Form Network Analysis S Network Analysis S Network Analysis Survey

Attachment 4:

OMB No. 0930-03xx

Expiration Date: xx/xx/xx

CHILDREN’S MENTAL HEALTH INITIATIVE

NATIONAL SYSTEM OF CARE EXPANSION EVALUATION

NETWORK ANALYSIS

Public Burden Statement: 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 project is 0930-03xx.  Public reporting burden for this collection of information is estimated to average 30 minutes per respondent, per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.

Attachment 4a

CHILDREN’S MENTAL HEALTH INITIATIVE

NATIONAL SYSTEM OF CARE EXPANSION EVALUATION

NETWORK ANALYSIS

OVERVIEW

Purpose

The purpose of the Network Analysis Survey is to assess the interrelationship between child-serving agencies and organizational partners within systems of care. Respondents will be asked to answer questions to indicate if their agency/organization has formal agreements for collaboration and/or data sharing and questions focused on specific collaborative activities such as policy development, enrollment, and training. Responses will help to describe the nature of the partnerships and collaborative behavior between the organizations and agencies. Two versions of the instrument have been developed, one for the jurisdiction level and one for the local service delivery level.

Respondents:

The instrument will be completed by a select group of key stakeholders within child serving agencies who address the needs of children and youth with severe emotional disturbances (SED) and their families. The jurisdiction version of the survey will be completed by leaders at the top administrative levels responsible for jurisdiction-wide Systems of Care implementation and expansion. The local service delivery survey will be completed by managers and other relevant staff working at direct service agencies within the local service system participating in the Systems of Care Expansion for the grantee.

Administration:

The survey will be self-administered electronically via an online interactive survey program. The survey will be prepopulated by the National Evaluation Team (NET) with specific agencies and organizations involved in the particular Systems of Care. In addition to the prepopulated organizations, the respondent will have the opportunity to include additional organizations with whom they are collaborating regarding Systems of Care Expansion Implementation Efforts. The survey will be administered twice per grantee, including a baseline within the first 18 months of the start of the grant and a follow up 2-3 years later. This survey is only conducted for implementation grantees.

Attachment 4b

OMB No. 0930-03xx

Expiration Date: xx/xx/xx

INFORMED CONSENT

As the Network Analysis Jurisdiction Level and the Network Analysis Local System Level, are online, self-administered surveys, an informed consent statement will be displayed on the screen when the respondent first accesses the surveys online. After the informed consent statements are displayed, the respondent will be asked if they agree to participate in the survey. The respondent will be able to proceed only after checking “Yes” for agreement to participate.

Attachment 4c OMB No. xxxx-xxxx

Expiration Date: xx/xx/201x

CHILDREN’S MENTAL HEALTH INITIATIVE

NATIONAL SYSTEM OF CARE EXPANSION EVALUATION

NETWORK ANALYSIS - JURISDICTION

INTRODUCTION

Thank you for your willingness to complete the Jurisdiction Level Network Survey. The purpose of this survey is to assess the interrelationships between child-serving agencies and organizational partners within system of care.

CONFIDENTIALITY/INFORMED CONSENT

This survey was developed by the National Evaluation Team.

In this survey, you will be asked to answer a series of questions regarding your agency/organization’s collaborations with other child serving agencies and organizations within the jurisdiction.

Your participation is completely voluntary.  You have the right to stop at any time or to refuse to answer any question.

Your responses to these questions will be kept confidential and will not be shared outside of the evaluation team. In any of our reports, your responses will be combined with other people’s responses, so your answers will never be attributed to your name.

By submitting this form you are indicating that you have read the description of the tool above and that you agree to participate.

[] Agree to Participate

If you have any questions, please contact the National Evaluation Team at cmhieval@westat.com

INSTRUCTIONS

This survey takes approximately 30 minutes to complete. Please try to answer each question on the basis of your impressions of how your organization works with partner agencies and other organizations. If you feel that you do not have enough information to answer any particular question, please select the “don’t know” option rather than leaving the item blank.

