Example - 1807 Reporting

Attachment 5: Sample Quantitative Instrument

DASH PS18-1807 Component 2 Funding Recipient Reporting Template

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

DASH PS18-1807 Component 2 Reporting Template

Public reporting burden of this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx),

Activities by Strategy	Components Requested
Sexual Health Education (SHE)	Short-term or Intermediate Outcomes (select from SHE outcomes A-F)	Achievement of Requirement	Comment and/ or Summarize Requirement Progress	Level of Implementation (Check all that apply)	Number of School Buildings and Enrollment
Required SHE1. Identify and approve a list of instructional competencies to be demonstrated by those teaching skills-based health and sexual health education in middle and school high.		☐ Completed ☐ In Progress ☐ Not started	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Required SHE2. Provide necessary training at LEA once per year, to ensure school health and sexual health education teachers have content knowledge, comfort, and instructional competencies to effectively implement approved school health and sexual health education instructional programs.		☐ Completed ☐ In Progress ☐ Not started	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Required SHE3. Establish, adopt, and implement a skills-based health education course requirement which includes sexual health education content for all students attending middle and high schools in the district/consortium.		☐ Completed ☐ In Progress ☐ Not started	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Required SHE4. Develop and approve a health education scope and sequence that delineates sexual health education learning outcomes for all students in middle and high schools in the district.		☐ Completed ☐ In Progress ☐ Not started	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Required SHE5. Develop, revise, or select a sexual health education instructional program consistent with the approved scope and sequence (see SHE4 above), and inclusive of instructional lessons, student learning activities, resources, and student assessment.		☐ Completed ☐ In Progress ☐ Not started	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Required SHE6. Develop, update, and foster use of teaching tools and resources (e.g., lesson pacing guide, specific lesson plans) for teachers to continuously improve delivery of the identified sexual health education instructional program.		☐ Completed ☐ In Progress ☐ Not started	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Required SHE7. Establish and maintain a School Health Advisory Council (SHAC) that regularly provides district-level advice and guidance to improve health and sexual health education programs for students and health and sexual health education instruction for staff.		☐ Completed ☐ In Progress ☐ Not started	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Required SHE8. Integrate strategies to actively engage parents in sexual health education instructional programs.		☐ Completed ☐ In Progress ☐ Not started	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Additional SHE9. Develop and implement a technical assistance plan that incorporates teacher observation, coaching, peer mentoring, and other methods to improve an individual teacher’s sexual health education instruction in a select number of schools annually.		☐ Completed ☐ In Progress ☐ Not started ☐ Not applicable	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Additional SHE10. Develop, revise, or select health education instructional programs for students in elementary grades that align with the priorities for health and sexual health education established in the health education scope and sequence.		☐ Completed ☐ In Progress ☐ Not started ☐ Not applicable	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Additional SHE11. Incorporate specific changes to existing instructional programs to better meet needs of lesbian, gay, bisexual, and transgender youth.		☐ Completed ☐ In Progress ☐ Not started ☐ Not applicable	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Additional SHE12. Strengthen student assessment instruments to more accurately assess student mastery of health education knowledge and skills.		☐ Completed ☐ In Progress ☐ Not started ☐ Not applicable	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
District Optional SHE: site-specific activity		☐ Completed ☐ In Progress ☐ Not started ☐ Not applicable	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
SHE Success: Please share a brief success of your SHE progress during the period of time reporting (may be bulleted) Click or tap here to enter text.

