Attachments CCC-LLL Safe Dates Sessions 1-10

Evaluation of Dating Matters: Strategies to Promote Healthy Teen Relationships

8th grade Standard Student Program Fidelity Logs_Session 1-10 (Atmts CCC-LLL)7_23_2012

Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)

OMB: 0920-0941

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0941 can be found here:

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Form Approved

OMB No. 0920-0941

Exp. Date: 6/30/2015

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Public reporting burden of this collection of information is estimated to average 15 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (0920-0941).

Attachment CCC:

Student Program Fidelity 8th Grade Session 1 (Standard)

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

Student Curriculum – 8th Grade, Session 1 – Defining Caring Relationships

Attendance Log

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Implementer Name: Last Name: _________________________ First Name______________________ Initial:___
Implementer Survey ID: _______________________________ School Number: ____________________________ Program Year: _______________________________________ Session Number: ___________________________ Grade: ________ Classroom Number: ________________________

Please have all students sign initials next to their names to indicate attendance to the session

Student Names (Pre-Typed) – Last, First, Initial	Student ID (pre-typed)	Student Initials for Present

Time Conversion Table

Military Time	Regular Time	Military Time	Regular Time
0100	1:00 AM	1300	1:00 PM
0200	2:00 AM	1400	2:00 PM
0300	3:00 AM	1500	3:00 PM
0400	4:00 AM	1600	4:00 PM
0500	5:00 AM	1700	5:00 PM
0600	6:00 AM	1800	6:00 PM
0700	7:00 AM	1900	7:00 PM
0800	8:00 AM	2000	8:00 PM
0900	9:00 AM	2100	9:00 PM
1000	10:00 AM	2200	10:00 PM
1100	11:00 AM	2300	11:00 PM
1200	Noon	0000 or 2400	Midnight

Student Curriculum – 8th Grade, Session 1 – Defining Caring Relationships

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Implementer Name: Last Name: _________________________ First Name______________________ Initial:___

Implementer Survey ID: ___________________

School Number: ________________________ Session Number: ________________________

Grade: _______________________________ Classroom Number: ______________________

Program Year: ________________________ Time lesson began: ___________ (military time- i.e: table pg.2)

Survey Date: __________________________ Time lesson ended: ___________ (military time- i.e: table pg.2)

Please indicate if you completed the following:

	Yes	Yes w/ changes	No
Introduced the Safe Dates program			
Acknowledged that students are at different places with dating and that Safe Dates is applicable to all			
Passed out Safe Dates journals			
Discussed ground rules			
Asked students for examples of dating			
Pointed out that Safe Dates refers to formal and informal dating			
Completed dating bingo activity using Handout 1 (“Dating Bingo” card)			
Gave instructions for completing Handout 2 (“Caring People and Relationships”)			
Asked students for examples of ways of being treated that have helped them feel good about themselves			
Pointed out that these caring actions are important in all relationships			
Gave instructions for completing Handout 3 (“Ways I Want to be Treated by a Dating Partner”)			
Pointed out that we all have choices in how we are treated			
Gave Handout 4 (“Ways I Want to Treat a Dating Partner”) to students either as homework or as an in-class assignment			
Pointed out that we all have a choice in how we are treated			
Pointed out that we all have a choice in how we treat others			
Concluded session	q	q	q

Please indicate if any of the following challenges interfered with your ability to implement the session. Check all that apply.

Not enough time.	
I did not have the needed materials.	
Students did not appear to understand the session.	
I was uncomfortable discussing some of the topics.	
Students were uncomfortable discussing some of the topics.	
Some part of the session was difficult for students (e.g., role plays)	
Other more pressing session demands.	
Other – please specify____________________________________	

Describe any changes you made to the session activities.

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please think about today’s session and tell us your answers to the following questions. Circle the number that shows your opinion about each question.

How engaged were the students in the session?

Shape8 Shape4 Shape5 Shape7 Shape6 _________________________________________________________________________________________________

Shape10 Shape12 Shape9 Shape11 Shape13

Fully Engaged

Not at all Engaged/Bored

Somewhat Engaged

Overall, how do you think the session went today, in terms of your implementation and the participation of students?

Shape18 Shape17 Shape14 Shape16 Shape15 _________________________________________________________________________________________________

Excellent

Very Poor/ Horrible

Poor

Fair

Good

How well do you think the students understood the session material?

Shape28 Shape27 Shape24 Shape26 Shape25 _________________________________________________________________________________________________

Excellent/

Complete Understanding

Did Not Understand

Poor

Fair

Good

How well did the session material fit into the allotted time period? (check the box for the statement that is most applicable for this session)

Session was too packed; not enough time to complete all activities and discussions
Session was somewhat packet; able to complete most but not all activities and discussions
Session was timed perfectly; able to complete all activities and discussions
Session ended before 50 minutes were up; not enough material was provided for the session

Form Approved

OMB No. 0920-0941

Exp. Date: 6/30/2015

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Attachment DDD:

Student Program Fidelity 8th Grade Session 2 (Standard)

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

Student Curriculum – 8th Grade, Session 2 – Defining Dating Abuse

Attendance Log

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Please have all students sign initials next to their names to indicate attendance to the session

Student Names (Pre-Typed) – Last, First, Initial	Student ID (pre-typed)	Student Initials for Present

