meeting for the key community players, publicizing the campaign throughout the 

community, implementing new policies, and checking enforcement of the policies and 

procedures. These project components are listed in the sample log's first column.

B. Dates For each of the components listed in the first column, indicate the relevant date or 

dates on which the component occurred. If the action is ongoing, note with an open 

arrow.

C. Number and Unit Involved For each of the components listed in the first column, write 

the number involved or participating and the unit to which it refers. This number and 

unit may represent committee members who attended a meeting, schools implementing 

new policies, advertisements printed, media spots announced, doors knocked on, 

billboards removed, etc. In some cases, the number will be unknown or uncountable and 

should be noted as such.

In the Metropolis example... Six (6) Carding Campaign committee members drafted a 

new plan, 83 attendees went to the Campaign kick-off meeting, 500 flyers were printed 

and distributed, an unspecified number of bars implemented the new carding policies, and 

on one evening police checked enforcement of the new policy at 15 bars.

D. Materials Used For each of the components listed in the first column, describe any 
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materials used to support the step, activity, or event. Relevant materials may include 

curricula, manuals, community records, petitions, flyers, billboards, etc. If no materials 

were used, write "NA" for "not applicable."

E. Notes and Explanations Enter any special notes or brief explanations that clarify the 

project component or explain levels of progress and participation. 

In the Metropolis Example... The delay in schedule for the draft Carding Campaign 

Plan and the under-representation of specific participants are noted in the final column. 
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INSERT EXAMPLE
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FORM 2-3A: SERVICE DELIVERY PROGRAM PROCESS ASSESSMENT 

WHEN TO USE:AT THE END OF THE PROGRAM PERIOD 

KEY FEATURES: REFLECTIONS ON IMPLEMENTATION PROCESS

This Form examines several process evaluation issues for your Title V service delivery program. 

In particular, the Form asks you to compare actual program implementation processes with the 

original program plans. Your responses on this Form can be very helpful in shaping your future 

program plans. 

BEFORE YOU BEGIN:

 Do not write on the original Form. Make additional copies of all three pages of Form 

2-3A. You will need one full set for each service delivery program that is part of your 

Title V Initiative. 

 Remember to use Form 2-3A for Title V service delivery programs and Form 2-3B for 

Title V systems change projects. Refer to the Unit 2 introduction for a description of 

the difference between service delivery programs and systems change projects. 

 Refer to Forms 2-1A and 2-2A that you completed for this service delivery program. 

The information on these Forms will be used to compare original program plans and 

actual implementation results.

1. Program Name Enter the name or title of your service delivery program.

2. Program Period

A. Dates of Program Implementation Enter the beginning and ending dates of actual 

program implementation. 

B. Actual Implementation Schedule Compared to Planned Program Schedule In 

relation to the planned program period entered on Item 1C of Form 2-1A, note whether 

actual implementation was, for the most part, on schedule, ahead of the originally 

planned schedule, or behind the originally planned schedule.

C. If implementation differed from the originally planned schedule, what caused the 
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differences or delays? To what extent did the differences affect the program? 

Explain the factors that both facilitated or hindered the implementation of the program. 

Many different factors can influence implementation schedules, such as the presence or 

absence of the following: effective planning processes, timely decision-making, efficient 

organization, availability of resources, staff turnover, volunteer support, etc. Even the 

weather can be a factor that affects program implementation schedules!

3. Program Activities and Services 

A. What program activities and services were planned but not implemented? Why? 

Explain how the activities conducted and services actually provided differ from those 

which were planned. Include program components that you listed on Form 2-1A, Service 

Delivery Program Description, Item 5, but did not list on Form 2-2A, Service Delivery 

Program Implementation Log. Briefly explain why these activities or services were not 

implemented as part of the program.

B. What program activities and services were implemented that were not originally 

planned? Why? List the activities and services that were added to your program after 

the original planning process. Include program components that you listed on Form 

2-2A, Service Delivery Program Implementation Log, but did not list on Form 2-1A, 

Service Delivery Program Description, Item 5. Briefly explain why these activities or 

services were added to your program.

4. Participation 

A. To what extent did you achieve your participation goals (e.g., 50%, 100%, 200%)?

Using percentages, indicate the extent to which you achieved your participation goals. 

Review Form 2-1A, Item 6D to see how many participants you planned to serve in this 

program. How does this number compare with the actual number served, from Form 

2-2A, Item 2D? Did you achieve your goal with 100% of participants planned? Or did 

you exceed your goal? Twice as many participants served would mean you achieved 

200% of your goal. On the other hand, if you only served half as many as planned, you 

would have achieved 50% of your goal. Enter the percentage that reflects the 

participation level in your program relative to your goals.

B. What factors contributed to the actual level of participation in this program? 

Briefly describe the facilitating factors or barriers to participation levels. These factors 

may include, for example, recruitment methods, publicity efforts, program location, 

operating schedules, or community acceptance/resistance. 
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C. What group(s) were missing that you had hoped or intended to have participate in 

the program? Why? List any specific target groups that did not participate at the levels 

anticipated. Briefly explain what may have contributed to their low participation rates.

5. Participant Feedback 

A. How did participants evaluate the program? Briefly describe participant feedback 

regarding levels of satisfaction with the program and program activities. This feedback 

can be collected through participant assessment surveys, focus groups, or interviews. Be 

sure to describe the mechanisms you used to solicit participant feedback. As part of the 

appendix to your Workbook, you may want to attach supporting materials that include the 

participant assessment surveys or interview guides you used and/or summaries of 

participant responses.

B. What did participants like the most? Based on participant feedback, describe the 

components of the program that were well received. 

C. What did participants dislike? Based on participant feedback, describe the components 

of the program that were not as well received and why. List aspects of the program that 

participants thought needed the most improvement. What steps can be taken to address 

these issues and concerns?

 Refer to the box on page 28 for more information on collecting participant 

feedback.

6. Resources 

A. Were sufficient Title V funds devoted to this program to accomplish what was 

planned? Check the appropriate box to indicate whether available funds generally were 

in-line with what was needed to support planned activities and services, less than what 

was needed, or more than what was needed.

B. If funds were insufficient to support program objectives, where specifically were 

more funds needed? Indicate the specific areas for which funding was insufficient. 

Examples might include: salary resources to hire an additional case worker, funds to 

adequately advertise program activities, support for the purchase of program materials 

and supplies.

7. Reflections and Lessons Learned
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A. If your group were to implement the program over again, what would you do 

differently? What lessons did you learn? Thinking back over this program, describe 

the things that you would do differently if you had it to do over again. Briefly explain 

the "lessons learned" from the program implementation. 

B. What would you be sure to do again? Again, thinking back over the program, 

describe the things that you would want to do again—or maybe do more of—if you had it 

to do over again. Focus on the achievements of the program and list the processes or 

activities that helped facilitate success.

C. What advice would you give to someone who was planning to implement a similar 

program? Based on your experiences, what advice would you give to others who were 

planning to implement a similar program? Note what you would recommend doing and 

also not doing to promote effective implementation. If more space is needed, continue 

on an additional page.

Participant Feedback

Participant feedback about a program collected through participant assessment surveys can be 

an important component of program planning, implementation, and evaluation. Feedback 

helps tell planners how programs and activities are being received and if they are having their 

desired effects. Over time, participant feedback can be extremely valuable to the fine-tuning 

of program methods and practices to best meet participant needs. 

Participant assessment surveys typically include questions that address participant perceptions 

of the program and its activities, their likes and dislikes, and their recommendations for 

program improvement. Surveys may include both rating scales and open-ended questions. 

