Big Brothers Big Sisters Service Delivery Model
PART I: COMMUNITY-BASED FORMS
Forms and other resources included in this section are listed below.
Volunteer Telephone Inquiry Guide
Volunteer Inquiry Record
Telephone Reference Checks Record Form
Volunteer Application
Parent/Youth Inquiry Record
Volunteer Pre-Interview Questionnaire
Volunteer Assessment and Match Support
Volunteer In-Person Interview
Parent/Youth Pre-Interview Form
Parent/Youth Interview
Transmission of Information Enrollment to Support
Sample Match Support Contact Record
Match Closure and Re-engagement Assessment
Volunteer Re-assessment Form
Volunteer Questionnaire (Post Enrollment)
Volunteer Satisfaction Questionnaire (Match)
Parent Satisfaction Questionnaire (Post Enrollment)
Parent Satisfaction Questionnaire (Match)
POE Forms
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POE instructions
History of the development of the POE survey
POE form for Bigs to complete, required for SBM Grantees
POE form for Little to complete (not required for SBM grantees)
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•
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POE form for Parent of Little to complete (not required for SBM grantees)
POE form for Case Manager of Little to complete (not required for SBM grantees)
POE form for Teacher to complete, does not include the additional questions
concerning grades, DO NOT USE THIS IF YOU ARE A SBM GRANTEE
POE form for SBM Grantees Teachers to complete, required for SBM grantees
Match Closure Codes
File Checklist
Match Introduction Record
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VOLUNTEER TELEPHONE INQUIRY GUIDE
What follows is a sample script of how Customer Relations staff should respond when a
volunteer calls and inquires about being a Big Brother or Big Sister. This sample script
can also be used when returning a call to a volunteer who leaves a message or inquired
about being a Big on the agency’s website.
1. We’re glad you called ……(or sent us an email asking for more information on being a
Big)
2. Being a Big Brother or Big Sister is a lot of fun for both the child and also the
volunteer. In fact, our volunteers tell us they get as much out of it as the kids!
3. Let me tell you a little about our different programs so you can find one that fits what
you are looking for:
•
In our community program, you get to share activities with a child that you both
enjoy! That might include fishing, playing board games, baking cookies, or going
to ball games. You get to enjoy these fun times two or three times a month with
your Little Brother or Little Sister, on your own schedule.
•
We also have a school mentoring program. Here, you get to go back to elementary
school and experience the hot lunches and little desks all over again! You visit your
Little Brother or Little Sister each week at their school. And remember, it’s a
chance for you can go to recess and act like a third grader again.
•
(Add additional program choices here).
4. We’d like to get you started - when would it be convenient for you to come in to meet
with us? It will require about an hour to an hour and a half and we have several times
available…
NOTES
The individual responding to the inquiry should decide, based on this initial interaction, whether it’s
best to wait for the individual to come to the in-person interview and then complete consent forms for
background checks and references. However, the individual should be informed that when they come
for the interview, they will be asked to provide the names and contact information for three
references. The volunteer can also be given additional information regarding the enrollment process,
i.e., criminal background checks. However, it must be expressed in non-threatening terms and
rationalized in terms of parents wanting to know who their son or daughter will be spending time
alone with.
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You should
September
2004also inform individuals that they will be required to show one form of a government
issued photo ID.
Big Brothers Big Sisters Service Delivery Model
VOLUNTEER INQUIRY RECORD
Complete this form when a volunteer calls and inquires about becoming a Big. When the
inquiry is generated from the agency’s web site, this form will also be used when making
first telephone contact with the volunteer to schedule an in-person interview.
Date of Inquiry: ________________________
Volunteer’s Name:
_______________________________________________________
Address: ________________________________________________________________
Home phone: ___________ Cell Phone: ___________ Work phone: _____________
Fax: _______________________ Email: ____________________________
Male: _____
Referred by:
Female: _____
□ TV
□ Radio
□ Friend
□ Self
□ High School Partner
□ Faith Organization □ Website
□ Special Event
□ Always known
□ College Partner □ Service Organization
□ Corporate Partner □ Other ____________
Interview date: __________________ Interview time: _______ Location: _________
Staff member doing the interview: ________________
□ No interview scheduled, wants to wait: ____________
Date to re-contact: _________________
Staff taking this inquiry: ____________________________________________
Comments: _______________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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TELEPHONE REFERENCE CHECKS-RECORD FORM
Volunteer Applicant:_______________
Reference Name:_____________
BBBS Staff Name:________________
Reference ph #:_______________
Date of Initial Contact:_____________
Relationship to Volunteer:
____Friend
Other:
Applying for:
____Employer ______
Comm-Based_____
____Teacher
School-Based_____
____Neighbor
____Youth Org.
____Spouse/Roommate
SAMPLE SCRIPT
Introduce yourself and the reason for your call.
(Volunteer’s name) is applying to become a Big Brother/Big Sister and has given us your
name as a reference. We’d like you to answer the questions below. We have obtained
consent from (Volunteer’s name) and assure you that your answers will be held in
confidence.
But first, here’s a little about our programs.
•
In our community program, a Big Brother/Big Sister gets to share activities with a
child that they both enjoy! That might include fishing, playing board games, baking
cookies, or going to ball games. They get to enjoy these fun times two or three
times a month with a Little Brother or Little Sister, on their own schedule.
•
We also have a school mentoring program. Here, the Big gets to go back to
elementary school and experience the hot lunches and little desks all over again!
They visit their Little Brother or Little Sister each week at their school. And
remember, it’s a chance for them can go to recess and act like a third grader again.
•
(Add additional program choices here).
With this information in mind, please provide the following:
How long have you known (volunteer’s name): Years
Months_____
In what capacity do you know (volunteer’s name)?
Can you tell me about their home environment, in particular how child friendly it is? Are
there any safety concerns or anything else that you would have concerns about that we
could help the volunteer to manage?
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Can you tell me about a time you observed (volunteer’s name) around a child or children?"
"What were your impressions or feelings about that interaction?"
Do you know of any reason why being a Big Brother or Big Sister may not be the right
volunteer experience for (volunteer’s name)?
Do you know of any reason why this may not be the best time for (volunteer’s name) to
commit to being a Big Brother or Big Sister?
What else would you like to tell us about (volunteer’s name)?
We’d like to thank you for your answers. We’d also like to know if you’d be interested to
know more about how even you can become involved with us. Could we send you some
of our materials?
Yes
No Thanks
Record:
• Follow-up contact needed? ___yes ___no
o Record concerns below:
•
Date reference information reviewed with Enrollment_________
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VOLUNTEER PRE-ENROLLMENT
Note: Volunteers are not required to submit a formal application prior to the in-person interview. Rather,
they provide certain identifying and demographic information, list references, and give consent for the
agency to conduct a criminal background check. The information to be collected as represented on this form
may be collected through a variety of means, e.g., separate criminal background consent form, directly
entering volunteer demographic data into a database, etc. Also, if previously involved with another BBBS
organization or youth organization, these will be contacted to verify individual’s involvement.
First Name:
Middle Name:
Home Address:
Last Name:
City:
County:
Email:
Home Ph #:
Work Ph #:
Male
Female
Address:
Social Security #:
Employer:
Occupation:
Date of Birth:
State:
Zip:
Cell Ph #:
City:
State:
Zip:
Ethnicity:
Marital Status:
Highest Level of
Education:
How Long Employed:
Can We Contact You At Work:
Work Hours:
_____Yes _____No
Possession of a driver’s license is not a requirement to participate in any of our programs but is required if
you will be transporting a youth in any vehicle you are operating.
Do you have a driver’s license?
If yes, state of issue and #
Expiration date:
_____Yes _____No
REFERENCES
Please type or print information requested for three references: 1) your current or past employer who has
known you for at least 1 year; 2) a co-worker, friend or neighbor who has known you for at least 2 years; and
3) a close family member (spouse/domestic partner) or a second friend who has known you for at least 3
years.
1. Employer’s Name (or school if student):
Address:
Day Phone #:
Supervisor’s Name (or teacher if a student):
City:
Fax #:
State:
Zip:
State:
Zip:
State:
Zip:
Email:
2. Coworker or Friend or Neighbor:
Address:
Day Phone #:
City:
Fax #:
Email:
3. Spouse/Domestic Partner/Friend:
Address:
Day Phone #:
City:
Fax #:
Have you ever applied before (or have been) to be a Big Brother or
Big Sister? Yes
No
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Email:
Where and When:
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What, if any, other youth organizations have you worked for or been involved with as a volunteer?
Have you ever been involved before with Big Brothers Big Sisters
in a capacity other then a Big? Yes
No
Where and When:
I understand that:
1) The references I listed may be contacted by mail, telephone, or email;
2) I am in no way obligated to perform any volunteer services;
3) The information I provided may be used to conduct a background check, to include driving
records check, criminal background check, and other records where required by local, state,
or federal law for volunteers working with youth;
4) The BBBS agency is not obligated to match me with a youth;
5) Other BBBS agencies or youth organizations where I have worked or volunteered may be
contacted as references; and,
6) As part of the enrollment processes, I will be asked to provide additional personal
information prior to any recommendations for assignment.
