Post: ___/___=____% of program participants selected “Hugging.” Measure #4: % of program participants demonstrating an understanding of the most effective forms of birth control. Choose the three types of birth control that work the best at preventing pregnancy. (Multiple Choice or ranked) IUD Implant Pill Demo-Provera shot Patch Ring Condom Withdrawal Pre: ___/___=____% Post: ___/___=____% of program participants selected ALL (and only) correct answer choices. Pre: ___/___=____% Post: ___/___=____% of program participants selected “IUD.” Pre: ___/___=____% Post: ___/___=____% of program participants selected “Implant.” Pre: ___/___=____% Post: ___/___=____% of program participants selected “Pill.” Pre: ___/___=____% Post: ___/___=____% of program participants selected “Depo-Provera shot.” Pre: ___/___=____% Post: ___/___=____% of program participants selected “Patch.” Pre: ___/___=____% Post: ___/___=____% of program participants selected “Ring.” Pre: ___/___=____% Post: ___/___=____% of program participants selected “Condom.”
Pre: ___/___=____% Post: ___/___=____% of program participants selected “Withdrawal.” Measure #5: % of program participants demonstrating an understanding of correct condom use and storage. T or F: Storing or carrying condoms in a hot or warm place can make them less effective. Pre: ___/___=____% Post: ___/___=____% of program participants answered “True.” Measure #6: % of program participants demonstrating an understanding of reproductive health services available in their area. Name three places where you can get tested for STDs or HIV. (Answers will depend upon the resources available in your community. Some examples are local health departments, clinics, your doctor’s office, the AIDS Foundation, Centro Hispano, or Planned Parenthood). Pre: ___/___=____% Post: ___/___=____% of program participants listed THREE correct answer choices. Pre: ___/___=____% Post: ___/___=____% of program participants listed TWO correct answer choices. Pre: ___/___=____% Post: ___/___=____% of program participants listed ONE correct answer choice. ATTITUDES towards healthy behaviors and relationships. (Target is 50% for all indicators at posttest) Measure #7: % of program participants expressing a belief that abstinence is a good way to prevent pregnancy and STDs, including HIV. I think that abstinence is a good way to prevent pregnancy and STDs, including HIV. Yes No Pre: ___/___=____% Post: ___/___=____% of program participants answered “Yes.” Measure #8: I think it’s important to use birth control if I have sex. Pre: ___/___=____%
SKILLS necessary to practice healthy behaviors and relationships. (Target is 70% for all indicators at posttest) Measure #15: % of program participants demonstrating effective communication, negotiation, and refusal skills. Participants will pass off a roleplay scenario to their program educator/facilitator. Post: ___/___=____% of program participants demonstrated effective communication, negotiation, and refusal skills through an in-class roleplay scenario. Measure #16: % of program participants demonstrating correct condom use skills. Participants will pass off a condom demonstration to their program educator/facilitator. Post: ___/___=____% of program participants demonstrated correct condom use skills through an in-class condom demonstration activity. INTENTION to practice healthy behaviors. (Target is 40% for all indicators at posttest) Measure #17: % of program participants reporting an intention to practice abstinence. I intend to remain abstinent (not to have sex) at this point in my life. Yes No Pre: ___/___=____% Post: ___/___=____% of program participants answered “Yes.” Measure #18: % of program participants reporting an intention to use contraception. When I have sex (whenever that is for me) my partner or I will use birth control (like the pill, IUD, implant, patch, etc.) Yes No Pre: ___/___=____% Post: ___/___=____% of program participants answered “Yes.” Measure #19: % of program participants reporting an intention to use a specific form of contraception. What type of birth control do you or your partner plan to use? IUD Implant Depo-Provera shot Pill Patch Ring Withdrawal Pre: ___/___=____% Post: ___/___= ____% of program participants reported an intention to use the IUD. Pre: ___/___=____% Post: ___/___=____% of program participants reported an intention to use the implant.
% of program participants demonstrating an understanding of the correct way to use a condom. Measure #30: % of program participants demonstrating an understanding of when a condom should be put on. T or F: The penis should be hard when the condom is put on it. Pre: ___/___=____% Post: ___/___=____% of program participants answered “True.” Measure #31: % of program participants demonstrating an understanding of what should be checked before a condom is opened. What should you check before opening a condom? (Multiple Choice) There’s air in the package (It hasn’t been opened or punctured) Expiration Date It’s made of latex or polyurethane It wasn’t kept in the heat, sun, or a wallet for more than 24 hours Pre: ___/___=____% Post: ___/___=____% of program participants listed ALL (and only) correct answer choices. Pre: ___/___=____% Post: ___/___=____% of program participants selected “There’s air in the package.” Pre: ___/___=____% Post: ___/___=____% of program participants selected “Expiration Date.” Pre: ___/___=____% Post: ___/___=____% of program participants selected “It’s made of latex or polyurethane.” Pre: ___/___=____% Post: ___/___=____% of program participants selected “It wasn’t kept in the heat, sun, or a wallet for more than 24 hours.” Measure #32: T or F: A condom should be completely unrolled before it is placed on the penis. Pre: ___/___=____%
% of program participants demonstrating an understanding of when a condom should be unrolled. Post: ___/___=____% of program participants answered “False.” Measure #33: % of program participants demonstrating an understanding of the characteristics of a healthy relationship. Which of the following are characteristics of a healthy relationship? (Multiple Choice) Communication Being with them for their looks Honesty Respect Having things in common Being a little jealous Sexual activity Trust Spending all your time together Having boundaries Pre: ___/___=____% Post: ___/___=____% of program participants listed ALL (and only) correct answer choices. Pre: ___/___=____% Post: ___/___=____% of program participants selected “Communication.” Pre: ___/___=____% Post: ___/___=____% of program participants selected “Being with them for their looks.” Pre: ___/___=____% Post: ___/___=____% of program participants selected “Honesty.” Pre: ___/___=____% Post: ___/___=____% of program participants selected “Respect.” Pre: ___/___=____% Post: ___/___=____% of program participants selected “Having things in common.” Pre: ___/___=____% Post: ___/___=____% of program participants selected “Being a little jealous.” Pre: ___/___=____%
Post: ___/___=____% of program participants selected “Sexual activity.” Pre: ___/___=____% Post: ___/___=____% of program participants selected “Trust.” Pre: ___/___=____% Post: ___/___=____% of program participants selected “Spending all your time together.” Pre: ___/___=____% Post: ___/___=____% of program participants selected “Having boundaries.” Measure #34: % of program participants demonstrating an understanding of the role of sexual activity in a healthy relationship. T or F: Being in a healthy relationship includes being sexually active. Pre: ___/___=____% Post: ___/___=____% of program participants answered “False.” ATTITUDES towards healthy behaviors and relationships. (Target is 50% for all indicators at posttest) Measure #35: % of program participants expressing a belief that using birth control correctly and consistently will prevent pregnancy. I think that using birth control correctly all the time will prevent pregnancy. Yes No Pre: ___/___=____% Post: ___/___=____% of program participants answered “Yes.” Measure #36: % of program participants expressing a belief that using condoms correctly and consistently will prevent STDs and HIV. I think that using condoms correctly all the time will prevent STDs and HIV. Yes No Pre: ___/___=____% Post: ___/___=____% of program participants answered “Yes.” SKILLS necessary to practice healthy behaviors and relationships. (Target is 70% for all indicators at posttest)
Measure #37: % of program participants demonstrating an ability to set S.M.A.R.T. goals List three goals that you have for yourself. (Open ended—Answers must meet all the criteria of a S.M.A.R.T. Goal-- specific, measurable, achievable, realistic, and time-bound). Pre: ___/___=____% Post: ___/___=____% of program participants demonstrated an ability to set S.M.A.R.T. goals. PROGRAM INDICATORS: Program Indicators Activity Description Explanation 1 Major activities and accomplishments during this period. List major activities and accomplishments during this reporting period. 2 Challenges Describe any deviations or departures from the original project implementation plan including actual/anticipated slippage in task completion dates, and special problems encountered or expected. Describe actions taken to resolve the challenges presented. 3 Project Evaluation & Participant Data List the type and number of services provided to the target population. If you have additional relevant project data not reported on Forms A/B or in the pre/post survey data section, please outline here. 4 Organizational Issues Briefly describe any organizational (i.e. staffing and personnel, policy and procedures) and planning team issues that affected the management of the grant during the reporting period.