Appendix B - 107
APPENDIX B
SAMPLE FORMS
Contact or Encounter Form — 109
Form for Items Distributed — 110
Form for Items Received — 111
Appendix B: Sample Forms - 109
CONTACT OR ENCOUNTER FORM
ONTACT
Design a brief form, similar to the one shown here, to keep track of all contacts related to program
activities between program personnel and people outside the program. Tailor the type of contact
and services provided sections to the activities conducted by your program. For example, an enforcement program might have a list of reasons for stopping drivers or a list of types of sobriety checks.
If a category labeled Other is used frequently, you need to add new categories to accommodate
items that are being assigned to Other. Below is a general contact form that can be adapted for any
program to prevent unintentional injury.
CONTACT
OR
Contact/Encounter No.:
ENCOUNTER FORM
[Number Consecutively]
Date:
Type of Contact
Other Assistance Provided
Telephone
t
Information Only
t
Personal Meeting
t
Training
t
Electronic Mail
t
Consultation
t
Other (Specify)
t
Counseling
t
Curriculum or Materials
t
Other (Specify)
t
Who Initiated Contact
Program Staff
t
Program Participant
t
Other (Specify)
t
Program Staff Who
Participated in Contact
Purpose of Contact
Request for Financial Support
t
Request for Legislative Support
t
Request for Other Support
t
Request for Volunteer Services
t
Offer of Volunteer Services
t
Request to Participate in Program
t
Request for Information
t
Request for Incentive
t
Other (Specify)
t
110 - Appendix B: Sample Forms
FORM FOR ITEMS DISTRIBUTED
A distribution form should be completed for each unit (i.e., person or household in the target
population) to whom items (e.g., infant safety seats) were distributed. The purpose is to document
the number of items distributed and the characteristics of the people who received the item(s).
Below is a generic form that can be adapted to suit your program.
ITEMS DISTRIBUTED
Distribution No.:
[Number Consecutively]
Date:
List of Items Distributed:
Number of item(s) distributed:
Location where item(s) were distributed:
To
Item(s) Distributed To Households
Number of people in household: ___________________
Age and sex of people in household: [Divide by appropriate intervals, say 5- or 10-year intervals]
10 years or under
Females: _______
Males: _______
11–20 years
Females: _______
Males: _______
21–30 years
Females: _______
Males: _______
31–40 years
Females: _______
Males: _______
41–50 years
Females: _______
Males: _______
51–60 years
Females: _______
Males: _______
61–70 years
Females: _______
Males: _______
71 years or older
Females: _______
Males: _______
To
Item(s) Distributed To Individuals
Age and sex of individual person: [Divide by appropriate intervals, say 5- or 10-year intervals]
10 years or under
Female: t
Male: t
11–20 years
Female: t
Male: t
21–30 years
Female: t
Male: t
31–40 years
Female: t
Male: t
41–50 years
Female: t
Male: t
51–60 years
Female: t
Male: t
61–70 years
Female: t
Male: t
71 years or older
Female: t
Male: t
Other Assistance Provided
Installation t
Training t
Counseling t
Referral t
Appendix B: Sample Forms - 111
FORM FOR ITEMS RECEIVED
Keep track of all items given to you by members of the target population. An example of items
received would be car safety seats returned to a loan program. The purpose is to document the
number of items received and the characteristics of the people who hand in the items. Below is a
generic form that can be adapted to suit your program.
ITEMS RECEIVED
Receipt No.:
[Number Consecutively]
Date:
List of Items Received:
Number of item(s) received:
Location where item(s) were received:
From
Item(s) Received From Households
Number of people in household: ___________________
Age and sex of people in household: [Divide by appropriate intervals, say 5- or 10-year intervals]
10 years or under
Females: _______
Males: _______
11–20 years
Females: _______
Males: _______
21–30 years
Females: _______
Males: _______
31–40 years
Females: _______
Males: _______
41–50 years
Females: _______
Males: _______
51–60 years
Females: _______
Males: _______
61–70 years
Females: _______
Males: _______
71 years or older
Females: _______
Males: _______
From
Item(s) Received From Individuals
Age and sex of individual person: [Divide by appropriate intervals, say 5- or 10-year intervals]
10 years or under
Female: t
Male: t
11–20 years
Female: t
Male: t
21–30 years
Female: t
Male: t
31–40 years
Female: t
Male: t
41–50 years
Female: t
Male: t
51–60 years
Female: t
Male: t
61–70 years
Female: t
Male: t
71 years or older
Female: t
Male: t
Other Assistance Provided
Counseling t
Referral t
Training t
Appendix C - 113
APPENDIX C
CHECKLIST OF TASKS
For Programs to Prevent Unintentional Injury
Program Development
As soon as you or someone in your organization has the
idea for a program to prevent unintentional injury, begin
evaluation.
