Direct Services Survey

Project LAUNCH Direct Services Survey

We are conducting a study to learn about the social and emotional development of children from birth through eight years of age. This study is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), an agency within the U.S. Department of Health and Human Services (HHS). By collecting information from Project LAUNCH grantees, we seek to gain a better understanding of direct services that are being provided through the grant to further child health and well-being in LAUNCH communities. We estimate this survey will take approximately 8.5 hours to complete, including the time it may take to gather the information needed to respond to the questions. Your participation in the survey is voluntary, and your responses will be kept private to the extent permitted by law. As described in the (XXXX grantee number entered here) cooperative agreement award this data collection must be completed by the grantee.

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 number for this information collection is 0970-0373 and the expiration date is XX/XX/XXXX.

How much did you spend from the current funding year’s overall Project LAUNCH budget since the last reporting period? $__________

• How much did you spend from your current funding year’s local Project LAUNCH budget since the last reporting period? $__________

• How much did you spend from your current funding year’s state Project LAUNCH budget since the last reporting period? $__________

HOME VISTING

Did you implement any home visiting activities during the current reporting period?

• Yes

• No

If NO, why did you not implement any home visiting activities during the current reporting period?

• There is another source of funding for this strand. Please specify source of funding: _________________

• Plan to implement activities in the future, but still in the planning stages.

• Policy barriers exist (e.g., delays in agreements/contracts among agencies).

• Wrapping up grant activities.

• Other reason. Please specify: _________________

(Next page)

Add Activity

Please list all of the home visiting activities that you have implemented during the current reporting period and answer the questions in the columns to the right. Please click on “Add activity” to add new activities to the table.

Activity	1) Please provide a brief description of this activity (100 words or less)	2) What type of activity is this?	3) How many times did this activity occur in the past 6 months?	4) Who directly participates in this activity?	5) How many of these individuals participated in the activity over the last 6 months?	6) Who is intended to benefit from this activity? (Note: This may not be the same people that you indicated in question 4)	7) If this activity was intended to help children, what specific age range of child?	8) Where is the activity implemented?
Select one response Screening / assessment of children Screening/ assessment of adults Consultation/ reflective supervision with home visitors Training for home visitors (e.g., child mental health and socio-emotional development, adult behavioral health, trauma, etc.) Training for home visitors on use of assessment tools Conducted home visits with parents/children Providing brief intervention crisis interviews alongside home visitors		Select one response Professional training Screening/ assessment Classroom intervention Parent/family education activity Consultation	Free text (numerical value only)	Select all that apply. Administrators Health Providers Home visitors Mental health providers Social service providers Educators (teachers, early childhood) Parents Children Other, Please specify:	Select a response by checking the box to the left and then fill in the number in the blank. Health Providers______ Home visitors Educators_____ Parents_____ Children ages 0-2____ ages 3-4____ ages 5-6____ ages 7-8____ ages 8 and over____ Other_____	Select all that apply. Health Providers Educators (teachers, early childhood, or home visitors) Parents Children Other, Please specify:	Select all that apply. Prenatal 0-2 3-4 5-6 7-8	Select all that apply. Children’s homes Schools Early childcare education centers Community-based locations (e.g., community centers, service agencies, faith-based locations) Community mental health centers Medical provider’s offices Other, please describe: _________________

[Note: Questions below do not fit into table. Please answer for each activity listed.]

9) If children participated in the activity, please list the percentage of children who were:

Male: ______

Female: ____

Other (please specify): ____

Hispanic, Latino/a, or Spanish origin: _____

American Indian or Alaskan Native: _____

Asian: _____

Black or African-American: _____

Native Hawaiian or Other Pacific Islander: _____

White: _____

Other (please specify): ____

10. How much (in dollars) was spent on this activity in the current reporting period? $______

11. What percentage of the current grant year’s local LAUNCH funding was spent on this activity in the current reporting period? ______%

12. What percentage of the current grant year’s state LAUNCH funding was spent on this activity in the current reporting period? ______%

13. Did you receive other sources of funding for this activity in the current reporting period?

    • Yes

    • No

14. If yes, what percentage of the activity’s funding came from LAUNCH in the current reporting period? _____%

15. Did any volunteer workers support this activity during the current funding period?

    • Yes

    • No

16. (Only if yes to #15). Please indicate the number of volunteer workers and overall total number of volunteer hours that supported this activity during the current reporting period.

    • Number of volunteers: ___

    • Total number of volunteer hours: ___

Pop-up window for screening activities

Which of the following child screening or assessment tools did you use?

Screening tools for children
[Insert drop down / check box list of possible screening and assessment tools]
Name of Screening Tool	Number of Times Administered in Past 6 Months
Ages and Stages Questionnaire (ASQ-3)
Ages and Stages Questionnaire: Social-Emotional (ASQ:SE)
Bailey Scales for Infant Toddler Development – III
Child Behavior Checklist
Devereux Early Childhood Assessment (DECA)
Modified Checklist for Autism in Toddlers (M-CHAT)
Peabody Picture Vocabulary – 4
Pediatric Emotional Distress Scale (PEDS)
Pediatric Symptom Checklist (PSC)
Social Skills Improvement System
Survey for Well-Being of Young Children
Other screening or assessment tool. Please describe: _____________________

Which of the following adult screening or assessment tools did you use?

Screening tools for adults
[Insert drop down / check box list of possible screening tools]
Name of Screening Tool	Number of Times Administered in Past 6 Months
Beck Depression Inventory
CAGE-AID
CES-D
Conflict Tactics Scale
Edinburgh Postnatal Depression Scale (EPDS)
Kempe Family Stress Checklist
Patient Health Questionnaire (PHQ)
Survey for Well-Being of Young Children – Family Form
Other screening or assessment tool. Please describe: ______________________

Pop-up window for evidence-based home visiting programs

Which of the following evidence-based or promising home visiting program models did you implement?

• Child FIRST 

• Early Head Start - Home Visiting

• Early Intervention Program for Adolescent Mothers

• Early Start (New Zealand)

• Family Check-Up

• Family Spirit

• Healthy Families America (HFA)

• Healthy Steps

• Home Instruction for Parents of Preschool Youngsters (HIPPY)

• Maternal Early Childhood Sustained Home Visiting Program (MESCH)

• Minding the Baby

• Nurse Family Partnership (NFP)

• Oklahoma Community-Based Family Resource and Support Program

• Parents as Teachers (PAT)

• Play and Learning Strategies (PALS) Infant

• SafeCare Augmented

• State-Specific Home Visiting model. Please describe: ______________________

• Other Home Visiting model. Please describe: _______________________________

MENTAL HEALTH CONSULTATION

Did you implement any mental health consultation in school and ECE settings activities during the current reporting period?

• Yes

• No

If NO, why did you not implement any home visiting activities during the current reporting period?

• There is another source of funding for this strand. Please specify source of funding: _________________

• Plan to implement activities in the future, but still in the planning stages.

• Policy barriers exist (e.g., delays in agreements/contracts among agencies).

• Wrapping up grant activities.

• Other reason. Please specify: _________________

Add Activity

Please list all of the mental health consultation in school and ECE settings activities that you have implemented during the current reporting period and answer the questions in the columns to the right. Please click on “Add activity” to add new activities to the table.

Activity	Please provide a brief description of this activity (100 words or less)	What type of activity is this?	Who directly participates in this activity?	How many of these individuals participated in the activity over the last 6 months?	Who is intended to benefit from this activity?	If this activity was intended to help children, what specific age range of child?	Where is the activity implemented?
Programmatic/ classroom consultation Individual child/parent consultation Implementation of an evidence-based mental health consultation model Implementation of a social-emotional curriculum Training for ECE or school staff on child mental health and socio-emotional development		Select one response Professional training Screening/ assessment Classroom intervention Parent/family education activity Consultation	Select all that apply. Administrators Health Providers Educators Parents Children Other, Please specify:	Select a response by checking the box to the left and then fill in the number in the blank. Health Providers______ Educators_____ Parents_____ Children ages 0-2____ ages 3-4____ ages 5-6____ ages 7-8____ ages 8 and over____ Other_____	Select all that apply. Health Providers Educators Parents Children Other, Please specify:	Select all that apply. 0-2 3-4 5-6 7-8	Select all that apply. Children’s homes Schools Early childcare education centers Community-based locations (e.g., community centers, service agencies, faith-based locations) Community mental health centers Medical provider’s offices Other, please describe: _________________

[Note: Questions below do not fit into table. Please answer for each activity listed.]