Time Conversion Table

Military Time	Regular Time	Military Time	Regular Time
0100	1:00 AM	1300	1:00 PM
0200	2:00 AM	1400	2:00 PM
0300	3:00 AM	1500	3:00 PM
0400	4:00 AM	1600	4:00 PM
0500	5:00 AM	1700	5:00 PM
0600	6:00 AM	1800	6:00 PM
0700	7:00 AM	1900	7:00 PM
0800	8:00 AM	2000	8:00 PM
0900	9:00 AM	2100	9:00 PM
1000	10:00 AM	2200	10:00 PM
1100	11:00 AM	2300	11:00 PM
1200	Noon	0000 or 2400	Midnight

Student Curriculum – 8th Grade, Session 2 – Defining Dating Abuse

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Implementer Name: Last Name: _________________________ First Name______________________ Initial:___

Implementer Survey ID: ___________________

School Number: ________________________ Session Number: ________________________

Grade: _______________________________ Classroom Number: ______________________

Program Year: ________________________ Time lesson began: ___________ (military time- i.e: table pg.2)

Survey Date: __________________________ Time lesson ended: ___________ (military time- i.e: table pg.2)

Please indicate if you completed the following:

	Yes	Yes w/ changes	No
Reminded students of ground rules			
Reviewed homework from Session 1			
Discussed harmful behaviors			
Distributed Handout 5 (“Typical Harmful Dating Behaviors”)			
Presented Handout 6 (“Defining Dating Abuse Scenarios”)			
Discussed Scenarios 1-4 from Handout 6			
Defined dating abuse			
Distributed Handout 7 (“Facts about Dating Abuse”)			
Distinguished physical and emotional abuse			
Distinguished harmful from abusive relationships			
Mentioned statistics about dating abuse prevalence			
Shared the following key concepts: Both boys and girls can be abused and can be abusive Dating violence does not just go away Dating abuse can happen to anyone in any relationship			
Reminded students of how they said they want to be treated			
Reminded students that they have choices in how they treat others			
Concluded session			

Please indicate if any of the following challenges interfered with your ability to implement the session. Check all that apply.

Not enough time.	
I did not have the needed materials.	
Students did not appear to understand the session.	
I was uncomfortable discussing some of the topics.	
Students were uncomfortable discussing some of the topics.	
Some part of the session was difficult for students (e.g., role plays)	
Other more pressing session demands.	
Other – please specify____________________________________	

Describe any changes you made to the session activities.

Please think about today’s session and tell us your answers to the following questions. Circle the number that shows your opinion about each question.

How engaged were the students in the session?

Shape41 Shape37 Shape38 Shape40 Shape39 _________________________________________________________________________________________________

Shape43 Shape45 Shape42 Shape44 Shape46

Fully Engaged

Not at all Engaged/Bored

Somewhat Engaged

Overall, how do you think the session went today, in terms of your implementation and the participation of students?

Shape51 Shape50 Shape47 Shape49 Shape48 _________________________________________________________________________________________________

Excellent

Very Poor/ Horrible

Poor

Fair

Good

How well do you think the students understood the session material?

Shape61 Shape60 Shape57 Shape59 Shape58 _________________________________________________________________________________________________

Excellent/

Complete Understanding

Did Not Understand

Poor

Fair

Good

How well did the session material fit into the allotted time period? (check the box for the statement that is most applicable for this session)

Session was too packed; not enough time to complete all activities and discussions
Session was somewhat packet; able to complete most but not all activities and discussions
Session was timed perfectly; able to complete all activities and discussions
Session ended before 50 minutes were up; not enough material was provided for the session

Form Approved

OMB No. 0920-0941

Exp. Date: 6/30/2015

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Attachment EEE:

Student Program Fidelity 8th Grade Session 3 (Standard)

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

Student Curriculum – 8th Grade, Session 3 – Why Do People Abuse

Attendance Log

Shape68

Please have all students sign initials next to their names to indicate attendance to the session

Student Names (Pre-Typed) – Last, First, Initial	Student ID (pre-typed)	Student Initials for Present

Time Conversion Table

Military Time	Regular Time	Military Time	Regular Time
0100	1:00 AM	1300	1:00 PM
0200	2:00 AM	1400	2:00 PM
0300	3:00 AM	1500	3:00 PM
0400	4:00 AM	1600	4:00 PM
0500	5:00 AM	1700	5:00 PM
0600	6:00 AM	1800	6:00 PM
0700	7:00 AM	1900	7:00 PM
0800	8:00 AM	2000	8:00 PM
0900	9:00 AM	2100	9:00 PM
1000	10:00 AM	2200	10:00 PM
1100	11:00 AM	2300	11:00 PM
1200	Noon	0000 or 2400	Midnight

Student Curriculum – 8th Grade, Session 3 - Why Do People Abuse

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Implementer Name: Last Name: _________________________ First Name______________________ Initial:___

Implementer Survey ID: ___________________

School Number: ________________________ Session Number: ________________________

Grade: _______________________________ Classroom Number: ______________________

Program Year: ________________________ Time lesson began: ___________ (military time- i.e: table pg.2)

Survey Date: __________________________ Time lesson ended: ___________ (military time- i.e: table pg.2)

Please indicate if you completed the following:

