Instrument 11b: On-line Working Alliance Inventory - Participants

OMB #: 0970-0403

EXPIRATION: XX/XX/201X

Parents and Children Together (PACT) Evaluation

INSTRUMENT (11)

ON-LINE WORKING ALLIANCE INVENTORY

(FOR PROGRAM STAFF AND PARTICIPANTS)

Reference No.: 06997.172

WORKING ALLIANCE INVENTORY- SHORT FORM (PROGRAM STAFF VERSION)

PACT Implementation Study

October 25, 2012

INTRODUCTION

The [PREFILL RF/HM PROGRAM NAME] program is part of the Parents and Children Together (PACT) study, a national study being conducted by the U.S. Department of Health and Human Services. The study is building knowledge about the effectiveness of Responsible Fatherhood and Healthy Marriage grant programs and is seeking to describe grantee programs to support replication and improvement. The Department of Health and Human Services asked a research team from Mathematica to assist with the study.

This survey asks staff members to describe ways she or he thinks or feels about working with fathers and couples in the [PREFILL RF/HM PROGRAM NAME] program. Participants in the program will complete a similar set of questions to describe how they think or feel about working with you. The survey should take no more than 10 minutes to complete. Your participation in this survey is important and will help us understand how staff members work with fathers and couples in fatherhood and marriage and relationship strengthening programs. Your responses will be kept private and used only for research purposes. They will be combined with the responses of other staff and program participants. No individual names will be reported.

Participation in the survey is completely voluntary and you may choose to skip any question.

If you have any questions about the survey, please do not hesitate to contact Mathematica. You can reach Mathematica by calling 1-866-XXX-XXXX or e-mailing

xxxxxxx@mathematica-mpr.com.

Thank you for completing this survey.

Before starting the survey, please read and answer the statement below.

ALL

Not REQUIRED

i1. I have read the introduction and understand that the information I provide will be kept private and used only for research purposes. My responses will be combined with the responses of other staff and program participants. No individual names will be reported.

 I agree with the above statement and will complete the survey 1

 I do not agree with the above statement and will not complete the survey 0 END SURVEY

This collection of information is voluntary and will be used to learn about [RF/HM PROGRAM NAME]. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to [Contact Name]; [Contact Address]; Attn: OMB-PRA (0970-0403).

ALL

Not REQUIRED

Below are statements that describe ways staff might think or feel about the fathers or couples with whom she/he is working. When completing questions, please think about how you feel about your work with [PREFILL CLIENT FIRST NAME]. For each statement, please check the box that describes how often you think or feel that way. For example, if the statement describes the way you always think or feel, check the “Always” box. Work fast, your first thoughts are the ones we would like to see. Please don't forget to respond to every item.

1. How often do you think or feel this way?

PROGRAMMER: CODE ONE PER ROW Select one per row

	NEVER	RARELY	OCCASIONALLY		SOMETIMES		OFTEN	VERY OFTEN	ALWAYS	DON’T KNOW
a. [PREFILL CLIENT FIRST NAME ] and I agree about the steps to be taken to improve his situation.	1 	2 	3 	4 		5 		6 	7 	d 
b. [PREFILL CLIENT FIRST NAME ] and I both feel confident about the usefulness of our current activities in the program.	1 	2 	3 	4 		5 		6 	7 	d 
c. I believe [PREFILL CLIENT FIRST NAME ] likes me.	1 	2 	3 	4 		5 		6 	7 	d 
d. I have doubts about the goals we are trying to accomplish in the program.	1 	2 	3 	4 		5 		6 	7 	d 
e. I am confident in my ability to help [PREFILL CLIENT FIRST NAME ].	1 	2 	3 	4 		5 		6 	7 	d 
f. We are working towards mutually agreed upon goals.	1 	2 	3 	4 		5 		6 	7 	d 
g. I appreciate [PREFILL CLIENT FIRST NAME ] as a person.	1 	2 	3 	4 		5 		6 	7 	d 
h. We agree on what is important for [PREFILL CLIENT FIRST NAME ] to work on.	1 	2 	3 	4 		5 		6 	7 	d 
i. [PREFILL CLIENT FIRST NAME ] and I have built a mutual trust.	1 	2 	3 	4 		5 		6 	7 	d 
j. [PREFILL CLIENT FIRST NAME ] and I have different ideas on what his needs are.	1 	2 	3 	4 		5 		6 	7 	d 
k. We have established a good understanding between us of the kind of changes that would be good for [PREFILL CLIENT FIRST NAME ].	1 	2 	3 	4 		5 		6 	7 	d 
l. [PREFILL CLIENT FIRST NAME ] believes the way we are approaching his situation is right.	1 	2 	3 	4 		5 		6 	7 	d 

Reference No.: 06997.172

WORKING ALLIANCE INVENTORY- SHORT FORM (PROGRAM PARTICIPANT VERSION)

PACT Implementation Study

October 25, 2012

INTRODUCTION

The [PREFILL RF/HM PROGRAM NAME] program is part of the Parents and Children Together (PACT) study, being conducted by the U.S. Department of Health and Human Services. The study is being done to learn more about which services help fathers and couples build better relationships with their children and their families, as well as improve their ability to get a job. The Department of Health and Human Services asked a research team from Mathematica to assist with the study.

This survey asks you about how you feel about working with staff members in the [PREFILL RF/HM PROGRAM NAME] program. Staff members in the [PREFILL RF/HM PROGRAM NAME] program will complete a similar set of questions to describe how they feel about working with you. The survey should take no more than 10 minutes to complete. Your participation is important and will help us understand how staff members work with fathers and couples. Your responses will be kept private and used only for research purposes. They will be combined with the responses of other staff and program participants. No individual names will be reported.

Participation in the survey is voluntary and you may choose to skip any question.

If you have any questions about the survey, please contact Mathematica. You can reach Mathematica by calling 1-866-XXX-XXXX or e-mailing xxxxxxx@mathematica-mpr.com.

Thank you for completing this survey.

Before starting the survey, please read and answer the question below.

ALL

Not REQUIRED

i1. I have read the introduction and understand that the information I provide will be kept private and used only for research purposes. My responses will be

combined with the responses of other staff and program participants. No individual names will be reported.

• I agree with the above statement and will complete the survey 1

 I do not agree with the above statement and will not complete the survey 0 END SURVEY

This collection of information is voluntary and will be used to learn about [RF/HM PROGRAM NAME]. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to [Contact Name]; [Contact Address]; Attn: OMB-PRA (0970-XXXX).

ALL

Not REQUIRED

Below are statements that describe ways a father or mother might think or feel about a staff member at this program. When completing questions, please think about how you feel about your work with [PREFILL NAME OF STAFF]. For each statement, please check the box that describes how often you think or feel that way. For example, if the statement describes the way you always think or feel, check the “Always” box. Work fast, your first thoughts are the ones we would like to see. Please don't forget to respond to every item.

1. How often do you think or feel this way?

PROGRAMMER: CODE ONE PER ROW Select one per row

	NEVER	RARELY	OCCASIONALLY	SOMETIMES	OFTEN	VERY OFTEN	ALWAYS	DON’T KNOW
a. [ PREFILL NAME OF STAFF ] and I agree about the things I will need to do to improve my situation.	1 	2 	3 	4 	5 	6 	7 	d 
b. What I am doing with [ PREFILL NAME OF STAFF ] gives me new ways to look at my situation.	1 	2 	3 	4 	5 	6 	7 	d 
c. I believe [ PREFILL NAME OF STAFF ] likes me.	1 	2 	3 	4 	5 	6 	7 	d 
d. [ PREFILL NAME OF STAFF ] does not understand the goals I am trying to accomplish.	1 	2 	3 	4 	5 	6 	7 	d 
e. I am confident in [ PREFILL NAME OF STAFF ]’s ability to help me.	1 	2 	3 	4 	5 	6 	7 	d 
f. We agree on what is important for me to work on.	1 	2 	3 	4 	5 	6 	7 	d 
g. I feel that [ PREFILL NAME OF STAFF ] appreciates me.	1 	2 	3 	4 	5 	6 	7 	d 
h. [ PREFILL NAME OF STAFF ] and I are working on goals we both agree are important.	1 	2 	3 	4 	5 	6 	7 	d 
i. [ PREFILL NAME OF STAFF ] and I trust one another.	1 	2 	3 	4 	5 	6 	7 	d 
j. [ PREFILL NAME OF STAFF ] and I have different ideas on what my needs are.	1 	2 	3 	4 	5 	6 	7 	d 
k. We have established a good understanding of the kind of changes that would be good for me.	1 	2 	3 	4 	5 	6 	7 	d 
l. I believe the way we are approaching my situation is right.	1 	2 	3 	4 	5 	6 	7 	d 

Parents and Children Together Evaluation – Implementation Study V01_10/25/12

Working Alliance Inventory (WAI) © Horvath 1994; Short form by Tracey and Kokotovic 1989