Example - CBO Assessment

Attachment 3: Sample Quantitative Instrument

DASH 1308-Strategy 4 Project: Community-based Organization (CBO) Assessment

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Community-Based Organizations

Respondent Information

1. What is the name of your organization? ____________________________________________

2. What is the address of your organization? ________________________________

CBO service Information

This set of questions asks about the characteristics of your CBO’s client population. Please answer these questions to the best of your ability, consulting with others as appropriate to complete them as accurately as possible. We understand that some of these responses will be estimates.

3. On average, how many clients does your organization serve per month?

• Less than 10

• 10-50

• 50-100

• More than 100

4. Over the last 12 months, about what percent of the clients your organization served were:

• Male ____%

• Female _____%

5. Over the last 12 months, about what percent of the clients your organization served were the following ages:

• 14 or younger ____ %

• 15-19 ____ %

• 20-24 ____%

• 25-29____%

• 30 or older____%

Public reporting burden of this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

6. Over the last 12 months, about what percent of the clients your organization served were:

• Hispanic or Latino ___%

• Not Hispanic or Latino ___%

7. Over the last 12 months, about what percent of the clients your organization served were:

• American Indian or Alaska Native ___%

• Asian ____%

• Black or African American___ %

• Native Hawaiian or Other Pacific Islander ____%

• White ___%

8. Over the last 12 months, about what percent of the clients that your organization served were:

   • Lesbian, gay, bisexual, transgender or queer (LGBTQ) ______%

   • Non-LGBTQ _____%

9. Over the last 12 months, about what percent of the LGBTQ clients that your organization served were:

• Male-identified ______%

• Female-identified ______%

10. Which of the following services does your organization offer? (Please select all that apply)

• HIV testing

• STD testing

• HIV/STD prevention education programs

• Mental health, counseling, or psychological services

• Social services

• Training or professional development for other organizations

• Other, please specify: _________________________________________

11. Which of the following services does your organization offer specifically for, or tailored to, LGBTQ clients? (Please select all that apply)

• HIV testing

• STD testing

• HIV/STD prevention education programs

• Mental health, counseling, or psychological services

• Social services

• Training or professional development for other organizations

• Other, please specify: _________________________________________

12. Does your organization offer an HIV test to any teen male who requests one?

    • Yes

    • No, we do not offer HIV tests

    • No, testing is limited (for example, to teens with known risk factors)

    • I don’t know

13. Does your organization offer an STD test to any teen male who requests one?

    • Yes

    • No, we do not offer STD tests

    • No, testing is limited (for example, to teens with known risk factors)

    • I don’t know

14. How do teens pay for services provided by your organization? (Please select all that apply)

• All services are free for teens

• Private pay/sliding scale

• Private insurance

• Public funding, such as Medicaid

• Other _______________________________________________________

15. For services that are not provided by your organization, how are referrals made? (Please select all that apply)

• My organization provides teens with contact information for the referral agency

• My organization assists teens in making an appointment with the referral agency

  • Notification is sent by my organization to the referral agency to alert them of the referral

• My organization conducts follow-up to confirm teen was seen by the referral agency

• Other ____________________________________________

Youth Service Environment

16. Please indicate whether the following statements describe the services provided by your organization.

Matrix, response options: yes, no, I don’t know (broken into two sets of questions if needed)

1. Services are available to teens for free.

2. Services are available for teens at low cost.

3. Services are designed specifically for teen clients.

4. Special service hours or all service hours are designated for teen clients.

5. Evening service hours are available to teen clients.

6. Weekend service hours are available to teen clients.

7. My organization has a waiting area or exam room dedicated to teen clients.

8. There are teen friendly materials available in the waiting room.

9. My organization’s facility is easily accessible by public transportation.

10. My organization provides transportation, or vouchers to cover the cost of transportation

11. My organization has implemented protocols to protect the confidentiality of clients who are under age 18.

12. Teen clients have input in the design of services.

13. Teen clients organize events or presentations for peers.

14. Providers have been trained within the last 12 months on how to work with and establish rapport with teen clients

15. My organization’s staff use client risk assessments.

16. My organization conducts outreach for teen clients in community settings (e.g., health fairs, mobile vans, neighborhood visits by outreach workers).