	Yes	Yes w/ changes	No
Reminded students of ground rules			
Distributed Handout 8 (“Why People Abuse Scenarios”)			
Discussed Scenario 1			
Pointed out that controlling behaviors are abusive			
Discussed Scenario 2			
Pointed out that abusers sometimes want victims to be dependent on them			
Discussed Scenario 3			
Pointed out that often the abuser tries to make the victim feel that the abuse is his/her fault			
Asked students to generate other reasons for why people may abuse			
Discussed short-term and long-term consequences of dating abuse			
Distributed Handouts 9A, 9B, and 9C (“The Consequences of Dating Abuse”)			
Discussed warning signs of abusive/potentially abusive relationships			
Distributed Handout 10 (“Dating Abuse Red Flags”)			
Pointed out that violence and abuse is a choice			
Pointed out that abuse is never the victim’s fault			
Concluded session	q	q	q

Please indicate if any of the following challenges interfered with your ability to implement the session. Check all that apply.

Not enough time.	
I did not have the needed materials.	
Students did not appear to understand the session.	
I was uncomfortable discussing some of the topics.	
Students were uncomfortable discussing some of the topics.	
Some part of the session was difficult for students (e.g., role plays)	
Other more pressing session demands.	
Other – please specify____________________________________	

Describe any changes you made to the session activities.

Please think about today’s session and tell us your answers to the following questions. Circle the number that shows your opinion about each question.

How engaged were the students in the session?

Shape74 Shape70 Shape71 Shape73 Shape72 _________________________________________________________________________________________________

Shape76 Shape78 Shape75 Shape77 Shape79

Fully Engaged

Not at all Engaged/Bored

Somewhat Engaged

Overall, how do you think the session went today, in terms of your implementation and the participation of students?

Shape84 Shape83 Shape80 Shape82 Shape81 _________________________________________________________________________________________________

Excellent

Very Poor/ Horrible

Poor

Fair

Good

How well do you think the students understood the session material?

Shape94 Shape93 Shape90 Shape92 Shape91 _________________________________________________________________________________________________

Excellent/

Complete Understanding

Did Not Understand

Poor

Fair

Good

How well did the session material fit into the allotted time period? (check the box for the statement that is most applicable for this session)

Session was too packed; not enough time to complete all activities and discussions
Session was somewhat packet; able to complete most but not all activities and discussions
Session was timed perfectly; able to complete all activities and discussions
Session ended before 50 minutes were up; not enough material was provided for the session

Form Approved

OMB No. 0920-0941

Exp. Date: 6/30/2015

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Attachment FFF:

Student Program Fidelity 8th Grade Session 4 (Standard)

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

Student Curriculum – 8th Grade, Session 4 – How To Help Friends

Attendance Log

Shape101

Please have all students sign initials next to their names to indicate attendance to the session

Student Names (Pre-Typed) – Last, First, Initial	Student ID (pre-typed)	Student Initials for Present

Time Conversion Table

Military Time	Regular Time	Military Time	Regular Time
0100	1:00 AM	1300	1:00 PM
0200	2:00 AM	1400	2:00 PM
0300	3:00 AM	1500	3:00 PM
0400	4:00 AM	1600	4:00 PM
0500	5:00 AM	1700	5:00 PM
0600	6:00 AM	1800	6:00 PM
0700	7:00 AM	1900	7:00 PM
0800	8:00 AM	2000	8:00 PM
0900	9:00 AM	2100	9:00 PM
1000	10:00 AM	2200	10:00 PM
1100	11:00 AM	2300	11:00 PM
1200	Noon	0000 or 2400	Midnight

Student Curriculum – 8th Grade, Session 4 – How To Help Friends

Shape102

Implementer Name: Last Name: _________________________ First Name______________________ Initial:___

Implementer Survey ID: ___________________

School Number: ________________________ Session Number: ________________________

Grade: _______________________________ Classroom Number: ______________________

Program Year: ________________________ Time lesson began: ___________ (military time- i.e: table pg.2)

Survey Date: __________________________ Time lesson ended: ___________ (military time- i.e: table pg.2)

Please indicate if you completed the following:

	Yes	Yes w/ changes	No
Completed the “I Want to Stay” “I Want to Leave” exercise			
Pointed out that abusive relationships are very complicated			
Pointed out that to be helpful to a friend in an abusive relationship, it is important to understand a friend’s fears about getting help			
Discussed why it may be difficult to get help			
Distributed Handout 11 (“Friends Wheel”)			
Pointed out that teens in abusive relationships are more likely to tell Friends than adults or professionals			
Encouraged friends to connect friends in abusive relationships with professional adults			
Distributed Handout 12 (“Dating Abuse: Who Can Help You”)			
Described and gave handouts about the crisis line, support groups, and community resources			
Encouraged students in abusive relationships to talk to someone			
Concluded session			

Please indicate if any of the following challenges interfered with your ability to implement the session. Check all that apply.

Not enough time.	
I did not have the needed materials.	
Students did not appear to understand the session.	
I was uncomfortable discussing some of the topics.	
Students were uncomfortable discussing some of the topics.	
Some part of the session was difficult for students (e.g., role plays)	
Other more pressing session demands.	
Other – please specify____________________________________	

Describe any changes you made to the session activities.

Please think about today’s session and tell us your answers to the following questions. Circle the number that shows your opinion about each question.

How engaged were the students in the session?