For the purpose of this study, the agency/organization for which you are responding is: [name of respondent’s organizational affiliation]  

After reading each question, you should respond to all agencies or organizations that are on the list. At the end of the list of agencies or organizations, there is a question that says “Other organization (please specify).” This allows you to: (1) Type in the name of any other organizational partners that are not included on the list; and (2) Respond to the question about that agency or organization. Specific instructions are provided at the beginning of each section.

Throughout the survey, the term “jurisdiction” refers to the broad state, multi-county, territory, or tribal area that received federal grant funds within which smaller community areas are providing direct services to children, youth and families.

We are interested in understanding your work with agencies and organizations at the jurisdiction level.

For your system of care, the term “jurisdiction” refers to [insert name of respondent’s jurisdiction].

Instructions for Questions 1 -2:

Please Read Carefully

• For each agency or organization, click on the "1" for "Yes" if you have some type of formal agreement or "0" for "No" if you do not.

• If you are unsure, provide a “best guess” rather than leaving blanks.

• Your response should reflect your agency’s or organization’s relationships, not your personal relationships.

Below are definitions of specific terms used in Question #1:

• Memo of Understanding (MOU): written interagency agreement or formal contract

• Liaison: formally designated contact person

• Legal Mandates: required by law or administrative regulations

1. Does your agency or organization have a formal agreement, such as a memo of understanding, a liaison, and or/or a legal mandate with any of the following agencies or organizations?

Please respond for each organization or agency.

	Yes	No
Organization 1	1	0
Organization 2	1	0
Organization 4	1	0
Organization 5	1	0
Organization 6	1	0
Organization 7	1	0
Organization 8	1	0
Organization 9	1	0
Other organization. Specify: _______________________	1	0
Other organization. Specify: _______________________	1	0
Other organization. Specify: _______________________	1	0

2. Does your agency or organization share access to electronic data and data systems with any of the following agencies or organizations?

Please respond for each organization or agency.

	Yes	No
Organization 1	1	0
Organization 2	1	0
Organization 4	1	0
Organization 5	1	0
Organization 6	1	0
Organization 7	1	0
Organization 8	1	0
Organization 9	1	0
Other organization. Specify: _______________________	1	0
Other organization. Specify: _______________________	1	0
Other organization. Specify:_______________________	1	0

Instructions for Questions 3-10:

Please Read Carefully

• Respond to the questions about each agency or organization on the list.

• For each item, use the scale of “1” to “4”

• If you are unsure about an item, please provide your best “guess rather than leaving the response blank.

• Your response should reflect your agency’s or organization’s relationships, not your personal relationships.

3. To what extent does your agency or organization work with the following agencies or organizations to develop jurisdiction-wide policies on the intended system of care population (e.g., definition, eligibility requirements)?

Please respond for each organization or agency.

	Not at all	A little	Somewhat	A lot	Don’t Know
Organization 1	1	2	3	4	99
Organization 2	1	2	3	4	99
Organization 4	1	2	3	4	99
Organization 5	1	2	3	4	99
Organization 6	1	2	3	4	99
Organization 7	1	2	3	4	99
Organization 8	1	2	3	4	99
Organization 9	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99

4. In the past year, how often has your agency or organization held joint expansion planning and implementation meetings with the following agencies or organizations?

Please respond for each organization or agency.

	Never	Less than 10 times per year	11 to 14 times per year	15 or more times a year	Don’t Know
Organization 1	1	2	3	4	99
Organization 2	1	2	3	4	99
Organization 4	1	2	3	4	99
Organization 5	1	2	3	4	99
Organization 6	1	2	3	4	99
Organization 7	1	2	3	4	99
Organization 8	1	2	3	4	99
Organization 9	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99

5. To what extent does your agency or organization integrate funding, share funding, or make shared funding decisions (e.g., blended funding, braided funding) about service delivery for children with serious emotional and behavioral disorders and their families with the following agencies or organizations?

