Z Student Program Fidelity 6th Grade Session 6

Form Approved

OMB No. 0920-XXXX

Exp. Date:

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Attachment Z:

Student Program Fidelity 6th Grade Session 6

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 – 6th Grade, Session 6 – Staying Safe in 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 – 6th Grade, Session 6 – Staying Safe in 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
Briefly reviewed Session 5			
Explained that Session 6 will cover rights in a relationship and ways to get help if those rights are violated			
Discussed the meaning of a “right”			
Allowed student volunteers read the R.E.S.P.E.C.T. M.E. Rights aloud.			
Gave instructions for Activity 1			
Completed Activity 1			
Explained that it is important to get help if one or more of one’s R.E.S.P.E.C.T. M.E. Rights is violated			
Gave instructions for Activity 2			
Ensured that students completed the My Safety Plan handout			
Helped students complete the “People in my school…” and “People in my community…” sections of the Where Can I Get Help? handout			
Reviewed the “National Organizations” and “Confidential Hotlines” section of the Where Can I Get Help? handout			
Recapped Session 6			
Allowed small groups of students to present the main points/messages of Sessions 1-6			

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 completed

Please reflect on your overall implementation of the program.

What is a student's time spent on program training over the past 12 months?

How much time (excluding travel time) did you spend on curricula implementation over the past 12 months?

How much travel time and mileage did you spend on curricula implementation over the past 12 months?