Community Partnership Reporting / Evaluation Form

Name of CPPC Site: Indianola DCAT Cluster	County(ies): Madison, Marion & Warren

Reporting Period: July 1, 2016-June 30, 2017	Check the Following: Propose Plan ☒ Year-End☐

(Please click inside of the box for desired answer).

Highlighted areas should be filled out at the beginning of the year. Dark Highlighted areas should be filled out at the end of the year.

Community Partnership Involvement Community Partnership Involvement

Partner (Categories)	# of professionals involved	FTDM (ICA)*	Shared Decision Making *	Neighborhood Networking	Policy and Practice Change	# of Comm. members involved*	FTDM (ICA)	Shared Decision-Making *	Neighborhood Networking	Policy and Practice Change	Comments
DHS	3	☒	☒	☒	☒	☐	☐	☐	☐
Decat	2	☒	☒	☒	☒	☐	☐	☐	☐
Empowerment	1	☐	☒	☒	☐	☐	☐	☐	☐
Neighborhood/Comm. Members*	0	☐	☐	☐	☐	1	☐	☐	☐	☐	Winterset Optimist Club
Domestic Violence	2	☒	☒	☒	☐	☐	☐	☐	☐
Substance Abuse	5	☐	☒	☒	☒	☐	☐	☐	☐
Mental Health	5	☒	☒	☒	☒	☐	☐	☐	☐
Faith-based groups	1	☐	☐	☐	☐	☐	☐	☐	☐
Health Care	3	☐	☒	☒	☐	☐	☐	☐	☐
Education	3	☐	☒	☒	☐	☐	☐	☐	☐
Business	0	☐	☐	☐	☐	☐	☐	☐	☐
Legal System (Court)	2	☐	☒	☒	☒	☐	☐	☐	☐
Law Enforcement	0	☐	☐	☐	☐	☐	☐	☐	☐
Government (i.e. City, Co.)	0	☐	☐	☐	☐	☐	☐	☐	☐
Practice Partners*	11	☐	☒	☒	☒	☐	☐	☐	☐	Parent Partner Coordinator, IMPACT, Partners in Family Development, 1st Five, ISU Extension, Parenting Way, Outreach, etc.
Economic Supports	2	☐	☒	☒	☒	☐	☐	☐	☐
Prevention Councils	1	☐	☒	☒	☒	☐	☐	☐	☐	Madison and Warren County Child Abuse Prevention Councils
Youth	0	☐	☐	☐	☐	☐	☐	☐	☐
Former Clients of DHS	0	☐	☒	☒	☒	☐	☐	☐	☐
Parent Partners	3	☒	☒	☒	☒	☐	☐	☐	☐
Other	0	☐	☒	☒	☐	☐	☐	☐	☐
Total	43	1

(To compile the TOTAL: highlight the number “0”, click the “Layout” tab and then click “Formula” [located to the upper right of the screen] and then click “OK”. This section can be manually calculated if needed.)

Total % of Professionals involved in the initiative	90%	Total % of Community Members Involved in the initiative	5%

Instructions & Definitions

In the gray columns put the number of professional and the number of community members who are associated with the respective category.

In the FTDM (ICA), Shared Decision-Making, Neighborhood Networking and Policy & Practice column put a check mark if there are professionals and/or

community members participating in these activities.

Please do not duplicate numbers. Select one primary category for each person. The comment section may be useful to explain

when more than one category applies to one person. If a person represents two or more categories, include the person in the number count of the

primary role and check mark the gray column for the other categories and explain in the comment section.

Provide a total count and % for both the professional and community members involved.

# of Community Members – This number count is for those who are involved as volunteer community members and are associated with one of the categories

listed. Examples: faith-based members can be volunteers if they are not being paid to attend, professional who is volunteers but is not serving/participating as a

representative in their official/professional capacity, substance abuse sponsor who is not being paid, volunteer advocate for domestic violence.

# of Neighborhood/Community Members – these are individuals who are neighborhood/community residents or parents and are not associated with any of the

other categories.

