Program/Practice Location:
____________________________________
____________________________________Contact
Person at Location:
Name: ______________________________
Phone or E-mail: ______________________
Fax Number: ______________________________ |
Prospector Information:
Name: ____________________________
Address: __________________________
_________________________________
_________________________________
Phone or E-mail: ____________________ |
PROMISING PROGRAM OR
PRACTICE NOMINATION
Brief description of program or practice:
Focus of program/practice. Which of the following are
involved in implementing the program or practice? (Please list all that apply.)
Agencies (e.g., schools, counselor, county mental health):
Organizations (e.g., family organization):
Natural supports (e.g., extended family):
Individual providers (public or private, e.g., clinicians):
Funding sources (e.g., IDEA, Medicaid):
3. How long has the promising program or practice been in
operation? ___________________
4. Degree of implementation and degree of
institutionalization. Please indicate below the extent to which the program or practice
has been implemented (i.e., Pervasiveness/penetration of the program or practice) and
institutionalized (i.e., internalized/routinized use of program or practice).
Implementation |
Institutionalization |
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High |
Medium |
Low |
High |
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Medium |
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Low |
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5.What are the salient values, philosophies, principles,
beliefs, or assumptions underlying the program or practice?
6. What are the key features of the program or practice
that make it promising?
7. What contextual factors (i.e., environment in which the
program or practice operates) appear to be necessary for its successful operation?
8. Which of the following principles underlying the
National Agenda for Achieving Better Results for Children and Youth With Serious Emotional
Disturbance, effective wraparound models, and systems of care, does the program or
practice encompass? (Please check all that apply.)
National Agenda Strategic Targets:
_____ 1. Expand Positive Learning and Developmental
Opportunities and Results
_____ 2. Strengthen School and Community Capacity
_____ 3. Value and Address Diversity, including
_____ 3a. Cultural Competency
_____ 4. Collaborate with Families
_____ 5. Promote Appropriate Assessment
_____ 6. Provide Ongoing Skill Development and Support
_____ 7. Create Comprehensive and Collaborative Systems
_____ 7a. Individualized Planning
_____ 7b. Zero Eject
_____ 7c. Routine Daily Collaboration
Cross-Cutting Themes:
_____ 8. Cultural Competence
_____ 9. Prevention and Early Intervention
_____10. Enabling All Relevant Parties to Collaborate Fully
9. Are data available (from site evaluations or from other
research or evaluation studies) that support the effectiveness of the program or practice?
No_____ Yes____ If yes, please describe briefly or indicate
where data may be obtained.
10. Any other observations that you think are important.
(Use an additional page, if necessary.)
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