Electronic Data Reporting: Services Measures

Project LAUNCH Cross-Site Evaluation

Appendix_G_Electronic Data Reporting-Services Measures_052213

Electronic Data Reporting: Services Measures

OMB: 0970-0373

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0970-0373 can be found here:

2019-01-30 - No material or nonsubstantive change to a currently approved collection
2017-10-05 - No material or nonsubstantive change to a currently approved collection

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Appendix G. Electronic Data Reporting: Services Measures

Electronic Data Reporting: Services Measures

The Paperwork Reduction Act Burden Statement: This collection of information is voluntary and will be used to evaluate implementation and outcomes of the Project LAUNCH program. Public reporting burden for this collection of information is estimated to average 480 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. The OMB control number for this collection is 0970-XXXX and it expires XX/XX/XXXX.

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Project LAUNCH

Cross-Site Evaluation

Please Single parent

asfasdfFamily home

Survey on Services to

Children and Families:

LAUNCH-Funded Direct Services

FINAL

Shape3

NOTE: Questions highlighted in yellow will be pre-populated with the response from the previous reporting period.

Abt Associates Inc.

Contents

Part I. All Direct Services 1

A. Program Description 1

Part II. Programs Initiated Under LAUNCH 6

A. Service Counts 6

B. Provider Training 9

C. Screening and Assessment for Children and Families 11

D. Demographics (for new families served in the last 6 months) 14

Part III. Programs/Services Expanded/Enhanced by LAUNCH 19

Types of Enhancements 19

A. Service Counts 21

B. Provider Training 23

C. Screening and Assessment for Children and Families 26

D. Demographics (for new families served in the last 6 months) 29

Part IV. Annual Module 34

A. Fidelity/Level of Implementation 34

B. Data Systems 35

C. Provider Changes 36

Part V. Survey Status 38

(Window shade for “Direct Service” has an Add Service feature. For each service that is listed, all Parts and all corresponding questions should appear.)

Part I. All Direct Services

A. Program Description

DS1. Please provide a brief description of the program. ________________

DS2. Does this program include services for parents or families?

Yes
No (skip to DS3) [If No, skip DS7,8,9]

DS2a. What types of services for families are provided in this program? Check all that apply.

Home visiting program
Family strengthening program
Short-term individual/group mental health treatment services for parents/ parent-child pairs
Family/child assessments and referrals for mental-health or other related services or evaluation (NOTE: If this response is selected, please delete this service from the list of Direct Services and enter it in the survey “Other Family Referrals”.)
Other - Please describe: _________________________

DS3. Does this program/service include separate services for children?

Yes
No (skip to DS4) [If No, skip DS10,11]

DS3a. What kinds of services for children are provided in this program? Check all that apply.

Early childhood education programming
Transition program (preK to kindergarten)
Short-term mental health treatment services for individual/groups of children
Other - Please describe: _______________________________

If neither DS2 nor DS3 are Yes, survey ends.

DS4. How would you describe this program/service? Please select only one.

“Branded” or national/international model (i.e., evidence-based model)
An evidence-based program/service that is not yet considered a national model
Based on a “best practice” or standard of care in the field
Locally-developed program model
Other

DS4a. What is the name of the program model? _______________

DS4b. Who developed the program model? _________________

DS4c. Has the model been adapted for your community?

Yes
No (skip to DS5)

DS4c1. What adaptation(s) have been made? ________________

DS4c2. What was the basis/reason for the adaptation(s)? _______________

DS5. Who is the target population for this program/service? Check all that apply.

Program is universal – all families in the community are eligible
Program targets families with children of a specific age (enter ages of eligible children: XX years/months – XX years/months): (If answer choice is selected, an open text field should appear to allow for ages to be entered)
Program targets families of children with behavioral/developmental concerns
Program targets families of children with special health care needs
Program targets first-time parents
Program targets teenage parents
Other - Please describe: ________________________________________

DS6. In the last 6 months, did the program include delivery of services to individual families?

Yes
No (skip to DS7)

DS6a. In what locations do these services occur? Check all that apply.

Family homes
Social service agencies/program offices
Early childhood settings (including school-based pre-kindergarten or elementary school attended by child)
Early childhood settings (including school-based pre-kindergarten program, elementary school not attended by child)
Educational settings attended by parents
Parent work sites
Primary care/health care settings
Community center/other community settings
Other - Please describe: ___________________________________

DS7. In the last 6 months, did the program services include parent groups, such as parent support groups, parent education, or parent training?

Yes
No (skip to DS8)

DS7a. In what locations are these parent groups held? Check all that apply.

Social service agencies/program offices
Early childhood settings (including school-based pre-kindergarten or elementary school attended by child)
Early childhood settings (including school-based pre-kindergarten program, elementary school not attended by child)
Educational settings attended by parents
Parent work sites
Primary care/health care settings
Community centers/other community settings
Other - Please describe: ___________________________________

DS8. In the last 6 months, did the program deliver services to parent-child pairs (individual child sessions and group sessions including both parents and children)?

Yes
No (skip to DS9)

DS8a. In what locations are these parent/child groups held? Check all that apply.

Social service agencies/program offices
Early childhood settings (including school-based pre-kindergarten or elementary school attended by child)
Early childhood settings (including school-based pre-kindergarten program, elementary school not attended by child)
Educational settings attended by parents
Parent work sites
Primary care/health care settings
Community centers/other community settings
Other - Please describe: ___________________________________

DS9. In the last 6 months, did the program include delivery of services to individual children?

Yes
No (skip to DS10)

DS9a. In what locations do these services occur? Check all that apply.

Social service agencies/program offices
Early childhood settings (including school-based pre-kindergarten or elementary school attended by child)
Early childhood settings (including school-based pre-kindergarten program, elementary school not attended by child)
Educational settings attended by parents
Parent work sites
Primary care/health care settings
Community centers/other community settings
Other - Please describe: ___________________________________

DS10. In the last 6 months, did the program deliver services to groups of children (apart from parents)?

Yes
No (skip to DS 11)

DS10a. In what locations are these children’s groups held? Check all that apply.

Social service agencies/program offices
Early childhood settings (including school-based pre-kindergarten or elementary school attended by child)
Early childhood settings (including school-based pre-kindergarten program, elementary school not attended by child)
Educational settings attended by parents
Parent work sites
Primary care/health care settings
Community centers/other community settings
Other - Please describe: ___________________________________

DS11. In the last 6 months, did the program services include working in any other ways with families, parents or children?

Yes
No (skip to DS12)

DS11a. Please describe the other ways that the program works with families, parents or children. _________________________________

DS11b. In what locations are these held? Check all that apply.

Social service agencies/program offices
Early childhood settings (including school-based pre-kindergarten or elementary school attended by child)
Early childhood settings (including school-based pre-kindergarten program, elementary school not attended by child)
Educational settings attended by parents
Parent work sites
Primary care/health care settings
Community centers/other community settings
Other - Please describe: ____________________________________

DS12. How long is a child or family eligible to receive this program/service?

No pre-determined length of service--as long as child/family needs service (skip to DS13)
Specified length of program/service

DS12a. How long can a parent/child/family receive services?

Based on number of sessions: __________ # sessions
Based on length of time: _________ # months
Based on age of child: Prenatal up to age 3 years
Based on age of child: eligible Age range: ___months/years to ____ months/years [enter youngest and oldest age of eligibility]
Other - Please describe: ___________________________________

DS13. Was this program/service initiated under LAUNCH; that is, was this program/service started “from scratch” by LAUNCH in the target community?

DS14. In the last 6 months, what proportion of the funding for this program came from LAUNCH? (estimated percentage) _____________ %

DS15. In the last 6 months, what other sources of funding supported this program/service? Check all that apply.

Private (e.g., foundation, donation)
Federal
County/state funding (public)
Local funding (public)
In-kind contribution
Other - Please describe: __________________________________

DS16. This space is provided for you to describe any other information that has not been covered previously in this Section.

(If DS13= Yes, answer Parts II, IV, and V)

(If DS13 = No, answer Parts III, IV, and V)

Part II. Programs Initiated Under LAUNCH

A. Service Counts

DS17. Program size: Annual enrollment of the program for the target community, defined as the estimated number of children/families that the program serves from October 1 to September 30. (Can be estimated)

DS17a. Number of families served in a year _____________

DS17b. Number of children served in a year ______________

DS18. Children/families served in the last 6 months

DS18a. Number of families that participated in/received services in the last 6 months ___

DS18b. Number of children that participated in/received services in the last 6 months ___

DS18c. Number of families that received services for the first time in the last 6 months ___

DS18d. Number of children that received services for the first time in the last 6 months ___

DS18e. Number of providers providing services to children/families in the last 6 months___

DS18f. Number of settings where service was provided in the last 6 months___

DS19. In the last 6 months, what is the number of families (estimated) who left before the planned end of this program/service or who only received parts of this program/service (i.e., who entered the program/service after it was initiated)? [NOTE: If this program/service doesn’t have a set number of contacts or an established time period, please leave the space provided blank.] ________ (If “0” or blank, skip to DS20)

DS19a. Of the families who left before the end of the program/service or who only received parts of the program/service, what is the number of families who completed:

DS19a1. Less than 25% of planned program/service ___ (#)

DS19a2. 25%-50% of planned program/service ___ (#)

DS19a3. 51%-75% of planned program/service ___ (#)

DS19a4. 76%-99% of planned program/service ___ (#)

DS20. In the last 6 months, in what ways were services provided to children and families in this program? (This refers to LAUNCH-funded families, if available, or for all families, if not available.)

DS20a. Regularly-scheduled home visits as part of a home visiting program?

Yes
No (skip to DS20b)

DS20a1. Please estimate the number of this type of home visits in last 6 months. ____

DS20b. Home visits as part of another program (for example, home visits to families as part of an early childhood education program or a family strengthening program)?

Yes
No (skip to DS20c)

DS19b1. Please estimate the number of this type of home visits in last 6 months. ____

DS20c. Parent training/parent education or parent support groups?

Yes
No (skip to DS20d)

DS19c1. Please estimate the number of parent groups in last 6 months. ______

DS20d. Parent/child sessions or parent/child groups for mental health treatment?

Yes
No (skip to DS20e)

DS20d1. Please estimate the number of parent/child groups and sessions in last 6 months. ____

DS20e. Parent/child sessions or parent/child groups other than for mental health treatment? [NOTE: This question asks about services attended by parents and children together, such as book groups or mental health sessions. This question does not ask about home visits. Data on home visits should be entered under DS20a or DS20b.]

Yes
No (skip to DS20f)

DS20e1. Please estimate the number of parent/child groups and sessions in last 6 months. ____

DS20f. Computerized lessons for parents (e.g., on parenting, child development)?

Yes
No (skip toDS20g)

DS20f1. Please estimate the number of computerized lessons completed in last 6 months. ___

DS20g. Any other types of direct contacts with parents/children?

Yes – Please describe:___________________
No (skip to DS21)

DS20g1. Please estimate the number of these contacts in last 6 months. ___

DS21. This space is provided for you to describe any other information that has not been covered previously in this Section.

B. Provider Training

DS22. In the last six months, how many staff were involved in delivering this program/service to families and children?

_______ (#)

DS23. Does the program model include requirements for staff to be trained by certified trainers or at certified training centers?

Yes
No (skip to DS24)

DS23a. To date, how many of the staff have been certified to deliver the program?
_______ (#)

DS23b. How many of these staff were newly certified (certified for the first time) in the last 6 months? _______ (#)

DS23c. Does the program model include requirements for periodic follow-up training for staff?

Yes
No (skip to DS24)

DS23c1. How is the follow-up training delivered?

Attending training by a certified trainer
Through written materials/materials on the internet
Through on-line training
Other - Please describe: _______________

DS23c2. How many of the already-certified staff received the required follow-up training in the last 6 months? _______ (#)

DS24. Other than certified training, does the program provide other forms of training for staff on how to deliver the program?

Yes
No (skip to DS25)

DS24a. What types of training are provided? Check all that apply.

Training by the developer
Being trained by other staff who are certified/trained by the developer
Written materials/materials on the internet
Other - Please describe: _______________

DS24b. To date, how many of the staff have received these other forms of training?
_______ (#)

DS24c. How many of the staff were newly trained (for the first time) to deliver the program model in the last 6 months? _______ (#)

DS24d. Does the program model provide any form of follow-up training for staff?

Yes
No (skip to DS25)

DS24d1. How many of the already-trained staff received follow-up training in the last 6 months? _______ (#)

DS25. Does the program/service provide monitoring/supervision of the program staff who are delivering the service to families and children?

Yes
No (skip to DS26)

DS25a. Who provides the monitoring or supervision?

Program director/coordinator
Developer staff
Other--Please describe: ________________

DS25b. How often is monitoring/supervision provided to staff?

On a regular basis (Please describe schedule): ___________________
On an as-needed basis

DS25c. How many staff received monitoring or supervision in the last 6 months? _______ (#)

DS26. In the last 6 months, did LAUNCH support any other training for providers/staff?

Yes
No (skip to DS27)

DS26a. What topics were covered in the training? Check all that apply

Developmental milestones in children's overall cognitive development
Developmental milestones in children's socio-emotional development/behavioral health
Physical health of young children
Identifying/screening/assessing children's cognitive development
Identifying/screening/assessing children's mental health/behavioral health/social-emotional development
Identifying/screening/assessing children’s physical health
Appropriate treatment options for children with behavioral/mental health concerns
Appropriate referrals for children with behavioral/mental health concerns
Resources in the community for children with mental/behavioral health concerns
Strategies for family engagement
Working with families to understand/support children's healthy development
LAUNCH orientation--LAUNCH objectives, service strategies
Other - Please describe:______________________

DS27. Providers Receiving LAUNCH-Supported Training in the Last 6 Months as Part of This Program/Service	Quarter 1	Quarter 2
DS27a. In each of the last two quarters, what is the number of providers/staff who received any LAUNCH-supported training in mental health-related practices/activities that are consistent with the goals of Project LAUNCH? (GPRA) [Please include training on implementing the model and other training.]
DS27b. Number of settings represented by staff who were trained in the last 6 months
DS27c. Number of children, ages 0 – 8, served by staff who were trained in the last 6 months

DS28. This space is provided for you to describe any other information that has not been covered previously in this Section.

C. Screening and Assessment for Children and Families

DS29. In the last 6 months, did LAUNCH support developmental screening and/or assessment of children as part of this program/service?

Yes
No (skip to DS32)

DS30. How many different screening/assessment measures were used as part of this program/service? ______________ (#)

(Repeat questions DS30a. and DS30a1. for the number of measures indicated in question DS30, where the “1” is replaced for each consecutive measure.)

DS30a. What is the name of measure 1? _____________________

DS30a1. What domains are screened and/or assessed by measure 1? Check all that apply.

Social-emotional development, social-personal behavior
Behavior/impulse control/self-regulation
Cognitive-language development
Problem-solving
Communication
School readiness
Literacy/reading
Gross/fine motor skills
Other - Please describe: ________________

DS31. Who conducted the screening and/or assessment of the children? Check all that apply.

Program staff, non-clinical
Program staff, clinical
Primary care providers/staff
Early childhood education and care providers
Mental health consultants
Other - Please describe: _________________

DS32. In the last 6 months, did LAUNCH support physical and health screening for children as part of this program/service?

Yes
No (skip to DS33)

DS32a. What aspects of physical health are screened? Check all that apply.

Vision
Hearing
Weight
Dental
Other - Please describe: _____________

DS33. Children Receiving LAUNCH-Supported Screening and/or Assessments in the Last 6 Months as Part of This Program/Service (Include physical and health screening)

Quarter 1

Quarter 2

DS33a. In each of the last two quarters, what is the number of children, ages 0 – 8, screened and/or assessed for mental health or related interventions at least once as part of this program/service? (GPRA)

DS33b. In each of the last two quarters, what is the number of children, ages 0 – 8, referred for mental health or related services? (GPRA)

DS34. In the last 6 months, did LAUNCH support screening and/or assessment for family members as part of this program/service?