Shape107 Shape103 Shape104 Shape106 Shape105 _________________________________________________________________________________________________

Shape109 Shape111 Shape108 Shape110 Shape112

Fully Engaged

Not at all Engaged/Bored

Somewhat Engaged

Overall, how do you think the session went today, in terms of your implementation and the participation of students?

Shape117 Shape116 Shape113 Shape115 Shape114 _________________________________________________________________________________________________

Excellent

Very Poor/ Horrible

Poor

Fair

Good

How well do you think the students understood the session material?

Shape127 Shape126 Shape123 Shape125 Shape124 _________________________________________________________________________________________________

Excellent/

Complete Understanding

Did Not Understand

Poor

Fair

Good

How well did the session material fit into the allotted time period? (check the box for the statement that is most applicable for this session)

Session was too packed; not enough time to complete all activities and discussions
Session was somewhat packet; able to complete most but not all activities and discussions
Session was timed perfectly; able to complete all activities and discussions
Session ended before 50 minutes were up; not enough material was provided for the session

Form Approved

OMB No. 0920-0941

Exp. Date: 6/30/2015

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Attachment GGG:

Student Program Fidelity 8th Grade Session 5 (Standard)

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

Student Curriculum – 8th Grade, Session 5 – Helping Friends

Attendance Log

Shape134

Please have all students sign initials next to their names to indicate attendance to the session

Student Names (Pre-Typed) – Last, First, Initial	Student ID (pre-typed)	Student Initials for Present

Time Conversion Table

Military Time	Regular Time	Military Time	Regular Time
0100	1:00 AM	1300	1:00 PM
0200	2:00 AM	1400	2:00 PM
0300	3:00 AM	1500	3:00 PM
0400	4:00 AM	1600	4:00 PM
0500	5:00 AM	1700	5:00 PM
0600	6:00 AM	1800	6:00 PM
0700	7:00 AM	1900	7:00 PM
0800	8:00 AM	2000	8:00 PM
0900	9:00 AM	2100	9:00 PM
1000	10:00 AM	2200	10:00 PM
1100	11:00 AM	2300	11:00 PM
1200	Noon	0000 or 2400	Midnight

Student Curriculum – 8th Grade, Session 5 – Helping Friends

Shape135

Implementer Name: Last Name: _________________________ First Name______________________ Initial:___

Implementer Survey ID: ___________________

School Number: ________________________ Session Number: ________________________

Grade: _______________________________ Classroom Number: ______________________

Program Year: ________________________ Time lesson began: ___________ (military time- i.e: table pg.2)

Survey Date: __________________________ Time lesson ended: ___________ (military time- i.e: table pg.2)

Please indicate if you completed the following:

	Yes	Yes w/ changes	No
Displayed a copy of the “Friends Wheel”			
Distributed Handout 13 (“Elijah’s Story”)			
Discussed red flags that Elijah is abusive			
Distributed Handout 14 (“Zoey’s Story”)			
Discussed red flags that Zoey is being abused			
Pointed out that it is important to let friends know that abuse is not OK			
Divided students into 1’s and 2’s			
Distributed Handout 15 (“Elijah’s Statements) to the 1’s			
Distributed Handout 17 (“Guidelines for Helping People Who Are Abusive”) to the 2’s			
Completed activity where students practiced responding to a friend abuser			
Distributed Handout 16 (“Zoey’s Statements”) to the 2’s			
Distributed Handout 18 (“Guidelines for Helping People Who Are Being Abused”) to the 1’s			
Completed activity where students practiced responding to a friend being abused			
Encouraged students to tell people who are being abusive that it is not an OK thing to do			
Encouraged students to support victims of abuse			
Concluded session			

Please indicate if any of the following challenges interfered with your ability to implement the session. Check all that apply.

Not enough time.	
I did not have the needed materials.	
Students did not appear to understand the session.	
I was uncomfortable discussing some of the topics.	
Students were uncomfortable discussing some of the topics.	
Some part of the session was difficult for students (e.g., role plays)	
Other more pressing session demands.	
Other – please specify____________________________________	

Describe any changes you made to the session activities.

Please think about today’s session and tell us your answers to the following questions. Circle the number that shows your opinion about each question.

How engaged were the students in the session?

Shape140 Shape136 Shape137 Shape139 Shape138 _________________________________________________________________________________________________

Shape142 Shape144 Shape141 Shape143 Shape145

Fully Engaged

Not at all Engaged/Bored

Somewhat Engaged

Overall, how do you think the session went today, in terms of your implementation and the participation of students?

Shape150 Shape149 Shape146 Shape148 Shape147 _________________________________________________________________________________________________

Excellent

Very Poor/ Horrible

Poor

Fair

Good

How well do you think the students understood the session material?

