Performance Measures Data Report Form - Grantees (Instrument 3)

Personal Responsibility Education Program (PREP) Performance Measures and Adulthood Preparation Subjects (PMAPS)

Instrument 3_PREP Performance Reporting System Data Entry Form

Performance Measures Data Report Form - Grantees (Instrument 3)

OMB: 0970-0497

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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





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