Safer ChoicesLevel 1
Fidelity Monitoring Form
Program Facilitator(s):______
Location: ______
BLDG/Room Number: ______
Date Pretest Collected: ______
Date Posttest Collected: ______
Safer ChoicesLevel 1 Fidelity Monitoring Purpose
This form is to help you keep track of how you use the 10lessons of Level 1 of the Safer Choices curriculum (SCL1). Keeping track as you are using Safer Choices can help you see what things are working well and what things you might want to improve when you use Safer Choicesin the future.
SCL1 Program Fidelity Monitoring Instructions
- There is one form for each of the lessons in Level 1 of Safer Choices. Try to fill out the form right after you teach a lesson (or part of a lesson).
- If you use a lesson over more than 1 day (for example, if you have to break a lesson into two parts because of a short class period), start filling out the form on the first day that lesson was used. You can add to that form each day that you teach part of that lesson.
- If you make changes to what was taught (knowledge, attitudes, values, norms, skills) or the activities used for the lesson, in addition to filling out this form, be sure to report those changes immediately at this website:
- If you add extra information or activities, make a note about what was included and why you added it.
Is this cohort comprised of 50% of any ONE of the following?
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 /dropout youth / □
In residential treatment for mental health issues / □
Lesson 1: Not Everybody’s Having Sex!
1) Date(s) Lesson 1 was taught: ______Time:______
2) How many students attended? ______
3) How long did the lesson take? ______hrs
4) How many days was Lesson 1 taught to this group?
1 day 2 days 3 or more days Zero Days (lesson not covered)
Did you refer any students to additional services? Y/N # ______
5) Did youteachall of the core content in Lesson 1?Core CONTENT means WHAT is being taught in a curriculum. knowledge, attitudes, values, norms, skills, etc. / Describe any changes made and reasons for changing or leaving out content
1.ATTITUDE – about having sex/not having sex; showing affection in other ways / Yes
No
Not sure
Date(s) taught:
2.COMMUNICATING – with parents/other adults / Yes
No
Not sure
Date(s) taught:
3.PEER NORMS – about reasons for having/not having sex; influences affecting sexual decision-making / Yes
No
Not sure
Date(s) taught:
6)Did you use each of these activities in Lesson 1? / Describe any changes made and reasons for changing or leaving out activities
1.Why Young People Choose to Have or Not Have Sex / Used as described
Used with changes
Did not use
Date(s) used:
2.Influences on Decisions / Used as described
Used with changes
Did not use
Date(s) used:
3.Expressing Affection / Used as described
Used with changes
Did not use
Date(s) used:
4.Homework – Then and Now / Used as described
Used with changes
Did not use
Date(s) used:
7) Did you add any content or activities to Lesson 1?
Yes (if yes, please describe)
No
Lesson 2: The SAFEST Choice: Deciding Not to Have Sex
1) Date(s) Lesson 2 was taught: ______Time:______
2) How many students attended? ______
3) How long did the lesson take? ______hrs
4) How many days was Lesson 2 taught to this group?
1 day 2 days 3 or more days Zero Days (lesson not covered)
Did you refer any students to additional services? Y/N # ______
5) Did you teach all of the core content in Lesson 2?Core CONTENT means WHAT is being taught in a curriculum. knowledge, attitudes, values, norms, skills, etc. / Describe any changes made and reasons for changing or leaving out content
1.KNOWLEDGE - Accurate knowledge/stats about rates of sexual activity among 9th graders / Yes
No
Not sure
Date(s) taught:
2.PEER NORMS – about rates of sexual activity among 9th graders and about saying no / Yes
No
Not sure
Date(s) taught:
3.SKILL-BUILDING and SELF-EFFICACY to say no / Yes
No
Not sure
Date(s) taught:
6) Did you use each of these activities in Lesson 2? / Describe any changes made and reasons for changing or leaving out activities
1.Correcting Misperceptions of the Norm / Used as described
Used with changes
Did not use
Date(s) used:
2.Effective NO statements / Used as described
Used with changes
Did not use
Date(s) used:
3.Student Skill Practice / Used as described
Used with changes
Did not use
Date(s) used:
7) Did you add any content or activities to Lesson 2?
