OFFICE OF JUVENILE JUSTICE AND DELINQUENCY PREVENTION JUVENILE MENTORING GRANT PROGRAM DCTAT SUBGRANTEE DATA COLLECTION FORM

Reporting Period: ________________________

This document is for your use to assist with gathering information that should be reported into the DCTAT tool. It is not necessary to submit this form to OJJDP. It is only for your information.

Award Information
Solicitation: (Prepopulated) Federal award number: (Prepopulated) Award Period Start Date: (Prepopulated) Award Period End Date: (Prepopulated)
(mm/dd/yyyy) (mm/dd/yyyy)

1. Please enter the total amount of grant (Federal Funds Only): $ 2. Was there grant activity during the reporting period?

*Any funds reported only represent an estimate of dollars allocated or used for activities covered by this grant award. Grant activity is defined as proposed activities in the OJJDP-approved grant application that are implemented or executed with the OJJDP grant.

___ Yes

___ No

3. Please enter the Federal Congressional District(s) of where services are provided: ___________________
Check boxes will appear in the system, where you will select your state/territory and Federal Congressional District(s). Click http://www.house.gov, to use the zip code(s) of the area(s) served by the project to determine the Federal Congressional District(s).

4. Please enter the Project Title: a. Please enter the Project Description: 5. Please enter the Implementing Organization Name: 6. Please select the implementing organization type:
___ Coalition ___ Juvenile Justice ___ Non-profit community-based organization ___ Other community-based organization ___ Other government agency ___ Police/other law enforcement ___ School/Other Education ___ Tribal Government ___ Unit of local government

7. Is this award used to implement evidence-based programs? 8. If yes, select one source from which the program model was cited:
___ Blueprints for Violence Prevention ___ CASEL (Collaborative for Academic, Social, & Emotional learning) ___ Centers for Disease Control and Prevention ___ Community Guide to Helping Americas Youth ___ Department of Education Safe, Disciplined, & Drug-free Schools ___ Drug Strategies, Inc. ___ Making the Grade

___ Yes

___ No

___ Hamilton Fish Institute ___ Institute for Medicine ___ NIDA Preventing Drug Abuse ___ National Institute of Justice What Works Report ___ OJJDP Model Programs Guide ___ Promising Practices Network ___ SAMSHA Model Programs ___ Surgeon Generals Youth Violence Report ___ Other (e.g., State model program resources) 1

9. If other, please specify:

OFFICE OF JUVENILE JUSTICE AND DELINQUENCY PREVENTION JUVENILE MENTORING GRANT PROGRAM Target Population for this Subaward
Please check the appropriate boxes to indicate for this subaward: 1. The population actually served during the project period; and 2. The populations, if any, to which the program offers targeted services. Targeted services include any services or approaches specifically designed to meet the needs of the population (e.g., gender specific, culturally based, developmentally appropriate services).
1. Did you serve this group during the reporting period? ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ 2. Did this subgrant provide targeted services for any of the following groups? ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Population

American Indian/Alaskan Native Asian Black/African American Hispanic or Latino (of any race) Native Hawaiian and Other Pacific Islander Other Race White/Caucasian Youth population not directly served At-Risk Population (no prior offense) First Time Offenders Repeat Offenders Sex Offenders Status Offenders Violent Offenders Youth population not directly served Male Female Youth population not directly served 0-10 11-18 Over 18 Youth population not directly served Rural Suburban Tribal Urban Youth population not directly served Mental Health Substance Abuse Truant/Dropout

OTHER

GEO

AGE

GENDER

JUSTICE

RACE/ETHNICITY

OFFICE OF JUVENILE JUSTICE AND DELINQUENCY PREVENTION JUVENILE MENTORING GRANT PROGRAM
Bold indicates mandatory indicators.