9) If children participated in the activity, please list the percentage of children who were:

Male: ______

Female: ____

Other (please specify): ____

Hispanic, Latino/a, or Spanish origin: _____

American Indian or Alaskan Native: _____

Asian: _____

Black or African-American: _____

Native Hawaiian or Other Pacific Islander: _____

White: _____

Other (please specify): ____

10) How much (in dollars) was spent on this activity in the current reporting period? $______

11. What percentage of the current grant year’s local LAUNCH funding was spent on this activity in the current reporting period? ______%

12. What percentage of the current grant year’s state LAUNCH funding was spent on this activity in the current reporting period? ______%

13. Did you receive other sources of funding for this activity in the current reporting period?

    1. Yes

    2. No

14. If yes, what percentage of the activity’s funding came from LAUNCH in the current reporting period? _____%

15. Did any volunteer workers support this activity during the current funding period?

    1. Yes

    2. No

16. (Only if yes to #15). Please indicate the number of volunteer workers and overall total number of volunteer hours that supported this activity during the current reporting period.

    1. Number of volunteers: ___

    2. Total number of volunteer hours: ___

Pop-up window for evidence-based mental health consultation models implemented with teachers

Which of the following evidence-based or promising practice mental health consultation models did you implement?

• Georgetown University Guidance for Mental Health Consultation

• Family Connections Mental Health Consultation and Professional Development Model

• Pyramid Model, Center on the Social and Emotional Foundations for Early Learning (CSEFEL)

• State-Specific Model. Please describe: ___________________________

• Locally developed model. Please describe: _______________________________________

• Other model. Please describe: _________________________________

Pop-up window for evidence-based social-emotional curricula

Which of the following evidence-based or promising practice social-emotional curricula did you implement? (May be used with or without MHC)

• CESEFL – Social Emotional Foundations for Early Learning

• Incredible Years Teacher-Child Programs

• Second Step – Conflict Resolution for Teachers in Classrooms

• Other program. Please describe: ___________________________

INTEGRATING BEHAVIORAL AND PRIMARY HEALTH CARE

Did you implement any activities related to integrating behavioral health into primary health care during the current reporting period?

• Yes

• No

If NO, why did you not implement any home visiting activities during the current reporting period?

• There is another source of funding for this strand. Please specify source of funding: _________________

• Plan to implement activities in the future, but still in the planning stages.

• Policy barriers exist (e.g., delays in agreements/contracts among agencies).

• Wrapping up grant activities.

• Other reason. Please specify: _________________

(Next page)

Add Activity

Please list all of the activities related to integrating behavioral health into primary health care that you have implemented during the current reporting period and answer the questions in the columns to the right. Please click on “Add activity” to add new activities to the table.

Activity	Please provide a brief description of this activity (100 words or less)	What type of activity is this?	Who directly participates in this activity?	How many of these individuals participated in the activity over the last 6 months?	Who is intended to benefit from this activity?	If this activity was intended to help children, what specific age range of child?	Where is the activity implemented?
Screening/ assessment of children Screening/ assessment of adults Training for primary care staff on child mental health and socio-emotional development Mental health consultation (e.g. in well-child visits, phone consults) Mental health assessment Mental health brief intervention Referral to mental health treatment		Select one response Professional training Screening/ assessment Classroom intervention Parent/family education activity Consultation	Select all that apply. Administrators Health Providers Mental health providers Social service providers Educators Parents Children Other, Please specify:	Select a response by checking the box to the left and then fill in the number in the blank. Health Providers______ Educators_____ Parents_____ Children ages 0-2____ ages 3-4____ ages 5-6____ ages 7-8____ ages 8 and over____ Other_____	Select all that apply. Health Providers Educators Parents Children Other, Please specify:	Select all that apply. 0-2 3-4 5-6 7-8	Select all that apply. Children’s homes Schools Early childcare education centers Community-based locations (e.g., community centers, service agencies, faith-based locations) Community mental health centers Medical provider’s offices Other, please describe: _______________

[Note: Questions below do not fit into table. Please answer for each activity listed.]

