Program Fidelity Checklist

Federal Evaluation of Making Proud Choices! (MPC!

Instrument 5_Fidelity Facilitator Log

Program Fidelity Checklist

OMB: 0990-0452

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MAKING PROUD CHOICES (MPC) SCHOOL EDITION CURRICULUM LOG SHEETS

Date: ______________________

FOR FACILITATORS

This packet contains 14 curriculum log sheets. Please complete the log sheet appropriate for each module you implement. These log sheets are a tool to document how much of the module you completed. If you wish to comment on any questions or explain your answers, feel free to write in the space in the margins.

FACILITATOR NAME: ____________________________________

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Instructions: For each activity, indicate whether the activity was fully completed, partially completed, or not done at all. Place a check in the appropriate column.



Module 1 – Getting to Know You and Making Your Dreams Come True



ACTIVITY

NOT DONE

PARTIALLY COMPLETED

FULLY COMPLETED

A. Welcome and Program Overview




B. Talking Circle




C. Creating Group Agreements




D. Making Proud Choices: Be Proud! Be Responsible! Brainstorm




E. Goals and Dreams Timeline




F. Brainstorming Obstacles to

Your Goals and Dreams





Did you add anything that was not a part of this module as written in the manual? ______Yes ______No

If yes, please describe what you added: _____________________________________________________________________________

_____________________________________________________________________________________________________________________



Did you make any other changes from the directions written in the facilitator’s manual? ______Yes ______No

If yes, please describe what changed and why. _______________________________________________________________________

_____________________________________________________________________________________________________________________

For each activity that you partially completed or did not complete, please indicate what was not completed and why: _________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________































Instructions: For each activity, indicate whether the activity was fully completed, partially completed, or not done at all. Place a check in the appropriate column.



Module 2 – The Consequences of Sex: HIV Infection: Part 1

ACTIVITY

NOT DONE

PARTIALLY COMPLETED

FULLY COMPLETED

A. The Subject Is HIV DVD and Discussion




B. Myths and Facts About HIV




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Did you add anything that was not a part of this module as written in the manual? ______Yes ______No

If yes, please describe what you added: _____________________________________________________________________________

_____________________________________________________________________________________________________________________



Did you make any other changes from the directions written in the facilitator’s manual? ______Yes ______No

If yes, please describe what changed and why. _______________________________________________________________________

_____________________________________________________________________________________________________________________

For each activity that you partially completed or did not complete, please indicate what was not completed and why: _________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________



Instructions: For each activity, indicate whether the activity was fully completed, partially completed, or not done at all. Place a check in the appropriate column.

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Module 3 – The Consequences of Sex: HIV Infection: Part 2

ACTIVITY

NOT DONE

PARTIALLY COMPLETED

FULLY COMPLETED

A. HIV Risk Continuum




B. Understanding Messages About Sex





Did you add anything that was not a part of this module as written in the manual? ______Yes ______No

If yes, please describe what you added: _____________________________________________________________________________

_____________________________________________________________________________________________________________________



Did you make any other changes from the directions written in the facilitator’s manual? ______Yes ______No

If yes, please describe what changed and why. _______________________________________________________________________

_____________________________________________________________________________________________________________________

For each activity that you partially completed or did not complete, please indicate what was not completed and why: _________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________


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Instructions: For each activity, indicate whether the activity was fully completed, partially completed, or not done at all. Place a check in the appropriate column.

Module 4 – Attitudes About Sex, HIV and Condom Use



ACTIVITY

NOT DONE

PARTIALLY COMPLETED

FULLY COMPLETED

A. The Hard Way DVD and Discussion




B. Calling Koko: Part 1








Did you add anything that was not a part of this module as written in the manual? ______Yes ______No

If yes, please describe what you added: _____________________________________________________________________________

_____________________________________________________________________________________________________________________



Did you make any other changes from the directions written in the facilitator’s manual? ______Yes ______No

If yes, please describe what changed and why. _______________________________________________________________________

_____________________________________________________________________________________________________________________

For each activity that you partially completed or did not complete, please indicate what was not completed and why: _________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________



Instructions: For each activity, indicate whether the activity was fully completed, partially completed, or not done at all. Place a check in the appropriate column.

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Module 5 – Strategies for Preventing HIV Infection: Stop, Think and Act: Part 1



ACTIVITY

NOT DONE

PARTIALLY COMPLETED

FULLY COMPLETED

A. Calling Koko: Part 2




B. STOP, THINK and ACT: Introduction to Problem Solving




C. Sean and Morgan Case Study: Problem Solving Using STOP, THINK and ACT





Did you add anything that was not a part of this module as written in the manual? ______Yes ______No

If yes, please describe what you added: _____________________________________________________________________________

_____________________________________________________________________________________________________________________



Did you make any other changes from the directions written in the facilitator’s manual? ______Yes ______No

If yes, please describe what changed and why. _______________________________________________________________________

_____________________________________________________________________________________________________________________

For each activity that you partially completed or did not complete, please indicate what was not completed and why: _________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

Instructions: For each activity, indicate whether the activity was fully completed, partially completed, or not done at all. Place a check in the appropriate column.

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Module 6 – Strategies for Preventing HIV Infection: Stop, Think and Act: Part 2



ACTIVITY

NOT DONE

PARTIALLY COMPLETED

FULLY COMPLETED

A. Nicole's Choice DVD and Discussion




B. The AIDS Basketball Game





Did you add anything that was not a part of this module as written in the manual? ______Yes ______No

If yes, please describe what you added: _____________________________________________________________________________

_____________________________________________________________________________________________________________________



Did you make any other changes from the directions written in the facilitator’s manual? ______Yes ______No

If yes, please describe what changed and why. _______________________________________________________________________

_____________________________________________________________________________________________________________________

For each activity that you partially completed or did not complete, please indicate what was not completed and why: _________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________



Instructions: For each activity, indicate whether the activity was fully completed, partially completed, or not done at all. Place a check in the appropriate column.

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Module 7 – The Consequences of Sex: STDs: Part 1

ACTIVITY

NOT DONE

PARTIALLY COMPLETED

FULLY COMPLETED

A. STD Facts OR The Subject Is STDs DVD




B. The Transmission Game





Did you add anything that was not a part of this module as written in the manual? ______Yes ______No

If yes, please describe what you added: _____________________________________________________________________________

_____________________________________________________________________________________________________________________



Did you make any other changes from the directions written in the facilitator’s manual? ______Yes ______No

If yes, please describe what changed and why. _______________________________________________________________________

_____________________________________________________________________________________________________________________

For each activity that you partially completed or did not complete, please indicate what was not completed and why: _________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________




Instructions: For each activity, indicate whether the activity was fully completed, partially completed, or not done at all. Place a check in the appropriate column.

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Module 8 – The Consequences of Sex: STDs: Part 2

ACTIVITY

NOT DONE

PARTIALLY COMPLETED

FULLY COMPLETED

A. Discussing HIV and AIDS




B. What I Think About HIV/STD and Safer Sex




C. Condom Use Skills





Did you add anything that was not a part of this module as written in the manual? ______Yes ______No

If yes, please describe what you added: _____________________________________________________________________________

_____________________________________________________________________________________________________________________



Did you make any other changes from the directions written in the facilitator’s manual? ______Yes ______No

If yes, please describe what changed and why. _______________________________________________________________________

_____________________________________________________________________________________________________________________

For each activity that you partially completed or did not complete, please indicate what was not completed and why: _________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

Instructions: For each activity, indicate whether the activity was fully completed, partially completed, or not done at all. Place a check in the appropriate column.

Module 9 – The Consequences of Sex: Pregnancy: Part 1

ACTIVITY

NOT DONE

PARTIALLY COMPLETED

FULLY COMPLETED

A. Brainstorming About Teens and Sex




B. Myths and Facts About Pregnancy




C. Tanisha & Shay DVD






Did you add anything that was not a part of this module as written in the manual? ______Yes ______No

If yes, please describe what you added: _____________________________________________________________________________

_____________________________________________________________________________________________________________________



Did you make any other changes from the directions written in the facilitator’s manual? ______Yes ______No

If yes, please describe what changed and why. _______________________________________________________________________

_____________________________________________________________________________________________________________________

For each activity that you partially completed or did not complete, please indicate what was not completed and why: _________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________



Instructions: For each activity, indicate whether the activity was fully completed, partially completed, or not done at all. Place a check in the appropriate column.



