The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

CdUEJNdB77yB7coXsSBMuq5jMVh6CFuMbGzvMjiqMGSq79a9gN8kfHMrMARaQ627BNAN2ryfQwtzrpVq

SRAE Fidelity Monitoring Form

Please complete the fidelity monitoring form for each curriculum sessions delivered within 72 hours after completion.

The information collected will ensure that:

Documentation of challenges for technical assistance needs
Adaptations made are for making program suitable for population without compromising core components
Positive outcomes accross all programs
Ensures identification of common barriers to advocate for changes if necessary

Please contact Sheila Amenumey at sheila.amenumey@state.mn.us or 651-201-3599 if you have any questions.

Thank you!

Funded SRAE Agency:

Division of Indian Work

Hennepin County/Minneapolis Health Department

St.Paul-Ramsey County

St James/Watonwan School District

MN Care/West Side Community Health Services

reset

Name of SRAE subsite funded by ______ if applicable:

Facilitator:

Staff completing this form (if not the same as the facilitator):

Program Setting:

In school, during school

In school, after school

In a community-based organization

In a clinic (includes school based clinics)

In a foster care setting

In a juvenile detention setting

In a residential mental health treatment facility

In another setting

reset

Please specify setting:

How was the session delivered?

In-person - select this option if session was face to Tele
Virtual - select this option if session was over
platforms such as Zoom, Google Meet, or Skype

In-person

Virtual

reset

Curriculum Implemented:

Making Authentic Choices

It's Easy

Making a Difference

Program Aim

Live It!

Top

Other

Positive Potential

reset

Please specify curriculum:

Date this session was delivered:

M-D-Y H:M

Approximate duration (hours and minutes) of this session:

Please include the time for all activities covered in this session.

H:M

Total number of participant in this session:

Total number of youth's parents/guardians and caring adults who attended this program session:

How many of the participants are in middle school?

How many of the participants are in high school?

Total participants = Middle School + High School

View equation

Total participants (middle school + high school) =
Total participants who attended this Session

Please review data entry if you see "99"

View equation

Were there challenges with the implementation of the ______ according the instructions in the facilitators manual/guide?

Yes

reset

Describe challenges you faced during this session:

*Include challenges faced due to COVID-19 pandemic

Expand

Did you make any changes to the activities?

Yes

reset

What changes were made to the session?

Activities were eliminated or skipped

Activities were substituted

Activities were modified

reset

Which activity was eliminated or skipped and why?

Expand

Which activity was substituted and why?

Expand

Which activity was modified and why?

Expand

How effective was the change(s)?

Very effective

Effective

Neutral

Ineffective

Very Ineffective

reset

Were the changes approved by the MDH or the program developers?

Yes

reset

Please email MDH PREP team as soon as possible if you made changes to the curriculum without approval:

Sheila Amenumey: sheila.amenumey@state.mn.us or gabriel.mcneal@state.mn.us

Thank you,

MDH PREP Team

Please indicate if ______ was observed delivering the program:

Yes

reset

Who observed ______ delivering this session? (Please provide name and organization of the observer)

Please select all that apply to your session activities:

Facilitator gender matched to participants

curriculum activities included reflection activity/Bringing it full circle

Session included community service learning exercise

Indigenous facilitator knowledgeable in language and cultural traditions

Lessons ended with closing circle

None of the above applies to this program

Other traditional/cultural curriculum activities not mentioned above

Please specify:

Please include any additional information that will be useful for evaluating the fidelity of ______:

Expand

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.