EVALUATION PACKET for IT S YOUR GAME KEEP IT REAL Grade 7

EVALUATION PACKET FOR IT’S YOUR GAME KEEP IT REAL – Grade 7

CAPP Coordinator______Dates for this cycle ___/___/___ - ___/___/___

Full name of lead agency______Is program facilitator a lead agency staff member? ___Yes ___No

Evaluation PacketCover Sheet

Do you want to avoid lots of follow-up calls and emails from the COE asking for clarification on your Attendance Records and Fidelity Checklists?This cover sheet will help CAPP Coordinators work with program facilitators to send accurate, complete data to the COE. Please use this sheet to review each cycle's evaluation packet with program facilitators.

Please return the evaluation packet as soon as possible after the end of the cycle.When the program cycle is complete, email this complete packet, including this Cover Sheet, the Attendance Record, and the Fidelity Checklist for one cycle of an EBP, to Amanda Purington, ACT for Youth Center of Excellence:

V2.12Evaluation Packet Page 1

EVALUATION PACKET FOR IT’S YOUR GAME KEEP IT REAL – Grade 7

Did you use the correct forms? The most recent version of each form is posted on the website:

Did you include the full, correct name of your lead agency above? (There are 58 CAPP agencies, including several Planned Parenthoods…please tell us exactly who you are!)

Attendance Record

Does the date rangegiven at the top of the form correspond to the individual dates given for each module?Are the dates accurate?

Have you provided all available demographics for each participant (age, ethnicity, race, gender)?

Have you removed the names of participants? (For confidentiality, all names must be removed before the COE can review the data.)

Fidelity Checklist

Are the datesaccurate for each module?

Was the site locationindicated?

Have you clearly explained every adaptation? Have you described what was done? Is the reason for adapting the program clearly stated? That is, can you determine both WHAT was changed and WHY it was changed from the description given?

If no adaptations are listed, have you checked with the facilitator to be sure this is correct? (The COE is attempting to track all adaptations – we are trying to learn how these EBPs are be used in real world settings.)

Are the Attendance Record and Fidelity Checklist consistent?

Do the individualdates listed on the Attendance Record match the individual dates on the Fidelity Checklist?

V2.12Evaluation Packet Page 1

EVALUATION PACKET FOR IT’S YOUR GAME KEEP IT REAL – Grade 7

Questions? Contact Amanda Purington at or 607-255-1861
Attendance Record for One EBP CycleDates for this cycle: __/__/__ - __/__/__

(EBP Cycle = One complete implementation of all the sessions for an EBP Total number of participants for this cycle: ___

as described in the facilitator's manual.)

Facilitators' Name(s) ______

Target Group? Check ONE:

___Youth in-school / After-school program___Youth out-of-school (not enrolled in school)___Runaway/homeless youth

___LGBTQ youth___Youth residing in institutions___Youth in foster care

___Incarcerated youth___Pregnant/parenting youth___Youth living with disability

___Recently immigrated youth___Youth involved in the juvenile justice system___Other:______

Participant's Name / Age / Ethnicity / Race / Gender / Module and Date
1. For each module, add date and module number
2. Place an X for each day the participant attended / Participant Number
IMPORTANT:
for confidentiality,
Remove names
before
submitting
to COE / Hispanic or Latino / Asian / Black / Native Hawaiian or other Pacific Islander / Native American / White / Other / Male / Female / Transgender / Date__/__/__ / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date:
Mod(s):__ / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s):
1
2
3
4
5
6
7
8
9
10
Age / Ethnicity / Race / Gender / Module and Date
1. For each module, add date and module number
2. Place an X for each day the participant attended / Participant Number
IMPORTANT:
for confidentiality,
Remove names
before
submitting
to COE / Hispanic or Latino / Asian / Black / Native Hawaiian or other Pacific Islander / Native American / White / Other / Male / Female / Transgender / Date__/__/__ / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date: / Date:
Mod(s):__ / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s): / Mod(s):

FIDELITY CHECKLIST

Facilitator(s)______Dates for this cycle ___/___/___ - ___/___/___

Site Location:

____ In School classroom ____ In-School after school program ____ Foster Care Facility ____ Other Residential Facility

____ Community Center /CBO____ Faith Based Institution ____ Clinical Setting ____ Other:______

Module 1: It’s Your Game Pre-Show

Module 2: Keeping It Real: Among Friends

Module 3: Keeping It Real: Among Friends

Activity / Date Activity Was Carried Out (MM/DD/YY)
if not carried out write“O” / Was Activity Carried Out According to Directions in the Facilitator’s Curriculum?
Y=YES
N=NO (describe changes in next column) / If Changed, WHAT was changed and WHY? Please be specific: describe things you left out, added, or changed and WHY. / Were Changes (If Any) Pre-Approved?
Y = YES
N = NO
A: Play Entire Lesson / Y / N / Y / N
B: Introduction To The Day / Y / N / Y / N
C: Recap: Build-A-Friend Activity / Y / N / Y / N
D: Reel World Serial / Y / N / Y / N
E: Peer Pressure And Social Support Activity / Y / N / Y / N
E: Teens Talk / Y / N / Y / N
F: Tailored Quiz Part I (Male) / Y / N / Y / N
G: Tailored Quiz Part I (Female) / Y / N / Y / N
H: Tailored Quiz Part II (Male) / Y / N / Y / N
I: Tailored Quiz Part II(Female) / Y / N / Y / N
J: Reel World Serial Evaluation / Y / N / Y / N
K: Reel World Serial Conclusion / Y / N / Y / N
L: Reel World Serial Discussion / Y / N / Y / N
M: Wrap-Up / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Module 4: It’s Your Game: Playing By Your Rules

Module 5: It’s Your Game: Playing By Your Rules

Activity / Date Activity Was Carried Out (MM/DD/YY)
if not carried out write“O” / Was Activity Carried Out According to Directions in the Facilitator’s Curriculum?
Y=YES
N=NO (describe changes in next column) / If Changed, WHAT was changed and WHY? Please be specific: describe things you left out, added, or changed and WHY. / Were Changes (If Any) Pre-Approved?
Y = YES
N = NO
A: Play Entire Lesson / Y / N / Y / N
B: Introduction To The Day / Y / N / Y / N
C: Recap: Select, Detect, Protect / Y / N / Y / N
D: Reel World Serial / Y / N / Y / N
E: Detect: Risky Or Not? / Y / N / Y / N
F: Teens Talk Video / Y / N / Y / N
G: Risky Situations: Tailored Quiz (Male) / Y / N / Y / N
H: Risky Situations: Tailored Quiz (Female) / Y / N / Y / N
I: The Fight/The Alley / Y / N / Y / N
J: Reel World Serial Evaluation / Y / N / Y / N
K: Reel World Serial Conclusion / Y / N / Y / N
L: Reel World Serial Discussion / Y / N / Y / N
M: Wrap-Up / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Module 6: Protecting Your Rules: A Clear No

Module 7: Protecting Your Rules: Alternative Actions

Module 8: Know Your Body

Activity / Date Activity Was Carried Out (MM/DD/YY)
if not carried out write“O” / Was Activity Carried Out According to Directions in the Facilitator’s Curriculum?
Y=YES
N=NO (describe changes in next column) / If Changed, WHAT was changed and WHY? Please be specific: describe things you left out, added, or changed and WHY. / Were Changes (If Any) Pre-Approved?
Y = YES
N = NO
A: Play Entire Lesson / Y / N / Y / N
B: Introduction To The Day / Y / N / Y / N
C: Body Development Introduction / Y / N / Y / N
D: Female Body Development / Y / N / Y / N
E: Male Body Development / Y / N / Y / N
F: Female Anatomy / Y / N / Y / N
G: Male Anatomy / Y / N / Y / N
H: The Expert’s Corner / Y / N / Y / N
I: About STDs / Y / N / Y / N
J: Menstruation and Reproduction / Y / N / Y / N
K: Wrap-Up / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Module 9: Keeping It Real: For Yourself

Module 10: Playing By Your Rules: Regarding Sex

Activity / Date Activity Was Carried Out (MM/DD/YY)
if not carried out write“O” / Was Activity Carried Out According to Directions in the Facilitator’s Curriculum?
Y=YES
N=NO (describe changes in next column) / If Changed, WHAT was changed and WHY? Please be specific: describe things you left out, added, or changed and WHY. / Were Changes (If Any) Pre-Approved?
Y = YES
N = NO
A: Play Entire Lesson / Y / N / Y / N
B: Introduction To The Day / Y / N / Y / N
C: The Story of LameBrain / Y / N / Y / N
D: LameBrain Recap / Y / N / Y / N
E: Reel World Serial / Y / N / Y / N
F: Teens Talk Video / Y / N / Y / N
G: James and Alana / Y / N / Y / N
I: Assess Intentions and Reasons (Female Version) / Y / N / Y / N
J: Assess Intentions and Reasons (Male Version) / Y / N / Y / N
K: Reducing the Risk / Y / N / Y / N
L: Reel World Serial Evaluation / Y / N / Y / N
M: Reel World Serial Conclusion / Y / N / Y / N
N: Wrap-Up / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Module 11: Protecting Your Rules: Regarding Sex

Module 12: It’s Your Game: Post Game Show

ADDITIONAL COMMENTS RE PROGRAM IMPLEMENTATION:

V2.12Evaluation Packet Page 1