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Module 10 – The Consequences of Sex: Pregnancy: Part 2

ACTIVITY

NOT DONE

PARTIALLY COMPLETED

FULLY COMPLETED

A. Birth Control Methods Demonstration




B. Agree/Disagree—Attitudes About Contraception





Did you add anything that was not a part of this module as written in the manual? ______Yes ______No

If yes, please describe what you added: _____________________________________________________________________________

_____________________________________________________________________________________________________________________



Did you make any other changes from the directions written in the facilitator’s manual? ______Yes ______No

If yes, please describe what changed and why. _______________________________________________________________________

_____________________________________________________________________________________________________________________

For each activity that you partially completed or did not complete, please indicate what was not completed and why: _________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________





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Instructions: For each activity, indicate whether the activity was fully completed, partially completed, or not done at all. Place a check in the appropriate column.

Module 11 – Developing Condom Use and Negotiation Skills: Part 1

ACTIVITY

NOT DONE

PARTIALLY COMPLETED

FULLY COMPLETED

A. Condom Line-Up




B. How to Make Condoms Fun and Pleasurable




C. Barriers to Condom Use/ Condom Pros and Cons





Did you add anything that was not a part of this module as written in the manual? ______Yes ______No

If yes, please describe what you added: _____________________________________________________________________________

_____________________________________________________________________________________________________________________



Did you make any other changes from the directions written in the facilitator’s manual? ______Yes ______No

If yes, please describe what changed and why. _______________________________________________________________________

_____________________________________________________________________________________________________________________

For each activity that you partially completed or did not complete, please indicate what was not completed and why: _________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

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Instructions: For each activity, indicate whether the activity was fully completed, partially completed, or not done at all. Place a check in the appropriate column.

Module 12 – Developing Condom Use and Negotiation Skills: Part 2

ACTIVITY

NOT DONE

PARTIALLY COMPLETED

FULLY COMPLETED

A. “What to Say if My Partner Says...”: Responding to Excuses




B. Introduction to SWAT and Scripted Roleplays





Did you add anything that was not a part of this module as written in the manual? ______Yes ______No

If yes, please describe what you added: _____________________________________________________________________________

_____________________________________________________________________________________________________________________



Did you make any other changes from the directions written in the facilitator’s manual? ______Yes ______No

If yes, please describe what changed and why. _______________________________________________________________________

_____________________________________________________________________________________________________________________

For each activity that you partially completed or did not complete, please indicate what was not completed and why: _________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________





Instructions: For each activity, indicate whether the activity was fully completed, partially completed, or not done at all. Place a check in the appropriate column.

Module 13 – Enhancing Refusal and Negotiation Skills: Part 1

ACTIVITY

NOT DONE

PARTIALLY COMPLETED

FULLY COMPLETED

A. Safer Sex Negotiation Skills and Wrap It Up DVD




B. Practicing and Enhancing Negotiation Skills: Unscripted Roleplays: Part 1





Did you add anything that was not a part of this module as written in the manual? ______Yes ______No

If yes, please describe what you added: _____________________________________________________________________________

_____________________________________________________________________________________________________________________



Did you make any other changes from the directions written in the facilitator’s manual? ______Yes ______No

If yes, please describe what changed and why. _______________________________________________________________________

_____________________________________________________________________________________________________________________

For each activity that you partially completed or did not complete, please indicate what was not completed and why: _________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________



Instructions: For each activity, indicate whether the activity was fully completed, partially completed, or not done at all. Place a check in the appropriate column.

Module 14 – Enhancing Refusal and Negotiation Skills: Part 2

ACTIVITY

NOT DONE

PARTIALLY COMPLETED

FULLY COMPLETED

A. Practicing and Enhancing Negotiation Skills: Unscripted Roleplays: Part 2




B. Talking to Your Partner About Condom Use




C. Talking Circle






Did you add anything that was not a part of this module as written in the manual? ______Yes ______No

If yes, please describe what you added: _____________________________________________________________________________

_____________________________________________________________________________________________________________________



Did you make any other changes from the directions written in the facilitator’s manual? ______Yes ______No

If yes, please describe what changed and why. _______________________________________________________________________

_____________________________________________________________________________________________________________________

For each activity that you partially completed or did not complete, please indicate what was not completed and why: _________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________




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