Performance Reporting System Data Entry Form

Instrument #3
performance reporting system data entry form

*Note. This instrument is almost identical to an instrument approved in the last ICR, which was approved on Marcy 12, 2013 (OMB Control # 0970-0398). The changes that were made were minimal. See Supporting Statement A for more information regarding the specific changes.

Measures of Demographics, Behaviors, Intentions, Perceived Effects

Collected at Program Entry

REPORT PERIOD	2013-2014
Grantee:	Enter grantee name
Program:	Enter program name

		Enter Count				Enter Count
Total Entry Surveys Completed:				Total Exempt from Sensitive Questions:
Age	Age 10			Gender	Male
	Age 11				Female
	Age 12
	Age 13			Orientation s	Straight
	Age 14				Gay or Lesbian
	Age 15				Bisexual
	Age 16				Transgender
	Age 17				Something Else/Not Decided
	Age 18				Missing
	Age 19				Total marked as LGBTQ
	Age 20
	Age 21 or older			Grade	Grade 4
					Grade 5
Hispanic	Yes - Mexican, Mexican American, Chicano/a				Grade 6
	Yes - Puerto Rican				Grade 7
	Yes - Cuban				Grade 8
	Yes - Another Hispanic, Latino/a or Spanish origin				Grade 9
	No				Grade 10
					Grade 11
Race	American Indian or Alaska Native				Grade 12
	Asian				School doesn’t assign grades
	Black or African American				Dropped out
	Native Hawaiian or Other Pacific Islander				Working toward GED
	White or Caucasian				HS grad, not enrolled in post-secondary
	Missing				HS grad, enrolled in post-secondary
(s) indicates a sensitive question.

Measures of Demographics, Behaviors, Intentions, Perceived Effects

Collected at Program Entry

REPORT PERIOD	2013-2014
Grantee:	Enter grantee name
Program:	Enter program name

	Enter Count
	All of the Time	Most of the Time	Some of the time	None of the time
Cared about doing well in school
Shared ideas or talked with a parent or guardian
Resisted or said no to peer pressure
Managed conflict without causing more conflict
	Definitely	Probably	Probably not	Definitely not
Intend to have intercourse in next 6 months s
	Yes	No
Ever had intercourse s
Ever been/gotten someone pregnant* s
* Report youth never having intercourse as “No”.
(s) indicates a sensitive question.

Measures of Demographics, Behaviors, Intentions, Perceived Effects

Collected at Program Entry

REPORT PERIOD	2013-2014
Grantee:	Enter grantee name
Program:	Enter program name

	Enter Count
	0	1	2	3+
How many times been/gotten someone pregnant* s
	0	1	2-3	4+
Number of people with whom had intercourse in past 3 months* s
	All of the time	Most of the time	Some of the time	None of the time
How often used birth control in past three months** s
How often used a condom in past three months** s
Knew how to manage stress
Managed money carefully
Had friendships that kept them out of trouble
Were respectful toward others
* Report youth never having intercourse as “0”.
* *Reported only for those who had intercourse within past three months. (s) indicates a sensitive question.

Measures of Demographics, Behaviors, Intentions, Perceived Effects

Collected at Program Exit

REPORT PERIOD	2013-2014
Grantee:	Enter grantee name
Program:	Enter program name

		Enter Count				Enter Count
Total Exit Surveys Completed:				Gender	Male
Age	Age 10				Female
	Age 11
	Age 12
	Age 13			Grade	Grade 4
	Age 14				Grade 5
	Age 15				Grade 6
	Age 16				Grade 7
	Age 17				Grade 8
	Age 18				Grade 9
	Age 19				Grade 10
	Age 20				Grade 11
	Age 21 or older				Grade 12
					School doesn’t assign grades
Hispanic	Yes - Mexican, Mexican American, Chicano/a				Dropped out
	Yes - Puerto Rican				Working toward GED
	Yes - Cuban				HS grad, not enrolled in post-secondary
	Yes - Another Hispanic, Latino/a or Spanish origin				HS grad, enrolled in post-secondary
	No
Race	American Indian or Alaska Native
	Asian
	Black or African American
	Native Hawaiian or Other Pacific Islander
	White or Caucasian
	Missing

Measures of Demographics, Behaviors, Intentions, Perceived Effects

Collected at Program Exit

REPORT PERIOD	2013-2014
Grantee:	Enter grantee name
Program:	Enter program name

	Enter Count
Enter the count of respondents who report the program made them more, or less, likely to exhibit the following adult behaviors or sexual activities.	Much more likely	Somewhat more likely	About the same	Somewhat less likely	Much less likely	Will Abstain
Resist or say no to peer pressure
Know how to manage stress
Manage conflict without causing more conflict
Form positive friendships that keep them out of trouble
Be respectful toward others
Make plans to reach goals
Care about doing well in school
Get a steady job after finishing school
Share ideas or talk with a parent or guardian
Make healthy decisions about drugs and alcohol
Get more education after high school
Manage money carefully
Be the best they can be
Have intercourse in the next 6 months
Use birth control in the next 6 months
Use a condom in the next 6 months
Abstain from sex in the next 6 months

Measures of Demographics, Behaviors, Intentions, Perceived Effects

Collected at Program Exit

REPORT PERIOD	2013-2014
Grantee:	Enter grantee name
Program:	Enter program name

	Enter Count
Enter the count of respondents who assessed their program experience according to the scale to the right.	All of the time	Most of the time	Some of the time	A little of the time	None of the time
Felt interested in program sessions and classes
Felt the material presented was clear
Found discussions or activities helped to learn program lessons
Felt respected as a person
Were picked on, teased, or bullied
Had a chance to ask questions about program topics and issues
Witnessed people being picked on, teased, or bullied because people thought they were LGBT
Witnessed people being picked on, teased, or bullied because of their race or ethnic background

Measures of Attendance, Reach, and Dosage

REPORT PERIOD	2013-2014
Grantee:	Enter grantee name
Program:	Enter program name

	Enter Count
m	Enter the number of youth during the 2013-2014program year who:
Program Setting	Attended at least one program session
	Attended a session in a school setting
	Attended a session in a community-based organization
	Attended a session in a clinic
	Attended a session in a foster care setting
	Attended a session in a juvenile detention center
	Attended a session in another setting
Reach	Mark an “X” in the cell for the program if more than 50% of youth were:
	In foster care
	Homeless or runaway
	Living with HIV/AIDS
	Pregnant or parenting
	LGBTQ
	In adjudication systems
	In residential treatment for mental health issues
	Have trouble speaking or understanding spoken English
Attendance	Enter the appropriate count below
	The number of youth completing at least 75% of scheduled program hours

Measures of Attendance, Reach, and Dosage

REPORT PERIOD			2013-2014
Grantee:			Enter grantee name
Program:			Enter program name
Enter a unique identifier for each cohort that received the program during this reporting period.	Did the cohort complete the program during the reporting period (Y/N)?	For those cohorts that completed the program during the reporting period, how many hours of programming, overall, were delivered?
Cohort-1
Cohort-2
Cohort-3
Cohort-4
Cohort-5
Cohort-6
Cohort-7
Cohort-8
Cohort-9
Cohort-10
Cohort-11
Cohort-12
Cohort-13
Cohort-14
Cohort-15
Cohort-16
Cohort-17
Cohort-18
Cohort-19
Cohort-20
Cohort-21
Cohort-22
Cohort-23
Cohort-24
Cohort-25

Measures of Implementation Challenges and Needs for Technical Assistance

REPORT PERIOD	2012-2013
Grantee:	Enter grantee name
Program:	Enter program name

Use the scale at the right to assess the implementation challenges below.	Not a Problem	Somewhat a problem	A serious problem
Recruiting youth
Keeping youth engaged
Getting youth to attend regularly
Recruiting qualified staff
Ensuring facilitators understand content
Covering program content
Staff turnover
Negative peer reactions
Youth behavioral problems
Natural disasters
Program facilities
Use the scale at the right to indicate if there is interest in receiving TA for the implementation factors below.	No Interested	Somewhat Interested	Very Interested
Recruiting youth
Keeping youth engaged in program sessions
Getting youth to attend regularly
Recruiting qualified staff
Training facilitators
Retaining staff
Minimizing negative peer reactions
Addressing youth behavioral issues
Other (please specify)

Measures of Structure, Cost, Support for Program Implementation

REPORT PERIOD	2012-2013
Grantee:	Enter grantee name
PREP Funding	Amt
Total PREP funding awarded for the 2012-2013program year	$
Funding allocated for PREP program services in the 2012-2013 federal grant year	$
Funding allocated for training, technical assistance, program monitoring, and evaluation activities in the 2012-2013 federal grant year	$
Funding retained for administrative purposes in the 2012-2013 federal grant year	$
Grantee Staffing	Count
Number of grantee staff administering PREP
Total grantee staff FTEs involved in administering PREP
Training and Quality Monitoring	(Y/N)
Grantee or its designee observed program delivery to monitor quality and/or fidelity
Grantee or its designee conducted training of PREP program facilitators)
Grantee or its designee provided technical assistance to support PREP program implementation

Measures of Structure, Cost, Support for Program Implementation

REPORT PERIOD	2012-2013
Grantee:	Enter grantee name
Program:	Enter program name
Did the grantee serve youth between October 2012 and September 2013?	Y/N
Number of PREP facilitators delivering program	Count
Number of PREP facilitators trained to deliver program	Count
Number of PREP facilitators observed exactly once	Count
Number of PREP facilitators observed exactly twice	Count
Number of PREP facilitators observed more than twice	Count
Non-PREP funding used to support the PREP program during the 2012-2013 federal grant year	$

Measures of Structure, Cost, Support for Program Implementation

REPORT PERIOD	2012-2013
Grantee:	Enter grantee name
Program:	Enter program name

Program Delivery
Core curriculum being delivered as part of PREP program model (if “other” please specify)	[pull-down menu]
Enter the number of intended program delivery hours	Count

Indicate which, if any, of the following youth groups are target populations for the program
Target Population	Youth in foster care	Y / N
	Homeless or runaway youth	Y / N
	Youth living with HIV/AIDS	Y / N
	Pregnant or Parenting youth	Y / N
	Hispanic / Latino youth	Y / N
	African American youth	Y / N
	Native American youth	Y / N
	Lesbian, gay, bisexual, transgendered, or questioning (LGBTQ) youth	Y / N
	Youth in adjudication systems	Y / N
	Male youth	Y / N
	Youth in high-need geographic areas	Y / N
	Out of school / dropout youth	Y / N
	In residential treatment for mental health issues	Y / N
Indicate which of the following adult preparation topics are covered by the program.
Adult Preparation Topics	Healthy Relationships	Y / N
	Adolescent Development	Y / N
	Financial Literacy	Y / N
	Parent Child Communication	Y / N
	Educational and Career Success	Y / N
	Healthy Life Skills	Y / N