17. My organization conducts outreach for teen clients in schools (e.g., school programs, school health fairs, school-based events).

17. Is confidentiality for teens mentioned in advertisements/outreach material used by your organization?

• Yes

• No

• I don’t know

18. Is parental consent for sexual health services required for clients who are under age 18?

• Yes, always

• Yes, for specific services

• No

• I don’t know

19. For the teens that you serve, what aspects of your program are you most proud of in meeting adolescents’ sexual and reproductive health needs? (Please select all that apply)

• Creating a teen friendly environment

• Providing high quality services

• Providing a comprehensive scope of services

• Providing confidential services

• Using innovative outreach strategies

• Providing partner notification/treatment services

• Retaining teen clients

• Maintaining strong links w/ other service providers

• Establishing provider-client relationship

• Improving parent-child communication

• Incorporating teen input in the design of programs and services

• Receiving support from community

• Other, please specify:__________________________

LGBTQ Friendliness

20. In the past 12 months, has your organization sponsored special training or supported continuing education for all staff on the needs of teen LGBTQ clients?

• Yes

• No

• I don’t know

21. Do your organization’s brochures and outreach materials include LGBTQ clients?

• Yes

• No

• I don’t know

22. Do any open lesbians, gay male, or bisexual staff provide services in your organization?

• Yes

• No

• I don’t know

Linkage with Schools: Formalization of the Partnership

23. Does your organization have a written agreement (for example, a memorandum of understanding or memorandum of agreement) with [LEA name]?

• Yes (skip to Q24)

• No

• I don’t know

24. Does your organization have a verbal agreement with [LEA name]?

• Yes (skip to Q26)

• No (skip to Q26)

• I don’t know (skip to Q26)

25. What type of agreement do you have?

• Memorandum of understanding (MOU) or memorandum of agreement (MOA)

• Contract to provide services

• Other type of agreement, please specify: _________________________________

26. When was your written agreement put in place?

• [month and year fields]

27. Which of the following statements applies to your partnership with [district name]?

• My organization initiated the partnership

• The district initiated the partnership

• My organization and the district were equally responsible for initiating the partnership

• I don’t know

28. Is the school that a teen attends recorded during your client intake process?

• Yes

• No

• I don’t know

• Not applicable

29. During your client intake process, how is information collected?

    • Using a database

    • Paper form

    • I don’t know

    • Other ______________________

30. Do all staff have access to your client intake information?

    • Yes

    • No

    • I don’t know

    • Not applicable

31. If a teen has been referred to your organization by a school staff member, is that information noted as part of your intake process?

• Yes

• No

• I don’t know

32. When a teen has been referred to your organization by a school staff member, how often does that staff member follow-up to determine if the student accessed the service?

• Always

• Very often

• Sometimes

• Rarely

• Never

• Not applicable

organizationAL Linkage with Schools: Communication in the Partnership

33. Are staff from your organization in regular contact with [LEA name]?

• Yes, as needed

• Yes, at least monthly

• Yes, at least weekly

• Yes, on a daily basis

• No

34. With which of the following schools did staff from your organization have any contact in the last 12 months (this could include requests for information, referrals, health education resources, or other service-related questions)? (Please select all that apply)

• List of school names for the appropriate LEA (If none, skip to Q41)

Please note: The following set of questions is about your CBO’s relationships with the schools you selected in the last question and their staff.