Shape160 Shape159 Shape156 Shape158 Shape157 _________________________________________________________________________________________________

Excellent/

Complete Understanding

Did Not Understand

Poor

Fair

Good

How well did the session material fit into the allotted time period? (check the box for the statement that is most applicable for this session)

Session was too packed; not enough time to complete all activities and discussions
Session was somewhat packet; able to complete most but not all activities and discussions
Session was timed perfectly; able to complete all activities and discussions
Session ended before 50 minutes were up; not enough material was provided for the session

Form Approved

OMB No. 0920-0941

Exp. Date: 6/30/2015

Shape166

Attachment HHH:

Student Program Fidelity 8th Grade Session 6 (Standard)

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

Student Curriculum – 8th Grade, Session 6 – Overcoming Gender Stereotypes

Attendance Log

Shape167

Please have all students sign initials next to their names to indicate attendance to the session

Student Names (Pre-Typed) – Last, First, Initial	Student ID (pre-typed)	Student Initials for Present

Time Conversion Table

Military Time	Regular Time	Military Time	Regular Time
0100	1:00 AM	1300	1:00 PM
0200	2:00 AM	1400	2:00 PM
0300	3:00 AM	1500	3:00 PM
0400	4:00 AM	1600	4:00 PM
0500	5:00 AM	1700	5:00 PM
0600	6:00 AM	1800	6:00 PM
0700	7:00 AM	1900	7:00 PM
0800	8:00 AM	2000	8:00 PM
0900	9:00 AM	2100	9:00 PM
1000	10:00 AM	2200	10:00 PM
1100	11:00 AM	2300	11:00 PM
1200	Noon	0000 or 2400	Midnight

Student Curriculum – 8th Grade, Session 6 – Overcoming Gender Stereotypes

Shape168

Implementer Name: Last Name: _________________________ First Name______________________ Initial:___

Implementer Survey ID: ___________________

School Number: ________________________ Session Number: ________________________

Grade: _______________________________ Classroom Number: ______________________

Program Year: ________________________ Time lesson began: ___________ (military time- i.e: table pg.2)

Survey Date: __________________________ Time lesson ended: ___________ (military time- i.e: table pg.2)

Please indicate if you completed the following:

	Yes	Yes w/ changes	No
Previewed/introduced the concept of preventing dating abuse to be covered during the next four sessions			
Facilitated exercise of unfair expectations			
Described the concept of images of relationships being scripts for how people act and for the expectations they have of others			
Facilitated free association exercise			
Described the concept of “gender stereotypes”			
Presented scenarios to illustrate gender stereotypes			
Presented the link between stereotypical beliefs and abusive behavior			
Distributed Handout 19 (“Stereotypes and Dating Abuse Scenarios”)			
Presented the scenarios and facilitated a discussion about how gender stereotypes may lead to abuse			
Pointed out that we get positive and negative stereotypes of relationships from TV, movies, song lyrics, parents, and friends			
Encouraged students to think about whether others are treating them based on gender stereotypes			
Asked students to think about whether their expectations of their dating partners are fair			
Concluded session	q	q	q

Please indicate if any of the following challenges interfered with your ability to implement the session. Check all that apply.

Not enough time.	
I did not have the needed materials.	
Students did not appear to understand the session.	
I was uncomfortable discussing some of the topics.	
Students were uncomfortable discussing some of the topics.	
Some part of the session was difficult for students (e.g., role plays)	
Other more pressing session demands.	
Other – please specify____________________________________	

Describe any changes you made to the session activities.

Please think about today’s session and tell us your answers to the following questions. Circle the number that shows your opinion about each question.

How engaged were the students in the session?

Shape173 Shape169 Shape170 Shape172 Shape171 _________________________________________________________________________________________________

Shape175 Shape177 Shape174 Shape176 Shape178

Fully Engaged

Not at all Engaged/Bored

Somewhat Engaged

Overall, how do you think the session went today, in terms of your implementation and the participation of students?

Shape183 Shape182 Shape179 Shape181 Shape180 _________________________________________________________________________________________________

Excellent

Very Poor/ Horrible

Poor

Fair

Good

How well do you think the students understood the session material?

Shape193 Shape192 Shape189 Shape191 Shape190 _________________________________________________________________________________________________

Excellent/

Complete Understanding

Did Not Understand

Poor

Fair

Good

How well did the session material fit into the allotted time period? (check the box for the statement that is most applicable for this session)

Session was too packed; not enough time to complete all activities and discussions
Session was somewhat packet; able to complete most but not all activities and discussions
Session was timed perfectly; able to complete all activities and discussions
Session ended before 50 minutes were up; not enough material was provided for the session

Form Approved

OMB No. 0920-0941

Exp. Date: 6/30/2015

Shape199

Attachment III:

Student Program Fidelity 8th Grade Session 7 (Standard)

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

Student Curriculum – 8th Grade, Session 7 – How We Feel, How We Deal

Attendance Log

Shape200

Please have all students sign initials next to their names to indicate attendance to the session

Student Names (Pre-Typed) – Last, First, Initial	Student ID (pre-typed)	Student Initials for Present

Time Conversion Table

Military Time	Regular Time	Military Time	Regular Time
0100	1:00 AM	1300	1:00 PM
0200	2:00 AM	1400	2:00 PM
0300	3:00 AM	1500	3:00 PM
0400	4:00 AM	1600	4:00 PM
0500	5:00 AM	1700	5:00 PM
0600	6:00 AM	1800	6:00 PM
0700	7:00 AM	1900	7:00 PM
0800	8:00 AM	2000	8:00 PM
0900	9:00 AM	2100	9:00 PM
1000	10:00 AM	2200	10:00 PM
1100	11:00 AM	2300	11:00 PM
1200	Noon	0000 or 2400	Midnight

Student Curriculum – 8th Grade, Session 7 – How We feel, How We Deal

Shape201

Implementer Name: Last Name: _________________________ First Name______________________ Initial:___

