Description of Program and Logic Model Describe an evidence-based intervention based on your completed needs assessment.

Benchmark – Program Implementation Plan Part 1 – Description of Program and Logic Model Describe an evidence-based intervention based on your completed needs assessment. Your intervention should be population-based and informed by your chosen theory and SMART goals and objectives. Population-based interventions can be directed at the entire population within a community, the systems that affect the health of those populations, and/or the individuals and families within those populations known to be at risk. Use the Logic Model to design your proposed intervention. 1. Description of the Intervention 0. Describe the population-based, evidence-based program/intervention. 0. Discuss how the intervention will support improving the health issue for the target population. 1. Goal and Objectives 1. Goal: 1. Process Objectives (the activities to be completed in a specific time period): 1. Outcome Objectives (changes in knowledge, attitudes, behaviors, policy, environment systems, etc.): 1. Complete the Logic Model. Design your intervention using the template on the following page: Inputs Long-Term Outcomes Intermediate Outcomes Short-Term Outcomes Outputs Activities Legend Inputs: What resources do you need to make this happen? (e.g., staff, space, funding) Activities: What are you going to do? (e.g., educate and establish partnerships) Outputs: What will happen because of your activities? (e.g., 100 people trained) Short-Term Outcomes: Immediate changes you expect to occur (e.g., changes in knowledge) Intermediate Outcomes: (e.g., changes in behavior) Long-Term Outcomes: How will this program help in the future (e.g., obesity prevention)? Target Population (as identified by needs assessment): Health issue affecting target population: Theory or model used to inform an intervention: Logic Model Part 2 – Implementation Timeline and Action Plan Develop a program timeline and action plan using a Gantt chart, depicting the key tasks, activities and people involved in the first 12 months (1 year) of implementing your program and the projected timeframe for completion of each task. Use the objectives you defined in Part 1. Example : Objective: By the end of the school year, district health educators will have delivered lessons on tobacco refusal skills to 90% of youth participants in the middle school tobacco prevention curriculum. Timeline for Tasks/Activities Task/Activity Personnel Responsible Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Train volunteers on curricula Program coordinator X X Deliver education classes Volunteers X X X 1. Complete the table below for your intervention (add rows, as needed): Objective 1: Timeline for Tasks/Activities Task/Activity Personnel Responsible Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Objective 1: Timeline for Tasks/Activities Task/Activity Personnel Responsible Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Objective 1: Timeline for Tasks/Activities Task/Activity Personnel Responsible Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Objective 1: Timeline for Tasks/Activities Task/Activity Personnel Responsible Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Objective 1: Timeline for Tasks/Activities Task/Activity Personnel Responsible Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Part 3 – Budget and Budget Justification Review the “Program Budget Resource” to complete your budget and justification. Identify a potential source of funding for your project. Add or remove rows from the tables below, as needed, to complete your budget. Source of Funding: 1. Personnel Staff Position Yearly Salary % of Time Fringe Benefits (as % or additional cost) Total Amount (Do not add fringe benefits twice.) Total 1. Travel Item Description of Travel Event Expenses Amount Item 1 Item 2 Item 3 Total 1. Equipment Equipment Item Description Amount Total Total 1. Supplies Supply Item Description Amount Total Total 1. Consultant Consultant/ Organizational Affiliation Services to Be Rendered and Relevance to Service Project Number of Days Expected Rate of Compensation Total Total 1. Other Item Description Amount or Amount/Month Total Total Total 1. Total Direct Costs Budget Item Total Amount Personnel Fringe Travel Equipment Supplies Contractual Consultant Other Total 1. Budget Proposal and Justification Write a 250-500 word justification for your budget. The justification summarizes the resources needed and why. Provide relevant rationale and evidence to support your summary.