Yes
No (skip to DS37)

DS35. How many screening or assessment instruments were used as part of this program/service? _________ (#)

(Repeat questions DS35a. and DS35a1. for the number of measures indicated in question DS35, where the “1” is replaced for each consecutive measure.)

DS35a. What is the name of measure 1? _____________________

DS35a1. What domains are screened and/or assessed by measure 1? Check all that apply.

Depression or parent/family mental health problems
Family violence/substance abuse
Parenting/family relationships
Physical health indicators
Family social support
Child development knowledge
Parenting knowledge
Family resources/family needs
Other - Please describe: _______________

DS36. Who conducted the screening and/or assessment of the families? Check all that apply.

Program staff, non-clinical
Program staff, clinical
Primary care providers/staff
Early childhood education and care providers
Mental health consultants
Other - Please describe: ___________________

DS37. Families Receiving LAUNCH-Supported Screening and/or Assessments in the Last 6 Months as Part of This Program/Service

Quarter 1

Quarter 2

DS37a. In each of the last two quarters, what is the number of family members, other than children ages 0 – 8, screened and/or assessed for mental health or related interventions at least once as part of this program/service? (GPRA)

DS37b. In each of the last two quarters, what is the number of family members, other than children ages 0 – 8, referred for mental health or related services? (GPRA)

DS38. This space is provided for you to describe any other information that has not been covered previously in this Section.

D. Demographics (for new families served in the last 6 months)

DS39. Total number of families or children who received services for the first time in the last 6 months: ___________

DS40. If demographic data reported do not include all newly-enrolled families or children (above #), indicate number of newly-enrolled families or children represented in demographics data: ___________

DS41. Is there a target child for this service?

Yes
No--program works with pregnant mothers. Skip to DS46
No--program works with all children in family. [NOTE: Select one child in family that is most appropriate age child in terms of program services or, if none, select youngest child to report on in items DS42-45]

DS42. Age of target child for reporting demographics

0-12 months # of families _____
13-24 months # of families _____
25-36 months # of families _____
37-48 months # of families _____
49-60 months # of families _____
5 years old # of families _____
6 years old # of families _____
7 years old # of families _____
8 years old # of families _____
Not known # of families _____

DS43. Gender of target child

Male # target children_____
Female # target children _____
Not known # target children _____

DS44. Target child Hispanic

Yes # target children _____
No # target children _____
Not known # target children _____

DS45. Race of target child

White (non-Hispanic) # target children _____
White (Hispanic) # target children _____
Black/African-American
(non-Hispanic) # target children _____
Black/African-American – Hispanic # target children _____
Asian # target children _____
American Indian or Alaska Native # target children _____
Native Hawaiian or other
Pacific Islander # target children _____
Other # target children _____
Other biracial # target children _____
Not known # target children _____

DS45a. Other - Please describe: ________
DS45b. Other biracial - Please describe: ________

DS46. Parents or primary caregiver(s) of target child in the household

DS46a. Single parent/caregiver family (Parent/primary caregiver not married or not living with a partner)

Mother (biological/adoptive/foster/step/non-biological) # of families _____

Father (biological/adoptive/foster/step/non-biological) # of families _____

Grandparent # of families _____

Other relative (please describe below) # of families _____

Other non-relative (please describe below) # of families _____

Other relative – Please describe: ________________

Other non-relative – Please describe: __________________

DS46b. Two parent/two primary caregivers family

Mother and father # of families _____

Other (describe two caregivers _________) # of families _____

Caregiver 1 – Please describe: ________________

Caregiver 2 – Please describe: __________________

DS46c. Other family structures

Mother and father in joint custody # of families _____

Other (please describe below) # of families _____

Other – Please describe: ________________

DS47. Highest education level of parents/primary caregiver(s)

DS47a. Single-parent household(s): Highest education level of parent or primary caregiver

No HS diploma/GED # of families _____

High school graduate or GED # of families _____

Some college credits/two-year (AA) degree # of families _____

4-year college degree or higher # of families _____

Not known # of families_____

DS47b. Two-parent household(s)/joint custody: Highest education level of Mother

No HS diploma/GED # of families _____

High school graduate or GED # of families _____

Some college credits/two-year (AA) degree # of families _____

4-year college degree or higher # of families _____

Not known # of families _____

DS47c. Two-parent household(s)/joint custody: Highest education level of Father

No HS diploma/GED # of families _____

High school graduate or GED # of families _____

Some college credits/two-year (AA) degree # of families _____

4-year college degree or higher # of families _____

Not known # of families _____

DS47d. Two-caregiver household(s): Highest level of education of caregiver1

No HS diploma/GED # of families _____

High school graduate or GED # of families _____

Some college credits/two-year (AA) degree # of families _____

4-year college degree or higher # of families ____

Not known # of families _____

DS47e. Two-caregiver household(s): Highest level of education of caregiver2

No HS diploma/GED # of families _____

High school graduate or GED # of families _____

Some college credits/two-year (AA) degree # of families _____

4-year college degree or higher # of families _____

Not known # of families _____

DS48. Average number of children in household

Children < 18 years # of children ___

Children < 8 years (“LAUNCH” children) # of children ___

DS49. Primary language in household

English # of families _____
Spanish # of families _____
Arabic # of families _____
Caribbean language (French-Creole/Haitian) # of families _____
European or Slavic language # of families _____
Pacific Island language # of families _____
Far Eastern Asian languages (Japanese, Vietnamese) # of families _____
Native North American or Alaska Native language # of families _____
African language # of families _____
Other (please describe below) # of families _____
Bilingual household: Spanish-English spoken equally # of families _____
Bilingual household: Other (specify two languages) (please describe below) # of families _____
Not known # of families _____

Other – Please describe: ________________

Other – Specify two languages: __________________

DS50. How many households have a member who is currently on active duty in the Armed Forces or in the reserve component (e.g. National Guard, Reserves)?

# households _____

# not known _____

DS51. In how many households has one or more of the children 0 - 8 years been homeless^¹ in the past 12 months?

# households ______

# not known _____

DS52. Please provide your best estimate of the number of families that have each of the following characteristics:

	# of families	# not known
DS52a. Mother was teen aged (less than 20 years of age) at time of birth of any child 0 - 8
DS52b. Single-parent family (single parent or caregiver of child in home is not married or living with a partner)
DS52c. Mother (or other primary caregiver if mother is not in household) does not have a high school diploma or GED
DS52d. Mother (or other primary caregiver if mother is not in household) is not employed and not in school
DS52e. Household participates in at least one assistance program (cash assistance, Food Stamps, WIC, unemployment, Medicaid)
DS52f. Considering the five categories above, how many families have three or more of these characteristics?

DS53. Please provide your best estimate of the number of families that have each of the following characteristics:

	# of families	# not known
DS53a. Someone in family/household has mental illness
DS53b. Someone in family/household has substance abuse problem
DS53c. Any child 0 - 8 years in family/household has ever been a victim of violence or trauma (physical, psychological or sexual abuse, neglect, community violence, natural disaster or traumatic grief)
DS53d. Considering the three categories above, how many families/households have more than one of these characteristics

DS54. This space is provided for you to describe any other information that has not been covered previously in this Section.

(Skip to Section IV)

Part III. Programs/Services Expanded/Enhanced by LAUNCH

Types of Enhancements

DS55. In the last 6 months, were LAUNCH funds used to expand the existing program/service by increasing the numbers of children/families who are being served?

Yes
No (skip to DS56)

DS55a. Were more families being served through funding for additional staff for the program/service?

Yes
No (skip to DS55b)

DS50a1. How many additional staff were funded? _________

DS55b. Do the additional families who were served represent a previously unserved or underserved population in the community?

Yes
No (skip to DS56)

DS55b1. Please describe this unserved/underserved population.

DS56. In the last 6 months, were LAUNCH funds used to expand the existing program/service by adding a new program component?

Yes
No (skip to DS57)

DS56a. Please describe the new program component.

DS57. In the last 6 months, were LAUNCH funds used to make the existing program culturally competent?

Yes
No (skip to DS58)

DS57a. Have LAUNCH funds been used to develop more culturally appropriate materials?

DS57b. Have LAUNCH funds been used to hire more diverse staff?

DS57c. Have LAUNCH funds been used in other ways to make this program/service more culturally competent?

Yes – Please describe:
No

DS58. In the last 6 months, were LAUNCH funds used to expand the existing program/service by providing training to staff?

Yes
No (skip to DS59)

DS58a. Was LAUNCH funding used to train staff on implementing the specific service/program?

DS58b. Was LAUNCH funding used to train staff on a new curriculum?

Yes
No (skip to DS58c)

DS58b1. What is the name of the curriculum? _________________________

DS58c. Was LAUNCH funding used to train staff on children’s mental/behavioral health and development?

DS58d. Was LAUNCH funding used to train staff on a new screening/assessment measure?

Yes – Please provide the name of the measure: ______________________
No

DS58e. Was LAUNCH funding used to train staff on other topics relevant to children’s health and development?

Yes – Please provide the topic of training: ______________________
No

DS59. In the last 6 months, were LAUNCH funds used to expand the existing program/service by funding program administration/management?

DS60. In the last 6 months, were LAUNCH funds used to expand the existing program/service in any other way?

Yes – Please describe:_________________________
No

DS61. This space is provided for you to describe any other information that has not been covered previously in this Section. ______________________

A. Service Counts

DS62. Program size: Annual enrollment of this service/program for the target community, defined as the estimated number of children/families that the program serves from October 1 – September 30. (Can be estimated)

DS62a. Number of families served in a year ____

DS62b. Number of children served in a year ____

(Ask DS63 only if DS55 (Types of Enhancements) is Yes. Otherwise, skip to DS64.)

DS63. How many additional families is the program able to serve in a year through LAUNCH funding? _____ (#)

DS63a. In the last 6 months, how many additional families received services as a result of LAUNCH funding? _____

DS63b. In the last 6 months, how many additional children received services as a result of LAUNCH funding? _____

DS63c. Of the additional families funded by LAUNCH who received services in the last 6 months, how many received services for the first time? _____

DS63d. Of the additional children funded by LAUNCH who received services in the last 6 months, how many received services for the first time? ____

DS64. Children/families served in the last 6 months

DS64a.	Number of families that participated in/received services in the last 6 months	___
DS64b.	Number of children that participated in/received services in the last 6 months	___
DS64c.	Number of families that received services for the first time in the last 6 months	___
DS64d.	Number of children that received services for the first time in the last 6 months	___
DS64e.	Number of providers providing services to children/families in the last 6 months	___
DS64f.	Number of settings where service was provided in the last 6 months	___

DS65. In the last 6 months, what is the number of families (estimated) who left before the planned end of this program/service or who only received parts of this program/service (i.e., who entered the program/service after it was initiated)? [NOTE: If this program/service doesn’t have a set number of contacts or an established time period, please leave the space provided blank.] ________ ( If “0” or blank, skip to DS66)

DS65a. Of the families who left before the end of the program/service or who only received parts of the program/service, what is the number of families who completed:

Less than 25% of planned program/service ___ (#)

25%-50% of planned program/service ___ (#)

51%-75% of planned program/service ___ (#)

76%-99% of planned program/service ___ (#)

DS66. In the last 6 months, in what ways were services provided to children and families in this program? (This refers to LAUNCH-funded families, if available, or for all families, if not available.)

DS66a. Regularly-scheduled home visits as part of a home visiting program?

Yes
No (skip to DS66b)

DS66a1. Please estimate the number of this type of home visits in last 6 months. ____

DS66b. Home visits as part of another program (for example, home visits to families as part of an early childhood education program or a family strengthening program)?

Yes
No (skip to DS66c)

DS66b1. Please estimate the number of this type of home visits in last 6 months. ____

DS66c. Parent training/parent education or parent support groups?

Yes
No (skip to DS66d)

DS66c1. Please estimate the number of parent groups in last 6 months. ______

DS66d. Parent/child sessions or parent/child groups for mental health treatment?

Yes
No (skip to DS66e)

DS66d1. Please estimate the number of parent/child groups and sessions in last 6 months. ____

DS66e. Parent/child sessions or parent/child groups other than for mental health treatment? [NOTE: This question asks about services attended by parents and children together, such as book groups or mental health sessions. This question does not ask about home visits. Data on home visits should be entered under DS66a or DS66b.]

Yes
No (skip to DS66f)

DS66e1. Please estimate the number of parent/child groups and sessions in last 6 months. ____

DS66f. Computerized lessons for parents (e.g., on parenting, child development)?

Yes
No (skip toDS66g)

DS66f1. Please estimate the number of computerized lessons completed in last 6 months. ___

DS66g. Any other types of direct contacts with parents/children?

Yes – Please describe:___________________
No (skip to DS67)

DS66g1. Please estimate the number of these contacts in last 6 months. ___

DS67. This space is provided for you to describe any other information that has not been covered previously in this Section.

B. Provider Training

DS68. In the last six months, how many staff were involved in delivering this program/service to families and children?

_______ (#)

DS69. Does the program model include requirements for staff to be trained by certified trainers or at certified training centers?

Yes
No (skip to DS70)

DS69a. To date, how many of the staff have been certified to deliver the program? _______ (#)

DS69b. How many of these staff were newly certified (certified for the first time) in the last 6 months? _______ (#)

DS69c. Does the program model include requirements for periodic follow-up training for staff?

Yes
No (skip to DS70)

DS69c1. How is the follow-up training delivered? Check all that apply.

Attending training by a certified trainer
Through written materials/materials on the internet
Through on-line training
Other - Please describe: _______________

DS69c2. How many of the already-certified staff received the required follow-up training in the last 6 months? _______ (#)

DS70. Other than certified training, does the program provide other forms of training for staff on how to deliver the program?

Yes
No (skip to DS71)

DS70a. What types of training are provided? Check all that apply.

Training by the developer
Being trained by other staff who are certified/trained by the developer
Written materials/materials on the internet
Other - Please describe: _______________

DS70b. To date, how many of the staff have received these other forms of training? _______ (#)

DS70c. How many of the staff were newly trained (for the first time) to deliver the program model in the last 6 months? _______ (#)

DS70d. Does the program model provide any form of follow-up training for staff?

Yes
No (skip to DS71)

DS70d1. How many of the already-trained staff received follow-up training in the last 6 months? _______ (#)

DS71. Does the program/service provide monitoring/supervision of the program staff who are delivering the service to families and children?

Yes
No (skip to DS72)

DS71a. Who provides the monitoring or supervision?

Program director/coordinator
Developer staff
Other--Please describe: ________________

DS71b. How often is monitoring/supervision provided to staff?

On a regular basis (Please describe schedule): ___________________
On an as-needed basis

DS71c. How many staff received monitoring or supervision in the last 6 months? _______ (#)

DS72. In the last 6 months, did LAUNCH support any other training for providers/staff?

Yes
No (skip to DS73)

DS72a. Was the training about how to implement the specific program/service?

DS72b. Was the training about other topics?

Yes
No (skip to DS73)

DS72b1. What topics were covered in the training? Check all that apply.

Developmental milestones in children's overall cognitive development
Developmental milestones in children's socio-emotional development/behavioral health
Physical health of young children
Identifying/screening/assessing children's cognitive development
Identifying/screening/assessing children's mental health/behavioral health/social-emotional development
Identifying/screening/assessing children’s physical health
Appropriate treatment options for children with behavioral/mental health concerns
Appropriate referrals for children with behavioral/mental health concerns
Resources in the community for children with mental/behavioral health concerns
Strategies for family engagement
Working with families to understand/support children's healthy development
LAUNCH orientation--LAUNCH objectives, service strategies
Other - Please describe:______________________

DS73. Providers Receiving LAUNCH-Supported Training in the Last 6 Months as Part of This Program/Service	Quarter 1	Quarter 2
DS73a. In each of the last two quarters, what is the number of providers/staff who received any LAUNCH-supported training in mental health-related practices/activities that are consistent with the goals of Project LAUNCH? (GPRA) [Please include training on implementing the model and other training.]
DS73b. Number of settings represented by staff who were trained in the last 6 months
DS73c. Number of children, ages 0 – 8, served by staff who were trained in the last 6 months

DS74. This space is provided for you to describe any other information that has not been covered previously in this Section.

C. Screening and Assessment for Children and Families

DS75. In the last 6 months, did LAUNCH support developmental screening and/or assessment of children as part of this program/service?

Yes
No (skip to DS78)

DS76. How many different screening/assessment measures were used as part of this program/service? ______________ (#)

(Repeat questions DS76a. and DS76a1. for the number of measures indicated in question DS76, where the “1” is replaced for each consecutive measure.)

DS76a. What is the name of measure 1? _____________________

DS76a1. What domains are screened and/or assessed by measure 1? Check all that apply.

Social-emotional development, social-personal behavior
Behavior/impulse control/self-regulation
Cognitive-language development
Problem-solving
Communication
School readiness
Literacy/reading
Gross/fine motor skills
Other - Please describe: ________________

DS77. Who conducted the screening and/or assessment of the children? Check all that apply.

Program staff, non-clinical
Program staff, clinical
Primary care providers/staff
Early childhood education and care providers
Mental health consultants
Other - Please describe: ____________________

DS78. In the last 6 months, did LAUNCH support physical and health screening for children as part of this program/service?

Yes
No (skip to DS79)

DS78a. What aspects of physical health are screened? Check all that apply.

Vision
Hearing
Weight
Dental
Other - Please describe: ________________________

DS79. Children Receiving LAUNCH-Supported Screening and/or Assessments in the Last 6 Months as Part of This Program/Service (Include physical and health screening)

Quarter 1

Quarter 2

DS79a. In each of the last two quarters, what is the number of children, ages 0 – 8, screened and/or assessed for mental health or related interventions at least once as part of this program/service? (GPRA)

DS79b. In each of the last two quarters, what is the number of children, ages 0 – 8, referred for mental health or related services? (GPRA)

DS80. Are LAUNCH-supported screening and/or assessment for family members being conducted as part of this program/service?

Yes
No (skip to Section DS83)

DS81. How many screening or assessment instruments for family members were used as part of this program/service? _________#

(Repeat questions DS80a. and DS80a1. for the number of measures indicated in question DS80, where the “1” is replaced for each consecutive measure.)

DS81a. What is the name of measure 1? _____________________

DS81a1. What domains are screened and/or assessed by measure 1? Check all that apply.

Depression or parent/family mental health problems
Family violence/substance abuse
Parenting/family relationships
Physical health indicators
Family social support
Child development knowledge
Parenting knowledge
Family resources/family needs
Other - Please describe: _______________

DS82. Who conducted the screening and/or assessment of the families? Check all that apply.

Program staff, non-clinical
Program staff, clinical
Primary care providers/staff
Early childhood education and care providers
Mental health consultants
Other - Please describe: ____________________

DS83. Families Receiving LAUNCH-Supported Screening and/or Assessments in the Last 6 Months as Part of This Program/Service

Quarter 1

Quarter 2

DS83a. In each of the last two quarters, what is the number of family members, other than children ages 0 – 8, screened and/or assessed for mental health or related interventions at least once as part of this program/service? (GPRA)

DS83b. In each of the last two quarters, what is the number of family members, other than children ages 0 – 8, referred for mental health or related services? (GPRA)

DS84. This space is provided for you to describe any other information that has not been covered previously in this Section.

D. Demographics (for new families served in the last 6 months)

DS85. Total number of families or children who received services for the first time in the last 6 months: ___________

DS86. If demographic data reported do not include all newly-enrolled families or children (above #), indicate number of newly-enrolled families or children represented in demographics data: ___________

DS87. Is there a target child for this service?

Yes
No--program works with pregnant mothers. Skip to DS92
No--program works with all children in family. [NOTE: Select one child in family that is most appropriate age child in terms of program services or, if none, select youngest child to report on in items DS88-91]

DS88. Age of target child for reporting demographics

0-12 months # of families _____
13-24 months # of families _____
25-36 months # of families _____
37-48 months # of families _____
49-60 months # of families _____
5 years old # of families _____
6 years old # of families _____
7 years old # of families _____
8 years old # of families _____
Not known # of families _____ _____

DS89. Gender of target child

Male # target children_____
Female # target children _____
Not known # target children _____

DS90. Target child Hispanic

Yes # target children _____
No # target children _____
Not known # target children _____

DS91. Race of target child

White (non-Hispanic) # target children _____
White (Hispanic) # target children _____
Black/African-American (non-Hispanic) # target children _____
Black/African-American – Hispanic # target children _____
Asian # target children _____
American Indian or Alaska Native # target children _____
Native Hawaiian or other Pacific Islander # target children _____
Other # target children _____
Other biracial # target children _____
Not known # target children _____
DS91a. Other - Please describe: ________
DS91b. Other biracial - Please describe: ________

DS92. Parents or primary caregiver(s) of target child in the household

DS92a. Single parent/caregiver family (Parent/primary caregiver not married or not living with a partner)

Mother (biological/adoptive/foster/step/non-biological) # of families _____

Father (biological/adoptive/foster/step/non-biological) # of families _____

Grandparent # of families _____

Other relative (please describe below) # of families _____

Other non-relative (please describe below) # of families _____

Other relative – Please describe: ________________

Other non-relative – Please describe: __________________

DS92b. Two parent/two primary caregivers family

Mother and father # of families _____

Other (describe two caregivers _________) # of families _____

Caregiver 1 – Please describe: ________________

Caregiver 2 – Please describe: __________________

DS92c. Other family structures

Mother and father in joint custody # of families _____

Other (please describe below) # of families _____

Other – Please describe: ________________

DS93. Highest education level of parents/primary caregiver(s)

DS93a. Single-parent household(s): Highest education level of parent or primary caregiver

No HS diploma/GED # of families _____

High school graduate or GED # of families _____

Some college credits/two-year (AA) degree # of families _____

4-year college degree or higher # of families _____

Not known # of families_____

DS93b. Two-parent household(s)/joint custody: Highest education level of Mother

No HS diploma/GED # of families _____

High school graduate or GED # of families _____

Some college credits/two-year (AA) degree # of families _____

4-year college degree or higher # of families _____

Not known # of families _____

DS93c. Two-parent household(s)/joint custody: Highest education level of Father

No HS diploma/GED # of families _____

High school graduate or GED # of families _____

Some college credits/two-year (AA) degree # of families _____

4-year college degree or higher # of families _____

Not known # of families _____

DS93d. Two-caregiver household(s): Highest level of education of caregiver1

No HS diploma/GED # of families _____

High school graduate or GED # of families _____

Some college credits/two-year (AA) degree # of families _____

4-year college degree or higher # of families ____

Not known # of families _____

DS93e. Two-caregiver household(s): Highest level of education of caregiver2

No HS diploma/GED # of families _____

High school graduate or GED # of families _____

Some college credits/two-year (AA) degree # of families _____

4-year college degree or higher # of families _____

Not known # of families _____

DS94. Average number of children in household:

Children < 18 years ___________ (#)

Children < 8 years (“LAUNCH” children) ___________ (#)

DS95. Primary language in household

English # of families _____
Spanish # of families _____
Arabic # of families _____
Caribbean language (French-Creole/Haitian) # of families _____
European or Slavic language # of families _____
Pacific Island language # of families _____
Far Eastern Asian languages (Japanese, Vietnamese) # of families _____
Native North American or Alaska Native language # of families _____
African language # of families _____
Other (please describe below) # of families _____
Bilingual household: Spanish-English spoken equally # of families _____
Bilingual household: Other (specify two languages) (please describe below) # of families _____
Not known # of families _____
Other – Please describe: ________________
Other – Specify two languages: __________________

DS96. How many households have a member who is currently on active duty in the Armed Forces or in the reserve component (e.g. National Guard, Reserves)?

# households _____

# not known _____

DS97. In how many households has one or more of the children 0 - 8 years been homeless^² in the past 12 months?

# households ______

# not known _____

DS98. Please provide your best estimate of the number of families that have each of the following characteristics:

	# of families	# not known
Mother was teen aged (less than 20 years of age) at time of birth of any child 0 - 8
Single-parent family (single parent or caregiver of child in home is not married or living with a partner)
Mother (or other primary caregiver if mother is not in household) does not have a high school diploma or GED
Mother (or other primary caregiver if mother is not in household) is not employed and not in school
Household participates in at least one assistance program (cash assistance, Food Stamps, WIC, unemployment, Medicaid)
Considering the five categories above, how many families have three or more of these characteristics?

DS99. Please provide your best estimate of the number of families that have each of the following characteristics:

	# of families	# not known
Someone in family/household has mental illness
Someone in family/household has substance abuse problem
Any child 0 - 8 years in family/household has ever been a victim of violence or trauma (physical, psychological or sexual abuse, neglect, community violence, natural disaster or traumatic grief)
Considering the three categories above, how many families/households have more than one of these characteristics

DS100. This space is provided for you to describe any other information that has not been covered previously in this Section. _____________________

(Go to Section IV)

Part IV. Annual Module

A. Fidelity/Level of Implementation

DS101. For this program/service, do you have a systematic process for monitoring the fidelity of implementation?

Yes
No (skip to DS106)

DS101a. To assess fidelity, which of the following types of measures do you use? Check all that apply.

Measures provided by the developer or model
Measures developed locally
Other- Please describe: ____________

DS102. What parts of the program/service are measured as part of your assessment of fidelity of implementation? Check all that apply.

Proportion of staff who have the qualifications/credentials recommended by the developer/model
Proportion of staff who have received model/developer-recommended training
Whether the curriculum/program content is being delivered according to the model
Whether the program is being delivered to families/children at the desired frequency and intensity
Whether families/children are engaged by the program/service
Other --Please describe: ___________________________________

DS103. What methods are used in assessing fidelity of implementation? Check all that apply.

Direct observation of program staff implementing the program with parents/children
Logs/records kept by program staff
Interviews/discussions with program staff
Other --Please describe: ________________

DS104. How often is fidelity of implementation assessed? (For example, once per month, quarterly, etc.) _________

DS105. Was the fidelity of implementation of this program model assessed in the last 12 months?

DS106. Please rate the overall fidelity of implementation of this program model, based on systematic assessment of fidelity or provide your best estimate.

Very early in the implementation process: less than 25% implemented
About 25% - 49% of program elements implemented with fidelity
About 50% - 74% of program elements implemented with fidelity
About 75% - 99% of program elements implemented with fidelity
At or close to 100% of program elements implemented with fidelity

B. Data Systems

DS107. Does this program/service have a data system in place to track client information?

Yes
No (skip to Section C)

DS107a. What types of data are included on this data system? Check all that apply.

Family/child demographic characteristics
Family/child baseline assessments
Family/child service plan
Family/child service receipt
Family/child outcomes
Other types of data– Please describe:___________________________

DS107b. Is the data system electronic, paper or a combination? Check one.

Electronic data system
Paper data system
Combination of electronic and paper

DS108. Does the program/service have in place any data sharing agreements with other services/programs/providers about client services and/or outcomes?

Yes
No (skip to Section C)

DS108a. What types of data sharing occur?

Providers enter data on clients into a common system
Providers can merge data across similar data bases
Providers share paper records on client service delivery and/or outcomes
Other – Please describe:___________________________

DS108b. How many other providers share data with this program/service? _________

DS108c. Who are the other services/programs/providers that are part of the data sharing? __________________________________________________

C. Provider Changes

In the last 12 months, please report the changes for providers/staff who have been involved in this LAUNCH-related program/service.

DS109. As a result of their involvement in this LAUNCH-related program/service, amount of change providers/staff report in their knowledge of children’s socio-emotional and behavioral health and development:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

DS110. As a result of their involvement in this LAUNCH-related program/service, amount of change providers/staff report in their knowledge of the available options for follow-up services for children with mental or behavioral health issues:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

DS111. As a result of their involvement in this LAUNCH-related program/service, amount of change providers/staff report in their use of mental health consultation for children with mental or behavioral health issues:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

DS112. As a result of their involvement in this LAUNCH-related program/service, amount of change providers/staff report in their work settings in the use of screening and/or assessment of children:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

DS113. As a result of their involvement in this LAUNCH-related program/service, what are some of the changes that providers/staff report in their work practices?
______________________________

DS114. As a result of this LAUNCH-related program/service, what are some of the changes that providers/staff report in their work settings?
________________________________

DS115. What is the number of providers/staff represented in these responses? ____________ #

DS116. What is the percentage (estimated) of providers/staff represented in these responses of the number of providers/staff who have been involved in this service in the last 12 months? ________%

Part V. Survey Status

 By checking this box you are indicating that data entry is complete for this survey.

Shape5 Shape4

Project LAUNCH

Cross-Site Evaluation

Survey on Services to

Children and Families:

Mental Health-Related Services in Early Education and Care Settings (0 - 8 Years)

FINAL

Shape6

NOTE: Questions highlighted in yellow will be pre-populated with the response from the previous reporting period.

Abt Associates Inc.

Contents

Part I. Mental Health-Related Services in Early Childhood Education and Care: Settings Serving Preschool-Aged Children 2

A. Mental Health-Related Models/Approaches and Settings 2

B. Provider Training 6

C. Screening/Assessment of Children and Families 7

D. Ongoing Consultation 9

Part II. Mental Health-Related Services in Early Childhood Education and Care: K-3 Settings 10

A. Mental Health-Related Models/Approaches and Settings 10

B. Provider Training 13

C. Screening/Assessment of Children and Families 14

D. Ongoing Consultation 16

Part III. Annual Module 17

A. Fidelity/Level of Implementation 17

B. Data Systems 18

C. Provider Changes 19

(Window shade for “Mental Health Related Service in Early Childhood Education and Care Settings” opens up to two windows: one labeled “Early childhood education (preschool) settings” and the other labeled “K-3 settings”. Within each of these windows, there should be an Add Model feature. For each model that is listed within preschool settings, Part I and III should appear and all corresponding questions. For each model that is listed in K-3 settings, Parts II and III should appear and all corresponding questions.)

Part I. Mental Health-Related Services in Early Childhood Education and Care: Settings Serving Preschool-Aged Children

A. Mental Health-Related Models/Approaches and Settings

EC1. Please provide a brief description of mental health consultation model/approach. _______________________________

EC2. In the last 6 months, what types of settings have been involved in the mental health consultation model/approach? Check all that apply.

Child care centers
Early Head Start programs
Head Start programs
School district preschool programs
Other preschool programs
Family child care homes
Other – Please describe:___________________________

EC3. As part of this mental health consultation model, in the last 6 months, did LAUNCH provide an evidence-based socio-emotional curriculum?

Yes
No (skip to EC4)

EC3a. Name of curriculum _______________________________________________

EC3b. In the last 6 months, did LAUNCH support training for the providers on how to implement the curriculum?

EC3c. In the last 6 months, did LAUNCH support any parent education or training programs associated with the curriculum?

Yes
No (skip to EC4)

EC3c1. Which parents had the opportunity to participate in the parent training program?

All parents of children in the early childhood programs
Parents of children with mental/behavioral health concerns

EC4. As part of this mental health consultation model, in the last 6 months, did LAUNCH support developmental screening and/or assessments of children conducted by the mental health consultant?

EC4a. In the past 6 months, as part of this model, did LAUNCH support training for the mental health staff on using these screening and/or assessment measures?

EC5. As part of this mental health consultation model, in the last 6 months, did LAUNCH support developmental screening and/or assessments of children conducted by the providers?

EC5a. In the past 6 months, as part of this model, did LAUNCH support training for the providers or other staff on using these screening and/or assessment measures?