Yes (if yes, please describe)
No
Lesson 3: Refusals
1) Date(s) Lesson 3 was taught: ______Time:______
2) How many students attended? ______
3) How long did the lesson take? ______hrs
4) How many days was Lesson 3 taught to this group?
1 day 2 days 3 or more days Zero Days (lesson not covered)
Did you refer any students to additional services? Y/N # ______
5) Did you teach all of the core content in Lesson 3?Core CONTENT means WHAT is being taught in a curriculum. knowledge, attitudes, values, norms, skills, etc. / Describe any changes made and reasons for changing or leaving out content
1.SKILLS – to use a clear no statement / Yes
No
Not sure
Date(s) taught:
2.SKILLS – to use alternative actions and delaying tactics / Yes
No
Not sure
Date(s) taught:
3.SKILLS – to use refusal skills / Yes
No
Not sure
Date(s) taught:
6) Did you use each of these activities in Lesson 3? / Describe any changes made and reasons for changing or leaving out activities
1.Review of Clear NO statements / Used as described
Used with changes
Did not use
Date(s) used:
2.More Ways to Say NO / Used as described
Used with changes
Did not use
Date(s) used:
3.Refusal Role plays / Used as described
Used with changes
Did not use
Date(s) used:
7) Did you add any content or activities to Lesson 3?
Yes (if yes, please describe below)
No
Lesson 4: Understanding STD and HIV
1) Date(s) Lesson 4 was taught: ______Time:______
2) How many students attended? ______
3) How long did the lesson take? ______hrs
4) How many days was Lesson 4 taught to this group?
1 day 2 days 3 or more days Zero Days (lesson not covered)
Did you refer any students to additional services? Y/N # ______
5) Did you teach all of the core content in Lesson 4?Core CONTENT means WHAT is being taught in a curriculum. knowledge, attitudes, values, norms, skills, etc. / Describe any changes made and reasons for changing or leaving out content
1.KNOWLEDGE - re transmission, prevention, symptoms, treatment, consequences of untreated STDs / Yes
No
Not sure
Date(s) taught:
2.KNOWLEDGE = re accessing information to answer questions / Yes
No
Not sure
Date(s) taught:
6) Did you use each of these activities in Lesson 4? / Describe any changes made and reasons for changing or leaving out activities
1.STD Posters / Used as described
Used with changes
Did not use
Date(s) used:
2.Homework – Calling a Hotline / Used as described
Used with changes
Did not use
Date(s) used:
7) Did you add any content or activities to Lesson 4?
Yes (if yes, please describe)
No
Lesson 5: Examining the Risk of Unsafe Choices
1) Date(s) Lesson 5 was taught: ______Time:______
2) How many students attended? ______
3) How long did the lesson take? ______hrs
4) How many days was Lesson 5 taught to this group?
1 day 2 days 3 or more days Zero Days (lesson not covered)
Did you refer any students to additional services? Y/N # ______
5) Did you teach all of the core content in Lesson 5?Core CONTENT means WHAT is being taught in a curriculum. knowledge, attitudes, values, norms, skills, etc. / Describe any changes made and reasons for changing or leaving out content
1.ATTITUDES about having sex and getting pregnant / Yes
No
Not sure
Date(s) taught:
2.COMMUNICATION with parents. / Yes
No
Not sure
Date(s) taught:
3.KNOWLEDGE about accessing HIV/STD information and about HIV risk/transmission / Yes
No
Not sure
Date(s) taught:
4.PERCEPTION OF RISK about HIV transmission / Yes
No
Not sure
Date(s) taught:
6) Did you use each of these activities in Lesson 5? / Describe any changes made and reasons for changing or leaving out activities
Homework Review – Calling a Hotline / Used as described
Used with changes
Did not use
Date(s) used:
Homework Review – Then and Now / Used as described
Used with changes
Did not use
Date(s) used:
HIV Risk / Used as described
Used with changes
Did not use
Date(s) used:
Dealing with a Pregnancy / Used as described
Used with changes
Did not use
Date(s) used:
7) Did you add any content or activities to Lesson 5?
Yes (if yes, please describe)
No
Lesson 6: Examining the Risk of Unsafe Choices
1) Date(s) Lesson 6 was taught: ______Time:______
2) How many students attended? ______
3) How long did the lesson take? ______hrs
4) How many days was Lesson 6 taught to this group?
1 day 2 days 3 or more days Zero Days (lesson not covered)
Did you refer any students to additional services? Y/N # ______
5) Did you teach all of the core content in Lesson 6?Core CONTENT means WHAT is being taught in a curriculum. knowledge, attitudes, values, norms, skills, etc. / Describe any changes made and reasons for changing or leaving out content
1.ATTITUDES toward people with HIV/AIDS and about HIV/STD / Yes
No
Not sure
Date(s) taught:
2.KNOWLEDGE about HIV/AIDS transmission / Yes
No
Not sure
Date(s) taught:
3.BEHAVORAL BELIEF - that youth can reach goals and dreams / Yes
No
Not sure
Date(s) taught:
4.PERCEPTION of HIV/AIDS risk / Yes
No
Not sure
Date(s) taught:
6) Did you use each of these activities in Lesson 6? / Describe any changes made and reasons for changing or leaving out activities
1.Video-Teen AIDS in Focus / Used as described
Used with changes
Did not use
Date(s) used:
2.Personalizing the Impact / Used as described
Used with changes
Did not use
Date(s) used:
7) Did you add any content or activities to Lesson 6?
Yes (if yes, please describe)
No
Lesson 7: Practicing the SAFEST Choice
1) Date(s) Lesson 7 was taught: ______Time:______
2) How many students attended? ______
3) How long did the lesson take? ______hrs
4) How many days was Lesson 7 taught to this group?
1 day 2 days 3 or more days Zero Days (lesson not covered)
Did you refer any students to additional services? Y/N # ______
5) Did you teach all of the core content in Lesson 7?Core CONTENT means WHAT is being taught in a curriculum. knowledge, attitudes, values, norms, skills, etc. / Describe any changes made and reasons for changing or leaving out content
1.COMMUNICATION about attitudes/values re having sex, HIV, STD / Yes
No
Not sure
Date(s) taught:
2.SOCIAL/PEER NORMS re responding to lines; refusal skills / Yes
No
Not sure
Date(s) taught:
3.SKILLS re clear No statements, alternative actions, delay tactics, responding to pressure lines / Yes
No
Not sure
Date(s) taught:
4.SELF EFFICACY re expressing love/affection without sex, saying no, refusing sex / Yes
No
Not sure
Date(s) taught:
6) Did you use each of these activities in Lesson 7? / Describe any changes made and reasons for changing or leaving out activities
1.Refusal Skills Review / Used as described
Used with changes
Did not use
Date(s) used:
2.Responding to Lines / Used as described
Used with changes
Did not use
Date(s) used:
3.Refusal Skills Role plays / Used as described
Used with changes
Did not use
Date(s) used:
4.What Not Having Sex Means to Me / Used as described
Used with changes
Did not use
Date(s) used:
5.Homework-What Do You Think? / Used as described
Used with changes
Did not use
Date(s) used:
7) Did you add any content or activities to Lesson 7?
Yes (if yes, please describe)
No
Lesson 8:SAFER Choices: Using Protection – Part I
1) Date(s) Lesson 8 was taught: ______Time:______
2) How many students attended? ______
3) How long did the lesson take? ______hrs
4) How many days was Lesson 8 taught to this group?
