Attachments AA-GG Student Program Fidelity 7th Grade Ses

Form Approved

OMB No. 0920-0941

Exp. Date: 6/30/2015

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (0920-0941).

Attachment AA:

Student Program Fidelity 7th Grade Session 1

Dating Matters: Strategies to Promote Healthy Teen Relationships™ Initiative

Division of Violence Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Student Curriculum – 7th Grade, Session 1 – Healthy Relationships

Attendance Log

Implementer Name: Last Name: _________________________ First Name______________________ Initial:___
Implementer Survey ID: _______________________________ School Number: ____________________________ Program Year: _______________________________________ Session Number: ___________________________ Grade: ________ Classroom Number: ________________________

Please have all students sign initials next to their names to indicate attendance to the session

Student Names (Typed) – Last, First, Initial	Student ID (pre-typed)	Student Initials for Present

Time Conversion Table

Military Time	Regular Time	Military Time	Regular Time
0100	1:00 AM	1300	1:00 PM
0200	2:00 AM	1400	2:00 PM
0300	3:00 AM	1500	3:00 PM
0400	4:00 AM	1600	4:00 PM
0500	5:00 AM	1700	5:00 PM
0600	6:00 AM	1800	6:00 PM
0700	7:00 AM	1900	7:00 PM
0800	8:00 AM	2000	8:00 PM
0900	9:00 AM	2100	9:00 PM
1000	10:00 AM	2200	10:00 PM
1100	11:00 AM	2300	11:00 PM
1200	Noon	0000 or 2400	Midnight

Student Curriculum – 7th Grade, Session 1 – Healthy Relationships

Implementer Name: Last Name: _________________________ First Name______________________ Initial:___

Implementer Survey ID: ___________________

School Number: ________________________ Session Number: ________________________

Grade: _______________________________ Classroom Number: ______________________

Program Year: ________________________ Time lesson began: ___________ (military time- i.e: table pg.2)

Survey Date: __________________________ Time lesson ended: ___________ (military time- i.e: table pg.2)

Please indicate if you completed the following:

	Yes	Yes w/ changes	No
Presented the Question of the Day			
Completed the Icebreaker activity, including introductions and responses to the question of the day			
Introduced the Dating Matters™ curriculum			
Explained that the purpose of the program is to explore ways to have healthy and safe relationships with others (including peers, friends, and dating partners)			
Stated that healthy relationship skills with friends and others will help students have healthy and happy relationships with the people they date, both now and in the future			
Distributed and explained Student Handbooks			
Collectively established ground rules			
Explained and made sure the two required rules were included in the ground rules: Respecting the privacy of others (confidentiality) The “no name” rule			
Discussed the consequences for breaking the rules			
Administered “Go-To Trusted Adults” activity			
Noted that if students have a question or concern about any type of relationship, they should talk to their implementer or one of their go-to trusted adults			
Made sure that students understood the purpose of trusted adults and had selected two “go-to” adults			
Lead class through brainstorming “ingredients” of a healthy friendship			
Administered “My Healthy Dating Relationship” activity			
Reinforced that although we have many different types of relationships, a lot of look for certain “ingredients” (qualities) in all types of relationships, such as healthy communication and trust.			
Emphasized that you do not have to be currently dating someone or have ever dated someone to think about how you want to be treated in a dating relationships			
Recapped Session 1			
Provided a preview for Session 2			

Please indicate if any of the following challenges interfered with your ability to implement the session. Check all that apply.

Not enough time.	
I did not have the needed materials.	
Students did not appear to understand the session.	
I was uncomfortable discussing some of the topics.	
Students were uncomfortable discussing some of the topics.	
Some part of the session was difficult for students (e.g., role plays)	
Other more pressing session demands.	
Other – please specify____________________________________	

Describe any changes you made to the session activities.

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please think about today’s session and tell us your answers to the following questions. Circle the number that shows your opinion about each question.

1. How engaged were the students in the session?

_________________________________________________________________________________________________

5

Fully Engaged

1

Not at all Engaged/Bored

2

3

Somewhat Engaged

4

2. Overall, how do you think the session went today, in terms of your implementation and the participation of students?

_________________________________________________________________________________________________

5

Excellent

1

Very Poor/ Horrible

2

Poor

3

Fair

4

Good

3. How well do you think the students understood the session material?

_________________________________________________________________________________________________

5

Excellent/

Complete Understanding

1

Did Not Understand

2

Poor

3

Fair

4

Good

4. How well did the session material fit into the allotted time period? (check the box for the statement that is most applicable for this session)

• Session was too packed; not enough time to complete all activities and discussions

• Session was somewhat packet; able to complete most but not all activities and discussions

• Session was timed perfectly; able to complete all activities and discussions

• Session ended before 50 minutes were up; not enough material was provided for the session

Form Approved

OMB No. 0920-0941

Exp. Date:6/30/2015

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (0920-0941).

Attachment BB:

Student Program Fidelity 7th Grade Session 2

Dating Matters: Strategies to Promote Healthy Teen Relationships™ Initiative

Division of Violence Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Student Curriculum – 7th Grade, Session 2 – Understanding Feelings

Attendance Log

Implementer Name: Last Name: _________________________ First Name______________________ Initial:___
Implementer Survey ID: _______________________________ School Number: ____________________________ Program Year: _______________________________________ Session Number: ___________________________ Grade: ________ Classroom Number: ________________________

Please have all students sign initials next to their names to indicate attendance to the session

Student Names (Pre-Typed) – Last, First, Initial	Student ID (pre-typed)	Student Initials for Present

Time Conversion Table

Military Time	Regular Time	Military Time	Regular Time
0100	1:00 AM	1300	1:00 PM
0200	2:00 AM	1400	2:00 PM
0300	3:00 AM	1500	3:00 PM
0400	4:00 AM	1600	4:00 PM
0500	5:00 AM	1700	5:00 PM
0600	6:00 AM	1800	6:00 PM
0700	7:00 AM	1900	7:00 PM
0800	8:00 AM	2000	8:00 PM
0900	9:00 AM	2100	9:00 PM
1000	10:00 AM	2200	10:00 PM
1100	11:00 AM	2300	11:00 PM
1200	Noon	0000 or 2400	Midnight

Student Curriculum – 7th Grade, Session 2 – Understanding Feelings

Implementer Name: Last Name: _________________________ First Name______________________ Initial:___

Implementer Survey ID: ___________________

School Number: ________________________ Session Number: ________________________

Grade: _______________________________ Classroom Number: ______________________

Program Year: ________________________ Time lesson began: ___________ (military time- i.e: table pg.2)

Survey Date: __________________________ Time lesson ended: ___________ (military time- i.e: table pg.2)

Please indicate if you completed the following:

	Yes	Yes w/ changes	No
Delivered the Question of the Day			
Briefly reviewed Session 1			
Provided an overview of Session 2			
Explained that naming feelings and finding healthy and safe ways to show them can improve our relationships with others			
Administered “Our Many Feelings” activity			
Emphasized that all feelings are important, and that it is normal and expected to experience a wide range of feeling			
Highlighted that sometimes uncomfortable feelings help us recognize when we are in danger or need help. These feelings might make us feel badly at the time, but in the long run can help keep us safe if we respond in a healthy way.			
Administered “How Would You Feel?” activity			
Emphasized that it is normal and expected to sometimes experience multiple feelings at the same time, such as feeling both excited and nervous			
Administered “Identifying Feelings in Ourselves” section			
Explained that our bodies send us clues about how we are feeling. These clues are either physiological (occurring inside our body) or body language (things that others can see or hear).			
Read and reviewed “Karl and Shaniqua’s Story”			
Emphasized that when feelings are out of control and we are not thinking clearly, it is much harder to act in a reasonable or healthy and safe way			
Reviewed “Staying in Control of Our Feelings: Introducing the Four Steps” Handout			
Presented step 1 – Notice what your body is telling you. Then, PAUSE! The earlier you notice the physical signs, the sooner you can begin to calm down your body and mind and stay in control			
Presented step 2 – Name your feeling Use your body clues to name your feeling, out loud or in your head			
Presented step 3 – Pick the best way to calm down (and do it!) What you choose to do may vary depending on the feeling and situation			
Presented step 4 – Check-in If you are not feeling calmer and thinking more clearly, you may need to try something else to calm down			
Recapped Session 2			
Provided a preview for Session 3			

Please indicate if any of the following challenges interfered with your ability to implement the session. Check all that apply.

Not enough time.	
I did not have the needed materials.	
Students did not appear to understand the session.	
I was uncomfortable discussing some of the topics.	
Students were uncomfortable discussing some of the topics.	
Some part of the session was difficult for students (e.g., role plays)	
Other more pressing session demands.	
Other – please specify____________________________________	

Describe any changes you made to the session activities.

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please think about today’s session and tell us your answers to the following questions. Circle the number that shows your opinion about each question.

7. How engaged were the students in the session?

_________________________________________________________________________________________________

5

Fully Engaged

1

Not at all Engaged/Bored

2

3

Somewhat Engaged

4

8. Overall, how do you think the session went today, in terms of your implementation and the participation of students?

_________________________________________________________________________________________________

5

Excellent

1

Very Poor/ Horrible

2

Poor

3

Fair

4

Good

3. How well do you think the students understood the session material?

_________________________________________________________________________________________________

5

Excellent/

Complete Understanding

1

Did Not Understand

2

Poor

3

Fair

4

Good

8. How well did the session material fit into the allotted time period? (check the box for the statement that is most applicable for this session)

• Session was too packed; not enough time to complete all activities and discussions

• Session was somewhat packet; able to complete most but not all activities and discussions

• Session was timed perfectly; able to complete all activities and discussions

• Session ended before 50 minutes were up; not enough material was provided for the session

Form Approved

OMB No. 0920-0941

Exp. Date: 6/30/2015

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (0920-0941).

Attachment CC:

Student Program Fidelity 7th Grade Session 3

Dating Matters: Strategies to Promote Healthy Teen Relationships™ Initiative

Division of Violence Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Student Curriculum – 7th Grade, Session 3 – Staying in Control of Feelings & Making Healthy Decisions

Attendance Log

Implementer Name: Last Name: _________________________ First Name______________________ Initial:___
Implementer Survey ID: _______________________________ School Number: ____________________________ Program Year: _______________________________________ Session Number: ___________________________ Grade: ________ Classroom Number: ________________________

Please have all students sign initials next to their names to indicate attendance to the session

Student Names (Pre-Typed) – Last, First, Initial	Student ID (pre-typed)	Student Initials for Present

Time Conversion Table

Military Time	Regular Time	Military Time	Regular Time
0100	1:00 AM	1300	1:00 PM
0200	2:00 AM	1400	2:00 PM
0300	3:00 AM	1500	3:00 PM
0400	4:00 AM	1600	4:00 PM
0500	5:00 AM	1700	5:00 PM
0600	6:00 AM	1800	6:00 PM
0700	7:00 AM	1900	7:00 PM
0800	8:00 AM	2000	8:00 PM
0900	9:00 AM	2100	9:00 PM
1000	10:00 AM	2200	10:00 PM
1100	11:00 AM	2300	11:00 PM
1200	Noon	0000 or 2400	Midnight

Student Curriculum – 7th Grade, Session 3 – Staying in Control of Feelings & Making Healthy Decisions

Implementer Name: Last Name: _________________________ First Name______________________ Initial:___

Implementer Survey ID: ___________________

School Number: ________________________ Session Number: ________________________

Grade: _______________________________ Classroom Number: ______________________

Program Year: ________________________ Time lesson began: ___________ (military time- i.e: table pg.2)

Survey Date: __________________________ Time lesson ended: ___________ (military time- i.e: table pg.2)

Please indicate if you completed the following:

	Yes	Yes w/ changes	No
Delivered the Question of the Day			
Briefly reviewed Session 2			
Provided an overview of Session 3			
Explained that there are two things that can help students make healthy, safe decisions: calming down before acting, and not assuming that we know exactly what others are doing (not believing myths or perceptions)			
Discussed the four ways to calm down			
Discussed the 4 ways to calm down			
Introduced the 1st way to calm down: Take deep breaths			
Lead class through deep breathing practice			
Introduced the 2nd way to calm down: Positive self-talk			
Differentiated between negative self-talk (making feelings more intense) and positive self-talk (helping calm us down)			
Administered “Negative Self-Talk  Positive Self-Talk” activity			
Introduced the 3rd way to calm down: Do something physically active or relaxing			
Introduced the 4th way to calm down: Talk to someone you trust			
Addressed the “Question of the Day,” including answering it and providing an explanation			
7. Administered “My Views” activity			
Emphasized that most middle school students are not using alcohol or other drugs or having sex			
Recapped Session 3			
Provided a preview for Session 4			

Please indicate if any of the following challenges interfered with your ability to implement the session. Check all that apply.

Not enough time.	
I did not have the needed materials.	
Students did not appear to understand the session.	
I was uncomfortable discussing some of the topics.	
Students were uncomfortable discussing some of the topics.	
Some part of the session was difficult for students (e.g., role plays)	
Other more pressing session demands.	
Other – please specify____________________________________	

Describe any changes you made to the session activities.

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please think about today’s session and tell us your answers to the following questions. Circle the number that shows your opinion about each question.

13. How engaged were the students in the session?

_________________________________________________________________________________________________

5

Fully Engaged

1

Not at all Engaged/Bored

2

3

Somewhat Engaged

4

14. Overall, how do you think the session went today, in terms of your implementation and the participation of students?

_________________________________________________________________________________________________

5

Excellent

1

Very Poor/ Horrible

2

Poor

3

Fair

4

Good

3. How well do you think the students understood the session material?

_________________________________________________________________________________________________

5

Excellent/

Complete Understanding

1

Did Not Understand

2

Poor

3

Fair

4

Good

12. How well did the session material fit into the allotted time period? (check the box for the statement that is most applicable for this session)

• Session was too packed; not enough time to complete all activities and discussions

• Session was somewhat packet; able to complete most but not all activities and discussions

• Session was timed perfectly; able to complete all activities and discussions

• Session ended before 50 minutes were up; not enough material was provided for the session

Form Approved

OMB No. 0920-0941

Exp. Date: 6/30/2015

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (0920-0941).

Attachment DD:

Student Program Fidelity 7th Grade Session 4

Dating Matters: Strategies to Promote Healthy Teen Relationships™ Initiative

Division of Violence Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Student Curriculum – 7th Grade, Session 4 – Healthy Communication

Attendance Log

Implementer Name: Last Name: _________________________ First Name______________________ Initial:___
Implementer Survey ID: _______________________________ School Number: ____________________________ Program Year: _______________________________________ Session Number: ___________________________ Grade: ________ Classroom Number: ________________________

Please have all students sign initials next to their names to indicate attendance to the session

Student Names (Pre-Typed) – Last, First, Initial	Student ID (pre-typed)	Student Initials for Present

Time Conversion Table

Military Time	Regular Time	Military Time	Regular Time
0100	1:00 AM	1300	1:00 PM
0200	2:00 AM	1400	2:00 PM
0300	3:00 AM	1500	3:00 PM
0400	4:00 AM	1600	4:00 PM
0500	5:00 AM	1700	5:00 PM
0600	6:00 AM	1800	6:00 PM
0700	7:00 AM	1900	7:00 PM
0800	8:00 AM	2000	8:00 PM
0900	9:00 AM	2100	9:00 PM
1000	10:00 AM	2200	10:00 PM
1100	11:00 AM	2300	11:00 PM
1200	Noon	0000 or 2400	Midnight

Student Curriculum – 7th Grade, Session 4 – Healthy Communication

Implementer Name: Last Name: _________________________ First Name______________________ Initial:___

Implementer Survey ID: ___________________

School Number: ________________________ Session Number: ________________________

Grade: _______________________________ Classroom Number: ______________________

Program Year: ________________________ Time lesson began: ___________ (military time- i.e: table pg.2)

Survey Date: __________________________ Time lesson ended: ___________ (military time- i.e: table pg.2)

Please indicate if you completed the following:

	Yes	Yes w/ changes	No
Delivered the Question of the Day			
Briefly reviewed Session 3			
Provided an overview of Session 4			
Explained that healthy communication means we feel heard, understood, and respected by the other person			
Explained that healthy communication, at the same time, also means that we must listen, understand, and respect what the other person is saying			
Administered “Silent Line-Up” activity			
Explained that there are two ways to communicate: nonverbally (the messages we send with our body and facial expression) and verbally (what we say and how we say it)			
Explained that healthy communication skills can help us have more positive conversations and avoid conflicts or problems with others, and can also help us when we are faced with a problem or conflict.			
Highlighted the fact that problems and conflicts with others cannot be avoided. However, if we choose our words and actions carefully, we can work through problems without hurting others.			
Delivered “Skills for Healthy Communication” section			
Reviewed “Skills for Healthy Communication”			
Reviewed Skill: Staying in Control of Feelings			
Reviewed Skill: Make eye contact			
Reviewed Skill: Watch facial expressions and gestures			
Reviewed Skill: Watch tone of voice			
Reviewed Skill: Active listening			
Administered activity, “I am Important!”			
Emphasized that our verbal and nonverbal communication should match, meaning that our facial expressions and body language should be consistent with what we are trying to say.			
Administered the “Communication Practice” activity			
a) Allowed several groups to perform in front of the class			
Recapped Session 4			
Previewed the concept of unhealthy and unsafe relationships in Session 5			

Please indicate if any of the following challenges interfered with your ability to implement the session. Check all that apply.

Not enough time.	
I did not have the needed materials.	
Students did not appear to understand the session.	
I was uncomfortable discussing some of the topics.	
Students were uncomfortable discussing some of the topics.	
Some part of the session was difficult for students (e.g., role plays)	
Other more pressing session demands.	
Other – please specify____________________________________	

Describe any changes you made to the session activities.

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please think about today’s session and tell us your answers to the following questions. Circle the number that shows your opinion about each question.

19. How engaged were the students in the session?

_________________________________________________________________________________________________

5

Fully Engaged

1

Not at all Engaged/Bored

2

3

Somewhat Engaged

4

20. Overall, how do you think the session went today, in terms of your implementation and the participation of students?

_________________________________________________________________________________________________

5

Excellent

1

Very Poor/ Horrible

2

Poor

3

Fair

4

Good

3. How well do you think the students understood the session material?

_________________________________________________________________________________________________

5

Excellent/

Complete Understanding

1

Did Not Understand

2

Poor

3

Fair

4

Good

16. How well did the session material fit into the allotted time period? (check the box for the statement that is most applicable for this session)

• Session was too packed; not enough time to complete all activities and discussions

• Session was somewhat packet; able to complete most but not all activities and discussions

• Session was timed perfectly; able to complete all activities and discussions

• Session ended before 50 minutes were up; not enough material was provided for the session

Form Approved

OMB No. 0920-0941

Exp. Date: 6/30/2015

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (0920-0941).

Attachment EE:

Student Program Fidelity 7th Grade Session 5

Dating Matters: Strategies to Promote Healthy Teen Relationships™ Initiative

Division of Violence Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Student Curriculum – 7th Grade, Session 5 – Unhealthy and Unsafe Relationships

Attendance Log

Implementer Name: Last Name: _________________________ First Name______________________ Initial:___
Implementer Survey ID: _______________________________ School Number: ____________________________ Program Year: _______________________________________ Session Number: ___________________________ Grade: ________ Classroom Number: ________________________

Please have all students sign initials next to their names to indicate attendance to the session

Student Names (Pre-Typed) – Last, First, Initial	Student ID (pre-typed)	Student Initials for Present

Time Conversion Table

Military Time	Regular Time	Military Time	Regular Time
0100	1:00 AM	1300	1:00 PM
0200	2:00 AM	1400	2:00 PM
0300	3:00 AM	1500	3:00 PM
0400	4:00 AM	1600	4:00 PM
0500	5:00 AM	1700	5:00 PM
0600	6:00 AM	1800	6:00 PM
0700	7:00 AM	1900	7:00 PM
0800	8:00 AM	2000	8:00 PM
0900	9:00 AM	2100	9:00 PM
1000	10:00 AM	2200	10:00 PM
1100	11:00 AM	2300	11:00 PM
1200	Noon	0000 or 2400	Midnight

Student Curriculum – 7th Grade, Session 5 – Unhealthy and Unsafe Relationships

Implementer Name: Last Name: _________________________ First Name______________________ Initial:___

Implementer Survey ID: ___________________

School Number: ________________________ Session Number: ________________________

Grade: _______________________________ Classroom Number: ______________________

Program Year: ________________________ Time lesson began: ___________ (military time- i.e: table pg.2)

Survey Date: __________________________ Time lesson ended: ___________ (military time- i.e: table pg.2)

Please indicate if you completed the following:

	Yes	Yes w/ changes	No
Delivered the Question of the Day			
Briefly reviewed Session 4			
Provided an overview of Session 5			
Lead class brainstorm of unhealthy relationship behaviors			
Provided prompts that elicited a broad range of unhealthy behaviors across multiple types of relationships:			
Explained that teen dating violence consists of situations that may cause physical, sexual, or emotional harm, and occurs when unhealthy relationship behaviors have crossed the line and are unsafe.			
Reviewed handout, “What is Teen Dating Violence?”			
6. Reviewed handout, “Teen Dating Violence: Example Behaviors”			
Emphasized that being the victim of teen dating violence is never someone’s fault. Everyone deserves to be in healthy, safe relationships.			
Administered “Teen Dating Violence: True or False” activity			
Emphasized that dating violence is a serious problem affecting all types of relationships, and all students are at risk for experiencing it			
Emphasized that if students or someone they know is using dating violence or is the victim of dating violence, they need to get help from a trusted adult.			
Administered “Red – Yellow – Green Light” activity			
Recapped Session 5			

Please indicate if any of the following challenges interfered with your ability to implement the session. Check all that apply.

Not enough time.	
I did not have the needed materials.	
Students did not appear to understand the session.	
I was uncomfortable discussing some of the topics.	
Students were uncomfortable discussing some of the topics.	
Some part of the session was difficult for students (e.g., role plays)	
Other more pressing session demands.	
Other – please specify____________________________________	

Describe any changes you made to the session activities.

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please think about today’s session and tell us your answers to the following questions. Circle the number that shows your opinion about each question.

25. How engaged were the students in the session?

_________________________________________________________________________________________________

5

Fully Engaged

1

Not at all Engaged/Bored

2

3

Somewhat Engaged

4

26. Overall, how do you think the session went today, in terms of your implementation and the participation of students?

_________________________________________________________________________________________________

5

Excellent

1

Very Poor/ Horrible

2

Poor

3

Fair

4

Good

3. How well do you think the students understood the session material?

_________________________________________________________________________________________________

5

Excellent/

Complete Understanding

1

Did Not Understand

2

Poor

3

Fair

4

Good

20. How well did the session material fit into the allotted time period? (check the box for the statement that is most applicable for this session)

• Session was too packed; not enough time to complete all activities and discussions

• Session was somewhat packet; able to complete most but not all activities and discussions

• Session was timed perfectly; able to complete all activities and discussions

• Session ended before 50 minutes were up; not enough material was provided for the session

Form Approved

OMB No. 0920-0941

Exp. Date: 6/30/2015

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (0920-0941).

Attachment FF:

Student Program Fidelity 7th Grade Session 6

Dating Matters: Strategies to Promote Healthy Teen Relationships™ Initiative

Division of Violence Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Student Curriculum – 7th Grade, Session 6 – Sexual Violence and Dating Safety

Attendance Log

Implementer Name: Last Name: _________________________ First Name______________________ Initial:___
Implementer Survey ID: _______________________________ School Number: ____________________________ Program Year: _______________________________________ Session Number: ___________________________ Grade: ________ Classroom Number: ________________________

Please have all students sign initials next to their names to indicate attendance to the session

Student Names (Pre-Typed) – Last, First, Initial	Student ID (pre-typed)	Student Initials for Present

Time Conversion Table

Military Time	Regular Time	Military Time	Regular Time
0100	1:00 AM	1300	1:00 PM
0200	2:00 AM	1400	2:00 PM
0300	3:00 AM	1500	3:00 PM
0400	4:00 AM	1600	4:00 PM
0500	5:00 AM	1700	5:00 PM
0600	6:00 AM	1800	6:00 PM
0700	7:00 AM	1900	7:00 PM
0800	8:00 AM	2000	8:00 PM
0900	9:00 AM	2100	9:00 PM
1000	10:00 AM	2200	10:00 PM
1100	11:00 AM	2300	11:00 PM
1200	Noon	0000 or 2400	Midnight

Student Curriculum – 7th Grade, Session 6 – Sexual Violence and Dating Safety

Implementer Name: Last Name: _________________________ First Name______________________ Initial:___

Implementer Survey ID: ___________________

School Number: ________________________ Session Number: ________________________

Grade: _______________________________ Classroom Number: ______________________

Program Year: ________________________ Time lesson began: ___________ (military time- i.e: table pg.2)

Survey Date: __________________________ Time lesson ended: ___________ (military time- i.e: table pg.2)

Please indicate if you completed the following:

	Yes	Yes w/ changes	No
Delivered the Question of the Day			
Briefly reviewed Session 5			
Provided a preview of Session 6			
Reviewed the Question of the Day			
Reviewed “Sexual Coercion” handout			
Explained that sexual coercion involves using pressure (like asking over and over again) or alcohol or drugs to get someone to do something sexual that he or she does not want to do			
Explained that sexual coercion is a form of sexual violence			
Delivered “Pressure Role-Play” activity			
Reviewed “4 Cs of Sexual Consent” handout			
Explained that, in a sexual situation, consent means that all people involved agree to and are comfortable engaging in a specific sexual behavior (e.g., touching, kissing, sex)			
Explained that, if someone gives consent to one behavior, it does not mean that he or she is willing to do anything else			
Explained that only “yes” means “yes”			
Explained that it is your right to decide when and if you engage in a specific sexual behavior, and it is your right to change your mind			
Delivered “Consent Check” activity			
Reviewed “Tips for Dating Safety” handout			
Explained that we do not always have control over what other people do. Sometimes people engage in unhealthy or unsafe behaviors (including physically forcing or pressuring someone into sexual activity). There are some things that students can do to help them stay safer or potentially avoid a situation that could turn unsafe.			
Delivered “Safe Move or Think Again” activity			
Recapped Session 6			
Provided a preview for Session 7			

Please indicate if any of the following challenges interfered with your ability to implement the session. Check all that apply.

Not enough time.	
I did not have the needed materials.	
Students did not appear to understand the session.	
I was uncomfortable discussing some of the topics.	
Students were uncomfortable discussing some of the topics.	
Some part of the session was difficult for students (e.g., role plays)	
Other more pressing session demands.	
Other – please specify____________________________________	

Describe any changes you made to the session activities.

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please think about today’s session and tell us your answers to the following questions. Circle the number that shows your opinion about each question.

31. How engaged were the students in the session?

_________________________________________________________________________________________________

5

Fully Engaged

1

Not at all Engaged/Bored

2

3

Somewhat Engaged

4

32. Overall, how do you think the session went today, in terms of your implementation and the participation of students?

_________________________________________________________________________________________________

5

Excellent

1

Very Poor/ Horrible

2

Poor

3

Fair

4

Good

3. How well do you think the students understood the session material?

_________________________________________________________________________________________________

5

Excellent/

Complete Understanding

1

Did Not Understand

2

Poor

3

Fair

4

Good

24. How well did the session material fit into the allotted time period? (check the box for the statement that is most applicable for this session)

• Session was too packed; not enough time to complete all activities and discussions

• Session was somewhat packet; able to complete most but not all activities and discussions

• Session was timed perfectly; able to complete all activities and discussions

• Session ended before 50 minutes were up; not enough material was provided for the session

Form Approved

OMB No. 0920-0941

Exp. Date: 6/30/2015

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (0920-0941).

Attachment GG:

Student Program Fidelity 7th Grade Session 7

Dating Matters: Strategies to Promote Healthy Teen Relationships™ Initiative

Division of Violence Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Student Curriculum – 7th Grade, Session 7 – Relationship Rights and Getting Help

Attendance Log

Implementer Name: Last Name: _________________________ First Name______________________ Initial:___
Implementer Survey ID: _______________________________ School Number: ____________________________ Program Year: _______________________________________ Session Number: ___________________________ Grade: ________ Classroom Number: ________________________

Please have all students sign initials next to their names to indicate attendance to the session

Student Names (Pre-Typed) – Last, First, Initial	Student ID (pre-typed)	Student Initials for Present

Time Conversion Table

Military Time	Regular Time	Military Time	Regular Time
0100	1:00 AM	1300	1:00 PM
0200	2:00 AM	1400	2:00 PM
0300	3:00 AM	1500	3:00 PM
0400	4:00 AM	1600	4:00 PM
0500	5:00 AM	1700	5:00 PM
0600	6:00 AM	1800	6:00 PM
0700	7:00 AM	1900	7:00 PM
0800	8:00 AM	2000	8:00 PM
0900	9:00 AM	2100	9:00 PM
1000	10:00 AM	2200	10:00 PM
1100	11:00 AM	2300	11:00 PM
1200	Noon	0000 or 2400	Midnight

Student Curriculum – 7th Grade, Session 7 – Relationship Rights and Getting Help

Implementer Name: Last Name: _________________________ First Name______________________ Initial:___

Implementer Survey ID: ___________________

School Number: ________________________ Session Number: ________________________

Grade: _______________________________ Classroom Number: ______________________

Program Year: ________________________ Time lesson began: ___________ (military time- i.e: table pg.2)

Survey Date: __________________________ Time lesson ended: ___________ (military time- i.e: table pg.2)

Please indicate if you completed the following:

	Yes	Yes w/ changes	No
Delivered the Question of the Day			
Briefly reviewed Session 5			
Provided an overview of Session 6			
Administered “RESPECT ME Rights” activity			
Explained that we all have rights in our relationships, and these rights outline how we have a right to be treated by others, and how others have a right to be treated by us. In the Dating Matters™ program, we call rights in dating relationships RESPECT ME rights.			
Lead discussion on why teens may not tell someone that they are being abused/hurt			
a) Emphasized that although it can be difficult to tell someone if you are being hurt by someone else, it is extremely important to tell someone.			
Reviewed resources			
Reviewed trusted adults, including school and community resources			
Reviewed national resources			
Emphasized that people at school and people within the community and national organizations can answer student questions about relationships and can help students who are being hurt by their dating partners.			
Allowed students to work individually or in groups to complete “RESPECT ME Rights Rewind” activity			
Allowed students to perform or present what they developed for the “RESPECT ME Rights Rewind” activity			
Recapped Session 6			
Allowed students to keep their Student Handbooks and encouraged them to review them regularly			
Delivered the Question of the Day			

Please indicate if any of the following challenges interfered with your ability to implement the session. Check all that apply.

Not enough time.	
I did not have the needed materials.	
Students did not appear to understand the session.	
I was uncomfortable discussing some of the topics.	
Students were uncomfortable discussing some of the topics.	
Some part of the session was difficult for students (e.g., role plays)	
Other more pressing session demands.	
Other – please specify____________________________________	

Describe any changes you made to the session activities.

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please think about today’s session and tell us your answers to the following questions. Circle the number that shows your opinion about each question.

37. How engaged were the students in the session?

_________________________________________________________________________________________________

5

Fully Engaged

1

Not at all Engaged/Bored

2

3

Somewhat Engaged

4

38. Overall, how do you think the session went today, in terms of your implementation and the participation of students?

_________________________________________________________________________________________________

5

Excellent

1

Very Poor/ Horrible

2

Poor

3

Fair

4

Good

3. How well do you think the students understood the session material?

_________________________________________________________________________________________________

5

Excellent/

Complete Understanding

1

Did Not Understand

2

Poor

3

Fair

4

Good

28. How well did the session material fit into the allotted time period? (check the box for the statement that is most applicable for this session)

• Session was too packed; not enough time to complete all activities and discussions

• Session was somewhat packet; able to complete most but not all activities and discussions

• Session was timed perfectly; able to complete all activities and discussions

• Session ended before 50 minutes were up; not enough material was provided for the session

Please reflect on your overall implementation of the program.

How much time (including preparation, supervision and implementation, but excluding travel time) did you spend on the Dating Matters for Students 7^th grade program over the past 12 months?

How much travel time and mileage did you spend on the Dating Matters for Students 7^th grade over the past 12 months?

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Author	Wendy LiKamWa
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File Created	2021-01-30