Following is a sample of the types of assessment questions that you might want to ask your 

program participants when soliciting feedback:

· Overall, how would you rate this program? (excellent, very good, satisfactory, fair, poor)
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· How well did the program meet your expectations (very well, somewhat, not at all)

· How useful was [specify program activity]? (very useful, somewhat useful, not very 

useful) 

· Was the material presented in an organized and coherent fashion? (very organized, 

somewhat organized, not at all organized)

· Was the material interesting to you? (very interesting, somewhat interesting, not at all 

interesting)

· Was the material relevant to your [specify needs]? (very relevant, somewhat relevant, not 

at all relevant)

· What did you like best about the program?

· What did you like least about the program?

· What should be done to improve the program?

Remember to keep the language in participant assessment surveys simple and to the point. 

Tailor your questions to reflect your program's particular characteristics and objectives. 

FORM 2-3B: SYSTEMS CHANGE PROJECT PROCESS ASSESSMENT 

WHEN TO USE:AT THE END OF THE PROJECT PERIOD 

KEY FEATURES: REFLECTIONS ON IMPLEMENTATION PROCESS

This Form examines several process evaluation issues for your Title V systems change project. 

In particular, the Form asks you to compare actual project implementation processes with the 

original project plans. Your responses on this Form can be very helpful in shaping your future 

project plans. 

BEFORE YOU BEGIN:

 Do not write on the original Form. Make additional copies of both pages of 

Form 2-3B. You will need one full set for each systems change project that is part of 

your Title V Initiative. 

 Remember to use Form 2-3B for Title V systems change projects and Form 2-3A for 
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Title V service delivery programs. Refer to the Unit 2 introduction for a description of 

the difference between service delivery programs and systems change projects. 

 Refer to Forms 2-1B and 2-2B that you completed for this systems change project. The 

information on these Forms will be used to compare original project plans and actual 

implementation results.

1. Project Name Enter the name or title of your systems change project.

2. Project Period

A. Dates of Project Implementation Enter the beginning and ending dates of actual project 

implementation. 

B. Actual Implementation Schedule Compared to Planned Project Schedule In 

relation to the planned project period entered on Item 1C of Form 2-1B, Systems Change 

Project Description, note whether actual implementation was, for the most part, on 

schedule, ahead of the originally planned schedule, or behind the originally planned 

schedule.

C. If implementation differed from the originally planned schedule, what caused the 

differences or delays? To what extent did the differences affect the project? 

Explain the factors that both facilitated or hindered the implementation of the project. 

Many different factors can influence implementation schedules, such as the presence or 

absence of the following: effective planning processes, timely decision-making, efficient 

organization, availability of resources, volunteer support, etc. Even the weather can be a 

factor that affects project implementation schedules!

3. Project Components 

A. What project steps, activities or events were planned but not implemented? Why? 

Explain how the project components differed from those that were planned. Include 

project components that you listed on Form 2-1B, Systems Change Project Description, 

Item 5, but did not list on Form 2-2B, Systems Change Project Implementation Log. 

Briefly explain why these activities or events were not implemented as planned.

B. What project steps, activities or events were implemented that were not originally 

planned? Why? List the project components that were added to your project after the 

original planning process. Include activities or events that you listed on Form 2-2B, 
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Systems Change Project Implementation Log, but did not list on Form 2-1B, Systems 

Change Project Description, Item 5. Briefly explain why your actual project steps, 

activities or events differed from your plans.

4. Resources 

A. Were sufficient Title V funds devoted to this project to accomplish what was 

planned? Check the appropriate box to indicate whether available funds generally were 

in-line with what was needed to support the planned project, less than what was needed, 

or more than what was needed.

B. If funds were insufficient to support project objectives, where specifically were more 

funds needed? Indicate the specific areas for which funds were insufficient. Examples 

might include: funds to adequately advertise and promote project activities or support 

for the purchase of project materials and supplies.

5. Reflections and Lessons Learned

A. If your group were to implement the project over again, what would you do 

differently? What lessons did you learn? Thinking back over this project, describe 

the things that you would do differently if you had it to do over again. Briefly explain 

the "lessons learned" from the project implementation. 

B. What would you be sure to do again? Again, thinking back over the project, describe 

the things that you would want to do again—or maybe do more of—if you had it to do 

over again. Focus on the achievements of the project and list the processes or activities 

that helped facilitate success.

C. What advice would you give to someone who was planning to implement a similar 

project? Based on your experiences, what advice would you give to others who were 

planning to implement a similar project? Note what you would recommend doing and 

also not doing to promote effective implementation. If more space is needed, continue 

on an additional page.
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FORM 2-4A: SERVICE DELIVERY PROGRAM OUTCOME ASSESSMENT

WHEN TO USE:AT THE END OF THE PROGRAM PERIOD

KEY FEATURES: MEASURES PROGRESS TOWARDS OBJECTIVES

This Form will help document the progress that your service delivery program has made towards 

achieving its objectives and desired outcomes. The Form focuses on the extent to which desired 

changes occurred as intended by the program in measurable outcome areas (e.g., test scores, 

school attendance, attitudes, and knowledge levels). This Form addresses whether or not each 

individual program has made progress toward achieving specific program objectives. The 

Forms in Unit 3 will address whether or not Title V programs and projects collectively have had 

an impact on reducing risk factors in the community.

BEFORE YOU BEGIN:

 Do not write on the original Form. Make additional copies of Form 2-4A. You will 

need one copy for each service delivery program that is part of your Title V Initiative. 

 Remember to use Form 2-4A for Title V service delivery programs and Form 2-4B for 

Title V systems change projects. Refer to the Unit 2 introduction for a description of 

the difference between service delivery programs and systems change projects. 

 Refer to Form 2-1A that you completed upon initiating this service delivery program. 

Information regarding desired outcomes and measures of program success will be used 

again here.

1. Program Name Enter the name or title of your service delivery program.

2. Outcome Assessment Table

A. Desired Outcomes Refer to the list of desired outcomes that you entered on Form 

2-1A, Service Delivery Program Description, Item 2, and list them again here. As 

explained in the instructions for Form 2-1A, these outcomes should represent the 

sought-after effects of the program.

B. Measure or Indicator ("Evidence" of Your Desired Outcome) For each desired 

outcome, indicate one or more measures or indicators for that outcome (refer to the 

Measures of Program Success that you listed on Form 2-1A, Item 7). For example, if 

the desired outcome of a tutoring program was to enhance school performance of 

students, then the appropriate measures/indicators might be school grades, teacher 
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assessments, or improvements in attendance. Alternatively, if the desired outcome 

was to provide an opportunity for youth to bond with volunteer mentors, then the 

indicator might be a survey question that asks youth how many adults they have in 

their lives that they feel they can "really talk to" or with whom they can "do fun 

things." The measure can be a simple tally of the number of participants, a 

standardized measure such as Grade Point Averages, scores of a test developed or 

adapted by the program (such as a test of knowledge on program topics), results of an 

attitude survey, behavioral indices, or some other measure that is unique to the 

program. 

C. Dates Measured or Observed Enter the dates for which evidence of your outcomes has 

been collected. To assess changes in outcome measures or indicators, you will need 

to collect data at two points in time: typically before, or at the beginning of the 

project period, and then again at the end, or soon after, the program period. In some 

instances, however, evidence will be collected only after the program has been 

completed. For example, a parent training program may administer a test—only at 

the final class session—which addresses the topics covered during the previous 

classes. If there is no before measure, write "none" in the "Before" column and then 

write the date of the single measure (e.g., the date the parenting test was administered) 

in the "After" column. 

