Form 1 SRAE Performance Reporting System Data Entry Form

instrument 3

SRAE performance reporting system data entry form

The 137 estimated grantees will report measures on participant demographics, behaviors, intentions, and perceived effects; attendance, reach, and dosage; implementation challenges and needs for technical assistance; and structure, cost, and support for program implementation. The contractor (Public Strategies) and subcontractor (Mathematica Policy Research) have developed this tool for grantees to use to collect data originating from sub-awardee providers and to organize all of the performance measures data elements to for submission into the data portal. However, this tool is considered voluntary and to be used at the discretion of the grantees. Grantees may elect to use alternative means to collect the data that will be submitted. The only requirement will be that all grantees enter the required measures into the data portal systematically, and for that they will use an online form that contains all of the items in this instrument.

Measures of Structure, Cost, and Support for Program Implementation

REPORT PERIOD		[reporting period]
Grantee:		Enter grantee name
Funding
Total amount of SRAE grant funding obligated (including any rollover funds) during [reporting period]			$
Percentage of total funding (including grant funding and matching funds for Title V grantees) obligated for:
Percent of funding obligated	Direct service provision (youth programming)		%
	Training, technical assistance, and monitoring conducted at the grantee level		%
	Evaluation and/or research		%
	Retained for administrative purposes at the grantee level		%
‡This measure is to be reported by Title V grantees only
Grantee Staffing			Count
Number of grantee staff involved in overseeing SRAE
Number of grantee FTEs involved in overseeing SRAE
Grantee Observation, Training and Technical Assistance			Y/N
Grantee or its designee observed program delivery to monitor quality and fidelity to program models
Type of organization that conducted observations:			Y/N
Type of Organization – Observations	Grantee
	Developer
	Training or technical assistance partner
	Evaluation partner
	Program provider
Grantee or its designee provided technical assistance to support program implementation
Type of organization that provided technical assistance:			Y/N
Type of Organization – TA	Grantee
	Developer
	Training or technical assistance partner
	Evaluation partner
	Program provider
Grantee or its designee conducted training of facilitators who deliver the program (or of other staff who might train facilitators)
Type of organization that conducted program facilitator training:			Y/N
Type of Organization – Training	Grantee
	Developer
	Training or technical assistance partner
	Evaluation partner
	Program provider
Number of providers			Count
Number of providers funded
Number of new providers

Target number of youth to be served by the grantee (in the original application or approved by your project officer)	Count
Target number of youth

Measures of Structure, Cost, and Support for Program Implementation

REPORT PERIOD	[reporting period]
Grantee:	Enter grantee name
Provider:	Enter provider name

Funding	Amount
SRAE annual award amount (for current grant year)	$
Amount of non-SRAE funding received during current reporting year to support SRAE programming	$
	Y/N
Is provider new for the [reporting year]?
Did provider serve youth during the [reporting year]?
Facilitators	Count
Number of SRAE facilitators working for provider
Number of SRAE facilitators trained in delivering core program model
Number of SRAE facilitators observed once
Number of SRAE facilitators observed at least twice

Measures of Structure, Cost, and Support for Program Implementation

REPORT PERIOD	[reporting period]
Grantee:	Enter grantee name
Provider:	Enter provider name

	Use the scale at the right to indicate how the provider assessed the implementation challenges below.	Not a Problem	Somewhat a problem	A serious problem
Implementation Challenges	Recruiting youth
	Keeping youth engaged
	Getting youth to attend regularly
	Recruiting qualified staff
	Ensuring facilitators understand content
	Covering program content
	Staff turnover
	Negative peer reactions
	Youth behavioral problems
	Natural disasters
	Program facilities
	Obtaining buy-in or support from key stakeholders
	Parent support or engagement
	Other
	Use the scale at the right to indicate if the provider has expressed interest in receiving technical assistance for the implementation factors below.	Not Interested	Somewhat Interested	Very Interested
Needs for Technical Assistance	Recruiting youth
	Keeping youth engaged in program sessions
	Getting youth to attend regularly
	Recruiting qualified staff
	Training facilitators
	Retaining staff
	Minimizing negative peer reactions
	Addressing youth behavioral issues
	Obtaining buy-in or support from key stakeholders
	Evaluation (e.g., how to select or manage an evaluator, data collection, data analysis, and report writing)
	Parent support and engagement
	Other

Measures of Structure, Cost, and Support for Program Implementation

REPORT PERIOD	[reporting period]
Grantee:	Enter grantee name
Provider:	Enter provider name
Program:	Enter program name