Implementer Survey ID: ___________________

School Number: ________________________ Session Number: ________________________

Grade: _______________________________ Classroom Number: ______________________

Program Year: ________________________ Time lesson began: ___________ (military time- i.e: table pg.2)

Survey Date: __________________________ Time lesson ended: ___________ (military time- i.e: table pg.2)

Please indicate if you completed the following:

	Yes	Yes w/ changes	No
Asked students for examples of feelings beyond mad, sad, or happy			
Explained to students why knowing your feelings is important and helpful			
Pointed out that students that feeling angry is OK, but how you deal with anger is most important			
Discussed the concept of “hot buttons”			
Distributed Handout 20 (“Hot Buttons”)			
Described and discussed “intermediate” and “pent-up” anger			
Pointed out that responses to anger are never uncontrollable			
Discussed ways to diffuse anger in the first few seconds			
Pointed out to students that once they have calmed down, they can use the Safe Dates communication skills			
Pointed out that feeling anger can be positive if handled carefully because it tells us about a situation we may need to change			
Facilitated discussion about occurrences of anger and brainstorming good ways to have responded			
Distributed Handout 21 (“Feelings”) and Handout 22 (“Feelings Diary”) for homework			
Concluded session			

Please indicate if any of the following challenges interfered with your ability to implement the session. Check all that apply.

Not enough time.	
I did not have the needed materials.	
Students did not appear to understand the session.	
I was uncomfortable discussing some of the topics.	
Students were uncomfortable discussing some of the topics.	
Some part of the session was difficult for students (e.g., role plays)	
Other more pressing session demands.	
Other – please specify____________________________________	

Describe any changes you made to the session activities.

Please think about today’s session and tell us your answers to the following questions. Circle the number that shows your opinion about each question.

How engaged were the students in the session?

Shape206 Shape202 Shape203 Shape205 Shape204 _________________________________________________________________________________________________

Shape208 Shape210 Shape207 Shape209 Shape211

Fully Engaged

Not at all Engaged/Bored

Somewhat Engaged

Overall, how do you think the session went today, in terms of your implementation and the participation of students?

Shape216 Shape215 Shape212 Shape214 Shape213 _________________________________________________________________________________________________

Excellent

Very Poor/ Horrible

Poor

Fair

Good

How well do you think the students understood the session material?

Shape226 Shape225 Shape222 Shape224 Shape223 _________________________________________________________________________________________________

Excellent/

Complete Understanding

Did Not Understand

Poor

Fair

Good

How well did the session material fit into the allotted time period? (check the box for the statement that is most applicable for this session)

Session was too packed; not enough time to complete all activities and discussions
Session was somewhat packet; able to complete most but not all activities and discussions
Session was timed perfectly; able to complete all activities and discussions
Session ended before 50 minutes were up; not enough material was provided for the session

Form Approved

OMB No. 0920-0941

Exp. Date: 6/30/2015

Shape232

Attachment JJJ:

Student Program Fidelity 8th Grade Session 8 (Standard)

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

Student Curriculum – 8th Grade, Session 8 – Equal Power Through Communication

Attendance Log

Shape233

Please have each student sign initials next to their name to indicate attendance to the session

Student Names (Pre-Typed) – Last, First, Initial	Student ID (pre-typed)	Student Initials for Present

Time Conversion Table

Military Time	Regular Time	Military Time	Regular Time
0100	1:00 AM	1300	1:00 PM
0200	2:00 AM	1400	2:00 PM
0300	3:00 AM	1500	3:00 PM
0400	4:00 AM	1600	4:00 PM
0500	5:00 AM	1700	5:00 PM
0600	6:00 AM	1800	6:00 PM
0700	7:00 AM	1900	7:00 PM
0800	8:00 AM	2000	8:00 PM
0900	9:00 AM	2100	9:00 PM
1000	10:00 AM	2200	10:00 PM
1100	11:00 AM	2300	11:00 PM
1200	Noon	0000 or 2400	Midnight

Student Curriculum – 8th Grade, Session 8 – Equal Power Through Communication

Shape234

Implementer Name: Last Name: _________________________ First Name______________________ Initial:___

Implementer Survey ID: ___________________

School Number: ________________________ Session Number: ________________________

Grade: _______________________________ Classroom Number: ______________________

Program Year: ________________________ Time lesson began: ___________ (military time- i.e: table pg.2)

Survey Date: __________________________ Time lesson ended: ___________ (military time- i.e: table pg.2)

Please indicate if you completed the following:

	Yes	Yes w/ changes	No
Distributed Handout 23 (“Four SAFE Skills for Building Equal Power through Communication”) and discussed it with students			
Pointed out that sometimes these skills may not be useful on their own if there is unequal power in the relationship			
Distributed Handout 24A (“LaToya and Marcus Script”) and facilitated role-play			
Distributed Handout 24B (“LaToya and Marcus Checklist”) and facilitated follow-up discussion			
Divided the class into groups of three, with a recorder, student A, and student B in each group			
Distributed Handout 25B (“Conflict Skills Checklist 1”) to group recorders			
Distributed Handout 25A (“Conflict Situation 1”) to students A and B			
Introduced and facilitated Conflict 1			
Asked students in each group to switch roles			
Distributed Handout 26A (“Conflict Situation 2”), role-play descriptions, and Handout 26B (“Conflict Skills Checklist 2”), recorder’s sheet			
Introduced and facilitated Conflict 2			
Asked group members to switch roles again			
Distributed Handout 27A (“Conflict Situation 3”), role-play descriptions, and Handout 27B (“Conflict Skills Checklist 3”), recorder’s sheet			
Introduced and facilitated Conflict 3			
Presented and discussed scenarios for developing plans to deal with unfair communication			
Pointed out that good communication can help keep equal power in relationships			
Pointed out that communication skills may not help in relationships that are already abusive			
Concluded session	q	q	q

Please indicate if any of the following challenges interfered with your ability to implement the session. Check all that apply.