1. Investigate to make sure an effective program similar
to the one you envision does not already exist in your
community.
2. If a similar program does exist and if it is fully meeting
the needs of your proposed target population, modify
your ideas for the program so that you can fill a need
that is not being met.
3. Decide where you will seek financial support.
®
Find out which federal, state, or local government
agencies give grants for the type of program you
envision.
®
Find out which businesses and community groups
are likely to support your goals and provide funds
to achieve them.
4. Decide where you will seek nonfinancial support.
®
Find out which federal, state, or local government
agencies provide technical assistance for the type of
program you envision.
®
Find out which businesses and community groups
support your goals and are likely to provide technical
assistance, staff, or other nonfinancial support.
5. Develop an outline of a plan for your injury-prevention
program. Include in the outline the methods you will use
to provide the program service to participants and the
methods you will use to evaluate your program’s impact
and outcome.
114 - Appendix C: Checklist of Tasks
6. Evaluate the outline. For example, conduct personal
interviews or focus groups with a small number of the
people you will try to reach with your injury-prevention
program. Consult people who have experience with
programs similar to the one you envision, and ask them
to review your plan. Modify your plan on the basis of
evaluation results.
7. Develop a plan to enlist financial and nonfinancial support from all the agencies, businesses, and community
organizations you have decided are likely sources of
support. Use the outline of your plan for the injuryprevention program to demonstrate your commitment,
expertise, and research.
8. Evaluate the plan for obtaining support. For example,
conduct personal interviews with business leaders in
your community. Modify your plan on the basis of
evaluation results.
9. Put your plan for obtaining support into action.
10. Keep track of all contacts you make with potential
supporters.
11. If unexpected problems arise while you are seeking
support, re-evaluate your plan or the aspect of your plan
that seems to be the source of the problem. For example,
if businesses are contributing much less than you had
good reason to expect, then seek feedback from
businesses that are contributing and those that are not.
Or if you did not receive grant funds for which you
believed you were qualified, contact the funding agency
to find out why your proposal was rejected. Modify
your plan according to your re-evaluation results, and
continue seeking support.
12. When you have enough support for your program,
expand on the outline of your plan for the injuryprevention program. Include in the design a mechanism
for evaluating the program’s impact and outcome.
13. Evaluate your program’s procedures, materials, and
activities. For example, conduct focus groups within
your target population. Modify the plan on the basis
of evaluation results.
14. Develop forms to keep track of program participants,
program supporters, and all contacts with participants,
supporters, or other people outside the program.
15. Measure the target population’s knowledge, attitudes,
beliefs, and behaviors that relate to your program goals.
The results are your baseline measurements.
Appendix C: Checklist of Tasks - 115
Program Operation
1. Put your program into operation.
®
Track all program-related contacts (participants,
supporters, or others). Track all items either
distributed to or collected from participants.
®
As soon as the program has completed its first
encounter with the target population, assess any
changes in program participants’ knowledge,
attitudes, beliefs, and (if appropriate) behaviors.
2. Continue tracking and assessing program-related
changes in participants throughout the life of the
program. Keep meticulous records.
3. If unexpected problems arise while the program is in
operation, re-evaluate (using qualitative methods) to
find the cause and solution. For example, your records
might show that not as many people as expected are
responding to your program’s message, or your assessment of program participants might show that their
knowledge is not increasing. Modify the program on
the basis of evaluation results.
4. Evaluate ongoing programs (e.g., classes on fire safety
given each year to third graders) at suitable intervals to
see how well the program is meeting its goal of reducing
injury-related morbidity and mortality.
Program Completion
1. Use the data you have collected throughout the program
to evaluate how well the program met its goals: to
increase behaviors that prevent unintentional injury
and, consequently, to reduce the rate of injuries and
injury-related deaths.
2. Use the results of this evaluation to justify continued
funding and support for your program.
3. If appropriate, publish the results of your program in
a scientific journal.
Appendix D - 117
APPENDIX D
BIBLIOGRAPHY
Evaluation in General
Capwell EM, Butterfoss F Francisco VT “Why Evaluate?”
,
.
Health Promotion Practice, Vol. 1(1)15–20; January 1999.
