Date

Mid-Year Project Report Form

(available at:

Kaiser Foundation Health Plan of Georgia, Inc.

Date

Organization:
Director:
Contact Person & Title (if not Director):
Contact Phone: / Contact Email:
Organization Street Address:
City: State: GA Zip: County:
Website:
Project Title:
Grant Amount: / Amount Expended as of this Report:
Target Population Served by this specific Kaiser Permanente-funded contribution:
Proposed Number Served by this specific Kaiser Permanente-funded contribution: / Actual Number Served to Date by this specific Kaiser Permanente-funded contribution:
Actual County(ies) Served to Date by this specific Kaiser Permanente-funded contribution:
Describe any need to amend the grant agreement.
What challenges, if any, have you encountered with project implementation?

Print Name/Title Signature, Date

Helping Communities Thrive

Kaiser Foundation Health Plan of Georgia, Inc. Grant Evaluation Plan

Instructions: Re-enter application & Mid-Year information report for Columns 1-4. Complete columns 5 & 6 for Final Report. DELETE EXAMPLES

Organization Name Project Name Begin Date End Date

Project Goal: EX: Improve self-care behavior to reduce morbidity and mortality rates among hypertension patients
Column 1 / Column 2 / Column 3 / Column 4 / Column 5 / Column 6
Expected Outcomes
List measurable, time-defined outcomes that will enable you to reach your goal. Outcomes should reflect changes in health status. List 1-3 Outcomes / Strategies/Activities
List and quantify the activities
(e.g. classes, events, and services) that will enable you to reach each outcome objective. List 1-3 activities, as needed. / Outcome Measures
List the specific measures that you will use to determine whether you have achieved each outcome. Describe data source for the measures. / Mid-Year Outcomes
List the actual project results achieved, to date, against the Column 1 proposed outcomes. / Grant-End Outcomes
List the actual project results achieved against the Column 1 proposed outcomes. / Lessons Learned/
Project Barriers/ Surprise Successes/ Comments
Example
  • 100 participants funded through this grant will lower their hypertension risk during the grant period.
/ Example
  • Participants document four 30-min exercise sessions/ week.
  • Participants will participate in at least 12 smoking cessation classes.
/ Example
  • At least 55 participants will reduce their BMI ratios.
  • At least 45 participants will reduce or stop smoking.
/ Example
  • 8 clients lowered their hypertension risk by reducing their BMI ratios, and smoking habit.
/ Example
  • 48 participants consistently attended exercise sessions
  • 39 participants reduced or stopped their smoking.
/ Example
  • We will build in more counseling time in future programs.

Outcome Objective #1 / Activity 1 -
Activity 2 -
Activity 3 -
Outcome Objective #2 / Activity 1 -
Activity 2 -
Activity3 -
Outcome Objective #3 / Activity 1 -
Activity 2 -
Activity 3 -

Helping Communities Thrive