EVALUATION PACKET FOR BE PROUD! BE RESPONSIBLE (2006 Inc. Add-on Session)!

CAPP Coordinator______Dates for this cycle ___/___/___ - ___/___/___

Full name of lead agency______Is program facilitator a lead agency staff member? ___Yes ___No

Evaluation PacketCover Sheet

Do you want to avoid lots of follow-up calls and emails from the COE asking for clarification on your Attendance Records and Fidelity Checklists?This cover sheet will help CAPP Coordinators work with program facilitators to send accurate, complete data to the COE. Please use this sheet to review each cycle's evaluation packet with program facilitators.

Please return the evaluation packet as soon as possible after the end of the cycle.When the program cycle is complete, email this complete packet, including this Cover Sheet, the Attendance Record, and the Fidelity Checklist for one cycle of an EBP, to Amanda Purington, ACT for Youth Center of Excellence:

V5.12Evaluation Packet Page 1

EVALUATION PACKET FOR BE PROUD! BE RESPONSIBLE (2006 Inc. Add-on Session)!

Did you use the correct forms? The most recent version of each form is posted on the website:

Did you include the full, correct name of your lead agency above? (There are 58 CAPP agencies, including several Planned Parenthoods…please tell us exactly who you are!)

Attendance Record

Does the date rangegiven at the top of the form correspond to the individual dates given for each module?Are the dates accurate?

Have you provided all available demographics for each participant (age, ethnicity, race, gender)?

Have you removed the names of participants? (For confidentiality, all names must be removed before the COE can review the data.)

Fidelity Checklist

Are the datesaccurate for each module?

Was the site locationindicated?

Have you clearly explained every adaptation? Have you described what was done? Is the reason for adapting the program clearly stated? That is, can you determine both WHAT was changed and WHY it was changed from the description given?

If no adaptations are listed, have you checked with the facilitator to be sure this is correct? (The COE is attempting to track all adaptations – we are trying to learn how these EBPs are be used in real world settings.)

Are the Attendance Record and Fidelity Checklist consistent?

Do the individualdates listed on the Attendance Record match the individual dates on the Fidelity Checklist?

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EVALUATION PACKET FOR BE PROUD! BE RESPONSIBLE (2006 Inc. Add-on Session)!

Questions? Contact Amanda Purington at or 607-255-1861
Attendance Record for One EBP CycleDates for this cycle: __/__/__ - __/__/__

(EBP Cycle = One complete implementation of all the sessions for an EBP Total number of participants for this cycle: ___

as described in the facilitator's manual.)

Facilitators' Name(s) ______

Target Group? Check ONE:

___Youth in-school / After-school program___Youth out-of-school (not enrolled in school)___Runaway/homeless youth

___LGBTQ youth___Youth residing in institutions___Youth in foster care

___Incarcerated youth___Pregnant/parenting youth___Youth living with disability

___Recently immigrated youth___Youth involved in the juvenile justice system___Other:______

Participant's Name / Age / Ethnicity / Race / Gender / Module and Date
1. For each module, add date and module number
2. Place an X for each day the participant attended / Participant Number
IMPORTANT:
for confidentiality,
Remove names
before
submitting
to COE / Hispanic or Latino / Asian / Black / Native Hawaiian or other Pacific Islander / Native American / White / Other / Male / Female / Transgender / Date__/__/__ / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date:
Mod(s):__ / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s):
1
2
3
4
5
6
7
8
9
10
Age / Ethnicity / Race / Gender / Module and Date
1. For each module, add date and module number
2. Place an X for each day the participant attended / Participant Number
IMPORTANT:
for confidentiality,
Remove names
before
submitting
to COE / Hispanic or Latino / Asian / Black / Native Hawaiian or other Pacific Islander / Native American / White / Other / Male / Female / Transgender / Date__/__/__ / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date:
Mod(s):__ / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s):

FIDELITY CHECKLIST

Facilitator(s)______Dates for this cycle ___/___/___ - ___/___/___

Site Location:

____ In School classroom ____ In-School after school program ____ Foster Care Facility ____ Other Residential Facility

____ Community Center /CBO____ Faith Based Institution ____ Clinical Setting ____ Other:______

Module 1: Introduction to HIV and AIDS

Activity / Date Activity Was Carried Out (MM/DD/YY)
if not carried out write“O” / Was Activity Carried Out According to Directions in the Facilitator’s Curriculum?
Y=YES
N=NO (describe changes in next column) / If Changed, WHAT was changed and WHY? Please be specific: describe things you left out, added, or changed and WHY. / Were Changes (If Any) Pre-Approved?
Y = YES
N = NO
A: Introduction and Overview / Y / N / Y / N
B: Creating Group Rules / Y / N / Y / N
C: Discussing HIV and AIDS / Y / N / Y / N
D: “What I Think about HIV, AIDS, and Safer Sex” / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Module 2: Building Knowledge about HIV and AIDS