EC6. As part of this mental health consultation model, in the last 6 months, did LAUNCH support training for providers on topics other than how to implement a curriculum or use a screening and/or assessment measure?

Yes
No (skip to EC7)

EC6a. What topics were covered in the training? Check all that apply.

Developmental milestones in children's overall cognitive development
Developmental milestones in children's socio-emotional development/behavioral health
Physical health of young children
Identifying/screening/assessing children's cognitive development
Identifying/screening/assessing children's mental health/behavioral health/social-emotional development
Identifying/screening/assessing children’s physical health
Appropriate treatment options for children with behavioral/mental health concerns
Appropriate referrals for children with behavioral/mental health concerns
Resources in the community for children with mental/behavioral health concerns
Strategies for family engagement
Working with families to understand/support children's healthy development
LAUNCH orientation--LAUNCH objectives, service strategies
Other - Please describe:______________________

EC7. In the last 6 months, as part of this mental health consultation model, did LAUNCH support consultation between the mental health staff and the providers about individual children with mental/behavioral health concerns?

Yes
No (skip to EC8)

EC7a. What types of consultation services did LAUNCH support? Check all that apply.

Observation of child(ren) in the classroom
Assessment/evaluation of child(ren)
Consultation on appropriate referrals for intervention/further evaluation for child(ren)
Consultation on appropriate classroom interventions for child(ren)
Consultation with parents of child(ren)
Parent groups for parents of children with behavioral concerns—[NOTE: If checked here, please describe this service in the Direct Services portion of the web portal.]
Referrals for additional services for families
Other – Please describe: ___________________

EC8. As part of this model, in the last 6 months, did LAUNCH support consultation on the setting?

Yes
No (skip to EC9)

EC8a. What aspects of the setting were addressed in the consultation? Check all that apply.

Increased setting-wide use of common battery of screening/assessment for mental/behavioral health
Increased setting-wide understanding of developmental milestones in socio-emotional domain
Increased setting-wide understanding of referral options for children with mental/behavioral health concerns
Coordination across providers of assessments/referrals for children with mental/behavioral health concerns
Other – Please describe: ___________________

EC9. As part of this model, in the last 6 months, did LAUNCH support any other mental-health related consultation activities?

Yes – Please describe: ________________________________________________
No

EC10. What is the number of settings serving preschool-aged children in which mental health consultation model/approach was implemented in the last 6 months? __________

EC11. What is the number of providers who work in these settings? ______

EC12. What is the number of children enrolled in these settings? ____________

EC13. What are the preferred/required qualifications of the mental health consultants who are working with the settings? ________________________________

EC14. What are the professional affiliations of these mental health consultants? ________________

EC15. Is there LAUNCH-supported supervision for the mental health consultants who are providing services in these settings?

EC16. Is there LAUNCH-supported training for the mental health consultants working with providers in these settings on the consultation model?

EC17. Training for Mental Health Consultants/Mental Health Staff

Quarter 1

Quarter 2

EC17a. In each of the last two quarters, what is the number of mental health consultants/ staff working with early childhood education and care settings who received any LAUNCH-supported training in mental health-related practices/activities that are consistent with the goals of Project LAUNCH? (GPRA) [Please include training on mental health related topics including assessments.]

EC18. Was this consultation model/approach initiated under LAUNCH; that is, was this mental health consultation model/approach started “from scratch” by LAUNCH in the target community?

EC19. In the last 6 months, what proportion of the funding for this mental health consultation model/approach came from LAUNCH? (estimated) ______ %

EC20. In the last 6 months, what other sources of funding supported this mental health consultation model/approach? Check all that apply.

Private (e.g., foundation, donation)
Federal
County/state funding (public)
Local funding (public)
In-kind contribution
Other - Please describe: ____________________________________

EC21. This space is provided for you to describe any other information that has not been covered previously in this Section.

B. Provider Training

EC22. In the last 6 months, how many providers were involved with the LAUNCH-supported mental health consultation model in settings serving preschool-aged children? _______ (#)

EC23. Who are the staff in the settings involved with these activities? Check all that apply

Classroom teachers
Program directors
Program specialists (curriculum/educational specialists, family workers, social workers, etc.)
Other program administrators
Other – Please describe: ___________________________

EC24. Is there training for the staff on the LAUNCH-supported mental health consultation model?

EC25. Providers Receiving LAUNCH-Supported Training in the Last 6 Months as Part of This Mental Health Consultation Model/Approach	Quarter 1	Quarter 2
EC25a. In each of the last two quarters, what is the number of providers/staff who received any LAUNCH-supported training in mental health-related practices/activities that are consistent with the goals of Project LAUNCH? (GPRA) [Please include training on the mental health consultation model and other mental health related topics including assessments.]
EC25b. Number of settings represented by staff who were trained in the last 6 months
EC25c. Number of children, ages 0 – 8, cared for by providers who were trained in the last 6 months

EC26. This space is provided for you to describe any other information that has not been covered previously in this Section.

C. Screening/Assessment of Children and Families

EC27. Were any developmental screenings and/or assessments of children conducted as part of the mental health consultation model/approach?

Yes
No (skip to EC30)

EC28. How many different developmental screening and/or assessment measures were used as part of the mental health consultation model/approach? ___________ #

(Repeat questions EC28a. and EC28a1. for the number of measures indicated in questionEC28, where the “1” is replaced for each consecutive measure.)

EC28a. What is the name of measure1? _____________________________

EC28a1. What domains are screened and/or assessed with measure1? Check all that apply.

Social-emotional development, social-personal behavior
Behavior/impulse control/self-regulation
Cognitive-language development
Problem-solving
Communication
School readiness
Literacy/reading
Gross/fine motor skills
Other - Please describe: ________________

EC29. Who conducted the screenings and/or assessments of the children? Check all that apply.

Program staff, non-clinical
Program staff, clinical
Primary care providers/staff
Early childhood education and care providers
Mental health staff
Other - Please describe: _________________________________________

EC30. Are LAUNCH-supported physical and health screening for children being conducted as part of the mental health consultation model/approach?

Yes
No (skip to EC31)

EC30a. What aspects of physical health are screened? Check all that apply.

Vision
Hearing
Weight
Dental
Other - Please describe: ________________________

EC31. Children Receiving LAUNCH-Supported Screening and/or Assessments in the Last 6 Months as Part of This Mental Health Consultation Model/Approach (Include physical and health screening)

Quarter 1

Quarter 2

EC31a. In each of the last two quarters, what is the number of children, ages 0 – 8, screened and/or assessed for mental health or related interventions at least once as part of this model/approach? (GPRA)

EC31b. In each of the last two quarters, what is the number of children, ages 0 – 8, referred for mental health or related services? (GPRA)

EC32. In the last 6 months, did LAUNCH support screening and/or assessment for family members as part of the mental health consultation model/approach?

Yes
No (skip to EC35)

EC33. How many screening or assessment instruments for family members were used as part of the mental health consultation model/approach? _________ (#)

(Repeat questions EC33a. and EC33a1. for the number of measures indicated in question EC33, where the “1” is replaced for each consecutive measure.)

EC33a. What is the name of measure1? _____________________

EC33a1. What domains are screened and/or assessed by measure1? Check all that apply.

Depression or parent/family mental health problems
Family violence/substance abuse
Parenting/family relationships
Physical health indicators
Family social support
Child development knowledge
Parenting knowledge
Family resources/family needs
Other - Please describe: _______________

EC34. Who conducted the screening and/or assessment of the families? Check all that apply.

Program staff, non-clinical
Program staff, clinical
Primary care providers/staff
Early childhood education and care providers
Mental health consultants
Other - Please describe: ____________________

EC35. Families Receiving LAUNCH-Supported Screening and/or Assessments in the Last 6 Months as Part of the Mental Health Consultation Model/Approach

Quarter 1

Quarter 2

EC35a. In each of the last two quarters, what is the number of family members, other than children ages 0 – 8, screened and/or assessed for mental health or related interventions at least once as part of this model/approach? (GPRA)

EC35b. In each of the last two quarters, what is the number of family members, other than children ages 0 – 8, referred for mental health or related services? (GPRA)

EC36. This space is provided for you to describe any other information that has not been covered previously in this Section.

D. Ongoing Consultation

EC37. Are the mental health consultants who provide services/work with the settings serving preschool-aged children:

Co-located and a full collaborator/member of the staff (skip to EC38)
Co-located (skip to EC38)
Not co-located

EC37a. For the settings where the mental health consultants are not co-located, in what ways are the consultants involved: Check all that apply.

Consultant scheduled to come into the setting on a regular basis. (Indicate number days/week ___)
Consultant comes to setting upon request
Consultant provides consultation by telephone or email

EC38. This space is provided for you to describe any other information that has not been covered previously in this Section.

(PROGRAMMING NOTE: ADMINISTER PART III AFTER THIS SECTION)

Part II. Mental Health-Related Services in Early Childhood Education and Care: K-3 Settings

A. Mental Health-Related Models/Approaches and Settings

EC39. Please provide a brief description of the mental health consultation model/approach. _________________________________

EC40. In the last 6 months, what grade levels in the K-3 settings have been involved in the mental health consultation model/approach? Check all that apply.

Prekindergarten
Kindergarten
Grade 1
Grade 2
Grade 3

EC41. As part of the mental health consultation model, in the last 6 months, did LAUNCH support developmental screening and/or assessments of children by the mental health consultant?

EC41a. As part of the mental health consultation model, in the last 6 months, did LAUNCH support training for mental health consultants on using screening and/or assessment measures?

EC42. As part of the mental health consultation model, in the last 6 months, did LAUNCH support developmental screening and/or assessments of children by the school staff?

EC42a. As part of the mental health consultation model, in the last 6 months, did LAUNCH support training for school staff on using screening and/or assessment measures?

EC43. As part of the mental health consultation model, in the last 6 months, did LAUNCH support training for school staff on topics other than screening and/or assessment measures?

Yes
No (skip to EC44)

EC43a. What topics were covered by the training? Check all that apply.

Developmental milestones in children's overall cognitive development
Developmental milestones in children's socio-emotional development/behavioral health
Physical health of young children
Identifying/screening/assessing children's cognitive development
Identifying/screening/assessing children's mental health/behavioral health/social-emotional development
Identifying/screening/assessing children’s physical health
Appropriate treatment options for children with behavioral/mental health concerns
Appropriate referrals for children with behavioral/mental health concerns
Resources in the community for children with mental/behavioral health concerns
Strategies for family engagement
Working with families to understand/support children's healthy development
LAUNCH orientation--LAUNCH objectives, service strategies
Other - Please describe:______________________

EC44. As part of the mental health consultation model, are LAUNCH funds being used to support consultation from a mental health professional on individual children with mental/behavioral health concerns?

Yes
No (skip to EC45)

EC44a. What types of consultation services did LAUNCH support about individual children with mental/behavioral health concerns? Check all that apply.

Observation of child(ren) in the classroom
Assessment/evaluation of child(ren)
Consultation on appropriate referrals for intervention/further evaluation for child(ren)
Consultation on appropriate classroom interventions for child(ren)
Consultation with parents of child(ren)
Parent groups for parents of children with behavioral concerns— [NOTE: If checked here, please describe this service in the Direct Services portion of the web portal.]
Referrals for additional evaluation/treatment services for child(ren)
Referrals for additional services for families
Other - Please describe: ___________________

EC45. As part of the mental health consultation model, does LAUNCH support any other types of mental-health related consultation activities in K-3 settings?

Yes – Please describe: ________________________________________________
No

EC46. What is the number of K-3 settings in which integrated mental health activities were conducted in the last 6 months? __________

EC47. What is the estimated number of children (5 - 8 years) who attend these settings? ____________

EC48. What are the preferred/required qualifications of the mental health consultants who are working with the K-3 settings? ______________________________________

EC49. What are the professional affiliations of these mental health consultants? ___________________

EC50. Is there LAUNCH-supported supervision for the mental health consultants who are working with K-3 settings?

EC51. Is there LAUNCH-supported training for the mental health consultants who are working with K-3 settings on the consultation model?

EC52. Training for Mental Health Consultants/Mental Health Staff

Quarter 1

Quarter 2

EC52a. In each of the last two quarters, what is the number of mental health consultants/ staff working with early childhood education and care settings who received any LAUNCH-supported training in mental health-related practices/activities that are consistent with the goals of Project LAUNCH? (GPRA) [Please include training on mental health related topics including assessments.]

EC53. Was this mental health consultation model/approach initiated under LAUNCH; that is, was model/approach started “from scratch” by LAUNCH in the target community?

EC54. In the last 6 months, what proportion of the funding for the mental health consultation model/approach came from LAUNCH? (estimated) ______ %

EC55. In the last 6 months, what other sources of funding supported the mental health consultation model/approach? Check all that apply.

Private (e.g., foundation, donation)
Federal
County/state funding (public)
Local funding (public)
In-kind contribution
Other - Please describe: ____________________________________

EC56. This space is provided for you to describe any other information that has not been covered previously in this Section.

B. Provider Training

EC57. How many school staff are involved with the LAUNCH-supported mental health related activities in the school? _______ (#)

EC58. Who are the school staff involved with these activities? Check all that apply

Counselors
Special Education Coordinators/Teachers
Classroom Teachers
Other administrators
Other – Please describe: ___________________________

EC59. Is there training for school staff on the LAUNCH-supported mental health related activities?

EC60. Providers Receiving LAUNCH-Supported Training in the Last 6 Months as Part of the Mental Health Consultation Model/Approach

Quarter 1

Quarter 2

EC60a. In each of the last two quarters, what is the number of providers/staff who received any LAUNCH-supported training in mental health-related practices/activities that are consistent with the goals of Project LAUNCH? (GPRA) [Please include training on the mental health consultation model and other mental health related topics including assessments.]

EC60b. Number of schools represented by staff who were trained in the last 6 months

EC61. This space is provided for you to describe any other information that has not been covered previously in this Section.

C. Screening/Assessment of Children and Families

EC62. Were any developmental screening and/or assessment of children conducted as part of the mental health consultation model/approach?

Yes
No (skip to EC65)

EC63. How many LAUNCH-supported screening and/or assessment measures were used as part of the mental health consultation model/approach? _______________ (#)

(Repeat questions EC63a. and EC63a1. for the number of measures indicated in question EC63, where the “1” is replaced for each consecutive measure.)

EC63a. What is the name of measure1?______________________________

EC63a1. What domains are screened and/or assessed by measure1? Check all that apply.

Social-emotional development, social-personal behavior
Behavior/impulse control/self-regulation
Cognitive-language development
Problem-solving
Communication
School readiness
Literacy/reading
Gross/fine motor skills
Other - Please describe: ________________

EC64 Who conducted the screenings and/or assessments of the children? Check all that apply.

Program staff, non-clinical
Program staff, clinical
Primary care providers/staff
Early childhood education and care providers
Mental health staff
Other - Please describe: _________________________________________

EC65. Are LAUNCH-supported physical and health screening for children being conducted as part of the mental health consultation model/approach?

Yes
No (skip to EC66)

EC65a. What aspects of physical health are screened? Check all that apply.

Vision
Hearing
Weight
Dental
Other - Please describe: ________________________

EC66. Children Receiving LAUNCH-Supported Screening and/or Assessments in the Last 6 Months as Part of This Mental Health Consultation Model/Approach (Include physical and health screening)	Quarter 1	Quarter 2
EC66a. In each of the last two quarters, what is the number of children, ages 0 – 8, screened and/or assessed for mental health or related interventions at least once as part of this model/approach? (GPRA)
EC66b. In each of the last two quarters, what is the number of children, ages 0 – 8, referred for mental health or related services? (GPRA)
EC66c. In the last 6 months, what is the estimated percentage of children, ages 0 – 8, referred who successfully received the recommended follow-up services? (%)

EC67. In the last 6 months, did LAUNCH support screening and/or assessment for family members as part of the mental health consultation model/approach?

