SPNS COOPERATIVE AGREEMENT EVALUATION

Module 56: Trainer Characteristics Form Instructions

Citation: Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1995). Module 56: Trainer Characteristics Form. Available: www.TheMeasurementGroup.com. Culver City, California: The Measurement Group.

This form is intended to be filled out by the trainer.

Answer questions by either filling in a circle, or writing a number or letter in a square box. If the answer goes in a square box, you must use a CAPITAL LETTER or number that does not touch the side of the box. Print only one letter or number in each box. If the letters or numbers that you print touch the sides of the boxes, or if you do not clearly print the information, the computer will "kick out" the form and we will need to return it to you to be completed correctly. If the question asks the answer to be filled in a circle, make sure that the circle is completely darkened. Only darken one circle for each question unless the instructions specifically tell you to darken as many as apply for that question.

Specific Parts of Module 56: Trainer Characteristics Form

Site. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form. If it has not been already entered on the form, check with your project to find out your site code and enter it in the boxes. Site codes are 3 letters.

Sub-Provider. If appropriate, enter the code for the service provider agency doing the activity. The provider codes are determined by your local project. Provider codes can be up to 3 letters.

Training #. Enter the three-digit code for the training session. For example, if this is the third training or presentation that your project has held, you would enter "003" in these boxes.

Staff Code. Enter the staff member code for this trainer. The staff codes are determined by your local project. Staff codes are 3 numbers. If the number is less than 3 digits, place "0"s to the left of the number. For example, 3 is "003."

Hour. Enter the starting time of the presentation as a two-digit number. Round to the nearest hour. For example, if the start time is between 10:31am and 11:30 am you would enter "11" in the boxes and darken the circle labeled "am."

Age. Write your age in years in the boxes indicated.

Training Date. Enter the numbers representing the date of the training in these boxes. Enter the month as a number from 01 to 12 for January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "95" for 1995). Make sure that if a month or day is less than 10, you place a "0" before the number.

Completed By. Darken the circle indicating who completed the form. Choose only one. Darken the "Trainer" circle if this form is completed by the trainer. Darken the "Project Drector for Trainer" circle if the form is completed by the project director for the trainer. If the person completing this form serves as both a project director and a trainer, fill in the bubble for "trainer" if the person was the trainer for this particular training session, and the bubble for "Project Director for Trainer" if the person was not the trainer for this particular session but is filling out this form.

Male / Female. Darken the appropriate circle.

What is your primary ethnic/cultural/racial background. Choose from among the two-digit codes provided on the form and fill in the appropriate boxes. Be as specific as possible in selecting the codes. If you cannot specify subcategories of ethnic/cultural/racial background, use the broader categories ("10" = Caucasian, "20" = African-American/Black (non-Hispanic), "30" = Hispanic, "40" = Asian/Pacific Islander, "50" = American Indian, Aleutian, Native Alaskan or Eskimo). Mark "99" if the ethnic/cultural/racial background is unknown.

Do you identify yourself as multi-racial? Darken either the "Yes," "No," or "Do Not Know" circle to indicate if you identify yourself as multi-racial. If you do identify yourself as multi-racial, and have filled in the circle labeled "Yes," you may enter the two-digit code for the second race or ethnicity in the boxes provided. Use the same codes as those listed under "Primary Ethnic/Cultural/Racial Background."

What are your professional credentials? Darken the circle which describes your professional credentials. Fill in as many circles as necessary. The boxes labeled "Other" may be used to write in one response not listed on the form.

How many persons with HIV/AIDS have you personally served in the past year? Darken the circle which best represents the range in number of persons with HIV/AIDS you have personally served in the past year. Choose only one.

Approximately how many hours of HIV/AIDS education/training have you had in the past 3 years? Darken the circle which represents the range in number of hours of HIV/AIDS education/training you have had in the past 3 years. Choose only one.

What is the highest level of education you have achieved? Darken the circle indicating the highest educational level achieved. Fill in only one circle to indicate the highest educational level achieved at the time of the training, not taking into account any coursework in progress. For example, if you are currently working toward completion of your first Master’s degree, you would darken the "Bachelor’s degree" circle. The boxes labeled "Other" may be used to write in one response not listed on the form.

Which setting best represents where most of your agency's clients come from? Darken the circle(s) that best describe the setting where most of your agency’s clients come from. Darken as many circles as is necessary. Fill in the circle labeled "Not relevant/here to be trained to meet my own needs" if this question does not apply to you.

What is your primary functional role in your job? Darken the circle indicating your main functional role in your job. The boxes labeled "Other" may be used to write in one response not listed on the form.

How would you characterize the organization in which you now work? Darken the circle which most closely describes the organization in which you are currently working. Fill in as many circles as necessary. The boxes labeled "Other" may be used to write in one response not listed on the form.

What is, or would be, your primary involvement with HIV+ individuals? Darken the circle which best describes your primary involvement with HIV+ individuals. Fill in as many circles as necessary. The boxes labeled "Other Physician" may be used to write in a type of physician not listed on the form. The boxes labeled "Other" may be used to write in one other type of occupation not listed on the form.

Primary Language. Darken the circle of the choice that indicates your primary language. Choose only one. The boxes labeled "Other" may be used to write in one language not indicated on the form.

Years of "Professional" Experience. Write in the two boxes the number of years you have been working in your chosen field. Enter the number of years as a two-digit number. For example, if you have been working in your chosen field for three years, you would enter "03" in the boxes.

Years of "Professional" Experience Working on HIV-Related Services & Problems. Write in the two boxes the number of years you have been working specifically with HIV-related issues. Enter the number of years as a two-digit number. For example, if you have worked specifically with HIV-related issues for three years, you would enter "03" in the boxes.

What is your sexual orientation? Darken the circle which best describes your sexual orientation. Choose only one. If you would rather not state your orientation on this form, please fill in the circle labeled "Prefer not to state." If your orientation is not listed on the form, please fill in the circle labeled "Other" and write in your orientation in the boxes below this circle.

 

How do you identify your sexual orientation to other staff in your agency? Darken the circle which best describes how you identify your sexual orientation to other staff in your agency. Fill in as many circles as necessary. If you do not usually state your orientation to other staff in your agency, please fill in the circle labeled, "Usually do not state." If your orientation is not listed on the form, please fill in the circle labeled "Other" and write in your orientation in the boxes below this circle.

 

How do you identify your sexual orientation to the people you train? Darken the circle which best describes how you identify your sexual orientation to the people you train. Fill in as many circles as necessary. If you do not usually state your orientation to the people you train, please fill in the circle labeled, "Usually do not state." If your orientation is not listed on the form, please fill in the circle labeled "Other" and write in your orientation in the boxes below this circle.

 

Are you HIV-positive? Darken the circle which best indicates your present HIV status. Choose only one. If you would rather not state your HIV status on this form, please fill in the circle labeled "Prefer not to state on this questionnaire."

 

How do you identify your HIV status to other staff in your agency? Darken the circle which best indicates how you identify your HIV status to other staff in your agency. Fill in as many circles as necessary. If you do not usually state your HIV status to other staff in your agency, please fill in the circle labeled, "Usually do not state."

 

How do you identify your HIV status to the people you train? Darken the circle which best indicates how you identify your HIV status to the people you train. Fill in as many circles as necessary. If you do not usually state your HIV status to the people you train, please fill in the circle labeled, "Usually do not state."