EVALUATION PACKET for IT S YOUR GAME KEEP IT REAL Grade 8

EVALUATION PACKET FOR IT’S YOUR GAME KEEP IT REAL – Grade 8

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

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

Evaluation Packet Cover Sheet

C 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.

C 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:

V2.12 Evaluation Packet Page 17

EVALUATION PACKET FOR IT’S YOUR GAME KEEP IT REAL – Grade 8

Did you use the correct forms? The most recent version of each form is posted on the website: www.actforyouth.net/capp-tools

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 range given 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 dates accurate for each module?

Was the site location indicated?

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

V2.12 Evaluation Packet Page 17

EVALUATION PACKET FOR IT’S YOUR GAME KEEP IT REAL – Grade 8

Questions? Contact Amanda Purington at or 607-255-1861
Attendance Record for One EBP Cycle Dates 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: Consequences of Pregnancy

Module 3: Keeping It Real: Consequences of STIs

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: Reel World Serial / Y / N / Y / N
D: Expert’s Corner: What is HIV? / Y / N / Y / N
E: Teens Talk: HIV / Y / N / Y / N
F: HIV Transmission Game / Y / N / Y / N
G: Expert’s Corner II: What is an STD? / Y / N / Y / N
H: Teens Talk: STDs / Y / N / Y / N
I: Expert’s Corner III: Getting Tested Part I / Y / N / Y / N
J: Expert’s Corner III: Getting Tested Part II / Y / N / Y / N
K: Reel World Serial Evaluation / Y / N / Y / N
L: Reel World Serial Conclusion / 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 Keeping It Real: Consequences of STIs

Module 5: Keeping It Real: Risk Reduction Strategies

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: Reel World Serial / Y / N / Y / N
D: Expert’s Corner I / Y / N / Y / N
E: Marvin’s Story / Y / N / Y / N
F: Review Marvin’s Story / Y / N / Y / N
G: Expert’s Corner II / Y / N / Y / N
H: Condom Steps / Y / N / Y / N
I: Other Contraceptive Methods / Y / N / Y / N
J: Reducing the Risk (Contraceptive Methods) / Y / N / Y / N
K: Teens Talk / Y / N / Y / N
L: Reel World Serial Evaluation / Y / N / Y / N
M: Reel World Serial Conclusion / Y / N / Y / N
N: Reel World Serial discussion / Y / N / Y / N
O: Wrap-up / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Module 6: Playing By Your Rules: A Review

Module 7: Playing By Your Rules: A 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: Play Entire Lesson / Y / N / Y / N
B: Introduction To The Day / Y / N / Y / N
C: Recap: Select, Detect, Protect (Female) / Y / N / Y / N
D: Recap: Select, Detect, Protect (Male) / Y / N / Y / N
E: Reel World Serial / Y / N / Y / N
F: The Partner Challenge / Y / N / Y / N
G: Self Assessment (Female) / Y / N / Y / N
H: Self Assessment (Male) / Y / N / Y / N
I: Protecting Your Rules / Y / N / Y / N
J: Reel World Serial Evaluation / Y / N / Y / N
K: Reel World 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 8: Keeping It Real: Healthy Relationships

Module 9: Keeping It Real: Healthy 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: Play Entire Lesson / Y / N / Y / N
B: Introduction To The Day / Y / N / Y / N
C: Recap: The Dating Game (Female) / Y / N / Y / N
D: Recap: The Dating Game (Male) / Y / N / Y / N
E: Reel World Serial / Y / N / Y / N
F: Respecting Other Peoples’ Rules / Y / N / Y / N
G: Teens Talk / Y / N / Y / N
H: Evaluating Dating Relationships / Y / N / Y / N
I: Reel World Serial Evaluation / Y / N / Y / N
J: Reel World Serial Conclusion / Y / N / Y / N
K: Reel World Serial Discussion / Y / N / Y / N
L: Wrap-Up / Y / N / Y / N
Please use this space if you have comments on this module or any of its activities:

Module 10: Playing By Your Rules: Regarding Sex