New Instrument 4: Performance Reporting System Data Entry Form

Personal Responsibility Education Program (PREP) Multi-Component Evaluation

PREP PAS+Baseline - Instrument 4 - PRS Data Entry Form - 6-7-12

New Instrument 4: Performance Reporting System Data Entry Form

OMB: 0970-0398

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Instrument 4
performance reporting system data entry form


Measures of Demographics, Behaviors, Intentions, Perceived Effects

Collected at Program Entry


REPORT PERIOD

2011 - 2012

Grantee:

Enter grantee name

Sub-awardee:

Enter sub-awardee name

Program:

Enter program name





Enter Count




Enter Count

Total Entry Surveys Completed:



Total Exempt from Sensitive Questions:









Age

Age 10



Gender

Male


Age 11



Female


Age 12






Age 13



Orientation s

Straight


Age 14



Gay or Lesbian


Age 15



Bisexual


Age 16



Transgender


Age 17



Something Else/Not Decided


Age 18



Missing


Age 19



Total marked as LGBTQ


Age 20






Age 21 or older



Grade

Grade 4






Grade 5


Hispanic

Yes - Mexican, Mexican American, Chicano/a



Grade 6


Yes - Puerto Rican



Grade 7


Yes - Cuban



Grade 8


Yes - Another Hispanic, Latino/a or Spanish origin



Grade 9


No



Grade 10






Grade 11


Race

American Indian or Alaska Native



Grade 12


Asian



School doesn’t assign grades


Black or African American



Dropped out


Native Hawaiian or Other Pacific Islander



Working toward GED


White or Caucasian



HS grad, not enrolled in post-secondary


Missing



HS grad, enrolled in post-secondary


(s) indicates a sensitive question.


Measures of Demographics, Behaviors, Intentions, Perceived Effects

Collected at Program Entry


REPORT PERIOD

2011 - 2012

Grantee:

Enter grantee name

Sub-awardee:

Enter sub-awardee name

Program:

Enter program name




Enter Count



All of the Time

Most of the Time

Some of the time

None of the time

Cared about doing well in school





Shared ideas or talked with a parent or guardian





Resisted or said no to peer pressure





Managed conflict without causing more conflict











Definitely

Probably

Probably not

Definitely not

Intend to have intercourse in next 6 months s











Yes

No



Ever had intercourse s





Ever been/gotten someone pregnant* s













* Report youth never having intercourse as “No”.




(s) indicates a sensitive question.







Measures of Demographics, Behaviors, Intentions, Perceived Effects

Collected at Program Entry


REPORT PERIOD

2011 - 2012

Grantee:

Enter grantee name

Sub-awardee:

Enter sub-awardee name

Program:

Enter program name




Enter Count


0

1

2

3+

How many times been/gotten someone pregnant* s











0

1

2-3

4+

Number of people with whom had intercourse in past 3 months* s











All of the time

Most of the time

Some of the time

None of the time

How often used birth control in past three months** s





How often used a condom in past three months** s










Knew how to manage stress





Managed money carefully





Had friendships that kept them out of trouble





Were respectful toward others










* Report youth never having intercourse as “0”.





* *Reported only for those who had intercourse within past three months.

(s) indicates a sensitive question.







Measures of Demographics, Behaviors, Intentions, Perceived Effects

Collected at Program Exit


REPORT PERIOD

2011 - 2012

Grantee:

Enter grantee name

Sub-awardee:

Enter sub-awardee name

Program:

Enter program name




Enter Count




Enter Count

Total Exit Surveys Completed:



Gender

Male






Age

Age 10



Female


Age 11



Age 12






Age 13



Grade

Grade 4


Age 14



Grade 5


Age 15



Grade 6


Age 16



Grade 7


Age 17



Grade 8


Age 18



Grade 9


Age 19



Grade 10


Age 20



Grade 11


Age 21 or older



Grade 12






School doesn’t assign grades


Hispanic

Yes - Mexican, Mexican American, Chicano/a



Dropped out


Yes - Puerto Rican



Working toward GED


Yes - Cuban



HS grad, not enrolled in post-secondary


Yes - Another Hispanic, Latino/a or Spanish origin



HS grad, enrolled in post-secondary


No













Race

American Indian or Alaska Native






Asian






Black or African American






Native Hawaiian or Other Pacific Islander






White or Caucasian






Missing







Measures of Demographics, Behaviors, Intentions, Perceived Effects

Collected at Program Exit


REPORT PERIOD

2011 - 2012

Grantee:

Enter grantee name

Sub-awardee:

Enter sub-awardee name

Program:

Enter program name



Enter Count

Enter the count of respondents who report the program made them more, or less, likely to exhibit the following adult behaviors or sexual activities.

Much more likely

Somewhat more likely

About the same

Somewhat less likely

Much less likely

Will Abstain

Resist or say no to peer pressure







Know how to manage stress







Manage conflict without causing more conflict







Form positive friendships that keep them out of trouble







Be respectful toward others







Make plans to reach goals







Care about doing well in school







Get a steady job after finishing school







Share ideas or talk with a parent or guardian







Make healthy decisions about drugs and alcohol







Get more education after high school







Manage money carefully







Be the best they can be














Have intercourse in the next 6 months







Use birth control in the next 6 months







Use a condom in the next 6 months







Abstain from sex in the next 6 months










Measures of Demographics, Behaviors, Intentions, Perceived Effects

Collected at Program Exit


REPORT PERIOD

2011 - 2012

Grantee:

Enter grantee name

Sub-awardee:

Enter sub-awardee name

Program:

Enter program name



Enter Count

Enter the count of respondents who assessed their program experience according to the scale to the right.

