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 |
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Enter Count |
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Enter Count |
Total Entry Surveys Completed: |
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Total Exempt from Sensitive Questions: |
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Age |
Age 10 |
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Gender |
Male |
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Age 11 |
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Female |
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Age 12 |
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Age 13 |
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Orientation s |
Straight |
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Age 14 |
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Gay or Lesbian |
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Age 15 |
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Bisexual |
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Age 16 |
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Transgender |
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Age 17 |
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Something Else/Not Decided |
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Age 18 |
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Missing |
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Age 19 |
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Total marked as LGBTQ |
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Age 20 |
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Age 21 or older |
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Grade |
Grade 4 |
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Grade 5 |
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Hispanic |
Yes - Mexican, Mexican American, Chicano/a |
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Grade 6 |
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Yes - Puerto Rican |
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Grade 7 |
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Yes - Cuban |
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Grade 8 |
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Yes - Another Hispanic, Latino/a or Spanish origin |
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Grade 9 |
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No |
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Grade 10 |
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Grade 11 |
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Race |
American Indian or Alaska Native |
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Grade 12 |
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Asian |
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School doesn’t assign grades |
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Black or African American |
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Dropped out |
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Native Hawaiian or Other Pacific Islander |
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Working toward GED |
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White or Caucasian |
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HS grad, not enrolled in post-secondary |
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Missing |
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HS grad, enrolled in post-secondary |
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(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 |
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Enter Count |
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All of the Time |
Most of the Time |
Some of the time |
None of the time |
Cared about doing well in school |
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Shared ideas or talked with a parent or guardian |
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Resisted or said no to peer pressure |
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Managed conflict without causing more conflict |
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Definitely |
Probably |
Probably not |
Definitely not |
Intend to have intercourse in next 6 months s |
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Yes |
No |
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Ever had intercourse s |
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Ever been/gotten someone pregnant* s |
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* Report youth never having intercourse as “No”. |
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(s) indicates a sensitive question.
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Measures of Demographics, Behaviors, Intentions, Perceived Effects
Collected at Program Entry
REPORT PERIOD |
2013-2014 |
Grantee: |
Enter grantee name |
Program: |
Enter program name |
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Enter Count |
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0 |
1 |
2 |
3+ |
How many times been/gotten someone pregnant* s |
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0 |
1 |
2-3 |
4+ |
Number of people with whom had intercourse in past 3 months* s |
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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 |
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How often used a condom in past three months** s |
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Knew how to manage stress |
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Managed money carefully |
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Had friendships that kept them out of trouble |
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Were respectful toward others |
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* Report youth never having intercourse as “0”. |
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* *Reported only for those who had intercourse within past three months. (s) indicates a sensitive question. |
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Measures of Demographics, Behaviors, Intentions, Perceived Effects
Collected at Program Exit
REPORT PERIOD |
2013-2014 |
Grantee: |
Enter grantee name |
Program: |
Enter program name |
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Enter Count |
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Enter Count |
Total Exit Surveys Completed: |
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Gender |
Male |
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Age |
Age 10 |
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Female |
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Age 11 |
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Age 12 |
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Age 13 |
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Grade |
Grade 4 |
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Age 14 |
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Grade 5 |
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Age 15 |
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Grade 6 |
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Age 16 |
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Grade 7 |
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Age 17 |
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Grade 8 |
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Age 18 |
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Grade 9 |
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Age 19 |
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Grade 10 |
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Age 20 |
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Grade 11 |
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Age 21 or older |
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Grade 12 |
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School doesn’t assign grades |
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Hispanic |
Yes - Mexican, Mexican American, Chicano/a |
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Dropped out |
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Yes - Puerto Rican |
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Working toward GED |
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Yes - Cuban |
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HS grad, not enrolled in post-secondary |
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Yes - Another Hispanic, Latino/a or Spanish origin |
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HS grad, enrolled in post-secondary |
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No |
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Race |
American Indian or Alaska Native |
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Asian |
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Black or African American |
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Native Hawaiian or Other Pacific Islander |
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White or Caucasian |
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Missing |
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Measures of Demographics, Behaviors, Intentions, Perceived Effects
Collected at Program Exit
REPORT PERIOD |
2013-2014 |
Grantee: |
Enter grantee name |
Program: |
Enter program name |
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Enter Count |
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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 |
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Know how to manage stress |
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Manage conflict without causing more conflict |
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Form positive friendships that keep them out of trouble |
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Be respectful toward others |
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Make plans to reach goals |
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Care about doing well in school |
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Get a steady job after finishing school |
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Share ideas or talk with a parent or guardian |
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Make healthy decisions about drugs and alcohol |
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Get more education after high school |
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Manage money carefully |
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Be the best they can be |
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Have intercourse in the next 6 months |
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Use birth control in the next 6 months |
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Use a condom in the next 6 months |
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Abstain from sex in the next 6 months |
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Measures of Demographics, Behaviors, Intentions, Perceived Effects
Collected at Program Exit
REPORT PERIOD |
2013-2014 |
Grantee: |
Enter grantee name |
Program: |
Enter program name |
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Enter Count |
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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 |
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Felt the material presented was clear |
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Found discussions or activities helped to learn program lessons |
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Felt respected as a person |
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Were picked on, teased, or bullied |
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Had a chance to ask questions about program topics and issues |
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Witnessed people being picked on, teased, or bullied because people thought they were LGBT |
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Witnessed people being picked on, teased, or bullied because of their race or ethnic background |
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Measures of Attendance, Reach, and Dosage
REPORT PERIOD |
2013-2014 |
Grantee: |
Enter grantee name |
Program: |
Enter program name |
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Enter Count |
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m |
Enter the number of youth during the 2013-2014program year who: |
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Program Setting |
Attended at least one program session |
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Attended a session in a school setting |
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Attended a session in a community-based organization |
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Attended a session in a clinic |
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Attended a session in a foster care setting |
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Attended a session in a juvenile detention center |
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Attended a session in another setting |
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Reach |
Mark an “X” in the cell for the program if more than 50% of youth were: |
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In foster care |
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Homeless or runaway |
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Living with HIV/AIDS |
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Pregnant or parenting |
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LGBTQ |
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In adjudication systems |
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In residential treatment for mental health issues |
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Have trouble speaking or understanding spoken English |
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Attendance |
Enter the appropriate count below |
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The number of youth completing at least 75% of scheduled program hours |
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Measures of Attendance, Reach, and Dosage
REPORT PERIOD |
2013-2014 |
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Grantee: |
Enter grantee name |
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Program: |
Enter program name |
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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? |
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Cohort-1 |
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Cohort-2 |
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Cohort-3 |
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Cohort-4 |
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Cohort-5 |
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Cohort-6 |
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Cohort-7 |
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Cohort-8 |
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Cohort-9 |
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Cohort-10 |
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Cohort-11 |
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Cohort-12 |
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Cohort-13 |
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Cohort-14 |
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Cohort-15 |
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Cohort-16 |
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Cohort-17 |
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Cohort-18 |
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Cohort-19 |
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Cohort-20 |
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Cohort-21 |
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Cohort-22 |
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Cohort-23 |
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Cohort-24 |
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Cohort-25 |
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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 |
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Keeping youth engaged |
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Getting youth to attend regularly |
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Recruiting qualified staff |
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Ensuring facilitators understand content |
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Covering program content |
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Staff turnover |
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Negative peer reactions |
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Youth behavioral problems |
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Natural disasters |
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Program facilities |
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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 |
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Keeping youth engaged in program sessions |
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Getting youth to attend regularly |
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Recruiting qualified staff |
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Training facilitators |
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Retaining staff |
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Minimizing negative peer reactions |
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Addressing youth behavioral issues |
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Other (please specify) |
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Measures of Structure, Cost, Support for Program Implementation
REPORT PERIOD |
2012-2013 |
Grantee: |
Enter grantee name |
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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 |
$ |
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Grantee Staffing |
Count |
Number of grantee staff administering PREP |
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Total grantee staff FTEs involved in administering PREP |
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Training and Quality Monitoring |
(Y/N) |
Grantee or its designee observed program delivery to monitor quality and/or fidelity |
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Grantee or its designee conducted training of PREP program facilitators) |
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Grantee or its designee provided technical assistance to support PREP program implementation |
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Measures of Structure, Cost, Support for Program Implementation
REPORT PERIOD |
2012-2013 |
Grantee: |
Enter grantee name |
Program: |
Enter program name |
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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 |
$ |
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Measures of Structure, Cost, Support for Program Implementation
REPORT PERIOD |
2012-2013 |
Grantee: |
Enter grantee name |
Program: |
Enter program name |
Program Delivery |
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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 |
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Target Population |
Youth in foster care |
Y / N |
Homeless or runaway youth |
Y / N |
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Youth living with HIV/AIDS |
Y / N |
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Pregnant or Parenting youth |
Y / N |
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Hispanic / Latino youth |
Y / N |
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African American youth |
Y / N |
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Native American youth |
Y / N |
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Lesbian, gay, bisexual, transgendered, or questioning (LGBTQ) youth |
Y / N |
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Youth in adjudication systems |
Y / N |
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Male youth |
Y / N |
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Youth in high-need geographic areas |
Y / N |
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Out of school / dropout youth |
Y / N |
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In residential treatment for mental health issues |
Y / N |
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Indicate which of the following adult preparation topics are covered by the program. |
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Adult Preparation Topics |
Healthy Relationships |
Y / N |
Adolescent Development |
Y / N |
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Financial Literacy |
Y / N |
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Parent Child Communication |
Y / N |
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Educational and Career Success |
Y / N |
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Healthy Life Skills |
Y / N |
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | LSarnoski |
File Modified | 0000-00-00 |
File Created | 2021-01-21 |