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Module 7: Agency Capacity and Needs Assessment Questionnaire
| Date: _____/_____/_____ | Site Code: _______________ |
Provide the following information about your program.
Organization/Program: ______________________________
Address: _____________________________________________
City: State: ______________________________ Zip Code: _______________
Phone: _______________
Contact person: ______________________________ Phone: _______________
Type of agency (check one):
| 1q Public | 4q Volunteer | 2q Private non-profit |
| 5q Religious non-profit | 3q Private for profit |
1. Which of the following statements describes the activities of your agency, program, or practice? (check as many as needed but as few as possible)
q a. HIV-specific community-based organization (CBO): CBO providing non-outreach social services primarily to HIV-positive individuals or to prevent the spread of HIV. May serve individuals with alcohol and/or other drug abuse problems in the course of providing social services. NOTE: Organizations providing outreach interventions that actively recruit service recipients by sending personnel into the community on foot, in vehicles, into shooting galleries, etc., please check "b" (outreach program).
q
b. Outreach program: CBO, university-based group, or other agency whose primary mission is to provide community/street outreach to drug abusers and others at high risk to become HIV-positive and link them to appropriate social, medical, or drug abuse treatment services. Actively recruits service recipients by sending personnel into the community on foot, in vehicles, into shooting galleries, etc.q
c. Home care Agency/Hospice: CBO, public, or private organizations whose primary function and mission is to provide at home or hospice services to individuals with diagnosed AIDS.q
d. Hospital or medical center: Agency specializing in general health care. May serve individuals with alcohol and/or other drug abuse problems in the course of providing general health care services. Provides for medical treatment for HIV-infection and AIDS.q
e. General health care clinic or similar agency: Program specializing in general health care; not a hospital. May serve individuals with alcohol and/or other drug abuse problems or HIV-infection in the course of providing general health care services.q
f. City health department or County health agency: Branch of local government with employees paid directly by the city, county, or other jurisdiction.q
g. General social services program or general social services community based agency (CBO): Agency specializing in one or more forms of social services, but not specifically alcohol and/or drug abuse treatment/recovery. May serve individuals with alcohol and/or other drug abuse problems and/or HIV-infection in the course of providing general social services.q
h. Dental care clinic or practice: Agency, group practice, or individual providing dental services. May serve individuals with alcohol and/or other drug abuse problems and/or HIV-infection in the course of providing dental services.q
i. Shelter, soup kitchen, or food bank: Agency specializing in providing for basic needs such as shelter, food, and clothing. May serve individuals with alcohol and/or other drug abuse problems and/or HIV-infection in the course of providing for general basic needs.q
j. Mental health hospital, clinic, or similar facility: Program specializing in general mental health care. May serve individuals with alcohol and/or other drug abuse problems and/or HIV-infection in the course of providing general mental health care services. May include outpatient, inpatient, treatment, recovery, and aftercare components.q
k. Alcohol treatment/recovery program ONLY: Program designed primarily for individuals with alcohol abuse problems. May include outpatient, inpatient, treatment, recovery, and aftercare components. Includes hospital-based alcohol programs. May serve HIV-positive individuals in the course of providing alcohol treatment-recovery services.q
l. Drug abuse treatment/recovery program ONLY: Program designed primarily for individuals with drug abuse problems. May include outpatient, inpatient, treatment, recovery, and aftercare components. Includes hospital-based drug programs. May serve HIV-positive individuals in the course of providing drug abuse treatment-recovery services.q
m. Alcohol AND Drug abuse treatment/recovery program: Program designed for individuals with either alcohol and/or other drug abuse problems (program is designed to accept either type of problem). May include outpatient, inpatient, treatment, recovery, and aftercare components. Includes hospital-based substance abuse programs.q
n. Religious-related services/Community centers: Religious- or municipality-related community center or community program. Provides a combination of social services and basic provisions such as food, shelter, and clothing. May serve individuals with alcohol and/or other drug abuse problems and/or HIV-infection in the course of providing services.q
o. Other (specify): ____________________________________________________________________
2. Does your program provide services specifically designed for individuals infected with HIV? (check one)
1q Yes 0q No
3. Does your program provide services specifically targeted for <fill in target group>? (check one)
1q Yes 0q No
4. How many staff are employed by your agency?
______________ total
______________ medical service providers (e.g., physicians, nurses, technicians)
______________ psychosocial service providers (e.g., psychologists, social workers, counselors)
______________ peer counselors
______________ administrative
______________ other (specify: ___________________________________________________)
5. What follows are more specific questions about the services provided by your organization. For each service you offer, please answer the questions asked. In some places, you are asked for some general statistics about who your program serves. If you can't easily provide them, it is okay to make an educated guess or estimate.
A. Office-Based Medical Care. Medical care provided in a doctor’s office or a clinic.
1. Does your program offer office-based medical care?
0
q no (if no, go to Part B now) 1q yes (if yes, continue with this part)a. Have you added this service or increased capacity in the last 12 months?
0
q no 1q yes 7q don’t know/refused
2. How many TOTAL males and females have you served in this service in the last 12 months? Estimate if you do not know the exact number. ________ males ________ females
3. What % of the males and females served in the last 12 months are known or estimated to be HIV-positive?
________ % of the males ________ % of the females
4. What % of the males and females served in the last 12 months are known or estimated to be <fill in target group>?
________ % of the males ________ % of the females
5. How likely are you to attempt to increase capacity for this service for <fill in target group> in the next 12 months?
1q not at all 2q somewhat 3q probably 4q almost certainly
B. Office-Based Dental Care. Dental care provided in a dentist’s office or clinic.
1. Does your program offer office-based dental care?
0
q no (if no, go to Part C now) 1q yes (if yes, continue with this part)a. Have you added this service or increased capacity in the last 12 months?
0
q no 1q yes 7q don’t know/refused
2. How many TOTAL males and females have you served in this service in the last 12 months? Estimate if you do not know the exact number. ________ males ________ females
3. What % of the males and females served in the last 12 months are known or estimated to be HIV-positive?
________ % of the males ________ % of the females
4. What % of the males and females served in the last 12 months are known or estimated to be <fill in target group>?
________ % of the males ________ % of the females
5. How likely are you to attempt to increase capacity for this service for <fill in target group> in the next 12 months?
1q not at all 2q somewhat 3q probably 4q almost certainly
C. Mental Health Treatment, Therapy, Counseling. Individual or group mental health services provided in an outpatient environment.
1. Does your program offer mental health treatment, therapy, counseling?
0
q no (if no, go to Part D now) 1q yes (if yes, continue with this part)
a. Have you added this service or increased capacity in the last 12 months?
0
q no 1q yes 7q don’t know/refused
2. How many TOTAL males and females have you served in this service in the last 12 months? Estimate if you do not know the exact number. ________ males ________ females
3. What % of the males and females served in the last 12 months are known or estimated to be HIV-positive?
________ % of the males ________ % of the females
4. What % of the males and females served in the last 12 months are known or estimated to be <fill in target group>?
________ % of the males ________ % of the females
5. How likely are you to attempt to increase capacity for this service for <fill in target group> in the next 12 months?
1q not at all 2q somewhat 3q probably 4q almost certainly
D. Substance Abuse Treatment, Therapy, Counseling. Individual or group services provided in an outpatient setting.
1. Does your program offer substance abuse treatment, therapy, counseling?
0
q no (if no, go to Part E now) 1q yes (if yes, continue with this part)
a. Have you added this service or increased capacity in the last 12 months?