__________________________________________________
Signature
_________________________
Date
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PARENT/YOUTH INQUIRY RECORD
Date of Inquiry:
Parent/Guardian’s Name:
Child’s Name:
Age:
Address:
City:
County:
State:
Name of Employer:
Email:
Zip:
Work Phone:
Cell:
Home Phone:
Child’s School:
Grade:
What is the primary reason for you wanting your child to have a Big Brother/Big Sister?
How did you hear about us?
Does your child have other siblings who could benefit from having a Big Brother or Big Sister?
When and where would it be most convenient to talk with you and your child so that we can start
going to get them matched?
Interview Date:
Time:
Location:
Enrollment Staff Assigned:
Staff Taking Inquiry:
Comments:
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VOLUNTEER PRE-INTERVIEW QUESTIONNAIRE
NOTE
This form can be completed by the volunteer prior to the in-person interview. It provides
information that can be used to assess the volunteer and determine with whom the volunteer
might be matched. It is also possible to add these questions to the in-person interview if the
interview is not in the agency and the volunteer does not have ‘waiting time’ before the
interview to complete it. Also, any demographic information about the volunteer not
captured elsewhere can be included on this form.
Prior to your in-person interview, we would like you to answer the questions below. Parents of
youth in our programs will often ask us questions about someone with whom their child will be
matched. We will only release information to a parent with your expressed permission. The
information you give will also help us make a better match for you and assure we can support you
during your involvement with our programs.
Your Name:
Date:
1. Which do you enjoy more?
Indoor Activities
Outdoor Activities
No preference
2. Would you describe yourself as a person who enjoys:
Watching events or activities
Actively participating in activities
Both
3. Do you have any guns or ammunition in your house?
No
Yes (If yes, we will discuss what safety precautions are necessary )
4. Would you be able to secure or otherwise make unavailable any youth inappropriate viewing
materials in your home? This would include television channels and Internet access?
Yes
No (If not, we will have you discuss during the in-person interview)
5. Do you have any pets?
No
Yes (If yes, we will discuss with you what safety precautions are
necessary around youth)
6.Are you experiencing any physical or mental health problems?
No
Yes (If yes, we will have you discuss during the in-person interview)
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7. Have you ever been arrested, charged, or convicted of a crime?
No
Yes (If yes, we will have you discuss during the in-person interview)
8. Have you had any driving citations and/or moving violations in the past 5 years?
No
Yes (If yes, we will have you discuss during the in-person interview)
9. How long have you lived in the area?
_________
10. Do you anticipate any significant life changes over the next year or have you had any in the
past year?
No
Yes (If yes, we will have you discuss during the in-person interview)
11. Do you speak any foreign languages?
Yes ____________________
No
12. Before we continue with some additional questions about your personal background
and life, is there anything else you’d like to tell us about yourself or any questions you may
have of me?
Signature
Date
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VOLUNTEER IN-PERSON INTERVIEW
Volunteer’s Name:
Interviewer’s Name:
Date of Interview:
Date of Write-Up:
_______
Instructions: The instructional and rationale portion of the interview form should NOT be
eliminated as they contain important information for conducting the interview and possible followup.
Prior to asking the interview questions, do the following:
Begin by sharing program information as part of the individualized orientation.
Explain the purpose of the interview, namely, that you’re trying to learn information about
the person so the most appropriate matching decision can be made.
Further explain that anytime during the interview, the volunteer can ask questions.
Briefly outline the process used with parents and children, that we interview them and
provide both parents and children training and materials relating to child abuse prevention
and other safety related issues.
Take a few moments to review the responses to the pre-interview questions. Questions 310 of that form are Yes/No questions that may require follow-up. Follow-up questions,
where indicated on the form, should be asked first before going into the questions on this
form.
Also tell the volunteer that what we collect is confidential and will not be released without
his or her written permission or as possibly required by local, state, or federal laws. Some
personal information will be shared with the parent of a prospective Little prior to a match.
Group Question #7 asks the volunteer to describe and name any involvement as either
volunteer or paid staff with youth (e.g., Little League, Boys & Girls Club, other BBBS
agency). Volunteer must be asked to provide contact information, and an attempt to
contact an appropriate selection of organizations should be made and documented in the
case notes.
Each question group consists of a lead-off question or statement and then one or more additional
questions. Each set of questions provides assessment rationale and Key Indicators (KI) or red flags
so that the interviewer will better understand the types of assessment information the questions are
intended to elicit. Note that the Key Indicators listed in each section are those that could
POSSIBLY show up in the volunteer’s answers to the questions in that group, and the questions
were designed to elicit the indicator if it is present.
Question Group 1 – Occupational Information:
Rationale:
Provides a safe and neutral start to the interview.
Gives a sense of the volunteer’s work history and career stability.
KI: Thinking Errors; Extreme self-centeredness/self-absorption; Lack of empathy for
others; Sporadic employment history; Ability to handle stress/conflict; Extensive work
history with youth (references?) ; Major life changes: Boundaries
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I see that you work with __________________________________________.
a. What do you do for them?
b. What do you currently find most rewarding in your job there?
c. Have you always been in this line of work? (Follow up, as appropriate, where, what
else/when)
Note: If the individual is retired, modify wording to past tense (e.g. where did you last work, what
did you do for them). Also modify for high school/college students (e.g., I see you attend_______.
When do you plan to graduate, what do you plan to do after graduation, and what are your summer
plans?)
Question Group 2 – Family Relationships:
Rationale:
Provides a better general understanding of the volunteer’s past.
Identifies any substantial emotional issues from the volunteer’s past and can help
determine resolution of those issues.
Provides insight into current relationships e.g., stability.
KI: Thinking errors; Lack of empathy for others; Extreme self-centeredness/selfabsorption; Ability to handle stress/conflict; Attitudes indicate extreme
homophobia/sexism; Limited or no contact with family members; Boundaries
What can you tell me about your memories and experiences as a young person growing up in your
family?
a. Tell me about your current relationship with family members?
Question Group 3 – Current Relationships:
Rationale:
Provides information on the volunteer’s current relationships.
Provides information on how supportive the volunteer’s significant other will be.
KI: Thinking errors; Lack of empathy for others; Extreme self-centeredness/selfabsorption; Handling of stress, conflict, sadness; Attitudes/values indicating extreme
sexism or homophobia; Support network; Peer (age-appropriate) friendships; Social
interactions and/or social skills; Ability to form close, age-appropriate relationships;
Support from spouse/partner/significant other; Boundaries
Who are the most significant people in your life right now?
a. How long have these individuals been part of your life?
b. In what ways do you feel they have played a significant role in your life?
c. How have they responded, if at all, to you wanting to be a Big Brother or Big Sister?
(Optional: Tell me about these individuals; what activities and interests you share, how you
resolve conflict?)
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Question Group 4 - Friends:
Rationale:
Determines whether the volunteer has stable and age-appropriate relationships.
Provides an understanding of the volunteer’s social skills.
Helps explore the volunteer’s problem-solving skills when relationship tensions and
problems arise.
KI: Thinking errors; Lack of empathy for others; Extreme self-centeredness/selfabsorption; Handling of stress, conflict, sadness; Attitudes/values indicating extreme
sexism or homophobia; Support network; Peer (age-appropriate) friendships; Social
interactions and/or social skills; Ability to form close, age-appropriate relationships;
Support from spouse/partner/significant other; Boundaries; Over-involvement with
children; Childlike behavior/interests; Childhood physical abuse (men)
Outside of the people you just mentioned, who make up your current circle of friends?
a. How long have you had these friendships?
b. How did you build these friendships? What do you do to maintain them currently?
c. When there are tensions and/or problems between you and your friends, how do you
typically resolve them?
d. Did you or anyone you know (friends or family) experience physical, emotional, or
sexual abuse?
(Optional: What type of activities do you share?)
Question Group 5 – Leisure Time/Drug & Alcohol Use:
Rationale:
Provides insight into interests and other activity pursuits volunteer has.
Assesses age-appropriate issues in the volunteer’s lifestyle.
Opens and facilitates frank discussion about alcohol and drug use.
KI: Thinking errors; Lack of empathy for others; Extreme self-centeredness/selfabsorption; Handling of stress, conflict, sadness; Support network; Peer (age-appropriate)
friendships; Social interactions and/or social skills; Boundaries
How do you currently spend your leisure time?
a. Over the past few years, have there been any changes in how you spend your leisure
time? Why do you think that is?
b. Have you ever or do you currently use alcohol, drugs, or tobacco? If so, how have
they played a part in your leisure time?
(Optional: How often do you use alcohol or drugs and how much? And is there any history of
drug or alcohol abuse in your family?)
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Question Group 6 – Home Assessment:
Rationale:
Provides a general assessment of the volunteer’s home.
Assesses whether volunteer is safety conscious.
KI: Thinking errors; Extreme self-centeredness/self-absorption; Lack of empathy for
others; Childlike behavior/interests; Over-involvement with children; Home environment
is created around children’s enjoyment or interests (context?); Privacy not available for
changing or overnights (if allowed); Reference indicate extreme messiness or extreme
(obsessive-compulsive) cleanliness
When you are matched, it means you may be spending some of your time together at your home.