Not enough time.	
I did not have the needed materials.	
Students did not appear to understand the session.	
I was uncomfortable discussing some of the topics.	
Students were uncomfortable discussing some of the topics.	
Some part of the session was difficult for students (e.g., role plays)	
Other more pressing session demands.	
Other – please specify____________________________________	

Describe any changes you made to the session activities.

Please think about today’s session and tell us your answers to the following questions. Circle the number that shows your opinion about each question.

How engaged were the students in the session?

Shape239 Shape235 Shape236 Shape238 Shape237 _________________________________________________________________________________________________

Shape241 Shape243 Shape240 Shape242 Shape244

Fully Engaged

Not at all Engaged/Bored

Somewhat Engaged

Overall, how do you think the session went today, in terms of your implementation and the participation of students?

Shape249 Shape248 Shape245 Shape247 Shape246 _________________________________________________________________________________________________

Excellent

Very Poor/ Horrible

Poor

Fair

Good

How well do you think the students understood the session material?

Shape259 Shape258 Shape255 Shape257 Shape256 _________________________________________________________________________________________________

Excellent/

Complete Understanding

Did Not Understand

Poor

Fair

Good

How well did the session material fit into the allotted time period? (check the box for the statement that is most applicable for this session)

Session was too packed; not enough time to complete all activities and discussions
Session was somewhat packet; able to complete most but not all activities and discussions
Session was timed perfectly; able to complete all activities and discussions
Session ended before 50 minutes were up; not enough material was provided for the session

Form Approved

OMB No. 0920-0941

Exp. Date: 6/30/2015

Shape265

Attachment KKK:

Student Program Fidelity 8th Grade Session 9 (Standard)

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

Student Curriculum – 8th Grade, Session 9 – Preventing Dating Sexual Abuse

Attendance Log

Shape266

Please have all students sign initials next to their names to indicate attendance to the session

Student Names (Pre-Typed) – Last, First, Initial	Student ID (pre-typed)	Student Initials for Present

Time Conversion Table

Military Time	Regular Time	Military Time	Regular Time
0100	1:00 AM	1300	1:00 PM
0200	2:00 AM	1400	2:00 PM
0300	3:00 AM	1500	3:00 PM
0400	4:00 AM	1600	4:00 PM
0500	5:00 AM	1700	5:00 PM
0600	6:00 AM	1800	6:00 PM
0700	7:00 AM	1900	7:00 PM
0800	8:00 AM	2000	8:00 PM
0900	9:00 AM	2100	9:00 PM
1000	10:00 AM	2200	10:00 PM
1100	11:00 AM	2300	11:00 PM
1200	Noon	0000 or 2400	Midnight

Student Curriculum – 8th Grade, Session 9 – Preventing Dating Sexual Abuse

Shape267

Implementer Name: Last Name: _________________________ First Name______________________ Initial:___

Implementer Survey ID: ___________________

School Number: ________________________ Session Number: ________________________

Grade: _______________________________ Classroom Number: ______________________

Program Year: ________________________ Time lesson began: ___________ (military time- i.e: table pg.2)

Survey Date: __________________________ Time lesson ended: ___________ (military time- i.e: table pg.2)

Please indicate if you completed the following activities:

Activity	Yes	Yes w/ changes	No
Defined “sexual assault”			
Distributed Handout 28 (“Sexual Assault Quiz”) and discussed with students			
Distributed Handout 29 (“Caitlin and Samir Scenario”) and facilitated follow-up discussion			
Pointed out that no matter what methods are used, if someone is forced to have sex without permission, it is rape, and rape is a crime			
Presented the concept of “date rape”			
Explained that date rap may occur when people misinterpret or ignore cues and facilitated discussion on interpreting signs			
Explained that there are some actions that can be taken to decrease the chance of being a potential victim			
Distributed Handout 30 (“Dating Tips” cards) for student completion and facilitated discussion on the eight dating tips			
Pointed out that dating sexual abuse and rape drugs are becoming more common among teens			
Pointed out that alcohol is probably the most common dating sexual abuse and rape drug			
Distributed Handout 31 (“Date Rape Drug Precautions”)			
*Pointed out that dating sexual abuse and rape are never* the victim’s fault**			
Pointed out that forced sex is rape, and rape is a crime			
Concluded session			

Please indicate if any of the following challenges interfered with your ability to implement the session. Check all that apply.

Not enough time.	
I did not have the needed materials.	
Students did not appear to understand the session.	
I was uncomfortable discussing some of the topics.	
Students were uncomfortable discussing some of the topics.	
Some part of the session was difficult for students (e.g., role plays)	
Other more pressing session demands.	
Other – please specify____________________________________	

Describe any changes you made to the session activities.

