Strengthening the Implementation of Responsible Fatherhood Programs (SIRF)

OMB #: 0970-0531

EXPIRATION: 07/31/2022

Observation /

Self-Reflection Form

By participating in SIRF, your program has demonstrated a commitment to learning, self-assessment, and program improvement. The SIRF team is here to support you on this journey! To help both your program team and the SIRF team identify the successes and challenges that you encounter during the study period, as well as understand whether the programming was implemented as intended, we request the following:

• One self-reflection per week, per implementing staff member

• Each implementing staff member should be observed by a peer or supervisor/manager once per week.

Note: Staff using this form will be trained on it prior to use.

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to gather preliminary information about the fatherhood field and explore with fatherhood programs the research questions that are of interest and the design options that are feasible. Public reporting burden for this collection of information is estimated to average 36 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. The answers you give will be kept private. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0531 and the expiration date is 07/31/2022. If you have any comments on this collection of information, please contact Charles Michalopoulos; [email protected], and Dina Israel; [email protected]; Attn: OMB-PRA (0970-0531).  

Observer OR Self-Reflector:	Initials of staff being observed:
Session Date:	Program Name:
Session Time:	Brief Description of Setting (e.g. virtual, in-person at program, at father’s home, etc.):

Facilitation Methods {This section will be tailored to intervention being observed. Some examples shown for coaching, peer support, and outreach interventions.}

What methods did the Case Manager use during the interaction? Check all that apply. 

	Staff-led lecture/instruction		Use of open-ended questions to guide discussion		Multimedia or technology used
	Staff-led interactive discussion		Demonstration of skill		Other
	Father-led discussion		Practice of skill		[TBD]
	Independent work		Reflection on skill practice/real-world implementation		[TBD]
What method did the staff member use the most?      

 

What methods did you use in meeting with the peer support individual or team? Check all that apply. 

	Self-led lecture/instruction		Use of open-ended questions to guide discussion		Multimedia or technology used
	Self-led interactive discussion		Demonstration of skill		Other
	Peer support-led discussion		Practice of skill		[TBD]
	Independent work		Reflection on skill practice/real-world implementation		[TBD]

 

What methods did you use during this week’s father outreach? Check all that apply. 

	Text message		In-person meeting		[TBD]
	Phone call		Group event		Other

 

Key Topics

This section is designed to capture the key topics addressed during the observations. It will be tailored to each approach being tested. The content included now is just for example purposes.

Parenting		Coparenting		Economic Stability		Other
	Age-appropriate play with child		Conflict resolution		Job search		Basic needs
	Emotional support for child		Custody arrangements/time		Resume development		Transportation
	Parenting fears		Child support		Mock interviewing		Legal aid
	[Other/TBD]		[Other/TBD]		[Other/TBD]		[Other/TBD]

Item	Strength of Implementation Circle or mark according to assessment Definition to be added later							Notes Note any information you think it important to share about this item and/or your assessment of it
	Weak		Moderate			Strong N/A
Organization/ preparation	1	2		3	4		5 N/A
Comfort with technology, tools, and materials	1	2		3	4		5 N/A
Staff cultivates change talk with father.	1	2		3	4		5 N/A
Staff exhibits empathy.	1	2		3	4		5 N/A
Staff affirms father’s strengths.	1	2		3	4		5 N/A
Staff uses reflective listening.	1	2		3	4		5 N/A
One-on-one relationship building	1	2		3	4		5 N/A
Overall facilitation	1	2		3	4		5 N/A
Implementation of programming/ session as designed/intended	1	2		3	4		5 N/A
Wrap-up/clear next steps	1	2		3	4		5 N/A

DRAFT | 2/15/2021