Can you just generally describe your home environment to me?
a. Who else lives with you? (what is their relationship to you?)
b. What are some of the things you have in your home in the way of games, sports
equipment, or other items that youth generally enjoy being around?
c. What are some of the things you can imagine doing with your Little at your home?
d. Both in and around your home, what do you think are some of the safety
considerations both you and a youth will have to take into account ? (see #6 on preinterview form)
Question Group 7 – Experience with Children:
Rationale:
The general experience the volunteer has had with youth. Helps inform and define
individualized training and future match support – prescriptive vs. developmental.
Helps staff make matching recommendations.
Allows staff to assess whether volunteer has real versus unrealistic expectations about
youth and their attributes.
KI: Thinking errors; Extreme self-centeredness/self-absorption; Lack of empathy for
others; Extensive volunteer and/or work history with youth; Over eagerness to be matched
or re-matched; Childlike behavior/interests; Peer (age-appropriate) friendships; Social
interactions and/or social skills; Stated preferences for Little are narrow and specific; A lot
of physical contact is desired; Tendency to overly indulge or be overly disciplining of
children; Unexplained changes in or termination of activities with children; Overinvolvement with children
Would you describe and name any involvement you’ve had with children and youth as either a
volunteer or paid staff person with, for example, a youth organization? Obtain contact
information for any youth organization’s mentioned. Follow up to obtain references.
a. What were the ages of the youth you worked with?
b. How long, and in what capacity was that work?
c. Tell me about that/those experience(s).
d. What qualities do you admire most in youth?
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e. Are there any particular qualities you do not desire in youth?
f.
Overall, what do you feel is important for us to consider in matching you. For
example, any age, interests, or personality trait factors?
g. What attracted you to BBBS as a way of becoming involved in working with youth?
Question Group 8 – Match Relationship:
Rationale:
Begins to explore the volunteer’s own youth and what type of experiences he or she brings.
Assesses the volunteer’s expectations and when they are on prescriptive vs. developmental
continuum.
Assesses the volunteer’s motivation, e.g., does the volunteer want to save a child?
Provides an opportunity to share with the volunteer what being a mentor is really about.
KI: Thinking errors; Extreme self-centeredness/self-absorption; Lack of empathy for
others; Extensive volunteer and/or work history with youth; Over eagerness to be matched
or re-matched; Childlike behavior/interests; Peer (age-appropriate) friendships; Social
interactions and/or social skills; Stated preferences for Little are narrow and specific; A lot
of physical contact is desired; Tendency to overly indulge or be overly disciplining of
children; Over-involvement with children
Think about a person other than your parents that, when you were a child, provided you with
friendship, guidance and support. What was that person like?
a. When you become matched, what are some of the things you might do to create that
same type of friendship and support?
b. In a few years from now, if you were to reflect back on the time you were matched,
what would have had to occur for you to consider the experience fun and worthwhile?
Question Group 9 – Potential Challenges in a Match:
Rationale:
Helps established individualized support needs for recurring contacts with the volunteer.
Assesses whether the volunteer may feel he or she is too self-reliant.
Assesses volunteer’s expectations about what may happen or not.
KI: Thinking errors; Extreme self-centeredness/self-absorption; Lack of empathy for
others; Extensive volunteer and/or work history with youth; Over eagerness to be matched
or re-matched; Childlike behavior/interests; Peer (age-appropriate) friendships; Social
interactions and/or social skills; Stated preferences for Little are narrow and specific; Little
must comply with certain level of expectations; Childlike behavior/interests; A lot of
physical contact is desired; Tendency to overly indulge or be overly disciplining of
children; Abrupt changes in or termination of activities if expectations not met; Overinvolvement with children
To help you have a meaningful and worthwhile experience as a Big, what do you feel will be some
of the initial challenges you might face in trying to form a friendship with a child?
a. What might be your reaction if, after meeting with a Little a few times, either the
overall experience or the child did not meet your expectations?
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b. What are some of the ways that we might be able to support you in a match?
Match Preferences
To help us make the best possible match, we would like to take a little more time and ask some
more detailed questions around the traits of a child with whom you would feel most comfortable.
We would like to have you imagine with us some things about your Little and your time together.
a. What is the youngest and oldest age you see yourself working best with?
b. Do you imagine your Little to be very active? What are some of the activities you see
yourself doing together?
c. Do you imagine yourself with a talkative child, or someone more on the quiet side?
d. Do you imagine yourself with a child who asks for your advice, or who prefers to work
things out on their own?
e. Which of the following words describe the Little you see yourself most comfortable
working with (circle):
introspective
f.
reflective
contemplative
loud
social
acts before thinking
How do you envision meeting your Little for the first time?
g. What kind of personality traits might be challenging for you?
Explain to the volunteer that parents of youth often state their preferences around who they
want their child to be matched with. Also explain that our policies focus on parental
choice and that some parents express specific preferences around a volunteer’s
characteristics. As such, we need the following information to assure we respect the rights
of parents and the preferences they may have. NONE of the answers will disqualify the
volunteer.
1.
What is your religious preference?
2.
What is your sexual orientation?
Now explain that, to the extent we have to honor preferences stated by parents, the volunteer may
have some preferences also. Since we want to provide the volunteer with a fun and rewarding
experience, his or her preferences are equally important.
1. Would you be willing to be matched with a child coming from a home with a history of
substance abuse?
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2. Would you be willing to be matched with a child who had been physically, emotionally, or
sexually abused?
3. Can you think of any other traits or qualities about a youth or his or her family that
would be difficult for you to interact with?
4. If not previously answered, ask the volunteer if he or she has any preferences
around age, race, ADD/ADHD, etc.
5. Is there anything else about yourself that we didn’t get a chance to discuss and that
you’d like to share now?
Training, Support & Guidance Needs:
1. Are there any topics around youth development and/or being a Big that you could use more
information about? For example, building a relationship or suggested activities for
particular age groups?
2. We can provide both training and further information before a match or after you’ve had
some experience. We can also offer training in a group or provide information in a one-onone setting? Do you have any preferences?
With all of these questions completed, make certain to ask the volunteer if he or she has any
questions. Also explain that the results of this interview, along with references and background
check results are all used in making the most appropriate matching recommendation.
SUMMARY OBSERVATIONS
Based on the overall interview and the responses to all questions, the interviewer now completes
interview summary observations noting additional comments as necessary.
This volunteer demonstrated good communication skills.
Yes
No
Responses to questions were thoughtful and provided useful
information about this volunteer.
Yes
No
The volunteer has a good understanding of what it means
to be a Big.
Yes
No
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This volunteer appears able and willing to form
a safe and meaningful relationship with a young person
and for the program time period expected.
Yes
No
What specific training, information, or support needs might this volunteer initially have?
(Examples: Will this volunteer need guidance in forming a friendship first before expecting
to “change” a Little? Does this volunteer have limited experience with children and might
need help identifying age-appropriate activities to share? )
ADDITIONAL COMMENTS:
Enrollment Staff
Date
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VOLUNTEER ASSESSMENT AND MATCH SUPPORT
Volunteer:
Enrollment staff:
References Checked
Criminal Background Checked
Youth organization involvement obtained & reviewed
Pre-interview form reviewed
I. Recommendations:
ο Accept
ο Not Accept
Assessment Summary: (Briefly summarize suitability of the applicant based on reference
checks, criminal background checks, in-person interview, home assessment, and any other
data provided by the volunteer. Include primary reasons to accept the applicant or the
concerns leading to non-acceptance.)
Match Recommendations: (Your recommendation for the type of child based on volunteer
preferences and other information gathered in interview. This might include age range of
child, geographic location, child’s interests, or behaviors.)
Volunteer Support and Training Needs: (Based on skills &experience of volunteer, list
projected support/training needs)
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PARENT/YOUTH INTERVIEW
Parent:
1. Could you tell me a little about how your child spends his or her time?
a. What do you feel your child enjoys more: indoor activities, outdoor activities, or a
combination of both?
b. In thinking about the activities your child enjoys, does he/she prefer to watch activities
and events or participate in them actively?
2. If we asked you to describe your child to a potential Big Brother or Big Sister, what would you
say that could help them get to know your child better and start developing a friendship?
3. Quite often, our volunteers want to know a little about the parent or parents of the youth they
will be matched with? How would you generally describe the relationship your child has with
you?
a. Describe his/her relationship with other members of the family (and/or absent parent as
appropriate):
b. If applicable, how supportive do you think the absent parent will be towards your son
or daughter’s match?
c. Where is the absent parent now and how involved is s/he in your child’s life?
4. Does you son or daughter have any type of behavioral, emotional, or physical challenges that
may pose a special challenge to a volunteer? (Give examples as needed, e.g., general health, on
medication, undergoing counseling)
a. Has your son or daughter been involved with the police or juvenile justice system?
5. Our volunteers will often ask something about the general home-life of the child they will be
matched with. How would you describe your home and family environment? Are there any issues
that a volunteer may want to know about? (Note: try to identify any issues around substance abuse,
history of domestic violence, etc)
a. Who else lives in the household and what is your child’s relationship with them?
b. What do they think about your child getting a Big Brother or Big Sister?
6. What is your general neighborhood like?
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7. To the best of your knowledge has your son or daughter experienced any form of emotional,
physical, or sexual abuse in the past? If so when, and how do you feel it currently affects him or
her?
8. What school does your child attend?
9. How would you describe your child’s school performance and behavior?
a. And how does he or she get along with his or her teachers?