Yes
No (skip to EC70)

EC68. How many screening or assessment instruments for family members were used as part of the mental health consultation model/approach? _________ (#)

(Repeat questions EC68a. and EC68a1. for the number of measures indicated in question EC68, where the “1” is replaced for each consecutive measure.)

EC68a. What is the name of measure1? ___________________________

EC68a1. What domains are screened and/or assessed by measure1? Check all that apply.

Depression or parent/family mental health problems
Family violence/substance abuse
Parenting/family relationships
Physical health indicators
Family social support
Child development knowledge
Parenting knowledge
Family resources/family needs
Other - Please describe: _______________

EC69. Who conducted the screening and/or assessment of the families? Check all that apply.

Program staff, non-clinical
Program staff, clinical
Primary care providers/staff
Early childhood education and care providers
Mental health consultants
Other - Please describe: ____________________

EC70. Families Receiving LAUNCH-Supported Screening and/or Assessment in the Last 6 Months as Part of the Mental Health Consultation Model/Approach

Quarter 1

Quarter 2

EC70a. In each of the last two quarters, what is the number of family members, other than children ages 0 – 8, screened and/or assessed for mental health or related interventions at least once as part of this model/approach? (GPRA)

EC70b. In each of the last two quarters, what is the number of family members, other than children ages 0 – 8, referred for mental health or related services? (GPRA)

EC71. This space is provided for you to describe any other information that has not been covered previously in this Section.

D. Ongoing Consultation

EC72. As part of the mental health consultation model, are the mental health consultants who are working in the K-3 settings?

Co-located and a full collaborator/member of the staff (skip to EC73)
Co-located (skip to EC73)
Not co-located

EC72a. For the school settings where the mental health consultants are not co-located, in what ways are the consultants involved:

Consultant scheduled to come into the setting on a regular basis. (Indicate number days/week ___)
Consultant comes to setting upon request
Consultant provides consultation by telephone or email

EC73. This space is provided for you to describe any other information that has not been covered previously in this Section.

Part III. Annual Module

A. Fidelity/Level of Implementation

EC74. For this mental health consultation model/approach, do you have a systematic process for monitoring the fidelity of implementation?

Yes
No (skip to EC79)

EC75. What parts of the model/approach are measured as part of your assessment of fidelity of implementation?

Proportion of mental health consultants who have the qualifications/credentials recommended by the developer/model
Proportion of mental health consultants who have received model/developer-recommended training
Whether the mental health consultation is being delivered according to the model
Whether the program is being delivered to settings at the desired frequency and intensity
Other --Please describe: ___________________________________

EC76. What methods are used in assessing fidelity of implementation?

Direct observation of program staff implementing the program with parents/children
Logs/records kept by program staff
Interviews/discussions with program staff
Other --Please describe: ________________

EC77. How often is fidelity of implementation assessed? (For example, once per month, quarterly, etc.) _________

EC78. Was the fidelity of implementation of this mental health consultation model/approach assessed in the last 12 months?

EC79. Please rate the overall fidelity of implementation of this mental health consultation model/approach, based on systematic assessment of fidelity or provide your best estimate.

Very early in the implementation process: less than 25% implemented
About 25% - 49% of program elements implemented with fidelity
About 50% - 74% of program elements implemented with fidelity
About 75% - 99% of program elements implemented with fidelity
At or close to 100% of program elements implemented with fidelity

B. Data Systems

EC80. Does this mental health consultation model/approach have a data system in place to track client information?

Yes
No (skip to Section C)

EC80a. What types of data are included on this data system? Check all that apply.

Number of contacts with providers
Number of families/children on whom mental health staff consulted
Family/child demographic characteristics
Family/child baseline assessments
Other types of data– Please describe:___________________________

EC80b. Is the data system electronic, paper or a combination? Check one.

Electronic data system
Paper data system
Combination of electronic and paper

EC81. Does the mental health consultation model/approach have in place any data sharing agreements with other services/programs/providers?

Yes
No (skip to Section C)

EC81a. What types of data sharing occur?

Consultants enter data on activities into a common system
Other - Please describe:

EC81b. How many other providers share data with this mental health model/approach? _________

EC81c. Who are the other services/programs/providers that are part of the data sharing? __________________________________________________

C. Provider Changes

In the last 12 months, please report the changes for providers/staff who have been involved in this LAUNCH-related mental health consultation model/approach.

EC82. As a result of their involvement in this LAUNCH-related mental health consultation model/approach, amount of change providers/staff report in their knowledge of children’s socio-emotional and behavioral health and development:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

EC83. As a result of their involvement in this LAUNCH-related mental health consultation model/approach, amount of change providers/staff report in their knowledge of the available options for follow-up services for children with mental or behavioral health issues:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

EC84. As a result of their involvement in this LAUNCH-related mental health consultation model/approach, amount of change providers/staff report in their use of mental health consultation for children with mental or behavioral health issues:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

EC85. As a result of their involvement in this LAUNCH-related model/approach, amount of change providers/staff report in their work settings in the use of screening and/or assessment of children:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

EC86. As a result of their involvement in this LAUNCH-related model/approach, what are some of the changes that providers/staff report in their work practices?

EC87. As a result of their involvement in this LAUNCH-related model/approach, what are some of the changes that providers/staff report in their work settings?

EC88. What is the number of providers/staff represented in these responses? ____________ #

EC89. What is the percentage (estimated) of providers/staff represented in these responses of the number of providers/staff who have been involved in this service in the last 12 months? ________%

Part IV. Survey Status

 By checking this box you are indicating that data entry is complete for this survey.

Shape8 Shape7

Cross-Site Evaluation of Project LAUNCH

Survey on Services:

LAUNCH-Supported Family Referrals

FINAL

Shape9

NOTE: Questions highlighted in yellow will be pre-populated with the response from the previous reporting period.

Abt Associates Inc.

Contents

Part I. Family Referrals 2

A. Service Counts 2

B. Developmental Screening/Assessments 4

C. Staff Training 5

D. Funding 8

E. Demographics (for new families served in the last 6 months) 8

Part II. Annual Module 14

A. Fidelity/Level of Implementation 14

B. Data Systems 15

C. Provider Changes 16

Part III. Survey Status 18

Part I. Family Referrals

A. Service Counts

FR1. In the last 6 months, what were the settings where the families were seen? Check all that apply.

LAUNCH office
Primary care setting
Social service agency
Community site (library, CBO, etc.)
School
Other – Please describe: __________________

FR2. What is the process by which families come to this setting?

Referral from primary care provider
Referral from other program/service (non-LAUNCH)
Referral from other program/service (LAUNCH)
Other – Please describe: __________________

FR3. What types of program staff meet with the families? Check all that apply.

Social worker
Mental health clinician
Family advocate
Public health nurse
Other - Please describe: __________________

FR4. Were any family members, other than children ages 0 – 8, screened and/or assessed as part of the referral activity?

Yes
No (skip to FR6)

FR5. How many screening or assessment instruments were used? _________ (#)

(Repeat questions FR5a and FR5a.1 for the number of measures indicated in question FR5, where the “1” is replaced for each consecutive measure.)

FR5a. What is the name of measure1?_____________________

FR5a1. What domains are screened and/or assessed by measure1? Check all that apply.

Depression or parent/family mental health problems
Family violence/substance abuse
Parenting/family relationships
Physical health indicators
Family social support
Child development knowledge
Parenting knowledge
Family resources/family needs
Other - Please describe: _______________

FR6. Families Receiving LAUNCH-Supported Screening and/or Assessments in the Last 6 Months as Part of the Referral Activity

Quarter 1

Quarter 2

FR6a. In each of the last two quarters, what is the number of family members, other than children ages 0 – 8, screened and/or assessed for mental health or related interventions at least once as part of this program/service? (GPRA)

FR6b. In each of the last two quarters, what is the number of family members, other than children ages 0 – 8, referred for mental health or related services? (GPRA)

FR7. How many family members were referred to programs/services that are receiving LAUNCH funding? ______________ (#)

FR8. This space is provided for you to describe any other information that has not been covered previously in this Section.

B. Developmental Screening/Assessments

FR9. In the last 6 months, did LAUNCH support developmental screenings and/or assessments of children as part of the family evaluation and referral process?

Yes
No (skip to FR12)

FR10. How many different screening/assessment measures were used as part of this activity? ______________ (#)

(Repeat questions FR10a. and FR10a1. for the number of measures indicated in question FR10, where the “1” is replaced for each consecutive measure.)

FR10a. What is the name of measure1? _______________

FR10a1. What domains are screened and/or assessed by measure1? Check all that apply.

Social-emotional development, social-personal behavior
Behavior/impulse control/self-regulation
Cognitive-language development
Problem-solving
Communication
School readiness
Literacy/reading
Gross/fine motor skills
Other - Please describe: ________________

FR11. Who conducted the screening and/or assessment of the children? Check all that apply.

Program staff, non-clinical
Program staff, clinical
Primary care providers/staff
Early childhood education and care providers
Mental health consultants
Other - Please describe: _________________

FR12. In the last 6 months, did LAUNCH support physical and health screening for children as part of this program/service?

Yes
No (skip to FR13)

FR12a. What aspects of physical health are screened? Check all that apply.

Vision
Hearing
Weight
Dental
Other - Please describe: _____________

FR13. Children Receiving LAUNCH-Supported Screening and/or Assessments in the Last 6 Months as Part of This Activity (Include physical and health screening)

Quarter 1

Quarter 2

FR13a. In each of the last two quarters, what is the number of children, ages 0 – 8, screened and/or assessed for mental health or related interventions at least once as part of this program/service? (GPRA)

FR13b. In each of the last two quarters, what is the number of children, ages 0 – 8, referred for mental health or related services? (GPRA)

FR14. This space is provided for you to describe any other information that has not been covered previously in this Section.

C. Staff Training

FR15. How many staff are delivering this program/service to families and children? _______ (#)

FR16. Does the program model include requirements for staff to be trained by certified trainers or at certified training centers?

Yes
No (skip to FR17)

FR16a. To date, how many of the staff have been certified to deliver the program? _______ (#)

FR16b. How many of these staff were newly certified (certified for the first time) in the last 6 months? _______ (#)

FR16c. Does the program model include requirements for periodic follow-up training for staff?

Yes
No (skip to FR17)

FR16c1. How is the follow-up training delivered? Check all that apply.

Attending training by a certified trainer
Through written materials/materials on the internet
Through on-line training
Other - Please describe: _______________

FR16c2. How many of the already-certified staff received the required follow-up training in the last 6 months? _______ (#)

FR17. Other than certified training, does the program provide other forms of training for staff on how to deliver the program?

Yes
No (skip to FR18)

FR17a. What types of training are provided? Check all that apply.

Training by the developer
Being trained by other staff who are certified/trained by the developer
Written materials/materials on the internet
Other - Please describe: _______________

FR17b. To date, how many of the staff have received these other forms of training?
_______ (#)

FR17c. How many of the staff were newly trained (for the first time) to deliver the program model in the last 6 months? _______ (#)

FR17d. Does the program model provide any form of follow-up training for staff?

Yes
No (skip to FR18)

FR17d1. How many of the already-trained staff received follow-up training in the last 6 months? _______ (#)

FR18. Does the program/service provide monitoring/supervision of the program staff who are delivering the service to families and children?

Yes
No (skip to FR19)

FR18a. Who provides the monitoring or supervision?

Program director/coordinator
Developer staff
Other--Please describe: ________________

FR18b. How often is monitoring/supervision provided to staff?

On a regular basis (Please describe schedule): ___________________
On an as-needed basis

FR18c. How many staff received monitoring or supervision in the last 6 months?

_______ (#)

FR19. In the last 6 months, did LAUNCH support any training for providers/staff?

Yes
No (skip to FR20)

FR19a. Was the training about how to implement the specific program/service?

FR19b. Was the training about other topics?

Yes
No (skip to FR20)

FR19b1. What topics were covered in the training? Check all that apply.

Developmental milestones in children's overall cognitive developmental
Developmental milestones in children's socio-emotional development/behavioral health
Physical health of young children
Identifying/screening/assessing children's cognitive development
Identifying/screening/assessing children's mental health/behavioral health/social-emotional development
Identifying/screening/assessing children’s physical health
Appropriate treatment options for children with behavioral/mental health concerns
Appropriate referrals for children with behavioral/mental health concerns
Resources in the community for children with mental/behavioral health concerns
Strategies for family engagement
Working with families to understand/support children's healthy development
LAUNCH orientation--LAUNCH objectives, service strategies
Other - Please describe:______________________

FR20. Providers Receiving LAUNCH-Supported Training in the Last 6 Months as Part of This Program/Service	Quarter 1	Quarter 2
FR20a. In each of the last two quarters, what is the number of providers/staff who received any LAUNCH-supported training in mental health-related practices/activities that are consistent with the goals of Project LAUNCH? (GPRA) [Please include training on the mental health consultation model and other mental health-related topics including assessments.]
FR20c. Number of settings represented by staff who were trained in the last 6 months
FR20d. Number of children, ages 0 – 8, served by staff who were trained in the last 6 months

FR21. This space is provided for you to describe any other information that has not been covered previously in this Section.

D. Funding

FR22. Was this evaluation and referral activity initiated under LAUNCH; that is, was this program/service started “from scratch” by LAUNCH in the target community?

FR23. In the last 6 months, what proportion of the funding for this program came from LAUNCH? (estimated percentage) ______ %

FR24. In the last 6 months, what other sources of funding supported this program/service? Check all that apply.

Private (e.g., foundation, donation)
Federal
County/state funding (public)
Local funding (public)
In-kind contribution
Other - Please describe: ____________________________________

FR25. This space is provided for you to describe any other information that has not been covered previously in this Section.

E. Demographics (for new families served in the last 6 months)

FR26. Total number of families or children who received services for the first time in the last 6 months: ___________

FR27. If demographic data reported do not include all newly-enrolled families or children (above #), indicate number of newly-enrolled families or children represented in demographics data: ___________

FR28. Is there a target child for this service?

