Session 1: Ethnic/Gender Pride
Facilitator 1: / ______/ Facilitator 2: / ______Date Session Presented: / ______/ Today’s Date: / ______
Time Started: / ______/ Time Ended: / ______
Number of Participants
in Attendance: / ______/ Location: / ______
Incentive Provided: / ______
Session Notes / Session Activities: Check one box for
each activity
Describe here reasons for eliminating, adding, or modifying activities, and suggested changes: / Activity 1.1 Opening Poem
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity 1.5 Personal Values
q Taught as suggested
q Taught with changes
q Did not teach
Remarks:
Activity 1.2 Introduction
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity 1.6 Homework
q Assigned as suggested
q Assigned with changes
q Did not assign
Remarks:
Activity 1.3 Development of Ground Rules
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity 1.7 Evaluation
q Administered
q Did not administer
Remarks:
Activity 1.4 Gender &
Ethnic Pride
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity 1.8 Closure
q Taught as suggested
q Taught with changes
q Did not teach
Remarks:
Session 2: HIV/AIDS Education
Facilitator 1: / ______/ Facilitator 2: / ______Date Session Presented: / ______/ Today’s Date: / ______
Time Started: / ______/ Time Ended: / ______
Number of Participants
in Attendance: / ______/ Location: / ______
Incentive Provided: / ______
Session Notes / Session Activities: Check one box for each activity
Describe here reasons for eliminating, adding, or modifying activities, and suggested changes: / Activity 2.1 Opening Poem
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity 2.6 “It’s Like This” Video
q Taught as suggested
q Taught with changes
q Did not teach
Remarks:
Activity 2.2 Session 1 Review
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity 2.7 Guided Discussion
q Taught as suggested
q Taught with changes
q Did not teach
Remarks:
Activity 2.3 Current Statistics
on AIDS
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity 2.8 Homework
q Assigned as suggested
q Assigned with changes
q Did not assign
Remarks:
Activity 2.4 HIV/AIDS 101
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity 2.9 Evaluation
q Administered
q Did not administer
Remarks:
Activity 2.5 Card Swap Game
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity 2.10 Closure
q Taught as suggested
q Taught with changes
q Did not teach
Remarks:
Check each of the following activities conducted during this session:
q Discussion: Condom/barrier use (11.17)
q Information: HIV/AIDS transmission (8.01)
q Discussion: Sexual risk reduction (11.01)
q Distribution: Education materials (13.06)
q Discussion: Other (11.66)
Session 3: Assertiveness Skills Training
Facilitator 1: / ______/ Facilitator 2: / ______Date Session Presented: / ______/ Today’s Date: / ______
Time Started: / ______/ Time Ended: / ______
Number of Participants
in Attendance: / ______/ Location: / ______
Incentive Provided: / ______
Session Notes / Session Activities: Check one box for each activity
Describe here reasons for eliminating, adding, or modifying activities, and suggested changes: / Activity 3.1 Opening Poem
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity 3.6 Assertiveness
q Discussion
q Taught as suggested
q Taught with changes
q Did not teach
Remarks:
Activity 3.2 Session 2 Review
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity 3.7 Homework
q Assigned as suggested
q Assigned with changes
q Did not assign
Remarks:
Activity 3.3 Assertion vs. Aggression
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity 3.8 Evaluation
q Administered
q Did not administer
Remarks:
Activity 3.4 Sticky
Situations Vignettes
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity 3.9 Closure
q Taught as suggested
q Taught with changes
q Did not teach
Remarks:
Activity 3.5 SISTA’s
Assertiveness Model
q Taught as suggested
q Taught with changes
q Did not teach
Remarks:
Check each of the following activities conducted during this session:
q Discussion: Sexual risk reduction (11.01)
q Information: Negotiation/communication (8.14)
q Discussion: Negotiation/communication (11.18)
q Demonstration: Decision-making (9.04)
q Discussion: Decision-making (11.19)
q Discussion: Other (11.66)
Session 4: Behavioral Self-Management
Facilitator 1: / ______/ Facilitator 2: / ______
Date Session Presented: / ______/ Today’s Date: / ______
Time Started: / ______/ Time Ended: / ______
Number of Participants
in Attendance: / ______/ Location: / ______
Incentive Provided: / ______
Session Notes / Session Activities: Check one box for each activity
Describe here reasons for eliminating, adding, or modifying activities, and suggested changes: / Activity 4.1 Opening Poem
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity 4.6 Safer Sex Role-Play
q Taught as suggested
q Taught with changes
q Did not teach
Remarks:
Activity 4.2 Session 3 Review
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity 4.7 Peer Norms Discussion
q Taught as suggested
q Taught with changes
q Did not teach
Remarks:
Activity 4.3 Development of Ground Rules
q Taught as suggested
q Taught with changes
q Did not teach
Remarks / Activity 4.8 Homework
q Assigned as suggested
q Assigned with changes
q Did not assign
Remarks:
Activity 4.4 Condom Card
Line Up
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity 4.9 Evaluation
q Administered
q Did not administer
Remarks:
Activity 4.5 Gender &
Ethnic Pride
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity 4.10 Closure
q Taught as suggested
q Taught with changes
q Did not teach
Remarks:
Check each of the following activities conducted
during this session:
q Demonstration: Condom/barrier use (9.01)
q Practice: Negotiation and communication (10.03)
q Practice: Condom/barrier use (10.01)
q Discussion: Sexual risk reduction (11.01)
q Practice: Decision-making (10.04)
Session 5: Coping Skills
Facilitator 1: / ______/ Facilitator 2: / ______Date Session Presented: / ______/ Today’s Date: / ______
Time Started: / ______/ Time Ended: / ______
Number of Participants
in Attendance: / ______/ Location: / ______
Incentive Provided: / ______
Session Notes / Session Activities: Check one box for each activity
Describe here reasons for eliminating, adding, or modifying activities, and suggested changes: / Activity 5.1 Opening Poem
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity 5.6 Safer Sex Role-Play
q Taught as suggested
q Taught with changes
q Did not teach
Remarks:
Activity 5.2 Session 4 Review
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity 5.7 Peer Norms Discussion
q Taught as suggested
q Taught with changes
q Did not teach
Remarks:
Activity 5.3 Development of Ground Rules
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity 5.8 Homework
q Assigned as suggested
q Assigned with changes
q Did not assign
Remarks:
Activity 5.4 Condom Card
Line Up
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity 5.9 Evaluation
q Administered
q Did not administer
Remarks:
Activity 5.5 Gender &
Ethnic Pride
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity 5.10 Closure
q Taught as suggested
q Taught with changes
q Did not teach
Remarks:
Check each of the following activities conducted during this session:
q Information: Sexual risk reduction (8.10)
q Discussion: Sexual risk reduction (11.01)
q Discussion: Negotiation/communication (11.18)
q Information: Decision-making (8.15)
q Discussion: Decision-making (11.19)
Session Booster 1
Facilitator 1: / ______/ Facilitator 2: / ______Date Session Presented: / ______/ Today’s Date: / ______
Time Started: / ______/ Time Ended: / ______
Number of Participants
in Attendance: / ______/ Location: / ______
Incentive Provided: / ______
Session Notes / Session Activities: Check one box for each activity
Describe here reasons for eliminating, adding, or modifying activities, and suggested changes: / Activity
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity
q Taught as suggested
q Taught with changes
q Did not teach
Remarks:
Activity
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity
q Taught as suggested
q Taught with changes
q Did not teach
Remarks:
Activity
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity
q Assigned as suggested
q Assigned with changes
q Did not assign
Remarks:
Activity
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity
q Administered
q Did not administer
Remarks:
Activity
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity
q Taught as suggested
q Taught with changes
q Did not teach
Remarks:
Session Notes / Session Activities: Check one box for
each activity
Describe here reasons for eliminating, adding, or modifying activities, and suggested changes (continued): / Check each of the following activities conducted during
this session:
q Postintervention booster session
q Information: Sexual risk reduction
q Demonstration: Negotiation and communication
q Practice: Negotiation and communication
q Demonstration: Decision-making
q Practice: Decision-making
q Demonstration: Condom use
q Practice: Condom use
Session Booster 2
Facilitator 1: / ______/ Facilitator 2: / ______Date Session Presented: / ______/ Today’s Date: / ______
Time Started: / ______/ Time Ended: / ______
Number of Participants
in Attendance: / ______/ Location: / ______
Incentive Provided: / ______
Session Notes / Session Activities: Check one box for each activity
Describe here reasons for eliminating, adding, or modifying activities, and suggested changes: / Activity
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity
q Taught as suggested
q Taught with changes
q Did not teach
Remarks:
Activity
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity
q Taught as suggested
q Taught with changes
q Did not teach
Remarks:
Activity
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity
q Assigned as suggested
q Assigned with changes
q Did not assign
Remarks:
Activity
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity
q Administered
q Did not administer
Remarks:
Activity
q Taught as suggested
q Taught with changes
q Did not teach
Remarks: / Activity
q Taught as suggested
q Taught with changes
q Did not teach
Remarks:
Session Notes / Session Activities: Check one box for each activity
Describe here reasons for eliminating, adding, or modifying activities, and suggested changes (continued): / Check each of the following activities conducted during this session:
q Postintervention booster session
q Information: Sexual risk reduction
q Demonstration: Negotiation and communication
q Practice: Negotiation and communication
q Demonstration: Decision-making
q Practice: Decision-making
q Demonstration: Condom use
q Practice: Condom use
C-1
C-1
B-1
B-1
B-1
C–2
C–2
C–3
C-1
C-1
C–3
1
SISTA Evaluation Field Guide September 2008