| Date:______________________________ |
Rater(s):__________________________ |
| Program Name:______________________ |
| Address:___________________________ |
| Contact Person:_____________________ |
Title:______________________________ |
| Phone:______________________________ |
Fax:________________________________ |
| E-mail:_____________________________ |
| ____ Chart review |
____ Agency brochure review |
| ____ Team meeting observation |
____ Supervision observation |
| ____ Interview with Program Director/Coordinator |
| ____ Interview with practitioners |
____ Interview with clients |
| ____ Interview with supervisors |
| ____ Interview with rehabilitation service providers |
| ____ Interview with ______________________ |
| ____ Interview with ______________________ |
| # of EBP Practitioners: ______ |
# of active clients served by EBP: ____ |
| # of clients served by EBP in preceding year:____________ |
| # of charts reviewed:_____________ |
| Date program was started: _____________________________ |