FTDM (ICA) - those who are facilitators conducting FTDM defined by Iowa’s Standards

Shared Decision Making- those who are involved on the CPPC leadership committee(s)

Practice Partners- includes social service agencies that do not fall under another category (i.e. in-home workers, early childhood programs,

Community Action Agency when applicable)

Economic Supports – includes social service agencies that provide financial and basic-need supports (FaDSS's workers, Income Maintenance

Community Action Agency when applicable)

Shared Decision-Making Shared Decision-Making

Describe your community partnership shared decision-making leadership group and oversight role. Who coordinates? How it is structured? How it is linked to Decat? Are there task teams or subcommittees? (Please click inside of the box for your desired answer.) Our shared decision-making (SDM) group is called the DCAT Steering Committee. The CPPC coordinator sends out agendas, records the minutes, and facilitates the meetings. The committee is designed to have four voting members per county, a total of 12 members. Currently, we have 4 members from Madison County, 2 members from Marion County, & 3 members from Warren County totaling 8 voting members. Guests are always encouraged to attend, but have no voting power. Each proposal that comes in for DCAT funds, first comes through the Steering Committee. The committee members give recommendations on how they would like to see the funding spent to the executive DCAT Board. Subcommittees are formed from the SDM team when necessary.
How often does this group meet?	Once per month on the first Tuesday. Usually taking the summer months off.
Attach meeting agendas.	Are meeting agenda's attached?	Yes: ☐ No: ☐
Identify Goal(s) for engaging new members:	Fill voting slots for each county due to resignations. Seek out potential voting members at local provider meetings.
Was your goal met? If no, please explain.	Yes: ☐ No:☐
State Goal(s) for identifying, and/or planning and/or addressing an unmet need(s)	Incorporate more community members’ input into SDM team process by filing all four voting slots in each county. Identify, through SDM, the unmet needs of families in our communities. Promote awareness of various programs/agencies through presentations at SDM team meetings.
Was your goal met? If no, please explain.	Yes: ☐ No: ☐
Have you identified the goal for the % of community membership on the SDM committee?	Yes: ☒ No: ☐ If yes, what %: 10% Because community membership is on a completely voluntary basis, it has been difficult to engage community members to volunteer their time.
Was your goal met? If no, please explain.	Yes: ☐ No: ☐
Describe how your SDM group has diverse representation.
Is there a community member in the leadership SDM role?	Yes: ☐ No: ☐ Please explain this leadership role. Click here to enter text.

Based on your activities, select the level* for Shared Decision-Making that best fits your site: 3

Describe strategies to advance to the next level: Engage diverse members according to unmet representation such as community members, law enforcement, youth & faith-based.

Based on your activities, circle the level* for Shared Decision-Making that best fits your site: Select

Please have each committee member on the leadership/steering committee fill out the Shared Decision Making form, compile the average response for each question, and report the average response below.
*Instructions: Baseline=1st year at the beginning of year on proposed plan (Yellow). Previous Year=Previous year on progress report (Green). Current Year: Current year on progress report (Green)	Baseline Year 2010	Previous Year 2016	Current Year 2017
Shared Decision Making Survey “1” disagree, "2" mildly disagree, "3" neutral "4"mildly agree "5" agree

Shared Decision Making	Description	Baseline Year:	Previous Year:	Current Year:
1. Common Vision:	Members have a shared common vision.	4.38	Click here to enter text.	Click here to enter text.
2. Understanding and Agreement Goals:	Members understand and agree on goals and proposed outcomes/objectives.	4.13	Click here to enter text.	Click here to enter text.
3. Clear Roles & Responsibilities:	Roles & responsibilities of Members are clear.	3.88	Click here to enter text.	Click here to enter text.
4. Shared Decision Making:	All members have a voice and are engaged in the decision making process.	4.38	Click here to enter text.	Click here to enter text.
5. Conflict Management:	We are able to successfully manage conflict.	4.25	Click here to enter text.	Click here to enter text.
6. Shared Leadership:	Leadership is effective and shared when appropriate.	4.5	Click here to enter text.	Click here to enter text.
7. Well Developed Work Plans:	Work Plans are well developed and followed.	4	Click here to enter text.	Click here to enter text.
8. Relationships/Trust	Members trust each other.	2.88	Click here to enter text.	Click here to enter text.
9. Internal Communication:	Members communicate well with each other.	3.88	Click here to enter text.	Click here to enter text.
10. External Communication:	Our external communication is open and timely within the broader community and partners.	4	Click here to enter text.	Click here to enter text.
11. Evaluation:	We have built evaluation performance into our activities.	2.5	Click here to enter text.	Click here to enter text.
12. Understanding of CPPC:	Members have a clear understanding of the Community Partnerships Four Strategies.	3.13	Click here to enter text.	Click here to enter text.
TOTAL:	(To compile the TOTAL highlight the number, click the “Layout” tab and then click “Formula” [located to the upper right of the screen] and then click “OK”) Total # of Participants:	46	0	0

