GAINS^™

Program Assessment

REVIEW QUESTIONNAIRE:
To help you assess the potential value of GAINS^™ to your program or services, thirty-three statements are provided to review the effectiveness of strategies currently being used. Please read each of the following statements and use the four-point "Problem" scale below in your review. Write on the line to the left of each statement a rating of:

1. IF...NOT OF CONCERN
   
2. IF...OF MILD CONCERN
   
3. IF...OF MODERATE CONCERN
   
4. IF...OF SERIOUS CONCERN

Ratings

1. ______ The strictness of staff is...
2. ______ The consistency of all staff is...
3. ______ The harshness or restrictiveness of discipline or correction methods use is...
4. ______ The frequency "Time Out" methods are used is...
5. ______ Vandalism is...
6. ______ The frequency isolation or seclusion are used is...
7. ______ The frequency of physical discipline (i.e., spanking, physical restraint, etc.) is...
8. ______ Racial disproportionality in frequency or severity of discipline is...
9. ______ The amount of time consumed by discipline issues is...
10. ______ The amount of time individuals are away from normalized activity for discipline is...
11. ______ The number of individuals referred out of the unit for discipline is...
12. ______ The seriousness of individual problems is...
13. ______ The effectiveness of new staff with discipline problems is...
14. ______ The effectiveness of experienced staff with discipline problems is...
15. ______ Confusion or lack of clarity concerning referrals between program staff is...
16. ______ The ability to specifically instruct staff regarding the solution to discipline problems in their work areas is...
17. ______ Confusion or lack of clarity concerning communications between staff-parent-administrator, administrator-bus driver, etc., is...
18. ______ Staff stress due to discipline problems is...
19. ______ Total improvement of individuals is...
20. ______ The time allotted by staff to preventive-discipline strategies is...
21. ______ The availability of practical and effective discipline methods is...
22. ______ Transportation discipline problems are...
23. ______ The frequency of use of restraint (physical, chemical, mechanical) is...
24. ______ The academic or vocational achievement of individuals is...
25. ______ The social-interpersonal achievement of individuals is...
26. ______ The value system development of individuals is...
27. ______ The frequency of fights and arguments between individuals is...
28. ______ The frequency of individual's visits with the administrator for non-discipline and positive issues is...
29. ______ The same individuals being referred constantly for discipline is...
30. ______ The frequency of runaways, AWOLs and escapes or attempts is...
31. ______ The frequency of aggressive challenging by individuals is...
32. ______ The number of "in-program failures" is...
33. ______ Preparation for "independent living status" is...

______ TOTAL

33–48 = Raising Children & Youth might be helpful.

49–60 = Raising Children & Youth would help with improving prevention strategies.

> 60 or more than two statements rated "4" = Raising Children & Youth Interpersonal Skills Development Model would be helpful in effectively resolving some of these problems.

Responsive Individual: Assessment and Profile

Rev:  08/04/08