35. Within the last 12 months, how frequently have staff from your organization been in contact with these schools?

• Once a year or less

• About once a quarter

• About once a month

• About once a week

• About once a day

36. Who typically initiates communication between your organization and these schools?

• My organization does

• The schools do

• My organization and the schools initiate communication equally

• I don’t know

37. Which staff members from the schools contact your organization? Please indicate what their position is within the school. (Please select all that apply)

• Nurse

• Counselor

• Teacher

• Administrator (for example, principal or vice principal)

• Other, please specify: _____________________________

• No school staff members contact my organization

38. Does your organization have a dedicated point of contact at the schools?

• Yes

• No (skip to Q39)

• I don’t know (skip to Q39)

39. What is the position of that point of contact? (Please select all that apply)

• Nurse

• Counselor

• Teacher

• Administrator (for example, principal or vice principal)

• Other

40. Do staff from your organization meet with school staff regularly?

• Yes

• No (skip to Q41)

• I don’t know (skip to Q41)

41. Approximately how often do these meetings take place?

• Once per week

• Twice per month

• Once per month

• Once per quarter

• Once every 6 months

• Less than once every 6 months

Linkage with Schools: Contribution to and Benefits of the Partnership

Please note: This set of questions asks about your perceptions of your organization’s relationship with the school district and schools. Please answer each question based on your impressions; there are no right or wrong answers.

42. To what extent do your organization and the school district/schools share a common understanding of what working together should accomplish (e.g. share a common vision or goal)?

• Not at all

• A small amount

• A fair amount

• A great deal

Please note: This project is focused on meeting the needs of young men who have sex with men (YMSM), which we define as males who:

• identify as gay or bisexual;

• engage in sexual activities with other males; or

• are attracted to other males

43. To what extent does your organization have influence with the school district/individual schools to help meet the needs of YMSM?

• Not at all

• A small amount

• A fair amount

• A great deal

44. To what extent is your organization committed to partnership with the school district/schools?

• Not at all

• A small amount

• A fair amount

• A great deal

45. To what extent is your organization active in partnership with the school district/schools?

• Not at all

• A small amount

• A fair amount

• A great deal

46. To what extent does your organization value its partnership with the schools/school district?

• Not at all

• A small amount

• A fair amount

• A great deal

47. How reliable is your organization in following through on the commitment made with the school district and schools as part of the partnership?

• Not at all

• A small amount

• A fair amount

• A great deal

48. How reliable are the school district and schools in following through on the commitments made with your organization as part of the partnership?

• Not at all

• A small amount

• A fair amount

• A great deal

49. To what extent is the school district/schools open to discussion, meaning they are willing to engage in frank, open and civil discussion (especially when disagreement exists) and consider a variety of viewpoints and talk together (rather than at each other)?

• Not at all

• A small amount

• A fair amount

• A great deal

50. To what extent is your organization open to discussion, meaning they are willing to engage in frank, open and civil discussion (especially when disagreement exists) and consider a variety of viewpoints and talk together (rather than at each other)?

• Not at all

• A small amount

• A fair amount

• A great deal

51. To what extent does your organization contribute to the health and well-being of YMSM as part of your work with the school district/individual schools?

• Not at all

• A small amount

• A fair amount

• A great deal

52. How much has your partnership with the school district increased your capacity to serve YMSM?

• Not at all

• A small amount

• A fair amount

• A great deal

53. How much has your partnership with the school district increased the number of YMSM being served by your organization?

• Not at all

• A small amount

• A fair amount

• A great deal

54. To what extent has your partnership with the school district improved the quality of the services your organization provides to YMSM?

• Not at all

• A small amount

• A fair amount

• A great deal

55. To what extent have you added or modified any of the programs and services that your organization offers YMSM as a result of your partnership with the school district?

• Not at all

• A small amount

• A fair amount

• A great deal

56. To what extent do you think your partnership with the school district has improved the schools’ ability to meet the needs of YMSM?

• Not at all

• A small amount

• A fair amount

• A great deal

Linkage with Schools: recommendations for the Partnership

57. How successful would you say your partnership with [district name] schools has been to date?

• Not successful

• Somewhat successful

• Successful

• Very successful

• Completely successful

58. Please share any recommendations you have for strengthening your organization’s partnership with [district name] schools: _____________________________________________________

59. In your opinion, what could the schools do to help you serve their students who are LGBTQ and, in particular, YMSM?
    ___________________________________________________________________________

60. In the space below, please feel free to add any other comments you would like to share with the school district: __________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

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