CDC. “ Framework for Assessing the Effectiveness of Disease
A
and Injury Prevention.” MMWR Recommendations and
Reports, Vol. 41 (RR03):1–12; March 27, 1992.
CDC. Evaluating Community Efforts to Prevent CardioVascular Diseases: Work-Group on Health Promotion
and Community Development. Atlanta, GA: National
Center for Chronic Disease Prevention and Health
Promotion; 1995.
CDC. “Framework for Program Evaluation in Public Health.”
MMWR Recommendations and Reports, Vol. 48 (RR11):
1–40; September 17, 1999.
CDC. Measuring Violence-Related Attitudes, Beliefs, and
Behaviors Among Youths: A Compendium of Assessment
Tools. Atlanta, GA: National Center for Injury Prevention
and Control, Publication No. 099-5626; 1998.
Fulbright-Anderson K, Kubisch AC, Connell JP “New
.
Approaches to Evaluating Community Initiatives.”
Vol. 2 - Theory, Measurement and Analysis. Queenstown,
MD:The Aspen Institute; 1998.
Hawe P Degeling D, Hall J. Evaluating Health Promotion: A
,
Health Worker’s Guide. Sydney: MacLennan and Petty
Pty, Limited; 1990.
Israel BA, Cummings M, Dignan MB, et al. “Evaluation of
Health Education Programs: Current Assessment and
Future Directions.” Health Education Quarterly, Vol. 22(3):
364–389; 1995.
118 - Appendix D: Bibliography
McKenzie JF, Smeltzer JL. Planning, Implementing and Evaluating Health Promotion Programs (2nd Edition). Needham
Heights, MA: Allyn and Bacon; 1997.
Rivera F Sleet D, Acree K, et al. “Chapter 4: Program Design
,
and Evaluation.” In: National Committee on Injury
Prevention and Control (Eds.). Injury Prevention: Meeting
the Challenge. Supplement to American Journal of Preventive
Medicine, Vol. 5, No. 3. New York: Oxford University
Press; 1989.
Rootman I, Goodstadt M, Hyndman B, et al. (Eds).
Evaluation in Health Promotion: Principles and Perspectives.
Copenhagen, Denmark: World Health Organization,
Euro; 1999 (in press).
Rossi PH, Freeman HE. Evaluation: A Systematic Approach.
Newbury Park, CA: Sage; 1993.
Udinsky BF Osterlind SJ, Lynch SW Evaluation Resource
,
.
Handbook: Gathering, Analyzing, Reporting Data. San Diego:
Edits; 1981.
Wye CG, Hatry HP Timely, Low-Cost Evaluation in the Public
.
Sector. San Francisco: Josey-Bass; 1988.
Experimental and Quasi-Experimental Design
Campbell DT, Stanley JC. Experimental and QuasiExperimental Designs for Research. Boston:
Houghton Mifflin; 1963.
Psychological Testing
Testing
Anastasi A. Psychological Testing. 6th Edition. New York:
MacMillan; 1988.
Questionnaires and Questionnaire Design
Bogozzi RP “Measurement in Marketing Research: Basic
.
Principles of Questionnaire Design.” In: Bagozzi RP,
Editor. Principles of Marketing Research. Cambridge, MA:
Blackwell Business; 1994.
Educational Testing Service. “
Attitude Tests.” In: The ETS Test
Collection Catalog, Vol. 5. Phoenix, AZ: Oryx Press; 1991.
Appendix D: Bibliography - 119
Erdos PL. Professional Mail Surveys. New York:
McGraw-Hill; 1970.
Hayes BE. Measuring Customer Satisfaction: Development
and Use of Questionnaires. Milwaukee: ASQC Quality
Press; 1992.
Kanda N. Group Interviews and Questionnaire Surveys.
Qual Control 1994; August:77–85.
Nogami GY. Eight Points for More Useful Surveys. Qual
Progress 1996; October:93–6.
Oppenheim AN. Questionnaire Design, Interviewing and
Attitude Measurement. London: Pinter; 1992.
Sudman S, Bradburn NM. Asking Questions. San Francisco:
Jossey-Bass; 1982.
Zimmerman DE, Muraski ML. The Elements of Information
Gathering: A Guide for Technical Communicators,
Scientists and Engineers. Phoenix, AZ: Oryx Press; 1995.
Risk for Morbidity or Mortality
Occupant Restraints in Motor Vehicles
Vehicles
Boehly WA, Lombardo IV “Safety Consequences of the Shift
.
to Small Cars in the 1980's.” In: National Highway Traffic
Safety Administration: Small Car Safety in the 1980's.