Yes
No--program works with pregnant mothers. Skip to FR33
No--program works with all children in family. [NOTE: Select one child in family that is most appropriate age child in terms of program services or, if none, select youngest child to report on in items FR29-32]

FR29. Age of target child for reporting demographics

0-12 months # of families _____
13-24 months # of families _____
25-36 months # of families _____
37-48 months # of families _____
49-60 months # of families _____
5 years old # of families _____
6 years old # of families _____
7 years old # of families _____
8 years old # of families _____
Not known # of families _____

FR30. Gender of target child

Male # target children_____
Female # target children _____
Not known # target children _____

FR31. Target child Hispanic

Yes # target children _____
No # target children _____
Not Known # target children _____

FR32. Race of target child

White (non-Hispanic) # target children _____
White (Hispanic) # target children _____
Black/African-American (non-Hispanic) # target children _____
Black/African-American – Hispanic # target children _____
Asian # target children _____
American Indian or Alaska Native # target children _____
Native Hawaiian or other Pacific Islander # target children _____
Other # target children _____ (Describe: _______)
Other biracial # target children _____ (Describe: _______)
Not known # target children _____

FR32a. Other - Please describe: ________

FR32b. Other biracial - Please describe: ________

FR33. Parents or primary caregiver(s) of target child in the household

FR33a. Single parent/caregiver family (Parent/primary caregiver not married or not living with a partner)

Mother (biological/adoptive/foster/step/non-biological) # of families _____

Father (biological/adoptive/foster/step/non-biological) # of families _____

Grandparent # of families _____

Other relative (please describe below) # of families _____

Other non-relative (please describe below) # of families _____

Other relative – Please describe: ________________

Other non-relative – Please describe: __________________

FR33b. Two parent/two primary caregivers family

Mother and father # of families _____

Other (describe two caregivers _________) # of families _____

Caregiver 1 – Please describe: ________________

Caregiver 2 – Please describe: __________________

FR33c. Other family structures

Mother and father in joint custody # of families _____

Other (please describe below) # of families _____

Other – Please describe: ________________

FR34. Highest education level of parents/primary caregiver(s)

FR34a. Single-parent household(s): Highest education level of parent or primary caregiver

No HS diploma/GED # of families _____
High school graduate or GED # of families _____
Some college credits/two-year (AA) degree # of families _____
4-year college degree or higher # of families _____
Not known # of families_____

FR34b. Two-parent household(s)/joint custody: Highest education level of Mother

No HS diploma/GED # of families _____
High school graduate or GED # of families _____
Some college credits/two-year (AA) degree # of families _____
4-year college degree or higher # of families _____
Not known # of families _____

FR34c. Two-parent household(s)/joint custody: Highest education level of Father

No HS diploma/GED # of families _____
High school graduate or GED # of families _____
Some college credits/two-year (AA) degree # of families _____
4-year college degree or higher # of families _____
Not known # of families _____

FR34d. Two-caregiver household(s): Highest level of education of caregiver1

No HS diploma/GED # of families _____
High school graduate or GED # of families _____
Some college credits/two-year (AA) degree # of families _____
4-year college degree or higher # of families _____
Not known # of families _____

FR34e. Two-caregiver household(s): Highest level of education of caregiver2

No HS diploma/GED # of families _____
High school graduate or GED # of families _____
Some college credits/two-year (AA) degree # of families _____
4-year college degree or higher # of families _____
Not known # of families _____

FR35. Average number of children in household:

FR35a. Children < 18 years ___________ (#)

FR35b. Children < 8 years (“LAUNCH” children) ___________ (#)

FR36. Primary language in household

English # of families _____
Spanish # of families _____
Arabic # of families _____
Caribbean language (French-Creole/Haitian) # of families _____
European or Slavic language # of families _____
Pacific Island language # of families _____
Far Eastern Asian languages (Japanese, Vietnamese) # of families _____
Native North American or Alaska Native language # of families _____
African language # of families _____
Other (please describe below) # of families _____
Bilingual household: Spanish-English spoken equally # of families _____
Bilingual household: Other (specify two languages) (please describe below) # of families _____
Not known # of families _____

Other – Please describe: ________________

Other – Specify two languages: __________________

FR37. How many households have a member who is currently on active duty in the Armed Forces or in the reserve component (e.g. National Guard, Reserves)?

# households _____

# not known _____

FR38. In how many households has one or more of the children 0 - 8 years been homeless^³in the past 12 months?

# households ______

# not known _____

FR39. Please provide your best estimate of the number of families that have each of the following characteristics:	# of families	# not known
FR39a. Mother was teen aged (less than 20 years of age) at time of birth of any child 0 - 8
FR39b. Single-parent family (single parent or caregiver of child in home is not married or living with a partner)
FR39c. Mother (or other primary caregiver if mother is not in household) does not have a high school diploma or GED
FR39d. Mother (or other primary caregiver if mother is not in household) is not employed and not in school
FR39e. Household participates in at least one assistance program (cash assistance, Food Stamps, WIC, unemployment, Medicaid)
FR39f. Considering the five categories above, how many families have three or more of these characteristics?

FR40. Please provide your best estimate of the number of families that have each of the following characteristics:	# of families	# not known
FR40a. Someone in family/household has mental illness
FR40b. Someone in family/household has substance abuse problem
FR40c. Any child 0 - 8 years in family/household has ever been a victim of violence or trauma (physical, psychological or sexual abuse, neglect, community violence, natural disaster or traumatic grief)
FR40d. Considering the three categories above, how many families/households have more than one of these characteristics

FR41. This space is provided for you to describe any other information that has not been covered previously in this Section.

(Go to Section II)

Part II. Annual Module

A. Fidelity/Level of Implementation

FR42. For this program/service, do you have a systematic process for monitoring the fidelity of implementation?

Yes
No (skip to FR47)

FR42a. To assess fidelity, which of the following types of measures do you use? Check all that apply

Measures provided by the developer or model
Measures developed locally
Other- Please describe: ____________

FR43. What parts of the program/service are measured as part of your assessment of fidelity of implementation?

Proportion of staff who have the qualifications/credentials recommended by the developer/model
Proportion of staff who have received model/developer-recommended training
Whether the curriculum/program content is being delivered according to the model
Whether the program is being delivered to families/children at the desired frequency and intensity
Whether families/children are engaged by the program/service
Other --Please describe: ___________________________________

FR44. What methods are used in assessing fidelity of implementation?

Direct observation of program staff implementing the program with parents/children
Logs/records kept by program staff
Interviews/discussions with program staff
Other --Please describe: ________________

FR45. How often is fidelity of implementation assessed? (For example, once per month, quarterly, etc.)_________

FR46. Was the fidelity of implementation of this program model assessed in the last 12 months?

FR47. Please rate the overall fidelity of implementation of this program model, based on systematic assessment of fidelity or provide your best estimate.

Very early in the implementation process: less than 25% implemented
About 25% - 49% of program elements implemented with fidelity
About 50% - 74% of program elements implemented with fidelity
About 75% - 99% of program elements implemented with fidelity
At or close to 100% of program elements implemented with fidelity

B. Data Systems

FR48. Does this program/service have a data system in place to track client information?

Yes
No (skip to Section C)

FR48a. What types of data are included on this data system? Check all that apply.

Family/child demographic characteristics
Family/child baseline assessments
Family/child service plan
Family/child service receipt
Family/child outcomes
Other types of data– Please describe:___________________________

FR48b. Is the data system electronic, paper or a combination? Check one.

Electronic data system
Paper data system
Combination of electronic and paper

FR49. Does the program/service have in place any data sharing agreements with other services/programs/providers about client services and/or outcomes?

Yes
No (skip to Section C)

FR49a. What types of data sharing occur?

Providers enter data on clients into a common system
Providers can merge data across similar data bases
Providers share paper records on client service delivery and/or outcomes
Other – Please describe:___________________________

FR49b. How many other providers share data with this program/service? _________

FR49c. Who are the other services/programs/providers that are part of the data sharing? __________________________________________________

C. Provider Changes

In the last 12 months, please report the changes for providers/staff who have been involved in this LAUNCH-related program/service.

FR50. As a result of their involvement in this LAUNCH-related program/service, amount of change providers/staff report in their knowledge of children’s socio-emotional and behavioral health and development:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

FR51. As a result of their involvement in this LAUNCH-related program/service, amount of change providers/staff report in their knowledge of the available options for follow-up services for children with mental or behavioral health issues:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

FR52. As a result of their involvement in this LAUNCH-related program/service, amount of change providers/staff report in their use of mental health consultation for children with mental or behavioral health issues:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

FR53. As a result of their involvement in this LAUNCH-related program/service, amount of change providers/staff report in their work settings in the use of screening and/or assessment of children:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

FR54. As a result of their involvement in this LAUNCH-related program/service, what are some of the changes that providers/staff report in their work practices?

FR55. As a result of this LAUNCH-related program/service, what are some of the changes that providers/staff report in their work settings?

FR56. What is the number of providers/staff represented in these responses? ____________ #

FR57. What is the percentage (estimated) of providers/staff represented in these responses of the number of providers/staff who have been involved in this service in the last 12 months? ________%

Part III. Survey Status

 By checking this box, you are indicating that data entry is complete for this survey.

Shape11 Shape10

Project LAUNCH

Cross-Site Evaluation

Survey on Services to

Children and Families:

Mental Health-Related Services in Other Settings

FINAL

Shape12

NOTE: Questions highlighted in yellow will be pre-populated with the response from the previous reporting period.

Abt Associates Inc.

Contents

Part I. All Mental Health-Related Services in Other Settings 2

A. Types of Mental Health-Related Activities 2

B. Screening/Assessment of Children and Families 7

C. Ongoing Consultation 9

Part II. Annual Module 10

A. Fidelity/Level of Implementation 10

B. Data Systems 11

C. Provider Changes 12

Part III. Survey Status 14

(Window shade for “Mental Health Related Service in Other Settings” has an Add Setting feature. For each setting that is listed, Parts I and II should appear and all corresponding questions.)

Part I. All Mental Health-Related Services in Other Settings

A. Types of Mental Health-Related Activities

OS1. Please provide a brief description of integration model/approach. _________________

OS2. In the last 6 months, for the mental health consultation model, which types of settings were involved? Check all that apply.

Community agencies
Home visiting/family strengthening programs
WIC offices
CPS offices
Other - Please describe: ___________________________________

OS3. What are the preferred/required qualifications of the mental health staff who are working with these settings? ______________________________________

OS3a. What are the professional affiliations of the mental health staff? _______________

OS4. What is the number of settings in which the mental health consultation model/approach was implemented in the last 6 months? __________ (#)

OS5. How many staff work in these settings? _______ (#)

OS6. How many of the staff who work in these settings have been involved with the LAUNCH-supported mental health related activities in the last 6 months? _______ (#)

OS6a. What types of staff in the settings have been involved with the mental health related activities? ___________________________

OS7. In the last 6 months, as part of the mental health consultation model, did LAUNCH support training for the mental health consultants?

Yes
No (skip to OS8)

OS7a. What topics were covered in this training? Check all that apply.

Developmental milestones in children's overall cognitive developmental
Developmental milestones in children's socio-emotional development/behavioral health
Physical health of young children
Identifying/screening/assessing children's cognitive development
Identifying/screening/assessing children's mental health/behavioral health/social-emotional development
Identifying/screening/assessing children’s physical health
Appropriate treatment options for children with behavioral/mental health concerns
Appropriate referrals for children with behavioral/mental health concerns
Resources in the community for children with mental/behavioral health concerns
Strategies for family engagement
Working with families to understand/support children's healthy development
LAUNCH orientation--LAUNCH objectives, service strategies
Other - Please describe:______________________

OS8. Training for Mental Health Consultants/Mental Health Staff in the Last 6 Months as Part of This Consultation Approach

Quarter 1

Quarter 2

OS8a. In each of the last two quarters, what is the number of mental health consultants/ staff working with these settings who received any LAUNCH-supported training in mental health-related practices/activities that are consistent with the goals of Project LAUNCH? (GPRA) [Please include training on mental health related topics including assessments.]

OS9. In the last 6 months, as part of the mental health consultation model, did LAUNCH support training for staff in these settings?

Yes
No (skip to OS10)

OS9a. What topics were covered in this training? Check all that apply.

Developmental milestones in children's overall cognitive developmental
Developmental milestones in children's socio-emotional development/behavioral health
Physical health of young children
Identifying/screening/assessing children's cognitive development
Identifying/screening/assessing children's mental health/behavioral health/social-emotional development
Identifying/screening/assessing children’s physical health
Appropriate treatment options for children with behavioral/mental health concerns
Appropriate referrals for children with behavioral/mental health concerns
Resources in the community for children with mental/behavioral health concerns
Strategies for family engagement
Working with families to understand/support children's healthy development
LAUNCH orientation--LAUNCH objectives, service strategies
Other - Please describe:______________________

OS10. Staff Receiving LAUNCH-Supported Training in the Last 6 Months as Part of This Consultation Approach	Quarter 1	Quarter 2
OS10a. In each of the last two quarters, what is the number of staff who received any LAUNCH-supported training in mental health-related practices/activities that are consistent with the goals of Project LAUNCH? (GPRA) [Please include both training on the mental health consultation model and other mental health-related topics including assessments.]
OS10b. Number of settings represented by staff who were trained in the last 6 months
OS10c. Number of children, ages 0 – 8, seen in the settings involved in the training in the last 6 months

OS11. In the last 6 months, did the mental health consultation model involve consultation about individual children or families with mental/behavioral health concerns?

Yes
No (skip to OS12)

OS11a. What types of consultation services did LAUNCH support? Check all that apply.

Observation of child(ren) in the classroom
Assessment/evaluation of child(ren)
Consultation on appropriate referrals for intervention/further evaluation for child(ren)
Consultation on appropriate classroom interventions for child(ren)
Consultation with parents of child(ren)
Parent groups for parents of children with behavioral concerns (NOTE: If checked here, please describe this service in the Direct Services portion of the web portal)
Referrals for additional evaluation/treatment services for child(ren)
Referrals for additional services for families
Other - Please describe: ___________________

OS12. In the last 6 months, did the mental health consultation model involve consultation about staff practices with children and/or families in the setting?

Yes
No (skip to OS13)

OS12a. What aspects of the settings were addressed in the consultation? Check all that apply.

Increased setting-wide use of common battery of screening/assessment for mental/behavioral health
Increased setting-wide understanding of developmental milestones in socio-emotional domain
Increased setting-wide understanding of referral options for children with mental/behavioral health concerns
Coordination across providers of assessments/referrals for children with mental/behavioral health concerns
Coordination of training with other providers on mental-health related topics
Supporting family/home environments to support children’s health and development
Increased understanding of how to support/build healthy parent-child relationships
Other – Please describe: ___________________

OS13. In the last 6 months, as part of the mental health consultation model, did LAUNCH support any other mental-health related activities in these settings?

Yes – Please describe: _______________
No

OS14. How many children and/or families were seen at these settings in the past 6 months (including children/families who are not involved in the consultation activities)? ____________ (#)

OS15. In the last 6 months, did LAUNCH support training for the mental health staff who are working with these settings on the consultation model?

OS16. In the last 6 months, did LAUNCH support supervision of the mental health staff who are working with these settings?

OS17. Was the mental health consultation model/approach initiated under LAUNCH; that is, was the mental health consultation model/approach started “from scratch” by LAUNCH in the target community?

OS18. In the last 6 months, what proportion of the funding for the mental health consultation model came from LAUNCH? (estimated) ______ % (Skip to OS20 if % = 100%)

OS19. In the past 6 months, what other sources of funding supported the mental health consultation model? Check all that apply.

Private (e.g., foundation, donation)
Federal
County/state funding (public)
Local funding (public)
In-kind contribution
Other - Please describe: ____________________________________

OS20. This space is provided for you to describe any other information that has not been covered previously in this Section.

B. Screening/Assessment of Children and Families

OS21. In the last 6 months, as part of the mental health consultation model, did LAUNCH support developmental screening and/or assessment of children?

Yes
No (skip to OS24)

OS22. How many different developmental screening and/or assessment measures were used as part of the mental health consultation model/approach? ___________ (#)

(Repeat questions OS22a. and OS22a1. for the number of measures indicated in question OS22, where the “1” is replaced for each consecutive measure.)

OS22a. What is the name of measure1? _____________________________

OS22a1. What domains are screened and/or assessed by measure1? Check all that apply.

Social-emotional development, social-personal behavior
Behavior/impulse control/self-regulation
Cognitive-language development
Problem-solving
Communication
School readiness
Literacy/reading
Gross/fine motor skills
Other - Please describe: ________________

OS23. Who conducted the screenings and/or assessments of children? Check all that apply.

Program staff, non-clinical
Program staff, clinical
Primary care providers/staff
Early childhood education and care providers
Mental health staff
Other - Please describe: _________________________________________

OS24. In the last 6 months, did LAUNCH support physical and health screening for children as part of the mental health consultation model/approach?

Yes
No (skip to OS25)

OS24a. What aspects of physical health were screened? Check all that apply.

Vision
Hearing
Weight
Dental
Other - Please describe: ________________________

OS25. Children Receiving LAUNCH-Supported Developmental Screening and/or Assessments in the Last 6 Months as Part of This Mental Health Consultation Model/Approach (Include physical and health screening)

Quarter 1

Quarter 2

OS25a. In each of the last two quarters, what is the number of children, ages 0 – 8, screened and/or assessed for mental health or related interventions at least once as part of this model/approach? (GPRA)

OS25b. In each of the last two quarters, what is the number of children, ages 0 – 8, referred for mental health or related services? (GPRA)

OS26. In the last 6 months, did LAUNCH support screening and/or assessment for family members as part of the mental health consultation model/approach?