Activity / Date Activity Was Carried Out (MM/DD/YY)
if not carried out write“O” / Was Activity Carried Out According to Directions in the Facilitator’s Curriculum?
Y=YES
N=NO (describe changes in next column) / If Changed, WHAT was changed and WHY? Please be specific: describe things you left out, added, or changed and WHY. / Were Changes (If Any) Pre-Approved?
Y = YES
N = NO
A: “The Subject is: HIV” / Y / N / Y / N
B: Myths and Facts about HIV/AIDS / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Module 3: Understanding Vulnerability to HIV Infection

Activity / Date Activity Was Carried Out (MM/DD/YY)
if not carried out write“O” / Was Activity Carried Out According to Directions in the Facilitator’s Curriculum?
Y=YES
N=NO (describe changes in next column) / If Changed, WHAT was changed and WHY? Please be specific: describe things you left out, added, or changed and WHY. / Were Changes (If Any) Pre-Approved?
Y = YES
N = NO
A: Acknowledging the Threat of HIV and AIDS / Y / N / Y / N
B: Film Clips and Discussion / Y / N / Y / N
C: “The Transmission Game” / Y / N / Y / N
D: HIV Risk Continuum Exercise / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Module 4: Attitudes and Beliefs about HIV, AIDS, and Safer Sex

Activity / Date Activity Was Carried Out (MM/DD/YY)
if not carried out write“O” / Was Activity Carried Out According to Directions in the Facilitator’s Curriculum?
Y=YES
N=NO (describe changes in next column) / If Changed, WHAT was changed and WHY? Please be specific: describe things you left out, added, or changed and WHY. / Were Changes (If Any) Pre-Approved?
Y = YES
N = NO
A: “The Hard Way” - Video and Discussion / Y / N / Y / N
B: “Tell It to Tyrone”: Sexual Health Advice Hotline / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Module 5: Building Condom Use Skills

Activity / Date Activity Was Carried Out (MM/DD/YY)
if not carried out write“O” / Was Activity Carried Out According to Directions in the Facilitator’s Curriculum?
Y=YES
N=NO (describe changes in next column) / If Changed, WHAT was changed and WHY? Please be specific: describe things you left out, added, or changed and WHY. / Were Changes (If Any) Pre-Approved?
Y = YES
N = NO
A: Discussing Condoms / Y / N / Y / N
B: Condom Use Skills / Y / N / Y / N
C: How to Make Condoms Fun and Pleasurable / Y / N / Y / N
D: What Gets in the Way of Proud and Responsible Sexual Behavior? / Y / N / Y / N
E: Barriers to Condom Use / Y / N / Y / N
F: Condom Line-Up / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Module 6: Building Negotiation and Refusal Skills

Activity / Date Activity Was Carried Out (MM/DD/YY)
if not carried out write“O” / Was Activity Carried Out According to Directions in the Facilitator’s Curriculum?
Y=YES
N=NO (describe changes in next column) / If Changed, WHAT was changed and WHY? Please be specific: describe things you left out, added, or changed and WHY. / Were Changes (If Any) Pre-Approved?
Y = YES
N = NO
A: “What to Say if My Partner Says…” / Y / N / Y / N
B: Using the S.W.A.T. Technique in Role Playing / Y / N / Y / N
C: Reviewing Important Issues on Talking with Partners about Condom Use or Abstinence / Y / N / Y / N
D: The AIDS Basketball Game / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Module 7: Identifying Risksand Preventing Pregnancy

Activity / Date Activity Was Carried Out (MM/DD/YY)
if not carried out write“O” / Was Activity Carried Out According to Directions in the Facilitator’s Curriculum?
Y=YES
N=NO (describe changes in next column) / If Changed, WHAT was changed and WHY? Please be specific: describe things you left out, added, or changed and WHY. / Were Changes (If Any) Pre-Approved?
Y = YES
N = NO
A: Myths and Facts about Pregnancy / Y / N / Y / N
B: Birth Control Methods Demonstration / Y / N / Y / N
C: How Safe is the Method? / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

ADDITIONAL COMMENTS RE PROGRAM IMPLEMENTATION:

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