D. Observed Measurable Outcome For each measure or indicator, write the appropriate 

value at the "Before" point and then write the value of the same measure at the 

"After" point. An example would be the average GPA of students before they 

completed a tutoring program and then the average GPA of the same group of students 

after the tutoring program ends. Note that if one of the participants drops out of the 

program and they are not included in the "After" group, then you should go back and 

take that participant's GPA out of the average shown for the "Before" group. In 

addition, if your program is using a "pre" and "post" survey, you should make sure to 

ask the same questions before and after the program is implemented. 

E. Amount of Change in Measure or Indicator (Before vs After) Compare the 

before and after values for the measures/indicators in column D. Calculate the 

amount of change in your outcome measure by subtracting the "Before" score from the 

"After" score and placing that value in column E. This value indicates how much 

your program gained on that measure over the course of the program. 
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For more detailed information about conducting outcome evaluations and the 

various resources you can use, see the resource list in the Unit 2 Introduction.

 Things to Think About When Completing Form 2-4A:

· What do the observed changes in measures/indicators indicate about the 

performance of your service delivery program? 

· What are the implications for future program planning and implementation?

· How much change is enough change for the program to be considered 

successful?

· What other factors—outside of the program—may be influencing the 

measures/indicators and the magnitude of change?
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FORM 2-4B: SYSTEMS CHANGE PROJECT OUTCOME ASSESSMENT

WHEN TO USE:AT THE END OF THE PROJECT PERIOD

KEY FEATURES: MEASURES PROGRESS TOWARDS OBJECTIVES

This Form will help document the progress that your systems change project has made towards 

achieving its objectives and desired outcomes. The Form focuses on the extent to which desired 

changes occurred as intended by the project in measurable outcome areas (e.g., amount of 

material distributed, number of billboards standing, attitudes and knowledge levels). This Form 

addresses whether or not each individual systems change project has made progress toward 

achieving specific project objectives. The Forms in Unit 3 will address whether or not Title V 

programs and projects collectively have had an impact on reducing risk factors in the community.

BEFORE YOU BEGIN:

 Do not write on the original Form. Make additional copies of Form 2-4B. You will 

need one copy for each systems change project that is part of your Title V Initiative. 

 Remember to use Form 2-4B for Title V systems change projects and Form 2-4A for 

Title V service delivery programs. Refer to the Unit 2 introduction for a description of 

the difference between service delivery programs and systems change projects. 

 Refer to Form 2-1B that you completed upon initiating this systems change project. 

Information regarding desired outcomes and measures of project success will be used 

again here.

1. Project Name Enter the name or title of your systems change project.

2. Outcome Assessment Table

A. Desired Outcomes Refer to the list of desired outcomes that you entered on Form 2-1B, 

Systems Change Project Description, Item 2, and list them again here. As explained in 

the instructions for Form 2-1B, these outcomes should represent the sought-after effects 

of the project.

B. Measure or Indicator ("Evidence" of Your Desired Outcome) For each desired 

outcome, indicate one or more measures or indicators for that outcome (refer to the 

Measures of Project Success that you listed on Form 2-1B, Item 7). For example, if a 

project's desired outcome is to increase the number of youth enrolled in school related 
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clubs and the project included a club fair at the school and increased publicity for clubs, 

then the "Before" project measurement might be the number of youth in clubs before the 

project, and the "After" project measurement might be the number of youth in clubs after 

the conclusion of project activities. The measure can be a simple count (e.g., number of 

materials distributed, number of PSAs, number of signatures on a petition, number of 

attendees at a community forum) or a survey measuring attitudes, knowledge, or reported 

behavior. 

C. Dates Measured or Observed Enter the dates for which evidence of your outcomes has 

been collected. To assess changes in outcome measures or indicators, data will need to 

be collected at two points of time: typically before or at the beginning of the project 

period and then again at the end or soon after the completion of the project period. In 

some instances, however, evidence will be collected only after the project. For example, 

in a lobbying effort you would only count the number of signatures on a petition after

they have been collected. If there is no before measure, write "none" in the "Before" 

column and then write the date of the single measure (e.g., the date the petition was 

submitted) in the "After" column.

D. Observed Measurable Outcome For each measure or indicator, write the appropriate 

value at the "Before" point and then write the value of the same measure at the "After" 

point. For example, enter the number of billboards advertising cigarettes before a 

billboard campaign and the number of billboards remaining after the campaign. 

E. Amount of Change in Measure or Indicator (Before vs After) Compare the before 

and after values for the measures/indicators in column D. Estimate the amount of 

change in your outcome measure by subtracting the "Before" score from the "After" score 

and placing that value in column E. This value indicates how much your project gained 

on that measure over the course of the project. 

Things to Think About When Completing Form 2-4B:

· What do the observed changes in measures/indicators indicate about the 

performance of your systems change project? 

· What are the implications for future project planning and implementation?

· How much change is enough change for the systems change project to be 

considered successful?
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· What other factors—outside of the project—may be influencing the 

measures/indicators and the magnitude of change?
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2-1A SERVICE DELIVERY PROGRAM DESCRIPTION

1. Program Overview (What?) 

A. Program Name: ____________________________________________________________________________________ 

B. Lead Organization(s): _______________________________________________________________________________

C. Planned Program Period: From ____/____/____To ____/____/____ 

D. Amount of Direct Funding for This Program From Title V: $____________________

E. Brief Program Description:

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

2. Objectives and Desired Outcomes (Why?)

What are the objectives and desired outcomes of this program? What do you hope to accomplish? 

What protective/resiliency factors will be enhanced?

"After completing this program or being involved in it, participants will..., should know how to..., be able to..., or 

understand..." 
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1) ___________________________________________________________________________________________________

___________________________________________________________________________________________________

2) ___________________________________________________________________________________________________

___________________________________________________________________________________________________

3) ___________________________________________________________________________________________________

___________________________________________________________________________________________________

4) ___________________________________________________________________________________________________

___________________________________________________________________________________________________

5) ___________________________________________________________________________________________________

___________________________________________________________________________________________________

3. Operations (Where? When?)

A. Program Site/Setting: _____________________________________________________________________________

B. Hours of Operation: _____________________________________________________________________________

4. Program Staff (Who?)

A. General Description of Program Staff: _______________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

B. Number of Program Staff:
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Staff

Managers

Service Providers

Administrative/Clerical Staff

Volunteers

Others

# Full-Time

 

 

 

 

 

# Part-Time

 

 

 

 

 

C. Special Training Needed by Program Staff to Provide Services:

Type of Training

 

 

 

 

 

 

Staff to be Trained

 

 

 

 

 

Dates Provided

 

 

 

5. Specific Program Services and Activities (What Goes On?) 

A. Services and Activities: _____________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________
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B. Materials and Curriculum: ___________________________________________________________________________

_______________________________________________________________________________________________________

6. Population Served (For Whom?)

A. Program Participants and Service Recipients (Target Population): _____________________________________

____________________________________________________________________________________________________

B. Age Range of Target Population(s): _________________________________________________________________ 

C. Eligibility Requirements (e.g., income level, academic standing, legal status, other): 

_______________________________________________________________________________________________________________________

_________________________________________________________________________________

D. Anticipated Number to Be Served: _________________________________________________________________

7. Measures of Program Success (If Successful, What Happens?)

How Will You Know If This Program Was Effective? What are Your Measures or Indicators of Success?

1)

___________________________________________________________________________________________________________________

_____________________________________________________________________________________ 

2)

___________________________________________________________________________________________________________________

_____________________________________________________________________________________ 
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3)

___________________________________________________________________________________________________________________

_____________________________________________________________________________________ 

4)

___________________________________________________________________________________________________________________

_____________________________________________________________________________________ 

5)

___________________________________________________________________________________________________________________

_____________________________________________________________________________________

8. Other Program Notes or Special Circumstances (But...) 

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

2-1B SYSTEMS CHANGE PROJECT DESCRIPTION
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1. Project Overview (What?)

A. Project Name: _____________________________________________________________________________________

B. Lead Organization: _______________________________________________________________________________

C. Planned Project Period: From ____/____/____ To ____/____/____

D. Amount of Direct Funding for This Project From Title V: $_________________

E. Brief Project Description:

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

____________________________________________________________________________________________

2. Objectives and Desired Outcomes (Why?)

What are the objectives and desired outcomes of this Project? What do you hope to accomplish? 

What protective/resiliency factors will be enhanced?

"After completing this Project, community members will..., should know how to..., be able to..., or understand..."

1) ___________________________________________________________________________________________________

___________________________________________________________________________________________________
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2) ___________________________________________________________________________________________________

___________________________________________________________________________________________________

3) ___________________________________________________________________________________________________

___________________________________________________________________________________________________

4) ___________________________________________________________________________________________________

___________________________________________________________________________________________________

5) ___________________________________________________________________________________________________

___________________________________________________________________________________________________

3. Operations (Where? When?)

A. Project Site/Setting: _____________________________________________________________________________

B. Schedule (if applicable): _____________________________________________________________________________

4. Project Staff (Who?)

General Description of Project Staff or Organizers:

_______________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

_________________________________________________________________
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5. Specific Project Events and Activities (What Goes On?) 

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

____________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

6. Target Audience(s), Community Population(s), or System(s) Served (For Whom?)

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________
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7. Measures of Project Success (If Successful, What Happens?)

How Will You Know If This Project Was Effective? What are Your Measures or Indicators of Success?

1)

___________________________________________________________________________________________________________________

_____________________________________________________________________________________ 

2)

___________________________________________________________________________________________________________________

_____________________________________________________________________________________ 

3)

___________________________________________________________________________________________________________________

_____________________________________________________________________________________ 

4)

___________________________________________________________________________________________________________________

_____________________________________________________________________________________ 

5)

___________________________________________________________________________________________________________________

_____________________________________________________________________________________

8. Other Project Notes or Special Circumstances (But...)

_______________________________________________________________________________________________________
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_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________
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2-3A SERVICE DELIVERY PROGRAM PROCESS ASSESSMENT

1. Program Name

Program Name: _______________________________________________________________________________________

2. Program Period

A. Dates of Program Implementation: From ____/____/____ To ____/____/____

B. Actual Implementation Schedule Compared to Planned Program Schedule:

 Generally On Schedule  Ahead of Planned Schedule  Behind Planned Schedule

C. If implementation differed from the originally planned schedule, what caused the differences or delays? To what 

extent did the differences affect the program?

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

3. Program Activities and Services 

A. What program activities and services were planned but not implemented? Why?
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____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

B. What program activities and services were implemented that were not originally planned? Why?

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

4. Participation 

A. To what extent did you achieve your participation goals (e.g., 50%, 100%, 200%)?: ___________ %

B. What factors contributed to this level of actual participation in the program? 

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

C. What group(s) were missing that you had hoped or intended to have participate in the program? Why?

____________________________________________________________________________________________________
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____________________________________________________________________________________________________

____________________________________________________________________________________________________

5. Participant Feedback 

A. How did participants evaluate the program? 

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

B. What did participants like the most?

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

C. What did participants dislike? 

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________
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____________________________________________________________________________________________________

6. Resources 

A. Were sufficient Title V funds devoted to this program to accomplish what was planned?

 Available funds were in line with what was needed 

 Available funds were less than needed

 Available funds were more than needed

B. If funds were insufficient to support program objectives, where specifically were more funds needed?

____________________________________________________________________________________________________

____________________________________________________________________________________________________

7. Reflections and Lessons Learned

A. If your group were to implement the program over again, what would you do differently? What lessons did 

you learn? 

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________
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B. What would you be sure to do again?

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

C. What advice would you give to someone who was planning to implement a similar program?

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

(Continue on an additional page if necessary)

2-3B SYSTEMS CHANGE PROJECT PROCESS ASSESSMENT

1. Project Name

Project Name: _______________________________________________________________________________________
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2. Project Period

A. Dates of Project Implementation: From ____/____/____ To ____/____/____

B. Actual Implementation Schedule Compared to Planned Project Schedule:

 Generally On Schedule  Ahead of Planned Schedule  Behind Planned Schedule

C. If implementation differed from the originally planned schedule, what caused the differences or delays? To what 

extent did the differences affect the project?

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

3. Project Components 

A. What project steps, activities, or events were planned but not implemented? Why?

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

B. What project steps, activities, or events were implemented that were not originally planned? Why?

____________________________________________________________________________________________________

____________________________________________________________________________________________________
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____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

4. Resources 

A. Were sufficient Title V funds devoted to this project to accomplish what was planned?

 Available funds were in line with what was needed 

 Available funds were less than needed

 Available funds were more than needed

B. If funds were insufficient to support project objectives, where specifically were more funds needed?

____________________________________________________________________________________________________

____________________________________________________________________________________________________

5. Reflections and Lessons Learned

A. If your group were to implement the project over again, what would you do differently? What lessons did you 

learn? 

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________
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____________________________________________________________________________________________________

B. What would you be sure to do again?

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

C. What advice would you give to someone who was planning to implement a similar project?

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

(Continue on an additional page if necessary)
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SAMPLE TABLE: FORM 2-2A SERVICE DELIVERY PROGRAM IMPLEMENTATION LOG

METROPOLIS COMMUNITY COLLEGE FAMILY LIFE PROGRAM 

1. Program and Year 

A. Program Name: Metropolis Community College Family Life Program 

 B. Year: 1995 

2. Implementation Log

A. Program Components 

B. Number Served/Participating Per Month (Unshaded Top Box)

C. Average Session Time in Hours (Shaded Bottom Box) D. Total 

Served 

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec and Unit E. Notes and Explanations

1) Training for Trainers

(full day training for trainers 

before parent classes began)

2 0 0 0 0 0 0 0 0 0 0 0 2 Trainers

8 0 0 0 0 0 0 0 0 0 0 0 

2) Parent Training Classes

(two classes per month, 2 

hours per class)

34 10* 28 30 34 36 30 18 26 27 32 35 18 Parents 

from

11 Families

* Bad snow storms, low turn 

out. 

4 4 4 4 4 4 4 2 ** 1 class not held in August. ** 4 4 4 4 

3) Home Visits 

(plan for one visit per family 

per month - 1 1/2 hour each)

10 9 12* 10 10 11 11 10 9 11 8 11 11 Families * Two families received two 

home visits in March 

because of emergency 

situations.

1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 

4) Family Dinners

(one dinner per quarter for 2 

hours each)

8 0 0 6 0 0 7 0 0 8 0 0 9 Families

2 0 0 2 0 0 2 0 0 2 0 0 

5) Special Lecture:

"How Children Learn 

Through Play" 

0 0 0 0 4 0 0 0 0 0 0 0 4 Parents Scheduled at last minute and 

not well-publicized. 

0 0 0 0 2.25 0 0 0 0 0 0 0 

6) Winter Holiday Family

Celebration

0 0 0 0 0 0 0 0 0 0 0 11 11 Families Very well-received.
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SAMPLE TABLE: FORM 2-2B SYSTEMS CHANGE PROJECT IMPLEMENTATION LOG

METROPOLIS CARDING CAMPAIGN

1. Project Name: Metropolis Carding Campaign 

 

2. Implementation Log

A. Project Components

B. Dates C. Number and Unit Involved D. Materials Used E. Notes and Explanations

1) Bob Smith and the Carding Campaign 

Committee drafted a Campaign Plan for stricter 

enforcement by local bars of checking 

identification before serving alcohol and 

refusing to serve minors.

