PRESENTATION FORM INSTRUCTIONS - TheMeasurementGroup.com

ADOLESCENT SPNS PROJECT

PRESENTATION FORM INSTRUCTIONS

Use a black writing instrument (pen or pencil) to complete this form. Answer questions by either filling in a circle, or writing a number or letter in a square box. If the answer goes in a square box, you must use a CAPITAL LETTER or number that does not touch the side of the box. Print only one letter or number in each box. Make the letter or number look like those in the boxes on the Instructions form. If they do not, the computer cannot read your answers. If the letters or numbers that you print touch the sides of the boxes, or if you do not clearly print the information, the computer will "kick out" the form and we will need to return it to you to be completed correctly. If the question asks the answer to be filled in a circle, make sure that the circle is completely darkened.

Specific Parts of the Presentation Form

SPNS SITE. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form. If it has not been already entered on the form, check with your project to find out your site code and enter it in the boxes. Site codes are 2 or 3 letters.

PROVIDER. Enter the code for the service provider agency doing the activity. The provider codes are on a separate sheet. Provider codes are 2 or 3 letters.

Language Used. Fill in the circle next to the language used during the activity. Darken only one circle.

SERVICE DATE. Enter the numbers representing today's date (the date of the activity) in these boxes. Enter the month as a number from 01 to 12 for January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "94" for 1994). Make sure that if a month or day is less than 10, you place a "0" before the number.

HOUR. Enter the approximate time that the activity started in these boxes. Use a "0" as a place holder if you use a number less than 10. Then darken the circle to indicate AM or PM. For example, if the activity occurred at 1:30 in the afternoon, enter "01" for Hour and darken the circle next to "PM." Round the time to the nearest hour. For example, 12:31 to 1:30 is entered as "01" to indicate 1:00. Do not enter the time in military or 24-hour format (such as 13:00).

LENGTH MINUTES. Enter the number of minutes that the activity lasted in these three boxes. If the activity lasted less than 100 minutes, enter a "0" before the number of minutes. For example, if the activity lasted 25 minutes, you would enter "025"; if it lasted 5 minutes, you would enter "005."

STAFF PROVIDING SERVICES. Enter the staff member code or codes for each of the staff providing services in the boxes numbered #1, #2, and #3. The staff codes are on a separate sheet. If there are more than 3 staff members providing the service, the staff codes for combinations of staff should be used. Staff codes are 3 numbers.

Topics Discussed. For the items listed under "Topics Discussed," darken the circle next to all of the topics that were discussed during the activity. For example, if you discussed HIV Risk Factors, you would darken the circle labeled "HIV Risk Factors."

HIV Risk Factors. Darken this circle if the topics discussed related to HIV risk factors, including but not limited to sexual behaviors, injection and other drug use, blood sharing, and other factors that increase a person's risk for HIV.

"Safer" Sex. Darken this circle if the topics discussed related to "safer sex" and ways to reduce risk through using latex protection and less risky sexual behaviors.

HIV Testing. Darken this circle if the topics discussed related to getting HIV testing, what the test means, pre- and post-test counseling, implications of getting tested, and other related topics.

HIV Services. Darken this circle if the topics discussed related to getting prevention, intervention, and/or treatment services for HIV for oneself or someone else.

SPNS Services. Darken this circle if the topics discussed related specifically to the services provided by your program (funded by SPNS).

Community AIDS Response. Darken this circle if the topics discussed related to community reactions to HIV and AIDS, activism, advocacy, and other related issues.

Substance Abuse. Darken this circle if the topics discussed related to alcohol and other drug abuse, including but not limited to prevention, identification of abuse, intervention and treatment services, links between substance abuse and HIV, 12-step groups, and other related issues.

Social/Psych Services. Darken this circle if the topics discussed related to social and psychological services such as counseling and case management. Service needs, availability, and accessibility of community resources may be included here.

Health Services (General). Darken this circle if the topics discussed related to health and medical services in general, not necessarily specific to HIV or AIDS.

Youth Empowerment. Darken this circle if the topics discussed related to teaching youth skills to negotiate the service system on their own. This is similar to advocacy, but in youth empowerment the youth learns how to advocate for him or herself.

PURPOSE OF THE ACTIVITY. Darken the circle next to all of the items that describe the purpose of the activity. If there were other purposes that are not listed here, write in a short description of them in the boxes under "Other Purposes." Write the first purpose in the boxes labeled "#1" and if there was a second purpose that is not listed here, write it in the boxes labeled "#2."

Advocacy for Clients. Darken this circle if the activity included promoting the needs of specific clients or groups. The advocacy may be done by a service provider or case manager. If the advocacy is done by the youth(s) needing services, you should also darken the circle for "Youth Empowerment" under "TOPICS DISCUSSED."

Policy Advocacy. Darken this circle if the activity included promoting the needs of youth in general or specific groups to those who can affect change at a policy level. This may include decision makers, or community groups.

Agency Education/Training. Darken this circle if the activity included educational or training activities provided directly to agencies, as opposed to individuals or the community at large.

Agency Outreach. Darken this circle if the activity included outreach to service provider agencies to raise awareness and explain the purpose of your program.

Community Outreach. Darken this circle if the activity included outreach to the community (not other service provider agencies) to raise awareness and explain the purpose of your program.

Education/Lecture. Darken this circle if the activity included educational group presentations.

Group Prevention. Darken this circle if the activity included prevention activities directed at a group, as opposed to individual-level activities.

Cross-Training. Darken this circle if the activity included sharing information with other service provider agencies and individuals about topics related to their mission that can help them meet the needs of their clients-participants. For example, if your agency deals primarily with HIV and youth, you might provide cross-training to a drug treatment program to help them know how to deal with certain aspects of HIV among youth.

Health Fair. Darken this circle if the activity included information booths, brochure distribution, or other types of representation for your agency at a community health fair.

Recruit Volunteers. Darken this circle if the activity included recruitment of volunteers to work with your program.

Fund-Raising. Darken this circle if the activity included raising money or other resources for your program.

ITEMS PROVIDED AT THE ACTIVITY. Darken the circle next to all of the items that were provided at the activity. For example, if brochures and condoms were available, you would darken the circle next to "Brochures" and the circle next to "Condoms." If you provided an item that is not listed here, write in a short description of the item in the boxes labeled "Other."

Brochures. Darken this circle if brochures, pamphlets, or flyers were provided. Any short printed material can be counted as a brochure.

Other Educational Materials. Darken this circle if other educational materials were provided (not brochures, service directories, or wallet cards).

Referral Lists/Directories. Darken this circle if you provided referral lists or service provider directories.

Wallet Cards. Darken this circle if you provided a wallet card or other small card with information about hotlines, service provider agencies and other programs.

Food/Vouchers. Darken this circle if you provided food or food vouchers.

Condoms. Darken this circle if you provided condoms.

Dental Dams. Darken this circle if you provided dental dams.

Bleach. Darken this circle if you provided bleach or bleach kits.

Bus Tokens/Transport. Darken this circle if you provided bus tokens, transportation or vouchers (such as taxi vouchers).

SETTINGS/PARTICIPANTS. Darken the circle next to all of the groups who participated in this session. Darken all that apply.

School. School groups may include administrators, educators, students, and parents.

Religious. This may include church or other religious-affiliated groups, including clergy, congregations, youth groups, etc.

Health Care Prov. Includes physicians, nurses, and other related health care providers.

CJS Workers. Includes criminal justice system workers such as probation or parole officers, police, judges, corrections personnel, and others in the criminal justice system.

Soc Service Prov. Includes providers of social or mental health services such as social workers, counselors, drug treatment providers, case managers, etc.

Planning/Policy. Groups include administrators, elected officials, planning councils, advisory boards.

Family Members. Includes parents, siblings, and extended family members.

Grass Roots. Includes general community groups and grass-roots coalitions.

Peers/Youth. Includes youth the same age as those served by your program.

Community Services. Includes groups such as Rotary, Soroptomists, League of Women Voters, etc.

INDIVIDUALS SERVED, CONTACTED, OR REACHED

NUMBER OF MALES. Write the number of males participating in this activity. If you do not have an actual count, provide an estimate. If the number is less than 100, place "0"s to the left of the number.

% aged 9-17. Enter the percentage of males aged 9-17. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., 050).

% aged 18-24. Enter the percentage of males aged 18-24. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., 050).

% aged 25+. Enter the percentage of males aged 25 and older. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., 050).

The total of the three age categories should add to 100%.

% African Am-Black. Enter the percentage of African American males. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., 050).

% Caucasian-White. Enter the percentage of Caucasian males. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., 050).

% Native Am-Am Indian. Enter the percentage of Native American males. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., 050).

% Asian Am-Pac Island. Enter the percentage of Asian American males. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., 050).

% Hispanic-Latino. Enter the percentage of Hispanic or Latino males. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., 050).

% Other-Multiracial. Enter the percentage of males with other ethnic/racial backgrounds. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., 050).

The total of the six race/ethnicity categories should add to 100%.

NUMBER OF FEMALES. Write the number of females participating in this activity. If you do not have an actual count, provide an estimate. If the number is less than 100, place "0"s to the left of the number.

% aged 9-17. Enter the percentage of females aged 9-17. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., 050).

% aged 18-24. Enter the percentage of females aged 18-24. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., 050).

% aged 25+. Enter the percentage of females aged 25 and older. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., 050).

The total of the three age categories should add to 100%.

% African Am-Black. Enter the percentage of African American females. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., 050).

% Caucasian-White. Enter the percentage of Caucasian females. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., 050).

% Native Am-Am Indian. Enter the percentage of Native American females. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., 050).

% Asian Am-Pac Island. Enter the percentage of Asian American females. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., 050).

% Hispanic-Latino. Enter the percentage of Hispanic or Latino females. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., 050).

% Other-Multiracial. Enter the percentage of females with other ethnic/racial backgrounds. If you do not have an actual count, provide an estimate. If the percentage is less than 100, place "0"s to the left of the percentage (e.g., 050).

The total of the six race/ethnicity categories should add to 100%.

Actual %s and Counts Used. Darken this circle if the numbers you provided were actual percentages and counts. If this is not marked, it will be assumed that they are estimates.

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