2015-2016 EHDI Evaluation Report
Instructions and Template
Due Date: July 25, 2016 by 4:30 p.m.
Revised September 2015
The EHDI Evaluation Report is designed for grantees to report on their project activities and evaluation
outcomes for the reporting period of July 1, 2015 to June 30, 2015. Please complete this report and send
it as a single Word document to OMMH via email to OMMH@STATE.MN.US. Be sure to include
attachments specified at the end of the reporting template. This document must be submitted by 4:30
p.m. on July 25, 2016.
What is the goal of this template?
The goal of this reporting template is for grantees to create succinct comprehensive summaries of their
projects and their evaluation results to share with a large range of audiences (e.g., community
stakeholders, legislators, Minnesota Department of Health). We are asking grantees to synthesize key
information about the approach, activities, outcomes, and lessons learned into one piece.
The EHDI Evaluation Report serves to benefit EHDI grantees, the Office of Minority and Multicultural
Health (OMMH), the newly established Center for Health Equity at Minnesota Department of Health
(MDH), as well as populations of color and American Indians living in Minnesota.
For example:
 Grantees can cut and paste components of the report for a variety of purposes such as creating a 13 page summary of the grant to share with community members, submit as an abstract for a
presentation, for newsletters or to post on a website, or for use in future RFPs.
 OMMH will summarize components of the report for legislative reports and to share with other
programs within MDH.
What information is available to help fill out this report?
Grantees can refer to documents they have already completed to write the report including: 1) RFP
application; 2) Logic Model; 3) Evaluation Plan; previous evaluation reports, and 4) other documents and
publications you have prepared about this grant.
Office of Minority and Multicultural Health
625 Robert St. N.
St. Paul, MN 55155
www.health.state.mn.us/ommh
____[INSERT GRANTEE ORGANIZATION NAME HERE)____
2015-2016 EHDI Programmatic and Evaluation Report
Eliminating Health Disparities Initiative
Due Date: July 25, 2016
**Include evaluation findings for 2015-2016 grant year only**
1. Grantee Information
Project Name:
Lead Agency:
Contact Name for Report:
Contact Email:
Contact Phone:
Priority Health Area(s)
Funded:
EHDI Target Population(s)
Served by your EHDI
Project: Check
appropriate box(es)
Geographic Area Served:
Provide brief description of
location of services and
who was served 100 words
Check all that apply
Priority Health Area
Breast and Cervical Cancer Screening
Diabetes
Heart Disease and Stroke
HIV/AIDS and Sexually-Transmitted Diseases
Immunizations for Adults and Children
Infant Mortality
Teen Pregnancy
Unintentional Injury and Violence
Community Primary Prevention
American
Asian/Pacific
Hispanic/
Indian
Islander
Latino
African/African
American
2. Description of Lead Agency and Project/Community Partners – (Limit to 250 words)
Include a short description of the lead agency and project/community partners and their role on the
project. If you developed an advisory group for your project, provide a description of the role and
composition of the committee. (1 – 2 sentences recommended per agency/partner)
Name of agency
Description of agency
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3. Describe how you received feedback from the community on your activities? (Limit to 200 words)
a) How did you collect community feedback, what kind of feedback did you receive.
b) How did you use this feedback to guide program activities?
4. Project Rationale - What problem are you addressing? (Limit to 150-200 words per health priority
area)
FOR PRIORITY HEALTH AREA GRANTS: Describe the priority health area(s) that you are focusing on. How
is this health problem(s) impacting your community? How will your project contribute to reducing the
disparity?
FOR COMMUNITY PRIMARY PREVENTION GRANTS - What is the problem area that you are focusing on?
How will your project impact or improve primary prevention of health disparities?
5. Updated Project Description (Limit to 250 words)
Provide an updated brief but comprehensive overview of your project goal (e.g. goal, mission, vision).
Include images such as diagrams of your project activities or logic model if appropriate. If you provided
this information previously, please re-enter it.
