Title V: Community Prevention Grants Program
Community Self-Evaluation Workbook

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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 line

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.

  1. 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.

  2. 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.

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?

FORM 1-9 (Wordperfect Format)