Program Delivery
Number of intended program delivery hours
Core program model
Indicate which SRAE topics are addressed by this core program model:			Y / N
SRAE topics covered through core program model	Advantage of refraining from non-marital sexual activity
	Self-regulation
	Goal setting
	Success sequence for poverty prevention*
	Healthy relationships
	Resisting sexual coercion
	Dating violence
	Other youth risk behaviors, such as alcohol, tobacco, and other drug use
Other program elements that address SRAE topics	Are there any other program elements – such as supplemental curriculum, guest speakers, or other program activities that are not part of the core curriculum – that address SRAE topics?
Indicate which SRAE topics are addressed through supplemental program elements:
SRAE topics covered through supplemental program elements	Advantage of refraining from non-marital sexual activity
	Self-regulation
	Goal setting
	Success sequence for poverty prevention*
	Healthy relationships
	Resisting sexual coercion
	Dating violence
	Other youth risk behaviors, such as alcohol, tobacco, and other drug use
*Success sequence for poverty prevention – The three steps that young adults should take to improve the likelihood of successful economic outcomes when reaching adulthood. The steps include, but are not limited to, graduating from high school, working a full time job, and waiting until age 21 or later to get married and have children (SRAE 2019 Funding Opportunity Announcement).

Measures of Structure, Cost, and Support for Program Implementation

REPORT PERIOD	[reporting period]
Grantee:	Enter grantee name
Provider:	Enter provider name
Program:	Enter program name

Indicate which, if any, of the following youth groups are target populations for the provider’s program		Y / N
Target Population	Youth in high-need geographic areas
	Youth in foster care
	Homeless or runaway youth
	Youth living with HIV/AIDS
	Pregnant or parenting youth
	Hispanic/Latino youth
	African American youth
	Native American youth
	LGBTQ youth
	Youth in adjudication systems
	Male youth
	Out of school or dropout youth
	Youth in residential treatment for mental health issues
	Trafficked youth

Measures of Attendance, Reach, and Dosage

REPORT PERIOD	[reporting period]
Grantee:	Enter grantee name
Provider:	Enter provider name
Program:	Enter program name

		Enter Count
	Enter the number of youth during the reporting period who:
Reach	Attended at least one program session
Program Setting	Attended a session in school during school
	Attended a session in school after school
	Attended a session in a community-based organization
	Attended a session in a clinic
	Attended a session in a foster care setting
	Attended a session in a juvenile detention center
	Attended a session in a residential mental health treatment facility
	Attended a session in another setting
Attendance/Dosage	Completed at least 75 percent of the scheduled program hours
	Enter the appropriate count below
Parent Involvement	Number of youths’ parents and other caring adults who attended at least one program session during the reporting period

Measures of Attendance, Reach, and Dosage

REPORT PERIOD			[reporting period]
Grantee:			Enter grantee name
Provider:			Enter provider name
Program:			Enter program name
Enter a unique identifier for each cohort that received the program during this reporting period.	Did the cohort complete the program during the reporting period (Y/N)?	For those cohorts that completed the program during the reporting period, how many hours of programming, overall, were delivered?
Cohort-1
Cohort-2
Cohort-3
Cohort-4
Cohort-5
Cohort-6
Cohort-7
Cohort-8
Cohort-9
Cohort-10
Cohort-11
Cohort-12
Cohort-13
Cohort-14
Cohort-15
Cohort-16
Cohort-17
Cohort-18
Cohort-19
Cohort-20
Cohort-21
Cohort-22
Cohort-23
Cohort-24
Cohort-25

Measures of Demographics and Behaviors

Collected at Program Entry

REPORT PERIOD	[reporting period]
Grantee:	Enter grantee name
Provider:	Enter provider name
Program:	Enter program name

Total Entry Surveys Completed	Enter Count
Participant Entry Survey

Age	Age 10
	Age 11
	Age 12
	Age 13
	Age 14
	Age 15
	Age 16
	Age 17
	Age 18
	Age 19
	Age 20 or older
	Total
	Missing

Language(s) Spoken at Home		Enter Count
	English
	Spanish
	Other:
	Total
	Missing

Sex	Male
	Female
	Total
	Missing

Orientation	Straight
	Gay or Lesbian
	Bisexual
	Something else
	Not sure
	Choose not to answer this question
	Total
	Missing

Hispanic/ Latino		Enter Count
	Yes
	No
	Total
	Missing

Race	American Indian or Alaska Native
	Asian
	Black or African American
	Native Hawaiian or Other Pacific Islander
	White or Caucasian
	Total
	Missing