10. How does your son or daughter get along with other kids his or her age?
11. What particular needs brought you here to BBBS?
12. Overall, how do you think your child will benefit by having a Big Brother or Big Sister?
13. What would be your reaction if, after your child meets with their BB/BS a few times, either the
overall experience or the volunteer did not meet your expectations?
14. Do you see any major changes occurring in your or your son’s/daughter’s living situation in the
next several months, e.g., moving, a new job, etc?
15. Are there any constraints such as available time, activity restrictions, and prior commitments
that might affect your son or daughter getting together with a Big Brother or Big Sister?
16. Do you have any concerns or preferences regarding volunteers who (have yes responses
explained):
Smoke:
Drink:
Own Pets:
Have Firearms:
17. Do you have any concerns or preferences regarding a volunteer’s (have yes responses
explained):
Race/Ethnicity:
Religion/Faith:
Sexual Orientation:
Age:
Any Other:
18. Are there any topics of conversation that you do not want the volunteer to discuss with your
child?
19. Are there any topics of discussion or areas of concern you specifically want the volunteer to
talk with your child about?
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20. Overall, what would the ‘best’ Big Brother/Big Sister look like for your son or daughter?
a. What are your expectations about what a Big Brother/Big Sister will do?
b. What would indicate a successful match for your child?
c. What do you see your role being with the match?
Youth:
1. If you could do anything you wanted with your time, what would you enjoy doing the most?
2. Describe what you think a Big Brother or Big Sister is:
3. Do you want a Big Brother or Big Sister? Why? (or why not?)
4. Why does your mother (or father, foster parent, etc.) want you to have a BB or BS?
5. What do you think is going to be the best part about having a Big Brother or Big Sister?
6. Sometimes a Big Brother or Big Sister will ask us about the family of a Little they will be
matched with. What should we tell them about your family? And what would you want me to tell
them about you?
7. Is there anything that you wonder or worry about by having a Big Brother or Big Sister?
8. What kind of person would you want for your Big Brother or Big Sister?
9. What would you want to do with a Big Brother or Big Sister?
10. Who is your favorite adult, other than a parent, and what do you like about them?
11. Do they talk to you in school about such things as: (Note: Questions may have to be expanded
or slightly reworded for age appropriateness, e.g., a 15 year may need more on drug avoidance than
who to call if a fire.)
Who to call if there’s a fire?
What to do if a stranger approaches you?
Not smoking and staying away from drugs or drinking alcohol?
12. What are some of the things you have learned about keeping yourself safe?
CHILD SAFETY: At this time, together with the parent, you should transition into more detailed
discussion and sharing of child safety information and materials.
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Assessment: (Briefly summarize results of the parent/youth interview)
Match Recommendation: (Briefly outline a specific matching recommendations, limitations, etc.
Example: age of volunteer, geographic location, preferences of parent, interests to share)
Outcome Objectives for the Match: (List two or three areas that might be goals for building
assets or removing risks in the child’s life after the first several months when the relationship
between the Big and Little is first formed.)
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SAMPLE MATCH SUPPORT CONTACT RECORD
CHILD:
Tommy Thompson
DOB:
xx/xx/xx
Parent:
June Cleaver
Employer:
Homemaker
Cell #:
No cell phone
Volunteer:
John Doe
Email: [email protected]
Employer:
Micron
Cannot be called at work
Cell #:
555-1234
DOM:
xx/xx/xx
Hours:
24-7
Hours:
M-F 8-5
No e-mail
HM #:
HM #:
555-1212
555-2121
10-14-02 CALL OUT TO JUNE & TOMMY:
Activities: Mom reports that LB has gone out with BB 3 times in the last month. They went to
PoJo’s to play video games, raced go-karts at the raceway, and went fishing at Park Center pond.
When mom handed the phone over to LB, I asked about the fishing trip and he told me that he
caught the only fish out of anyone they saw fishing the whole day! Mom says that BB sees LB
regularly and has been very good about scheduling activities ahead of time with her.
Child Safety: Mom says that LB is always excited and happy when he gets back from activities
with BB. She has never observed anything that she would consider to be inappropriate.
Relationship Development: Mom says that LB really likes BB. He is developing a lot of trust and
is very comfortable around BB.
Satisfaction Level/Agency Affiliation: Mom describes the match as “being just what I expected”
for Tommy. She would recommend the program to other parents.
Noticeable Youth Outcomes: Mom has already noticed an improvement in LB’s manners and
attitude. He hasn’t had any referrals at school for 3 months.
Other Comments, Suggestions for BBBS, etc: Mom was asking if there is any way that BBBS
could rent a bus or van for group events like the Halloween Hayride so that people could ride
together. I told her that I would check into it.
Update to Outcome Based Plan: Continue to provide regular contact to the family and offer praise
and support related to LB’s progress in school. Make quarterly contact with school to monitor
progress and identify any emerging issues and brainstorm with parent and BB on possible
solutions. Check with parent regularly regarding behavior at home.
Contact Frequency/Next contact goal: Monthly/November
Staff: Tom Peterson.
10-14-02 IN PERSON JOHN:
Activities: I ran into BB at the Volunteer Social and he collaborated with Mom’s report about
recent activities. He said that LB was so excited when he caught a fish that he nearly fell into the
pond! BB laughed for about a half-hour before he could cast again!
Child Safety: LB hasn’t told BB about any more big fights with Step-dad. Things seem to have
settled down from what BB can see.
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Relationship Development: BB feels the fun he and Tommy are having is forming the foundation
for a good friendship. BB is always careful about showing up when he says he will so that LB will
learn to trust him. BB knows it isn’t realistic to expect LB to initiate calls.
Satisfaction Level/Agency Affiliation: BB is very happy with his experiences in the program so far.
The rewards have exceeded his own expectations and he gave me the names of 2 friends who want
to be Bigs after seeing how much fun he has had.
Noticeable Youth Outcomes: BB said that LB is making more of an effort to clean himself up
before they go out. He combs his hair and doesn’t talk about fighting with Mom as much as he
used to.
Other Comments: none
Next Expected Contact: Since this contact was in person, the next expected contact is in 2 months.
(December)
Staff: Tom Peterson
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MATCH SUPPORT CONTACT RECORD
CHILD:
DOB:
DOM:
Parent:
E-Mail:
Employer:
Work Phone #:
Cell #
HM #:
Volunteer:
Email:
Employer:
Work Phone #:
Cell #
HM #:
Hours:
Hours:
Date/Type of Contact/Who Was Contacted:
Activities:
Child Safety:
Relationship Development:
Satisfaction Level/Affiliation with Agency:
Noticeable Youth Outcomes:
Other Comments:
Update to Outcome Based Plan:
Contact Frequency/Next contact goal:
Staff Name:
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MATCH CLOSURE AND RE-ENGAGEMENT ASSESSMENT
Volunteer:
Child:
Date of Match:
Date of Closure:
Name of Staff Closing Match:
Closure Code:
How many months matched:
1. Summarize the reason(s) for closure:
2. Recommended Re-Match of Child?
Comments:
3. Recommended Re-Match of Volunteer?
If YES, answer the following questions:
Yes
Yes
No
No
What were the most positive experiences for the volunteer in this match?
What were the most positive experiences for the child in this match?
What negative experiences did the volunteer have in this match?
What negative experiences did the child have in this match?
What would you say are the primary obstacles to a re-match (or what are the
expectations of the volunteer and/or parent & child that we need to meet)?
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Have you discussed a re-match with this volunteer? Describe the status of where we
are at in re-matching him/her:
4. If no recommendation for Re-Match of volunteer, why not?
Obtain permission for following as appropriate:
Mailing List
Alumni organization membership
Potential Donor
Invite to point of entry event
Potential Board Member
Other volunteer work such office work, one-time fundraiser, etc.).
Volunteer Recruitment (Speaker? Written testimonial? Recruitment at their place of
work?) List suggestions:
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VOLUNTEER SATISFACTION QUESTIONNAIRE
(Post Enrollment)
Name:
Date:
Now that you have completed the enrollment process for becoming a Big, we would like
you to answer the questions that follow. Please feel free to provide any additional
comments in the space provided.
Strongly
Disagree
Strongly
Agree
1 When I first contacted the agency, I was
given enough information about what I was
volunteering to do.
1
2
3
4
5
2 Staff were always available to answer my
questions.
1
2
3
4
5
3 I felt that the time it took to go through the
enrollment process was reasonable.
1
2
3
4
5
4 I felt that the interview and other enrollment
processes, such as reference checks, were
appropriate and necessary.
1
2
3
4
5
5 I have a good understanding of what my role
will now be as a Big.
1
2
3
4
5
6 Now that my match is starting, I will feel
comfortable contacting the agency for
support and direction.
1
2
3
4
5
7 What suggestions do you have for how we might improve the enrollment process?
8 Is there anything else you'd like to tell us?
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VOLUNTEER SATISFACTION QUESTIONNAIRE
Name:
Date:
We want to know what you think of our agency, how well we have supported you in your
match throughout the past several months, and share some opportunities that are available.
Please answer the following questions by circling the number that corresponds to your
level of agreement. Feel free to include any other comments you may have. Thank you for
your participation and quick reply.
Strongly
Disagree
Strongly
Agree
I've found agency staff to be friendly and
courteous.
1
2
3
4
5
I feel staff were there to support me and the
relationship with my little.
