Free Wisconsin Abstinence Intiative For Youth Club Annual Report, dph 40077 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 40077 (Rev. 12/04)

STATE OF WISCONSIN Bureau of Community Health Promotion Direct questions to: 608-261-7654

WISCONSIN ABSTINENCE INITIATIVE FOR YOUTH ANNUAL CLUB REPORT
Completion of this form is required under the provisions of OMB Circular A-110.51. Failure to complete this form may result in a whole or partial suspension or termination of the club grant (OMB Circular A-100.62b) or participation in WAIY Club Network activities. INSTRUCTIONS: This report is to be completed by organizations sponsoring a club in the Wisconsin Abstinence Initiative for Youth Club (WAIY) Network. It is required from any club receiving support through mini-grants, free or reduced cost training, access to a regional coordinator, or inclusion in other developments of the WAIY Club Network. The report is to be submitted to the Department of Health and Family Services Abstinence Program Consultant May 15 of each year.

SECTION 1 - WAIY CLUB IDENTIFICATION INFORMATION
Sponsoring Organization Name Club No. Region

Mailing Address

City and Zip Code

Authorized Agency Representative Name and Title

Telephone

Email Address

Key Contact Name and Title within Organization

Telephone

Email Address

Mailing Address

City and Zip Code

Alternate Identification Information
Club Advisor(s) Name(s) if Different from Key Contact Telephone Email Address

Mailing Address

City and Zip Code

Fiscal Agency Name if Different from Sponsoring Organization

Fiscal Agency Representative Name and Title

Telephone

Email Address

Mailing Address

City and Zip Code

DPH-40077 (Rev. 12/04)

Page 2 of 7

SECTION 2 - GENERAL UPDATE AND REPORT
Name of Club Club Number No. of Males in Club Date Club Started Regional Coordinator WAIY Region

No. of Females in Club

No. of Youth Leaders In Club

No. of Youth who Attended a WAIY Training

No. of Adults who Attended a WAIY Training

Number of Youth That Learned the Six "Abstinence Pays Back" Messages Eight Discussion Topics - Check those discussed Basic Information and Definitions Love Friendships and Dating Relationships Intimacy Postponing Sex Skills for Developing Strong Relationships Looking for Love in All the Right Places Self-Development and Self-Awareness

Number of Youth That Demonstrated an Ability to Identify and Explain at Least Five of the "Abstinence Pays Back" Messages Eight Monthly Activities - Check the Core Activity Goal or Goals Addressed for Each of the Eight Monthly Activities 1 2 3 4 5 6 7 8 Abstinence Promotion Fun Service Fund Raising

Monthly Discussions - Describe any barriers to completing the eight discussions (such as registering later in the school year)and give any suggestions for future topics. If your club held more than the eight required topics, indicate how many.

Monthly Activities - Describe any barriers to completing the eight activities (such as registering later in the school year). If your club held more than the eight required activities, indicate how many.

DPH-40077 (Rev. 12/04)

Page 3 of 7

SECTION 2 CONTINUED - GENERAL UPDATE AND REPORT
Highlights - Describe any special events that were found to be successful and worth replicating in other clubs.

Challenges - Describe any barriers to implementing the club and how they were addressed.

Youth Led Activities - Describe how youth leadership skills and involvement in community were developed or built.

DPH-40077 (Rev. 12/04)

Page 4 of 7

SECTION 3 - ACHIEVEMENT AWARD LOG - MAKE COPIES OF THIS PAGE AS NEEDE
Assign a number to each event or activity that earned achievement award points. For activity numbers and points, see the Achievement Award Activity List and Point Guide in the handbook.
Event/Activity No. Date Total Achievement Points Earned Record the activity number(s) included in the event under the appropriate category. (Show the points earned in parentheses.) See sample for the category of monthly discussion, activity1 in the last cell. LTP M A F SL FR C D N M Sample: Brief Description of Event Brief Description of Event

Event/Activity No. Date Total Achievement Points Earned

Event/Activity No. Date Total Achievement Points Earned

Record the activity number(s) included in the event under the appropriate category. (Show the points earned in parentheses.) See sample for the category of monthly discussion, activity1 in the last cell. LTP M A F SL FR C D N M Sample: Brief Description of Event

Event/Activity No. Date Total Achievement Points Earned

Record the activity number(s) included in the event under the appropriate category. (Show the points earned in parentheses.) See sample for the category of monthly discussion, activity1 in the last cell. LTP M A F SL FR C D N M Sample: Brief Description of Event

Event/Activity No. Date Total Achievement Points Earned

Record the activity number(s) included in the event under the appropriate category. (Show the points earned in parentheses.) See sample for the category of monthly discussion, activity1 in the last cell. LTP M A F SL FR C D N M Sample: Brief Description of Event

Event/Activity No. Date Total Achievement Points Earned

Record the activity number(s) included in the event under the appropriate category. (Show the points earned in parentheses.) See sample for the category of monthly discussion, activity1 in the last cell. LTP M A F SL FR C D N M Sample: Brief Description of Event

Event/Activity No. Date Total Achievement Points Earned

Record the activity number(s) included in the event under the appropriate category. (Show the points earned in parentheses.) See sample for the category of monthly discussion, activity1 in the last cell. LTP M A F SL FR C D N M Sample: Brief Description of Event

Event/Activity No. Date Total Achievement Points Earned

Record the activity number(s) included in the event under the appropriate category. (Show the points earned in parentheses.) See sample for the category of monthly discussion, activity1 in the last cell. LTP M A F SL FR C D N M Sample: Brief Description of Event

Record the activity number(s) included in the event under the appropriate category. (Show the points earned in parentheses.) See sample for the category of monthly discussion, activity1 in the last cell. LTP M A F SL FR C D N M Sample:

DPH-40077 (Rev. 12/04)

Page 5 of 7

SECTION 4 - DATA COLLECTION
Include services to youth and adults through both club and outreach events. Federal Form 2--Unduplicated Count of Clients Served Collected by the U.S. Department of Health and Human Services' Abstinence Education Program. Use this form to record the total number of clients you have served. Do not count a client each time you have served him or her. Age in Years Males <10 10-14 15-17 18-19 20-24 >24 Total

Non-Hispanic White

Black

Hispanic

Others

Age in Years Females <10 10-14 15-17 18-19 20-24 >24 Total

Non-Hispanic White

Black

Hispanic

Others

Total Males and Females

DPH-40077 (Rev. 12/04)

Page 6 of 7

Federal Form 3--Total Encounters by Clients Collected by the U.S. Department of Health and Human Services' Abstinence Education Program. Use this form to record the total encounters for all clients you have served. If a client has attended 5 meetings or events, there should be 5 encounters recorded for that youth alone. The total number of encounters (shaded box) will be higher than the total number of youth served (Federal Form 2). Age in Years Males <10 10-14 15-17 18-19 20-24 >24 Total

Non-Hispanic White

Black

Hispanic

Others

Age in Years Females <10 10-14 15-17 18-19 20-24 >24 Total

Non-Hispanic White

Black

Hispanic

Others

Total Males and Females

DPH-40077 (Rev. 12/04)

Page 7 of 7

SECTION 5 - WAIY CLUB LEDGER
Date of event Description of event and purchased item Payment Deposit Balance

SECTION 6 - SIGNATURE Name of Authorized Agency Representative SIGNATURE - Authorized Agency Representative

Title Date Signed

Submit completed form with attachments to: Abstinence Program Consultant Department of Health and Family Services Division of Public Health, Room 351 P.O. Box 2659 One West Wilson Street Madison WI 53701-2659