U Student Program Fidelity 6th Grade Session 1

Form Approved

OMB No. 0920-XXXX

Exp. Date:

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Attachment U:

Student Program Fidelity 6^th Grade Session 1

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 – 6^th Grade, Session 1 – Health and Healthy Relationships

Attendance Log

Implementer Name: _________________________ Implementer ID: ___________________

School ID: ____________________________ Session ID: _________________

Classroom ID: ____________________ Program Year: ____________________

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

Student Names (Pre-Typed)	Student ID (pre-typed)	Student Initials for Present

Student Curriculum – 6^th Grade, Session 1 – Health and Healthy Relationships

Implementer Name: _____________________ Implementer ID: ___________________

School ID: ____________________________ Session ID: _________________

Classroom ID: ____________________

Program Year: ____________________ Time lesson began: ___________

Date: __________________________ Time lesson ended: ___________

Please indicate if you completed the following activities:

Activity	Yes	Yes w/ changes	No
Introduced the Dating Matters curriculum			
Defined “dating” as it applies to this program			
Acknowledged that students may or may not be dating and indicate that either is fine			
Explained that Dating Matters will span the course of the next three years			
Distributed Student Handbooks			
Collectively established ground rules			
Made sure the following were included in the ground rules: Be respectful of other people and their feelings. Treat others in the way you would want to be treated—try to imagine yourself in their shoes. If you disagree about something, focus on the ideas that you disagree with, not the person himself/herself. Remember, it is okay to agree to disagree! Everything that is said in the room is confidential. This means you should not repeat what your classmates say outside of this room. If you share a personal story, avoid using the names of teachers, students, or other people.			
Gave instructions for Activity 1			
Ensured groups of students for Activity 1 were generating responses for 1) physical health and 2) emotional health			
Allowed groups to present their drawings for Activity 1			
Gave instructions for Activity 2			
Allowed students to individually list characteristics of a healthy relationship			
Ensured students shared characteristics of a healthy relationship in small groups			
Discussed how the three types of health (physical, emotional, relationship) can affect each other			
Allowed students to take the Healthy Relationships quiz			
Recapped Session 1			
Previewed the feelings concept for Session 2			

Describe any changes you made to the session activities (please identify which activity you are describing by number).

Please indicate if you experienced any of these challenges that interfered with implementing today’s session.  Check all that apply.

Not enough time	
I did not have the needed materials	
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, reading aloud, worksheets)	
Classroom behavior management issues	
Other more pressing classroom demands	
Other – please specify____________________________________	

Please check the extent to which the students were engaged in today’s lesson on the following measures:

Most students…	Strongly Agree	Agree	Don’t Know	Disagree	Strongly Disagree
Asked relevant questions.					
Suggested solutions to scenario problems.					
Responded correctly to questions.					
Distracted other students.					
Participated extensively in discussions.					
Discouraged other students from participating.					

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.

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

1  Not at all

2  A little

3  A lot

4  Completely

2. How well did the session material fit into the allotted time period?

1 Session was too packed/not enough time to complete all activities

2 Session was somewhat packed/able to complete most but not all

3 Session was just right

4 Not enough material/session ended before class period complete

Attachment U: Student Program Fidelity 6^th Grade Session 1 7