Please respond for each organization or agency.

	Not at all	A little	Somewhat	A lot	Don’t Know
Organization 1	1	2	3	4	99
Organization 2	1	2	3	4	99
Organization 4	1	2	3	4	99
Organization 5	1	2	3	4	99
Organization 6	1	2	3	4	99
Organization 7	1	2	3	4	99
Organization 8	1	2	3	4	99
Organization 9	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99

6. To what extent does your agency or organization collaborate with the following agencies or organizations at the jurisdiction level, to support interagency collaboration at the local-system level?

Please respond for each organization or agency.

	Not at all	A little	Somewhat	A lot	Don’t Know
Organization 1	1	2	3	4	99
Organization 2	1	2	3	4	99
Organization 4	1	2	3	4	99
Organization 5	1	2	3	4	99
Organization 6	1	2	3	4	99
Organization 7	1	2	3	4	99
Organization 8	1	2	3	4	99
Organization 9	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99

7. To what extent does your agency or organization collaborate with the following agencies or organizations to improve access to services across the jurisdiction?

Please respond for each organization or agency.

	Not at all	A little	Somewhat	A lot	Don’t Know
Organization 1	1	2	3	4	99
Organization 2	1	2	3	4	99
Organization 4	1	2	3	4	99
Organization 5	1	2	3	4	99
Organization 6	1	2	3	4	99
Organization 7	1	2	3	4	99
Organization 8	1	2	3	4	99
Organization 9	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99

8. To what extent does your agency or organization coordinate efforts at the jurisdiction level with the following agencies or organizations to empower family leadership in system of care implementation and expansion?

Please respond for each organization or agency.

	Not at all	A little	Somewhat	A lot	Don’t Know
Organization 1	1	2	3	4	99
Organization 2	1	2	3	4	99
Organization 4	1	2	3	4	99
Organization 5	1	2	3	4	99
Organization 6	1	2	3	4	99
Organization 7	1	2	3	4	99
Organization 8	1	2	3	4	99
Organization 9	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99

9. To what extent does your agency or organization coordinate efforts at the jurisdiction level with the following agencies or organizations to empower youth leadership in system of care implementation and expansion?

Please respond for each organization or agency.

	Not at all	A little	Somewhat	A lot	Don’t Know
Organization 1	1	2	3	4	99
Organization 2	1	2	3	4	99
Organization 4	1	2	3	4	99
Organization 5	1	2	3	4	99
Organization 6	1	2	3	4	99
Organization 7	1	2	3	4	99
Organization 8	1	2	3	4	99
Organization 9	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99

10. To what extent does your agency or organization collaborate with the following agencies or organizations at the jurisdiction level to support the implementation of evidence-supported models in the delivery of services and supports?

Please respond for each organization or agency.

	Not at all	A little	Somewhat	A lot	Don’t Know
Organization 1	1	2	3	4	99
Organization 2	1	2	3	4	99
Organization 4	1	2	3	4	99
Organization 5	1	2	3	4	99
Organization 6	1	2	3	4	99
Organization 7	1	2	3	4	99
Organization 8	1	2	3	4	99
Organization 9	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99

End of Instrument:

Thank you for participating in the Network Analysis portion of the National Systems of Care Expansion Evaluation.

Attachment 4d

OMB No. xxxx-xxxx

Expiration Date: xx/xx/201x

CHILDREN’S MENTAL HEALTH INITIATIVE

NATIONAL SYSTEM OF CARE EXPANSION EVALUATION

NETWORK STUDY – LOCAL SYSTEM SURVEY

INTRODUCTION

Thank you for your willingness to complete the Local System Level Network Survey. The purpose of this survey is to assess the interrelationships between child-serving organizational partners within systems of care.

CONFIDENTIALITY/INFORMED CONSENT

This survey was developed by the National Evaluation Team.

