Form 1190-0021 Fidelity Log

FIDELITY LOG

OMB # 1190-0021

Expiration Date: XX/XX/XXXX

Evaluation of Community Relation Service (CRS) Process Evaluation

Fidelity Logs

The Evaluation team will use this toolkit to collect data from CRS staff and program facilitators on how well the program adhered to program facilitation guides. CRS staff and program facilitators will be asked to complete the fidelity log within 24 hours after program completion. All respondents may not be required to answer all the questions on the fidelity log.

Adherence to facilitator guides
Was the program implemented in the intended order or sequence?	Yes No
If no, please explain.
Was each activity in the facilitator guide completed?	Yes No
If any activity was partially completed or not done at all, please explain.
Did you add anything that was not part of this program as written in the facilitator’s guide (such as content, activities, and so on)?	Yes No
If yes, please describe what you added.
Did any “hot spots” occur that required you to de-escalate a situation? For example, a critical or contentious discussion that requires extra attention, or resources, such as disagreements, unexpected topics, challenging concepts, or bottlenecks	Yes No
If yes, please describe the situation and how you handled it.
Did you make any other changes to the program from what is in the facilitator’s guide?	Yes No
If yes, please describe what you changed and why.
For SPCP, SPIRIT, and DoR programs: Was a council group created?	Yes No
If not, please explain why.
Did you experience any distractions or interruptions during the program (such as loudspeaker announcements, participants arriving late, and so on)?	Yes No
How would you rate your satisfaction with the program’s implementation?	1 2 3 4 5 Not at all satisfied Very satisfied
Facilitator preparedness (for facilitators of the program only)
How prepared did you feel to deliver the program?	1 2 3 4 5 Not at all prepared Very prepared
What, if anything, would you do differently next time?
Participant engagement
How engaged were participants during the program?	1 2 3 4 5 Not engaged Actively engaged
What behaviors did you observe that led to this rating?
How comfortable did participants appear to be in engaging in these discussions?	1 2 3 4 5 Very uncomfortable Very comfortable
What behaviors did you observe that led to this rating?
Did the program have mix of participants, including members of the impacted community and those external to the community? Circle one.	Yes (all relevant parties were present) Somewhat (some key parties were present) No (no relevant parties were present)
Please explain.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control Number. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is voluntary. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to ATF, Contracts & Forms please contact Melody Diegor Caprio, CRS/DOJ, at 202-353-1806 or melody.caprio@usdoj.gov located at 145 N. ST NE, Washington, DC 20002, and reference OMB Control No. 11190-0021.