8/16-8/30/96 6 committee members Assessment of current city 

regulations. Review of records 

related to historical carding practices 

and drunk driving occurrences 

among minors. 

Delay in completion of Plan 

due to conflicting schedules 

of committee members 

2) Campaign Plan presented at kick-off meeting 

involving local bar owners, bartenders, 

bouncers, police officers, and liquor control 

board members. 

9/30/96 83 attendees N/A Bars from East Metropolis 

under represented

3) Publicity efforts for Carding Campaign:

flyers announcing carding and ID policies 

printed, distributed to local high school 

students, and posted throughout community. 

10/1/96-10/30/9

6 

500 flyers One page flyers drafted by Campaign 

Committee and printed 

free-of-charge by Total Printers

4) Local bars implement new carding policies. 10/1/96→ unknown N/A

5) Special police operation checks carding 

enforcement at local bars.

12/10-12/31/96 15 bars N/A
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2-2A SERVICE DELIVERY PROGRAM IMPLEMENTATION LOG

1. Program and Year 

A. Program Name: ______________________________________________________________________________________________________ B. Year: ___________

2. Implementation Log 

A. Program Components

B. Number Served/Participating Per Month (Unshaded Top Box)

D. Total 

Served

and Unit E. Notes and Explanations

C. Average Session Time in Hours (Shaded Bottom Box)

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
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2-2B SYSTEMS CHANGE PROJECT IMPLEMENTATION LOG

1. Project Name: __________________________________________________________________________________________________________________________________ 
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2. Implementation Log 

A. Project Components

B. Dates C. Number and Unit Involved D. Materials Used E. Notes and Explanations
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2-4A SERVICE DELIVERY PROGRAM OUTCOME ASSESSMENT

1. Program Name: _______________________________________________________________________________________________________________________________

2. Outcome Assessment Table

A. Desired Outcomes

B. Measure or Indicator

("Evidence" of Your Desired 

Outcome) 

C. Dates Measured or 

Observed 

D. Observed Measurable 

Outcome E. Amount of Change in 

Measure or Indicator

Before After Before After (Before vs After)
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1)

2)

3)

4)

5)
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2-4B SYSTEMS CHANGE PROJECT OUTCOME ASSESSMENT

1. Project Name: _______________________________________________________________________________________________________________________________

2. Outcome Assessment Table

A. Desired Outcomes

B. Measure or Indicator

("Evidence" of Your Desired 

Outcome) 

C. Dates Measured or 

Observed 

D. Observed Measurable 

Outcome E. Amount of Change in

Measure or Indicator

Before After Before After (Before vs After)

1)

2)
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3)

4)

5)
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UNIT 3 RISK FACTOR TRACKING

In the first two Units of the Community Self-Evaluation Workbook you described and assessed 

the component service delivery programs and systems change projects of your Title V Initiative. 

Unit 3 will help you to evaluate the impact of your community's Initiative as a whole. 

Specifically, this Unit is designed to help you track the changes in the indicators of risk in your 

community over time.

The Title V Delinquency Prevention Program is a risk-focused program based on the premise 

that in order to prevent a problem from occurring, the factors that contribute to the development 

of that problem must be identified and addressed. In your grant application, your community 

identified the priority risk factors present in your community for juvenile delinquency and other 

adolescent problem behaviors. During the period of your Title V grant, your Prevention Policy 

Board (PPB) directed the implementation of programs and strategies that addressed the priority 

risk factors and enhanced protective factors. 

With the Forms in this Unit, you will re-visit the priority risk factors that you identified and 

observe how they have been affected by the Title V Initiative. Please keep in mind that 

delinquency prevention is a long-term effort and that changes in risk factors and indicators of 

risk take time. You may not see immediate changes in your data, but that does not necessarily 

mean that your programs are not working. Don't be discouraged!

Evaluation is an ongoing process. Completing the Forms in this Workbook in general—and in 

Unit 3 in particular—also will be an on-going process. The data regarding risk factors that you 

submitted in your grant application's risk assessment will serve as the baseline for completing 

these Forms. To update your community's risk assessment, you will add data incrementally, 

over time, to the Forms in this Unit. 

Unit 3 is organized in the following manner:

· Form 3-1: Risk Factors and Indicator Summary outlines your community's priority 

risk factors and the indicators of the prevalence of those risk factors. You will complete 

one copy of Form 3-1 at the end of the first year of the grant period.

· Form 3-2: Tracking Risk Factor Indicators walks you through the creation of a data 

table and then a graph to present a picture of changes in indicator data over time. You 

will need one copy of Form 3-2 for each indicator of each of your community's priority 

risk factors. You will start Form 3-2 at the end of the first year of the grant period. You 

will continue to add to the Form's tables and graphs at the end of each subsequent year.
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· Form 3-3: Risk Factor Data Analysis asks you to describe the apparent trends of the 

indicator data, assess the changes in risk factors, and interpret the implications of the 

changes. At the end of each year after the grant begins, you will complete one Form 3-3 

for each of your community's priority risk factors.

· Form 3-4: Tracking Indicators of Juvenile Problem Behaviors repeats the data table 

and graph procedures of Form 3-2 for selected overall indicators of problem behaviors 

(e.g., number of juvenile arrests, dispositions of juvenile cases, and school dropout rates). 

· Form 3-5: Juvenile Problem Behaviors Data Analysis asks you, in the same manner as 

Form 3-3, to describe the apparent trends of the indicator data, assess the changes in the 

prevalence of juvenile delinquency and other adolescent problem behaviors, and interpret 

the implications of the observed changes. At the end of each year after your grant begins, 

you will complete one Form 3-5 for each of the overall indicators. 

Instructions on each Form will explain further how many copies you will need and when to 

complete the Form.

UNIT 3 FORMS

3-1 Risk Factors and Indicator Summary

3-2 Tracking Risk Factor Indicators 

3-3 Risk Factor Data Analysis

3-4 Tracking Indicators of Juvenile Problem Behaviors

3-5 Juvenile Problem Behaviors Data Analysis 
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FORM 3-1: RISK FACTORS AND INDICATOR SUMMARY

WHEN TO USE:AT THE END OF THE FIRST YEAR OF THE GRANT PERIOD

KEY FEATURES: RISK FACTORS AND INDICATORS

This Form outlines the priority risk factors identified by your community and the indicators 

which demonstrate levels of risk.

 Refer to the section of your Title V grant application that describes the prevalence of 

delinquency risk factors in your target community. Your initial risk assessment should 

include baseline data for the priority risk factors identified in your target community. 

These data will serve as the starting point for completing the Forms in Unit 3.

A. Priority Risk Factors In the left hand column of the table, list the priority risk factors 

that were identified in your community's initial risk assessment. These should be the 

same priority risk factors you listed on Form 1-9 (Risk Factor and Program Plan). Each 

box should contain only one risk factor. (If your community has more than five priority 

risk factors, make a copy of Form 3-1, insert it in the Workbook behind the original Form, 

and continue to list one risk factor in each box.)

B. Indicators of Risk For each priority risk factor, list the indicators of that risk factor in 

the right hand column. Indicators of risk are the quantifiable data that provide 

information about the degree to which the risk factor is a problem in the community. 

Consult the Workbook's Appendix for a partial list of indicators of risk.

