Instrument 3_PREP Performance Reporting System Data Entry Form_092721_clean

Personal responsibility education program (PREP)

Instrument 3

performance reporting system data entry form

october 2021

The 101 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) will develop tools grantees can use to aggregate data originating from subrecipient 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 is 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 (Middle School):			Total Entry Surveys Completed (High School or Older):

Did the program receive an approval from their Federal Project Officer to delay their survey data collection start date?	Y/N
Did the program receive an approved waiver from their Federal Project Officer for any entry survey items?	Y/N
At any point during the reporting period [DATES], was the program unable to collect Entry Survey data due to COVID-19?	Y/N
What mode(s) of data collection did the program use for participant entry surveys during the reporting period? MARK YES OR NO FOR EACH
In-person paper-and-pencil survey	Y/N
Online, web-based survey	Y/N
Telephone survey	Y/N
Mail survey	Y/N
Other (specify: )	Y/N

Measures of Demographics and Behaviors

Collected at Program Entry

		Enter Count				Enter Count
Age	Age 10			Grade	Grade 5+
	Age 11				Grade 6+
	Age 12				Grade 7+
	Age 13				Grade 8+
	Age 14				Grade 9
	Age 15				Grade 10*
	Age 16				Grade 11*
	Age 17*				Grade 12*
	Age 18*				School does not assign grade levels
	Age 19*				Dropped out of school and is not working on getting a high school diploma or GED*
	Age 20*				Working toward GED*
	Age 21*				Has high school diploma or GED but is not currently enrolled in college or technical school*
	Total				Not currently enrolled in school+
	Missing				Total
					Missing

		Enter Count				Enter Count
Language(s) spoken at home	English			Sex	Male
	Spanish				Female
	Other (specify:				Total
	______________________)				Missing
	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				Enter Count
Hispanic/ Latino		Yes				Vulnerable Populations	Living with family [parent(s), guardian, grandparents, or other relatives]
		No					In foster care, living with a family
		Total					In foster care, living in a group home
		Missing					Couch surfing or moving from home to home
							Living outside, in a tent city or homeless camp, in a car, in an abandoned vehicle, or in an abandoned building
Race		American Indian or Alaska Native					Staying in an emergency shelter or transitional living program
		Asian					Staying in a hotel or motel
		Black or African American					In juvenile detention center, juvenile group home, and/or under the supervision of a probation officer
		Native Hawaiian or Other Pacific Islander					None of the above
		White or Caucasian					Total
		Other (specify: _________________)
		Total
		Missing
							Missing
							Total (unduplicated) youth in foster care
							Total (unduplicated) runaway or homeless youth
							Total (unduplicated) youth in adjudication system

Measures of Demographics, Behaviors, and Intentions

Collected at Program Entry

REPORT PERIOD

[reporting period]

Grantee:

Enter grantee name

Provider:

Enter provider name

Program:

Enter program name

Enter Count

In past three months, the respondent:

All of the time

Most of the time

Some of the time

None of the time

Missing

Total

Resisted or said no to peer pressure

Managed emotions in healthy ways

Made decisions to not use drugs and alcohol

Thought about the consequences before making a decision

Talked with parent, guardian, or caregiver about things going on in their life

Talked with parent, guardian, or caregiver about sex

REPORT PERIOD

[reporting period]

Grantee:

Enter grantee name

Provider:

Enter provider name

Program:

Enter program name

	Enter Count
How true is each statement:	Not true at all	Somewhat true	Very true	Missing	Total
Makes plans to reach goals
Cares about doing well in school
Plans to graduate high school or get GED
Plans to get more education and/or training after high school or completing GED
Plans to get a full-time steady job after school
Would speak up or ask for help if being bullied in person or online, via text, while gaming, or through other social media
Would speak up or ask for help if others were being bullied in person or online, via text, while gaming, or through other social media
Saves money to get what they want
Feels confident about how to open a bank account
Feels confident about how to prepare a budget
Feels confident about tracking expenses
Understands costs associated with raising a child
Understands what makes a relationship healthy
Would be able to resist or say no to someone if pressured to participate in sexual acts
Would talk to a trusted person/adult if someone makes them uncomfortable, hurts them, or pressures them to do things they don’t want to do

Measures of Demographics, Behaviors, and Intentions

Collected at Program Entry

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

	Enter Count
	Yes	No	Never had sex	Not sure	Missing	No response because completed middle school version of survey	Total
Ever had sexual intercourse*
Ever been/gotten someone pregnant*
Ever been told by doctor or other medical provider they had an STI*