Community / Neighborhood Networking Community / Neighborhood Networking	Level #	Network Activity	Description (include what was goal, what was invested and what was done)	# of Participants	Outcome(s)
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Total # of Activities:	Click here to enter text.	Total # of Participants:	0
Community / Neighborhood Networking Community / Neighborhood Networking

Activities may overlap and meet several goals, or one activity may meet only one goal.	Goals
Please list goal(s) for level 1 Neighborhood/ Community Networking Activities:	Maintain website (www.cppconline1.com). 2. Order promotional items as needed (pens, reusable grocery bags, etc.) 3. Complete semi-annual & year-end newsletter. 4. New member orientation for voting members to prepare them to be spokespeople for CPPC in our area.
Was your goal met? If yes, include this information in prior section. If no, please explain.	Yes: ☐ No: ☐ Click here to enter text.
Please list goal(s) for level 2 Neighborhood/ Community Networking Activities:	Provide access to community service brochures. 2. Maintain website. 3. Provide resource information to providers through local presentations. 4. Continue to provide assistance in sending out requests to mailing lists for family needs. 5. Forward any received information on local events/collaboration opportunities to Parent Partner Coordinators. 6. Work with local mental health, domestic violence, etc. providers to establish a network of individuals to be called on if those supports are needed for a family (especially for a family team meeting)
Was your goal met? If yes, include this information in prior section. If no, please explain.	Yes: ☐ No: ☐ Click here to enter text.
Please list goal(s) for level 3 Neighborhood/ Community Networking Activities:	Continue to maintain website as a “hub” for local events, resources, job openings, etc. 2. Continue to promote and support 24/7 Dads and Parent Partner involvement in our counties. 3. Host a Race: The Power of Illusion training.
Was your goal met? If yes, include this information in prior section. If no, please explain.	Yes: ☐ No: ☐ Click here to enter text.
Please list goal(s) for level 4 Neighborhood/ Community Networking Activities:	No goal identified at this time.
Was your goal met? If yes, include this information in prior section. If no, please explain.	Yes: ☐ No: ☐

Based on your activities, select the level* for Community / Neighborhood Networking that best fits your site: 2

Describe strategies to advance to the next level: Develop a plan to move to Level 3 & 4 with SDMT.

Based on your activities, circle the level* for Community / Neighborhood Networking that best fits your site: Select

Level #	Network Activity	Description (include what was goal, what was invested and what was done)	# of Participants	Outcome(s)
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Total # of Activities: 0	Total # of Participants: 0

Individualized Course of Action/Family Team &Youth Transition (Dream Team) Decision Making Individualized Course of Action

Please describe how Family Team Meetings are implemented in your area. Who facilitates? How are referrals made? What funding is used? Community Based Family Team Meetings (CBFTMs) and Community Based Youth Transition Decision Making Meetings (CBYTDM) are facilitated by the CPPC Coordinator. The CPPC Coordinator has completed the below mentioned trainings in order to be able to facilitate our meetings at state standards. Referrals come from community agencies, schools, churches and private providers. DCAT funds the meetings with a separate budget but they are part of the CPPC process.
Please list goal(s) for Level 1 Individualized Course of Action:	Promote CBFTMs and CBYTDMs through schools, provider meetings, daycares, etc. 2. Promote trainings and coaching and mentoring to those interested in becoming a facilitator in our area. 3. Work with agency to understand their process for working with DHS involved families. 4. Collaborate with facilitators from other agencies by inviting them to SDM meeting and other relevant community events.
Was your goal met? If no, please explain.	Yes: ☐ No: ☐
Please list goal(s) for Level 2 Individualized Course of Action:	Maintain above listed items. Develop plan for tracking, evaluation and quality assurance with assistance of SDM team. Maintain list of state-approved facilitators. Promote CBFTMs and CBYTDMs at provider groups. Maintain relationships with current referral sources.
Was your goal met? If no, please explain.	Yes: ☐ No: ☐
Please list goal(s) for Level 3 Individualized Course of Action:	Maintain above listed items. Facilitate, track and evaluate CBFTMs and CBYTDMs for quality assurance.
Was your goal met? If no, please explain.	Yes: ☐ No: ☐
Please list goal(s) for Level 4 Individualized Course of Action:	Maintain above listed items. Continue implementing CBFTMs and CBYTDMs.
Was your goal met? If no, please explain.	Yes: ☐ No: ☐
# of state approved facilitators	Goal (# value) 3	Current # of FTM: Click here to enter text.	Goal Met (Y/N): Choose an item.
# of Community education activities about CBFTDM and CBYTDM	Goal (# value) 3	Current # of FTM: Click here to enter text.	Goal Met (Y/N): Choose an item.
# of CBFTDM held annually for families Not involved with child protection service	Goal (# value) 6	Current # YTDM: Click here to enter text.	Goal Met (Y/N): Choose an item.
# of CBYTDM held annually for families Not involved with child protection service	Goal (# value) 1	Current # YTDM: Click here to enter text.	Goal Met (Y/N): Choose an item.