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6. Overall Programmatic Highlights (Limit to 250 words)
In thinking about all your work this year, what key accomplishments did you achieve during the twelve
months grant period (7/1/15-06/30/16)? Provide 3-7 bullets briefly summarizing program activity
highlights for your answer.
7. Evaluation Outcomes
Describe the outcomes of your evaluation. This section has three parts –
Part A. Work Plan Update
Part B. Summary of Numbers of People Reached
Part C. Summary of Key Evaluation Outcomes
Part A. Work Plan Update
Attach to this report a copy of your work plan with updates. Follow the attached format to
provide specific information on the progress of your 2015-2016 work plan.
See EHDI 2015– 2016 Work Plan & Progress Report – Sample attached to this
report
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Part B. Numbers of People Reached from July 1, 2015 to June 30, 2016.
i. Direct Contact.
Provide an amount of direct contacts made in each priority health area with individuals from EHDI’s
target populations. A direct contact includes one to one/individual contact (e.g. counseling, clinical
services, screenings, education in private settings), group contact (e.g. classes, workshops, and group
education sessions). There may be duplicate numbers if a person participated in both individual contact
and a class.
EHDI Target Populations
African/
American
Asian/Pacific
Hispanic/
African
Indian
Islander
Latino
American
Priority Health Area
Breast and Cervical Cancer Screening
Diabetes
Heart Disease and Stroke
HIV/AIDS and Sexually-Transmitted
Diseases
Immunizations for Adults and
Children
Infant Mortality
Teen Pregnancy
Unintentional Injury and Violence
Community Primary Prevention
TOTAL
ii. Indirect Contact from July 1, 2015 to June 30, 2016.
Provide an amount of indirect contacts made in each priority health area with individuals from EHDI’s
target populations. An indirect contact could occur when your project conducts outreach at large
events. Indirect contact is minimal or fleeting contact (e.g. Health Fairs- an estimate of the number of
pamphlets distributed. Indirect contact could include sending letters out as reminder for breast and
cervical cancer screening. Provide your best estimate. Complete only if applicable to your project.
EHDI Target Populations
African/
American
African
Indian
American
Priority Health Area
Breast and Cervical Cancer
Screening
Diabetes
Heart Disease and Stroke
HIV/AIDS and Sexually-Transmitted
Diseases
Immunizations for Adults and
Children
Infant Mortality
Teen Pregnancy
Unintentional Injury and Violence
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Asian/Pacific Hispanic/
Islander
Latino
Part B. Numbers of People Reached from July 1, 2015 to June 30, 2016.
Community Primary Prevention
TOTAL
Part C. Key Evaluation Findings (Limit to 1000 words)
Summarize the key evaluation findings. We recommend you refer to and update your evaluation plan
to assist with answering this section. This section is meant to be a brief summary of your results and not
comprehensive. You may use bullets to highlight major findings from your evaluation report. Report
evaluation outcomes from each health disparity area your project focused on. Include outputs (e.g.
number of people reached, systems changes) and outcomes (e.g. changes in behavior, changes in health
indicators). Include more comprehensive results in the appendices. Base your answer on the evaluation
questions in your evaluation plan. If you have any graphs or charts please include.
8. Use of Evidence-Based, Promising Practices and Culturally Responsive Practices Models
In the 2012 EHDI RFP all grantees were encouraged to use evidence-based or promising practices and
culturally specific approaches in grant activities. Please Refer to the 2012 EHDI RFP Menu of Activities in
appendices D-K.
In this section, please describe and highlight any evidence-based or promising practices or culturally
specific models or approaches used. Indicate if the practice is evidence-based or a promising practice
(see definitions below) If you have a link to a web page or article discussing the practice or model- please
include it.
If you are adapting a model or practice to be culturally specific or to meet the needs of your project,
please describe. Tell us why adapting or creating new approach is significant for reaching your
community.
Definitions:
Evidence
Based (EB)
Interventions that have demonstrated effectiveness based on the principles of scientific evidence,
