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Date of Publication: December 2000 CYFERNet For Professionals

Section 3: Doing Process Evaluation

Worksheets

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Worksheet 3.1
Characteristics of the Target Population and the Current Participating Population
Can be used for both individual clients and communities.

Family Characteristics Target Population Actual Population
Ethnicity/Ethnic Mix  

 

  
Housed off-base/on-base  

 

  
Socioeconomic Status  

 

  
Marital Status  

 

  
Family Needs/Risk Factors  

 

  
Children? Ages?  

 

  

Conclusions:

1. How well does the actual population match the target population?

 

2. Where is the discrepancy?

 

3. What do you think may be barriers to participation? What can you do to overcome these barriers?

 

Worksheet 3.2
Monitoring Attempts to Contact
Can be used for both recruitment and retention.

Client Number/Name______________________________

Date Type of Contact Attempt (letter, phone, visit)  Result
 

 

    
 

 

    
 

 

    
 

 

    
 

 

    
 

 

    
 

 

    
 

 

    
 

 

    

Worksheet 3.3
Monitoring Program Retention
Use for programs where clients have more than one contact with program staff.

How many clients did you have at the beginning of the program?  

 
How many clients completed your program?  

 
What is your retention rate (number of those who complete/number who started)?  

 
What are the characteristics of those who start the program (see Worksheet 3.1)?  

 
How do they compare to the clients who finish the program?  

 
Does there appear to be any bias in your retention?  

 

Worksheet 3.4
Monitoring Program Services
Can be used for classes, clinic visits or home visits.

  Classes Clinic visits Home visits Provider of Services
Number of specified contacts        
Number of contacts actually occurring        
Timing of planned contacts        
Timing of actual contacts        
Frequency        

 

  Yes No Comments
Does the number and timing of actual contacts match the protocol?      
Is there sufficient staff at each site to implement the program?      
Have the staff been adequately trained to provide this program?      
Is there consistency in program delivery (intra- and inter-provider)?      
Does this program meet the needs of a military population?      

 

Recording Service Activities for Educational Programs
Form 3.1

 

Client Name             

                                                                                                      
Course name  

 
Learning objectives 
  1.  
  2.  
  3.  
  4.  
  5.  
Number of sessions  

 

 

Date/Session number In attendance? (Y/N) Length of session Total hours of instruction Pretest completed? Post-test completed?
 

 

 

 

 

          

Program Completed!


Client Activity

 

CID: _______________ 

  

Client Name: _____________________________ 
Form 3.2

Month/Year: ____________

Staff Name:___________________________ Staff Position:___________________________ (e.g., FAN, T.M.)

Staff ID DATE (mm/dd/yy) Service Activity Provided Location Of Contact Who Contacted No Show Travel Time (in minutes) Duration of Activity (in minutes) Notes, Comments and Progress on Goals
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 

 

Service Activity Provided (Enter only one activity per line) Location Of Contact Who Contacted  
  1. Ongoing Problem Solving
  2. In-home Visiting
  3. Parenting Group
  4. Play Group
  5. Crisis Intervention
  1. Child Development Services & Case Coordination
  2. Mental Health Services
  3. Substance Abuse Services
  4. Health Education
  5. Other (Specify)
  1. FAP Office
  2. In Home
  3. Telephone
  4. Other Agency
  5. Other
  6. Hospital
  1. Mother
  2. Father
  3. Both Parents
  4. Index Child
  5. Sibling
  6. Other (Specify)
  7. NA
 		 

New York's Home Visiting Program
Service Referrals

Make entries on this form each time a family member is referred to a service (either within the agency or to an outside program). A referral consists of either making arrangements for a participant to receive services or providing information about specific providers so that the participant can make arrangements herself. Workers will be responsible for determining the outcomes of those referrals and entering them on this form. Only one referral should be entered on each line. If you refer more than one person to a service complete one line for each individual. This is a two-sided form. Codes used on this form are found on the back.

