Form DDDD STUDENT PROGRAM MASTER TRAINER TECHNICAL ASSISTANCE TRAC

Evaluation of Dating Matters: Strategies to Promote Healthy Teen Relationships

Atmt DDDD Student Master Trainer TA Track Form

STUDENT PROGRAM MASTER TRAINER TECHNICAL ASSISTANCE TRACKING FORM

OMB: 0920-0941

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Form Approved

OMB No. 0920-XXXX

Exp. Date:

Public Reporting burden of this collection of information is estimated at 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-XXXX).















Attachment DDDD:

STUDENT PROGRAM MASTER TRAINER TECHNICAL ASSISTANCE TRACKING FORM



Dating Matters: Strategies to Promote Healthy Teen Relationships™ Initiative



Division of Violence Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention






MASTER TRAINER (MT) TECHNICAL ASSISTANCE TRACKING FORM

No

Questions


1

Dating matters site: Alameda CountY Baltimore Broward County Chicago


2

School NAME:


3

DATE TA REQUEST WAS MADE:_____________________________________


4



NAME OF MASTER TRAINER HANDLING TA REQUEST: ______________________________________


5



ID NUMBER OF MASTER TRAINER HANDLING THE TA REQUEST:_________________________________



6

TA REQUESTOR’S ROLE IN SCHOOL:

(PLEASE CIRCLE ALL THAT APPLY)

DM CURRICULA IMPLEMENTER PRINCIPAL EDUCATOR SCHOOL LIAISON FOR DM PROJECT DM PROGRAM MANAGER

Other: _______________________________________


7



DURING WHAT PHASE OF THE DATING MATTERS INITITATIVE WAS THIS TA REQUEST MADE?

YEAR 0 (PLANNING YEAR) YEAR 1 YEAR 2 YEAR 3 YEAR 4


8

TYPE OF TA REQUEST:

INITIAL (NEW) FOLLOW-UP

IF FOLLOW-UP REQUEST, WHEN WAS THE INITAL REQUEST MADE :_____________________________________


9

THE TA REQUEST WAS RELATED TO WHICH OF THE FOLLOWING STUDENT CURRICULA:

(PLEASE CIRCLE ALL THAT APPLY)



SAFE DATES (COMPREHENSIVE)

SAFE DATES (STANDARD)

CDC-DEVELOPED 7TH GRADE CURRICULA

CDC-DEVELOPED 6TH GRADE CURRICULA


10

WHAT WAS THE NATURE OF THE TA REQUEST?

(PLEASE CIRCLE ALL THAT APPLY)



GENERAL IMPLEMENTATION ISSUES

CURRICULA DELIVERY ISSUES

CURRICULA CONTENT ISSUES

SCHEDULING CONFLICTS

DISCLOSURE OF SIGNIFICANT EVENTS

ISSUES WITH PARTICIPANT RETENTION

ISSUES WITH PARTICIPANT ENGAGEMENT

STUDENT BEHAVIOR PROBLEMS

OTHER:_____________________________________




11



HOW DID THE TA REQUESTOR CONTACT YOU?

TELEPHONE E-MAIL IN-PERSON Other: _______________________________________


12



DATE TA WAS PROVIDED IN RESPONSE TO TA REQUEST:______________________________________


13



HOW WAS THE TA DELIVERED?

TELEPHONE E-MAIL IN-PERSON WEBINAR Other: _______________________________________


14

WHO WERE THE RECIPENTS OF THE TA

(PLEASE CIRCLE ALL THAT APPLY)



DM CURRICULA IMPLEMENTER PRINCIPAL EDUCATOR SCHOOL LIAISON FOR DM PROJECT DM PROGRAM MANAGER

Other: _______________________________________



15

WHAT WERE THE MASTER TRAINER TA RECOMMENDATIONS?





16

WHAT WERE SOME ACTION STEPS FOR THE TA RECIPENT AS A RESULT OF THE TA PROVIEDED?





17

WHAT WERE SOME ACTION STEPS FOR THE MASTER TRAINER AS A RESULT OF THE TA PROVIDED?





18

WERE THERE PLANS FOR ANY ADDITIONAL FOLLOW-UP?

YES NO



19

DID THE NATURE OF THE TA REQUEST REQUIRE YOU TO CONTACT ONE OR MORE OF THE FOLLOWING:

(PLEASE CIRCLE ALL THAT APPLY)


HAZELDEN TA PROVIDER SCHOOL LIAISON FOR DM PROJECT DM PROGRAM MANAGER



Other: _______________________________________








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