Sexual Risk Avoidance Education National Evaluation: Co-regulation Guidance Pilot Study

SRAENE – Core Components Evaluation, Co-Regulation Strategies, Instrument 1

OMB Control No: 0970-0356

Expiration Date: 01/31/2027

Sexual Risk Avoidance Education National Evaluation 2.0

Facilitator Log

This study is sponsored by the Administration for Children and Families (ACF) within the U.S. Department of Health and Human Services and is being conducted by Mathematica. The purpose of this log is to learn about your experience using the co-regulation strategies when delivering Love Notes. The information we collect will not be used to evaluate your performance as a facilitator so please just do your best to answer honestly.

If you have any questions or comments about this information collection, contact Melissa Thomas, the survey director, at [email protected] or (609) 275-2231. If you have any questions or concerns about your rights as a study participant, please contact the Health Media Lab Institutional Review Board at (202) 246-8504.

Please complete this log after each class where you deliver Love Notes. This should take 2 minutes to complete.

Facilitator: ____________________ School: ____________________ Class period: ________ Love Notes lesson #: ________

	During this class, did you use…		For strategies I used, I thought it went …
Welcome	Yes	No	Poorly	Pretty good	Excellent
Two-part praise	Yes	No	Poorly	Pretty good	Excellent
Written praise	Yes	No	Poorly	Pretty good	Excellent
Group agreements	Yes	No	Poorly	Pretty good	Excellent
Breath to focus	Yes	No	Poorly	Pretty good	Excellent
Take note	Yes	No	Poorly	Pretty good	Excellent
Rest and return	Yes	No	Poorly	Pretty good	Excellent

Did anything happen during class that prevented you from delivering the Love Notes lesson? (for example, a fire drill, school assembly, etc.)

Yes No

THE PAPERWORK REDUCTION ACT OF 1995

This collection of information is voluntary and will be used to provide the Administration for Children and Families with information to help refine and guide program development in the area of adolescent pregnancy prevention. Public reporting burden for the collection of information is estimated to average 2 minutes 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. The OMB number and expiration date for this collection are OMB #: 0970-0356, Exp: 01/31/2027. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Melissa Thomas at [email protected]..

DRAFT 05/29/25 Mathematica^® Inc. 1