Sample Table: Form 3-1 Risk Factors and Indicator Summary

The risk assessment of South Valley Township identified three priority risk factors supported by 

data collected on eight indicators of risk.

 

A. Priority Risk Factors B. Indicators of Risk

1) Extreme economic and social deprivation a. Number of families living below poverty level

b. Unemployment rates

c. Number of food stamp recipients

d. Number of AFDC recipients

2) Family management problems a Reported cases of child abuse

b. Number of children in foster homes

c. Number of runaway reports

3) Favorable attitudes toward the problem behavior a. Results of survey of student attitudes 

FORM 3-2: TRACKING RISK FACTOR INDICATORS
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WHEN TO USE:AT THE END OF EACH YEAR AFTER THE GRANT BEGINS

KEY FEATURES: GRAPH OF RISK FACTOR INDICATOR DATA

This Form walks you through the creation of a graph of risk indicator data. The Form and graph 

will be completed incrementally over time.

 Do not write on the original Form. Make additional copies of both pages of Form 

3-2. You will need one copy of the Form to document each indicator of each of your 

community's priority risk factors. Make a set of Forms equal to the total number of 

indicators you listed in column B of Form 3-1. In the example provided for Form 3-1, 

South Valley Township would need a total of eight copies of Form 3-2 for the eight 

indicators of risk listed in the Risk Factors and Indicator Summary Table.

1. Risk Factor and Indicator

A. Risk Factor Enter the name of one of the priority risk factors listed in column A of 

Form 3-1. 

B. Indicator Name one indicator or measure of the specified risk factor from column B of 

Form 3-1. For each indicator listed in column B of Form 3-1, you should complete a 

separate copy of Form 3-2. 

2. Indicator Data Table 

This table will be used to organize the indicator data you have collected. The table is 

designed to capture data over an extended period of time. To reflect the impact of your 

Title V Initiative, ideally the data table should include three to five years of data before

the Title V grant period began, the three years of the grant period, and then several years 

after the initial Title V grant ends. Therefore, the first time you work on this Form, you 

could be filling in several columns of the left hand side of the table, representing several 

years' prior data. Each year thereafter you should continue to enter new data into the 

additional columns of the table. (There are columns for 13 years of data on this Form). 

It should be noted that there may be some lag time before data becomes available for 

certain indicators. Due to the time and effort required for data collection, analysis, and 

dissemination, certain information, such as census data, may not be available for many 

months or even years after the year of study. On an annual basis, enter the data that is 

accessible at that time. Fill in the boxes for previous years as the information becomes 

available. In addition, in some cases data will not be available on an annual basis from 
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the information source. For example, some surveys are conducted every other year 

rather than every year. Where data cannot be obtained for a given year, mark the boxes 

"NA" for not available.

A. Data Unit Name the unit in which indicator data is measured and specify exactly what is 

being described. The data unit can be a number, percentage, rate, weight, score, or other 

measure. Examples of data units include: the number of G.E.D. Diplomas issued in 

thousands; gallons of alcoholic beverages consumed by each adult; the percentage of 

responses to the question "How many of your friends would you estimate smoke 

cigarettes?"; and the average SAT score.

B. Data Group In this first column of the table, enter the separate indicator data groups, 

categories, or variables. These groups will reflect the different break-outs for which the 

indicator data have been collected and are used for comparison or analysis purposes. 

Data groups may include different racial/ethnic groups, age groups, or geographic groups. 

They also may refer to different categories of the overall indicator, such as different 

reasons for juvenile arrest or types of drugs available. Examples of data groups include: 

 

· Local, State, National (level of government).

· African-American, Native American, White, All races (race). 

· 8th grade, 9th grade, 10th grade, 11th grade (grade level). 

· Murder, Robbery, Aggravated Assault, Weapons Violations (type of offense). 

In some cases, there may be only one data group for a given indicator. If there is only 

one variable, enter the label for that group in the first row (a) and leave the other rows 

blank. 

C. Years Across the top row of the data table, enter the years for which data have been 

collected.

 Entering the Indicator Data For each year and data group, record the appropriate 

values in the data table. Data should be entered in the column for the year it represents. 

(Remember that the year the data actually represent might be different from the year in 

which they were published or made available.) Make sure that all data is entered 

consistently in the appropriate data unit (e.g., in thousands, percentages, rate per 100,000 

population). 

Sample Data Table: Form 3-2 Tracking Risk Factor Indicators
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The following is an example of a completed data table for the Morris County School District: 

1. Risk Factor and Indicator

A. Risk Factor: Availability of Drugs B. Indicator: Perceived Availability of Marijuana Among 

Morris County Students

2. Indicator Data Table A. Unit: Percentage of students reporting that marijuana would be "easy" to get 

 

B. Data Group

C. Years

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 

a. 8th Graders 30 32 34 34 37 38 38 36 33 30 27 25 

b. 10th Graders 60 60 64 65 69 69 69 68 60 55 51 47 

c. 12th Graders 89 93 91 93 93 94 94 90 85 82 76 76 

d. 

The Sample Data Table shows 30% of the 8th graders, 60% of the 10th graders, and 89% of the 12th graders in 

Morris County thought that marijuana would be easy to get in 1989. By the year 2000, the percentage of 

students who thought marijuana would be easy to get declined to 25% of the 8th graders, 47% of the 10th 

graders, and 76% of the 12th graders. 

3. Indicator Data Sources

Indicate your sources of information for the indicator data shown in the data table. 

Specify the particular records or survey name from which the data were collected. For 

example, the indicator data source in the table above is the "Drugs in Your School 

Survey" distributed annually to Morris County Students. Other examples of local and 

national data sources include: Police or Sheriff's Departments, District Attorney's Offices, 

School Districts, Child Protective Services Agencies, Liquor Control Boards, 

Employment and Welfare Offices, Hospitals and Health Clinics, Government Agencies, 

the U.S. Bureau of the Census, and the Bureau of Justice Statistics. (If your community 

attended the Communities That Care Risk and Resource Assessment Training, you may 

want to consult the Communities That Care Data Workbook produced by Developmental 

Research and Programs, Inc. (DRP) for a more complete list of sources of data on 

indicators of risk factors for adolescent problem behaviors.)
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4. Indicator Graph

The indicator graph will be used to present a picture of changes in indicator data over time. To 

create the graph, you will transfer information from Section 2, the Indicator Data Table. Each 

year as the data table is updated, you will add additional data points to the graph.

A. Unit Enter the same data unit that you wrote in 2A above. This unit of measure serves 

as the title of the vertical (Y) axis.

B. Vertical (Y) Axis Label the tick marks along the vertical side of the graph frame (the Y 

axis) with increments of the data unit. First determine the range of values to be shown 

and then label the axis to form a numerical scale of the data values. Starting at the 

bottom tick mark of the vertical axis, write the minimum number possible for that data 

unit. In many cases the minimum value will be 0, but not always. In some instances, 

for example with some test scores, very low values are possible but rarely achieved; in 

such cases, you may want to start with the lowest number obtained rather than the lowest 

number possible. After marking the lowest value, enter a range of sequential values up 

the axis, ending with the highest probable value to be recorded. Make sure the 

differences between each value and the one above it and below it are equal. That is to 

say, for any value on the vertical axis, you would add the same number to produce the 

next higher value on the axis. For example, if your indicator unit is the percentage of 

households with a spouse absent, then you could label the vertical axis from 0% to 90% 

in increments of 15: 0, 15, 30, 45, 60, 75, 90. 

C. Horizontal (X) Axis The horizontal side of the graph frame (the X axis) represents the 

years for which data have been collected. Label the horizontal axis tick marks from left 

to right starting with the earliest year of your data and adding each subsequent year. 