In this survey, you will be asked to answer a series of questions regarding your organization’s collaborations with other child-serving organizations.

Your participation is completely voluntary.  You have the right to stop at any time or to refuse to answer any question.

Your responses to these questions will be kept confidential and will not be shared outside of the evaluation team. In any of our reports, your responses will be combined with other people’s responses, so your answers will never be attributed to your name.

By submitting this form you are indicating that you have read the description of the tool above and that you agree to participate.

[] Agree to Participate

If you have any questions, please contact the National Evaluation Team at cmhieval@westat.com

INSTRUCTIONS

This survey takes approximately 30 minutes to complete. Please try to answer each question on the basis of your impressions of how your organization works with partner organizations. If you feel that you do not have enough information to answer any particular question, please select the “don’t know” option rather than leaving the item blank.

For the purpose of this study, the organization for which you are responding is: [insert name of respondent’s organizational affiliation] 

After reading each question, you should respond to all organizations that are on the list. At the end of the list of organizations, there is a question that says “Other organization (please specify).” This allows you to: (1) Type in the name of any other organizational partners that are not included on the list; and (2) Respond to the question about that organization. Specific instructions are provided at the beginning of each section.

We are interested in understanding your work with organizations at the local service delivery level - the smaller community areas within your system of care that are providing direct services to children, youth and families.

Instructions for Question 1:

Please Read Carefully

• For each agency or organization, click on the "1" for "Yes" if you have some type of formal agreement or "0" for "No" if you do not.

• If you are unsure, provide a “best guess” rather than leaving blanks.

• Your response should reflect your organization’s relationships, not your personal relationships.

Below are definitions of specific terms used in Question #1:

• Memo of Understanding (MOU): written interagency agreement or formal contract

• Liaison: formally designated contact person

• Legal Mandates: required by law or administrative regulations

1. Does your organization have a formal agreement, such as a memo of understanding, a liaison, and or/or a legal mandate with any of the following organizations?

Please respond for each organization or agency.

	Yes	No
Organization 1	1	0
Organization 2	1	0
Organization 4	1	0
Organization 5	1	0
Organization 6	1	0
Organization 7	1	0
Organization 8	1	0
Organization 9	1	0
Other organization. Specify: _______________________	1	0
Other organization. Specify: _______________________	1	0
Other organization. Specify: _______________________	1	0

Instructions for Questions 2-11:

Please Read Carefully

• Respond to the questions about each organization on the list

• For each item, use the scale of "1" to "4"

• If you are unsure about an item, please provide your best "guess" rather than leaving the response blank.

2. To what extent does your organization collaborate with the following organizations at the local service delivery level to develop eligibility criteria for system of care clients?

Please respond for each organization.

	Not at all	A little	Somewhat	A lot	Don’t Know
Organization 1	1	2	3	4	99
Organization 2	1	2	3	4	99
Organization 4	1	2	3	4	99
Organization 5	1	2	3	4	99
Organization 6	1	2	3	4	99
Organization 7	1	2	3	4	99
Organization 8	1	2	3	4	99
Organization 9	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99

3. How often does your organization hold joint staffing or case consultation meetings for individual children and families with the following organizations?

Please respond for each organization.

	Never	Less than 10 times per year	11 to 14 times per year	15 or more times a year	Don’t Know
Organization 1	1	2	3	4	99
Organization 2	1	2	3	4	99
Organization 4	1	2	3	4	99
Organization 5	1	2	3	4	99
Organization 6	1	2	3	4	99
Organization 7	1	2	3	4	99
Organization 8	1	2	3	4	99
Organization 9	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99

4. To what extent does your organization develop joint policies and procedures with the following organizations to support system of care expansion and implementation?

Please respond for each organization.