	Enter Count
	Never had sex	Have had sex but not in the past 3 months	1	2-3	4 or more people	No response because completed middle school version of the survey	Missing	Total
Number of people with whom had sexual intercourse in past 3 months*

	Enter Count
	Never had sex	Have had sex but not in the past 3 months	All of the time	Most of the time	Some of the time	None of the time	Missing	No response because completed middle school version of survey	Total
How often used a condom for sexual intercourse in past three months*
How often used birth control other than condoms for sexual intercourse in past three 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 Count				Enter Count
Total Exit Surveys Completed (Middle school):					Total Exit Surveys Completed (High school and older):

Did the program receive an approval from their Federal Project Officer to delay their survey data collection start date?						Y/N
Did the program receive an approved waiver from their Federal Project Officer for any exit survey items?						Y/N
At any point during the reporting period [DATES], was the program unable to collect Exit Survey data due to COVID-19?						Y/N
What mode(s) of data collection did the program use for participant exit surveys during the reporting period? MARK YES OR NO FOR EACH
In-person paper-and-pencil survey						Y/N
Online, web-based survey						Y/N
Telephone survey						Y/N
Mail survey						Y/N
Other (specify: )						Y/N
		Enter Count				Enter Count
Age	Age 10			Sex	Male
	Age 11				Female
	Age 12				Total
	Age 13				Missing
	Age 14
	Age 15
	Age 16			Language(s) spoken at home	English
	Age 17*				Spanish
	Age 18*				Other (specify:
	Age 19*
	Age 20*				Total
	Age 21*				Missing
	Total
	Missing

				Enter Count				Enter Count
Hispanic/ Latino		Yes				Grade	Grade 5+
		No					Grade 6+
		Total					Grade 7+
		Missing					Grade 8+
							Grade 9
Race		American Indian or Alaska Native					Grade 10*
		Asian					Grade 11*
		Black or African American					Grade 12*
		Native Hawaiian or Other Pacific Islander					School does not assign grade levels
		White or Caucasian					Dropped out of school and is not working on getting a high school diploma or GED*
		Other (specify: ____________)
		Total					Working toward GED*
		Missing					Has high school diploma or GED but is not currently enrolled in college or technical school*
							Has high school diploma or GED and is currently enrolled in college or technical school*
Vulnerable Populations		Living with family [parent(s), guardian, grandparents, or other relatives]					Not currently enrolled in school+
		In foster care, living with a family					Total
		In foster care, living in a group home					Missing
		Couch surfing or moving from home to home				+ = Middle school survey only * = High school and older survey only
		Living 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 or transitional living program
		Staying in a hotel or motel
		In juvenile detention center, juvenile group home, and/or under the supervision of a probation officer
		None of the above
		Total
		Missing
		Total (unduplicated) youth in foster care
		Total (unduplicated) runaway or homeless youth
		Total (unduplicated) youth in adjudication system

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
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	Missing	Total
Resist or say no to peer pressure
Manage emotions in healthy ways
Make decisions to not use drugs and alcohol
Think about the consequences before making a decision
Make plans to reach their goals
Care about doing well in school
Graduate high school or get GED
Get more education and/or training after high school or completing GED
Get a steady full-time job after school
Save money to get things they want
Feel confident about how to open a bank account
Feel confident about how to prepare a budget
Feel confident about how to track expenses
Understand the costs associated with raising a child
Talk with parent, guardian, or caregiver about things going on in their life
Talk with parent, guardian, or caregiver about sex
Better understand what makes a relationship healthy
Resist or say no to someone if they pressure them to participate in sexual acts
Talk to a trusted person/adult if someone makes them uncomfortable, hurts them, or pressures them to do things they don’t want to do

Measures of Demographics, Intentions, and Perceived Effects

Collected at Program Exit

		Enter Count
	Yes		No	Not sure	Missing	No response because completed middle school version of survey	Total
As a result of being in the program, plans to abstain from sexual intercourse for at least the next 3 months*

	Enter Count
How important are each of these reasons in respondent’s decision to not have sex for at least the next 3 months:	Not at all important	Not too important	Somewhat important	Very important	Question does not apply because they do not plan to abstain for next 3 months	No response because completed middle school version of the survey	Missing	Total
How it might affect plans for the future*
Possible emotional and social consequences (for example, feeling sadness or regret, disappointing your parent(s) or guardian(s), and/or negative reactions from your peers) *
Risk of getting a sexually transmitted infection (STI) *
Risk of getting pregnant or getting someone pregnant*