D. Legend Next to each letter and symbol in the legend box, enter one data group that is 

listed in the data table. Each group will be identified in the graph by the symbol shown 

next to the letter.

 Plotting the Data Points For each variable, locate the data values in the data table and 

show the values on the graph by marking each data point with the identifier symbol from 

the legend box. Find and mark the appropriate values along the grid lines of the vertical 

axis for every year displayed on the horizontal axis. Draw a line to connect like symbol 

marks of each year's plotted value. Data for each data group should be shown in its own 

data line.
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Many communities may have access to computer spreadsheet and graphics programs 

that can store indicator data and generate tables and graphs like the ones described 

here. If this is true for your community, we encourage you to use these tools. You 

can then insert printouts of the computer-generated tables and graphs into your 

Workbook rather than entering the requested information by hand onto these forms. 

Sample Indicator Graph: Form 3-2 Tracking Risk Factor Indicators

Below is an example of the completed indicator graph for "Perceived Availability of Marijuana 

in the Morris County School District" based on the data in the sample indicator data table shown 

on page 6. 

 Repeat the instructions for Form 3-2 for each indicator of each risk factor.
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FORM 3-3: RISK FACTOR DATA ANALYSIS

WHEN TO USE: AT THE END OF EACH YEAR AFTER THE GRANT BEGINS 

KEY FEATURES: INTERPRETATION OF DATA

Use this Form to interpret the data presented in the graphs in Form 3-2. 

 Do not write on the original Form. Make additional copies of Form 3-3. Each 

year, you will need one copy of the Form for each of the priority risk factors listed on 

Form 3-1. In the example provided above for Form 3-1, South Valley Township would 

need a total of three copies of Form 3-3 each year.

1. Risk Factor and Indicators

A. Risk Factor Refer to Form 3-1 and write the name of one of your community's priority 

risk factors in the space provided. 

B. Indicators For the identified risk factor, list all of the indicators of risk for which you 

completed Form 3-2. 

2. Data Trends

First, look at your indicator graphs and assess the data trends shown for each of the 

indicators of risk. In completing this section, think about the entire group of indicators 

listed in Section 1. You may have several graphs to review. Consider the following 

questions: 

· Are the values higher or lower than what you expected? 

· Are the values increasing, decreasing, or staying the same over time? Is there a 

noticeable pattern in the changes?

· How have the trends changed since the Title V Initiative began?

· Are the trends similar for different data groups (e.g., different age, race, gender, 

or geographic groups) for the same indicator? 

· Are the trends similar for different indicators of the same risk factor?
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In the space provided, describe the data trends you have observed. Add additional pages 

if necessary.

3. Data Interpretation

Now think about the risk factors. For each risk factor, summarize how you interpret the 

indicator data trends. Consider the following questions: 

· What do the indicator data trends tell you about the prevalence of the risk factor 

in your community? Do the data trends suggest a reduction or stabilization of 

risk in your community?

· To what do you attribute the changes in risk indicators?

· What factors other than the Title V Initiative (e.g., new law enforcement policies, 

legislative changes, current political events) may have influenced changes in 

indicator data? 

· Why are the data trends different for different age, race, gender, or geographic 

groups? 

· Do you expect the trends to continue in the foreseeable future? Why or why not? 

· Should your community's prevention programs continue to focus on this risk 

factor?

Based on the data trends, indicate whether there appears to be a reduction or increase of 

risk in your community. Explain briefly what factors — including Title V prevention 

programs, outside events, or legislative changes — could have influenced the data trends. 

Where data are available, make comparisons between your community's data and State 

or national data. Finally, based on what you see, decide whether or not this risk factor 

should remain a priority in your community. If you need more space to explain your 

data interpretation, attach additional pages. 

 Repeat the instructions for Form 3-3 for each priority risk factor. 
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FORM 3-4: TRACKING INDICATORS OF JUVENILE PROBLEM BEHAVIORS

WHEN TO USE:AT THE END OF EACH YEAR AFTER THE GRANT BEGINS

KEY FEATURES: GRAPH OF PROBLEM BEHAVIOR DATA

With Form 3-2 you created tables and graphs of indicator data that measure the prevalence of 

risk for juvenile delinquency and other adolescent problem behaviors. With this Form, you will 

follow the same procedures to create tables and graphs of indicator data that relate to the 

occurrence of delinquency and other juvenile problem behaviors in your community. 

 We suggest that all communities, regardless of their individual priority risk factors, 

track the following measures of delinquent and other problem behavior: 

· Number of juvenile arrests (by type of offense).

· Disposition of cases (by type of offense).

· School dropout rates. 

Your community also may want to track additional measures of juvenile problem 

behaviors, such as birth rates to mothers under 18 years of age or, where self-reported 

survey data are available, the prevalence of alcohol and other drug use among 

minors.

 Do not write on the original Form. Make additional copies of Form 3-4. You 

will need one copy of the Form for each of the indicators of juvenile problem 

behavior that you plan to track. 

1. Indicator

Name one of the indicators from the group listed above for which you will create a data 

table and graph.

2. Indicator Data Table 

Follow the instructions given for section 2 of Form 3-2. 

3. Indicator Data Sources

Follow the instructions given for section 3 of Form 3-2. 
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4. Indicator Graph

Follow the instructions given for section 4 of Form 3-2.

 Repeat the instructions for Form 3-4 for each overall indicator of juvenile 

problem behaviors.
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FORM 3-5: JUVENILE PROBLEM BEHAVIORS DATA ANALYSIS

WHEN TO USE:AT THE END OF EACH YEAR AFTER THE GRANT BEGINS

KEY FEATURES: INTERPRETATION OF DATA

Use this Form to analyze the data presented in the graphs in Form 3-4. 

 Do not write on the original Form. Make additional copies of Form 3-5. Each 

year, you will need one copy of the Form for each of the overall indicators of juvenile 

delinquency and other problem behaviors that you graphed in Form 3-4. 

1. Indicator

List one indicator of the occurrence of delinquent or other juvenile problem behavior. 

2. Data Trends

Look at your indicator graphs and assess the data trends shown for the indicator. As you 

did on Form 3-3, consider the following questions: 

· Are the values higher or lower than what you expected? 

· Are the values increasing, decreasing, or staying the same over time? Is there a 

noticeable pattern in the changes?

· How have the trends changed since the Title V Initiative began?

· Are the trends similar for different data groups (e.g., different age, race, gender, 

or geographic groups) for the same indicator? 

In the space provided, describe the data trends you have observed. Add additional pages 

if necessary.

3. Data Interpretation

Now think about the related delinquent behaviors and summarize how you interpret the 

indicator data trends. Consider the following questions: 
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· What do the data tell you about the prevalence of juvenile delinquency or other 

adolescent problem behaviors in your community? Do the trends suggest that the 

problem behaviors in your community have been reduced or stabilized?

· To what do you attribute the changes in behaviors?

· How do the data trends compare to the trends observed in the indicators of risk 

associated with the problem behavior? 

· What factors other than the Title V Initiative (e.g., new law enforcement policies, 

legislative changes, current political events) may have influenced changes in 

indicator data? 

· Are the data trends different for different age, race, gender or geographic groups? 

Why?

· What are the implications of these data for your Title V Initiative?

Based on the data trends, indicate whether there appears to be a reduction, stabilization, 

or increase of juvenile delinquency or other adolescent problem behaviors in your 

community. Explain briefly what factors—including the Title V Initiative, outside 

events, or legislative changes—could have influenced the data trends. Where data are 

available, make comparisons between your community's data and State or national data. 