Activities by Strategy	Components Requested
Sexual Health Services (SHS)	Short-term or Intermediate Outcomes (select from SHS outcomes A-I)	Achievement of Requirement	Comment and/ or Summarize Requirement Progress	Level of Implementation (Check all that apply)	Number of School Buildings and Enrollment
Required SHS1. Provide training and professional development (PD) to staff to support SHS activities annually.		☐ Completed ☐ In Progress ☐ Not started	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Required SHS2. Assess district and priority school capacity to implement activities to increase student access to SHS, in collaboration and coordination with the Component 3B recipient.		☐ Completed ☐ In Progress ☐ Not started	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Required SHS3. Incorporate skill-based instruction to students on accessing SHS into SHE annually.		☐ Completed ☐ In Progress ☐ Not started	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Required SHS4. [check one] ☐ Establish or improve use of a referral system to link sexually active students to community providers for SHS by using the referral system toolkit to implement the 7 core components of a referral system. OR ☐ Improve student use and quality of SHS provided by School-Based Health Centers (SBHCs).		☐ Completed ☐ In Progress ☐ Not started	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Required SHS5. Implement school-wide, student-planned marketing campaigns that promote recommended health services for teens and selected school SHS programs.		☐ Completed ☐ In Progress ☐ Not started	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Additional SHS6. Conduct school-based STD screening (SBSS) events.		☐ Completed ☐ In Progress ☐ Not started ☐ Not applicable	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Additional SHS7. Implement or improve a condom availability program (CAP).		☐ Completed ☐ In Progress ☐ Not started ☐ Not applicable	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Additional SHS8. Disseminate SHS-related materials for parents.		☐ Completed ☐ In Progress ☐ Not started ☐ Not applicable	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
District Optional SHS: site-specific activity		☐ Completed ☐ In Progress ☐ Not started ☐ Not applicable	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
SHS Success: Please share a brief success of your SHS progress during the period of time reporting (may be bulleted) Click or tap here to enter text.

Activities by Strategy	Components Requested
Safe and Supportive Environments (SSE)	Short-term or Intermediate SSE Outcomes (select from outcomes A-E)	Achievement of Requirement	Comment and/ or Summarize Requirement Progress	Level of Implementation (Check all that apply)	Number of School Buildings and Enrollment
Required SSE1. Provide professional development to teachers on classroom management annually.		☐ Completed ☐ In Progress ☐ Not started	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Required SSE2. Provide professional development to all school staff on supporting lesbian, gay, bisexual, and transgender (LGBT) youth annually.		☐ Completed ☐ In Progress ☐ Not started	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Required SSE3. Implement mentoring, service learning, and/or other positive youth development programs for students and/or connect students to such community-based programs.		☐ Completed ☐ In Progress ☐ Not started	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Required SSE4. Establish or enhance student-led clubs that support LGBT youth (often known as Gay-Straight Alliances or Genders and Sexualities Alliances).		☐ Completed ☐ In Progress ☐ Not started	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Required SSE5. Disseminate resources to parents/caregivers on parental monitoring and parent-adolescent communication (generally and specifically about sex).		☐ Completed ☐ In Progress ☐ Not started	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Additional SSE6. Disseminate resources specifically relevant to parents of LGBT students		☐ Completed ☐ In Progress ☐ Not started ☐ Not applicable	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
Additional SSE7. Implement and/or connect parents to skill-building parenting programs		☐ Completed ☐ In Progress ☐ Not started ☐ Not applicable	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
District Optional SSE. site-specific activity		☐ Completed ☐ In Progress ☐ Not started ☐ Not applicable	Click or tap here to enter text.	☐ District-level ☐ Priority Schools ☐ Diffusion schools	# of Middle Schools: # of Middle School students enrolled across all schools: # of High Schools: # of High School students enrolled across all schools:
SSE Success: Please share a brief success of your SSE progress during the period of time reporting (may be bulleted) Click or tap here to enter text.

1807 Program Cross-cutting activities

	Annual Professional Development Plan Update
Meets 1807 Required Activity:	Title of event & Summary of Key Content/Topics Covered	Primary Target Audience (i.e., all staff, nurses, teachers)	Who Attended and # of attendees	Date/Length of Event	PD Type (select)	PD Mode (select)
District added:

Evaluation Activities: Please share any evaluation efforts and updates (i.e., reports, 1-pager, infographics, conference abstracts, developing systems to capture referrals, technical assistance, etc.) developed during the reporting period:

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District 1807 Program in media: Please share any media coverage (online or print) your 1807 program activities have received:

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Leveraged/In-kind Support: Please share all resources that have been leveraged through this initiative (staffing, supplies, additional funding, etc.):

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