EVALUATION PACKET FOR DRAW THE LINE/RESPECT THE LINE - 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:

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EVALUATION PACKET FOR DRAW THE LINE/RESPECT THE LINE - 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?

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EVALUATION PACKET FOR DRAW THE LINE/RESPECT THE LINE - 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:______

Add-On Session – Review of Reproduction

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: Reproductive System / Y / N / Y / N
B: Where Does It Belong – To The Male Or Female Body? / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Module 1: Welcome

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: Introduction and Plan for the Day / Y / N / Y / N
B: Class Rules / Y / N / Y / N
C: Draw the Line Logo / Y / N / Y / N
D: Dicho (Saying) for the Day / Y / N / Y / N
E: What Makes It Hard to Say NO to Sex? / Y / N / Y / N
F: Question Box and Closure / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Module 2: Reasons for Not Having 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: Lesson 1 Review / Y / N / Y / N
B: Plan for the Day / Y / N / Y / N
C: Tina and Marco / Y / N / Y / N
D: Closure / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Module 3: Handling Risky Situations

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: Lesson 2 Review / Y / N / Y / N
B:Plan for the Day / Y / N / Y / N
C: Warning Signs / Y / N / Y / N
D: Risky Situations: Small-Group Activity / Y / N / Y / N
E: Closure and Family Activity / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Module 4: Drawing the Line in Situations That Could Lead to 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: Lesson 3 and Homework Review / Y / N / Y / N
B: Plan for the Day / Y / N / Y / N
C: Draw the Line Review / Y / N / Y / N
D: Demonstration Role-Play / Y / N / Y / N
E: Student Role-Plays / Y / N / Y / N
F: Closure / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Module 5: STD Facts

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: Lesson 4 Review / Y / N / Y / N
B: Plan for the Day / Y / N / Y / N
C: STD Quiz / Y / N / Y / N
D: Story About STD / Y / N / Y / N
E: Quiz Review / Y / N / Y / N
F: STD Hotline Homework / Y / N / Y / N
G: Closure / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Module 6: STD and Relationships

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: Homework Review / Y / N / Y / N
B: Plan for the Day / Y / N / Y / N
C: Draw the Line Talk Show / Y / N / Y / N
D: Student Role-Plays / Y / N / Y / N
E: Closure / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Module 7: Making a Commitment

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: Plan for the Day / Y / N / Y / N
B: Dicho (Saying) for the Day / Y / N / Y / N
C: Draw the Line/Respect the Line Review / Y / N / Y / N
D: How Do You Draw the Line? / Y / N / Y / N
E: Question Box / Y / N / Y / N
F: Closure / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Add-On – Pregnancy Prevention and Birth Control Methods

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: Introduction – Meet The Contraceptives / Y / N / Y / N
B: Birth Control Methods Demonstration / 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:

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