Performance Measures
Output Measure
1

Definition

Data Grantee Provides

A. The number of youth served using an evidence-based model or program B. The number of youth served C. Percent (A/B)

Record Data Here

Number and percent of The number and percent of youth with whom an youth with whom an evidence-based practice was used. Evidenceevidence-based practice was based practice models include program models used that have been shown, through rigorous evaluation and replication, to be effective at preventing or reducing juvenile delinquency or related risk factors, such as substance abuse. Model programs can come from many valid sources (e.g., Blueprints, OJJDPs Model Programs Guide, SAMHSAs Model Programs, state model program resources, etc.) Increase in number of program mentors recruited The number of new mentors recruited during the reporting period. Recruited mentors are those who have completed requirements to be ready for training. Program records are the preferred data source.

A. The increase in number of program mentors recruited (ready for training) during the reporting period

Number and percent of program mentors successfully completing training

The number and percent of program mentors successfully completing training during the reporting period. Program records are the preferred data source.

A. Number of program mentors successfully completing training during the reporting period B. Total number of program mentors who began training during the reporting period C. Percent (A/B) A. Number of trained program mentors demonstrating increased knowledge of the program during the reporting period B. Number of trained program mentors (Auto fill from 3A) C. Percent (A/B) A. Number of mentors who have left the program during the reporting period B. The total number of mentors in the program during the reporting period C. (B A)/B = Mentor Retention Rate A. Number of youth enrolled at the beginning of the reporting period B. Number of NEW youth added during the reporting period

Number and percent of The number of trained program mentors trained program mentors demonstrating increased knowledge of the with increased knowledge of program during the reporting period. the program area Program records are the preferred data source. Mentor Retention The number of program mentors retained by the program within the reporting period. Program records are the preferred data source.

Increase in youth enrolled since the beginning of the grant program

Increase in the number of youth enrolled (being mentored) since the beginning of the grant program.

OFFICE OF JUVENILE JUSTICE AND DELINQUENCY PREVENTION JUVENILE MENTORING GRANT PROGRAM
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1

Outcome Measure
Percent of mentoring programs with active partners

Definition
The percent of mentoring programs with active partners representing the following types of groups: non-profit service organizations and / or faith based organizations; private industry; secondary education provider; and post-secondary education provider or vocational training provider; other active partners. The number and percent of program youth who have successfully fulfilled all program obligations and requirements. This does not include youth who are still in ongoing programs. Program obligations will vary by program, but should be a predefined list of requirements or obligations that clients must meet before program completion. The total number of youth (the B value) includes those youth who have exited successfully and unsuccessfully. Program records are the preferred data source.

Data Grantee Provides

A. Number of mentoring programs with active partners B. Number of mentoring programs C. Percent (A/B)

Record Data Here

Number and percent of program youth completing program requirements (short term)

A. Number of program youth who exited the program having completed program requirements B. Total number of youth who exited the program during the reporting period (both successfully and unsuccessfully) C. Percent (A/B)

Select at least one of the following from 3A through 3I depending on the primary focus of the program. 3A Antisocial behavior (short term) The number and percent of youth who have exhibited a decrease in antisocial behavior during the reporting period. A. Number of program youth served during the reporting period with the noted behavioral change B. Total number of youth receiving services for Anti-social behavior is a pervasive pattern of target behavior during the reporting period behavior that displays disregard for and violation of C. Percent (A/B) the rights of others, societal mores, or the law (such as deceitfulness, irritability, consistent irresponsibility, lack of remorse, failure to conform to social norms). Self-report or staff ratings are the most likely data sources. 3A Antisocial behavior (long term) The number and percent of program youth who exhibited a desired change in antisocial behavior 612 months after exiting the program. Antisocial behavior is a pervasive pattern of behavior that displays disregard for and violation of the rights of others, societal mores, or the law (such as deceitfulness, irritability, fighting, disruptive behavior, consistent irresponsibility, lack of remorse, or failure to conform to social norms). Self-report or staff ratings are the most likely data sources. A. Total number of youth who exited the program 6-12 months ago who had the noted behavioral change B. Total number of youth who received services for the target behavior and who exited the program 612 months ago C. Percent (A/B)

OFFICE OF JUVENILE JUSTICE AND DELINQUENCY PREVENTION JUVENILE MENTORING GRANT PROGRAM
# Outcome Measure Definition Data Grantee Provides Record Data Here

3D Gang resistance/involvement (short term)

The number and percent of program youth who have exhibited a desired change in gang resistance behavior during the reporting period. Self-reported or staff ratings are the most likely data sources.

