EVALUATION PACKET FOR ABAN AYA YOUTH PROJECT GRADE 5

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 5

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 5

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 to the Aban Aya Youth Project

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 & Brief Introduction to the Aban Aya Youth project / Y / N / Y / N
B: Introduction to the Aban Aya Goals / Y / N / Y / N
C: Introduction to Ground Rules / Y / N / Y / N
D: Music Videotape: African-American Images / Y / N / Y / N
E: Wrap-up and Explanation of Special Assignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson2: Know Thyself/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: Preview of Today’s Lesson & Review of Previous Lesson / Y / N / Y / N
B: Explanation of the Role of the Proverb / Y / N / Y / N
C: Class Discussion About Strengths and Responsibilities Within Self, Family & Community / Y / N / Y / N
D: Activity: All My Friends / Y / N / Y / N
E: Rap Song (See Section E on Page 27 for Song Used in the Original Implementation of Aban Aya) / Y / N / Y / N
F: Wrap-up/Special Assignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson3: History & Culture (Being Proud of Who You Are)

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: Preview of Today’s Lesson; Collect Special Assignment: Who am I? & Review Special Assignment: Interview About Me!!; Review Previous Lesson and Proverb / Y / N / Y / N
B: Discussion On Strengths & Responsibilities Within African-American History & Culture / Y / N / Y / N
C: Activity: Stand Up and Be Proud / Y / N / Y / N
D: Discussion On Strengths & Responsibilities Within African History/Culture / Y / N / Y / N
E: Wrap-Up/Special Assignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson4: Connectedness

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: Preview of Today’s Lesson; Review of Special Assignments: “Who am I?” & “Facts to be Proud Of;” Review Proverb / Y / N / Y / N
B: Class Discussion About Ancestors, Role Models and Mentors / Y / N / Y / N
C: Activity: Ancestors/Role Models/Mentors / Y / N / Y / N
D: Wrap-up/Special Assignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson5: Values Identification & Goal Setting

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: Preview of Today’s Lesson; Review of Special Assignment / Y / N / Y / N
B: Introduction of Values & Activity / Y / N / Y / N
C: Storytelling / Y / N / Y / N
D: Class Discussion & Activity: Goal-setting / Y / N / Y / N
E: Wrap-up/Special Assignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson6: The Talking Circle

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: Preview of Today’s Lesson; Review of previous Lesson & Special Assignment: Writing My Goals / Y / N / Y / N
B: Affirmation Activity: “I Believe in Me” / Y / N / Y / N
C: Aban Aya Quiz Lessons 1-5 / Y / N / Y / N
D: Talking Circle Activity / Y / N / Y / N
E: Wrap-up/Special Assignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson7: UJIMA Groups

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: Preview of Today’s Lesson; Review of Quiz & Special Assignment / Y / N / Y / N
B: Introduction of Lesson Proverb / Y / N / Y / N
C: Ujima Group Assignment and Formation / Y / N / Y / N
D: Ujima Group Responsibilities / Y / N / Y / N
E: Ujima Group Activity: Name That Group / Y / N / Y / N
F: Wrap-Up/Special Assignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson8: Introduction to Decision Making

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: Preview of Today’s Lesson/ Introduction to Decision-making and Influences to Decision-making / Y / N / Y / N
B: “Check Yourself” model / Y / N / Y / N
C: STOP Step: A Matter of Time / Y / N / Y / N
D: Calm Down / Y / N / Y / N
E: Wrap-up and Special Assignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 9: Think: Check Yourself Before You Wreck Yourself

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: Preview of Today’s Lesson; Review Previous Lesson & Special Assignment / Y / N / Y / N
B: Ujima groups: THINK “What Are My Choices?” / Y / N / Y / N
C: Ujima groups: THINK “What Are The Consequences?” / Y / N / Y / N
D: Influences / Y / N / Y / N
E: Wrap-up/Special Assignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 10: ACT Step & Introduction to the ABAN AYA Safety 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: Preview of Today’s Lesson; Review Previous Lesson & Special Assignment / Y / N / Y / N
B: Introduction to ACT Step and Refusal skills / Y / N / Y / N
C: Role Playing: Refusal Skills / Y / N / Y / N
D: Wrap-up/Special Assignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 11: Role Playing—Decision Making & ABAN AYA Safety 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: Preview of Today’s Lesson; Review Previous Lesson & Special Assignment / Y / N / Y / N
B: Assertiveness & One Liners: Give Us Your Best Shot Activity / Y / N / Y / N
C: Role Playing: Refusal Skills / Y / N / Y / N
D: Wrap-up and Special Assignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 12: Stress & How to Cope/Calm Down

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: Preview of Today’s Lesson; Review of Special Assignment / Y / N / Y / N
B: Introduce Quote / Y / N / Y / N
C: Introduction to Stress & Signs & Symptoms of Stress / Y / N / Y / N
D: Introduction to Coping & Review Deep Breathing & Affirmation; Introduce Imaging Practice Skills / Y / N / Y / N
E: Wrap-up & Special Assignment: Calming Down Log / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 13: Past Experiences & Coping With Feelings

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: Preview of Today’s Lesson; Review of Previous Lesson & Special Assignment / Y / N / Y / N
B: Class Discussion: Recognizing and Claiming Feelings / Y / N / Y / N
C: Talking Circle Activity: Exploring Our Past Experiences & Feelings / Y / N / Y / N
D: Coping With Feelings From Past Experiences / Y / N / Y / N
E: Batman Story-telling Activity / Y / N / Y / N
F: Practice Calming Down Skills / Y / N / Y / N
G: Wrap-up & Explanation of Special Asssignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 14: Stop the Violence

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: Preview Today’s Lesson, Review Previous Lesson & Review Special Assignment / Y / N / Y / N
B: Quiz #2 / Y / N / Y / N
C: Introduce Today’s Quote & Violence / Y / N / Y / N
D: Agree/Disagree Activity: The Facts About Violence / Y / N / Y / N
E: Wrap-up/Special Assignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 15: Getting Along

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: Preview of Lesson/Review Quiz #2/Special Assignment/Previous Lesson / Y / N / Y / N
B: UJIMA GROUPS: How Our Decisions About Conflict Impact on Others / Y / N / Y / N
C: Talk Time: Experience of Resolving Conflict / Y / N / Y / N
D: Wrap-up/Special Assignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 16: Handling Conflict—Let’s Work it Out

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: Preview of Today’s Lesson/Review Special Assignment/Previous Lesson / Y / N / Y / N
B: Introduce Today’s Quote / Y / N / Y / N
C: Introduce Steps of Conflict Resolution / Y / N / Y / N
D: Mini Role Play / Y / N / Y / N
E: Wrap-up/Special Assignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 17: Working It Out

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: Preview of Today’s Lesson/Review Special Assignment & Previous Lesson / Y / N / Y / N
B: Proverb and Role Play Activity: Working it Out / Y / N / Y / N
C: Ujima Group Activity: Working Out Daily Hassles / Y / N / Y / N
D: Wrap-up/Special Assignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 18: Healthy Relationships with Friends, Family & Others

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: Preview of Today’s Lesson; Review Previous Lesson & Special Assignment / Y / N / Y / N
B: Introduce Today’s Proverb & Lesson / Y / N / Y / N
C: Qualities of a Good Friend: Ujima Group Activity / Y / N / Y / N
D: Changes in Relationships: What’s Puberty Got to do With It? / Y / N / Y / N
E: Wrap-up & Special Assignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 19: Spending Time with Friends Should Be Fun