Please think about today’s session and tell us your answers to the following questions. Circle the number that shows your opinion about each question.

How engaged were the students in the session?

Shape272 Shape268 Shape269 Shape271 Shape270 _________________________________________________________________________________________________

Shape274 Shape276 Shape273 Shape275 Shape277

Fully Engaged

Not at all Engaged/Bored

Somewhat Engaged

Overall, how do you think the session went today, in terms of your implementation and the participation of students?

Shape282 Shape281 Shape278 Shape280 Shape279 _________________________________________________________________________________________________

Excellent

Very Poor/ Horrible

Poor

Fair

Good

How well do you think the students understood the session material?

Shape292 Shape291 Shape288 Shape290 Shape289 _________________________________________________________________________________________________

Excellent/

Complete Understanding

Did Not Understand

Poor

Fair

Good

How well did the session material fit into the allotted time period? (check the box for the statement that is most applicable for this session)

Session was too packed; not enough time to complete all activities and discussions
Session was somewhat packet; able to complete most but not all activities and discussions
Session was timed perfectly; able to complete all activities and discussions
Session ended before 50 minutes were up; not enough material was provided for the session

Form Approved

OMB No. 0920-0941

Exp. Date: 6/30/2015

Shape298

Attachment LLL:

Student Program Fidelity 8th Grade Session 10 (Standard)

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

Student Curriculum – 8th Grade, Session 10 – Reviewing the Safe Dates Program

Attendance Log

Shape299

Please have all students sign initials next to their names to indicate attendance to the session

Student Names (Pre-Typed) – Last, First, Initial	Student ID (pre-typed)	Student Initials for Present

Time Conversion Table

Military Time	Regular Time	Military Time	Regular Time
0100	1:00 AM	1300	1:00 PM
0200	2:00 AM	1400	2:00 PM
0300	3:00 AM	1500	3:00 PM
0400	4:00 AM	1600	4:00 PM
0500	5:00 AM	1700	5:00 PM
0600	6:00 AM	1800	6:00 PM
0700	7:00 AM	1900	7:00 PM
0800	8:00 AM	2000	8:00 PM
0900	9:00 AM	2100	9:00 PM
1000	10:00 AM	2200	10:00 PM
1100	11:00 AM	2300	11:00 PM
1200	Noon	0000 or 2400	Midnight

Student Curriculum – 8th Grade, Session 10 – Reviewing the Safe Dates Program

Shape300

Implementer Name: Last Name: _________________________ First Name______________________ Initial:___

Implementer Survey ID: ___________________

School Number: ________________________ Session Number: ________________________

Grade: _______________________________ Classroom Number: ______________________

Program Year: ________________________ Time lesson began: ___________ (military time- i.e: table pg.2)

Survey Date: __________________________ Time lesson ended: ___________ (military time- i.e: table pg.2)

Please indicate if you completed the following:

	Yes	Yes w/ changes	No
Administered Post-Test (optional)			
Reviewed key components of Safe Dates: Healthy relationships Types of dating abuse Helping friends Gender stereotypes Handling anger positively Effective communication in dating relationships Protection against sexual abuse Prevention against using dating sexual dating abuse			
Described Safe Dates poster contest			
Reviewed poster contest flyer			
Congratulated students for the hard work they put into the program			
Allowed students to keep their journals and encouraged them to review them regularly (Optional)			

Please indicate if any of the following challenges interfered with your ability to implement the session. Check all that apply.

Not enough time.	
I did not have the needed materials.	
Students did not appear to understand the session.	
I was uncomfortable discussing some of the topics.	
Students were uncomfortable discussing some of the topics.	
Some part of the session was difficult for students (e.g., role plays)	
Other more pressing session demands.	
Other – please specify____________________________________	

Describe any changes you made to the session activities.

Please think about today’s session and tell us your answers to the following questions. Circle the number that shows your opinion about each question.

How engaged were the students in the session?

Shape305 Shape301 Shape302 Shape304 Shape303 _________________________________________________________________________________________________

Shape307 Shape309 Shape306 Shape308 Shape310

Fully Engaged

Not at all Engaged/Bored

Somewhat Engaged

Overall, how do you think the session went today, in terms of your implementation and the participation of students?

Shape315 Shape314 Shape311 Shape313 Shape312 _________________________________________________________________________________________________

Excellent

Very Poor/ Horrible

Poor

Fair

Good

How well do you think the students understood the session material?

Shape325 Shape324 Shape321 Shape323 Shape322 _________________________________________________________________________________________________

Excellent/

Complete Understanding

Did Not Understand

Poor

Fair

Good

How well did the session material fit into the allotted time period? (check the box for the statement that is most applicable for this session)

Session was too packed; not enough time to complete all activities and discussions
Session was somewhat packet; able to complete most but not all activities and discussions
Session was timed perfectly; able to complete all activities and discussions
Session ended before 50 minutes were up; not enough material was provided for the session

Please reflect on your overall implementation of the program.

How much time (including preparation, supervision and implementation, but excluding travel time) did you spend on the Safe Dates program over the past 12 months?

How much travel time and mileage did you spend on the Safe Dates program over the past 12 months?

Shape332

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Wendy LiKamWa
File Modified	0000-00-00
File Created	2021-01-30