Finally, based on what you observe, assess the suggested implications of these data as 

they relate to the perceived impact of your Title V Initiative. If you need more space to 

explain your data interpretation, attach additional pages.

 Remember: Don't be discouraged if you don't see changes in the data right away. 

These problems won't be fixed over night!
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3-1 RISK FACTORS AND INDICATOR SUMMARY

A. Priority Risk Factors B. Indicators of Risk

1) a.

b.

c.

d.

e.

2) a.

b.

c.

d.

e.

3) a.

b.

c.

d.

e.
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4) a.

b.

c.

d.

e.

5) a.

b.

c.

d.

e.

3-3 RISK FACTOR DATA ANALYSIS

1. Risk Factor and Indicators

A. Risk Factor: _________________________________________________________________________________

B. Indicators: a. ______________________________________________________________________________

b. ______________________________________________________________________________

c. ______________________________________________________________________________
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d. ______________________________________________________________________________

e. ______________________________________________________________________________

2. Data Trends

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

3. Data Interpretation

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________
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_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Continue on an additional page if necessary

3-5 JUVENILE PROBLEM BEHAVIORS DATA ANALYSIS

1. Indicator _____________________________________________________________________________________________

2. Data Trends

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

3. Data Interpretation

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________
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_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Continue on an additional page if necessary
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3-2 TRACKING RISK FACTOR INDICATORS 

1. Risk Factor and Indicator

A. Risk Factor: _______________________________________ B. Indicator: ___________________________________________________________ 

2. Indicator Data Table A. Data Unit: ______________________________________________________________________________________________________



B. Data Group 

C. Years 

19____

a.

b.

c.

d.
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3. Indicator Data Sources

Name of Data Source(s)

_____________________________________________________________________________________________

_____________________________________________________________________________________________

4. Indicator Graph

A. Unit: ________________________________

B. Vertical (Y) Axis ↑
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Year C. Horizontal (X) Axis ← 

D. Legend

a. • c. 

b.  d. _
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3-4 TRACKING INDICATORS OF JUVENILE PROBLEM 

BEHAVIORS 

1. Indicator: _________________________________________________

2. Indicator Data Table A. Data Unit: ______________________________________________________________________________________________________



B. Data Group 

C. Years 

19____

a.

b.

c.

d.

3. Indicator Data Sources
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Name of Data Source(s)

_____________________________________________________________________________________________

_____________________________________________________________________________________________
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4. Indicator Graph 

A. Unit: ________________________________

B. Vertical (Y) Axis ↑ 
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Year C. Horizontal (X) Axis ←
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D. Legend

a. • c. 

b.  d. _
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APPENDIX: RISK FACTORS AND SAMPLE INDICATORS*

COMMUNITY DOMAIN

Risk Factor: Availability of Drugs

Indicators: Perceived Availability of Drugs 

Trends in Exposure to Drug Use

Per Capita Consumption of Alcohol

Sales of Alcoholic Beverages

Liquor Sales Outlets

Risk Factor: Availability of Firearms

Indicators: Firearm Sales

Firearms in Home 

Risk Factor: Community Laws and Norms Favorable to Drug Use, Firearms, and Crime

Indicators: Juvenile Arrests for Drug Law Violations 

Juvenile Arrests for Violent Crimes

Juvenile Arrests for Curfew, Vandalism and Disorderly Conduct

Disposition of Juvenile Arrest Cases

Adult Drunken Driving Arrests

Average Length of Prison Sentence

Sentencing Below Federal Guidelines

Quantity of Drugs Seized

Areas Targeted by Law Enforcement for Drug Cleanup

School Discipline for Behavior Problems

Schools with Student Assistance Programs

Attitudes Favoring Gun Control

* Communities That Care® (CTC) Developmental Research and Programs, Inc., Seattle, WA. Information 

presented here is adapted from the Communities That Care Data Workbook, a manual provided to CTC 

training participants. The workbook provides information on risk factors that have been identified in 

longitudinal research studies as predictors of adolescent health and behavior problems (e.g., delinquency, 

violence, substance abuse, school dropout, and teenage pregnancy). The indicators are selected data found 

in national and local sources that provide information about the prevalence of risk in the community.

Risk Factor: Media Portrayal of Violence
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Indicators: General Violent Behavior Portrayed on Television

Serious Assaults Portrayed on Television

Risk Factor: Transitions and Mobility

Indicators: Existing Home Sales

New Home Construction

Rental Residential Properties

Rental Unit Turnover

Utility Connections

Student Movement In and Out of School

Risk Factor: Low Neighborhood Attachment and Community Disorganization

Indicators: Percent of Population Voting in Elections

Rental Housing Vacancy Rates

Homeowners Unit Vacancy Rates

Number of Churches and Synagogues

Homicides

Risk Factor: Extreme Economic and Social Deprivation

Indicators: Persons/Families/Children Living Below Poverty Level

Unemployment Rates

Exhausted Unemployment Benefits

AFDC Recipients

Food Stamp Recipients

AFDC and Food Stamp Benefits as a Percentage of Poverty Level

Free and Reduced Lunch Program

Single Female Head of Household as a Percentage of All Households

FAMILY DOMAIN

Risk Factor: Family History of High Risk Behavior

Indicators: Adults in Treatment

Liver Cirrhosis Deaths

Adults/Parents in Prison

Educational Attainment of Adults 
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Adult Illiteracy

Risk Factor: Family Management Problems

Indicators: Reported Child Neglect and Abuse Cases

Runaway Reports

Children Living in Foster Homes

Risk Factor: Family Conflict

Indicators: Domestic Violence Reports

Divorce Rates

Households with Spouse Absent

Risk Factor: Favorable Parental Attitudes and Involvement in the Problem Behaviors

Indicators: Adult Violent Crime Arrests

Adult Property Crime Arrests

Adult Alcohol-Related Arrests

Babies Born Affected by Alcohol or Other Drug Use

Drug Use During Pregnancy
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SCHOOL DOMAIN

Risk Factor: Early and Persistent Anti-Social Behavior

Indicators: Elementary School Disciplinary Problems

Special Education Classes for Students with Behavior Disorders

Elementary School Students Diagnosed with Behavioral Disorders 

Risk Factor: Academic Failure

Indicators: Grade Repetition

ACT Test Scores

SAT Test Scores

Reading Proficiency

Math Proficiency

Science Proficiency

GED Diplomas Issued

Risk Factor: Lack of Commitment to School

Indicators: School Enrollment

Average Daily Attendance

Truancy Rates

High School Completion Rates 

INDIVIDUAL/PEER DOMAIN

Risk Factor: Alienation and Rebelliousness

Indicators: Suicide Death Rates 

Reported Gang Involvement

Reported Vandalism and Graffiti Damage

Risk Factor: Friends Who Engage in the Problem Behavior
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Indicators: Adolescents in Juvenile Justice System

Reported Use of Drugs and Alcohol by Friends

Adolescents in Treatment

Adolescents Diagnosed with Sexually Transmitted Diseases

Adolescent Pregnancies

Risk Factor: Favorable Attitudes Toward the Problem Behavior

Indicators: Disapproval of Use of Alcohol, Cigarettes, and Drugs

Perceived Harmfulness of Use of Alcohol, Cigarettes, and Drugs

Attitudes Regarding Marijuana Laws

Risk Factor: Early Initiation of the Problem Behavior

Indicators: Grade of First Use of Alcohol, Cigarettes, and Drugs

Age of Initial Sexual Activity 

School Reports of Disciplinary Problems

Dropouts Prior to 9th Grade

Arrests Related to Alcohol and Other Drugs (Ages 10 to 14)

Violence Arrests (Ages 10 to 14)