S A M P L E F O R M United Way of Blair County Appendix 4: sample Logic Model Form A: Program Outcomes Model Worksheet Organization: To Your Health Program: Smoking Cessation Program Mission or Goal(s): To provide smokers who wish to quit smoking with the information, skills, and support to successfully reach their goal. Brief Description of Program: The smoking cessation course, taught over 8 weekly meetings of 1.5 hours educates smokers about the risks. Please refer to 2: Definitions of Terms for Measuring Program Outcomes” for additional information. Note: “Appendix Indicators & Indicators & Indicators & Initial Intermediate Long-term Targets for Targets for Targets for Inputs Activities Outputs Outcomes & Outcomes & Outcomes & Initial Intermediate Long-term Timeframe Timeframe Timeframe Outcomes Outcomes Outcomes -2 RNs Program # of classes Outcome: Indicator: # of Outcome: Indicator: # of Outcome: Indicator: # of -Educational provides 8 Participants participants Participants participants Participants participants materials weekly gain knowledge who can change their that report they make plans to who make # of (pamphlets, smoking about health identify 3 ways attitude about are more likely quit smoking plans to quit participants videos, cessation hazards of smoking smoking to quit smoking Timeframe: smoking within (initial) kits) sessions which smoking. negatively now than when Weeks 6-8 the next three Timeframe: -Meeting space may include: Timeframe: impacts health Weeks 6-8 they started the weeks. # of -Funding Videos Within two Target: 85% of class. Target: 75% of Outcome: participants -Trained Guest Speakers weeks of intake participants 75% of participants Target: Participants (ending) facilitators Role Playing participants quit smoking. (past smokers) Meditation Outcome: Indicator: # of Timeframe: Indicator: # of # of guest Participants participants End of 8th participants speakers learn effective that can session who quit smoking identify 2 smoking by the cessation effective end of the 8th techniques cessation session. Timeframe: techniques that Target: 60% of Weeks 5 & 6 work for participants them. Target: 80% of participants Constraints on Inputs: Participants must be willing to take risk to quit
S A M P L E F O R M United Way of Blair County Appendix 4: sample Logic Model Form A: Program Outcomes Model Worksheet Organization: To Your Health Program: Smoking Cessation Program Mission or Goal(s): To provide smokers who wish to quit smoking with the information, skills, and support to successfully reach their goal. Brief Description of Program: The smoking cessation course, taught over 8 weekly meetings of 1.5 hours educates smokers about the risks. Note: Please refer to “Appendix 2: Definitions of Terms for Measuring Program Outcomes” for additional information. Inputs Activities Outputs Initial Outcomes & Timeframe Indicators & Targets for Initial Outcomes Intermediate Outcomes & Timeframe Indicators & Targets for Intermediate Outcomes Long-term Outcomes & Timeframe Indicators & Targets for Long-term Outcomes -2 RNs -Educational materials (pamphlets, videos, kits) -Meeting space -Funding -Trained facilitators (past smokers) Program provides 8 weekly smoking cessation sessions which may include: Videos Guest Speakers Role Playing Meditation # of classes # of participants (initial) # of participants (ending) # of guest speakers Outcome: Participants gain knowledge about health hazards of smoking. Timeframe: Within two weeks of intake Outcome: Participants learn effective smoking cessation techniques Timeframe: Weeks 5 & 6 Indicator: # of participants who can identify 3 ways smoking negatively impacts health Target: 85% of participants Indicator: # of participants that can identify 2 effective cessation techniques that work for them. Target: 80% of participants Outcome: Participants change their attitude about smoking Timeframe: Weeks 6-8 Indicator: # of participants that report they are more likely to quit smoking now than when they started the class. Target: 75% of participants Outcome: Participants make plans to quit smoking Timeframe: Weeks 6-8 Outcome: Participants quit smoking. Timeframe: End of 8th session Indicator: # of participants who make plans to quit smoking within the next three weeks. Target: 75% of participants Indicator: # of participants who quit smoking by the end of the 8th session. Target: 60% of participants Constraints on Inputs: Participants must be willing to take risk to quit
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