Washington, DC: US Department of Transportation; 1980.
Bicycle Helmets
Thompson DC, Thompson RS, Rivara FP Wolf ME.
,
“Case-Control Study of the Effectiveness of Bicycle Safety
Helmets in Preventing Facial Injury.” Am J Public Health
1990; 80:1471–4.
Thompson RS, Rivara FP Thompson DC. “Case-Control Study
,
of the Effectiveness of Bicycle Safety Helmets,” New Engl J
Med 1989; 320:1361–7.
120 - Appendix D: Bibliography
Smoke Detectors
Hall JR. “The U.S. Experience with Smoke Detectors.” NFPA J
1994; Sept/Oct:36–46.
Mallonee S, Istre GR, Rosenberg M, Reddish-Douglas M,
Jordan F, Silverstein P et al. “Surveillance and Prevention
,
of Residential Fires.” New Engl J Med 1996; 335:27–31.
Runyan CW Shrikant IB, Linzer MA, Sacks JJ, Butts J. “Risk
,
Factors for Fatal Residential Fires.” New Engl J Med 1992;
327:859–63.
Sampling Methods and Survey Research
Fowler FJ. “Survey Research Methods.” In: Applied Social
Research Methods Series, Vol. 1. Newbury Park, CA:
Sage; 1993.
Green LW Lewis FM. Measurement and Evaluation in
,
Health Education and Health Promotion. Palo Alto, CA:
Mayfield; 1986.
Rossi PH, Wright JD, Anderson AB. Handbook of Survey
Research. San Diego: Academic Press; 1983.
Appendix E - 121
APPENDIX E
GLOSSARY
Attitudes: People’s biases, inclinations, or tendencies that
influence their response to situations, activities, people,
or program goals.
Baseline information: Data gathered on the target population
before an injury-prevention program begins.
Closed-ended questions: Questions that allow respondents
to choose only from a list of possible answers. (Compare
Open-ended questions.)
Comparison group: (see Control group)
Contact: Any personal interaction between program staff and
a person or household in the target population (sometimes
called encounter). Also the person or household with
whom program staff interacted.
Control group (or comparison group): A group whose
characteristics are as similar as possible to those of the
intervention group. To evaluate program effects,
evaluators compare differences in changes between
the two groups. See also Intervention group.
Encounter (contact): In evaluation, any personal interaction
between a program and a person, household, or group of
people in the target population.
Experimental designs: In evaluation, methods that involve
randomly assigning people in the target population to
one of two or more groups in order to eliminate the effects
of history and maturation. The program’s effects are
measured by comparing the change in one group or set of
groups with the change in another group or set of groups.
Focus group: A qualitative method of evaluating program
materials, plans, and results. A facilitator moderates a
discussion among four to eight people, allowing them
to talk freely on the subject of interest.
122 - Appendix E: Glossary
Formative evaluation: Research conducted (usually while the
program is being developed) on a program’s proposed
materials, procedures, and methods.
History: The knowledge, skills, or other attributes that people
have with regard to the goals of an injury-prevention
program before the program begins.
Impact evaluation: Research to determine how well a
program is meeting its intermediate goals of changes
in people’s knowledge, attitudes, and beliefs.
Instrument: The tool used to gather information on
people’s knowledge, attitudes, beliefs, or behavior
(e.g., a questionnaire).
Intervention: The method, device, or process used to prevent
an undesirable outcome.
Intervention group: The group in an experimental study or
evaluation who is to receive the intervention. See also
Control group.
Item: One question or statement on an instrument used to
measure knowledge, attitudes, beliefs, or behaviors.
Maturation: The knowledge, skills, or other attributes that
people gain with regard to the goals of an injuryprevention program while the program is going on, but
which are not due to program activities.
Morbidity: Any deviation from a state of well-being, either
physiological or psychological; any mental or physical
illness or injury.
Outcome evaluation: Research to determine how well
programs succeeded in achieving their ultimate
objective of reducing morbidity and mortality.
Open-ended questions: Questions that allow respondents to
answer freely in their own words. (Compare Closed-ended
questions.)
Pilot test: A small-scale trial conducted before a full-scale
program begins to see if the planned methods,
procedures, activities, and materials will work.
Placebo: A service, activity, or item that is similar to the
intervention service, activity, or item but without the
intervention characteristic that is being evaluated.
Prevalence: The amount of a factor of interest
(e.g., knowledge or head injury) that is present
in a specified population at a specified time.