All of the time

Most of the time

Some of the time

A little of the time

None of the time

Felt interested in program sessions and classes






Felt the material presented was clear






Found discussions or activities helped to learn program lessons






Felt respected as a person






Were picked on, teased, or bullied






Had a chance to ask questions about program topics and issues












Witnessed people being picked on, teased, or bullied because people thought they were LGBT






Witnessed people being picked on, teased, or bullied because of their race or ethnic background








Measures of Attendance, Reach, and Dosage


REPORT PERIOD

2011 - 2012

Grantee:

Enter grantee name

Sub-awardee:

Enter sub-awardee name

Program:

Enter program name




Enter Count

m

Enter the number of youth during the 2011 – 2012 program year who:

Program Setting

Attended at least one program session


Attended a session in a school setting


Attended a session in a community-based organization


Attended a session in a clinic


Attended a session in a foster care setting


Attended a session in a juvenile detention center


Attended a session in another setting


Reach

Mark an “X” in the cell for the program if more than 50% of youth were:

In foster care


Homeless or runaway


Living with HIV/AIDS


Pregnant or parenting


LGBTQ


In adjudication systems


In residential treatment for mental health issues


Have trouble speaking or understanding spoken English


Attendance

Enter the appropriate count below

The number of youth completing at least 75% of scheduled program hours



Measures of Attendance, Reach, and Dosage


REPORT PERIOD

2011 - 2012

Grantee:

Enter grantee name

Sub-awardee:

Enter sub-awardee name

Program:

Enter program name



Enter a unique identifier for each cohort that received the program during this reporting period.

Did the cohort complete the program during the reporting period (Y/N)?

For those cohorts that completed the program during the reporting period, how many hours of programming, overall, were delivered?

Cohort-1



Cohort-2



Cohort-3



Cohort-4



Cohort-5



Cohort-6



Cohort-7



Cohort-8



Cohort-9



Cohort-10



Cohort-11



Cohort-12



Cohort-13



Cohort-14



Cohort-15



Cohort-16



Cohort-17



Cohort-18



Cohort-19



Cohort-20



Cohort-21



Cohort-22



Cohort-23



Cohort-24



Cohort-25




Measures of Implementation Challenges and Needs for Technical Assistance


REPORT PERIOD

2011 - 2012

Grantee:

Enter grantee name

Sub-awardee:

Enter sub-awardee name


Use the scale at the right to indicate how sub-awardee assessed the implementation challenges below.

Not a Problem

Somewhat a problem

A serious problem

Recruiting youth




Keeping youth engaged




Getting youth to attend regularly




Recruiting qualified staff




Ensuring facilitators understand content




Covering program content




Staff turnover




Negative peer reactions




Youth behavioral problems




Natural disasters




Program facilities








Use the scale at the right to indicate if the sub-awardee has expressed interest in receiving TA for the implementation factors below.

No Interested

Somewhat Interested

Very Interested

Recruiting youth




Keeping youth engaged in program sessions




Getting youth to attend regularly




Recruiting qualified staff




Training facilitators




Retaining staff




Minimizing negative peer reactions




Addressing youth behavioral issues




Other






Measures of Structure, Cost, Support for Program Implementation



REPORT PERIOD

2011 - 2012

Grantee:

Enter grantee name



PREP Funding

Amt

Total PREP funding awarded for the 2011 – 2012 program year

$

Funding allocated to sub-awardees for program services

$

Funding allocated for program services by a state agency

$

Funding allocated for training/TA/eval/monitoring conducted at the grantee level

$

Funding retained for administrative purposes at the grantee level

$



Grantee Staffing

Count

Grantee staff involved in overseeing PREP

 

Grantee FTEs involved in overseeing PREP

 



Training and Quality Monitoring

(Y/N)

Grantee observed program delivery to monitor quality and fidelity to program models


Grantee conducted training of facilitators who deliver the program (or of other staff who might train facilitators)


Grantee provided technical assistance to support program implementation




Measures of Structure, Cost, Support for Program Implementation




REPORT PERIOD

2011 - 2012

Grantee:

Enter grantee name

Sub-awardee:

Enter sub-awardee name



PREP Award Amount

$

Is subawardee new for the 2011 – 2012 program year?

Y/N

Number of PREP facilitators working for sub-awardee

Count

Number of PREP facilitators trained

Count

Number of PREP facilitators observed once

Count

Number of PREP facilitators observed twice

Count

Number of PREP facilitators observed more than twice

Count

Non-PREP funding received during this report period

$





Measures of Structure, Cost, Support for Program Implementation



REPORT PERIOD

2011 - 2012

Grantee:

Enter grantee name

Sub-awardee:

Enter sub-awardee name

Program:

Enter program name


Program Delivery

Enter the number of intended program delivery hours

Count


Indicate which, if any, of the following youth groups are target populations for the subawardee’s program

Target Population

Youth in foster care

Y / N

Homeless or runaway youth

Y / N

Youth living with HIV/AIDS

Y / N

Pregnant or Parenting youth

Y / N

Hispanic / Latino youth

Y / N

African American youth

Y / N

Native American youth

Y / N

LGBTQ youth

Y / N

Youth in adjudication systems

Y / N

Male youth

Y / N

Youth in high-need geographic areas

Y / N

Out of school / dropout youth

Y / N

In residential treatment for mental health issues

Y / N


Indicate which of the following adult preparation topics are covered by the program.

Adult Preparation Topics

Healthy Relationships

Y / N

Adolescent Development

Y / N

Financial Literacy

Y / N

Parent Child Communication

Y / N

Educational and Career Success

Y / N

Healthy Life Skills

Y / N



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