Take Control of Your Health Program

Workshop Checklist Summary of Observations

Date

Session Attended

Peer Leader

Observer

County

Number of Participants in Class

Skills	Comments/Suggestions
Class Prep

Arrived on time with materials/charts.

Room appropriate re: protecting confidentiality, seating arranged in a “U” or circle, lighting, temperature, ADA, noise and distractions, ability of all trainees to see and hear, charts are legible handwriting, dark colored marking pens, charts displayed on easels or easily readable.
Delivery of program

Follows the curriculum as scripted in the Peer Leader Manual.

Clearly explained topics and activities.

Presentation style appropriate; articulate, eye contact, inflection.

Modeled activities correctly.

Positively reinforced participants.
Group Interaction

Encouraged group participation.

Limited personal stories.

Handled problem people effectively.

Adhered to timelines.

Worked well as a partner with co-leader.
Brainstorming

Encouraged to produce as many ideas as possible, if there are 15, tell the group you will take 2 more and end brainstorm.

Repeated ideas.

Reminded group not to comment on ideas.

Did not allow discussion/questions.

Used silence.

Person writing not leading activity.

Offered own response only at end.

Reviewed the list by reading ideas.

Add other ideas from manual only when NOT previously mentioned.

Provided opportunity for clarification.
Action Planning

Leaders model action plans correctly using different plans.

Used chart to point out steps as trainees shared their action plans.

Pointed out “will” if participant used try, should, want or think.

Helped identify barriers if confidence level is less than 7.

Asked the group for suggestions before the leaders offered responses.
Feedback/Problem Solving

Asked person to state their action plan and success/problems.

Complimented appropriate action plan adjustment/modification.

If problems, what barriers existed and did they try a solution?

Asked person if they would like help.

Conducted brainstorm appropriately.

Limited to 3 ‘yes but’.

Offered the person to choose one idea.

Recommended that person make a note of suggestions offered.
Fidelity

Delivered all content materials according to the current Stanford leaders’ manual.

Accurately paraphrased sections of activities (provided info clearly, without adding or deleting material that changed the content).

Distributed and collected appropriate data collection forms.
Additional Comments:

Signature of Peer Leader

Signature of Observer

Session 1 Fidelity Checklist

Item	Comments
___	Agenda and Charts 2, 3, 4 and 5

___	Name tags available.

___	Sign in sheet distributed / Attendance log available.

___	Read Welcome and Confidentiality Statement.

___	Participant Information Survey distributed.
Activity #1 – Introduction to the Workshop
___	Reviewed acute vs. chronic conditions accurately.

___	Reviewed Charts 1 (Self-Management Tasks) and 2 (Toolbox)	accurately.

___	Distributed hand-out, explained workshop topics and homework.

___	Reviewed Chart 3 (Guidelines) accurately.
Activity #2 – Group Introductions
___	Modeled introductions, 2-3 problems caused by chronic conditions.

___	Leader not leading the activity is writing responses

___	Pointed out concerns are the same.

___	Related concerns to the tools in the Tool Box.
Activity #3 – The Mind-Body Connection/Distraction
___	Accurately delivered content.

___	Guided through lemon activity slowly.

___	Noted distraction not to be used with chest pain.

___	Clearly discussed Chart 4 (Brainstorm Guidelines).

___	Conducted brainstorm appropriately (see summary sheet).

___	Noted difference between mind and activity distrations.

___	Timed distraction techniques correctly.
Activity #4 – Getting a Good Night’s Sleep
___	Accurately presented content.

___	Conducted brainstorm appropriately (see summary sheet).
Activity #5 - Introduction to Action Plans
___	Presented info in Chart 5; posted on wall.

___	Modeled action plan, leaders have different plans.

___	Broke people into pairs; family members not paired with each other. Used a timekeeper.

___	Asked for volunteer to report on action plan.

___	Summarized each action plan by using the standard.

___	Something YOU WANT to do:

Achievable.

Action specific.

Answers what, how much, when, how often, confidence level of 7 or more.

___	For confidence levels less than 7, guided through identification of barriers.

___	Informed participants leaders will be calling them to support them in their plans.
Activity #6 – Closing
___	Reviewed 7 items.

___	Followed activity timelines; class ended within 2-1/2 hours.

Session 2 Fidelity Checklist

Item	Comments
___	Agenda and Charts 2, 3, 4, 5 and 6 posted.

___	Charts are legible handwriting, dark colored marking pens, easily readable, name tags available.
Activity #1 - Feedback/Problem Solving
___	Modeled action plan; stated action plan and level of success; asked for volunteer.

___	Complimented appropriate action plan adjustment/modification.

___	If action plan is not achieved:

asked participant about barriers and if they tried a solution

asked if help is wanted from the group, if yes:

___	Conducted brainstorm appropriately (see summary sheet).

___	Limited to 3 ‘yes but’, offered the person to choose one idea.

___	Recommended person make a note of suggestions offered.

___	Modeled problem-solving steps appropriately; reviewed Chart 6.
Activity #2 - Dealing with Difficult Emotions
___	Utilized Chart 7 (Symptom Cycle) to illustrate difficult emotions.

___	Accurately delivered instructions for group activity:

Model the cause of your difficult emotion

Family members not paired, caregivers with caregivers

Reporting for your partner.

Info does not have to be shared.

Checked that the report was accurate.

___	Co-leader writes cause of emotions, starting with self.

___	Conducted brainstorm appropriately (see summary sheet).

___	Asked participants to volunteer any new things they are going to use to deal with these emotions in the future.

___	Specified writing or journaling for dealing with difficult emotions.

___	Leaders model and lead group in reporting one thing for which they are grateful or has made the happy today.
Activity #3 - Introduction to Physical Activity and Exercise
___	Conducted brainstorm appropriately (see summary sheet).

___	Utilized Chart 8, paraphrased section appropriately.

___	Refer participants to exercises in their book.

___	Asked participants to identify physical activity goal and barrier.

___	Problem solved 2-3 participants.

___	Encouraged choosing a goal around physical activity.
Activity #4 – Preventing Falls and Improving Balance
___	Deliver content accurately.

___	Conducted brainstorm appropriately (see summary sheet).

___	Utilized Chart 9, paraphrased section appropriately.
Activity #4 - Making an Action Plan
___	Clearly utilized Chart 5-reminded participants that the plan should be something they want to do and be realistic.

___	Conducted action plan appropriately (see summary sheet).
Activity #5 – Closing
___	Reviewed all items; asked members to choose a buddy to call.

___	Followed activity timelines, class ended within 2-1/2 hours.

Session 3 Fidelity Checklist

Item	Comments
___	Agenda and charts 2, 3, 4, 5, 6 and 7 posted.

___	Charts are legible handwriting, dark colored marking pens, easily readable, name tags available.
Activity #1 - Feedback/Problem Solving
___	Modeled action plan; stated action plan and level of success; asked for volunteer.

___	Complimented appropriate action plan adjustment/modification.

___	If action plan is not achieved:

asked participant about barriers and if they tried a solution

asked if help is wanted from the group, if yes:

___	Conducted brainstorm appropriately (see summary sheet).

___	Limited to 3 ‘yes but’, offered the person to choose one idea.

___	Recommended person make a note of suggestions offered.

___	Modeled problem-solving steps appropriately; reviewed Chart 6.
Activity #2 – Making Decisions
___	Accurately delivered content of Charts 10 and 11, paraphrased section appropriately.

___	Break into pairs, remind group they do not have to share.

___	Accurately deliver instructions, time no more than 10 minutes.

___	Ask 2 or 3 people to share the decision they were trying to make, what they decided, and if that is what their gut told them, redirect to answer the 3 questions only.
Activity #3 - Pain and Fatigue Management
___	Clearly delivered activity content, appropriately brainstormed using different color markers to represent pain and fatigue.

___	Deliver content accurately.
Activity #4 - Endurance Exercise
___	Clearly delivered content, using Charts 7, 12, 13, and 14.

___	During endurance monitoring, one leader marched in place and the other led the orchestra.

___	Clearly explained establishing baseline with time and/or distance examples.

___	Suggested to participants to choose one of the methods for monitoring exertion and during the week check your exertion level during different activities and exercises.
Activity #5 – Body Scan
___	Informed participants their participation in optional, created environment conducive to relaxation exercise.

___	Informed participants the script is in the book or they can order the CD.
Activity #6 - Making an Action Plan
___	Accurately utilized Chart 5-reminded participants that the plan should be something they want to do and be realistic.

___	Conducted action plan appropriately (see summary sheet).
Activity #7 – Closing
___	Reviewed 7 items, note homework or physical activities and food diary.

___	Followed activity timelines, class ended within 2-1/2 hours.
Session 4 Fidelity Checklist

Item	Comments
___	Agenda and charts 2, 3, 5, 6, and 7 posted.

___	Charts are legible handwriting, dark colored marking pens, easily readable, name tags available.
Activity #1 - Feedback/Problem Solving
___	Modeled action plan; stated action plan and level of success; asked for volunteer.

___	Complimented appropriate action plan adjustment/modification.

___	If action plan is not achieved:

asked participant about barriers and if they tried a solution

asked if help is wanted from the group, if yes:

___	Conducted brainstorm appropriately (see summary sheet).

___	Limited to 3 ‘yes but’, offered the person to choose one idea.

___	Recommended person make a note of suggestions offered.

___	Modeled problem-solving steps appropriately; reviewed Chart 6.
Activity #2 – Better Breathing
___	Accurately delivered material and review of Chart 15.

___	Conducted brainstorm appropriately (see summary sheet).

___	Correctly demonstrated pursed lip and diaphragmatic breathing technique.
Activity #3 - Healthy Eating
___	Clearly presented information and Charts 16 and 17.

___	Described healthy eating not as dieting, but making small changes.

___	Clearly explained place method.

___	Presented info on portion size accurately, group involved by using book to identify portion sizes.
Activity #4 - Communication Skills
___	Delivered content according to manual, clearly explained “I” messages and Chart 18, paraphrase section appropriately.
Activity #5 - Problem Solving
___	Reviewed Chart 6.

