IB Site Visit Informant Form

RPG Cross-site Evaluation
Site Visit Informant Information Form
Implementing Agency Name: _____________________________________________________
Evidence-Based Program (EBP): ___________________________________________________
Date of Interview: ______________________________________________________________
Informant First Name: _____________________________________________
1. Sex:
____Male
____Female
2. Age:
____Under 20 years
____20-29 years
____30-39 years

____40-49 years
____50-59 years
____60 or older

3. Race/Ethnicity: Check all that apply
____Black/African-American
____American Indian/Native American
____Asian/Pacific Islander
____Hispanic/Latina
____White, non-Hispanic
____Other (specify): _____________
4. Highest degree obtained:
___High school degree or GED
___Vocational/technical training program
___Some college, no degree
___Associate degree
___Bachelors degree
___Masters degree (for example: MA, MS, MSW, MFT)
___Professional degree (for example: LLB, LD, MD, DDS)
___Doctorate degree (for example: PhD, EdD)
5. When did you begin working in this EBP?
__ __ / __ __ __ __ (mm/yyyy)
6. Did you have prior experience delivering EBPs before you began your work in this EBP?
___Yes
___No