Overview of Forms
| Form Name | Description | Purpose | How to Use | Memo | E-format (PDF) | Online | Paper |
|---|---|---|---|---|---|---|---|
| Calendar Request Form | 1 page | Used to schedule BCBH workshop. training or EF class/ Training | Fillout and submit to Michiyo | Calendar Request Form | |||
| Workshop Information Cover Sheet | 1 page One per workshop |
Records all the details about the location, leaders, and evaluation forms. | Fill in the requested details about workshop. Use as a cover sheet for the packet of evaluation forms that you return to Statewide Evaluator (make a copy, if you need). | Workshop Information Cover Sheet | |||
| Attendance Sheet | 1 page One per workshop |
Records attendance by session for each participant Records details about fidelity monitoring. | At the first session, write the names of participants. Record each person’s attendance at each session for all six weeks. | Attendance Sheet | |||
| Consent Form | 1 page, double sided County-specific |
Provides participants with information about the workshop and explain the data are used for research purpose. | Distribute to participants at the beginning of the workshop with Questionnaire, and explains to participants. | Use the explanation: “We are asking you to complete this consent form and allow us to collect data from you. BCBH-CD is a short-term program in Hawai‘i now. By completing the consent and allowing us to collect some information from you, we hope to show that this program works in Hawai‘i. This can help us make the program permanent in Hawai‘i. Please read and sign the form and let us know if you have any specific questions." |
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Consent form is attached to the online questionnaires |
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| Questionnaire | BCBH-CD: 9 pages single sided (or 5 pages double sided) BCBH-DS: 11 pages single sided (or 6 pages double sided) |
Collects data on participant demographic characteristics, health status, health behaviors, and self-efficacy. | Distribute to participants at the beginning of the workshop with Consent form. | Please copy as a double-sided page to save trees. You will also use this form for 6-month follow-up. |
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| Satisfaction Survey | 1 page, double sided Program-specific (Hawai‘i county has their own survey due to many partners- will send to BI only- not in this packet) |
Collects data on participant program satisfaction. | Distribute to participants at the end of the workshop. | Optional: You can use the additional form to get feedback on fees. It is half-page (2 on one page). The file is called “Addendum to Satisfaction Survey.” |
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Online Satisfaction Survey | |
| Leader Self-Evaluation Form | 4 pages, double sided |
Collects data on leader’s performance. | Leaders complete the form at the end of the workshop. If it is their first time, they have to complete this form for every session. | Leader Self-Evaluation Form | Online Evaluation Form | Leader Self-Evaluation Form | |
| Leader Evaluation Form | 4 pages, double sided |
Collects data on leader’s performance. | Fidelity Monitoring Evaluator completes the form one time in each workshop. This form can be used for coaching newly trained Lay Leaders. |
HAP recommends monitoring at 2nd session. If you used this form for coaching, you do not have to send them to Statewide Evaluator. |
Leader Evaluation Form | Online Evaluation Form | Leader Evaluation Form |
| Exit Survey BCBH | 2 pages | Exit Survey BCBH | |||||
| One Year Follow Up Survey | 1 page | Administer at 1 year after the workshop | Fillable One Year Follow Up Survey | Online One Year Follow Up Survey | One Year Follow Up Survey |
Evaluation Form Status
Evaluation Plan for CDSMP 2-26-15 View/Download
Form Checklist 2-26-2015 View/Download