Instrument 4_Fidelity Log832021

INSTRUMENT 4
 
FIDELITY LOG

OMB Control No: 0990-new

Expiration Date: XX/XX/XXXX

Fidelity Log

Table 1. Overview and attendance

Facilitator name	[Pre-programmed]
Organization or school name	[Pre-programmed]
Date	[Select]
Period or block when programming was delivered	Drop down [select one]
Class session # you completed	Drop down [select one from pre-specified/planned scope and sequence]
Deselect any students who were not present in the session	Deselect from pre-programmed list of consented students who were not present in the session
Were you wearing a mask when implementing?	Drop down [select one – yes/no]
Approximately what percentage of youth were wearing a mask?	Drop down [select one – in deciles]
Did you implement remotely?	Drop down [select one] – yes/no
Approximately what percentage of youth were attending remotely?	Drop down [select one – in deciles]

THE PAPERWORK REDUCTION ACT OF 1995

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-new. The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review 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

Instructions: Please complete the following questions for each of the REA lesson(s) you expected to complete in today’s session.

Table 2. Fidelity

REA lesson [lesson number]: [lesson name]	Indicate whether the lesson was fully completed, completed with changes, or not completed [Dropdown- Select one]	If completed with changes, describe the changes made and why. Note that changes might include changing the names in a role play, adding new content or activities, using other materials, or changing the way you teach something (e.g., making something into a game or using pairs instead of small groups for an activity) [Open response]	Method(s) used [Dropdown- Select all that apply]	Material(s) used [Dropdown- Select one]	Describe any materials you used that were not provided or indicated in the curriculum [Open response]	How prepared did you feel to deliver the lesson? [Dropdown- Select one]	Indicate amount of time (in minutes) spent on the lesson? [Open response]	Please note any factors that affected the lesson [Dropdown-Select all that apply]		Did you use any of the following tools to complete the lesson? [Dropdown- Select all that apply]	If this session included more than one lesson, to what extent did you use transitions connecting content across lessons? [Dropdown-Select one]
Response options	Fully completed Completed with changes Not completed		Independent activity Small-group activity Small-group discussion Class discussion Class activity Lecture or presentation Homework assignment Video Role play Game Other Debrief	Used only materials provided or indicated in the curriculum Used materials provided or indicated in the curriculum as well as other materials not in the curriculum Used only other materials not part of the curriculum		Highly prepared Somewhat prepared Not prepared at all		Lack of time Disruptions caused by school issues (e.g., changes in bell schedules, student activities, etc.) Disruptions caused by challenges with students in the class (e.g., behavioral issues, etc.) Lack of communication with teacher or administrators Lack of adequate space Other, please describe: [open-ended response]		Educator note Make an impact Character spotlight Connect at home All of the above	Always Sometimes Never
Introduction and review of lesson/ activity objectives
[Lesson]
Takeaways, best practices, and questions to consider (from REA certification handbook)

Table 3. Student engagement and classroom climate

	On a scale of 1 to 5, how engaged were the students in the lesson? [Dropdown - Select one]	Please select any strategies you used to engage students in the lesson [Dropdown - Select all that apply]	Did you have a co-facilitator? [Dropdown -Select one]	What was the role of the classroom teacher for the lesson? [Dropdown -Select one]	How well did the material covered match the level of students' maturity? [Dropdown - Select one]
Response options	1- Students appear consistently inattentive, distracted, uninterested, apathetic, and/or uncooperative during this activity 2- 3- Students’ levels of interest, attentiveness, or cooperation vary during the activity; students are somewhat attentive and generally cooperative but do not ask questions, have trouble listening and responding to the facilitator, or are easily distracted; some students are using cell phones, reading, talking, etc. 4- 5- Students appear consistently interested in the activity, ask questions, respond to facilitator’s questions and directions; students are not using their cell phones, talking, passing notes, or reading	Used student names to call on them or to engage them Used demonstrations or examples to illustrate content Used incentives (including raffles, incentive charts, etc.) Used icebreakers at the beginning of the lesson Used strategies to increase energy levels Asked open-ended questions Asked students to pair and share Asked students to lead activities Circulated in the room Other, please describe: [open-ended response]	Yes No	Not present Present but only observing Present and managing students/timing Present and actively helping to facilitate Other: please describe.	Very well Somewhat well Not well at all
Introduction and review of lesson/activity objectives
[Lesson]
Takeaways, best practices, and questions to consider (from REA certification handbook)

Wrap-up and notes: Overall, on a scale from 1 to 10 (with 10 being extremely satisfied and 1 being extremely unsatisfied): How satisfied were you with the implementation of today’s lesson(s)? [Select a rating from 1 to 10]

Please use this field to add any notes about the session overall.