RPC BLUEPRINT COVER SHEET

KDMHMRS RPC Blueprint FY 2008 Form 110 Page 1 of 11 RPC BLUEPRINT COVER SHEET FY2008 Region # Regional Prevention Center Address: City, Zip: Contact Person: Position: Phone: Fax: Counties to be served in FY2008: PROGRAM SUMMARY OVERVIEW: FY 2008 RPC budget allocation: Budget Justification: Regional Mental Health/Mental Retardation Board Address: City, Zip: Contact Person: Position: Phone: Fax: KDMHMRS RPC Blueprint FY 2008 Form 110 Page 2 of 11 RPC Region: Projected Activities, Programs, And/Or Strategies For STEP ONE (1): ASSESSMENT Community Readiness Survey Conduct or Assist in Analysis Table 1 Organize/ prioritize needs & resource assessment data for logic model Provide TA and/or review needs & resource assessment instrument to assure cultural competency Community (May be county, coalition, or other group name that identifies a community of people within the region) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. Community Norms Survey Conduct or Assist in Analysis KIP Survey Other Youth Survey Conduct or Assist in Analysis Risk and Protective Factor Assessment Conduct or Provide TA Conduct or Assist in Analysis Needs Assessment Conduct or Assist in Analysis Resource Assessment Conduct or Assist in Analysis Conduct or Provide TA Conduct or Provide TA Conduct or Provide TA Conduct or Assist in Analysis Conduct or Provide TA Conduct or Provide TA Conduct or Provide TA Analyze or provide TA with analysis of resource assessment including ID of gaps in resources Develop or provide TA to develop “Theory of Change” Offer TA on prevention opportunities available through RPC KDMHMRS RPC Blueprint FY 2008 Form 110 Page 3 of 11 RPC Region: Community (May be county, coalition, or other group name that identifies a community of people within the region) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. Projected Activities, Programs, And/Or Strategies For STEP ONE (1): ASSESSMENT (continued) Table 2 Additional activities, programs and/or strategies not previously listed (checked) Please provide a brief rationale for the activities, programs, and/or strategies checked or listed for each community. (In other words, why are you choosing these activities, programs and/or strategies for this specific community?) KDMHMRS RPC Blueprint FY 2008 Form 110 Page 4 of 11 RPC Region: Projected Activities, Programs, And/Or Strategies For STEP TWO (2): CAPACITY BUILDING Identify and mobilize local community resources Identify and access additional funding Recruit community volunteers and stakeholders Analyze internal organizational cultural competency Analyze external (community) cultural competency Table 3 Community (May be county, coalition, or other group name that identifies a community of people within the region) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. Additional activities, programs and/or strategies not previously listed (checked) Please provide a brief rationale for the activities, programs, and/or strategies checked or listed for each community. (In other words, why are you choosing these activities, programs and/or strategies for this specific community?) KDMHMRS RPC Blueprint FY 2008 Form 110 Page 5 of 11 RPC Region: Projected Activities, Programs, And/Or Strategies For STEP TWO (2): CAPACITY BUILDING (continued) Conduct Community Training List proposed individuals/groups/organizations and topics of proposed training Table 4 Name of individual/group/organization 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. Topic of proposed training Rationale for proposed training KDMHMRS RPC Blueprint FY 2008 Form 110 Page 6 of 11 RPC Region: Projected Activities, Programs, And/Or Strategies For STEP TWO (2): CAPACITY BUILDING (continued) Staffing Plan Describe the training and/or professional development plan for each staff person Staff ID Date CPP Awarded by KCBPP (if applicable) Table 5 Name (four digit number assigned by CMHC HR Dept.) Position (select from dropdown list) Training Plan Rationale 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One Select One KDMHMRS RPC Blueprint FY 2008 Form 110 Page 7 of 11 RPC Region: Projected Activities, Programs, And/Or Strategies For STEP THREE (3): PROJECT PLANNING Assist the Community Table 6 Community (May be county, coalition, or other group name that identifies a community of people within the region) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. Develop a project plan that is community focused Identify resources Develop a longterm sustainability plan Identify importance of considering Step One results Develop a plan to increase community capacity and infrastructure to address identified priorities Identify culturally appropriate strategies to address identified priorities Describe Methods and Measures for Monitoring Community Level Outcomes KDMHMRS RPC Blueprint FY 2008 Form 110 Page 8 of 11 RPC Region: Community (May be county, coalition, or other group name that identifies a community of people within the region) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. Projected Activities, Programs, And/Or Strategies For STEP THREE (3): PROJECT PLANNING (continued) Table 7 Additional activities, programs and/or strategies not previously listed (checked) Please provide a brief rationale for the activities, programs, and/or strategies checked or listed for each community. (In other words, why are you choosing these activities, programs and/or strategies for this specific community?) KDMHMRS RPC Blueprint FY 2008 Form 110 Page 9 of 11 RPC Region: Assist community in identifying resources (materials, facilities, etc) necessary to implement programming and/or strategies to address identified priorities Projected Activities, Programs, And/Or Strategies For STEP FOUR (4): IMPLEMENTATION Provide technical assistance to community on delivering strategies with fidelity (number, length and frequency of sessions, covering all topics, etc.) Table 8 Community (May be county, coalition, or other group name that identifies a community of people within the region) Identify the role of key RPC staff in the implementation of the plan Monitor the implementation of the plan Additional activities, programs and/or strategies not previously listed (checked) Please provide a brief rationale for the activities, programs, and/or strategies checked or listed for each community. (In other words, why are you choosing these activities, programs and/or strategies for this specific community?) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. KDMHMRS RPC Blueprint FY 2008 Form 110 Page 10 of 11 RPC Region: Community (May be county, coalition, or other group name that identifies a community of people within the region) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. Conduct or provide technical assistance to the community on data collection and analysis Projected Activities, Programs, And/Or Strategies For STEP FIVE (5): EVALUATION Provide technical assistance to the community on disseminating information from the evaluation to recruit, inform, and engage community members Provide technical assistance in the design of the evaluation Communicate/ coordinate with evaluators in evaluation implementation Table 9 Assist in data gathering Assist in summarizing findings and report writing Additional activities, programs and/or strategies not previously listed (checked) Please provide a brief rationale for the activities, programs, and/or strategies checked or listed for each community. (In other words, why are you choosing these activities, programs and/or strategies for this specific community?) KDMHMRS RPC Blueprint FY 2008 Form 110 Page 11 of 11 RPC Region: Describe the plan for assuring complete, accurate and timely reporting of all prevention-related activities into the Prevention Data System: