Community Advisory Board (CAB) Survey

Name of CAB member: ____________________________________ Date __________

Business or Organization Name: ________________________________________________

Business or Organization Type:

q Nail/Hair

q Salon

q Bank

q Welfare

q Office

q Restaurant

q Drugstore

q Convenience store

q Record

q Store

q Counseling center

q Women’s shelter

q Health care setting

q Religious setting

q Other, specify ___________________

Type of Interviewee:

q Internal interview (e.g., your agency outreach workers)

q Agency systems interviews (e.g., people working in systems that provide services to the target population)

q Interactor interviews (e.g., people who interact closely with the target population more directly)

q Community gatekeeper

Meeting Type:

q Role Model Story Review

q Content

q Design and Layout

q Information Sharing – Community Identification Process

Targeted Population: __________________________________________________________

Targeted Behavior: ___________________________________________________________

Resources Provided: __________________________________________________________

Ideas/Suggestions: ___________________________________________________________

Recommended contacts: ______________________________________________________