Checklist for Process Evaluation of Bystander Intervention Strategies

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1. Name of Facilitator(s)/Presenter(s):

Name of Facilitator(s)/Presenter(s):

2. Name of Observer:

Name of Observer:

3. Type of Observer:

Type of Observer:   AmeriCorps Member Coalition Member Staff Advocate Volunteer

Other (please specify):

4. Name of Implementation Site:

Name of Implementation Site:

5. Start Date of Session:

	MM		DD		YYYY
example : 00/00/0000	Start Date of Session:   example : 00/00/0000   Month	/	Day	/	Year

6. End Date of Session:

	MM		DD		YYYY
example: 00/00/0000	End Date of Session:   example: 00/00/0000   Month	/	Day	/	Year

7. Duration of Session:

	Duration
Answer	1 hour2 hours3 hours4 hours5 hoursHalf DayFull DayOther Duration of Session:   Answer   Duration

Other:

8. Sexual Violence Program Name:

Agency By County

Program

Atlantic: Rape Crisis Services, Atlantic County Women's CenterBergen: Rape Care Program, YWCA of Bergen CountyBurlington: Sexual Assault Services, CONTACT of Burlingon CountyCamden: Services Empowering the Rights of Victims, Center for Family ServicesCape May: Coalition Against Rape and AbuseCumberland: Services Empowering the Rights of Victims, Center for Family ServicesEssex: Rape Care Program, Family Service LeagueGloucester: Services Empowering the Rights of Victims, Center for Family ServicesHudson: Rape Crisis Center, Christ Hospital Counseling CenterHunterdon: SAFE in HunterdonMercer: Sexual Assault Support Services, WomanspaceMiddlesex: Rape Crisis Intervention Center, Middlesex County Public Health Dept.Monmouth: Victim Support Program, 180 Turning Lives AroundMorris: Sexual Assault Center, Morristown Memorial HospitalOcean: Sexual Abuse and Assault Program, St. Francis Counseling ServicePassaic: Sexual Assault Program, Passaic County Women's CenterSalem: Salem County Women's ServicesSomerset: Sexual Assault Support Services, Women's Health and Counseling CenterSussex: Domestic Abuse and Sexual Assault Intervention ServicesUnion: Rape Crisis CenterWarren: Domestic Abuse and Sexual Assault Crisis CenterRutgers University: Office for Violence Prevention and Victim Assistance Sexual Violence Program Name:   Program   Agency By County

9. Primary Strategy Name:

	Name
Strategy	Green DotSCREAM TheatreMentors in Violence PreventionMOST ClubsNew Mexico Media Literacy ProjectSocial Norms MarketingOther Primary Strategy Name:   Strategy   Name

Other: