Performance Measures Data Report Form (Instrument 3)

Instrument #3
performance reporting system data entry form

The 93 estimated grantees will report measures on participant demographics, behaviors, intentions, and perceived effects; attendance, reach, and dosage; implementation challenges and needs for technical assistance; and structure, cost, and support for program implementation. The contractor (Mathematica Policy Research) will develop tools grantees can use to aggregate data originating from sub-awardee providers and to organize all of the performance measures data elements to facilitate entry into the national system. However, these tools are considered voluntary and to be used at the discretion of the grantees. Grantees may elect to use alternative means to collect and aggregate the data that will be submitted. The only requirement will be that all grantees enter the required measures into the national system systematically, and for that they will use an online form that contains all of the items in this instrument.

Measures of Demographics and Behaviors

Collected at Program Entry

REPORT PERIOD	[reporting period]
Grantee:	Enter grantee name
Provider:	Enter provider name
Program:	Enter program name

			Enter Count						Enter Count
Total Entry Surveys Completed:					Total Exempt from Sensitive Questions:
Age		Age 10			Gender Identity	Male
		Age 11				Female
		Age 12				Transgender
		Age 13				Something else
		Age 14				Unsure
		Age 15				Total
		Age 16				Missing
		Age 17
		Age 18			Orientation	Straight
		Age 19				Gay or Lesbian
		Age 20				Bisexual
		Age 21 or older				Something else
		Total				Unsure
		Missing				Total
						Missing
Language(s) Spoken at Home		English
		Spanish				Total marked as LGBTQ
		Other: ___________________				Missing
		Total
		Missing

				Enter Count						Enter Count
Hispanic/Latino		Yes				Grade	Grade 4
		No					Grade 5
		Total					Grade 6
		Missing					Grade 7
							Grade 8
Race		American Indian or Alaska Native					Grade 9
		Asian					Grade 10
		Black or African American					Grade 11
		Native Hawaiian or Other Pacific Islander					Grade 12
		White or Caucasian					School does not assign grade levels
		Total					Dropped out of school and is not working on getting a high school diploma or GED
		Missing					Working toward GED
							Has high school diploma or GED but is not currently enrolled in college or technical school
Vulnerable Populations		In foster care, living with a family					Has high school diploma or GED and is currently enrolled in college or technical school
		In foster care, living in a group home					Total
		Couch surfing or moving from house to house					Missing
		Living in a place not meant to be a residence, such as outside, in a tent city or homeless camp, in a car, in an abandoned vehicle, or in an abandoned building
		Staying in an emergency shelter, transitional living program, or motel
		In juvenile detention, jail, prison or another correctional facility, or under the supervision of a probation officer
		Total
		Missing

Measures of Demographics and Behaviors

Collected at Program Entry

REPORT PERIOD	[reporting period]
Grantee:	Enter grantee name
Provider:	Enter provider name
Program:	Enter program name

	Enter Count
How often in past three months:	All of the Time	Most of the Time	Some of the Time	None of the time	Missing	Total
Cared about doing well in school
Shared ideas or talked about things that really matter with a parent or guardian
Resisted or said no to peer pressure
Managed conflict without causing more conflict
Knew how to manage stress
Managed money carefully
Had friends that kept them out of trouble
Were respectful toward others

Measures of Demographics and Behaviors

Collected at Program Entry

REPORT PERIOD	[reporting period]
Grantee:	Enter grantee name
Provider:	Enter provider name
Program:	Enter program name

	Enter Count
	Yes		No		Missing	Total
Ever had vaginal sex
Ever had oral sex s
Ever had anal sex s
Ever been/gotten someone pregnant*
	0	1	2	3+	Missing	Total
How many times been/gotten someone pregnant*
	0	1	2-3	4+	Missing	Exempt	Total
How many times had vaginal sex in past 3 months*
Number of people with whom had vaginal sex in past 3 months*
How many times had oral sex in past 3 months* s
Number of people with whom had oral sex in past 3 months* s
How many times had anal sex in past 3 months* s
Number of people with whom had anal sex in past 3 months* s
	All of the time	Most of the time	Some of the time	None of the time	Missing	Exempt	Total
How often used a condom for vaginal sex in past three months**
How often used birth control other than condoms for vaginal sex in past three months**
How often had vaginal sex without condom or birth control in past three months**
How often used a condom or dental dam for oral sex in past three months** s
How often used a condom for anal sex in past three months** s
* Report youth never having that type of sex as “0”.
** Reported only for those who had that type of sex within past three months. (s) indicates a sensitive question.

Measures of Demographics, Intentions, and Perceived Effects

Collected at Program Exit

REPORT PERIOD	[reporting period]
Grantee:	Enter grantee name
Provider:	Enter provider name
Program:	Enter program name

				Enter Count
Total Entry Surveys Completed:										Enter
										Count
Age		Age 10				Gender Identity	Male
		Age 11					Female
		Age 12					Transgender
		Age 13					Something else
		Age 14					Unsure
		Age 15					Total
		Age 16					Missing
		Age 17
		Age 18				Orientation	Straight
		Age 19					Gay or Lesbian
		Age 20					Bisexual
		Age 21 or older					Something else
		Total					Unsure
		Missing					Total
							Missing
Language(s) Spoken at Home		English
		Spanish					Total marked as LGBTQ
		Other: ___________________					Missing
		Total
		Missing

				Enter Count				Enter Count
Hispanic/ Latino		Yes				Grade	Grade 4
		No					Grade 5
		Total					Grade 6
		Missing					Grade 7
							Grade 8
Race		American Indian or Alaska Native					Grade 9
		Asian					Grade 10
		Black or African American					Grade 11
		Native Hawaiian or Other Pacific Islander					Grade 12
		White or Caucasian					School does not assign grade levels
		Total					Dropped out of school and is not working on getting a high school diploma or GED
		Missing					Working toward GED
							Has high school diploma or GED but is not currently enrolled in college or technical school
Vulnerable Populations		In foster care, living with a family					Has high school diploma or GED and is currently enrolled in college or technical school
		In foster care, living in a group home					Total
		Couch surfing or moving from house to house					Missing
		Living in a place not meant to be a residence, such as outside, in a tent city or homeless camp, in a car, in an abandoned vehicle, or in an abandoned building
		Staying in an emergency shelter, transitional living program, or motel
		In juvenile detention, jail, prison or another correctional facility, or under the supervision of a probation officer
		Total
		Missing

Measures of Demographics, Intentions, and Perceived Effects

Collected at Program Exit

REPORT PERIOD	[reporting period]
Grantee:	Enter grantee name
Provider:	Enter provider name
Program:	Enter program name

Enter the number of respondents who report the program made them much more, somewhat more, about the same, somewhat less, or much 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	Not at all likely	Will Abstain	Missing	Total
Be the best they can be
Resist or say no to peer pressure
Know how to manage stress
Manage conflict without causing more conflict
Form friendships that keep them out of trouble
Be respectful toward others
Make plans to reach their goals
Care about doing well in school
Get more education after high school
Get a steady job or after finishing school
Share ideas or talk about things that really matter with a parent or guardian
Make healthy decisions about drugs and alcohol
Manage money carefully, such as making a budget, saving, or investing
Have vaginal sex in the next 3 months
Use a condom if having vaginal sex in the next 3 months
Use birth control other than condoms if having vaginal sex in the next 3 months
Use a condom or other form of birth control if having vaginal sex in the next 3 months
Have oral sex in the next 3 months
Use a condom or dental dam if having oral sex in the next 3 months
Have anal sex in the next 3 months
Use a condom if having anal sex in the next 3 months

Measures of Demographics, Intentions, and Perceived Effects

Collected at Program Exit

REPORT PERIOD	[reporting period]
Grantee:	Enter grantee name
Provider:	Enter provider name
Program:	Enter program name

Enter the number 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	None of the time	Missing	Total
Felt interested in program sessions and classes
Felt the material presented was clear
Felt discussions or activities helped to learn program lessons
Had a chance to ask questions about topics or issues that came up in the program
Felt respected as a person
Were picked on, teased, or bullied
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	[reporting period]
Grantee:	Enter grantee name
Provider:	Enter provider name
Program:	Enter program name

		Enter Count
	Enter the number of youth during the reporting period who:
Reach	Attended at least one program session
Program Setting	Attended a session in school during school
	Attended a session in school after school
	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 a residential mental health treatment facility
	Attended a session in another setting
Majority population	Indicate whether more than 50 percent of youth attending the program were:
	In foster care
	Homeless or runaway
	Pregnant or parenting
	LGBTQ
	In adjudication systems
Attendance/dosage	Enter the appropriate count below
	The number of youth who completed at least 75 percent of scheduled program hours

Measures of Attendance, Reach, and Dosage

REPORT PERIOD			[reporting period]
Grantee:			Enter grantee name
Provider:			Enter provider 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	[reporting period]
Grantee:	Enter grantee name
Provider:	Enter provider name

Use the scale at the right to indicate how provider assessed 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
Obtaining buy-in or support from key stakeholders
Use the scale at the right to indicate if the provider has expressed interest in receiving technical assistance for the implementation factors below.	Not 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
Obtaining buy-in or support from key stakeholders
Evaluation (e.g., how to select or manage an evaluator, data collection, data analysis, and report writing)
Parent support and engagement
Other

Measures of Structure, Cost, and Support for Program Implementation

REPORT PERIOD	[reporting period]
Grantee:	Enter grantee name
PREP Funding
Total amount of PREP grant funding obligated (including any rollover funds) during [reporting period]	$
Of that total, percentage obligated for: Direct service provision (youth programming) Training, technical assistance, and monitoring conducted at the grantee level Evaluation and/or research Retained for administrative purposes at the grantee level	% % % %
Grantee Staffing	Count
Number of grantee staff involved in overseeing PREP
Number of grantee FTEs involved in overseeing PREP
Grantee Observation, Training and Technical Assistance	(Y/N)
Grantee or its designee observed program delivery to monitor quality and fidelity to program models
Type of organization that conducted observations (mark all that apply):  Grantee  Developer  Training or technical assistance partner  Evaluation partner  Program provider
Grantee or its designee provided technical assistance to support program implementation
Type of organization that provided technical assistance (mark all that apply):  Grantee  Developer  Training or technical assistance partner  Evaluation partner  Program provider
Grantee or its designee conducted training of facilitators who deliver the program (or of other staff who might train facilitators)
Type of organization that conducted program facilitator training (mark all that apply):  Grantee  Developer  Training or technical assistance partner  Evaluation partner  Program provider
Provider Count	Count
Number of providers funded
Number of new providers

Measures of Structure, Cost, and Support for Program Implementation

REPORT PERIOD	[reporting period]
Grantee:	Enter grantee name
Provider:	Enter provider name
	Amount
PREP award amount (for current reporting period only)	$
Amount of non-PREP funding received during current reporting period to support PREP programming	$
	(Y/N)
Is provider new for the [reporting period]?
Did provider serve youth during the [reporting period]?
	Count
Number of PREP facilitators working for provider
Number of PREP facilitators trained in delivering core program model
Number of PREP facilitators observed once
Number of PREP facilitators observed twice or more

Measures of Structure, Cost, and Support for Program Implementation

REPORT PERIOD	[reporting period]
Grantee:	Enter grantee name
Provider:	Enter provider name
Program:	Enter program name

Program Delivery
Program model implemented
Number of intended program delivery hours

Indicate which, if any, of the following youth groups are target populations for the provider’s program		Y / N
Target Population	Youth in foster care
	Homeless or runaway youth
	Youth living with HIV/AIDS
	Pregnant or parenting youth
	Hispanic/Latino youth
	African American youth
	Native American youth
	LGBTQ youth
	Youth in adjudication systems
	Male youth
	Youth in high-need geographic areas
	Out of school or dropout youth
	Youth in residential treatment for mental health issues
	Trafficked youth
Indicate which of the following adulthood preparation subjects (APS) are covered by the program		Y / N
Adulthood Preparation Subjects	Healthy relationships
	Adolescent development
	Financial literacy
	Parent child communication
	Educational and career success
	Healthy life skills
For each APS selected, indicate whether content is (mark all that apply):		Y / N
Source of Adulthood Preparation Subjects Content	Included in the program’s evidence-based or evidence-informed APP curriculum
	Covered by incorporating an entire additional existing curriculum
	Covered by adding selected lessons from another existing curriculum
	Covered by original content that we or a partner organization created