Instr 5_Facilitator log_for OMB

OMB Control No: 0970-0356

Expiration Date: 0 2/29/2024

Facilitator Co-Regulation Implementation Log

DRAFT

August 2022

THE PAPERWORK REDUCTION ACT OF 1995

This collection of information is voluntary and will be used to provide the Administration for Children and Families with information to help refine and guide program development in the area of adolescent pregnancy prevention. Public reporting burden for the collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number and expiration date for this collection are OMB #: 0970-0356, Exp: 02/29/2024. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Tiffany Waits at twaits@mathematica-mpr.com.

Thank you in advance for completing this log! This study is sponsored by the Administration for Children and Families (ACF) within the U.S. Department of Health and Human Services and is being conducted by Mathematica. The purpose of this log is to understand what co-regulation strategies you used when teaching Love Notes today. The information you provide will help ACF learn about your experiences using these strategies when teaching youth.

Completion of this log is voluntary. There are no risks or benefits associated with completing the log, which should take about 3 minutes. We will not collect any personal information (for example, your name, email, or phone number). Your answers will remain private, except as required by law, and no staff at your organization will see your individual responses. We hope you complete the log, but you may skip any question you do not want to answer.

If you have any questions or comments about this information collection, contact Tiffany Waits, the survey director, at twaits@mathematica-mpr.com or (202) 264-3498. If you have any questions or concerns about your rights as a study participant, please contact the Health Media Lab Institutional Review Board at (202) 246-8504.

If you agree to complete this log, click NEXT to begin.

1. In how many classes did you teach Love Notes today?

Drop down with numbers 0-9 (if 0, skip to end)

Please answer the remaining questions about the first Love Notes class you taught today.

2. Which lesson of Love Notes did you teach during your first Love Notes class today?

Drop down with numbers 1-13

Thinking about the Welcome strategy …

3. Where were you located when students entered the classroom during your first Love Notes class today?

Select one response

m Near the entrance or door for the classroom 1

m Near the front of the classroom 2

m Near the back of the classroom 3

m Entering the classroom with the students 4

m Walking around the classroom 5

m Other 6

Fill for other: ________________________

4. How many students were you able to greet when they entered the classroom during your first Love Notes class today?

Select one only

m I greeted no students 1

m I greeted some students 2

m I greeted most students 3

m I greeted each student 4

5. How many one-on-one check-ins were you able to complete with individual students during your first Love Notes class today? A check-in involves having a personal conversations with a student and is separate from the content covered for Love Notes.

Drop down with numbers 0-9

6. How comfortable did you feel with the Welcome strategy during your first Love Notes class today?

Select one only

m I did not use the Welcome strategy today 0

m Not at all comfortable 1

m Somewhat comfortable 2

m Very comfortable 3

Thinking about the Breath to Focus strategy …

7. How many times were you able to use Breath to Focus during your first Love Notes class today?

Drop down with numbers 0-9 (If 0, skip to #10)

8. How many students participated in Breath to Focus during your first Love Notes class today?

Select one only

m No students 1

m A few students 2

m Most students 3

m All students 4

9. How comfortable did you feel using Breath to Focus during your first Love Notes class today?

Select one only

m I did not use the Breath to Focus strategy today 0

m Not at all comfortable 1

m Somewhat comfortable 2

m Very comfortable 3

Related to the Written Praise strategy …

10. How many Written Praise notes were you able to deliver to students during your first Love Notes class today?

Drop down with numbers 0-12

11. How comfortable did you feel delivering Written Praise notes to students during your first Love Notes class today?

Select one only

m I did not use the Written Praise strategy today 0

m Not at all comfortable 1

m Somewhat comfortable 2

m Very comfortable 3

Related to the Verbal Praise strategy …

12. Please share the approximate number of verbal praises you were able to provide during your first Love Notes class today.

	No verbal praise provided	Between 1 and 5 verbal praises provided	Between 6 and 10 verbal praises provided	More than 10 verbal praises provided
General verbal praise For example, “good job” or “great answer”	1 m	2 m	3 m	4 m
Specific verbal praise to a group of students For example, “your group worked well together to come up with a clear answer, it tells me how committed you are to the rest of the class”	1 m	2 m	3 m	4 m
Specific verbal praise to individual students For example, “Joe, I’ve noticed that when you work hard to focus in class, it has a powerful impact on our class community”	1 m	2 m	3 m	4 m

13. How comfortable did you feel providing Verbal Praise to students during your first Love Notes class today?

Select one only

m I did not use the Verbal Praise strategy today 0

m Not at all comfortable 1

m Somewhat comfortable 2

m Very comfortable 3

14. Overall, how engaged was the class in your first Love Notes class today?

Select one only

m Very disengaged 1

m Somewhat disengaged 2

m Somewhat engaged 3

m Very engaged 4

Thank you for sharing your experiences with us today.