EVALUATION PACKET FOR ABAN AYA YOUTH PROJECT GRADE 6

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 ABAN AYA YOUTH PROJECT GRADE 6

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 ABAN AYA YOUTH PROJECT GRADE 6

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:______

Lesson 1: Welcome Back to the Aban Aya Youth Project!

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: Welcome & Introduction / Y / N / Y / N
B: Aban Aya Symbols / Y / N / Y / N
C: Aban Aya Ground Rules / Y / N / Y / N
D: Review Goal-setting / Y / N / Y / N
E: ABAN AYA Goal Shield: What ABAN AYA Goals have you Worked On? / Y / N / Y / N
F: Wrap-up / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson2: Values & Goals

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: Review ABAN AYA Goal Shield / Y / N / Y / N
B: Review Values / Y / N / Y / N
C: Values Game / Y / N / Y / N
D: Complete Goal Shields & Wrap-up / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson3: Ujima Cheza – Check Yourself Review

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: Review Goal Shield Progress / Y / N / Y / N
B: Review Check Yourself in Ujima Groups / Y / N / Y / N
C: Ujima Cheza - I / Y / N / Y / N
D: Wrap Up & Country Flag Assignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson4: Check Your Beliefs

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: UJIMA CHEZA: Bonus Round / Y / N / Y / N
B: Checking Your Beliefs / Y / N / Y / N
C: Proverb & Special Assignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson5: STOP – Look & Listen

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: Review Proverb Assignment & Reinforce Previous Lesson / Y / N / Y / N
B: What Do I need to Know? Understanding the Situation / Y / N / Y / N
C: What’s Happening Game / Y / N / Y / N
D: Calming Down / Y / N / Y / N
E: Wrap-up / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson6: What Do Others Believe?

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: Ujima Group Activity: What Others Believe / Y / N / Y / N
B: What Could Support Me or Get In My Way / Y / N / Y / N
C: Wrap-up and Special Assignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson7: ABAN AYA Quiz #1 & Talk Time – Safety First

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: Administer & Review Quiz 1 / Y / N / Y / N
B: Review Special Assignment: What Others Believe / Y / N / Y / N
C: Talk Time: Safety First / Y / N / Y / N
D: Wrap-up / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson8: How Do You Solve Your Problems?

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: Working it Out- Non-Violently / Y / N / Y / N
B: ROLE PLAY: Dealing With Conflicts / Y / N / Y / N
C: Wrap-up: Proverb & Special Assignment / Y / N / Y / N
D: Distribute Graded Quizzes / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 9: Expressing Your Anger in a Positive Way

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: Review Special Assignment / Y / N / Y / N
B: Learning How To “Talk It Out” With Ananse / Y / N / Y / N
C: ROLE PLAY: Can You Control Your Anger? / Y / N / Y / N
D: Wrap-up: Proverb & Special Assignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 10: Listening Skills

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: Review Special Assignment / Y / N / Y / N
B: Introduce Listening Skills & Proverb / Y / N / Y / N
C: Model & Practice Listening Skills / Y / N / Y / N
D: Putting It All Together – TALKING IT OUT / Y / N / Y / N
E: Parent Letter / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 11: Managing Anger

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: Introduce Proverb / Y / N / Y / N
B: Coping With Anger / Y / N / Y / N
C: ROLE PLAY: Putting It All Together – TALKING IT OUT / Y / N / Y / N
D: Announcements: Quiz #2 & Special Assignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 12: ABAN AYA Quiz #2 & Griot Circle: Let’s Rap!!

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: Administer & Review Quiz 2 / Y / N / Y / N
B: Activity: Griot Circle / Y / N / Y / N
C: Wrap-up / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 13: The ABC’s of Puberty

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: Review Special Assignment / Y / N / Y / N
B: Discussion: Puberty and Me / Y / N / Y / N
C: Facts and Beliefs About Puberty/Sex / Y / N / Y / N
D: Wrap-up & Special Assignment / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 14: The Realities of HIV & AIDS, Part I

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: Overview of Today’s Lesson& Introduce Proverb / Y / N / Y / N
B: Introduction & Discussion of HIV/AIDS / Y / N / Y / N
C: Special Assignment: PSA / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 15: The Reality of HIV & AIDS, Part II

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: Review Previous Lesson / Y / N / Y / N
B: Review The “What Do You Know About HIV/AIDS” Special Assignment / Y / N / Y / N
C: Review PSAs / Y / N / Y / N
D: Wrap-up / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 16: Having Fun & Staying Healthy

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: Influences on Decisions About Sexual Behavior / Y / N / Y / N
B: How Did I Get Here? Roll Back Risky Situations / Y / N / Y / N
C: Role Play / Y / N / Y / N
D: Wrap-up / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 17: ABAN AYA Quiz #3 & Griot Circle – Let’s Rap!

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: Administer & Review Quiz 3 / Y / N / Y / N
B: Griot Circle / Y / N / Y / N
C: Wrap-up / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Lesson 18: ABAN AYA Carries On…

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: Brief Review& Introduce Proverb / Y / N / Y / N
B: ABAN AYA SUMMMER – in Ujima Groups / Y / N / Y / N
C: ABAN AYA SUMMMER: Students Work on Personal Sheet / Y / N / Y / N
D: Wrap-up / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

ADDITIONAL COMMENTS RE PROGRAM IMPLEMENTATION:

V2.12Evaluation Packet Page 1