SPNS COOPERATIVE AGREEMENT EVALUATION

MODULE 64: SELF EFFICACY SCALE FORM INSTRUCTIONS

Citation: Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1996). Module 64: Self-Efficacy Form. Available: www.TheMeasurementGroup.com. Culver City, California: The Measurement Group.

Source Citations: Pearlin, L. and Schooler, C. (1978). The structure of coping. Journal of Health and Social Behavior, 19, 2-21; Pearlin, L., Lieberman, M., Menaghan, E., and Mullan, J. (1981). The stress process. Journal of Health and Social Behavior, 22, 337-356.

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 the Module 64: Self Efficacy Form

Note: Project staff should fill out the top two rows before handing the form to the client.

ID Letters/ID Numbers. These boxes are provided for entering the unique identifier your site is using to track client information. The four boxes on the left are to be used for letters, while the ten boxes on the right are reserved for numbers. You may use letters, numbers, or a combination of letters and numbers, for identification purposes. If you use a combination of letters and numbers, however, please use the letters first in your alphanumeric sequence (for example, if your unique identifier is MD-1479, the letters "M" and "D" would be entered in the first two of the four boxes reserved for letters and the numbers "1", "4", "7", and "9" would be entered into the first four of the ten boxes reserved for numbers). If you are unsure about the unique identifier for this client, check with you project director.

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 in the table below. Site codes are 3 letters.

Sub-Provider. This field may be used to designate specific sites or providers within your project. If appropriate, enter the code of the service provider agency doing the activity. Provider codes can be up to three letters.

Date. Enter the numbers representing today's date (the date of the activity) 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.

Staff Code. Each staff member should be assigned a unique number code (up to 3 digits). Make sure that each new staff member has a unique code. Do not reassign any staff codes that have been previously assigned. Enter the 3-digit code for the person who provided the services. If the staff code is less than 3 digits, place "0"s before the number. For example, 3 is 003.

Client Gender. Darken the circle next to the response that indicates the person's gender.

Instructions for Items 1 through 7: Darken the circle next to each statement which asks you about how much control you feel you have in your daily live. How strongly do you agree or disagree that:

Items 1 through 7. Give the form to the respondent and have him/her read the box in which the instructions are written. You may want to read these instructions to him/her: "Darken the circle next to each statement which asks you about how much control you feel you have in your daily live. How strongly do you agree or disagree that." You should then go over the response options with the client. Darken the first circle ("'Strongly Agree") if the respondent feels strongly that the statement applies to him or her. Darken the second circle ("Agree") if the respondent feels that the statement is reasonably true for him or her. Darken the third circle ("Disagree") if the respondent feels that the statement is not true for him or her most of the time. Darken the fourth circle ("Strongly Disagree") if the respondent feels that the statement is never true for him or her. Make sure the respondent understands the format and allow him/her enough time to complete the form.