1
2
3
4
5
If I contacted the agency with a problem or
question, I would get prompt service.
1
2
3
4
5
I would encourage my friends to become
involved with the agency.
1
2
3
4
5
Up to this point, I've had a fun and rewarding
expereince.
1
2
3
4
5
(New Volunteer Opportunities)
I would like to volunteer in some other capacity to help the agency (activity planning for
matches, administrative projects, special events, volunteer training/support, recruiting,
fund raising, speakers bureau, leadership, other). Indicate areas of interest.
I would like to help build our program support base by inviting friends, relatives, business
and community contacts to learn more about Big Brothers Big Sisters.
Yes _____
Not at this time _____
Is there anything else you’d like to tell us?
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PARENT/YOUTH PRE-INTERVIEW QUESTIONNAIRE
Parent/Guardian’s Name:
Home Address:
Child’s Name:
City:
County:
State:
Parent’s Place of Employment
Is Parent Receiving Income Assistance?
Home Phone:
Cell Phone:
Best time to call:
Work Phone:
Youth’s DOB:
Yes
Zip:
No
Email:
Youth’s Gender
Youth’s Ethnicity:
1. What is the primary reason for you wanting your child to have a Big Brother/Big
Sister?
2. What is your living situation?
Two parent household
____ One Parent: _____ Female _____ Male
____ Other relative of child (non-parent)
____ Foster Home
____ Group Home
____ Other:
3. Does your child have any medical conditions that might affect him or her
participating in activities with a Big Brother/Big Sister? _____ Yes ____ No
If yes, please describe: _______________________________________________
4. Is there a person who shares custody of this child? ______ Yes _____ No
If yes, are they aware of the child’s enrollment in BBBS? _____ Yes _____ No
5. Do you anticipate any significant life changes over the next year or have you had
any in the past year?_____ Yes _____ No
If yes, please explain:
(Optional question if the agency has a need for this information)
6. We have a special program for children of incarcerated parents. Would this
program apply to your child?______ Yes ______ No
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I give my permission for my child, ____________________, to participate in the Big
Brothers Big Sisters program. I understand that the BBBS agency is not obligated to match
my child with a volunteer and that as part of the enrollment process I will be asked to
provide additional personal information. If my child is matched with a Big Brother or Big
Sister I agree to support my child’s match and to immediately report any concerns I might
have to the Big Brothers Big Sisters staff.
Signed: _________________________________ Date: __________________________
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VOLUNTEER REASSESSMENT
Name of Volunteer: ____________________________________
The following questions should be asked of volunteers as part of the reassessment for a
new match:
1. Based on your experience as a Big and looking ahead, what do you think would be
important for making a successful match?
2. Since beginning as a Big with us, can you tell me about any changes in your life
that we might want to consider this time around?
3. What would it take for a new match to meet your expectations?
4. Based on your prior match experience, do you have any preferences for your next
match?
Prior to a new match the following must be completed:
1. Full review of file(s) of all prior matches (look for continuity between
information given in enrollment & actual match practice; areas of support
that might be needed; child safety key indicators in either enrollment or
match support; level of relationship with agency. It is advisable to have a
staff member or supervisor who has not been supporting the volunteer to
provide an independent review.).
Completed by: ______ Date: _______
2. When available, ask Little of prior match for input on this Big getting
another Little.
Completed by: _____ Date: _____
Notes:___________________________________________________
________________________________________________________
3. New Criminal Background check if more than 1 year since last one.
Completed by: _______ Date: ______
4. New MVR check if more than 1 year since last one.
Completed by: _______ Date: ______
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Recommendation for Re-Match:
_____ Approve
_____ Disapprove
Reasons:
Signed: _________________________ Date: __________________________
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PARENT SATISFACTION QUESTIONNAIRE
(Post Match)
Name:
Date:
__
We want to know what you think of our agency and how well we have supported you and
your child in your match throughout the past several months. Please take a few minutes to
answer the following questions by circling the number that corresponds to your level of
agreement with the question. Please feel free to provide any additional comments in the
space provided.
Strongly
Disagree
1.
2.
3.
4.
5.
6.
7.
8.
I have found the BBBS staff to be
friendly and courteous.
During my child’s match I have felt
that BBBS staff were available to
support me and my child.
When I have contacted the agency
with a problem or question I have
received prompt service.
I would encourage my friends to
involve their child with the agency.
I feel comfortable contacting the
agency for any questions, assistance,
and concerns.
Up to this point, my child has had a
positive and fun experience.
My suggestions for improving the
match support are:
My other comments are:
Copyright 2003 Big Brothers Big Sisters of America
September 2004
Strongly
Agree
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
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Big Brothers Big Sisters Service Delivery Model
PARENT SATISFACTION QUESTIONNAIRE
(Post Enrollment)
Name:
Date:
Thank you for your time in meeting with Big Brothers Big Sisters staff. Your time and
input will be valuable in working towards making the right Big Brother or Big Sister match
for your child. We would appreciate any feedback on the service you’ve provided
throughout your enrollment process and would ask that you please take a moment to
complete the following questions. Please feel free to provide any additional comments in
the space provided.
Strongly
Disagree
1.
2.
3.
4.
5.
6.
7.
8.
9.
When I first contacted the agency, I
was given enough information about
the program and the benefits that my
child would gain by having a
volunteer in their life.
In scheduling my interview I felt the
staff was accommodating and helpful
in working with my schedule and
needs.
Upon meeting BBBS staff, I was
greeted in a friendly, professional
manner.
I felt that the interview and other
enrollment processes were appropriate
and necessary.
I have a good understanding of what
to expect from a Big Brother or Big
Sister.
I have a good understanding of what
my role will be now as a parent in this
program.
Now that my child is enrolled, I will
feel comfortable contacting the agency
for any questions, assistance, and
support.
My suggestions for improving the
enrollment process are:
My other comments are:
Copyright 2003 Big Brothers Big Sisters of America
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Strongly
Agree
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
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TRANSMISSION OF INFORMATION FROM ENROLLMENT TO SUPPORT
(This information should be provided to Match Support when a new match is made. It may
be provided electronically or in hard-copy.)
1. Volunteer motivation & expectations for becoming a Big:
2. Rationale for why this volunteer & child were paired (Why did you make this
particular match? What interests, personality traits, life experiences, location,
schedule, etc. do they share?)
3. General concerns/impressions (Please note impressions of the match meeting &
match; e.g. anything that came up at the match meeting, how parent/volunteer
interacted, etc.):
4. Likely support needs for the match (What support needs do you see for this match,
either immediate or longer term? e.g. Mom seems over-protective, Little is very
shy, Big doesn’t have any experience with kids, etc.):
5. Suggested Action (Specific suggestions for helping this match get off to a great
start, e.g. “Provide Big with suggestions for activities that his Little might enjoy”):
6. Need to Know Information:
• Availability issues (e.g. “Little leaves every summer to visit Dad”, or “Big
can only see Little on weekends”) –
•
Siblings in the home in the program (e.g. any matched and/or RTBM
siblings) -
•
Best time/place to contact match parties –
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POE 2001
OVERVIEW:
In 1998, Big Brothers Big Sisters of America published Program-Based Outcome Evaluation (POE): A
Casework Management Approach to Measuring Outcomes in Mentoring Programs. This publication
described a step-by-step process for collecting outcome data and included outcome assessment forms to
be used by mentors, parents, teachers, and case managers of youth who were being mentored.
Each form listed 18 outcomes that were intended to measure the impact on a youth being mentored in the
community-based mentoring program. These 18 outcomes were conceptually related to many of the
Search Institute’s developmental assets and the assessment forms exhibited strong content validity.
The POE methodology and forms were subsequently used to assess youth outcomes in a 1998-1999 pilot
of a school-based mentoring program initiative. The results showed that the POE methodology was both
a valid and reliable means of assessing outcomes in school-based relationships. For example, teacher
assessments using the POE forms were found to correlate positively and significantly with data from
report cards and academic records.
Concurrent with the school-based pilot, the Search Institute conducted an evaluation of a School-Plus
mentoring program initiative under a grant from the Pillsbury Foundation. The Search Institute adopted
the POE methodology and added three additional outcomes to BBBSA’s original 18. These three
additional outcomes were specific to school behavior and enhanced the validity of the assessment process
in a school-based setting.
Collectively, the research of BBBSA and the Search Institute clearly establishes both a methodology and
a set of core outcome indicators that can be used to measure the impact mentoring has on youth. As such,
the POE assessment process is a valid and reliable means for assessing outcomes for youth being
mentored, regardless of where that mentoring relationship occurs.
ASSESSING OUTCOMES:
The revisions to the POE forms are intended to enhance their use in assessing outcomes in all mentoring
programs. The retrospective methodology remains identical. However, there are some slight
modifications regarding when outcomes are assessed and who are the most reliable reporters of change.
Specifically, the type of mentoring program, as addressed below, should guide both the timing and who
reports on the change.
Community-Based: For community-based, the mentor and the parent of the youth are the two
most logical and reliable sources for reporting change. The form should still be completed at the 12month anniversary date of the match, with both parties being asked to report change over the previous 12month period. You may elect to perform a preliminary gathering of outcome data at the first 6-month
point of the match; this option is up to you.
POE 2001
1
Big Brothers Big Sisters of America
School-Based: The youth’s teacher and mentor are the two most logical and reliable sources for
reporting change. The form should be completed at the end of the school year, say with one or two weeks
remaining, as long as the match has been active for at least 3 months.
Other Site-Based: The mentor or other informed individual is the most logical and reliable source.
The form should be completed at the end of the site-based program cycle.
There may be instances where an informed source, such as a mentor in a community-based match, may
not be able to report change in some outcomes, e.g. school behavior. This is fine. The assessment forms
accommodate this by providing a category called “Don’t Know.” When the outcome data is aggregated,
“Don’t Know” responses can be selected out of the data analysis or used by the agency to get a sense of
what types of information a mentor knows about regarding the young person he or she is mentoring.
IMPLEMENTING THE REVISED FORMS:
Although the revised forms include three additional outcomes, the 18 original outcome indicators remain
the same. As such, you can begin using the revised forms immediately. The only special accommodation
you may have to make is if you’re using a database or spreadsheet to enter responses. In either case, you
should be able to insert three new fields (for databases) or 3 new rows (for spreadsheets). The response
categories are the same so the actual analysis of the responses will be performed as you’ve done so in the
past. Note that a block to record various youth demographic data has also been added in the event you
want to perform more detailed analyses of data, e.g., outcomes for boys versus girls.
ENCLOSED FORMS:
The following revised forms are enclosed. The first page provides some brief instructions and definitions
of the 21 indicators. The second page is the actual assessment form completed by the informed source.
The pages are intended to be printed front-to-back. All forms are available for download on the agency’s
only page of the BBBSA website.
Mentor Report on the Match
Parent Report on the Match
Teacher Report on the Match
Case Manager Report on the Match
If you have any questions, contact [email protected].
POE 2001
2
PROGRAM-BASED OUTCOME EVALUATION
Overview
In 1996, BBBSA received funding to pilot and implement an outcome evaluation system that
could be used to demonstrate how youth were impacted by a mentoring relationship. In addition
to developing an assessment form, the intent of the pilot was to also develop a system for
incorporating outcome measurement into the on-going assessment of mentoring relationships and
make it a component of the agency’s casework management system.
In the spring of 1997, 10 BBBS agencies were selected to participate in the pilot. The first step
involved conducting two focus groups. Approximately 25 BBBS agency staff participated in
each focus group and they included executive directors, program directors, and case managers.
In these initial focus groups, they identified a core set of positive outcomes expected to and
likely to occur in a mentoring relationship.
Two additional focus groups were then conducted: one in Los Angeles and one in Baltimore.
Participants in these two groups were mentoring program practitioners from non-BBBS
mentoring organizations. They, too, identified what they felt were critical outcomes deriving out
of a mentoring experience.
The result of these four focus groups was the identification of 18 core outcome indicators that
were thought to be both valid and reliable in the context of a mentoring relationship. To enhance
the validity of these 18 outcome indicators, the research literature on positive youth development
was reviewed and these 18 indicators were shown to have strong validity with the Search
Institute’s developmental assets model.
Throughout the second half of 1997 and into 1998, 10 BBBS agencies implemented use of the
forms to measure outcomes primarily for community-based matches. The results clearly showed
that the POE method of assessing outcomes was indeed valid.
Then, in 1999, through a grant from the United Parcel Service Foundation, POE was used to
measure outcomes in youth in a 5 agency pilot of a school-based mentoring pilot. Again, the
POE methodology was found to be extremely valid. And a more detailed statistical analysis
found that when teachers completed the forms, there was strong reliability when examined
against student academic and behavioral school records.
Finally, the Search Institute expanded on the POE model during a mentoring project they were
responsible for evaluating. They added three additional outcomes, keeping the original 18.
Again, the POE method was found to be valid in the context of measuring the various outcomes
associated with positive youth development.
Pursuant to the Search Institute’s work, BBBSA revised POE in its current form: POE 2001.
POE 2001 reflects a total of 21 outcome indicators that are valid and reliable measures in all
mentoring programs, with now the vast majority of BBBS agencies using it as part of its
casework management system to both track outcomes and provide valuable feedback into the
case planning process. POE is also being used by other mentoring organizations across the
country as well as by a number of mentoring organizations in Europe.
MENTOR REPORT ON THE MATCH
Match ID ____________________
Date ___________________________
INSTRUCTIONS:
This form is used to report changes you have observed in the young person you are mentoring.
The following definitions are offered to clarify the items on the reverse side of this form. Note that these
items are somewhat general. You’re encouraged to report on your own specific observations within the
general meaning of these definitions. Any questions should be referred to your case manager. If you feel
you do not have enough information based on your interactions with the young person you’re mentoring,
mark Don’t Know as necessary.
GOAL AREA #1: CONFIDENCE
1)
2)
3)
4)
5)
6)
Self confidence - A sense of being able to do or accomplish something.
Able to express feelings - Is able to reveal, talk about, or discuss feelings.
Can make decisions - Thinks before acting and is aware of consequences of behavior.
Has interests or hobbies - Pursues activities such as reading, sports, music, computers, etc.
Personal hygiene, appearance - Dresses appropriately and keeps self neat and clean.
Sense of the future - Knows about educational and career opportunities.
GOAL AREA #2: COMPETENCE
7) Uses community resources - Partakes in service activities, libraries, recreation, church/other faithbased activities.
8) Uses school resources - Uses the library, guidance counselors, tutorial centers.
9) Academic performance - Makes good grades or improves grades.
10) Attitude toward school – Is positive about going to school and abut what can be learned.
11) School preparedness – Completes homework and other assignments.
12) Classroom participation – Actively takes part in learning; responds to questions.
13) Classroom behavior – Pays attention in class; isn’t disruptive.
14) Able to avoid delinquency - Refrains from behaviors that are illegal for person of his or her age.
15) Able to avoid substance abuse - Doesn't use illegal or harmful substances (e.g., drugs, alcohol,
tobacco).
16) Able to avoid early parenting - Doesn't engage in sexual behavior likely to result in early parenting.
GOAL AREA #3: CARING
17) Shows trust toward you - Isn't reluctant to confide in you, to accept your suggestions.
18) Respects other cultures - Doesn't stereotype or put down other ethnic, racial, language, or national
groups.
19) Relationship with family - Interacts well with other family members.
20) Relationship with peers - Interacts well with persons of own age.
21) Relationship with other adults - Has good interactions with other adults who are not family members.
Continued On Other Side
Big Brothers Big Sisters of America
MENTOR REPORT ON THE MATCH
For Agency Use
Match ID: __________
Date Completed: __________
Length of match when administered: __________
(Specify in months/years)
Age: __________
White †
Male † Female †
Black †
Hispanic †
Community-Based †
Asian †
School-Based †
Native American †
Other Site-Based †
Other †
We would like you to describe any changes you’ve observed in the below areas over the past _____ months? It’s
okay to indicate “don’t know” if you have no knowledge about change in a given area.
Much
Better
A Little
Better
No
Change
A Little
Worse
Much
Worse
Don't
Know
Not A
Problem
CONFIDENCE
1) Self-confidence
2) Able to express feelings
3) Can make decisions
4) Has interests or hobbies
5) Personal hygiene, appearance
6) Sense of the future
COMPETENCE
7) Uses community resources
8) Uses school resources
9) Academic performance
10) Attitude toward school
11) School preparedness (homework)
12) Class participation
13) Classroom behavior
14) Able to avoid delinquency
15) Able to avoid substance abuse
16) Able to avoid early parenting
CARING
17) Shows trust toward you
18) Respects other cultures
19) Relationship with family
20)Relationship with peers
21) Relationship with other adults
Thank you!
Copyright © 2001 by Big Brothers Big Sisters of America. Affiliated agencies of Big Brothers Big Sisters of America may
reproduce this document for agency use without restriction. Other not-for-profit organizations may reproduce this document
with acknowledgment of Big Brothers Big Sisters of America.
YOUTH QUESTIONNAIRE
Name:
Match ID:
(Little Brother or Little Sister)
Date:
We want you to tell us a few things about what you feel about your Big. We will not tell anyone what
you said without asking for your permission.
Since I was matched
with my Big
Much
Better
A Little
Better
About The
Same
A Little
Worse
A Lot
Worse
My grades are:
My interest in school
is:
I get along with
everyone at home:
My friendships are:
My wanting to learn
new things is:
Overall, what do you think about your Big?
What do you like most about your Big?
What sort of things might you want to change about your relationship with your Big?
Is there anything else you want to tell me about your experience with your Big?
Copyright © 1998 by Big Brothers Big Sisters of America. Affiliated agencies of Big Brothers Big Sisters of America may
reproduce this document for agency use without restriction. Other not-for-profit organizations may reproduce this document
with acknowledgment of Big Brothers Big Sisters of America.
PARENT REPORT ON THE MATCH
Match ID:
Date:
INSTRUCTIONS:
This form is used to report changes you have observed in your son/daughter who’s being mentored.
The following definitions are offered to clarify the items on the reverse side of this form. Note that these
items are somewhat general. You’re encouraged to report on your own specific observations within the
general meaning of these definitions. Any questions should be referred to your case manager.
GOAL AREA #1: CONFIDENCE
1)
2)
3)
4)
5)
6)
Self confidence - A sense of being able to do or accomplish something.
Able to express feelings - Is able to reveal, talk about, or discuss feelings.
Can make decisions - Thinks before acting and is aware of consequences of behavior.
Has interests or hobbies - Pursues activities such as reading, sports, music, computers, etc.
Personal hygiene, appearance - Dresses appropriately and keeps self neat and clean.
Sense of the future - Knows about educational and career opportunities.
GOAL AREA #2: COMPETENCE
7) Uses community resources - Partakes in service activities, libraries, recreation, church/other faithbased activities.
8) Uses school resources - Uses the library, guidance counselors, tutorial centers.
9) Academic performance - Makes good grades or improves grades.
10) Attitude toward school – Is positive about going to school and abut what can be learned.
11) School preparedness – Completes homework and other assignments.
12) Classroom participation – Actively takes part in learning; responds to questions.
13) Classroom behavior – Pays attention in class; isn’t disruptive.
14) Able to avoid delinquency - Refrains from behaviors that are illegal for person of his or her age.
15) Able to avoid substance abuse - Doesn't use illegal or harmful substances (e.g., drugs, alcohol,
tobacco).
16) Able to avoid early parenting - Doesn't engage in sexual behavior likely to result in early parenting.
GOAL AREA #3: CARING
17) Shows trust toward you - Isn't reluctant to confide in you, to accept your suggestions.
18) Respects other cultures - Doesn't stereotype or put down other ethnic, racial, language, or national
groups.
19) Relationship with family - Interacts well with other family members.
20) Relationship with peers - Interacts well with persons of own age.
21) Relationship with other adults - Has good interactions with other adults who are not family members.
Continued On Other Side
Big Brothers Big Sisters of America
PARENT REPORT ON THE MATCH
For Agency Use
Match ID: __________
Date Completed: __________
Length of match when administered: __________
(Specify in months/years)
Age: __________
White †
Male † Female †
Black †
Hispanic †
Community-Based †
Asian †
School-Based †
Native American †
Other Site-Based †
Other †
We would like you to describe any changes you’ve observed in the below areas over the past _____ months? It’s
okay to indicate “don’t know” if you have no knowledge about change in a given area.
Much
Better
A Little
Better
No
Change
A Little
Worse
Much
Worse
Don't
Know
Not A
Problem
CONFIDENCE
1) Self-confidence
2) Able to express feelings
3) Can make decisions
4) Has interests or hobbies
5) Personal hygiene, appearance
6) Sense of the future
COMPETENCE
7) Uses community resources
8) Uses school resources
9) Academic performance
10) Attitude toward school
11) School preparedness (homework)
12) Class participation
13) Classroom behavior
14) Able to avoid delinquency
15) Able to avoid substance abuse
16) Able to avoid early parenting
CARING
17) Shows trust toward you
18) Respects other cultures
19) Relationship with family
20)Relationship with peers
21) Relationship with other adults
Thank you!
Copyright © 2001 by Big Brothers Big Sisters of America. Affiliated agencies of Big Brothers Big Sisters of America may
reproduce this document for agency use without restriction. Other not-for-profit organizations may reproduce this document
with acknowledgment of Big Brothers Big Sisters of America.
CASE MANAGER REPORT ON THE MATCH
Match ID:
Date:
INSTRUCTIONS:
This form is used to report changes you have observed in the young person whose match you are
supervising.
The following definitions are offered to clarify the items on the reverse side of this form. Note that these
items are somewhat general. You’re encouraged to report on your own specific observations within the
general meaning of these definitions. If you feel you do not have enough information based on your
interactions with the young person, mark Don’t Know as necessary.
GOAL AREA #1: CONFIDENCE
1)
2)
3)
4)
5)
6)
Self confidence - A sense of being able to do or accomplish something.
Able to express feelings - Is able to reveal, talk about, or discuss feelings.
Can make decisions - Thinks before acting and is aware of consequences of behavior.
Has interests or hobbies - Pursues activities such as reading, sports, music, computers, etc.
Personal hygiene, appearance - Dresses appropriately and keeps self neat and clean.
Sense of the future - Knows about educational and career opportunities.
GOAL AREA #2: COMPETENCE
7) Uses community resources - Partakes in service activities, libraries, recreation, church/other faithbased activities.
8) Uses school resources - Uses the library, guidance counselors, tutorial centers.
9) Academic performance - Makes good grades or improves grades.
10) Attitude toward school – Is positive about going to school and abut what can be learned.
11) School preparedness – Completes homework and other assignments.
12) Classroom participation – Actively takes part in learning; responds to questions.
13) Classroom behavior – Pays attention in class; isn’t disruptive.
14) Able to avoid delinquency - Refrains from behaviors that are illegal for person of his or her age.
15) Able to avoid substance abuse - Doesn't use illegal or harmful substances (e.g., drugs, alcohol,
tobacco).
16) Able to avoid early parenting - Doesn't engage in sexual behavior likely to result in early parenting.
GOAL AREA #3: CARING
17) Shows trust toward you - Isn't reluctant to confide in you, to accept your suggestions.
18) Respects other cultures - Doesn't stereotype or put down other ethnic, racial, language, or national
groups.
19) Relationship with family - Interacts well with other family members.
20) Relationship with peers - Interacts well with persons of own age.
21) Relationship with other adults - Has good interactions with other adults who are not family members.
Continued On Other Side
Big Brothers Big Sisters of America
CASE MANAGER REPORT ON THE MATCH
For Agency Use
Match ID: __________
Date Completed: __________
Length of match when administered: __________
(Specify in months/years)
Age: __________
White †
Male † Female †
Black †
Hispanic †
Community-Based †
Asian †
School-Based †
Native American †
Other Site-Based †
Other †
We would like you to describe any changes you’ve observed in the below areas over the past _____ months? It’s
okay to indicate “don’t know” if you have no knowledge about change in a given area.
Much
Better
A Little
Better
No
Change
A Little
Worse
Much
Worse
Don't
Know
Not A
Problem
CONFIDENCE
1) Self-confidence
2) Able to express feelings
3) Can make decisions
4) Has interests or hobbies
5) Personal hygiene, appearance
6) Sense of the future
COMPETENCE
7) Uses community resources
8) Uses school resources
9) Academic performance
10) Attitude toward school
11) School preparedness (homework)
12) Class participation
13) Classroom behavior
14) Able to avoid delinquency
15) Able to avoid substance abuse
16) Able to avoid early parenting
CARING
17) Shows trust toward you
18) Respects other cultures
19) Relationship with family
20)Relationship with peers
21) Relationship with other adults
Thank you!
Copyright © 2001 by Big Brothers Big Sisters of America. Affiliated agencies of Big Brothers Big Sisters of America may
reproduce this document for agency use without restriction. Other not-for-profit organizations may reproduce this document
with acknowledgment of Big Brothers Big Sisters of America.
TEACHER REPORT ON THE MATCH
Match ID:
Date:
INSTRUCTIONS:
This form is used to report changes you have observed in your student who is being mentored.
The following definitions are offered to clarify the items on the reverse side of this form. Note that these
items are somewhat general. You’re encouraged to report on your own specific observations within the
general meaning of these definitions. Any questions should be referred to BBBS agency staff. If you feel
you do not have enough information based on your observations of this student being mentored, mark
Don’t Know as necessary.
GOAL AREA #1: CONFIDENCE
1)
2)
3)
4)
5)
6)
Self confidence - A sense of being able to do or accomplish something.
Able to express feelings - Is able to reveal, talk about, or discuss feelings.
Can make decisions - Thinks before acting and is aware of consequences of behavior.
Has interests or hobbies - Pursues activities such as reading, sports, music, computers, etc.
Personal hygiene, appearance - Dresses appropriately and keeps self neat and clean.
Sense of the future - Knows about educational and career opportunities.
GOAL AREA #2: COMPETENCE
7) Uses community resources - Partakes in service activities, libraries, recreation, church/other faithbased activities.
8) Uses school resources - Uses the library, guidance counselors, tutorial centers.
9) Academic performance - Makes good grades or improves grades.
10) Attitude toward school – Is positive about going to school and abut what can be learned.
11) School preparedness – Completes homework and other assignments.
12) Classroom participation – Actively takes part in learning; responds to questions.
13) Classroom behavior – Pays attention in class; isn’t disruptive.
14) Able to avoid delinquency - Refrains from behaviors that are illegal for person of his or her age.
15) Able to avoid substance abuse - Doesn't use illegal or harmful substances (e.g., drugs, alcohol,
tobacco).
16) Able to avoid early parenting - Doesn't engage in sexual behavior likely to result in early parenting.
GOAL AREA #3: CARING
17) Shows trust toward you - Isn't reluctant to confide in you, to accept your suggestions.
18) Respects other cultures - Doesn't stereotype or put down other ethnic, racial, language, or national
groups.
19) Relationship with family - Interacts well with other family members.
20) Relationship with peers - Interacts well with persons of own age.
21) Relationship with other adults - Has good interactions with other adults who are not family members.
Continued On Other Side
Big Brothers Big Sisters of America
TEACHER REPORT ON THE MATCH
For Agency Use
Match ID: __________
Date Completed: __________
Length of match when administered: __________
(Specify in months/years)
Age: __________
White †
Male † Female †
Black †
Hispanic †
Community-Based †
Asian †
School-Based †
Native American †
Other Site-Based †
Other †
We would like you to describe any changes you’ve observed in the below areas over the past _____ months? It’s
okay to indicate “don’t know” if you have no knowledge about change in a given area.
