Warning:

This document is being maintained for historical purposes, but is now out of date. To view current guidelines please visit:

• HIV/AIDS Guidelines and Recommendations   at http://www.cdc.gov/hiv/guidelines/index.html

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Table_A2

                                       QUALITY ASSURANCE

                                    PROGRAM ASSESSMENT FORM
                                 STREET AND COMMUNITY OUTREACH


OUTREACH SPECIALIST: ______________________

REVIEWER: ______________________

DATE: _____________

DIRECTIONS:  Check the appropriate columns to indicate degree to which the outreach 
specialist met criteria:

              EXCELLENT  indicates that performance met criteria beyond fully successful.

              FULLY SUCCESSFUL  indicates performance met criteria successfully.

              NEEDS ATTN  indicates performance needs supervisory guidance to meet criteria.

              N/A  indicates this criteria did not apply to this situation.


Check only within and not between the boxes.  If undecided, use "comments" section to clarify.
                                                                                                         
                                                                                    EXCELLENT   FULLY        NEEDS       N/A
                                                                                                SUCCESSFUL   ATTN
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 STAFF
 
 1.  Staff respects client's privacy and confidentiality at all times.
 
 2.  Staff is trained and experienced in health education.                                               
 
 3.  Staff is sensitive to community norms, values, cultural beliefs, and 
     traditions.
 
 4.  Staff advocates for the population served.                                                          
 
 5.  Staff acts as liaison between the community and agency.                                             
 
 6.  Staff is representative of the population served.                                                   
 
 7.  Staff is informed about community resources and is able to use them.
     
     COMMENTS:
 
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 PROGRAM                                                                                                 
 
 1.  Program proposes realistic, measurable, and attainable goals and objectives.
 
 2.  Program identifies specific methodologies and activities t achieve stated 
     goals and objectives.
 
 3.  Program defines target population by geographic locale, risk behavior(s), 
     gender, sexual orientation, and race  and ethnicity.
 
 4.  Program ensures adequate supplies of appropriate and relevant risk-
     reduction materials before conducting outreach activities (e.g., pamphlets, 
     condoms, bleach, sexual responsibility kits).
 
 5.  Program includes observation of potential outreach areas to determine the 
     locations, times of day, and the day of the week that are most productive for 
     reaching the population to be served.
 
 6.  Program has regular and consistent hours for outreach activities.
 
 7.  Program facilitates professional development of progral staff.
 
 8.  Program has a comprehensive and written field safety protocol.
 
 9.  Program has a written policy and personnel procedures to address stress, 
     burn-out, and relapse among staff.
 
 10. Program has written procedures for the referral of clients to appropriate 
     services outside the agency.
 
 11. Program has long-range plans for the continuation of services.

 12. Program establishes and maintains a relationship between the agency and 
     other local authorities.

 13. Program identifies and develops collaborative relationships with relevant 
     gatekeepers (key informants) to the target population.

 14. Program coordinates intervention services with identified gate-keepers.

     COMMENTS:
 
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 EVALUATION                                                                                              
                                                                                             
 1.  Evaluation plan includes process evaluation measures.                                               
 
 2.  Evaluation plan has consistent, accurate data collection procedures.

 3.  Evaluation plan includes staff supervision, observation, and feedback on a 
     regularly scheduled basis.

 4.  Evaluation plan provides findings for program modifications, as appropriate.

     COMMENTS:
 
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 TRAINING                                                                                                
 
 1.  Training plan defines staff roles, duties, and responsibilities.

 2.  Training plan includes staff orientation to the agency (organization) and the 
     community served.

 3.  Training plan includes ongoing staff professional development.

 4.  Training plan uses role play, observation, and feedback.                                            
     
     COMMENTS:
 
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