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OMB No. 0920-XXXX
Exp. Date:
Public
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Attachment K:
School Leadership Capacity and Readiness Survey
Division of Violence Prevention
National Center for Injury Prevention and Control
Centers for Disease Control and Prevention
School ID number:
Survey Date:
Program Year:
Survey Iteration:
(Introduction text to be added)
What is your primary role within the school? Select one answer.
1 Administrator (e.g., Principal, Assistant Principal) |
2 Teacher |
3 Counselor, Psychologist, Social Worker |
4 Physical or Occupational Therapist, Nurse |
5 School District-level Administrator |
6 Other If other, please specify: ____________________________________ |
How long have you been in this role at
this school?
|
|
Years |
|
|
|
Months |
In the past 12 months, how much of a problem has teen dating violence been at your school? Select one answer.
1 Major problem |
2 Moderate problem |
3 Minor problem |
4 Not a problem 5 Don’t know |
Scoring: Report 1 and 2 responses in action plan.
In the past 12 months, how much of a problem has teen dating violence been at other schools in the district? Select one answer.
1 Major problem |
2 Moderate problem |
3 Minor problem |
4 Not a problem 5 Don’t know |
Scoring: Report 1 and 2 responses in action plan.
In the past 12 months, has your school done any of the following? Select one answer per row.
|
Yes |
No |
Don’t know |
a. Adapted a prevention curriculum (on any topic) to better meet the needs of your community |
1 |
0 |
2 |
b. Implemented a curriculum that included healthy relationship topics (but not specific to teen dating violence) |
1 |
0 |
2 |
c. Implemented a teen dating violence prevention curriculum with students |
1 |
0 |
2 |
d. Implemented a teen dating violence prevention curriculum with parents/caregivers or families |
1 |
0 |
2 |
e. Provided training for staff, teachers, or administrators about a teen dating violence prevention curriculum |
1 |
0 |
2 |
f. Provided training for staff, teachers, or administrators on the prevalence, causes, and consequences of teen dating violence |
1 |
0 |
2 |
g. Facilitated youth-led teen dating violence prevention programming |
1 |
0 |
2 |
h. Identified gaps in school district policies on teen dating violence prevention |
1 |
0 |
2 |
i. Supported the promotion of school district policies on teen dating violence prevention |
1 |
0 |
2 |
Scoring: sum of “yes” responses. Report “no” responses in action plan.
In the past 12 months, has your school implemented any of the following types of prevention and/or health promotional programming? Select one answer per row.
|
Yes |
No |
Don’t know |
a. Substance abuse prevention |
1 |
0 |
2 |
b. Gang prevention |
1 |
0 |
2 |
c. Teen pregnancy prevention or sexual health promotion |
1 |
0 |
2 |
d. Bullying prevention |
1 |
0 |
2 |
e. Sexual violence prevention |
1 |
0 |
2 |
f. School violence prevention |
1 |
0 |
2 |
g. Suicide prevention |
1 |
0 |
2 |
h. Positive behavioral interventions and supports (PBIS) |
1 |
0 |
2 |
i. Healthy living (e.g., exercise, nutrition) |
1 |
0 |
2 |
j. Other |
1 |
0 |
2 |
If
other, please specify ______________________
Score: Sum of
a – j.
Please indicate whether your school currently has the following resources to implement the Dating Matters initiative. Select one answer per row.
|
Yes |
No |
Don’t know |
a. Staff who could assist an evaluator in collecting evaluation data, such as surveys. |
1 |
0 |
2 |
b. Training for evaluation assistant. |
1 |
0 |
2 |
c. Staff who understand the importance of adhering to the curriculum implementation manual. |
1 |
0 |
2 |
d. School staff to facilitate Dating Matters. |
1 |
0 |
2 |
e. Access to a copier to prepare Dating Matters handouts. |
1 |
0 |
2 |
f. Classroom space to teach Dating Matters. |
1 |
0 |
2 |
g. Funds to hire substitute teachers when teachers receive the Dating Matters training. |
1 |
0 |
2 |
h. Funds for purchasing Dating Matters supplies (e.g., paper, markers). |
1 |
0 |
2 |
i. Funds to pay for Dating Matters training (excluding funds to hire substitute teachers). |
1 |
0 |
2 |
j. Access to ongoing technical assistance for implementing Dating Matters |
1 |
0 |
2 |
k. Class time for 10 classroom sessions. |
1 |
0 |
2 |
l. Time allocated to show Dating Matters play. |
1 |
0 |
2 |
Scoring: sum of “yes” responses. Report “no” responses in action plan.