Much
Better
A Little
Better
No
Change
A Little
Worse
Much
Worse
Don't
Know
Not A
Problem
CONFIDENCE
1) Self-confidence
2) Able to express feelings
3) Can make decisions
4) Has interests or hobbies
5) Personal hygiene, appearance
6) Sense of the future
COMPETENCE
7) Uses community resources
8) Uses school resources
9) Academic performance
10) Attitude toward school
11) School preparedness (homework)
12) Class participation
13) Classroom behavior
14) Able to avoid delinquency
15) Able to avoid substance abuse
16) Able to avoid early parenting
CARING
17) Shows trust toward you
18) Respects other cultures
19) Relationship with family
20)Relationship with peers
21) Relationship with other adults
Thank you!
Copyright © 2001 by Big Brothers Big Sisters of America. Affiliated agencies of Big Brothers Big Sisters of America may
reproduce this document for agency use without restriction. Other not-for-profit organizations may reproduce this document
with acknowledgment of Big Brothers Big Sisters of America.
TEACHER REPORT ON THE MATCH
Match ID ____________________
Date ___________________________
INSTRUCTIONS:
This form is used to report changes you have observed in your student who is being mentored.
The following definitions are offered to clarify the items on the reverse side of this form. Note that these items are
somewhat general. You’re encouraged to report on your own specific observations within the general meaning of
these definitions. Any questions should be referred to BBBS agency staff. If you feel you do not have enough
information based on your observations of this student being mentored, mark Don’t Know as necessary.
GOAL AREA #1: CONFIDENCE
1)
2)
3)
4)
5)
6)
Self confidence - A sense of being able to do or accomplish something.
Able to express feelings - Is able to reveal, talk about, or discuss feelings.
Can make decisions - Thinks before acting and is aware of consequences of behavior.
Has interests or hobbies - Pursues activities such as reading, sports, music, computers, etc.
Personal hygiene, appearance - Dresses appropriately and keeps self neat and clean.
Sense of the future - Knows about educational and career opportunities.
GOAL AREA #2: COMPETENCE
7) Uses community resources - Partakes in service activities, libraries, recreation, church/other faithbased activities.
8) Uses school resources - Uses the library, guidance counselors, tutorial centers.
9) Academic performance - Makes good grades or improves grades.
10) Attitude toward school – Is positive about going to school and about what can be learned.
11) School preparedness – Completes homework and other assignments.
12) Classroom participation – Actively takes part in learning; responds to questions.
13) Classroom behavior – Pays attention in class; isn’t disruptive.
14) Able to avoid delinquency - Refrains from behaviors that are illegal for person of his or her age.
15) Able to avoid substance abuse - Doesn't use illegal or harmful substances (e.g., drugs, alcohol,
tobacco).
16) Able to avoid early parenting - Doesn't engage in sexual behavior likely to result in early parenting.
GOAL AREA #3: CARING
17) Shows trust toward you - Isn't reluctant to confide in you, to accept your suggestions.
18) Respects other cultures - Doesn't stereotype or put down other ethnic, racial, language, or national
groups.
19) Relationship with family - Interacts well with other family members.
20) Relationship with peers - Interacts well with persons of own age.
21) Relationship with other adults - Has good interactions with other adults who are not family members.
Continued On Other Side
Big Brothers Big Sisters of America
TEACHER REPORT ON THE MATCH
For Agency Use
Match ID: __________Date Completed: __________Length of match when administered: __________(Specify in months/years)
Age: __________ Male † Female †
Community-Based † School-Based †
Other Site-Based †
White †
Black †
Hispanic †
Asian †
Native American †
Other †
We would like you to describe any changes you’ve observed in the below areas over the past _____ months. It’s
okay to indicate “don’t know” if you have no knowledge about change in a given area.
Much
Better
A Little
Better
No
Change
A Little
Worse
Much
Worse
Don't
Know
Not A
Problem
CONFIDENCE
1) Self-confidence
2) Able to express feelings
3) Can make decisions
4) Has interests or hobbies
5) Personal hygiene, appearance
6) Sense of the future
COMPETENCE
7) Uses community resources
8) Uses school resources
9) Academic performance
10) Attitude toward school
11) School preparedness (homework)
12) Class participation
13) Classroom behavior
14) Able to avoid delinquency
15) Able to avoid substance abuse
16) Able to avoid early parenting
CARING
17) Shows trust toward you
18) Respects other cultures
19) Relationship with family
20) Relationship with peers
21) Relationship with other adults
Has there been any improvement in the student’s grades, in any school subjects, since the beginning of the school year? (please
circle)
a. Yes
b. No
If yes, in how many subjects have you observed an improvement in grades? (please circle)
a. 1
b. 2
c. 3
d. 4 or more
Thank you!
Copyright © 2001 by Big Brothers Big Sisters of America. Affiliated agencies of Big Brothers Big Sisters of America may
reproduce this document for agency use without restriction. Other not-for-profit organizations may reproduce this document
with acknowledgment of Big Brothers Big Sisters of America.
Big Brothers Big Sisters Service Delivery Model
SDM Closure Reasons/Code
Match Completion
Premature Yes
No
Reason for Closure
Reason Was Change In Status:
05-Child Moved
10-Child Changed School/Site
15-Child Graduated
20-Child or Parent Time Constraints
21-New Parent/Adult in Child’s life
25-Child Health or Behavior Problem
30-Child Deceased
35-Child/Parent’s Other Reason
55-Vol Moved
60-Vol Changed Work Site
65-Vol Graduated from School
70-Vol Changed School or other Site
75-Vol Health Problem
80-Vol Deceased
85-Vol’s Family Change
Reason Was Dissatisfaction:
100-Child lost contact with Vol
150-Child Lost Interest
200-Child's/Parent’s Unrealistic Expectations
210-Severity of Child Problems
250-Child/Parent says “Incompatible w/Vol”
300-Child/Parent does not like Vol
450-Custodial Adult unsupportive/interfered
475-Child/Parent Infractions of rules, standards
600-Vol lost contact with Child
650-Vol Lost Interest
700 Vol's Unrealistic Expectations
750-Vol says “Incompatible w/Child/Parent
800-Vol does not like Child/Parent
850-Vol Infractions of rules, standards
875-Agency concern w/Vol (red flag)
Reason Was Successful Closure
900 - Successful Closure
Copyright 2003 Big Brothers Big Sisters of America
September 2004
43
Big Brothers Big Sisters Service Delivery Model
FILE CHECKLIST FOR ALL PROGRAMS
Volunteer Name
Std
Child Name
Check If
Completed
VOLUNTEER
Std
Community-Based
(CBM)
School-based
(SBM)
CHILD – Parent/Guardian
13
Vol. Inquiry Record
13
Parent/Youth Inquiry Record
13
Pre-enrollment
14
Parent/Youth Pre-Interview/Written Consent
15
Reference #1 (CBM, SBM, OSBM)
14
Parent/Child Interview /Orientation
Reference #2 (CBM, SBM, OSBM)
14
Child safety information Child
Reference #3 (CBM)
14
Child safety information Parent/Guardian
15
Criminal Background Check
P/G satisfaction questionnaire (Post enrollment)
15
MVR Check (CBM)
Parent POE (CBM)
15
Pre-Interview
Teacher POE (SBM)
15
15
In-Person Interview/Orientation/Home
assess.
Child safety information Volunteer
15
Volunteer Assessment & Match Support
Satisfaction Questionnaire (Post
enrollment)
Other Forms: Confidentiality, Media
release, etc.
Other Site-Based
(OSBM)
Check If
Completed
Average Percentage of Completion (%)
Total all items required at your agency.
Divide this number into the total checked, to
arrive at a percentage of total completion.
[Example – 28 total items divided into 13
checked items = 46%] The percentage should
be at the recommended figure of at least 90%
Transmission of Information
(Enrollment to Support)
16
Match Introduction/approval
18
19
Match Support Records (Vol. &
Parent./Child)
Match Closure & Re-engagement
20
Volunteer Reassessment
Volunteer Satisfaction Survey (Post
Match)
Volunteer POE
Quality of Performance Ratings
1
Interviews of Volunteers and Parent/Child – Rate the quality of the Enrollment Specialist using appropriate follow-up
questions to make informed decisions regarding eligibility/matchability/coachability.
2
Volunteer Assessment and Match Support – Rate the quality of the Enrollment Specialist in providing quality, written,
professional matching recommendations, including assessment of training and match support needs.
3
Transmission of information – Rate the quality of the Enrollment Specialist in providing meaningful information to Match
Support.
Q Rating (1-5)
Rating scale – 1 is the lowest score and 5 is the highest score. You may provide ratings in 25/100, when appropriate (i.e., 3.25, 3.50, 3.75)
Copyright 2003 Big Brothers Big Sisters of America
September 2004
1
Big Brothers Big Sisters Service Delivery Model
MATCH INTRODUCTION RECORD
Name of Volunteer:
Name of Child:
Name of Parent/Guardian:
Date of in-person introduction by staff:
Child approves match:
Parent approves match:
Volunteer approves match:
Staff Making Match Introduction:
Copyright 2003 Big Brothers Big Sisters of America
September 2004
2