Yes
No (skip to OS29)

OS27. How many screening or assessment instruments for family members were used as part of the mental health consultation model/approach? _________ (#)

(Repeat questions OS27a. and OS27a1. for the number of measures indicated in question OS27, where the “1” is replaced for each consecutive measure.)

OS27a. What is the name of measure1? _____________________

OS27a1. What domains are screened and/or assessed by measure1? Check all that apply.

Depression or parent/family mental health problems
Family violence/substance abuse
Parenting/family relationships
Physical health indicators
Family social support
Child development knowledge
Parenting knowledge
Family resources/family needs
Other - Please describe: _______________

OS28. Who conducted the screenings and/or assessments of the families? Check all that apply.

Program staff, non-clinical
Program staff, clinical
Primary care providers/staff
Early childhood education and care providers
Mental health consultants
Other - Please describe: ____________________

OS29. Families Receiving LAUNCH-Supported Screening and/or Assessments in the Last 6 Months as Part of the Mental Health Consultation Model/Approach

Quarter 1

Quarter 2

OS29a. In each of the last two quarters, what is the number of family members, other than children ages 0 – 8, screened and/or assessed for mental health or related interventions at least once as part of this model/approach? (GPRA)

OS29b. In each of the last two quarters, what is the number of family members, other than children ages 0 – 8, referred for mental health or related services? (GPRA)

OS30. This space is provided for you to describe any other information that has not been covered previously in this Section.

C. Ongoing Consultation

OS31. In the mental health consultation model, are the mental health consultants/staff who provide services/work with the staff:

Co-located and a full collaborator/member of the staff (skip to OS32)
Co-located (skip to OS32)
Not co-located

OS31a. For the settings where the mental health consultants/staff are not co-located, in what ways are the consultants/staff involved: Check all that apply.

Consultant scheduled to come into the setting on a regular basis. (Indicate number days/week ___)
Consultant comes to setting upon request
Consultant provides consultation by telephone or email

OS32. This space is provided for you to describe any other information that has not been covered previously in this Section.

Part II. Annual Module

A. Fidelity/Level of Implementation

OS33. For this mental health consultation model/approach, is there a systematic process for monitoring the fidelity of implementation?

Yes
No (skip to OS38)

OS33a. To assess fidelity, which of the following types of measures are used? Check all that apply

Measures provided by the developer or model
Measures developed locally
Other- Please describe: ____________

OS34. What parts of the mental health consultation model/approach are measured as part of your assessment of fidelity of implementation?

Proportion of mental health consultants who have the qualifications/credentials recommended by the developer/model
Proportion of mental health consultants who have received model/developer-recommended training
Whether the mental health consultation is being delivered according to the model
Whether the program is being delivered to settings at the desired frequency and intensity
Other --Please describe: ___________________________________

OS35. What methods are used in assessing fidelity of implementation?

Direct observation of service providers delivering services to parents/children
Logs/records kept by service providers
Interviews/discussions with service providers
Other — Please describe: ________________

OS36. How often is fidelity of implementation assessed? (For example, once per month, quarterly, etc.) _________

OS37. Was the fidelity of implementation of this mental health consultation model/approach assessed in the last 12 months?

OS38. Please rate the overall fidelity of implementation of this mental health consultation model/approach, based on systematic assessment of fidelity (or provide your best estimate):

Very early in the implementation process: less than 25% implemented
About 25% - 49% of program elements implemented with fidelity
About 50% - 74% of program elements implemented with fidelity
About 75% - 99% of program elements implemented with fidelity
At or close to 100% of program elements implemented with fidelity

B. Data Systems

OS39. Does the mental health consultation model have a data system in place to track contacts with providers/staff or children/families?

Yes
No (skip to Section C)

OS39a. What types of data are included on this data system? Check all that apply.

Number of contacts with providers
Number of families/children on whom mental health staff consulted
Family/child demographic characteristics
Family/child baseline assessments
Other types of data– Please describe:___________________________

OS39b. Is the data system electronic, paper or a combination? Check one.

Electronic data system
Paper data system
Combination of electronic and paper

OS40. Does the model/service have in place any data sharing agreements with other services/programs/providers about consultation services and/or outcomes?

Yes
No (skip to Section C)

OS40a. What types of data sharing occur?

Consultants enter data on activities into a common system
Other – Please describe:___________________________

OS40b. How many other mental health consultants share data with the mental health consultation model/approach? _________

OS40c. Who are the other services/programs that are part of the data sharing? __________________________________________________

C. Provider Changes

In the last 12 months, please report the changes for providers/staff who have been involved in this LAUNCH-related mental health consultation model/approach.

OS41. As a result of their involvement in this LAUNCH-related mental health consultation model/approach, amount of change providers/staff report in their knowledge of children’s socio-emotional and behavioral health and development:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

OS42. As a result of their involvement in this LAUNCH-related mental health consultation model/approach, amount of change providers/staff report in their knowledge of the available options for follow-up services for children with mental or behavioral health issues:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

OS43. As a result of their involvement in this LAUNCH-related mental health consultation model/approach, amount of change providers/staff report in their use of mental health consultation for children with mental or behavioral health issues:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

OS44. As a result of their involvement in this LAUNCH-related mental health consultation model/approach, amount of change providers/staff report in their work settings in the use of screening and/or assessment of children:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

OS45. As a result of their involvement in this LAUNCH-related model/approach, what are some of the changes that providers/staff report in their work practices?

OS46. As a result of this LAUNCH-related model/approach, what are some of the changes that providers/staff report in their work settings?

OS47. What is the number of providers/staff represented in these responses? ____________ #

OS48. What is the percentage (estimated) of providers/staff represented in these responses of the number of providers/staff who have been involved in this service in the last 12 months? ________%

Part III. Survey Status

 By checking this box you are indicating that data entry is complete for this survey.

Shape14 Shape13

Project LAUNCH

Cross-Site Evaluation

Survey on Services to

Children and Families:

Mental Health-Related Services in Primary Care

FINAL

Shape15

NOTE: Questions highlighted in yellow will be pre-populated with the response from the previous reporting period.

Abt Associates Inc.

Contents

Part I. All Mental Health-Related Services in Primary Care Settings 2

A. Types of Mental Health-Related Activities 2

B. Provider Training 6

C. Screening/Assessment of Children and Families 7

D. Ongoing Consultation 9

Part II. Annual Module 10

A. Fidelity/Level of Implementation 10

B. Data Systems 11

C. Provider Changes 12

Part III. Survey Status 14

(Window shade for “Mental Health Related Service in Primary Care” has an Add Model feature. For each model that is listed, Parts I and II should appear and all corresponding questions.)

Part I. All Mental Health-Related Services in Primary Care Settings

A. Types of Mental Health-Related Activities

PC1. Please provide a brief description of integration model/approach. _________________

PC2. In the last 6 months, for the mental health consultation model, which types of primary care settings were involved? Check all that apply.

Community/Tribal health centers/health clinics
Individual pediatrician offices/group practices
Hospital clinic
Other - Please describe: ___________________________________

PC3. As part of the mental health consultation model, in the last 6 months, did LAUNCH support developmental screening and/or assessments of children conducted by the mental health consultant?

Yes
No (skip to PC4)

PC3a. In the past 6 months, as part of the mental health consultation model, did LAUNCH support training for the mental health staff on using these screening and/or assessment measures?

PC4. As part of the mental health consultation model, in the last 6 months, did LAUNCH support developmental screening and/or assessments of children conducted by the primary care providers or other primary care staff?

Yes
No (skip to PC5)

PC4a. In the past 6 months, as part of the mental health consultation model, did LAUNCH support training for the primary care providers or other primary care staff on using these screening and/or assessment measures?

PC5. As part of the mental health consultation model, in the last 6 months, did LAUNCH support training for providers on topics other than how to implement a curriculum or use a screening and/or assessment measure?

Yes
No (skip to PC6)

PC5a. What topics were covered in this training? Check all that apply.

Developmental milestones in children's overall cognitive development
Developmental milestones in children's socio-emotional development/behavioral health
Physical health of young children
Identifying/screening/assessing children's cognitive development
Identifying/screening/assessing children's mental health/behavioral health/social-emotional development
Identifying/screening/assessing children’s physical health
Appropriate treatment options for children with behavioral/mental health concerns
Appropriate referrals for children with behavioral/mental health concerns
Resources in the community for children with mental/behavioral health concerns
Strategies for family engagement
Working with families to understand/support children's healthy development
LAUNCH orientation--LAUNCH objectives, service strategies
Other - Please describe:______________________

PC6. In the last 6 months, as part of the mental health consultation model, did LAUNCH support consultation between the mental health staff and the primary care providers about individual children with mental/behavioral health concerns?

Yes
No (skip to PC7)

PC6a. What types of consultation services did LAUNCH support? Check all that apply.

Assessment/evaluation of child(ren)
Consultation on appropriate referrals for intervention/further evaluation for child(ren)
Consultation with parents of child(ren)
Referrals for additional services for families
Other - Please describe: ___________________

PC7. In the last 6 months, as part of the mental health consultation model, did LAUNCH support consultation between the mental health staff and families of individual children with mental/behavioral health concerns?

PC8. In the last 6 months, as part of the mental health consultation model, did LAUNCH support consultation by the mental health staff about practices in the primary care setting?

Yes
No (skip to PC9)

PC8a. What aspects of the primary care settings were addressed in the consultation? Check all that apply.

Increased setting-wide use of common battery of screening/assessment for mental/behavioral health
Increased setting-wide understanding of developmental milestones in socio-emotional domain
Increased setting-wide understanding of referral options for children with mental/behavioral health concerns
Coordination across providers of assessments/referrals for children with mental/behavioral health concerns
Coordination of training across members of team(s) of providers on mental-health related topics
Other – Please describe: ___________________

PC9. In the last 6 months, as part of the mental health consultation model, did LAUNCH support any other mental-health related activities in primary care settings?

Yes – Please describe: _______________
No

PC10. What is the number of primary care settings in which model/approach was implemented in the last 6 months? __________

PC11. What is the number of primary care providers who work in these settings? ______

PC12. What is the number of children who receive care in these settings? ____________

PC13. What are the preferred/required qualifications of the mental health staff who are working with the primary care settings? ______________________________________

PC14. What are the professional affiliations of these mental health staff? _____________________

PC15. In the last 6 months, did LAUNCH support supervision of the mental health staff who are working with primary care settings?

PC16. In the last 6 months, did LAUNCH support training for the mental health staff who are working with primary care settings on the consultation model?

PC17. Training for Mental Health Consultants/Mental Health Staff

Quarter 1

Quarter 2

PC17a. In each of the last two quarters, what is the number of mental health consultants/ staff working with primary care settings who received any LAUNCH-supported training in mental health-related practices/activities that are consistent with the goals of Project LAUNCH? (GPRA) [Please include training on mental health related topics including assessments.]

PC18. Was the mental health consultation model/approach initiated under LAUNCH; that is, was the mental health consultation model/approach started “from scratch” by LAUNCH in the target community?

PC19. In the last 6 months, what proportion of the funding for the mental health consultation model came from LAUNCH? (estimated percentage) ______ %

PC20. In the past 6 months, what other sources of funding supported the mental health consultation model? Check all that apply.

Private (e.g., foundation, donation)
Federal
County/state funding (public)
Local funding (public)
In-kind contribution
Other - Please describe: ____________________________________

PC21. This space is provided for you to describe any other information that has not been covered previously in this Section.

B. Provider Training

PC22. How many primary care providers/other primary care staff are involved with the LAUNCH-supported mental health related activities in the settings? _______ (#)

PC23. Who are the staff involved with these activities? Check all that apply.

Primary care providers
Other primary care staff (nurses, physician assistants)
Other – Please describe: ___________________________

PC24. Does the program provide training for primary care providers/other primary care staff on the LAUNCH-supported mental health related activities?

PC25. Providers Receiving LAUNCH-Supported Training in the Last 6 Months as Part of the Mental Health Consultation Model/Approach	Quarter 1	Quarter 2
PC25a. In each of the last two quarters, what is the number of providers/staff who received any LAUNCH-supported training in mental health-related practices/activities that are consistent with the goals of Project LAUNCH? (GPRA) [Please include training on the mental health consultation model and other mental health related topics including assessments.]
PC25b. Number of settings represented by staff who were trained in the last 6 months
PC25c. Number of children, ages 0 – 8, cared for by the primary care providers who were trained in the last 6 months

PC26. This space is provided for you to describe any other information that has not been covered previously in this Section.

C. Screening/Assessment of Children and Families

PC27. In the last 6 months, did LAUNCH support developmental screening and/or assessment of children as part of this model/approach?

Yes
No (skip to PC30)

PC28. How many different developmental screening and/or assessment measures were used as part of model/approach? ___________ (#)

(Repeat questions PC28a. and PC28a1. for the number of measures indicated in question PC28, where the “1” is replaced for each consecutive measure.)

PC28a. What is the name of measure1? _____________________________

PC28a1. What domains are screened and/or assessed by measure1? Check all that apply.

Social-emotional development, social-personal behavior
Behavior/impulse control/self-regulation
Cognitive-language development
Problem-solving
Communication
School readiness
Literacy/reading
Gross/fine motor skills
Other - Please describe: ________________

PC29. Who conducted the screenings and/or assessments of children? Check all that apply.

Program staff, non-clinical
Program staff, clinical
Primary care providers/staff
Early childhood education and care providers
Mental health staff
Other - Please describe: _________________________________________

PC30. In the last 6 months, did LAUNCH support physical and health screening for children as part of this program/service?

Yes
No (skip to PC31)

PC30a. What aspects of physical health were screened? Check all that apply.

Vision
Hearing
Weight
Dental
Other - Please describe: ________________________

PC31. Children Receiving LAUNCH-Supported Screening and/or Assessments in the Last 6 Months as Part of This Mental Health Consultation Model/Approach (Include physical and health screening)

Quarter 1

Quarter 2

PC31a. In each of the last two quarters, what is the number of children, ages 0 – 8, screened and/or assessed for mental health or related interventions at least once as part of this program/service? (GPRA)

PC31b. In each of the last two quarters, what is the number of children, ages 0 – 8, referred for mental health or related services? (GPRA)

PC32. In the last 6 months, did LAUNCH support screening and/or assessment for family members as part of the mental health consultation model/approach?

Yes
No (skip to PC35)

PC33. How many screening or assessment instruments for family members were used as part of the mental health consultation model/approach? _________ (#)

(Repeat questions PC33a. and PC33a1. for the number of measures indicated in question PC33, where the “1” is replaced for each consecutive measure.)

PC33a. What is the name of measure1? _____________________

PC33a1. What domains are screened and/or assessed by measure1? Check all that apply.

Depression or parent/family mental health problems
Family violence/substance abuse
Parenting/family relationships
Physical health indicators
Family social support
Child development knowledge
Parenting knowledge
Family resources/family needs
Other - Please describe: _______________

PC34. Who conducted the screenings and/or assessments of the families? Check all that apply.

Program staff, non-clinical
Program staff, clinical
Primary care providers/staff
Early childhood education and care providers
Mental health staff
Other - Please describe: _________________________________________

PC35. Families Receiving LAUNCH-Supported Screening and/or Assessments in the Last 6 Months as Part of the Mental Health Consultation Model/Approach

Quarter 1

Quarter 2

PC35a. In each of the last two quarters, what is the number of family members, other than children ages 0 – 8, screened and/or assessed for mental health or related interventions at least once as part of this program/service? (GPRA)

PC35b. In each of the last two quarters, what is the number of family members, other than children ages 0 – 8, referred for mental health or related services? (GPRA)

PC36. This space is provided for you to describe any other information that has not been covered previously in this Section.