	Enter Count
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 behaviors.	Much more likely	Somewhat more likely	About the same	Somewhat less likely	Much less likely	Missing	Question does not apply because will not have sex	No response because completed middle school version of survey	Total
Have sexual intercourse in the next 3 months*
Use (or ask your partner to use) a condom if having sexual intercourse in the next 3 months*
Use (or ask your partner to use) birth control other than condoms if having sexual intercourse 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 Count
Enter the number of respondents who assessed their program experience according to the scale to the right. How often in this program…	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

	Enter Count
Enter the number of respondents who assessed their program experience according to the scale to the right. How satisfied were they with…	Very satisfied	Somewhat satisfied	A little satisfied	Not at all satisfied	Missing	Total
The amount of information they received about abstaining from sex (choosing to not have sex)
The amount of information they received about condoms and birth control

Measures of Attendance, Reach, and Dosage

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

		Enter Count
Reach	Enter the number of youth during the reporting period who:
	Attended at least one program session
	Number of middle school age participants
	Number of high school age or older participants
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 virtual session1
	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
	In adjudication systems
	LGBTQ youth
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
	Cohort:2
	1	2	3		4	5	6	7	8	9	10
Enter a unique identifier for each cohort that ended the program during this reporting period.
How many hours of programming, overall, were delivered to the cohort?

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 Because Already Received	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 Operational Status Related to COVID-19
Did the grantee experience any interruptions of PREP administrative operations during the reporting period due to COVID-19?	Y/N
Did the grantee experience any interruptions of PREP services to youth during the reporting period due to COVID-19?	Y/N

PREP Funding
Total amount of PREP grant funding obligated (including any carryover funds) during [reporting period]	$
Of that total, percentage obligated for: Direct service provision (youth programming) Training, technical assistance, and monitoring conducted at the grantee level3 Evaluation and/or research Retained for administrative purposes at the grantee level4	% % % %

Grantee Staffing	Count
Number of grantee staff involved in overseeing PREP5	#
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

Provider Funding	Amount
PREP award amount (for current reporting period only)	$
Amount of non-PREP funding received during current reporting period to support PREP programming	$

Provider Staff Administering PREP	Count
Number of provider staff involved in administering PREP programs6
Number of provider FTEs involved in administering PREP programs
Provider Status	Y/N
Is provider new for the [reporting period]?
Did provider serve youth during the [reporting period]?

Facilitators	Count
Number of PREP facilitators working for provider
Facilitator Training and Observation	Count
Number of PREP facilitators trained in delivering core program model
Number of PREP facilitators observed exactly 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

1¹Virtual includes any programming that is facilitated online rather than by an in-person facilitator, regardless of the physical setting where participants are located

2 PMMS will include the following hover-over text: “A cohort, in this context, represents a group of youth that all jointly receive a defined PREP program, which could include a specific curriculum and any additional hours of programming added to meet all requirements for the PREP program, including requirements for covering select adulthood preparation subjects. If a provider is delivering a PREP program to multiple groups of youth simultaneously, but these groups meet separately, each group of youth should be considered a separate cohort. A cohort could consist of an individual, if programming is delivered one-on-one.”

3 PMMS will include the following hover-over text: “This would include funds for training or TA that is provided by the grantee or its designee for grantee staff, provider staff, or program staff. However, it would exclude funds given to subrecipient program providers and used by those providers for their own training or TA.”

4 PMMS will include the following hover-over text: “This would include funds used for grantee administrative purposes but would exclude funds given to subrecipient program providers and used by those providers for administrative purposes.”

5 PMMS will include the following hover-over text: “This measure should include grantee staff, such as PREP program directors and program coordinators, who were directly responsible for administering, managing, and overseeing the PREP program. Do not include grantee staff who provide programming directly to youth but do not oversee PREP in this measure. Those staff should be counted in the measure of facilitators on the program provider data page. If staff play both roles, they should be included in both measures.”

6 PMMS will include the following hover-over text: “This measure should include provider staff, such as PREP program directors and program coordinators, who were directly responsible for administering, managing, and overseeing the PREP program for the provider. Do not include staff who provide programming directly to youth in this measure. Those staff should be counted in the measure of facilitators later in this section. If staff play both roles, they should be included in both measures.”

THE PAPERWORK REDUCTION ACT OF 1995

Public reporting burden for this collection of information is estimated to average 14 to 18 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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.