0
q no 1q yes 7q don’t know/refused
2. How many TOTAL males and females have you served in this service in the last 12 months? Estimate if you do not know the exact number. ________ males ________ females
3. What % of the males and females served in the last 12 months are known or estimated to be HIV-positive?
________ % of the males ________ % of the females
4. What % of the males and females served in the last 12 months are known or estimated to be <fill in target group>?
________ % of the males ________ % of the females
5. How likely are you to attempt to increase capacity for this service for <fill in target group> in the next 12 months?
1q not at all 2q somewhat 3q probably 4q almost certainly
E. Rehabilitation Services (Physical Therapy, Speech Pathology, Low Vision Training, Occupational Therapy).
1. Does your program offer rehabilitation services?
0
q no (if no, go to Part F now) 1q yes (if yes, continue with this part)
a. Have you added this service or increased capacity in the last 12 months?
0
q no 1q yes 7q don’t know/refused
2. How many TOTAL males and females have you served in this service in the last 12 months? Estimate if you do not know the exact number. ________ males ________ females
3. What % of the males and females served in the last 12 months are known or estimated to be HIV-positive?
________ % of the males ________ % of the females
4. What % of the males and females served in the last 12 months are known or estimated to be <fill in target group>?
________ % of the males ________ % of the females
5. How likely are you to attempt to increase capacity for this service for <fill in target group> in the next 12 months?
1q not at all 2q somewhat 3q probably 4q almost certainly
F. Case Management.
1. Does your program offer office-based case management?
0
q no (if no, go to Part G now) 1q yes (if yes, continue with this part)
a. Have you added this service or increased capacity in the last 12 months?
0
q no 1q yes 7q don’t know/refused
2. How many TOTAL males and females have you served in this service in the last 12 months? Estimate if you do not know the exact number. ________ males ________ females
3. What % of the males and females served in the last 12 months are known or estimated to be HIV-positive?
________ % of the males ________ % of the females
4. What % of the males and females served in the last 12 months are known or estimated to be <fill in target group>?
________ % of the males ________ % of the females
5. How likely are you to attempt to increase capacity for this service for <fill in target group> in the next 12 months?
1q not at all 2q somewhat 3q probably 4q almost certainly
G. Home Health Care. Individual medical services provided by a nurse, physician, or other medical provider in the patient’s home.
1. Does your program offer home health care?
0
q no (if no, go to Part H now) 1q yes (if yes, continue with this part)a. Have you added this service or increased capacity in the last 12 months?
0
q no 1q yes 7q don’t know/refused
2. How many TOTAL males and females have you served in this service in the last 12 months? Estimate if you do not know the exact number. ________ males ________ females
3. What % of the males and females served in the last 12 months are known or estimated to be HIV-positive?
________ % of the males ________ % of the females
4. What % of the males and females served in the last 12 months are known or estimated to be <fill in target group>?
________ % of the males ________ % of the females
5. How likely are you to attempt to increase capacity for this service for <fill in target group> in the next 12 months?
1q not at all 2q somewhat 3q probably 4q almost certainly
H. Hospice.
1. Does your program offer hospice services?
0
q no (if no, go to Part I now) 1q yes (if yes, continue with this part)
a. Have you added this service or increased capacity in the last 12 months?
0
q no 1q yes 7q don’t know/refused
2. How many TOTAL males and females have you served in this service in the last 12 months? Estimate if you do not know the exact number. ________ males ________ females
3. What % of the males and females served in the last 12 months are known or estimated to be HIV-positive?
________ % of the males ________ % of the females
4. What % of the males and females served in the last 12 months are known or estimated to be <fill in target group>?
________ % of the males ________ % of the females
5. How likely are you to attempt to increase capacity for this service for <fill in target group> in the next 12 months?
1q not at all 2q somewhat 3q probably 4q almost certainly
I. Client Advocacy Services. Services designed to help the client receive needed services, overcome institutional barriers, or assert her-his rights.
1. Does your program offer client advocacy services?
0
q no (if no, go to Part J now) 1q yes (if yes, continue with this part)a. Have you added this service or increased capacity in the last 12 months?
