TPP Grantees, Performance Measures Form

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

TPP Performance Measures Form for Cohort 3: Grantee Form

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 7 hours per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete 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

General Information

1. Classification of project (select one of the following):

• Sexual risk reduction (SRR)

• Sexual risk avoidance (SRA)

• On the continuum between SRR and SRA

• Projects Addressing Protective Factors Only (Tier 2)

2. Select the name of the program(s) to be replicated (2018 Tier 1 only)

• SMARTool

• Tool to Assess Characteristics of Effective Sex and STD/HIV Programs

3. Is the programming to be implemented stand-alone or part of a curriculum?

• Stand-alone

• Part of existing curriculum

4. Program model Name (curriculum, intervention, strategy) name(s)

5. Implementation Setting(s) (select one):

In-school

Out-of-school time (on school campus)

Community-based programs

6. State (select)

7. Urbanicity (select one for each class implemented):

• Urban

• Rural

• Suburban

Partnerships

8. Enter the number of Implementation sites planned as of the start of the grant (Year 1 of Phase 1) ______

9. Enter the Number of planned implementation sites with fully executed Memorandum of Understanding (MOU) in place as of this reporting deadline. _______

10. Enter the Number of new implementation sites with fully executed MOUs in place as of this reporting deadline. ___________

11. Enter the Number of implementation sites retained as of this reporting deadline. _________

Reach and Demographics

These data are collected and entered for every participant in aggregate at the level of a class or group receiving the program or services together

Youth Served

12. For each group or class, enter the total number of youth participants that were served? ______

13. For each group or class, enter the total number of youth participants that were served, by gender:

    1. Male

    2. Female

    3. Does not identify

    4. Did not report

14. For each group or class, enter the total number of youth participants that were served, by age group:

    1. < 10 years _________

    2. 11-12 years _________

    3. 13-14 years _________

    4. 15-16 years _________

    5. 17-18 years _________

    6. 19+ years _________

    7. Did not report

15. For each group or class, enter the total number of program participants (youth ages 11-19) that were served, by grade level?

­< 6 ________

7- 8 _________

9 – 10 _________

11-12 __________

Not currently attending school __________

College student ___________

Unknown Educational Status _______

16. For each group or class, enter the total number of program participants (youth ages 11-19) that were served, by race and ethnicity? [cross-tabulate individual reports]

1. Hispanic/Latinx, White

2. Hispanic/Latinx, Black

3. Hispanic/Latinx, Asian

4. Hispanic/Latinx, American Indian/Alaska Native

5. Hispanic/Latinx, Hawaiian/Pacific Islander

6. Hispanic/Latinx, Race not specified

7. Non-Hispanic/Latinx, White

8. Non-Hispanic/Latinx, Black

9. Non-Hispanic/Latinx, Asian

10. Non-Hispanic/Latinx, American Indian/Alaska Native

11. Non-Hispanic/Latinx, Hawaiian/Pacific Islander

12. Non-Hispanic/Latinx, Race not specified

13. Unreported Race and Ethnicity

Reach of other, non-youth program participants.

17. For each group or class, enter the total number of parent/guardians (of youth ages 11-19) that were served? ______

18. For each group or class, enter the total number of youth-serving professionals (such as teachers, social workers, and other professions who work with youth ages 11-19) that were served? ______

Fidelity and Quality

Fidelity and Quality Items reference to OAH observation form, the OAH TPP Fidelity Process Form, and the individual program model fidelity logs.

19. For each session of programming observed, what is the overall quality of programming (on scale of 1 – 5) [Uses the OAH Observation Form]

20. DurIng the past six month reporting period, how many sessions [meetings] of programming were observed by an independent observer for fidelity and quality? _______

21. DurIng the past six month reporting period, how many sessions [meetings] of programming were implemented overall?

22. How many sessions (meetings) were planned for each class or group of the program model/strategy/intervention? ____________

23. How many sessions (meetings) were implemented for each class or group of the program model/strategy/intervention? ___________

24. How many activities were planned for each class meeting? _____________

25. How many activities were completed for each class meeting? __________

26. What is your project’s total score on the fidelity process scale? [Refers to the OAH Fidelity Process Form] ___________

Dosage

Dosage metrics are derived from attendance records, and are reported in aggregate for each class or group who received programming together.

27. How many youth received at least 75% of the overall program? __________

28. What was the average participant daily attendance for the class? ___________

29. How long (in minutes) was each meeting of the program? __________

Dissemination (Phase 2 Measure)

30. 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. _____

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

32. During the reporting period, where was information about the program presented? Write the number of times each presentation occurred.

    1. _____National Conference/Event

    2. _____Statewide Conference/Event

    3. _____Local Meeting/Event

    4. _____Other (explain)