1. Primary Caretaker's Identifier
    / / / /
Last Name (3 let) F1 Birth Date(Mo/Day/Yr) Date of Intake (Mo/Day/Yr)
2.County
1. Albany 5. Clinton 9. Rensselaer
2. Bronx 6. Erie 10. Schenectady
3. Brooklyn 7. Madison 11. Steuben
4. Chemung 8. New York 12. Ulster
 

3. Home Visitor's Name
4. Service Code (see codes) 5. Family Member Referred (see codes) 6. Nature of Referral 7. Referral Date (m/dd/yy) 8. Services Received 9. Date Started (mm/dd/yy) 10. Reason Not Received (see codes) 11. Agency Providing Service (Local Use Only)
    1. Arrangements
2. Information		   1. Yes
2. No		      
    1. Arrangements
2. Information		   1. Yes
2. No		      
    1. Arrangements
2. Information		   1. Yes
2. No		      
    1. Arrangements
2. Information		   1. Yes
2. No		      
    1. Arrangements
2. Information		   1. Yes
2. No		      
    1. Arrangements
2. Information		   1. Yes
2. No		      

 

Date Form Submitted

 

 Reviewer's Initials

 

 Date of Data Entry

 

 Initials of Data Entry Operator

 

 

SERVICE CODES
Health Care
  1. Adult primary care
  2. Child Primary Care
  3. Dental Services
  4. Family Planning
  5. HIV testing
  6. IHAP
  7. EIP
  8. Attention Deficit or Hyperactivity
  9. Immunization
  10. Lead assessment/testing or follow-up services
  11. Prenatal care
  12. Postpartum care
  13. Pregnancy testing
  14. Public health nursing
  15. STD testing
  16. Child Health Plus
  17. Developmental screening and services
  18. Other health service

Nutrition

  1. Food pantry
  2. WIC
  3. Nutritional counseling 
 DSS/NRA
  1. AFDC/Home Relief
  2. Food Stamps
  3. Medicaid
  4. Emergency Assistance
  5. SSI
  6. HEAP
  7. Child Protective Services
  8. Preventive Services

Family and Social Support Services

  1. Childbirth education
  2. Parenting education/training
  3. Day care/baby-sitting
  4. Parent aide services
  5. Recreational services

Employment, Training and Education

  1. Adult basic education
  2. ESL (English as a Second Language)
  3. GED preparation
  4. Special Education
  5. Vocational or job skills training
  6. College
  7. Other educational services
  1. Job readiness/employability skills
  2. Job search and placement assistance
  3. Work experience

Counseling and Support Services

  1. Psychiatric or psychological treatment
  2. Other mental health counseling
  3. Domestic violence services
  4. Substance abuse services
  5. HIV support/counseling
  6. Support groups

Concrete Services

  1. Clothing, furniture, other household items
  2. Housing assistance/emergency shelter
  3. Transportation

Other Services

  1. Legal services
  2. Money management
  3. Immigration services
  4. Translation services
  5. Other services (specify)

 

FAMILY MEMBER REFERRED (RELATIONSHIP TO PRIMARY CARETAKER 1)
  1. Primary Caretaker 1
  2. Primary Caretaker 2
  3. Biological parent
  4. Boyfriend, girlfriend, partner
  5. Parent
  6. Target child
  7. Other child
  8. Other relative
  9. Non-relative
  10. Other (specify)
 NATURE OF REFERRAL
  1. HV worker made contact with provider/service and/or arrangements for family member to receive service.
  2. HV worker provided information about specific providers to family member with the intent that the family member would make arrangements to receive the service. 
 REASON CODES
  1. Service not available
  2. Client not eligible for service
  3. Client rejected for service
  4. Client did not follow through
  5. No transportation available
  6. Parent will not give consent
  7. Child care unavailable
  8. Unable to speak English
  9. No health insurance
  10. Geographically inaccessible
  11. Insufficient participant resources
  12. Other (specify)
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