including systematic uses of data and information systems, and appropriate use of behavioral
science theory in order to explicitly demonstrate effectiveness.
Promising
Practice (PP)
Interventions that have demonstrated effectiveness based on local practices and/or cultural
experiences, for example, non-experimental data or the experience of practitioners.
Culturally
Responsive
Practices (CR)
Interventions that are adapted to meet the unique cultural needs of different communities but
might not yet been demonstrated to be evidence-based or promising.
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Target Group
A/AA = African/African American; AI = American Indian; API = Asian/Pacific Islander; H =
Hispanic/Latino
Practice or
Model Used
Description of evidence-based, promising practice, or
culturally responsive practices. Tell us why adapting or
creating new approach is significant for reaching your
community. EB and PP activities can also be CR. (Add rows as
needed)
Type
(EB or PP
and /or CR)
Target
Group
(A/AA,
AI, API,
H)
Setting
(Clinic,
Community,
or please
specify)
Example
Celebration
Of Change for
African
American
Females
Program
A culturally specific and evidence-based curriculum for African
American females created by the Annex Teen clinic from
community input. The program is designed to strengthen
communication and knowledge of puberty and sexuality
among mother/adult women and girls ages 9-12.
CR
AA/A
Community
/schools/
Faith-based
Describe successes in implementing Evidence-Based, Promising Practices and Culturally Responsive
Practices Models.
Describe any barriers and challenges to implementing Evidence-Based, Promising Practices and
Culturally Responsive Practices Models, and how you addressed or propose to address them.
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9. Policy, Systems and Environmental (PSE) Change Activities
In the 2012 RFP, you were asked to select activities that would provide individual- or group-based
services or change policies, systems, or the environment. If your project is making changes in policy,
systems or the environment, please identify if it is a policy, system or environmental change, describe the
change you are making, and provide a status report on your progress. See definitions below.
Definitions for Type – See RFP Appendix B Glossary
Policy
Intervention (P)
Systems
Intervention (S)
Environmental
Intervention (E)
Includes implementation of an ordinance, resolution, requirement or procedure (both formal and
informal) that governs behavior or practice within a clinic, organization, or community). An example is
a policy that all clinic staff is trained periodically on the developmental and health needs of culturallydiverse adolescents.
Includes changes that impact all elements of an organization, institution, or system; they may include a
policy or environmental change strategy. Examples include an organization implementing a wellness
program for all employees or a school district implementing age appropriate reproductive health
classes in secondary schools.
Includes physical or material changes to the economic, social, or physical environment. Examples are
incorporating sidewalks, walking paths, and recreational areas into community development design;
and an elementary school making health snacks and beverages available in all its vending machines
Codes for Implementation Status
NS = Not Started
IP = In Progress
C = Completed
Describe the Policy, Systems or Environmental Change (Add rows if needed)
Type
(P,S,E)
Progress
(NS,IP,C)
Describe successes in implementing PSE changes.
Describe any barriers and challenges to implementing PSE changes and how you addressed or propose
to address them.
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10. Photograph – OPTIONAL
Please include a photograph from your project that can be featured on the OMMH website. Please be
sure that the people in the photo have signed a photo release. You may use your own photo release
or find at the end of this template a copy of a photo release form. Please insert your photo into this
report and attach as a jpeg or tiff file when you submit the report.
Title for Photograph:
Photograph:
11. Story (Limit to 250 words)
Tell a story that illustrates the impact of your project on an individual, agency or system. This story
should highlight one or more of your strategies or activities. Please answer the following questions in
your story:




What strategy or activity are you highlighting?
Who and how many people has it impacted?
What’s changed due to your efforts? How will/has this made a difference?
What partners did you work with?
Title for Story:
Story:
13. Lessons Learned
Describe up to 3 lessons learned.
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14. Recommendations for Center for Health Equity (CHE), EHDI
In terms of addressing racial and ethnic health disparities for Minnesota’s population of color and
American Indians, what suggestions or recommendations do you have for CHE/EHDI and MDH on how
to coordinate collaborations between the CHE, EHDI grantees and non-funded community- based
organizations.
15. Cost Savings.
Did your project activities have direct or indirect economic impact on health care cost for the state of
Minnesota? Tell us how you see your program contributing toward cost savings? If you cite specific
statistics please include references or web links to a document. Please see tip sheet number 8 on the
grantee portal for an example.
16. Describe how you plan to sustain your program. Have you been able to leverage EHDI funds to
sustain your program beyond the EHDI grant? (100 words)
17. Grantee Logo
Insert Grantee Logo HERE- Please also attach as an attachment with the report.
18. Attachments - Summary
Please submit these additional attachments with your report

A. Copy of 2015-2016 Work Plan Update with updates

B. Electronic attachment of photo(s)

C. Signed Photo Release Form(s)

D. Electronic attachment of grantee logo

E. Attach any additional information or reports you would like to include
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19. Other information for grantee use
Logos
If you decided to use portions of this report to create a short summary of your project for your own use, we
include here copies of the MDH and OMMH logos and a copy of the disclosure statement that needed to be
included. If you do create such a document, please submit a copy with your report.
Logos can also be found here: Acknowledging EHDI Support Provided by MDH/OMMH
- Minnesota Dept. of Health
This activity is made possible by a grant from the Eliminating Health
Disparities Initiative (EHDI) of the Minnesota Department of
Health’s Office of Minority & Multicultural Health, through an appropriation from the Minnesota
State Legislature.
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Photograph and Video Release Form
Date__________________
I, _______________________________,
(Name – Please Print)
do hereby grant permission to the Minnesota Department of Health (MDH) to videotape or
photograph me, and to use the images thus obtained a part or in connection with the production
of MDH publications and audio-visual presentations. I understand that these materials will be
used for the purpose of informing and educating the public about MDH programs and activities. I
further understand that these photographic or video images may be distributed or displayed to
members of the general public in connection with MDH informational programs and activities.
I also understand that refusal to grant such permission would not and cannot result in the loss of
any rights to which I am otherwise entitled by law.
_________________________________
(Witness)
_________________________________
(Signature)
_________________________________
(Parent or Guardian)
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EHDI 2015 – 2016 Work Plan & Progress Report - Sample
Objectives:
 Improve sexual health of young people

Reduce the risk factors and increase the protective factors related to teen pregnancy

Reduce the rate of new infections of HIV and STDs
Strategies:
 Reduce risky sexual behaviors which lead to the transmission of HIV and STDs

Improve sexual health education of young people

Reduce the frequency of sex and number of partners and increase condom and contraceptive use among sexually-active adolescents
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2015-2016 EHDI Evaluation Report Instructions & Reporting Template
Activity
Key Staff
Partners
Planned
Timeline
Start and
Finish
Dates
1. Work with Partner organizations
to recruit Community Advisory
Panel members and Youth
Community Advisory Committee
members for African & Hmong
Youth Peer Education program.
Lin Chen, 40%
Lin Chen, 40%
Valens Ben,
20%
-Hmong Women’s
Association
-Center for Families,
Greater Minneapolis
Council of Churches
(GMCC)
-African Organization
-Hmong Organization
-County Organization
July 15 –
August
30, 2014
Partners will assist in
recruiting members
-MAWA
-Lao Family
Estimated
Unduplicated
Numbers
to be
Reached
N/A
Projected Outcomes
Achieved Outcomes
A minimum of five (5)
community and five
(5) youth members are
recruited for the
African and Hmong
programs.
Six youth that are former
participants of the (2007,
2009, Spring-2010) Youth
Power Program joined youth
Committee.
We have an existing pool of
community advisors that
include staff from our
community partner
organizations.
July 15,
2014 –
June 30.
2015
N/A
At least four CAP
meeting sessions are
held for each youth
program.
Three of four meetings were held.
2. Convene a minimum of four
Community Advisory Panel
meetings for each of the Youth
Education programs to provide input
and assess the implementation of the
programs.
Lin Chang,
40%
Valens Ben,
40%
Bill Ortiz, 20%
3. Convene a minimum of four (4)
Youth Community Advisory
Committee meetings for each of the
Youth Education programs to
provide youth and community input
on program implementation
Lin Chang,
40%
Valens Ben,
20%
Bill Ortiz, 20%
-African Organizations
-Hmong Organizations
-Local Health Public
Organizations
July 15,
2014 –
June 30,
2015
N/A
At least four Youth
meeting sessions are
held for each youth
program.
Five youth session held for
each youth program.
4. Develop culturally appropriate
curriculum with participation from
Advisory Committee.
Lin Chang,
40%
Valens Ben,
20%
Bill Ortiz, 20%
Advisory Committees
August –
March
2015
N/A
Culturally
appropriated
curriculum developed
and approved by
community members
Curriculum completed.
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2015-2016 EHDI Evaluation Report Instructions & Reporting Template
5. Conduct developed curriculum in
the African and Asian communities.
Lin Chang,
40%
Valens Ben,
20%
Bill Ortiz, 20%
-African Organizations
-Hmong Organizations
-Local Health Public
Organizations
March –
June 2015
75
Sixty youth will
complete the
curriculum.
Seventy-five percent (75%) of
youth complete program.
15
2015-2016 EHDI Evaluation Report Instructions & Reporting Template
(Insert your Organizational Name)
EHDI 2015– 2016 Work Plan & Progress Report Form
Objectives:
Strategies:
Activity
Key Staff
Partners
Planned
Timeline
Start and
Finish
Dates
Estimated
Unduplicated
Numbers
to be
Reached
Projected Outcomes
Achieved Outcomes
16
2015-2016 EHDI Evaluation Report Instructions & Reporting Template