Appendix E: Glossary - 123
Probe: A method of soliciting more information about an
issue than respondents gave in their first response to
questions.
Process evaluation: Research to determine how well a
program is operating. Includes assessments of whether
the program and its materials are reaching the target
population and, if so, in what quantity.
Qualitative methods: Ways of collecting descriptive data on
the knowledge, attitudes, beliefs, and behaviors of the
target population. In general, information gathered using
qualitative methods is not given a numerical value.
Quality assurance: A system to ensure that all aspects of a
program will be of the highest possible caliber.
Quantitative methods: Ways of collecting numerical data on
the target population. Use quantitative data to draw
conclusions about the target population.
Quasi-experimental design: In evaluation, methods that do
not involve randomly assigning members of the target
population either to an intervention or to a comparison
group but which, nevertheless, reduce the effects of
history and maturation. Evaluators have less control over
factors that affect the comparison group than they do
with experimental designs.
Randomization: Assigning individuals by chance (using a
predetermined method) to groups that will either receive
the injury-prevention intervention or not receive it. It is
used for experimental-design programs. The predetermined method is usually based on a table of random
numbers or a computer-generated list.
Rate: A measurement of how frequently an event occurs
among people in a certain population at a point in time
or during a specified period of time.
Reach: The number of people or households who receive the
program’s message or intervention.
Readability: The level of reading skill required to be able to
understand written materials.
Sample: A subset of people in a particular population.
Sampling frame: Complete list of all people or households in
the target population.
Schematic: The order (in symbols) in which events occur
during an experimental or quasi-experimental study.
124 - Appendix E: Glossary
Survey: A quantitative (nonexperimental) method of
collecting information at one point in time on the target
population. Surveys may be conducted by interview
(in person or by telephone) or by questionnaire.
Survey instrument: (see Instrument).
Survey item: (see Item)
Target population: The people or households the program
intends to serve.
Unit: One person or household in the target population.
COMMENT FORM
apply.
1. Which sections of this book did you read? [Check all answers that apply.]
Introduction
How This Primer Is Organized
t
Section 1: General Information
t
Section 2: Stages of Evaluation
t
Section 3: Methods of Evaluation
Appendix A: Examples of Questions t
to Ask, Events to Observe, and
Who or What to Count
t
t
Appendix B: Sample Forms
Appendix C: Checklist of Tasks
t
Appendix E: Glossary
2. What is your opinion of this book?
t
Appendix D: Bibliography
Useful
t
t
Somewhat
Useful
Not
Useful
Did Not
Read
t
t
t
t
What is your opinion of each section
of this book?
Introduction
t
t
t
t
How This Primer Is Organized
t
t
t
t
Section 1: General Information
t
t
t
t
Section 2: Stages of Evaluation
t
t
t
t
Section 3: Methods of Evaluation
t
t
t
t
Appendix A: Examples of Questions
to Ask, Events to Observe, and
Who or What to Count
t
t
t
t
Appendix B: Sample Forms
t
t
t
t
Appendix C: Checklist of Tasks
t
t
t
t
Appendix D: Bibliography
t
t
t
t
Appendix E: Glossary
t
t
t
t
apply.
3. How did you use this book? [Check all answers that apply.]
Personal reference t
Staff instruction t
Library resource t
Other (Specify) _________
4. Check your job category
Health Professional t
Other Professional t
Other (Specify) _____________________
Executive/Manager t
Educator t
employer’s
5. Check your employer ’s category
Government t
Academia t
Nonprofit Organization t
Private Corporation t
Other (Specify) _______________
6. Do you have suggestions on how to improve this book?
--------------------------------------------------------------------------------------------------------------------------------
Fold
No postage necessary - Fold along dotted lines - Seal with tape
-------------------------------------------------------------------------------------------------------------------------------DEPARTMENT OF
HEALTH AND HUMAN SERVICES
NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES
Public Health Service
Centers for Disease Control
and Prevention (CDC)
Atlanta, Georgia 30333
Official Business
Penalty for Private Use, $300
Return After Five Days
Return Service Requested
BUSINESS REPLY MAIL
FIRST CLASS MAIL
PERMIT NO. 99110
ATLANTA, GA 30333
Postage Will Be Paid by Department of Health and Human Services
To:
Your Program’s Worth
To: Demonstrating Your Program’s Worth
(MS-K63)
NCIPC - Division of Unintentional Injury (MS-K63)
4770 Buford Highway NE
Atlanta, GA 30341-3724
