Performance Measures Data Report Form (Instrument 3)

Instrument #3
PREP performance reporting system data entry form

The 98 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 (Mathematica Policy Research) will develop tools grantees can use to aggregate data originating from sub-awardee providers and to organize all of the performance measures data elements to facilitate entry into the national system. However, these tools are considered voluntary and to be used at the discretion of the grantees. Grantees may elect to use alternative means to collect and aggregate the data that will be submitted. The only requirement will be that all grantees enter the required measures into the national system systematically, and for that they will use an online form that contains all of the items in this instrument.

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

			Enter Count						Enter Count
Total Entry Surveys Completed (Middle School):					Total Entry Surveys Completed (High School or Older):
Age		Age 10			Sex	Male
		Age 11				Female
		Age 12				Total
		Age 13				Missing
		Age 14
		Age 15
		Age 16
		Age 17*
		Age 18*
		Age 19*
		Age 20 or older*
		Total
		Missing
Language(s) Spoken at Home		English
		Spanish
		Other: ___________________
		Total
		Missing

				Enter Count						Enter Count
Hispanic/Latino		Yes				Grade	Grade 5+
		No					Grade 6+
		Total					Grade 7+
		Missing					Grade 8+
							Grade 9
Race		American Indian or Alaska Native					Grade 10*
		Asian					Grade 11*
		Black or African American					Grade 12*
		Native Hawaiian or Other Pacific Islander					School does not assign grade levels
		White or Caucasian					Dropped out of school and is not working on getting a high school diploma or GED*
		Total					Working toward GED*
		Missing					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*
Vulnerable Populations		Living with family [parent(s), guardian, grandparents, or other relatives]					Not currently enrolled in school+
		In foster care, living with a family					Total
		In foster care, living in a group home					Missing
		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

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

	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
Made decisions to not use drugs and alcohol
Were respectful of others
Thought about the consequences before making a decision
Talked with parent, guardian, or caregiver about things going on in their life
Talked with parent, guardian, or caregiver about sex

How true is each statement:	Not true at all	Somewhat true	Very true	Missing	Total
Makes plans to reach goals
Cares about doing well in school
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 full-time steady 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
Saves money to get what they want
Feels confident about how to open a bank account
Feels confident about how to prepare a budget
Feels confident about tracking expenses
Understands costs associated with raising a child
Understands what makes a relationship healthy
Looks for information and resources about dating violence
Would be able to resist or say no to someone they are dating or going out with if pressured to participate in sexual acts
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 sexual intercourse until graduates high school or receives GED*
Plans to delay having sexual intercourse until graduates college or completes another education or training program*
Plans to delay having sexual intercourse 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*

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

				Enter Count
	Yes	No	Never had sex		Not sure	Missing	No response because completed middle school version of survey	Total
Ever had sexual intercourse*
Ever been/gotten someone pregnant*
Ever been told by doctor or other medical provider they had an STI*

Enter Count

	Never had sex	Have had sex but not in the past 3 months	1	2-3	4 or more people	Missing	No response because completed middle school version of survey	Total
Number of people with whom had sexual intercourse in past 3 months*

		Enter Count
	Never had sex		Have had sex but not in the past 3 months	All of the Time	Most of the Time	Some of the Time	None of the time	Missing	No response because completed middle school version of survey	Total
How often used a condom for sexual intercourse in past three months*
How often used birth control other than condoms for sexual intercourse in past three months*

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 Count						Enter Count
Total Entry Surveys Completed (Middle school):						Total Entry Surveys Completed (High school and older):
Age		Age 10				Sex	Male
		Age 11					Female
		Age 12					Total
		Age 13					Missing
		Age 14
		Age 15
		Age 16
		Age 17*
		Age 18*
		Age 19*
		Age 20 or older*
		Total
		Missing
Language(s) Spoken at Home		English
		Spanish
		Other: ___________________
		Total
		Missing

				Enter Count				Enter Count
Hispanic/ Latino		Yes				Grade	Grade 5+
		No					Grade 6+
		Total					Grade 7+
		Missing					Grade 8+
							Grade 9
Race		American Indian or Alaska Native					Grade 10*
		Asian					Grade 11*
		Black or African American					Grade 12*
		Native Hawaiian or Other Pacific Islander					School does not assign grade levels
		White or Caucasian					Dropped out of school and is not working on getting a high school diploma or GED*
		Total					Working toward GED*
		Missing					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*
Vulnerable Populations		Living with family [parent(s), guardian, grandparents, or other relatives]					Not currently enrolled in school+
		In foster care, living with a family					Total
		In foster care, living in a group home					Missing
		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 motel or hotel
		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

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 adult behaviors or sexual activities.	Much more likely	Somewhat more likely	About the same	Somewhat less likely	Much less likely	Missing	Total
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
Make decisions to not use drugs and alcohol
Be respectful of others
Think about the consequences before making a decision
Make plans to reach their goals
Care about doing well in school
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
Save money to get things they want
Feel confident about how to open a bank account
Feel confident about how to prepare a budget
Feel confident about how to track expenses
Understand the costs associated with raising a child
Talk with parent, guardian, or caregiver about things going on in their life
Talk with parent, guardian, or caregiver about sex
Feel comfortable talking with 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
Better understand what makes a relationship healthy
Look for information and resources about dating violence
Resist or say no to someone they are dating or going out with if they pressure them to participate in sexual acts
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
How true is each statement:	Not true at all	Somewhat true	Very true	Missing	Total
Plans to delay having sexual intercourse until graduates high school or receives GED
Plans to delay having sexual intercourse until graduates college or completes another education or training program
Plans to delay having sexual intercourse 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	No response because completed middle school version of survey	Total
As a result of being in the program, plans to abstain from sexual intercourse for at least the next 3 months*

			Enter Count
How important are each of these reasons in respondent’s decision to not have sex for at least the next 3 months:	Not at all important	Not too important		Somewhat important	Very important	Question does not apply because they plan to abstain for next 3 months	No response because completed middle school version of the survey	Missing	Total
How it might affect plans for the future*
Possible emotional consequences (for example, feeling sadness or regret) *
Possible social consequences (for example, get a bad reputation or have rumors spread about you, have to deal with drama, make your relationship with someone you are dating or going out with worse, or get in trouble with your parents) *
Risk of getting a sexually transmitted infection (STI) *
Risk of getting pregnant or getting someone pregnant*

			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 exhibit the following behaviors.	Much more likely	Somewhat more likely		About the same	Somewhat less likely	Much less likely	Missing	Question does not apply because will not have sex	No response because completed middle school version of survey	Total
Have sexual intercourse in the next 3 months*
Use (or ask your partner to use) a condom if having sexual intercourse in the next 3 months*
Use (or ask your partner to use) birth control other than condoms if having sexual intercourse in the next 3 months*

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 assessed their program experience according to the scale to the right. How often in this program…	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
Any youth were picked on, teased, or bullied

Enter the number of respondents who assessed their program experience according to the scale to the right. How satisfied were they with…	Very satisfied	Somewhat satisfied	A little satisfied	Not at all satisfied	Missing	Total
The amount of information they received about abstaining from sex (choosing to not have sex)
The amount of information they received about condoms and birth control

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
Majority population	Indicate whether more than 50 percent of youth attending the program were:
	In foster care
	Homeless or runaway
	Pregnant or parenting
	In adjudication systems
Attendance/dosage	Enter the appropriate count below
	The number of youth who completed at least 75 percent of scheduled program hours

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 Implementation Challenges and Needs for Technical Assistance

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

Use the scale at the right to indicate how provider assessed the implementation challenges below.	Not a Problem	Somewhat a problem	A serious problem
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
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
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
PREP Funding
Total amount of PREP grant funding obligated (including any rollover funds) during [reporting period]	$
Of that total, percentage obligated for: 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	% % % %
Grantee Staffing	Count
Number of grantee staff involved in overseeing PREP
Number of grantee FTEs involved in overseeing PREP
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 (mark all that apply):  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 (mark all that apply):  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 (mark all that apply):  Grantee  Developer  Training or technical assistance partner  Evaluation partner  Program provider
Provider Count	Count
Number of providers funded
Number of new providers

Measures of Structure, Cost, and Support for Program Implementation

REPORT PERIOD	[reporting period]
Grantee:	Enter grantee name
Provider:	Enter provider name
	Amount
PREP award amount (for current reporting period only)	$
Amount of non-PREP funding received during current reporting period to support PREP programming	$
	(Y/N)
Is provider new for the [reporting period]?
Did provider serve youth during the [reporting period]?
	Count
Number of PREP facilitators working for provider
Number of PREP facilitators trained in delivering core program model
Number of PREP facilitators observed once
Number of PREP facilitators observed twice or more

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
Program model implemented
Number of intended program delivery hours

Indicate which, if any, of the following youth groups are target populations for the provider’s program		Y / N
Target Population	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
	Youth in high-need geographic areas
	Out of school or dropout youth
	Youth in residential treatment for mental health issues
	Trafficked youth
Indicate which of the following adulthood preparation subjects (APS) are covered by the program		Y / N
Adulthood Preparation Subjects	Healthy relationships
	Adolescent development
	Financial literacy
	Parent child communication
	Educational and career success
	Healthy life skills
For each APS selected, indicate whether content is (mark all that apply):		Y / N
Source of Adulthood Preparation Subjects Content	Included in the program’s evidence-based or evidence-informed APP curriculum
	Covered by incorporating an entire additional existing curriculum
	Covered by adding selected lessons from another existing curriculum
	Covered by original content that we or a partner organization created