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At a minimum, enter all activity that took place under your Commerce/CM contract during the period July 1, 2012 through December 31, 2012. You may also at any time enter activity that took place after December 31, 2012.

Entering Program Activity Reports for the above period for each planned activity included in your 2012-2013 CM workplan is a contract deliverable and must be "SUBMITTED" to Commerce no later than April 30, 2013.

If you need a copy of your 2012-2013 workplan or if you have questions, contact ramona.leber@commerce.wa.gov.
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* 1. Please select your County or County Consortium

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* 2. Please tell us your name.

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* 3. Enter today's date.

Date

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* 4. Enter your Planned Activity Number from your 2012-2013 Workplan. Make sure the activity number used is consistent with the number you assigned to the activity in your workplan. If you need a copy of your workplan, contact ramona.leber@commeerce.wa.gov.

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* 5. Enter your activity title (from your 2012-2013 workplan). Make sure the activity title used is consistent with the title you assigned to the activity in your workplan.

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* 6. Enter the site(s) where the activity actually took place.

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* 7. Enter the PAR number for this activity. Please begin with 1.

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* 8. Curriculum - Please check the one option that best describes this activity.

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* 9. Topical - Please check the one option that best describes this activity.

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* 10. Community Organizing - Please check the one option that best describes this activity.

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* 11. Public Awareness - Please check the one option that best describes this activity.

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* 12. Activity Start/End Dates

Date
Date
Date

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* 13. Actual funds and/or match spent on this activity. ---------- Note* Please round to the nearest dollar. DO NOT USE DOLLAR SIGNS, COMMAS OR PERIODS IN YOUR FIGURES.

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For questions 14 through 30, you must respond to at least one section for this activity:
-- Direct Service;
-- Large Event; and/or
-- Community Organizing/Planning
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* IF THE ACTIVITY LISTED IN QUESTIONS 4 AND 5 IS A DIRECT SERVICE ACTIVITY, PLEASE PROCEED TO QUESTION 14.

* IF IT IS A LARGE EVENT THAT DOES NOT INCLUDE DIRECT SERVICE SESSIONS, SKIP TO QUESTION 19.

* IF IT IS A COMMUNITY ORGANIZING OR PLANNING ACTIVITY THAT DOES NOT INCLUDE DIRECT SERVICE OR A LARGE EVENT, SKIP TO QUESTION 25.

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* 14. For this Direct Service Activity, ENTER THE...

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* 15. Direct Service Activity: Of the counted individuals in question 14, indicate the race of participants, one per participant. The total count must match total unduplicated participant count. You may estimate the breakdown.

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* 16. Direct Service Activity: Ethnicity of participants counted in question 14. Total must match. You may estimate.

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* 17. Direct Service Activity: Age of participants counted in question 14. Total must match. You may estimate.

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* 18. Direct Service Activity: Gender of participants counted in question 14. Total must match. You may estimate.

* CONTINUE TO QUESTION 19 IF THE ACTIVITY NOTED IN QUESTIONS 4 AND 5 INCLUDED A LARGE EVENT.

* PROCEED TO QUESTION 25 IF THE ACTIVITY NOTED IN QUESTIONS 4 AND 5 INCLUDED A COMMUNITY ORGANIZING OR PLANNING EFFORT, BUT NO LARGE EVENT.

* IF THE ACTIVITY NOTED IN QUESTIONS 4 AND 5 DID NOT INCLUDE A LARGE EVENT OR A COMMUNITY ORGANIZING/PLANNING EFFORT, SKIP TO QUESTION 31.

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* 19. Large Event: Briefly describe the large event

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* 20. For this Large Event, ENTER THE...

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* 21. Large Event: Of the counted individuals in question 20, indicate the race of participants, one per participant. The total count must match total unduplicated participant count. You may estimate the breakdown.

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* 22. Large Event: Ethnicity of participants counted in question 20. Total must match. You may estimate.

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* 23. Large Event: Age of participants counted in question 20. Total must match. You may estimate.

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* 24. Large Event: Gender of participants counted in question 20. Total must match. You may estimate.

* CONTINUE TO QUESTION 25 IF THE ACTIVITY NOTED IN QUESTIONS 4 AND 5 INCLUDED A COMMUNITY ORGANIZING OR PLANNING EFFORT.

* OTHERWISE, SKIP TO QUESTION 31.

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* 25. For the Community Organizing or Planning Effort noted in Questions 4 and 5, if a coalition or other type of group was involved, please enter the coalition name.

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* 26. For this Community Organizing or Planning Effort, ENTER THE...

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* 27. Community Organizing/Planning Effort: Of the counted individuals in question 26, indicate the race of participants, one per participant. The total count must match total unduplicated participant count. You may estimate the breakdown.

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* 28. Community Organizing/Planning Effort: Ethnicity of participants counted in question 26. Total must match. You may estimate.

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* 29. Community Organizing/Planning Effort: Age of participants counted in question 26. Total must match. You may estimate.

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* 30. Community Organizing/Planning Effort: Gender of participants counted in question 26. Total must match. You may estimate.

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EACH OF THE FOLLOWING EVALUATION QUESTIONS (31-35) REQUIRES A RESPONSE IN REGARDS TO THE ACTIVITY NOTED IN QUESTIONS 4 AND 5. The evaluation questions are designed to gather information about the activity after the activity has been completed for the contract year. If the activity is not yet complete for the contract year, you may note this in each response.
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* 31. Evaluation: Please describe evidence of this activity's effectiveness in meeting your program goals or impacting substance abuse or violence. For example: survey results, participant comments, attendance rates, etc.

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* 32. Evaluation: What were this activity's successes?

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* 33. Evaluation: What were this activity's shortcomings or areas of possible improvement?

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* 34. If you are planning to continue the activity, will you be making changes to your activity in response to perceived shortcomings or ideas for improvement? Please explain.

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* 35. Evaluation: Are there any specific components of this activity that the CM funding allowed you to do that would not otherwise have been done? Please explain.

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* 36. Additional comments/information about this Program Activity Report.

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IMPORTANT! PRINT OR COPY AND PASTE THIS PAGE INTO A WORD DOCUMENT FOR YOUR RECORD. Contact ramona.leber@commerce.wa.gov if you experience challenges with this Survey.

Thank you for completing your report. Please click 'SUBMIT' to forward your PAR to Commerce.

NOTE - If you don't click "SUBMIT", your PAR is not submitted.
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