Fidelity Monitoring Forms

Making Proud Choices

Fidelity Monitoring Form

Program Facilitator(s):______

Location: ______

BLDG/Room Number: ______

Date Entry Survey Collected: ______

Date Exit Survey Collected: ______

MPC Program Fidelity Monitoring Purpose

This form is to help you keep track of how you use the eight lessons of the Making Proud Choices (MPC) curriculum. Keeping track as you are using Making Proud Choices can help you see what things are working well and what things you might want to improve when you use Making Proud Choices in the future.

MPC Program Fidelity Monitoring Instructions

·  There is one form for each of the 8 lessons in Making Proud Choices. Try to fill out the form right after you teach a lesson (or part of a lesson).

·  If you use a lesson over more than 1 day (for example, if you have to break a lesson into two parts because of a short class period), start filling out the form on the first day that lesson was used. You can add to that form each day that you teach part of that lesson.

·  If you make changes to what was taught (knowledge, attitudes, values, norms, skills) or the activities used for the lesson, in addition to filling out this form, be sure to report those changes immediately at this website: http://www.surveymonkey.com/s/CGKN5WB

·  If you add extra information or activities, make a note about what was included and why you added it.

Is this cohort comprised of 50% of any ONE of the following?
Target Population / Youth in foster care / □
Homeless or runaway youth / □
Youth living with HIV/AIDS / □
Pregnant or Parenting youth / □
Hispanic / Latino youth / □
African American youth / □
Native American youth / □
LGBTQ youth / □
Youth in adjudication systems / □
Male youth / □
Youth in high-need geographic areas / □
Out of school /dropout youth / □
In residential treatment for mental health issues / □

Lesson 1: Getting to Know You and Steps to Making Your Dreams Come True

1) Date(s) Lesson 1 was taught: ______Time:______

2) How many students attended? ______

3) How long did the lesson take? ______hrs

4) How many days was Lesson 1 taught to this group?

1 day 2 days 3 or more days Zero Days (lesson not covered)

Did you refer any students to additional services? Y/N # ______

5) Were any changes made to WHAT core content was taught in Lesson 1?

Core CONTENT means WHAT is being taught in a curriculum — the knowledge, attitudes, values, norms, skills, etc., that are likely to influence and change sexual behaviors.

Did you teach all of the core content in Lesson 1? / Describe any changes made and reasons for changing or leaving out content /
1.  Youth can make proud and responsible choices
(BEHAVORAL BELIEF) / Yes
No
Not sure
Date(s) taught:
2.  Positive attitudes about safer sex (ATTITUDE) / Yes
No
Not sure
Date(s) taught:
3.  Youth can reach goals and dreams (BEHAVORAL BELIEF) / Yes
No
Not sure
Date(s) taught:
4.  How to protect yourself from pregnancy (KNOWLEDGE) / Yes
No
Not sure
Date(s) taught:

6) Did you add any content to Lesson 1?

Yes (if yes, please describe below)

No

7) What activities were used in Lesson 1?

Did you use each of these activities in Lesson 1? / Describe any changes made and reasons for changing or leaving out activities /
1.  Welcome and Program Overview / Used as described
Used with changes
Did not use
Date(s) used:
2.  Talking Circle / Used as described
Used with changes
Did not use
Date(s) used:
3.  Creating Ground Rules / Used as described
Used with changes
Did not use
Date(s) used:
4.  Making Proud Choices: Be Proud, Be Responsible Brainstorm / Used as described
Used with changes
Did not use
Date(s) used:
5.  Brainstorming About Teens and Sex / Used as described
Used with changes
Did not use
Date(s) used:
6.  Goals and Dreams Timeline / Used as described
Used with changes
Did not use
Date(s) used:
7.  Brainstorming Obstacles to Your Goals and Dreams / Used as described
Used with changes
Did not use
Date(s) used:

8) Did you add any activities to Lesson 1?

Yes (if yes, please describe below)

No

Lesson 2: The Consequences of Sex: HIV Infection

1) Date(s) Lesson 2 was taught: ______Time:______

2) How many students attended? ______

3) How long did the lesson take? ______hrs

4) How many days was Lesson 2 taught to this group?

1 day 2 days 3 or more days Zero Days (lesson not covered)

Did you refer any students to additional services? Y/N # ______

5) Were any changes made to WHAT core content was taught in Lesson 2?

Core CONTENT means WHAT is being taught in a curriculum — the knowledge, attitudes, values, norms, skills, etc., that are likely to influence and change sexual behaviors.

Did you teach all of the core content in Lesson 2? / Describe any changes made and reasons for changing or leaving out content /
1.  KNOWLEDGE – about HIV definitions, transmission, prevention / Yes
No
Not sure
Date(s) taught:
2.  BEHAVIORAL BELIEFS – that sexual involvement might interfere with goals and dreams for education and career / Yes
No
Not sure
Date(s) taught:
3.  BEHAVIORAL BELIEFS –that condoms can reduce the risk of HIV, STDs and pregnancy; that the proud and responsible thing to do is use a condom / Yes
No
Not sure
Date(s) taught:
4.  PERCEPTION OF RISK – learning about HIV can help you assess your risk / Yes
No
Not sure
Date(s) taught:

6) Did you add any content to Lesson 2?

Yes (if yes, please describe below)

No

7) What activities were used in Lesson 2?

Did you use each of these activities in Lesson 2? / Describe any changes made and reasons for changing or leaving out activities /
1.  Discussing HIV and AIDS / Used as described
Used with changes
Did not use
Date(s) used:
2.  ”The Subject is HIV” – Video and Discussion / Used as described
Used with changes
Did not use
Date(s) used:
3.  Myths and Facts about HIV/AIDS / Used as described
Used with changes
Did not use
Date(s) used:
4.  HIV Risk Continuum / Used as described
Used with changes
Did not use
Date(s) used:

8) Did you add any activities to Lesson 2?

Yes (if yes, please describe below)

No

Lesson 3: Attitudes and Beliefs about HIV/AIDS and Condom Use

1) Date(s) Lesson 3 was taught: ______Time:______

2) How many students attended? ______

3) How long did the lesson take? ______hrs

4) How many days was Lesson 3 taught to this group?

1 day 2 days 3 or more days Zero Days (lesson not covered)

Did you refer any students to additional services? Y/N # ______

5) Were any changes made to WHAT core content was taught in Lesson 3?

Core CONTENT means WHAT is being taught in a curriculum — the knowledge, attitudes, values, norms, skills, etc., that are likely to influence and change sexual behaviors.

Did you teach all of the core content in Lesson 3? / Describe any changes made and reasons for changing or leaving out content /
1.  KNOWLEDGE – about HIV definitions, transmission, prevention / Yes
No
Not sure
Date(s) taught:
2.  KNOWLEDGE – about talking to a partner about condom use / Yes
No
Not sure
Date(s) taught:
3.  PERCEPTION OF RISK – learning about HIV can help you assess your risk / Yes
No
Not sure
Date(s) taught:
4.  BEHAVIORAL BELIEFS – that condoms can reduce the risk of HIV, STDs and pregnancy; that the proud and responsible thing to do is use a condom / Yes
No
Not sure
Date(s) taught:
5.  SKILL – talking about condom use with a partner / Yes
No
Not sure
Date(s) taught:

6) Did you add any content to Lesson 3?

Yes (if yes, please describe below)

No

7) What activities were used in Lesson 3?

Did you use each of these activities in Lesson 3? / Describe any changes made and reasons for changing or leaving out activities /
1.  “AIDS, Not Us” Video and Discussion / Used as described
Used with changes
Did not use
Date(s) used:
2.  Tell It to Tanisha / Used as described
Used with changes
Did not use
Date(s) used:

8) Did you add any activities to Lesson 3?

Yes (if yes, please describe below)

No

Lesson 4: Strategies for Preventing HIV Infection: Stop, Think and Act

1) Date(s) Lesson 4 was taught: ______Time:______

2) How many students attended? ______

3) How long did the lesson take? ______hrs

4) How many days was Lesson 4 taught to this group?

1 day 2 days 3 or more days Zero Days (lesson not covered)

Did you refer any students to additional services? Y/N # ______

5) Were any changes made to WHAT core content was taught in Lesson 4?

Core CONTENT means WHAT is being taught in a curriculum — the knowledge, attitudes, values, norms, skills, etc., that are likely to influence and change sexual behaviors.

Did you teach all of the core content in Lesson 4? / Describe any changes made and reasons for changing or leaving out content /
1.  KNOWLEDGE – about the problem-solving framework called STOP, THINK and ACT, or similar problem-solving framework / Yes
No
Not sure
Date(s) taught:
2.  KNOWLEDGE - about the importance of using a condom for protection / Yes
No
Not sure
Date(s) taught:
3.  KNOWLEDGE - about HIV/AIDS / Yes
No
Not sure
Date(s) taught:
4.  SELF-EFFICACY – to use problem-solving framework for reducing sexual risk and having safer sex / Yes
No
Not sure
Date(s) taught:
5.  BEHAVIORAL BELIEF - that condoms can reduce the risk of HIV, STDs and pregnancy; that the proud and responsible thing to do is use a condom / Yes
No
Not sure
Date(s) taught:
6.  PERCEPTION OF RISK – learning about HIV can help you assess your risk / Yes
No
Not sure
Date(s) taught:

6) Did you add any content to Lesson 4?

Yes (if yes, please describe below)

No

7) What activities were used in Lesson 4?

Did you use each of these activities in Lesson 4? / Describe any changes made and reasons for changing or leaving out activities /
1.  STOP, THINK and ACT: Introduction to Problem Solving / Used as described
Used with changes
Did not use
Date(s) used:
2.  Jasmine and Derrick Case Study: Problem Solving using STOP, THINK and ACT / Used as described
Used with changes
Did not use
Date(s) used:
3.  “Robert Townsend and His Partners in Crime” – Video and Discussion / Used as described
Used with changes
Did not use
Date(s) used:
4.  “Nicole” - video and Discussion / Used as described
Used with changes
Did not use
Date(s) used:
5.  “Jesse” – Video and Discussion / Used as described
Used with changes
Did not use
Date(s) used:
6.  AIDS Basketball / Used as described
Used with changes
Did not use
Date(s) used:

8) Did you add any activities to Lesson 4?

Yes (if yes, please describe below)

No

Lesson 5: The Consequences of Sex: STDs & Correct Condom Use

1) Date(s) Lesson 5 was taught: ______Time:______

2) How many students attended? ______

3) How long did the lesson take? ______hrs

4) How many days was Lesson 5 taught to this group?

1 day 2 days 3 or more days Zero Days (lesson not covered)

Did you refer any students to additional services? Y/N # ______

5) Were any changes made to WHAT core content was taught in Lesson 5?

Core CONTENT means WHAT is being taught in a curriculum — the knowledge, attitudes, values, norms, skills, etc., that are likely to influence and change sexual behaviors.

Did you teach all of the core content in Lesson 5? / Describe any changes made and reasons for changing or leaving out content /
1.  KNOWLEDGE – about transmission, symptoms, prevention and testing / Yes
No
Not sure
Date(s) taught:
2.  BEHAVIORAL BELIEF – that condoms can reduce the risk of HIV, STDs and pregnancy; that the proud and responsible thing to do is use a condom / Yes
No
Not sure
Date(s) taught:
3.  BEHAVIORAL BELIEF – that a partner will approve of condom use and react positively to it / Yes
No
Not sure
Date(s) taught:
4.  PERCEPTION OF RISK – learning about HIV can help you assess your risk / Yes
No
Not sure
Date(s) taught:
5.  ATTITUDE – positive attitude about condom use / Yes
No
Not sure
Date(s) taught:
6.  SKILL – how to use condoms correctly / Yes
No
Not sure
Date(s) taught:

6) Did you add any content to Lesson 5?

Yes (if yes, please describe below)

No

7) What activities were used in Lesson 5?

Did you use each of these activities in Lesson 5? / Describe any changes made and reasons for changing or leaving out activities /
1.  STD Facts and “The Truth about Sex” Video / Used as described
Used with changes
Did not use
Date(s) used:
2.  The Transmission Game / Used as described
Used with changes
Did not use
Date(s) used:
3.  What I Think about HIV/AIDS and Safer Sex – Forced Choice / Used as described
Used with changes
Did not use
Date(s) used:
4.  Condom Use Skills / Used as described
Used with changes
Did not use
Date(s) used:

8) Did you add any activities to Lesson 5?