| Module |
Section |
Question |
Text |
Potential
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Core |
Supplmnt |
S1 |
S2 |
S3 |
S4 |
| Module 1 |
Section 1 |
STF01 |
As the Health Manager, how many EHS/HS sites (or centers) are you responsible for? |
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| Module 1 |
Section 1 |
STF02 |
How many hours per week do you usually work for EHS/HS? |
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| Module 1 |
Section 1 |
STF03 |
How many weeks per year do you work for EHS/HS? |
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| Module 1 |
Section 1 |
STF04 |
Aside from your responsibilities as Health Manager, do you have other responsibilities with this EHS/HS program? |
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| Module 1 |
Section 1 |
STF05 |
Other than your responsibilities as a health manager, what other responsibilities do you have with EHS/HS? |
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| Module 1 |
Section 1 |
STF06 |
What percentage of the hours that you work for EHS/HS is spent managing the health service area (this can include time planning health activities, supervising other health staff, maintaining budgets, etc.)? |
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| Module 1 |
Section 1 |
STF07,07a |
Please select the staff person who is primarily responsible for each task. |
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| Module 1 |
Section 1 |
STF08 |
How often does your program have a regular meeting where the health service area or health-related program activities (e.g., screening days, health education of families) are discussed as either the only focus of or a dedicated part of the meeting agenda? |
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| Module 1 |
Section 1 |
STF09 |
In your position now, what conditions or situations make it harder for you to do your job well? |
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| Module 1 |
Section 1 |
STF10 |
Do you or your health staff work with any of the following specialists (a specialist may be working as staff, a volunteer, or a consultant)? |
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| Module 1 |
Section 1 |
STF11 |
Pick the sentence that best describes the languages spoken and understood by EHS/HS health staff |
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| Module 1 |
Section 1 |
STF12 |
Do you have teachers, staff members, or consultants who provide guidance on ethnic customs, culture, traditions and values that may relate to the health, behavioral health, and oral health of the children and families in your program? |
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| Module 1 |
Section 2 |
PDV01,01a,01b |
First think about training and other professional development activities you have had in the past three years. Please identify the main health issues covered by your training and say where the training took place and who conducted it. If no training was received on a health issue, please say whether the training was offered. |
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| Module 1 |
Section 2 |
PDV02 |
In the past three years, has your EHS/HS program provided training, either offsite or onsite, for other EHS/HS staff members (not including you) in... |
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| Module 1 |
Section 2 |
PDV03 |
What kinds of things does your EHS/HS program do to make it easier for you or your staff to attend health-related trainings outside of the program? Does it . . . |
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| Module 1 |
Section 2 |
PDV04 |
In the past year, how many times did you connect with health managers in other EHS/HS programs to discuss challenges, share strategies and lessons learned, or to seek advice about your program? |
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| Module 1 |
Section 3 |
HSC01 |
Do you run more than one HSAC? |
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| Module 1 |
Section 3 |
HSC02 |
How many individuals currently serve on the HSAC for your program? |
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| Module 1 |
Section 3 |
HSC03 |
Of these, how many would you consider to be “active” members? These are individuals who regularly engage in their role as a member of the HSAC. |
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| Module 1 |
Section 3 |
HSC04 |
Which of the following groups are represented as members on your HSAC? |
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| Module 1 |
Section 3 |
HSC05 |
Do you share a HSAC with another EHS/HS/MSHS/AIAN program? |
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| Module 1 |
Section 3 |
HSC06 |
With which type of Head Start program do you share the HSAC? |
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| Module 1 |
Section 3 |
HSC07 |
Do members of your HSAC have similar racial, ethnic, cultural, and language backgrounds to the children and families you serve? |
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| Module 1 |
Section 3 |
HSC08 |
How often does your HSAC meet? |
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| Module 1 |
Section 3 |
HSC09 |
How often do you consult with one or more members of your HSAC apart from regular committee meetings |
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| Module 1 |
Section 3 |
HSC10 |
How strongly do you agree or disagree with the following statements about your HSAC? The HSAC… |
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| Module 1 |
Section 3 |
HSC11 |
Does your HSAC participate in annual self-assessment of your EHS/HS program’s effectiveness? |
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| Module 1 |
Section 4 |
POL01 |
According to your program’s policy, about how many minutes per day should children take part in physical activity? |
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| Module 1 |
Section 4 |
POL02 |
Think about how your program prepares children for school. Do you have health-specific goals or objectives that are part of your school readiness plan? |
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| Module 1 |
Section 4 |
POL03 |
How do you keep track of the Consumer Product Safety Commission (CPSC) recalls or regulations (e.g., cribs, toys)? |
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| Module 1 |
Section 4 |
POL04 |
How do you or your program ensure children are not left alone in the classroom, in another part of the facility? |
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| Module 1 |
Section 4 |
POL05 |
How do you or your program ensure children are not left alone on the bus or van? |
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| Module 2 |
Section 1 |
HLT01 |
What do you see as the health concerns facing the children and families served by your [HS] program? |
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| Module 2 |
Section 1 |
HLT02 |
For children, what is the average number of hours per week staff in your [HS] program spend managing these health issues and related complications? |
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| Module 2 |
Section 1 |
HLT03 |
How many children in your program are not eligible for services under Part B or Part C of the Individuals with Disabilities Education Act, but have chronic health conditions that you feel need additional supports? |
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| Module 2 |
Section 1 |
HLT04 |
What health condition(s) require enough additional supports in the EHS/HS program to make you think a diagnosis of that condition could make a child eligible for Part B or Part C services? |
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| Module 2 |
Section 1 |
HLT05 |
What is the most common method you use to share information about the health of specific children among program staff? |
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| Module 2 |
Section 2 |
PEN01 |
During the months when your program is open, how often do you or your health team you communicate with parents or guardians about their child’s health and developmental status, on average? |
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| Module 2 |
Section 2 |
PEN02 |
What is the most common method you use to share information with parents or guardians about the health of their child? |
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| Module 2 |
Section 2 |
PEN03 |
During the months that your program is open, about how often do you meet with parents or guardians (either by phone or in person) to discuss the health management of a child with special health care needs (e.g., medication management, special supports) apart from daily interactions? |
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| Module 2 |
Section 2 |
PEN04 |
When discussing the health of a child with their parent/guardian, what language is used? |
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| Module 2 |
Section 2 |
PEN05 |
Does your program create Individual Family Partnership Agreements (IFPAs) with families specific to reaching health goals? |
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| Module 2 |
Section 2 |
PEN06 |
Within your program, which of the following make it harder for you to communicate with parents or guardians about the health of their child? |
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| Module 3 |
Section 1 |
SRF01 |
Does your program have a process you are supposed to follow for getting and keeping track of health information about each child in the program? |
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| Module 3 |
Section 1 |
SRF02 |
Where do you get information about the health of a child when she or he first enters the program? |
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| Module 3 |
Section 1 |
SRF03 |
How often do you use the following information to update a child’s health record? |
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| Module 3 |
Section 1 |
SRF04 |
Does your [HS] program regularly provide any of the following health screenings to children at no cost to them, in the program? |
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| Module 3 |
Section 1 |
SRF05 |
What process or processes do you use to ensure that children receive necessary screenings? |
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| Module 3 |
Section 1 |
SRF06 |
What funds are used to pay for screening? |
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| Module 3 |
Section 1 |
SRF07 |
How often are the following efforts made to encourage parents or guardians to attend follow-up evaluations? |
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| Module 3 |
Section 1 |
SRF08 |
What process or processes do you use to ensure that children receive follow-up evaluations? |
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| Module 3 |
Section 2 |
MCR01 |
What types of medical care do health providers who come to the EHS/HS program provide on-site? |
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| Module 3 |
Section 2 |
MCR02 |
How are physical health services usually coordinated with other agencies or community partners? |
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| Module 3 |
Section 2 |
MCR03 |
Do your partnership agreements with physical health care providers include the following? |
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| Module 3 |
Section 2 |
MCR04 |
Thinking about the physical health of the children and families you serve, please describe your relationship with each of the following types of service providers during the past 12 months. Please rate your relationship on a scale of 0 (no working relationship) to 3 (MOU/formalized collaboration or partnership) |
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| Module 3 |
Section 2 |
MCR05 |
What barriers do you face when working with parents or guardians to obtain screening and treatment services for physical health? |
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| Module 3 |
Section 2 |
MCR06 |
Overall, how would you describe the ability of your partnerships to handle the physical health needs of children in your program? |
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| Module 3 |
Section 2 |
MCR07 |
How would you describe the ability of your partnerships to handle the needs of children living with disabilities in your program? |
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| Module 3 |
Section 2 |
MCR08 |
Thinking about the behavioral/mental health of the children and families you serve, please describe your relationship with each of the following types of service providers during the past 12 months. Please rate your relationship on a scale of 0 (no working relationship) to 3 (MOU/formalized collaboration or partnership). |
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| Module 3 |
Section 2 |
MCR09 |
You mentioned that you use behavioral or mental health consultants. How do you use behavioral health consultants in your program? |
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| Module 3 |
Section 2 |
MCR10 |
How are behavioral health services typically coordinated with other agencies or community partners? |
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| Module 3 |
Section 2 |
MCR11 |
Do your partnership agreements with behavioral or mental health care providers include the following? |
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| Module 3 |
Section 2 |
MCR12 |
What barriers do you face when working with parents/guardians to obtain necessary screening and treatment services for behavioral health? |
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| Module 3 |
Section 2 |
MCR13 |
Overall, how would you describe the ability of your partnerships to handle the behavioral health needs of children in your program? |
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| Module 3 |
Section 2 |
MCR14 |
Thinking about the oral health of the children and families you serve, please describe your relationship with each of the following types of service providers during the past 12 months. |
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| Module 3 |
Section 2 |
MCR15 |
How are oral health services usually coordinated with other agencies or community partners? |
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| Module 3 |
Section 2 |
MCR16 |
Do your partnership agreements with oral health care providers include the following? |
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| Module 3 |
Section 2 |
MCR17 |
What barriers do you face when working with parents/guardians to obtain necessary screening and treatment services for oral health? |
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| Module 3 |
Section 2 |
MCR18 |
Overall, how would you describe the ability of your partnerships to handle the oral health needs of children in your program? |
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| Module 3 |
Section 2 |
MCR19 |
What process or processes do you use to ensure that children receive follow-up services [for physical health, oral health, behavioral health]? |
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| Module 3 |
Section 2 |
MCR20 |
Is a set portion of your EHS/HS budget designated for treatment services for physical health, behavioral health and/or oral health? |
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| Module 3 |
Section 2 |
MCR21 |
What funds are used to pay for physical health, behavioral health and oral health treatment services? |
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| Module 3 |
Section 2 |
MCR22 |
Do you (or your staff) provide health services or health programs in the home? |
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| Module 3 |
Section 2 |
MCR23 |
What health service or health programs do you conduct in the home? |
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| Module 3 |
Section 2 |
MCR24 |
What barriers, if any, do you face when providing health services or programs in the home? |
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| Module 4 |
Section 1 |
PRG01 |
For the following list of health topics and health promotion activities, please say whether you are addressing the topic with children and families in your EHS/HS program |
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| Module 4 |
Section 1 |
PRG02 |
What factors/information contributed to you choosing these health topics as targets of health promotion? |
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| Module 4 |
Section 1 |
PRG03 |
When there is a health topic that you feel needs to be addressed, how do you find possible resources or curriculum? |
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| Module 4 |
Section 1 |
PRG04 |
Please fill out the table below, listing the health topic or health promotion area being addressed, the name of the curricula, whether the curricula is “off the shelf”, adapted, or created by your program staff, and how long you have been using it. |
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| Module 4 |
Section 1 |
PRG04a |
You did not list I am Moving, I am Learning (IMIL) as a program that you are using. What are the reasons you are not currently using IMIL? |
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| Module 4 |
Section 1 |
PRG05 |
To what extent are health materials selected or adapted to match the cultures and languages of families you serve? |
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| Module 4 |
Section 1 |
PRG06 |
What method(s) do you use most often to share health promotion information with the families that you serve? |
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| Module 4 |
Section 1 |
PRG07 |
What funds are used for prevention and health promotion activities? |
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| Module 4 |
Section 2 |
IMP01 |
What are the biggest challenges to starting health promotion activities started in your EHS/HS program? |
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| Module 4 |
Section 2 |
IMP02 |
Does your program do any of the following to encourage parents/guardians to take part in health-related activities or events? Do you: |
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| Module 4 |
Section 2 |
IMP03 |
Does your program regularly monitor the health promotion activities (e.g., education, curricula) offered to children? |
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| Module 4 |
Section 2 |
IMP04 |
Does your program regularly monitor the health promotion activities (e.g., education, curricula) offered to families? |
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| Module 4 |
Section 2 |
IMP05 |
What types of information do you use to keep track of how your health promotion activities are going? |
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| Module 4 |
Section 3 |
PRO01 |
Do you offer any of the following services to families? |
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| Module 4 |
Section 3 |
PRO02 |
Even if your program does not include EHS, does your program offer any services to pregnant women? |
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| Module 4 |
Section 3 |
PRO03 |
Which of the following services to pregnant women? |
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| Module 4 |
Section 3 |
PRO04 |
What funds are used to pay for family health promotion activities? |
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| Module 5 |
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SWL01 |
Within the past year, has your program offered staff members the following…..? |
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| Module 5 |
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SWL02 |
How often do staff members participate in emergency preparedness education sessions or trainings? |
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| Module 5 |
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SWL03 |
What funds are used to pay for staff well-being activities? |
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| Module 6 |
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PRT01 |
With which agencies and organizations do you normally work to address or support the health needs of the children and families in your [HS] program? |
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| Module 6 |
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PRT02 |
In your [HS] program, which of the following health needs are NOT being met (or being met well) by the agencies and organizations you work with? |
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| Module 6 |
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PRT03 |
What types of health-related services or knowledge do your community partners provide (e.g., help with referrals, treatment services, health education)? |
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| Module 6 |
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PRT04 |
What types of health-related community partners do you NOT have a relationship with now, but you would LIKE TO have a relationship with? |
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| Module 6 |
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PRT05 |
In the past 12 months, please say how much the following things got in the way of providing health services or programs to your EHS/HS children and families |
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| Module 6 |
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PRT06 |
What percentage of your community partners are culturally responsive to the needs of your ethnic and linguistic minority families? |
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| Module 7 |
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EDUC01 |
What is the highest grade or year of school that you completed? |
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| Module 7 |
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EDUC02 |
Please describe how much coursework you had in the following areas? |
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| Module 7 |
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EDUC03 |
Have you ever had any licenses, certificates or credentials relating to health such as medicine, nursing, or oral health (include those earned outside of the United States)? |
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| Module 7 |
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EDUC04 |
For each one that you have had, say whether it is active at this time. |
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| Module 7 |
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EDUC05 |
Have you completed training to become a Child Care Health Consultant (CCHC)? |
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| Module 7 |
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EDUC06 |
Counting this program year, how many years have you ever worked … |
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| Module 7 |
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EDUC07 |
Before the position you have now, what other positions have you held at your program now or another EHS/HS program? |
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| Module 7 |
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DEM01 |
What is your sex? |
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| Module 7 |
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DEM02 |
Are you Hispanic, Latino/a, or Spanish origin? |
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| Module 7 |
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DEM03 |
What is your race? |
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| Module 7 |
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DEM04 |
How well do you speak English? |
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| Module 7 |
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DEM05 |
Do you speak a language other than English at home? |
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| Module 7 |
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DEM06 |
What is this language? |
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| Module 7 |
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DEM07 |
Is your age…? |
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| Module 7 |
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DEM08 |
About how much do you make each year at EHS/HS? |
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| Module 7 |
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DEM09 |
Do you or did you ever have a child in your household who attends/attended EHS/HS? |
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| Module 7 |
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DEM10 |
How satisfied are you with your current position as a health manager? |
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| Module 7 |
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DEM11 |
Is there anything else that you would like to mention about your experience with the health service area of your program and/or the health needs of children and families in your program? |
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| Module 7 |
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FUP01 |
We reached you at [email address]. Is this the best email address to reach you? If no, please enter your preferred email address. |
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| Module 7 |
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FUP02 |
Is there a phone number we can use to get in touch with you? If yes, please enter the phone number starting with the area code. |
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| Module 7 |
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FUP03 |
What is the best time of day for our study staff member to call you? |
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| Module 7 |
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FUP04 |
Is there anything else we should know about the best time or method to reach you? |
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