Grantee Program staff-Tier 1 C/D and Ter 2/PREIS

Instrument 4

Tier 1 C/D and Tier 2/PREIS performance measure reporting form

Does include measures on participant behaviors (sexual activity, contraceptive use, condom use) and intentions (intention to have sex, use contraception, or use condoms) OMB approval # 0970-0360.

Participant-level measures Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

Please provide the data for the following variables collected from your evaluation for any of the following time points for which you have collected data:

Programs lasting 12 months or less:

• Baseline

• Follow-up 1 (immediately after the intervention)

• Follow-up 2 (6 months after the intervention)

• Follow-up 3 (12 months after the intervention)

Programs lasting 15 months or longer:

• Baseline

• Follow-up 1 (12-18 months after program start)

• Follow-up 2 (24 months after program start)

• Follow-up 3 (30-36 months after program start)

Variables:

• Participant ID

• Grantee name

• Program type (e.g., TOP, Cuídate, etc.)

• Date of data collection

• Follow-up period (e.g., baseline, immediately after intervention, 6-months after intervention, etc.)

• Demographic characteristics

  • Month of birth

  • Year of birth

  • Grade

  • Gender

  • Race

  • Ethnicity

  • Language spoken at home

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-XXXX . The time required to complete this information collection is estimated to average 20 hours 40 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

• Ever had sex

• Ever been pregnant/gotten someone pregnant

• # of times been pregnant/gotten someone pregnant

• Any sex in past 3 months

• # of times had sex in past 3 months

• Had sex without a condom in past 3 months

• # of times had sex without a condom in past 3 months

• Had sex without birth control in past 3 months

• # of times had sex without birth control in past 3 months

• Intent to have sex in next year

• Intent to use a condom in next year

• Intent to use birth control in next year

Please upload data from your most recent collection of data about the perceived impact of the program for the following variables. (This may be from your evaluation data collection, or a separate data collection).

• Participant ID

• Grantee name

• Program type (e.g., TOP, Cuídate, etc.)

• Date of data collection

• Demographic characteristics

  • Month of birth

  • Year of birth

  • Grade

  • Gender

  • Race

  • Ethnicity

  • Language spoken at home

• Perceived impact of the program on sex

• Perceived impact of the program on condom use

• Perceived impact of the program on contraceptive use

Dissemination

• How many manuscripts have you had accepted for publication in the past year (including both articles that were published and those that have been accepted but not yet published)? Do not include manuscripts previously reported as published. __

• Please list the references for any published manuscripts published in the past year.

• How many presentations have you made at each of the following levels in the past year:

  • National or regional? ___

Please list titles of all presentations and venue (e.g., conference or organization to which the presentation was made)

• State? ____

Please list titles of all presentations and venue (e.g., conference or organization to which the presentation was made)

• (Tier 2/PREIS grantees only): Please indicate which of the following have been completed and approved:

  • Logic model

  • Core components

  • Fidelity monitoring tools

  • Curriculum manual

  • Facilitator manual

  • Training materials

  • Adaptation Guidance

Retention

• With how many organizations and/or schools do you have a formal agreement in place to assist with implementing your program? ___

• With how many organizations or schools are you currently working that are assisting with intervention implementation? ___

• How many organizations have been involved in planning and implementing your program, but not in a formal role? (Do not include organizations with which you have a formal agreement). ___

• How many of the organizations or schools with which you had a formal agreement at the start of the program year remained engaged at the end of the program year? ___

• In the past program year, how many new intervention facilitators (including teachers) have you or one of your partners trained? Please include only training provided to new facilitators. ___

• In the past program year, how many intervention facilitators (including teachers) have you or one of your partners given follow-up training? ___

Dosage of services received by participants

• What is the median % of program services received by youth? ___

• What is the median % of program services received by parents (if applicable)? ___

• What % of youth received at least 75% of the program? ___

• What % of parents received at least 75% of the program? ___

Fidelity

• In the past program year, what percentage of sessions were observed by an independent observer for fidelity assessment? ___

• What is the median percentage of activities completed, across sessions observed? ___

• What is the minimum and maximum percentage of activities completed, across sessions observed?

  • Minimum

  • Maximum

• What percentage of sessions were rated either 4 or 5 for overall quality? ___

• For what percentage of sessions completed do you have a completed fidelity monitoring log from the facilitator? ___

• What is the median percentage of activities completed, across sessions for which you have a completed fidelity monitoring log? ___

• Across cohorts, what is the median percentage of sessions implemented? ___

• What is your score on the 24-point fidelity process scale? ___