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This is the form used by the Center's Prospectors when they suggest programs or projects that are successful in changing outcomes for students with or at risk of developing emotional/behavioral problems and their families. If you know of such programs or projects, you too can submit information about them one of two ways:

  • complete an online form, or  Coming Soon!
  • print out the form below, complete and and mail or fax it to the Center at:

Center for Effective Collaboration and Practice
American Institutes for Research
1000 Thomas Jefferson St NW
Washington, DC 20007

FAX: (202) 944-5454

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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

 

High

Medium

Low

High

     

Medium

     

Low

     

 

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.)

 

 

Thank you for your help!

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