EVALUATION PACKET FOR PROJECT AIM- 40 MINUTE ADAPTATION

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

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

Evaluation Packet Cover Sheet

C  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.

C  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:

V2.12 Evaluation Packet Page 11

EVALUATION PACKET FOR PROJECT AIM- 40 MINUTE ADAPTATION

Did you use the correct forms? The most recent version of each form is posted on the website: www.actforyouth.net/capp-tools

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 range given 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 dates accurate for each module?

Was the site location indicated?

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

V2.12 Evaluation Packet Page 11

EVALUATION PACKET FOR PROJECT AIM- 40 MINUTE ADAPTATION

Questions? Contact Amanda Purington at or 607-255-1861
40 MINUTE ADAPTATION MASTER LIST

Attendance Record for One EBP Cycle Dates 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 / Interview Completed?
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
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 / Interview Completed?
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:______

Session 1: What Is A Legacy?

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
1A: Introduction / Y / N / See Below / Y / N
1B: Ice-breaker / Y / N / Y / N
1C: Group Agreements / Y / N / Y / N
1D: What is my Legacy? / Y / N / See Below / Y/ N
Please use this space if you have comments on this module or any of its activities:
Approved Adaptations:
Activity 1A: Shortened by 5 minutes, group introduction was dropped (as part of an existing class, youth know each other)
Activity 1D: Shortened by 5 minutes; responses kept short for poster activity

Session 2: Looking Ahead To My 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
2A: Web Chart – Positive and Negative Futures / Y / N / See Below / Y / N
2B: Practices for Self-Confidence / Y / N / See Below / Y / N
Please use this space if you have comments on this module or any of its activities:
Approved Adaptations:
Activity 2A: Shortened by 5 minutes; took responses from the first few volunteers
Activity 2B: Shortened by 5 minutes; responses from the first few volunteers only

Session 3: Guest Speakers

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
3A: Guest Speaker(s) & Note-Taking / Y / N / See Below / Y / N
Please use this space if you have comments on this module or any of its activities:
Approved Adaptations:
Activity 3A: Extended by 5 minutes; gave youth more time to ask guest speaker questions

Session 4: Guest Speakers Cont’d; What Lifts Me Up, What Holds Me Back?

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
3 B: Thank You Letters / Y / N / Y / N
4A: Color Block / Y / N / See Below / Y / N
Please use this space if you have comments on this module or any of its activities:
Approved Adaptations:
Activity 4A: Shortened by 5 minutes; got responses from those who volunteer to share-to-do task from Session 2 and kept responses brief (allow 2-3 minutes)

Session 5: What Lifts Me Up… Cont’d; Expressing Myself In My Future Career

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
4B: Influences in my Life / Y / N
5A: Career Puzzles / Y / N / See Below / Y / N
Please use this space if you have comments on this module or any of its activities:
Approved Adaptations:
Activity 5A: Extended activity by 20 minutes, gave youth more time to complete puzzle and discuss activity

Session 6: Expressing Myself in MY Future Career, cont’d

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
5B: Career Game Explorer / Y / N / See Below / Y / N
Please use this space if you have comments on this module or any of its activities:
Approved Adaptations:
Activity 5B: Extended by 10 minutes, gave more time for youth to complete the activity

Session 7: Module 6: Exploring My 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
6A: Making My Choice / Y / N / See Below / Y / N
6B: Career Aspiration & Discussion / Y / N / See Below / Y / N
Please use this space if you have comments on this module or any of its activities:
Approved Adaptations:
Activity 6A: Shortened by 5 minutes; kept responses from to-do task to a minimum
Activity 6B: Shortened by 5 minutes; discussion responses taken from first few volunteers only

Session 8: Module 7: What Does Today Have To Do With My 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
7A: My Personal Work Experience / Y / N / See Below / Y / N
7B: It’s My Resume / Y / N / See Below / Y / N
Please use this space if you have comments on this module or any of its activities:
Approved Adaptations:
Activity 7A: Shortened by 5 minutes; kept responses from to-do task to a minimum and accepted responses to question from first 2 volunteers
Activity 7B: Shortened by 5 minutes; kept responses to summarizing worksheet activity to a minimum

Session 9: Module 8: What Can I Do Now To Get There?

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
8A: What Can I do Now to Get There? / Y / N / See Below / Y / N
8B: Designing my Business Card / Y / N / See Below / Y / N
Please use this space if you have comments on this module or any of its activities:
Approved Adaptations:
Activity 8A: Shortened by 5 minutes; kept responses from to-do task to a minimum
Activity 8B: Shortened by 5 minutes; took responses from the first few volunteers

Session 10: Module 9: Expressing Myself In Communication And Relationships

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
9A: Peer Pressure / Y / N / See Below / Y / N
9B: Choosing my Style & Acting it Out / Y / N / See Below / Y / N
Please use this space if you have comments on this module or any of its activities:
Approved Adaptations:
Activity 9A: Brainstorm shortened by 5 minutes
Activity 9B: Shortened by 5 minutes; kept responses to questions short and accepted answer from only 1 volunteer for each question

Session 11: Module 10: Vacation Exploration

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
10A: My Dream Vacation / Y / N / See Below / Y / N
10B: Imagining my Future / Y / N / See Below / Y / N
Please use this space if you have comments on this module or any of its activities:
Approved Adaptations:
Activity 10A: Shortened by 5 minutes; gave youth 10 minutes to work together
Activity 10B: Shortened by 5 minutes; kept answers to discussion brief, accepted first volunteers’ response

Session 12: Extra Module: Teen Pregnancy Prevention CAPP AD Hoc Workshop