	Not at all	A little	Somewhat	A lot	Don’t Know
Organization 1	1	2	3	4	99
Organization 2	1	2	3	4	99
Organization 4	1	2	3	4	99
Organization 5	1	2	3	4	99
Organization 6	1	2	3	4	99
Organization 7	1	2	3	4	99
Organization 8	1	2	3	4	99
Organization 9	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99

5. To what extent does your organization integrate pooled, braided, or blended funding with the following organizations to support the direct delivery of services and supports for children with serious emotional and behavioral disorders and their families?

Please respond for each organization.

	Not at all	A little	Somewhat	A lot	Don’t Know
Organization 1	1	2	3	4	99
Organization 2	1	2	3	4	99
Organization 4	1	2	3	4	99
Organization 5	1	2	3	4	99
Organization 6	1	2	3	4	99
Organization 7	1	2	3	4	99
Organization 8	1	2	3	4	99
Organization 9	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99

6. How often does your organization work with the following organizations to cross train staff on issues related to the delivery of mental health services specific to system of care principles?

Please respond for each organization.

	Never	Less than 10 times per year	11 to 14 times per year	15 or more times a year	Don’t Know
Organization 1	1	2	3	4	99
Organization 2	1	2	3	4	99
Organization 4	1	2	3	4	99
Organization 5	1	2	3	4	99
Organization 6	1	2	3	4	99
Organization 7	1	2	3	4	99
Organization 8	1	2	3	4	99
Organization 9	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99

7. To what extent does your organization collaborate with the following organizations to develop quality assurance and/or evaluation processes?

Please respond for each organization.

	Not at all	A little	Somewhat	A lot	Don’t Know
Organization 1	1	2	3	4	99
Organization 2	1	2	3	4	99
Organization 4	1	2	3	4	99
Organization 5	1	2	3	4	99
Organization 6	1	2	3	4	99
Organization 7	1	2	3	4	99
Organization 8	1	2	3	4	99
Organization 9	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99

8. To what extent does your organization collaborate with the following organizations to implement and expand evidence-supported practices?

Please respond for each organization.

	Not at all	A little	Somewhat	A lot	Don’t Know
Organization 1	1	2	3	4	99
Organization 2	1	2	3	4	99
Organization 4	1	2	3	4	99
Organization 5	1	2	3	4	99
Organization 6	1	2	3	4	99
Organization 7	1	2	3	4	99
Organization 8	1	2	3	4	99
Organization 9	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99

9. To what extent does your organization collaborate with the following organizations to promote cultural competence in service delivery?

Please respond for each organization.

	Not at all	A little	Somewhat	A lot	Don’t Know
Organization 1	1	2	3	4	99
Organization 2	1	2	3	4	99
Organization 4	1	2	3	4	99
Organization 5	1	2	3	4	99
Organization 6	1	2	3	4	99
Organization 7	1	2	3	4	99
Organization 8	1	2	3	4	99
Organization 9	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99

10. To what extent does your organization collaborate with the following organizations to involve youth in planning and implementing system of care?

Please respond for each organization.

	Not at all	A little	Somewhat	A lot	Don’t Know
Organization 1	1	2	3	4	99
Organization 2	1	2	3	4	99
Organization 4	1	2	3	4	99
Organization 5	1	2	3	4	99
Organization 6	1	2	3	4	99
Organization 7	1	2	3	4	99
Organization 8	1	2	3	4	99
Organization 9	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99

11. To what extent does your organization collaborate with the following organizations to involve families in planning and implementing system of care?

Please respond for each organization.

	Not at all	A little	Somewhat	A lot	Don’t Know
Organization 1	1	2	3	4	99
Organization 2	1	2	3	4	99
Organization 4	1	2	3	4	99
Organization 5	1	2	3	4	99
Organization 6	1	2	3	4	99
Organization 7	1	2	3	4	99
Organization 8	1	2	3	4	99
Organization 9	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99
Other organization. Specify: _______________________	1	2	3	4	99

End of Survey:

Thank you for participating in the Network Analysis portion of the National Systems of Care Expansion Evaluation.

26

Attachment 4: Network Analysis