___	Instruction for group activity clear, pair up according to manual.

___	Kept reports concise, statement of problem clear, one or two solutions, one solution chosen.

___	Checked with partner for correctness.

___	Ask if anyone heard new solutions they may add to their own list.

___	Ask how it felt to help another.
Activity #7 - Making an Action Plan
___	Accurately utilized Chart 7-reminded participants that the plan should be something they want to do and be realistic.

___	Conducted action plan appropriately (see summary sheet).
Activity #8 - Closing
___	Reviewed 6 items, remind to bring in books and food labels.

___	Followed activity timelines, class ended within 2 ½ hours.

Session 5 Fidelity Checklist

Item	Comments
___	Agenda and Charts 2, 3, 5, 6, and 7 posted.

___	Charts are legible handwriting, dark colored marking pens, easily readable, name tags available.
Activity #1 - Feedback/Problem Solving
___	Modeled action plan; stated action plan and level of success; asked for volunteer.

___	Complimented appropriate action plan adjustment/modification.

___	If action plan is not achieved:

asked participant about barriers and if they tried a solution

asked if help is wanted from the group, if yes:

___	Conducted brainstorm appropriately (see summary sheet).

___	Limited to 3 ‘yes but’, offered the person to choose one idea.

___	Recommended person make a note of suggestions offered.

___	Modeled problem-solving steps appropriately; reviewed Chart 6.
Activity #2 – Making Healthy Food Choices
___	Accurately deliver contact of Chart 19, ask group questions.

___	Referred participants to book to look at food labels.

___	Asked participants to read their food labels from home, provided labels for those who did not bring them.
Activity #3 –Medication Usage
___	Clearly delivered content, used Charts 20, 21, and 22, paraphrase section appropriately.

___	Conducted brainstorm appropriately (see summary sheet).

___	Chose one or two problems to brainstorm.

___	Brainstorm “forgetting to take medications”.

___	Suggest personal medication list.
Activity #4 - Making Informed Treatment Decisions
___	Clearly delivered content, used Chart 23, paraphrased correctly.
Activity #5 - Depression Management
___	Utilized Chart 7 appropriately.

___	Conducted brainstorms appropriately (see summary sheet).

___	Reminded participants that alcohol and some drugs can make depression worse.

___	Noted need for professional treatment for severe depression.
Activity #6 - Positive Thinking
___	Accurately delivered content using Chart 24.

___	Allowed time for participants to suggest examples of changing negative thoughts to positive.
Activity #7 - Making an Action Plan
___	Accurately utilized Chart 5-reminded participants that the plan should be something they want to do and be realistic.

___	Conducted action plan appropriately (see summary sheet).
Activity #8 – Closing
___	Reviewed 7 items, including food diary, letters to doctors and practice positive thinking.

___	Followed activity timelines, class ended within 2-1/2 hours.

Session 6 Fidelity Checklist

Item	Comments
___	Agenda and Charts 2, 3, 5, 6, and 7 posted

___	Charts are legible handwriting, dark colored marking pens, easily readable, name tags, available.
Activity #1 - Feedback/Problem Solving
___	Modeled action plan; stated action plan and level of success; asked for volunteer.

___	Complimented appropriate action plan adjustment/modification.

___	If action plan is not achieved:

asked participant about barriers and if they tried a solution

asked if help is wanted from the group, if yes:

___	Conducted brainstorm appropriately (see summary sheet).

___	Limited to 3 ‘yes but’, offered the person to choose one idea.

___	Recommended person make a note of suggestions offered.

___	Modeled problem-solving steps appropriately; reviewed Chart 6.
Activity #2 - Working with Your Health Care Professional and Health Care System
___	Clearly defined health care system compared to health care provider.

___	Conducted brainstorm appropriately (see summary sheet).

___	Reviewed Chart 25 accurately, paraphrased appropriately.
Activity #3 – Weight Management
___	Asked participants to share what they have learned from food diary.

___	Reviewed Chart 26 accurately, paraphrased appropriately.
Activity #3 - Looking Back and Planning for the Future
___	Conducted brainstorm appropriately (see summary sheet).

___	Reviewed Chart 2.

___	Clearly modeled 3 to 6-month goals and steps to reach the goal.

___	Problem solved if appropriate.

___	Participants shared accomplishments, pointed out helped each other.

___	Led participants in visualization.

___	Certificates prepared and distributed.

___	Distributed and collected Workshop Evaluation Form.
Activity #4 – Closing
___	Reviewed 5 items.

___	Peer Leaders complete Workshop Information Cover Sheet.

___	Peer Leaders complete PL Feedback Form.

___	Followed activity timelines, class ended within 2-1/2 hours.

Summary of Observations

(Continued)

ACS-28

DEC 13	-4-

DEC 13

DEC 13	-3-

ACS-28, TCYH, Workshop Checklist, Master Trainer Checklist for Observing Peer Leaders, Summary of Observations

ACS-28, workshop checklist, summary of observations, TCYH, take control of your health, master trainer checklist for observing peer leaders

Windows User

2013-12-03

human services