D. Ongoing Consultation

PC37. In this model, are the mental health consultants/staff who provide services/work with the primary care providers:

Co-located and a full collaborator/member of the staff (skip to PC38)
Co-located (skip to PC38)
Not co-located

PC37a. For the settings where the mental health consultants/staff are not co-located, in what ways are the consultants/staff involved: Check all that apply.

Consultant scheduled to come into the setting on a regular basis. (Indicate number days/week ___)
Consultant comes to setting upon request
Consultant provides consultation by telephone or email

PC38. This space is provided for you to describe any other information that has not been covered previously in this Section.

Part II. Annual Module

A. Fidelity/Level of Implementation

PC39. For this program/service, do you have a systematic process for monitoring the fidelity of implementation?

Yes
No (skip to PC44)

PC39a. To assess fidelity, which of the following types of measures do you use? Check all that apply

Measures provided by the developer or model
Measures developed locally
Other- Please describe: ____________

PC40. What parts of the program/service are measured as part of your assessment of fidelity of implementation?

Proportion of staff who have the qualifications/credentials recommended by the developer/model
Proportion of staff who have received model/developer-recommended training
Whether the curriculum/program content is being delivered according to the model
Whether the program is being delivered to families/children at the desired frequency and intensity
Whether families/children are engaged by the program/service
Other --Please describe: ___________________________________

PC41. What methods are used in assessing fidelity of implementation?

Direct observation of program staff implementing the program with parents/children
Logs/records kept by program staff
Interviews/discussions with program staff
Other — Please describe: ________________

PC42. How often is fidelity of implementation assessed? _________

PC43. Was the fidelity of implementation of this program model assessed in the last 12 months?

PC44. Please rate the overall fidelity of implementation of this program model, based on systematic assessment of fidelity or provide your best estimate.

Very early in the implementation process: less than 25% implemented
About 25% - 49% of program elements implemented with fidelity
About 50% - 74% of program elements implemented with fidelity
About 75% - 99% of program elements implemented with fidelity
At or close to 100% of program elements implemented with fidelity

B. Data Systems

PC45. Does this program/service have a data system in place to track client information?

Yes
No (skip to Section C)

PC45a. What types of data are included on this data system? Check all that apply.

Family/child demographic characteristics
Family/child baseline assessments
Family/child service plan
Family/child service receipt
Family/child outcomes
Other types of data– Please describe:___________________________

PC45b. Is the data system electronic, paper or a combination? Check one.

Electronic data system
Paper data system
Combination of electronic and paper

PC46. Does the program/service have in place any data sharing agreements with other services/programs/providers about client services and/or outcomes?

Yes
No (skip to Section C)

PC46a. What types of data sharing occur?

Providers enter data on clients into a common system
Providers can merge data across similar data bases
Providers share paper records on client service delivery and/or outcomes
Other – Please describe:___________________________

PC46b. How many other providers share data with this program/service? _________

PC46c. Who are the other services/programs/providers that are part of the data sharing? __________________________________________________

C. Provider Changes

In the last 12 months, please report the changes for providers/staff who have been involved in this LAUNCH-related program/service.

PC47. As a result of their involvement in this LAUNCH-related program/service, amount of change providers/staff report in their knowledge of children’s socio-emotional and behavioral health and development:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

PC48. As a result of their involvement in this LAUNCH-related program/service, amount of change providers/staff report in their knowledge of the available options for follow-up services for children with mental or behavioral health issues:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

PC49. As a result of their involvement in this LAUNCH-related program/service, amount of change providers/staff report in their use of mental health consultation for children with mental or behavioral health issues:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

PC50. As a result of their involvement in this LAUNCH-related program/service, amount of change providers/staff report in their work settings in the use of screening and/or assessment of children:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

PC51. As a result of their involvement in this LAUNCH-related program/service, what are some of the changes that providers/staff report in their work practices?

PC52. As a result of this LAUNCH-related program/service, what are some of the changes that providers/staff report in their work settings?

PC53. What is the number of providers/staff represented in these responses? ____________ #

PC54. What is the percentage (estimated) of providers/staff represented in these responses of the number of providers/staff who have been involved in this service in the last 12 months? ________%

Part III. Survey Status

 By checking this box you are indicating that data entry is complete for this survey.

Shape17 Shape16

Cross-Site Evaluation of Project LAUNCH

Survey on Services:

Other LAUNCH-Supported Screening and/or Assessment of Children or Families

FINAL

Shape18

NOTE: Questions highlighted in yellow will be pre-populated with the response from the previous reporting period.

Abt Associates Inc.

Contents

Part I. Screening and Assessment 2

A. Developmental Screening/Assessments 2

B. Provider Training 5

Part II. Annual Module 6

A. Provider Changes 6

Part III. Survey Status 8

(Window shade for “Other Screening and Assessment” has an Add Screening/Assessment Activity feature. For each model that is listed, Parts I and II should appear and all corresponding questions.)

Part I. Screening and Assessment

A. Developmental Screening/Assessments

SA1. In the last 6 months, did LAUNCH support developmental screening and/or assessment of children that is not part of another program/service?

Yes
No (skip to SA8)

SA2. What are the ways that LAUNCH supported this screening and/or assessment? Check all that apply.

Funding assessment materials and/or training materials
Funding trainer salaries
Funding the cost of conducting the assessments
Other - Please describe: _______________

SA3. Who conducted the screening and/or assessment? Please describe: _______________

SA4. How many screening and/or assessment measures were used? ______ (#)

(Repeat questions SA4a. and SA4a1. for the number of measures indicated in question SA4, where the “1” is replaced for each consecutive measure.)

SA4a. What is the name of measure1? ______________________________

SA4a1. What domains are screened and/or assessed with measure1? Check all that apply.

Social-emotional development, social-personal behavior
Behavior/impulse control/self-regulation
Cognitive-language development
Problem-solving
Communication
School readiness
Literacy/reading
Gross/fine motor skills
Other - Please describe: ________________

SA5. Who conducted the screening and/or assessment of the children? Check all that apply.

Program staff, non-clinical
Program staff, clinical
Primary care providers/staff
Early childhood education and care providers
Mental health consultants
Other - Please describe: _________________

SA6. What are the settings where the developmental screening and/or assessment was conducted? Check all that apply.

Child’s home
Child’s early childhood program
Child’s school
Project LAUNCH office
Other social service agency
Community site (library, etc.)
Other - Please describe: _______________

SA7. In the last 6 months, did LAUNCH support physical and health screening for children as part of this program/service?

Yes
No (skip to SA8)

SA7b. What aspects of physical health are screened? Check all that apply.

Vision
Hearing
Weight
Dental
Other - Please describe: _____________

SA8. Children Receiving Other LAUNCH-Supported Screening and/or Assessments in the Last 6 Months (Include physical and health screening)

Quarter 1

Quarter 2

SA8a. In each of the last two quarters, what is the number of children, ages 0 – 8, screened and/or assessed for mental health or related interventions at least once as part of this program/service? (GPRA)

SA8b. In each of the last two quarters, what is the number of children, ages 0 – 8, referred for mental health or related services? (GPRA)

SA9. In the last 6 months, did LAUNCH support screening and/or assessment for family members that is not part of a program/service?

Yes
No (skip to SA13)

SA10. What are the ways that LAUNCH supported this screening and/or assessment? Check all that apply.

Funding assessment materials and/or training materials
Funding trainer salaries
Funding the cost of conducting the assessments
Other - Please describe: _______________

SA11. Who conducted the screening and/or assessment of the families? Please describe: _______________

SA12. How many screening and/or assessment measures were used for families? ____ (#)

(Repeat questions SA12a. and SA12a1. for the number of measures indicated in question SA12, where the “1” is replaced for each consecutive measure.)

SA12a. What is the name of measure1? ______________________________

SA12a1. What domains are screened/assessed with measure1? Check all that apply.

Depression or parent/family mental health problems
Family violence/substance abuse
Parenting/family relationships
Physical health indicators
Family social support
Child development knowledge
Parenting knowledge
Family resources/family needs
Other - Please describe: _______________

SA13. Families Receiving LAUNCH-Supported Screening and/or Assessments in the Last 6 Months

Quarter 1

Quarter 2

SA13a. In each of the last two quarters, what is the number of family members, other than children ages 0 – 8, screened and/or assessed for mental health or related interventions at least once as part of this program/service? (GPRA)

SA13b. In each of the last two quarters, what is the number of family members, other than children ages 0 – 8, referred for mental health or related services? (GPRA)

SA14. Was this screening and/or assessment 100% funded by LAUNCH?

SA15. This space is provided for you to describe any other information that has not been covered previously in this Section.

B. Provider Training

SA16. How many service providers are involved in conducting this LAUNCH-supported screening and assessment? _______ (#)

SA17. Who are the service providers involved in conducting this LAUNCH-supported screening and assessment? (For example, mental health clinicians from a community health center.) __________________________

SA18. In the last 6 months, did LAUNCH support training for the service providers involved in conducting this LAUNCH-supported screening and assessment?

Yes
No (skip to SA19)

SA19. Providers Receiving LAUNCH-Supported Training in the Last 6 Months as Part of This Program/Service

Quarter 1

Quarter 2

SA19a. In each of the last two quarters, what is the number of providers/staff who received any LAUNCH-supported training in mental health-related practices/activities that are consistent with the goals of Project LAUNCH? (GPRA)

SA20. This space is provided for you to describe any other information that has not been covered previously in this Section.

Part II. Annual Module

A. Provider Changes

In the last 12 months, please report the changes for providers/staff who have been involved in this LAUNCH-related program/service.

SA21. As a result of their involvement in this LAUNCH-related program/service, amount of change providers/staff report in their knowledge of children’s socio-emotional and behavioral health and development:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

SA22. As a result of their involvement in this LAUNCH-related program/service, amount of change providers/staff report in their knowledge of the available options for follow-up services for children with mental or behavioral health issues:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

SA23. As a result of their involvement in this LAUNCH-related program/service, amount of change providers/staff report in their use of mental health consultation for children with mental or behavioral health issues:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

SA24. As a result of their involvement in this LAUNCH-related program/service, amount of change providers/staff report in their work settings in the use of screening and/or assessment of children:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

SA25. As a result of their involvement in this LAUNCH-related program/service, what are some of the changes that providers/staff report in their work practices?

SA26. As a result of this LAUNCH-related program/service, what are some of the changes that providers/staff report in their work settings?

SA27. What is the number of providers/staff represented in these responses? ____________ #

SA28. What is the percentage (estimated) of providers/staff represented in these responses of the number of providers/staff who have been involved in this service in the last 12 months? ________%

Part III. Survey Status

 By checking this box you are indicating that data entry is complete for this survey.

Shape20 Shape19

Cross-Site Evaluation of Project LAUNCH

Survey on Services:

Other LAUNCH-Supported Training

(Service Providers, Others)

FINAL

Shape21

NOTE: Questions highlighted in yellow will be pre-populated with the response from the previous reporting period.

Abt Associates Inc.

Contents

Part I. Provider Training 2

Part II. Annual Module 4

Part III. Survey Status 6

(Window shade for “Other Training” has an Add Training feature. For each training that is listed, Parts I and II should appear and all corresponding questions.)

Part I. Provider Training

TR1. What was the content/topics of training? Check all that apply.

Developmental milestones in children's overall cognitive developmental
Developmental milestones in children's socio-emotional development/behavioral health
Physical health of young children
Identifying/screening/assessing children's cognitive development
Identifying/screening/assessing children's mental health/behavioral health/social-emotional development
Identifying/screening/assessing children’s physical health
Appropriate treatment options for children with behavioral/mental health concerns
Appropriate referrals for children with behavioral/mental health concerns
Resources in the community for children with mental/behavioral health concerns
Strategies for family engagement
Working with families to understand/support children's healthy development
LAUNCH orientation--LAUNCH objectives, service strategies
Other - Please describe:______________________

TR2. Please describe the service providers/administrators/others that were targeted by or invited to the training. Include the names of the agencies/organizations represented at the training. (For example 3 Public Health Nurses from the County Health Department, 2 WIC Counselors, etc.) _______________________________________________________________

TR3. Was this training 100% funded by LAUNCH?

TR4. Who provided the training? Check all that apply.

Program staff, non-clinical
Program staff, clinical
Primary care providers/staff
Early childhood education and care providers
Mental health consultants
Other - Please describe: _________________

TR5. Providers Receiving LAUNCH-Supported Training in the Last 6 Months as Part of This Program/Service	Quarter 1	Quarter 2
TR5a. In each of the last two quarters, what is the number of providers/staff who received any LAUNCH-supported training in mental health-related practices/activities that are consistent with the goals of Project LAUNCH? (GPRA)
TR5b. Number of settings represented by staff who were trained in the last 6 months
TR5c. Number of children, ages 0 – 8, served by staff who were trained in the last 6 months

TR6. This space is provided for you to describe any other information that has not been covered previously in this Section.

Part II. Annual Module

A. Provider Changes

In the last 12 months, please report the changes for providers/staff who have been involved in this LAUNCH-related program/service.

TR99. As a result of their involvement in this LAUNCH-related program/service, amount of change providers/staff report in their knowledge of children’s socio-emotional and behavioral health and development:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

TR100. As a result of their involvement in this LAUNCH-related program/service, amount of change providers/staff report in their knowledge of the available options for follow-up services for children with mental or behavioral health issues:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

TR101. As a result of their involvement in this LAUNCH-related program/service, amount of change providers/staff report in their use of mental health consultation for children with mental or behavioral health issues:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

TR102. As a result of their involvement in this LAUNCH-related program/service, amount of change providers/staff report in their work settings in the use of screening and/or assessment of children:

Percentage who reported no change _____

Percentage who reported a little change _____

Percentage who reported some change _____

Percentage who reported substantial change _____

TR103. As a result of their involvement in this LAUNCH-related program/service, what are some of the changes that providers/staff report in their work practices?

TR104. As a result of this LAUNCH-related program/service, what are some of the changes that providers/staff report in their work settings?

TR105. What is the number of providers/staff represented in these responses? ____________ #

TR106. What is the percentage (estimated) of providers/staff represented in these responses of the number of providers/staff who have been involved in this service in the last 12 months? ________%

Part III. Survey Status

 By checking this box you are indicating that data entry is complete for this survey.

1 According to section 725(2) of the McKinney-Vento Homeless Assistance Act (42 U.S.C. 11434a(2)), the term “homeless children and youths”— means individuals who lack a fixed, regular, and adequate nighttime residence..; and includes—

children and youths who are sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason; are living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative accommodations; are living in emergency or transitional shelters; are abandoned in hospitals; or are awaiting foster care placement;
children and youths who have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings..
children and youths who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings; and
migratory children who qualify as homeless for the purposes of this subtitle because the children are living in circumstances described in clauses (i) through (iii).

2 According to section 725(2) of the McKinney-Vento Homeless Assistance Act (42 U.S.C. 11434a(2)), the term “homeless children and youths”— means individuals who lack a fixed, regular, and adequate nighttime residence..; and includes—

children and youths who are sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason; are living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative accommodations; are living in emergency or transitional shelters; are abandoned in hospitals; or are awaiting foster care placement;
children and youths who have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings..
children and youths who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings; and
migratory children who qualify as homeless for the purposes of this subtitle because the children are living in circumstances described in clauses (i) through (iii).

3 According to section 725(2) of the McKinney-Vento Homeless Assistance Act (42 U.S.C. 11434a(2)), the term “homeless children and youths”— means individuals who lack a fixed, regular, and adequate nighttime residence..; and includes—

children and youths who are sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason; are living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative accommodations; are living in emergency or transitional shelters; are abandoned in hospitals; or are awaiting foster care placement;
children and youths who have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings..
children and youths who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings; and
migratory children who qualify as homeless for the purposes of this subtitle because the children are living in circumstances described in clauses (i) through (iii).

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	Cross-Site Evaluation
Author	DHHS
File Modified	0000-00-00
File Created	2021-01-29