0920-19BOI BYB Discovery Session Implementation Fidelity Checklist

---

Overview

Instructions
Definitions
Section I
Section II
Section III
Section IV
Section V

---

Sheet 1: Instructions

		Form Approved
		OMB No. 0920-xxx
		Exp. Date xx/xx/xx
BYB Discovery Session Implementation Fidelity Checklist
INSTRUCTIONS
Purpose The purpose of this checklist is to document whether Be Your Best Discovery Session activities were implemented as intended at each session. This checklist should be completed by trained site staff. If possible, a staff member other than the Discovery Session lead should fill out Section III during the Discovery Session.
How to Complete the Checklist
Step 1:		Review the instructions and checklist items before each session.
Step 2:		Indicate whether each checklist item was completed for or during the specified Discovery Session by selecting "Yes," "No," or "N/A" from the dropdown menu. The dropdown menu will appear when you click the cell. Note the session date, organization name, DPRP code, initials of the person completing the checklist, and class start and end times in Section II.
Step 3:		Review Sections I through IV within 24 hours of the end of the Discovery Session to ensure they are complete. It is important to do this as soon as possible while details of the session are fresh in your mind. Section V must be completed after the Discovery Session.
Step 4:		Send the completed checklist with the participant pre- and post-surveys to RTI International.
When to Submit
Please submit this form to RTI International within 21 days of the date of the discovery session.
Upload the document to [LINK].
Questions
If you have any questions, please contact RTI International [EMAIL].
CDC estimates the average public reporting burden for this collection of information as 90 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxx).

---

Sheet 2: Definitions

BYB Discovery Session Implementation Fidelity Checklist
CHECKLIST DEFINITIONS
Key definitions are provided below for your reference.
1.	Discovery Session Attendees – Any individual attending the session to gain information about the lifestyle change program for themselves and/or a friend or family member. Those staffing the session are not considered attendees.
2.	Session Staff – Anyone presenting or providing support to implement the Discovery Session. This may include the Session Lead, testimonial presenters and any other staff or volunteers assisting with sign-in, distribution of materials, presentation, or enrollment.
3.	Session Lead – The staff member presenting the Be Your Best Discovery Session and leading activities.
4.	Organization Name – The official name of the organization running the National DPP (e.g., Anytown YMCA).
5.	Title – The title of any individual staffing the Discovery Session (e.g., lifestyle change program director or coach).
6.	Session Role – The role a person (non-attendee) plays in staffing the Discovery Session (e.g., greeter, sign-in, material distribution, local lifestyle change program presentation, and enrollment).
7.	Registration – The term used to describe an eligible person’s formal documentation of intent to attend the first session of a National DPP lifestyle change program. Formal documentation may include filling out paperwork, providing health insurance information, and/or providing contact information. Registration for the lifestyle change program is not a standardized process and will have a different format among different programs.
Please respond to the questions in the next tab.

---

Sheet 3: Section I

Section I: Discovery Session Preparation
Instructions: The tasks listed in this section must be done before the Discovery Session. Complete this section before the start of the session.
Task	Was this Task Completed?
Attendee Reminders
Session attendees were sent at least one reminder for the Discovery Session that included the session date, time, and location.
Materials Preparation
The Discovery Session slides were updated with information about your organization and lifestyle change program.
Discovery Session folders were compiled and included all the following items: • Pre-session Survey • Values Affirmation Form • Movement Activity Worksheet • Diabetes Screening Test
Please respond to the questions in the next tab.

---

Sheet 4: Section II

Section II: Discovery Session Information
Instructions: Enter the information below at the start and end of the Discovery Session.
Discovery Session Date	Enter date here
Organization Name	Enter organization name here
Organization DPRP Code	Enter DPRP code here
Site/Class Location	Enter location here
Your Initials	Enter initials here
Discovery Session Time	Start (time that first attendee arrives):			Start time
	End (time that last attendee completes enrollment):			End time

---

Sheet 5: Section III

Section III: Discovery Session Staffing
Instructions: This section can be completed before or after the Discovery Session. In the table below, list all people who staffed the Discovery Session, including organization staff and testimonial participants.
No.	Organization & Title	Session Role
Example	YMCA LCP Director	Session Lead
1
2
3
4
5

---

Sheet 6: Section IV

Section IV: Discovery Session
Instructions: This section should be completed throughout the Discovery Session by a staff member other than the Session Lead, if possible. Review this section before the session so that you are familiar with the items that you should be looking for. Indicate whether each item was completed at the Discovery Session by entering "Yes," "No," or "N/A" or by selecting the appropriate option from the dropdown menu.
Task		Was this Task Completed?
Attendee Welcome
All attendees were greeted at arrival.
All attendees received a folder.
Attendees completed the pre-session survey.
The Session Lead asked attendees who still need to learn their individual risk to complete the CDC Diabetes Risk Test and calculate their risk score.
Introduction & Goals
The Session Lead introduced past or current lifestyle change program (LCP) participants. Check N/A if no past or current LCP participants are present at the Discovery Session.
The Session Lead acknowledged that attendees have successfully taken a critical step in coming to the session.
All attendees briefly introduced themselves.
The Session Lead conducted an ice breaker activity.
Values Affirmation Activity
Attendees were given time to write about or talk with other attendees about an action that connected to their top values.
Attendees reported out about their response to the Values Affirmation Activity.
The Session Lead described how the Values Affirmation Activity relates to diabetes prevention.
Prediabetes & Diabetes Information
The Session Lead explained that the consequences of prediabetes are reversible.
National DPP & Local LCP Information
The Session Lead explained that the National DPP can delay or reverse the consequences of prediabetes.
The Session Lead reviewed the costs of the LCP in terms of time.
The Session Lead presented information about the LCP’s cost in terms of money in a behaviorally informed way (e.g., least cost scenario first, cost per month rather than total). Check N/A if there is no cost for participating in the LCP.
The Session Lead reviewed whether insurance or employers may cover the cost. Check N/A if there is no cost for participating in the LCP.
Testimonial
The Session Lead conducted the testimonial with a current or past participant.
The testimonial was delivered in person by a current or past participant.
The testimonial was delivered using a video.
Movement Activity
The Session Lead gave examples for how attendees can achieve the movement goal.
The Session Lead asked attendees to share their strategies to increase movement.
The Session Lead acknowledged that by completing this activity attendees have already made another critical step toward a healthier lifestyle.
Small Group Activity
The Session Lead asked attendees to pair up and discuss one thing regarding their health that they are good at doing.
Wrap-Up
The Session Lead invited attendees to ask any remaining questions.
The Session Lead asked attendees to complete the Post-session Survey.
Staff walked around to offer attendees help calculating their risk score.
LCP staff passed out magnets listing the date, time, and location of Session 1.
Enrollment
LCP staff were available to offer one-on-one help with enrollment forms.

---

Sheet 7: Section V

Section V: Post-session Reminders
Instructions: This section must be completed after the Discovery Session.
Task		Was this Task Completed?
Enrolled Participant Reminders
At least one reminder was sent to participants who registered for the LCP.
Other Participant Reminders
At least one reminder was sent to participants who registered for the LCP.