Vulnerable Populations	In foster care, living with a family
	In foster care, living in a group home
	Couch surfing or moving from home to home
	Living in a place not meant to be a residence, such as outside, in a tent city or homeless camp, in a car, in an abandoned vehicle, or in an abandoned building
	Staying in an emergency shelter, or transitional living program
	Staying in a hotel or motel
	In juvenile detention, jail, prison or another correctional facility, or under the supervision of a probation officer
	None of the above
	Total
	Missing
	Total (unduplicated) youth in foster care
	Total (unduplicated) runaway or homeless youth
	Total (unduplicated) youth in adjudication system

Grade		Enter Count
	Grade 4
	Grade 5
	Grade 6
	Grade 7
	Grade 8
	Grade 9
	Grade 10
	Grade 11
	Grade 12
	School does not assign grade levels
	Dropped out of school and is not working on getting a high school diploma or GED
	Working toward GED
	Has high school diploma or GED but is not currently enrolled in college or technical school
	Has high school diploma or GED and is currently enrolled in college or technical school
	Total
	Missing

Measures of Demographics and Behaviors

Collected at Program Entry

REPORT PERIOD	[reporting period]
Grantee:	Enter grantee name
Provider:	Enter provider name
Program:	Enter program name
How often in past three months:		Yes	No	Missing	Total
Drank alcohol
Smoked cigarettes
Smoked cigars, cigarillos, or little cigars
Used other tobacco products
Used electronic vapor products
Used marijuana
Taken prescription pain medicine without a doctor’s prescription or differently than how a doctor told them to use it

	Enter Count
How often in past three months:	All of the Time	Most of the Time	Some of the Time	None of the time	Missing	Total
Resisted or said no to peer pressure
Managed emotions in healthy ways
Worked together to find a solution when disagreed with a friend
Chose to spend time with friends that keep them out of trouble
Were respectful of others
Thought about consequences before making a decision

	Enter Count
How true is each statement:	Not true at all	Somewhat true	Very true	Missing	Total
Makes plans to reach their goals
Cares about doing well in school
Saves money to get something he/she wants
Plans to graduate high school or get GED
Plans to get more education and/or training after high school or completing GED
Plans to get a steady full-time job after school
Feels comfortable talking to parent, guardian, or caregiver about sex
Would speak up or ask for help if being bullied in person or online, via text, while gaming, or through other social media
Would speak up or ask for help if others were being bullied in person or online, via text, while gaming, or through other social media
Understands what makes a relationship healthy
Looks for information and resources about dating violence (for example, websites, social media, hotlines, organizations, etc.)
Would resist or say no to someone they are dating or going out with if pressured to participate in sexual acts, such as kissing, touching private parts, or sex
Would talk to a friend if someone they are dating or going out with makes them uncomfortable, hurts them, or pressures them to do things they don’t want to do
Would talk to a trusted adult if someone they are dating or going out with makes them uncomfortable, hurts them, or pressures them to do things they don’t want to do
Would talk to a trusted adult if someone other than the person they are dating or going out with makes them uncomfortable, hurts them, or pressures them to do things they don’t want to do
Plans to delay having sex until graduates high school or receives GED
Plans to delay having sex until graduates college or completes another education or training program
Plans to delay having sex until married
Plans to be married before having a child
Plans to have a steady full-time job before getting married
Plans to have a steady full-time job before having a child

	Enter the number of respondents who reported the following at program entry	Enter Count
		Yes	No	Not sure	Missing	Total
Sexual Behaviors	Ever kissed non-family member on the mouth
	Ever touched/let someone touch private parts
	Ever had sexual intercourse
	Ever been pregnant/gotten someone pregnant
	Ever had an STI

Measures of Demographics, Intentions, and Perceived Effects

Collected at Program Exit

REPORT PERIOD	[reporting period]
Grantee:	Enter grantee name
Provider:	Enter provider name
Program:	Enter program name

Total Exit Surveys Completed	Enter Count
Participant Exit Survey

Age	Age 10
	Age 11
	Age 12
	Age 13
	Age 14
	Age 15
	Age 16
	Age 17
	Age 18
	Age 19
	Age 20 or older
	Total
	Missing

Language(s) Spoken at Home		Enter Count
	English
	Spanish
	Other:
	Total
	Missing

Sex	Male
	Female
	Total
	Missing

Orientation	Straight
	Gay or Lesbian
	Bisexual
	Something else
	Not sure
	Choose not to answer this question
	Total
	Missing

Hispanic/ Latino		Enter Count
	Yes
	No
	Total
	Missing

Race	American Indian or Alaska Native
	Asian
	Black or African American
	Native Hawaiian or Other Pacific Islander
	White or Caucasian
	Total
	Missing

