Instrument 3_PREP Performance Reporting System Data Entry Form_092721_clean

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

Instrument 3_PREP Performance Reporting System Data Entry Form_092721_clean

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Personal responsibility education program (PREP)

Instrument 3

performance reporting system data entry form

october 2021














The 101 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) will develop tools grantees can use to aggregate data originating from subrecipient 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 is 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):



Did the program receive an approval from their Federal Project Officer to delay their survey data collection start date?

Y/N

Did the program receive an approved waiver from their Federal Project Officer for any entry survey items?

Y/N

At any point during the reporting period [DATES], was the program unable to collect Entry Survey data due to COVID-19?

Y/N

What mode(s) of data collection did the program use for participant entry surveys during the reporting period? MARK YES OR NO FOR EACH


In-person paper-and-pencil survey

Y/N

Online, web-based survey

Y/N

Telephone survey

Y/N

Mail survey

Y/N

Other (specify: )

Y/N


Measures of Demographics and Behaviors

Collected at Program Entry




Enter Count




Enter Count

Age

Age 10



Grade

Grade 5+


Age 11



Grade 6+


Age 12



Grade 7+


Age 13



Grade 8+


Age 14



Grade 9


Age 15



Grade 10*


Age 16



Grade 11*


Age 17*



Grade 12*


Age 18*



School does not assign grade levels


Age 19*



Dropped out of school and is not working on getting a high school diploma or GED*


Age 20*



Working toward GED*


Age 21*



Has high school diploma or GED but is not currently enrolled in college or technical school*


Total



Not currently enrolled in school+


Missing



Total





Missing






Enter Count




Enter Count

Language(s) spoken
at home

English



Sex

Male


Spanish



Female


Other (specify:



Total


______________________)



Missing


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






Enter Count




Enter Count

Hispanic/
Latino

Yes



Vulnerable Populations

Living with family [parent(s), guardian, grandparents, or other relatives]


No



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 outside, in a tent city or homeless camp, in a car, in an abandoned vehicle, or in an abandoned building


Race

American Indian or Alaska Native



Staying in an emergency shelter or transitional living program


Asian



Staying in a hotel or motel


Black or African American



In juvenile detention center, juvenile group home, and/or under the supervision of a probation officer


Native Hawaiian or Other Pacific Islander


None of the above


White or Caucasian



Total


Other (specify: _________________)


Total


Missing









Missing






Total (unduplicated) youth in foster care







Total (unduplicated) runaway or homeless youth







Total (unduplicated) youth in adjudication system



Measures of Demographics, Behaviors, and Intentions

Collected at Program Entry

REPORT PERIOD

[reporting period]

Grantee:

Enter grantee name

Provider:

Enter provider name

Program:

Enter program name


Enter Count

In past three months, the respondent:

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







Made decisions to not use drugs and alcohol







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














REPORT PERIOD

[reporting period]

Grantee:

Enter grantee name

Provider:

Enter provider name

Program:

Enter program name



Enter Count

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






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






Would be able to resist or say no to someone if pressured to participate in sexual acts






Would talk to a trusted person/adult if someone makes them uncomfortable, hurts them, or pressures them to do things they don’t want to do







Measures of Demographics, Behaviors, and Intentions

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

No response because completed middle school version of the survey

Missing

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 Exit Surveys Completed (Middle school):



Total Exit Surveys Completed

(High school and older):



Did the program receive an approval from their Federal Project Officer to delay their survey data collection start date?

Y/N

Did the program receive an approved waiver from their Federal Project Officer for any exit survey items?

Y/N

At any point during the reporting period [DATES], was the program unable to collect Exit Survey data due to COVID-19?

Y/N

What mode(s) of data collection did the program use for participant exit surveys during the reporting period?