Sometimes, programs like Dating Matters encounter challenges with gaining full support of stakeholders. How much do you agree or disagree with each of the following statements? Select one answer per row.
|
Strongly Disagree |
Disagree |
Neither Disagree nor Agree |
Agree |
Strongly Agree |
Don’t Know |
a. Dating Matters has support from school district leaders. |
1 |
2 |
3 |
4 |
5 |
6 |
b. Dating Matters has support from administrators and staff. |
1 |
2 |
3 |
4 |
5 |
6 |
c. Dating Matters has support from teachers. |
1 |
2 |
3 |
4 |
5 |
6 |
d. Dating Matters has support from parents. |
1 |
2 |
3 |
4 |
5 |
6 |
e. Dating Matters has support from students. |
1 |
2 |
3 |
4 |
5 |
6 |
Scoring: means of items a–e.
How much do you agree or disagree with each of the following statements? Select one answer per row.
I am confident that my school can….
|
Strongly Disagree |
Disagree |
Neither Disagree nor Agree |
Agree |
Strongly Agree |
Don’t Know |
a. Explain the benefits of evaluation to parents and youth. |
1 |
2 |
3 |
4 |
5 |
6 |
b. Work with an evaluator to collect survey and other outcome data from Dating Matters participants. |
1 |
2 |
3 |
4 |
5 |
6 |
c. Work with an evaluator to collect implementation data from Dating Matters participants and program staff. |
1 |
2 |
3 |
4 |
5 |
6 |
Scoring: mean of items a–c. Report items with “disagree” response in action plan.
In the past 12 months, have any of the following advocacy or promotional efforts occurred? Select one answer per row.
|
Yes |
No |
Don’t Know |
a. Someone in our school advocated for resources, other than Dating Matters, for teen dating violence prevention. |
1 |
0 |
2 |
b. Someone in our school advocated for district policies on teen dating violence. |
1 |
0 |
2 |
c. There have been school-wide or district-wide events promoting Dating Matters. |
1 |
0 |
2 |
d. The school has organized community-wide events promoting Dating Matters. |
1 |
0 |
2 |
Scoring: mean of items a–d.
11a. Our Dating Matters school staff has received training to implement Dating Matters. Select one answer.
|
1 Yes Go to 11b |
2 No Go to 11c |
3 Don’t know Go to 11c |
11b. How much do you agree or disagree with this statement? Select one answer
Our Dating Matters school staff has been effectively trained to implement Dating Matters.
|
1 Strongly disagree |
2 Disagree |
3 Neither disagree or agree |
4 Agree |
5 Strongly agree |
6 Don’t know |
11c. Our Dating Matters school staff has received ongoing technical assistance to implement Dating Matters. Select one answer.
|
1 Yes Go to 11d |
2 No Go to 11e 3 Don’t know Go to 11e |
11d. The on-going technical assistance our school staff has received to implement Dating Matters has been useful. Select one answer.
|
1 Strongly disagree |
2 Disagree |
3 Neither disagree or agree |
4 Agree |
5 Strongly agree |
6 Don’t know |
11e. Our Dating Matters school staff has received training or information on how to adapt the Dating Matters initiative to our school. Select one answer.
|
1 Yes Go to 11f |
2 No Go to 12 3 Don’t know Go to 12 |
11f. How much do you agree or disagree with this statement? Select one answer.
Training or information on adapting the Dating Matters initiative has been useful to Dating Matters school staff.
|
1 Strongly disagree |
2 Disagree |
3 Neither disagree or agree |
4 Agree |
5 Strongly agree |
6 Don’t know |
Scoring: mean of items b and d and f.
How much do you agree or disagree with each of the following statements? Select one answer per row.
|
Strongly Disagree |
Disagree |
Neither Disagree nor Agree |
Agree |
Strongly Agree |
Don’t Know |
a. Our school has the fiscal resources to implement the Dating Matters initiative. |
1 |
2 |
3 |
4 |
5 |
6 |
b. Our school has the time to implement Dating Matters. |
1 |
2 |
3 |
4 |
5 |
6 |
c. Our school has the time to participate in an evaluation of Dating Matters. |
1 |
2 |
3 |
4 |
5 |
6 |
d. Our school has the knowledge needed to implement Dating Matters. |
1 |
2 |
3 |
4 |
5 |
6 |
e. Our school understands the steps that are required to implement Dating Matters. |
1 |
2 |
3 |
4 |
5 |
6 |
f. Dating Matters fits with our school’s educational philosophy. |
1 |
2 |
3 |
4 |
5 |
6 |
g. School district policies will not interfere with implementing Dating Matters. |
1 |
2 |
3 |
4 |
5 |
6 |
h. Our school feels a strong commitment to implement Dating Matters. |
1 |
2 |
3 |
4 |
5 |
6 |
i. Our school believes that Dating Matters will benefit our students. |
1 |
2 |
3 |
4 |
5 |
6 |
Scoring: mean of items a–i with one item reverse coded.