1 day 2 days 3 or more days Zero Days (lesson not covered)
Did you refer any students to additional services? Y/N # ______
5) Did you teach all of the core content in Lesson 8?Core CONTENT means WHAT is being taught in a curriculum. knowledge, attitudes, values, norms, skills, etc. / Describe any changes made and reasons for changing or leaving out content
1.KNOWLEDGE re protection methods, safety / Yes
No
Not sure
Date(s) taught:
2.KNOWLEDGE about safety of different methods / Yes
No
Not sure
Date(s) taught:
3.SKILL-BUILDING and SELF-EFFICACY re accessing methods of protection / Yes
No
Not sure
Date(s) taught:
6) Did you use each of these activities in Lesson 8? / Describe any changes made and reasons for changing or leaving outactivities
1.Methods of Protection / Used as described
Used with changes
Did not use
Date(s) used:
2.Clarifying UNSAFE, SAFER and SAFEST Methods / Used as described
Used with changes
Did not use
Date(s) used:
3.Homework-Researching Methods of Protection / Used as described
Used with changes
Did not use
Date(s) used:
7) Did you add any content or activities to Lesson 8?
Yes (if yes, please describe)
No
Lesson 9:SAFER Choices: Using Protection – Part II
1) Date(s) Lesson 9 was taught: ______Time:______
2) How many students attended? ______
3) How long did the lesson take? ______hrs
4) How many days was Lesson 9 taught to this group?
1 day 2 days 3 or more days Zero Days (lesson not covered)
Did you refer any students to additional services? Y/N # ______
5) Did you teach all of the core content in Lesson 9?Core CONTENT means WHAT is being taught in a curriculum. knowledge, attitudes, values, norms, skills, etc. / Describe any changes made and reasons for changing or leaving out content
1.BEHAVORAL BELIEF - that youth can make proud and responsible choices / Yes
No
Not sure
Date(s) taught:
2.ATTITUDE - positive attitudes about safer sex / Yes
No
Not sure
Date(s) taught:
3.BEHAVORAL BELIEF - that youth can reach goals and dreams / Yes
No
Not sure
Date(s) taught:
4.KNOWLEDGE - about how to protect yourself from pregnancy / Yes
No
Not sure
Date(s) taught:
6) Did you use each of these activities in Lesson 9? / Describe any changes made and reasons for changing or leaving out activities
1.Condom Demonstration / Used as described
Used with changes
Did not use
Date(s) used:
2.Practicing Proper Use of Condoms / Used as described
Used with changes
Did not use
Date(s) used:
3.Barriers to Using Protection / Used as described
Used with changes
Did not use
Date(s) used:
4.Condom Negotiation Role plays / Used as described
Used with changes
Did not use
Date(s) used:
7) Did you add any content or activities to Lesson 9?
Yes (if yes, please describe)
No
Lesson 10:Knowing What You Can Do
1) Date(s) Lesson 10 was taught: ______Time:______
2) How many students attended? ______
3) How long did the lesson take? ______hrs
4) How many days was Lesson 10 taught to this group?
1 day 2 days 3 or more days Zero Days (lesson not covered)
Did you refer any students to additional services? Y/N # ______
5) Did you teach all of the core content in Lesson 10?Core CONTENT means WHAT is being taught in a curriculum. knowledge, attitudes, values, norms, skills, etc. / Describe any changes made and reasons for changing or leaving out content
1.ATTITUDES toward contraception, sex, and unprotected sex / Yes
No
Not sure
Date(s) taught:
2.COMMUNICATION with parents/other adults / Yes
No
Not sure
Date(s) taught:
3.INTENT to make safer choices / Yes
No
Not sure
Date(s) taught:
4.SKILLS –refusal skills and delaying tactics / Yes
No
Not sure
Date(s) taught:
6) Did you use each of these activities in Lesson 10? / Describe any changes made and reasons for changing or leaving out activities
1.Homework Review – Researching Methods of Protection / Used as described
Used with changes
Did not use
Date(s) used:
2.Homework Review – What Do You Think? / Used as described
Used with changes
Did not use
Date(s) used:
3.Closure – What You Can Do / Used as described
Used with changes
Did not use
Date(s) used:
7) Did you add any content or activities to Lesson 10?
Yes (if yes, please describe)
No