MARK YES OR NO FOR EACH


In-person paper-and-pencil survey

Y/N

Online, web-based survey

Y/N

Telephone survey

Y/N

Mail survey

Y/N

Other (specify: )

Y/N











Enter Count




Enter Count


Age

Age 10



Sex

Male



Age 11



Female



Age 12



Total



Age 13



Missing



Age 14







Age 15







Age 16



Language(s) spoken at home

English



Age 17*



Spanish



Age 18*



Other (specify:



Age 19*





Age 20*



Total



Age 21*



Missing



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*


Other (specify: ____________)



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



+ = Middle school survey only

* = High school and older survey only

Living 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 center, juvenile group home, and/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 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 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








Make decisions to not use drugs and alcohol








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








Better understand what makes a relationship healthy








Resist or say no to someone if they pressure them to participate in sexual acts








Talk to a trusted person/adult if someone makes them uncomfortable, hurts them, or pressures them to do things they don’t want to do










Measures of Demographics, Intentions, and Perceived Effects

Collected at Program Exit




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 do not 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 and social consequences (for example, feeling sadness or regret, disappointing your parent(s) or guardian(s), and/or negative reactions from your peers) *









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 Count

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









Enter Count

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

Reach

Enter the number of youth during the reporting period who:


Attended at least one program session


Number of middle school age participants


Number of high school age or older participants


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 virtual session1


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


LGBTQ youth


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




Cohort:2


1

2

3

4

5

6

7

8

9

10

Enter a unique identifier for each cohort that ended the program during this reporting period.











How many hours of programming, overall, were delivered to the cohort?












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 Because Already Received

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 Operational Status Related to COVID-19


Did the grantee experience any interruptions of PREP administrative operations during the reporting period due to COVID-19?


Y/N

Did the grantee experience any interruptions of PREP services to youth during the reporting period due to COVID-19?


Y/N



PREP Funding


Total amount of PREP grant funding obligated (including any carryover funds) during [reporting period]

$

Of that total, percentage obligated for:

  • Direct service provision (youth programming)

  • Training, technical assistance, and monitoring conducted at the grantee level3

  • Evaluation and/or research

  • Retained for administrative purposes at the grantee level4

%

%

%

%


Grantee Staffing

Count

Number of grantee staff involved in overseeing PREP5

#

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


Provider Funding

Amount

PREP award amount (for current reporting period only)

$

Amount of non-PREP funding received during current reporting period to support PREP programming

$


Provider Staff Administering PREP

Count

Number of provider staff involved in administering PREP programs6


Number of provider FTEs involved in administering PREP programs




Provider Status

Y/N

Is provider new for the [reporting period]?


Did provider serve youth during the [reporting period]?



Facilitators

Count

Number of PREP facilitators working for provider




Facilitator Training and Observation

Count

Number of PREP facilitators trained in delivering core program model


Number of PREP facilitators observed exactly 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



11Virtual includes any programming that is facilitated online rather than by an in-person facilitator, regardless of the physical setting where participants are located

2 PMMS will include the following hover-over text: “A cohort, in this context, represents a group of youth that all jointly receive a defined PREP program, which could include a specific curriculum and any additional hours of programming added to meet all requirements for the PREP program, including requirements for covering select adulthood preparation subjects. If a provider is delivering a PREP program to multiple groups of youth simultaneously, but these groups meet separately, each group of youth should be considered a separate cohort. A cohort could consist of an individual, if programming is delivered one-on-one.

3 PMMS will include the following hover-over text: “This would include funds for training or TA that is provided by the grantee or its designee for grantee staff, provider staff, or program staff. However, it would exclude funds given to subrecipient program providers and used by those providers for their own training or TA.”

4 PMMS will include the following hover-over text: “This would include funds used for grantee administrative purposes but would exclude funds given to subrecipient program providers and used by those providers for administrative purposes.”

5 PMMS will include the following hover-over text: “This measure should include grantee staff, such as PREP program directors and program coordinators, who were directly responsible for administering, managing, and overseeing the PREP program. Do not include grantee staff who provide programming directly to youth but do not oversee PREP in this measure. Those staff should be counted in the measure of facilitators on the program provider data page. If staff play both roles, they should be included in both measures.”

6 PMMS will include the following hover-over text: “This measure should include provider staff, such as PREP program directors and program coordinators, who were directly responsible for administering, managing, and overseeing the PREP program for the provider. Do not include staff who provide programming directly to youth in this measure. Those staff should be counted in the measure of facilitators later in this section. If staff play both roles, they should be included in both measures.”

THE PAPERWORK REDUCTION ACT OF 1995

Public reporting burden for this collection of information is estimated to average 14 to 18 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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.


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