A. Number of program youth served during the reporting period with the noted behavioral change B. Total number of youth receiving services for target behavior during the reporting period C. Percent (A/B) A. Total number of youth who exited the program 6-12 months ago who had the noted behavioral change B. Total number of youth who received

3D Gang resistance/involvement (long term)

The number and percent of program youth who exhibited a desired change in gang resistance behavior 612 months after exiting the program. Self-report or staff ratings are the most likely data sources.

services for the target behavior and who exited the program 612 months ago
C. Percent (A/B) A. Number of program youth served during the reporting period with the noted behavioral change B. Total number of youth receiving services for target behavior during the reporting period C. Percent (A/B)

3E Substance use (short term)

The number and percent of program youth who have exhibited a decrease in substance use during the reporting period. Self-report or staff ratings are most likely data sources.

OFFICE OF JUVENILE JUSTICE AND DELINQUENCY PREVENTION JUVENILE MENTORING GRANT PROGRAM
# Outcome Measure Definition
The number and percent of program youth who exhibited a decrease in substance use 612 months after exiting the program. Self-report, staff rating, or urinalysis are most likely data sources. 3F School attendance (short term) The number of program youth who have exhibited an increase in school attendance during the reporting period. Self-report or staff ratings are most likely data sources. 3F School attendance (long term) The number and percent of program youth who exhibited a desired change in school attendance 612 months after exiting the program. Self-report or official records are the most likely data sources.

Data Grantee Provides

A. Total number of youth who exited the program 6-12 months ago who had the noted behavioral change B. Total number of youth who received services for the target behavior and who exited the program 612 months ago C. Percent (A/B) A. Number of program youth served during the reporting period with the noted behavioral change B. Total number of youth receiving services for target behavior during the reporting period C. Percent (A/B) A. Total number of youth who exited the program 6-12 months ago who had the noted behavioral change. B. Total number of youth who received services for the target behavior and who exited the program 612 months ago C. Percent (A/B)

Record Data Here

3E Substance use (long term)

3H GPA (short term)

The number and percent of program youth who exhibited an increase in GPA during the reporting period. Self-report or staff ratings are most likely data sources.

A. Number of program youth served during the reporting period with the noted behavioral change B. Total number of youth receiving services for target behavior during the reporting period C. Percent (A/B) A. Total number of youth who exited the program 612 months ago who had the noted behavioral change B. Total number of youth who received services for the target behavior and who exited the program 612 months ago C. Percent (A/B)

3H GPA (long term)

The number and percent of program youth who exhibited a desired change in GPA 612 months after exiting the program. Self-report or official records are the most likely data sources.

OFFICE OF JUVENILE JUSTICE AND DELINQUENCY PREVENTION JUVENILE MENTORING GRANT PROGRAM
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3I