Based on your activities, select the level* for Individualized Course of Action that best fits your site: 3

Describe strategies to advance to the next level: Develop a plan for implementing CBYTDMs in our area.

Based on your activities, select the level* for Individualized Course of Action that best fits your site: Choose an item.

Policy and Practice Change Policy and Practice Changes Policy and Practice Changes Policy and Practice Changes

Please list goal(s) for Level 1 Policy and Practice Change:	1. Work with families/agencies involved with Al’s Pals and SDM team to determine needs relating to policy and practice change. 2. Attend local and regional meetings to learn of needs 3. Engage SDM team in discussions that identify needs 4. Create and utilize informal surveys to gather data from parents and youth impacted by policy and practice change to investigate needs
Was your goal met? If no, please explain.	Yes: ☐ No: ☐
Please list goal(s) for Level 2 Policy and Practice Change:	1. Establish a plan with objectives and dates for completion once a need is identified and prioritized. 2. Identify partners to engage to accomplish change. 3. Identify cultural disproportionality and disparity issues (if relevant).
Was your goal met? If no, please explain.	Yes: ☐ No: ☐
Please list goal(s) for Level 3 Policy and Practice Change:	1. Carry out and monitor plan developed in level 2 for completion and effectiveness 2. Evaluate effectiveness based upon end-user input
Was your goal met?	Yes: ☐ No: ☐
Please list goal(s) for Level 4 Policy and Practice Change:	1. Ensure that SDM team and other service providers are aware that needs for policy and practice change is a priority of CPPC- invite and encourage participation at monthly CPPC Steering Committee meetings 2. Regularly evaluate surveys and feedback from families/community members.
Identify training/technical assistance goal(s) that will assist in the development and/or implementation of CPPC and the four strategies: Examples: Regional 101 Attend 201 One on one Technical Assistance with state CPPC consultant	The CPPC Coordinator will continue to attend trainings on various topics relating to family safety, assessment, and prevention when appropriate including, but not limited to: statewide meetings and regional meetings. CPPC Coordinator will encourage SDM members to attend Immersion 101, 201, statewide and regional meetings.
List Trainings/Technical Assistance sponsored and/or attended that assisted in the development and/or implementation of CPPC and the four strategies	Click here to enter text.
Was your goal met?	Yes: ☐ No: ☐

Based on your activities, select the level* for Policy and Practice that best fits your site: 1

Describe strategies to advance to the next level: Identify new needs in FY17, develop a plan to address those needs and carry out the plan involving DHS, CPPC attendees and the community in the process.

Based on your activities, select the level* for Policy and Practice that best fits your site: Choose an item.

Name: Sarah Hohanshelt Title: CPPC Coordinator

Site: Indianola DCAT Cluster	Address: 200 S Howard Street, Indianola 50125	Phone: 515.468.8181

Please return this completed form to both Sandy Lint and Shelby Zirbel:

Sandy Lint, DHS-CFS

1305 E Walnut

Des Moines, Iowa 50319-0114

Email: slint@dhs.state.ia.us

Phone: (515) 242-5319

Fax: (515) 281-4597

Shelby Zirbel, DHS-CFS

1305 E Walnut

Des Moines, Iowa 50319-0114

Email: szirbel@dhs.state.ia.us

Phone: (641) 330-4828

Fax: (515) 281-4597