Vulnerable Populations	In foster care, living with a family
	In foster care, living in a group home
	Couch surfing or moving from home to home
	Living in a place not meant to be a residence, such as outside, in a tent city or homeless camp, in a car, in an abandoned vehicle, or in an abandoned building
	Staying in an emergency shelter, or transitional living program
	Staying in a hotel or motel
	In juvenile detention, jail, prison or another correctional facility, or under the supervision of a probation officer
	None of the above
	Total
	Missing
	Total (unduplicated) youth in foster care
	Total (unduplicated) runaway or homeless youth
	Total (unduplicated) youth in adjudication system

Grade		Enter Count
	Grade 4
	Grade 5
	Grade 6
	Grade 7
	Grade 8
	Grade 9
	Grade 10
	Grade 11
	Grade 12
	School does not assign grade levels
	Dropped out of school and is not working on getting a high school diploma or GED
	Working toward GED
	Has high school diploma or GED but is not currently enrolled in college or technical school
	Has high school diploma or GED and is currently enrolled in college or technical school
	Total
	Missing

Measures of Demographics, Intentions, and Perceived Effects

Collected at Program Exit

REPORT PERIOD	[reporting period]
Grantee:	Enter grantee name
Provider:	Enter provider name
Program:	Enter program name

Enter the number of respondents who report the program made them much more, somewhat more, about the same, somewhat less, or much less likely to exhibit the following behaviors.

Much more likely

Somewhat more likely

About the same

Somewhat less likely

Much less likely

Missing

Total

Make decisions to not drink alcohol

Make decisions to not smoke cigarettes

Make decisions to not smoke cigars, cigarillos, or little cigars

Make decisions to not use other tobacco products

Make decisions to not use electronic vapor products

Make decisions to not use marijuana

Make decisions to not take prescription pain medicine without a doctor’s prescription or differently than how a doctor told them to use it

Resist or say no to peer pressure

Manage emotions in healthy ways

Work together to find a solution when disagree with a friend

Choose to spend time with friends that keep them out of trouble

Be respectful of others

Think about the consequences before making a decision

Make plans to reach goals

Care about doing well in school

Save money to get something they want

Graduate high school or get GED

Get more education and/or training after high school or completing GED

Get a steady full-time job after school

Feel comfortable talking to parent, guardian, or caregiver about sex

Speak up or ask for help if being bullied in person or online, via text, while gaming, or through other social media

Speak up or ask for help if others were being bullied in person or online, via text, while gaming, or through other social media

Much more likely

Somewhat more likely

About the same

Somewhat less likely

Much less likely

Missing

Total

Better understand what makes a relationship healthy

Look for information and resources about dating violence (for example, websites, social media, hotlines, organizations, etc.)

Resist or say no to someone they are dating or going out with if pressured to participate in sexual acts, such as kissing, touching private parts, or sex

Talk to a friend if someone they are dating or going out with makes them uncomfortable, hurts them or pressures them to do things they don’t want to do

Talk to a trusted adult if someone they are dating or going out with makes them uncomfortable, hurts them, or pressures them to do things they don’t want to do

Talk to a trusted adult if someone other than the person they are dating or going out with makes them uncomfortable, hurts them or pressures them to do things they don’t want to do

	Enter Count
Enter the number of respondents who report the program made them much more, somewhat more, about the same, somewhat less, or much less likely to:	Much more likely	Somewhat more likely	About the same	Somewhat less likely	Much less likely	Missing	Total
Plans to delay having sex until graduates high school or receives GED
Plans to delay having sex until graduates college or completes another education or training program
Plans to delay having sex until married
Plans to be married before having a child
Plans to have a steady full-time job before getting married
Plans to have a steady full-time job before having a child

	Enter Count
	Yes	No	Not sure	Missing	Total
As a result of being in the program, plans to abstain from sex

			Enter Count
How important are each of these reasons in respondent’s decision to not have sex:		Not at all important			Not too important		Somewhat important		Very important		Missing		Total
How it might affect their plans for the future
The possible emotional consequences
The possible social consequences
The risk of getting a sexually transmitted infection
The risk of getting pregnant or getting someone pregnant
	Enter Count
Enter the number of respondents who assessed their program experience according to the scale to the right.	All of the time			Most of the time		Some of the time		None of the time		Missing		Total
Felt interested in program sessions and classes
Felt the material presented was clear
Felt discussions or activities helped to learn program lessons
Had a chance to ask questions about topics or issues that came up in the program
Felt respected as a person
Were picked on, teased, or bullied
Other people were picked on, teased, or bullied because people thought they were LGBT
Other people were picked on, teased, or bullied because of their race or ethnic background
Other people were picked on, teased, or bullied for any other reason