Outcome Measure

Definition

Data Grantee Provides

Record Data Here

Number and percent of program youth who OFFEND (short term) Updated 11/04/2011

The number and percent of participating program A. Number of program youth tracked during the youth who were arrested or seen at a juvenile court reporting period for a delinquent offense during the reporting B. Of A, the number of program youth who had period. Appropriate for any youth-serving program. an arrest or delinquent offense during the Official records (police, juvenile court) are the reporting period preferred data source. C. Number of program youth who were committed to a juvenile facility during the The number of youth tracked should reflect the reporting period number of program youth that are followed or D. Number of program youth who were monitored for arrests or offenses. Ideally this sentenced to adult prison during the number should be all youth served by the program reporting period during this reporting period. E. Percent OFFENDING (B/A) A youth may be committed to a juvenile facility anytime that he/she is held overnight. Certain jurisdictions refer to adjudications as sentences. Example: If I am tracking 50 program youth then, A would be 50. Of these 50 program youth that I am tracking, if 25 of them were arrested or had a delinquent offense during the reporting period, then B would be 25. This logic should follow for C values. The percent of youth offending measured short-term will be auto calculated in D.

OFFICE OF JUVENILE JUSTICE AND DELINQUENCY PREVENTION JUVENILE MENTORING GRANT PROGRAM
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5

Outcome Measure
Number and percent of program youth who OFFEND (long term) Updated 11/04/2011

Definition

Data Grantee Provides

Record Data Here

The number and percent of participating program A. Total number of program youth who exited the program 6-12 months ago that you are youth who were arrested or seen at a juvenile court tracking for a delinquent offense during the reporting period. Appropriate for any youth-serving program. B. Of A, the number of program youth who had an arrest or delinquent offense during the Official records (police, juvenile court) are the reporting period preferred data source. C. Number of program youth who were committed to a juvenile facility during the The number of youth tracked should reflect the reporting period number of program youth that are followed or D. Number of program youth who were monitored for arrests or offenses 6-12 months after sentenced to adult prison during the exiting the program. reporting period E. Percent OFFENDING (B/A) A youth may be committed to a juvenile facility anytime that he/she is held overnight. Certain jurisdictions refer to adjudications as sentences. Example: A grantee may have several youth who exited the program 6-12 months ago, however, they are tracking only 100 of them, therefore, and the A value will be 100. Of these 100 program youth that exited the program 6-12 months ago. 65 had an arrest or delinquent offense during the reporting period, therefore the B value should be recorded as 65. This logic should follow for C values. The percent of youth offending measured long-term will be auto calculated in D.

Number and percent of program youth who RE-OFFEND (short term) Updated 11/04/2011

The number and percent of participating program A. Number of program youth tracked during the reporting period youth who were arrested or seen at a juvenile court B. Of A, number of program youth who had a for a new delinquent offense during the reporting new arrest or new delinquent offense during period. Appropriate for any youth-serving program. the reporting period Official records (police, juvenile court) are the C. Number of program youth who were preferred data source. recommitted to a juvenile facility during the reporting period The number of youth tracked should reflect the D. Number of program youth who were number of program youth that are followed or sentenced to adult prison during the monitored for new arrests or offenses. Ideally this reporting period number should be all youth served by the program E. Number of youth who received another during this reporting period. sentence during the reporting period F. Percent RECIDIVISM (B/A) Certain jurisdictions refer to adjudications as sentences. Example: If I am tracking 50 program youth then the A value would be 50. Of these 50 program youth that I am tracking, if 25 of them had a new arrest or had a new delinquent offense during the reporting period, then B would be 25. This logic should follow for C, D, and E values. The percent of youth re-offending measured short-term will be auto calculated in F.

OFFICE OF JUVENILE JUSTICE AND DELINQUENCY PREVENTION JUVENILE MENTORING GRANT PROGRAM
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7

Outcome Measure
Number and percent of program youth who RE-OFFEND (long term) Updated 11/04/2011

