Grantee program staff-all grantees

OMB Approval # 0990-0392
Expiration Date: 05/31/2015

TPP Performance Measures for A/B Grantees
September 2014
ALL GRANTEES
Participant ID (unique and non-identifiable, i.e. no names or birthdates)
Demographic characteristics (collected and entered for every participant individually)
o Age
o Grade
o Gender
o Race
o Ethnicity
o Language spoken at home
o Special populations (if applicable)
Fidelity (based on facilitator and observer logs, observer quality rating & fidelity process form)
 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?
o Minimum
o 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?
Dosage of services received by participants (attendance is entered for every program
participant for every scheduled class/session). OAH calculates the following:
 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?
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 0990-0392 . The time required to complete this information collection is estimated to
average 7 hours 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.

OMB Approval # 0990-0392
Expiration Date: 05/31/2015
 What % of parents received at least 75% of the program?
Partners
Formal partners are organizations (e.g., schools) with whom the grantee has an MOU,
contract or other formal written agreement in place to provide service or other
contribution relevant to the TPP program.
Informal partners are organizations with whom the grantee does not have a formal
written agreement in place.
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How many formal/informal partners are you currently working with?
How many of these formal/informal partners are new for this reporting period?
How many formal/informal partners did you lose during this reporting period?
What is the total number of formal/informal partners you have had since the beginning of
the project?
How many formal/informal partners have you lost since the beginning of the project?

Training
 In the reporting period, 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 reporting period, how many intervention facilitators (including teachers) have you or
one of your partners given follow-up training?
Dissemination
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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:
o National or regional? ___
Please list titles of all presentations and venue (e.g., conference or organization
to which the presentation was made)
o State? ____
Please list titles of all presentations and venue (e.g., conference or organization
to which the presentation was made)

OMB Approval # 0990-0392
Expiration Date: 05/31/2015
Actual Participant-Level Performance Measure Questions
Date ______/_______/______
Demographic Questions (Inform Reach)
1. In what month and year were you born?
MARK (X) ONE MONTH AND ONE YEAR

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January
February
March
April
May
June
July
August
September
October
November
December

 2002
 2001
 2000
 1999
 1998
 1997
 1996
 1995
 1994
 1993
 1992
 1991

Alternative question:
How old are you? __________
2. What grade are you in? (If you are currently on vacation between grades, please indicate the
grade you will be in when you go back to school).
MARK (X) ONE ANSWER

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6th
7th
8th
9th
10th
11th
12th
Ungraded
College/Technical school
Not currently in school

OMB Approval # 0990-0392
Expiration Date: 05/31/2015
3. Are you male or female?
MARK (X) ONE ANSWER

 Male
 Female

4. Are you Hispanic or Latino?
MARK (X) ONE ANSWER

 Yes
 No
5. What is your race?
MARK (X) ONE OR MORE THAN ONE ANSWER

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American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or Other Pacific Islander
White

6. When you are at home or with your family, what language or languages do you usually
speak?
MARK (X) ONE OR MORE THAN ONE ANSWER

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English
Spanish
Chinese language such as Mandarin or Cantonese
Some other language: _________________________

Indicate Special Populations (as applicable)
 Pregnant or parenting teens
 Youth in foster care
 Homeless youth
 Youth in the juvenile justice system
 Other