0
q no 1q yes 7q don’t know/refused
2. How many TOTAL males and females have you served in this service in the last 12 months? Estimate if you do not know the exact number. ________ males ________ females
3. What % of the males and females served in the last 12 months are known or estimated to be HIV-positive?
________ % of the males ________ % of the females
4. What % of the males and females served in the last 12 months are known or estimated to be <fill in target group>?
________ % of the males ________ % of the females
5. How likely are you to attempt to increase capacity for this service for <fill in target group> in the next 12 months?
1q not at all 2q somewhat 3q probably 4q almost certainly
J. Support Services (Food Assistance, Housing Assistance, Transportation, Emergency Financial Assistance). Ancillary lifestyle supports.
1. Does your program offer support services?
0
q no (if no, go to Part K now) 1q yes (if yes, continue with this part)a. Have you added this service or increased capacity in the last 12 months?
0
q no 1q yes 7q don’t know/refused
2. How many TOTAL males and females have you served in this service in the last 12 months? Estimate if you do not know the exact number. ________ males ________ females
3. What % of the males and females served in the last 12 months are known or estimated to be HIV-positive?
________ % of the males ________ % of the females
4. What % of the males and females served in the last 12 months are known or estimated to be <fill in target group>?
________ % of the males ________ % of the females
5. How likely are you to attempt to increase capacity for this service for <fill in target group> in the next 12 months?
1q not at all 2q somewhat 3q probably 4q almost certainly
K. Education/Risk Reduction Techniques for Individuals and Groups including Information Dissemination, Outreach About Medical and Psychosocial Support Services and Counseling, HIV Testing, and Providing Information About Methods to Reduce the Spread of HIV.
1. Does your program offer education/risk reduction?
0
q no (if no, go to Part L now) 1q yes (if yes, continue with this part)a. Have you added this service or increased capacity in the last 12 months?
0
q no 1q yes 7q don’t know/refused
2. How many TOTAL males and females have you served in this service in the last 12 months? Estimate if you do not know the exact number. ________ males ________ females
3. What % of the males and females served in the last 12 months are known or estimated to be HIV-positive?
________ % of the males ________ % of the females
4. What % of the males and females served in the last 12 months are known or estimated to be <fill in target group>?
________ % of the males ________ % of the females
5. How likely are you to attempt to increase capacity for this service for <fill in target group> in the next 12 months?
1q not at all 2q somewhat 3q probably 4q almost certainly
M. Barriers.
6. If a <fill in target group> wanted to receive this service from your agency, how much of a barrier would each of these factors be to accessing your services? Rate each potential barrier on a scale of 1 to 7, with 1 not being a barrier at all, and 7 being an extreme barrier. Circle one answer for each barrier.
|
Barrier |
Not a barrier at all |
Moder-ate or Average Barrier |
Extreme Barrier |
n/a for this service |
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| a. There is a lack of funding for our agency. | 1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
| b. Our staff are not comfortable working with HIV+ clients. | 1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
| c. Our staff are not comfortable working with _____. | 1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
| d. Serving HIV+ _____ is not in the mission of our agency or Board of Directors. | 1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
| e. HIV+ _____ would not comply with our rules. | 1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
| f. HIV+ _____ do not know about our services. | 1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
| g. The interagency service network in our city is disorganized (affecting referrals, etc.). | 1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
| h. There is a lack of transportation to our services. | 1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
| i. There is a lack of other services the client needs at our program site. | 1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
| j. We have problems with issues like licensure, facility permits, etc. | 1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
| k. We just started providing services to ______. | 1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
| l. We just started providing services for HIV. | 1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
| m. The waiting lists are too long at our service. | 1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
| n. The community doesn’t want our services. | 1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
| o. We cannot provide services in appropriate languages. | 1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
| p. We have a lack of child care. | 1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
| q. The cost of our services is too high to the clients. | 1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
| r. The community is unaware of the availability of services. | 1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
| s. Other:(what?) | 1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
Developed by The Measurement Group. Adapted from an
instrument developed under contract to HRSA and NIDA in September 1993. Portions taken
from instruments © 1990-1992 by The Measurement Group and used with permission for this
instrument. Version of 6/19/95.
Copyright © 1997-2005 by The Measurement Group LLC. All rights reserved. This may not be current and will not be updated.