Definition

Data Grantee Provides

Record Data Here

The number and percent of participating program A. Total number of program youth who exited the program 6-12 months ago that you are youth who were arrested or seen at a juvenile court tracking for a new delinquent offense during the reporting period. Appropriate for any youth-serving program. B. Of A, the number of program youth who had an arrest or delinquent offense during the Official records (police, juvenile court) are the reporting period preferred data source. C. Number of program youth who were committed to a juvenile facility during the The number of youth tracked should reflect the reporting period number of program youth that are followed or D. Number of program youth who were monitored for new arrests or offenses 6-12 months sentenced to adult prison during the after exiting the program. reporting period E. Percent OFFENDING (B/A) Ex. I have a lot of youth who exited my program 612 months ago, but we are only tracking 100 of them, so A is 100. Of these 100 program youth that exited the program 6-12 months ago 65 had a new arrest or delinquent offense during the reporting period, so B is 65. The measure determines the number of program youth who are harmed or adversely affected by someone elses criminal actions. Victimization can be physical or psychological; it also includes harm or adverse effects to youths property. The number of youth tracked should reflect the number of program youth that are followed or monitored for victimization. Ideally this number should be all youth served by the program during the reporting period. Example: If I am tracking 50 program youth, then, the B value would be 50. Of these 50 program youth that I am tracking, if 25 of them were victimized during the reporting period, then B would be 25. The percent of youth who are victimized measured short-term will be auto calculated in C based on A and B values. A. Number of program youth tracked during the reporting period for victimization B. Of A, the number of program youth who were victimized C. Percent VICTIMIZED (B/A)

Number and percent of program youth who are VICTIMIZED (short term) Updated 11/04/2011

Number and percent of program youth who are VICTIMIZED (long term) Updated 11/04/2011

The measure determines the number of program youth who are harmed or adversely affected by someone elses criminal actions. Victimization can be physical or psychological; it also includes harm or adverse effects to youths property. The number of youth tracked should reflect the number of program youth that are followed or monitored for victimization 6-12 months after exiting the program. Example: A grantee may have several youth who exited the program 6-12 months ago, however, they are tracking only 100 of them, therefore, and the A value will be 100. Of these 100 program youth that exited the program 6-12 months ago 65 had been victimized during the reporting period, therefore the B value should be recorded as 65. The percent of youth who are victimized measured long-term will be auto calculated in C based on A and B values.

A. Number of program youth who exited the program 6-12 months ago that you are tracking for victimization B. Of A, the number of program youth who were victimized during the reporting period C. Percent VICTIMIZED (B/A)

OFFICE OF JUVENILE JUSTICE AND DELINQUENCY PREVENTION JUVENILE MENTORING GRANT PROGRAM
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10

Outcome Measure
Number or percentage of youth who are RE-VICTIMIZED (short term) Updated 11/04/2011

Definition
The re-victimization measure counts the number of youth who experienced subsequent victimization. Victimization can be physical or psychological; it also includes harm or adverse effects to youths property. The number of youth tracked should reflect the number of program youth that are followed or monitored for re-victimization. Ideally this number should be all youth served by the program during the reporting period. Example: If I am tracking 50 program youth, then, the B value would be 50. Of these 50 program youth that I am tracking, if 25 of them were revictimized during the reporting period, then B would be 25. The percent of youth who are revictimized measured short-term will be auto calculated in C based on A and B values.

Data Grantee Provides

A. Number of program youth tracked during the reporting period for re-victimization B. Of A, the number of program youth who were re-victimized C. Percent RE-VICTIMIZED (B/A)

Record Data Here

11

Number or percentage of youth who are RE-VICTIMIZED (long term) Updated 11/04/2011

The re-victimization measure counts the number of youth who experienced subsequent victimization. Victimization can be physical or psychological; it also includes harm or adverse effects to youths property. The number of youth tracked should reflect the number of program youth that are followed or monitored for re-victimization 6-12 months after exiting the program. Example: If I am tracking 50 program youth, then, the B value would be 50. Of these 50 program youth that I am tracking, if 25 of them were revictimized during the reporting period, then B would be 25. The percent of youth who are revictimized measured long-term will be auto calculated in C based on A and B values.

A. Number of program youth who exited the program 6-12 months ago that you are tracking for re-victimization B. Of A, the number of program youth who were re-victimized during the reporting period C. Percent RE-VICTIMIZED (B/A)

10