Please describe any barriers that may hinder implementation of the Dating Matters initiative.
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
How much do you agree or disagree with each of the following statements? Select one answer per row.
In order for an evidence-based intervention to achieve results like those demonstrated in its research studies…
|
Strongly Disagree |
Disagree |
Neither Disagree nor Agree |
Agree |
Strongly Agree |
Don’t Know |
a. The implementer should cover all of the topic areas laid out in the intervention manual. |
1 |
2 |
3 |
4 |
5 |
6 |
b. The implementer should complete all of the specific activities laid out in the intervention manual. |
1 |
2 |
3 |
4 |
5 |
6 |
c. The implementer should deliver intervention content in the method specified in the intervention manual (e.g., lecture vs. reading assignment). |
1 |
2 |
3 |
4 |
5 |
6 |
d. The intervention should be delivered in the setting specified in the intervention manual (e.g., community vs. school, small group vs. large group). |
1 |
2 |
3 |
4 |
5 |
6 |
e. Intervention activities should be delivered according to the schedule specified in the intervention manual. |
1 |
2 |
3 |
4 |
5 |
6 |
Scoring: mean of items a–e.
How much do you agree or disagree with
each of the following statements?
Select one answer per row.
|
Strongly Disagree |
Disagree |
Neither Disagree nor Agree |
Agree |
Strongly Agree |
Don’t Know |
a. Teachers at my school know better than researchers how to address teen dating violence prevention in our school. |
1 |
2 |
3 |
4 |
5 |
6 |
b. Research-based programs are not useful in “real world” prevention efforts. |
1 |
2 |
3 |
4 |
5 |
6 |
c. Frontline experience is more important than using interventions from a manual. |
1 |
2 |
3 |
4 |
5 |
6 |
d. Teachers at my school would not use interventions from a manual |
1 |
2 |
3 |
4 |
5 |
6 |
e. Teachers at my school believe that they should implement only those curricula lessons that they think are important. |
1 |
2 |
3 |
4 |
5 |
6 |
f. Teachers at my school believe it is OK to adapt curricula to make it more relevant to their students. |
1 |
2 |
3 |
4 |
5 |
6 |
Scoring: mean of items a–f. Reverse code so that higher score equals a more positive attitude.
In the past 12 months, has your school collaborated with other organizations in any of the following ways?
|
Yes |
No |
Don’t Know |
|
1 |
2 |
3 |
|
1 |
2 |
3 |
|
1 |
2 |
3 |
|
1 |
2 |
3 |
Scoring: mean of items a–c.
Please rate how much these characteristics are true for your Dating Matters initiative. Select one answer per row.
|
Not at All |
A Little |
Some-what |
A Lot |
Don’t Know |
a. Our school is planning for sustainability of Dating Matters. |
1 |
2 |
3 |
4 |
5 |
b. Our school is looking for other funding resources to support Dating Matters when the grant ends. |
1 |
2 |
3 |
4 |
5 |
c. Our school leadership is committed to the long-term goals of Dating Matters. |
|
2 |
3 |
4 |
5 |
d. Our school district leadership is committed to the long-term goals of Dating Matters. |
|
2 |
3 |
4 |
5 |
e. Dating Matters is part of a long-term collaborative effort with other organizations to reduce youth violence. |
1 |
2 |
3 |
4 |
5 |
f. Dating Matters addresses key needs of our students. |
1 |
2 |
3 |
4 |
5 |
g. Dating Matters has strong local government support. |
1 |
2 |
3 |
4 |
5 |
Scoring: mean of items a–f.
How much time did you spend on program administration over the past 12 months?
What is the teacher's annual salary?
$0 to $9,999
$10,000 to $19,999
$20,000 to $29,999
$30,000 to $39,999
$40,000 to $49,999
$50,000 to $59,999
$60,000 to $69,999
$70,000 to $79,999
$80,000 to $89,999
$90,000 to $99,999
$100,000 or above
What is the student curricular implementer’s annual salary?
$0 to $9,999
$10,000 to $19,999
$20,000 to $29,999
$30,000 to $39,999
$40,000 to $49,999
$50,000 to $59,999
$60,000 to $69,999
$70,000 to $79,999
$80,000 to $89,999
$90,000 to $99,999
$100,000 or above
What is your annual salary?
$0 to $9,999
$10,000 to $19,999
$20,000 to $29,999
$30,000 to $39,999
$40,000 to $49,999
$50,000 to $59,999
$60,000 to $69,999
$70,000 to $79,999
$80,000 to $89,999
$90,000 to $99,999
$100,000 or above
What is your travel expense for Dating Matters over the past 12 months?
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | 2001 DEPARTMENT OF DEFENSE |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |