Instrument 4
Tier 1 C/D and Tier 2/PREIS performance measure reporting form
Does include measures on participant behaviors (sexual activity, contraceptive use, condom use) and intentions (intention to have sex, use contraception, or use condoms) OMB approval # 0970-0360.
Participant-level measures Form Approved
OMB No. 0990-
Exp. Date XX/XX/20XX
Please provide the data for the following variables collected from your evaluation for any of the following time points for which you have collected data:
Programs lasting 12 months or less:
Baseline
Follow-up 1 (immediately after the intervention)
Follow-up 2 (6 months after the intervention)
Follow-up 3 (12 months after the intervention)
Programs lasting 15 months or longer:
Baseline
Follow-up 1 (12-18 months after program start)
Follow-up 2 (24 months after program start)
Follow-up 3 (30-36 months after program start)
Variables:
Participant ID
Grantee name
Program type (e.g., TOP, Cuídate, etc.)
Date of data collection
Follow-up period (e.g., baseline, immediately after intervention, 6-months after intervention, etc.)
Demographic characteristics
Month of birth
Year of birth
Grade
Gender
Race
Ethnicity
Language spoken at home
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-XXXX . The time required to complete this information collection is estimated to average 20 hours 40 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Ever had sex
Ever been pregnant/gotten someone pregnant
# of times been pregnant/gotten someone pregnant
Any sex in past 3 months
# of times had sex in past 3 months
Had sex without a condom in past 3 months
# of times had sex without a condom in past 3 months
Had sex without birth control in past 3 months
# of times had sex without birth control in past 3 months
Intent to have sex in next year
Intent to use a condom in next year
Intent to use birth control in next year
Please upload data from your most recent collection of data about the perceived impact of the program for the following variables. (This may be from your evaluation data collection, or a separate data collection).
Participant ID
Grantee name
Program type (e.g., TOP, Cuídate, etc.)
Date of data collection
Demographic characteristics
Month of birth
Year of birth
Grade
Gender
Race
Ethnicity
Language spoken at home
Perceived impact of the program on sex
Perceived impact of the program on condom use
Perceived impact of the program on contraceptive use
Dissemination
How many manuscripts have you had accepted for publication in the past year (including both articles that were published and those that have been accepted but not yet published)? Do not include manuscripts previously reported as published. __
Please list the references for any published manuscripts published in the past year.
How many presentations have you made at each of the following levels in the past year:
National or regional? ___
Please list titles of all presentations and venue (e.g., conference or organization to which the presentation was made)
State? ____
Please list titles of all presentations and venue (e.g., conference or organization to which the presentation was made)
(Tier 2/PREIS grantees only): Please indicate which of the following have been completed and approved:
Logic model
Core components
Fidelity monitoring tools
Curriculum manual
Facilitator manual
Training materials
Adaptation Guidance
Retention
With how many organizations and/or schools do you have a formal agreement in place to assist with implementing your program? ___
With how many organizations or schools are you currently working that are assisting with intervention implementation? ___
How many organizations have been involved in planning and implementing your program, but not in a formal role? (Do not include organizations with which you have a formal agreement). ___
How many of the organizations or schools with which you had a formal agreement at the start of the program year remained engaged at the end of the program year? ___
In the past program year, how many new intervention facilitators (including teachers) have you or one of your partners trained? Please include only training provided to new facilitators. ___
In the past program year, how many intervention facilitators (including teachers) have you or one of your partners given follow-up training? ___
Dosage of services received by participants
What is the median % of program services received by youth? ___
What is the median % of program services received by parents (if applicable)? ___
What % of youth received at least 75% of the program? ___
What % of parents received at least 75% of the program? ___
Fidelity
In the past program year, what percentage of sessions were observed by an independent observer for fidelity assessment? ___
What is the median percentage of activities completed, across sessions observed? ___
What is the minimum and maximum percentage of activities completed, across sessions observed?
Minimum
Maximum
What percentage of sessions were rated either 4 or 5 for overall quality? ___
For what percentage of sessions completed do you have a completed fidelity monitoring log from the facilitator? ___
What is the median percentage of activities completed, across sessions for which you have a completed fidelity monitoring log? ___
Across cohorts, what is the median percentage of sessions implemented? ___
What is your score on the 24-point fidelity process scale? ___
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | ewilson |
File Modified | 0000-00-00 |
File Created | 2021-01-30 |