Description of Your School-Based Sexual Assault Prevention Program
Please complete this form describing the prevention program that you evaluated.
Name/Location of your agency: ______
Title of Prevention Program: ______
Your name: ______Phone number: ______
Email address: ______
Primary focus of program (check one):
__ Sexual Assault/Date Rape__ Teen Dating Violence (may include date rape)
__ Sexual Harassment__ Other, please specify ______
The program is designed for:0 Males0 Females 0 Mixed-gender classrooms
in grades: 0 7th-8th 0 High School 0 College 0 Other, please specify
______
Number of Sessions ______
Time per session ______
Average audience size______
Approximately how many participants do you serve in a year with this specific program? ______
Gender of Presenter(s):0 Male 0 Female 0 Male-Female Team
Age of Presenter(s): ______
Race of Presenter(s): 0 American Indian/Alaskan Native 0 Asian 0 Black/African American 0 Hispanic or Latino 0 White
Years of prevention education experience: ____
What topics did your curricula cover? Indicate on a 0 to 3 scale how much your program addressed each topic, where: 0 = Did not cover this topic
1 = Briefly covered this topic
2 = Covered this topic
3 = This was a primary focus of the program
__ Statistics about incidence and prevalence__ Myths and facts
__ Related definitions __ Communication skills
__ Consent vs. Coercion__ Respect/Self-esteem
__ How to help a friend who has been abused__ Gender roles
__ What you should do if victimized/How to report__ Alcohol
__ Negative consequences for perpetrating violence__ Drugs
__ Empathy for victims of violence__ Date rape drugs
__ How to avoid high-risk situations__ Self-defense strategies
__ Warning signs of an abusive person__ The “Real Men” pledge
__ The school’s sexual harassment policy__ Child Sexual Abuse
__ Healthy Relationships__ Local resources
__ Other (please specify)______
What presentation formats did you use? (Check all that apply)
__ Lecture
__ Discussion (whole group)
__ Discussion (smaller groups)
__ Video
__ Role Play
__ Anonymous question box
__ Drama
__ Games
__ Art work
__ Quizzes/tests
__ Homework assignments
__ Other (please specify)______
On average, how many days after the intervention did students complete the post-intervention questionnaires? ____
How many parents denied permission for their children to participate in the evaluation? _____
How many students chose not to participate in the evaluation? _____
How many students disclosed abusive relationships to you this year as a result of your prevention programs? _____
Thanks
Please return this form to Paul Schewe when you send him the completed pre and post intervention questionnaires and the completed assent forms.
Paul Schewe
University of Illinois at Chicago
Dept. of Psych (MC 285)
1007 W. Harrison St.
Chicago, IL 60607-7137