EVALUATION PACKET FOR ABAN AYA YOUTH PROJECT GRADE 8

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:

V2.12Evaluation Packet Page 1

EVALUATION PACKET FOR ABAN AYA YOUTH PROJECT GRADE 8

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?

V2.12Evaluation Packet Page 1

EVALUATION PACKET FOR ABAN AYA YOUTH PROJECT GRADE 8

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:______

Lesson 1: Welcome Back to ABAN AYA

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: Welcome & Introduction / Y / N / Y / N
B: Rights & Responsibilities for the Classroom Community / Y / N / Y / N
C: ABAN AYA Bingo / Y / N / Y / N
D: Wrap-up / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson2: Review Cheza

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: Review Community Rights & Responsibilities Poster / Y / N / Y / N
B: ABAN AYA Review Cheza / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson3: Who Am I?

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: Introduce Today’s Lesson & UJIMA Group Formation / Y / N / Y / N
B: Who AM I? Game / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson4: Goal Setting the SMART Way

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: Review Previous Lesson & Introduce Today’s Lesson / Y / N / Y / N
B: Goal Setting: Toni’s Story / Y / N / Y / N
C: Being Smart in Goal- Setting / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson5: Steps to Goal Attainment

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: Review & Introduce Today’s Lesson / Y / N / Y / N
B: Steps to My Smart Goal / Y / N / Y / N
C: A Stands for Assessment: Know Thyself / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson6: Transition to High School – A Time of Change

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: Review “Steps to My Smart Goal” Sheets & Parent/Student Assignment / Y / N / Y / N
B: Transition to High School / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson7: Personal Strengths & Interests: Looking Ahead to the Future

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: Personal Strengths and Interests: Looking Ahead to My Future / Y / N / Y / N
B: Wrap-up Lesson / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson8: Responsibilities in High school

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: 411 – Getting the Info for Freshman Year / Y / N / Y / N
B: Success Begins With Attendance / Y / N / Y / N
C: Creating a Safe Learning Environment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 9: Gangs – You Decide Part I

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: Gangs – You Decide, Part I / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 10: Gangs – You Decide Part II

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: Gangs – You DecidePart 2 / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 11: The Real Deal on Drugs

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 Real Deal on Drugs / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 12: Resisting Peer Pressure – Putting the Safety Skills to Work

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: Review Previous Lesson & Introduce Today’s Lesson / Y / N / Y / N
B: Review of ABAN AYA Safety Skills & ANANSE Assertiveness Skills / Y / N / Y / N
C: Putting Your Skills to Work / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 13: Relationships in Transition

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: Review & Introduce Today’s Lesson / Y / N / Y / N
B: My Relationship Circle / Y / N / Y / N
C: Relationships in Transition / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 14: Play Safe – Stay Safe

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: Review & Introduce Today’s Lesson / Y / N / Y / N
B: Abstinence and Safer Sex Review / Y / N / Y / N
C: Talk to Your Partner / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 15: Becoming Part of ABAN

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: Review Lesson 14 Activity “He Said, She Said” & Special Assignment “Play Safe – Stay Safe” / Y / N / Y / N
B: From Hand to Heart / 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:

V2.12Evaluation Packet Page 1