W Student Program Fidelity 6th Grade Session 3

Form Approved

OMB No. 0920-XXXX

Exp. Date:

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Attachment W:

Student Program Fidelity 6th Grade Session 3

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 3 – Healthy Coping Strategies

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 3 – Healthy Coping Strategies

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 2			
Explained that Session 3 will cover healthy ways of managing uncomfortable feelings			
Defined coping			
Allowed students to brainstorm healthy coping strategies and listed the strategies on the board			
Gave instructions for Activity 1			
Allowed students to star the coping strategies they use on activity handout			
Allowed students to match the coping strategies they use with 3 other classmates			
Led class through Blowing Bubbles coping strategy			
Led class through Robot to Ragdoll coping strategy			
Led class through Pause for Positives coping strategy			
Recapped Session 3			
Previewed the concept of healthy communication in Session 4			

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 W: Student Program Fidelity 6th Grade Session 3