9) If children participated in the activity, please list the percentage of children who were:

Male: ______

Female: ____

Other (please specify): ____

Hispanic, Latino/a, or Spanish origin: _____

American Indian or Alaskan Native: _____

Asian: _____

Black or African-American: _____

Native Hawaiian or Other Pacific Islander: _____

White: _____

Other (please specify): ____

10. How much (in dollars) was spent on this activity in the current reporting period? $______

11. What percentage of the current grant year’s local LAUNCH funding was spent on this activity in the current reporting period? ______%

12. What percentage of the current grant year’s state LAUNCH funding was spent on this activity in the current reporting period? ______%

13. Did you receive other sources of funding for this activity in the current reporting period?

    1. Yes

    2. No

14. If yes, what percentage of the activity’s funding came from LAUNCH in the current reporting period? _____%

15. Did any volunteer workers support this activity during the current funding period?

    1. Yes

    2. No

16. (Only if yes to #15). Please indicate the number of volunteer workers and overall total number of volunteer hours that supported this activity during the current reporting period.

    1. Number of volunteers: ___

    2. Total number of volunteer hours: ___

Pop-up window for screening activities

Which of the following child screening or assessment tools did you use?

Screening tools for children
[Insert drop down / check box list of possible screening and assessment tools]
Name of Screening Tool	Number of Times Administered in Past 6 Months
Ages and Stages Questionnaire (ASQ-3)
Ages and Stages Questionnaire: Social-Emotional (ASQ:SE)
Bailey Scales for Infant Toddler Development – III
Child Behavior Checklist
Devereux Early Childhood Assessment (DECA)
Modified Checklist for Autism in Toddlers (M-CHAT)
Peabody Picture Vocabulary – 4
Pediatric Emotional Distress Scale (PEDS)
Pediatric Symptom Checklist (PSC)
Social Skills Improvement System
Survey for Well-Being of Young Children
Other screening or assessment tool. Please describe: _____________________

Which of the following adult screening or assessment tools did you use?

Screening tools for adults
[Insert drop down / check box list of possible screening tools]
Name of Screening Tool	Number of Times Administered in Past 6 Months
Beck Depression Inventory
CAGE-AID
CES-D
Conflict Tactics Scale
Edinburgh Postnatal Depression Scale (EPDS)
Kempe Family Stress Checklist
Patient Health Questionnaire (PHQ)
Survey for Well-Being of Young Children – Family Form
Other screening or assessment tool. Please describe: ______________________

FAMILY STRENGTHENING

Did you implement any family strengthening activities during the current reporting period?

• Yes

• No

If NO, why did you not implement any home visiting activities during the current reporting period?

• There is another source of funding for this strand. Please specify source of funding: _________________

• Plan to implement activities in the future, but still in the planning stages.

• Policy barriers exist (e.g., delays in agreements/contracts among agencies).

• Wrapping up grant activities.

• Other reason. Please specify: _________________

Add Activity

Please list all of the family strengthening activities you have implemented during the current reporting period and answer the questions in the columns to the right. Please click on “Add activity” to add new activities to the table.

Activity	Please provide a brief description of this activity (100 words or less)	What type of activity is this?	Who directly participates in this activity?	How many of these individuals participated in the activity over the last 6 months?	Who is intended to benefit from this activity?	If this activity was intended to help children, what specific age range of child?	Where is the activity implemented?
Screening/ assessment of children Screening/ assessment of adults Training for providers on socio-emotional screening Training for providers on child socio-emotional development Training for providers on an evidence-based parenting intervention to be implemented (e.g., Incredible Years, Nurturing Parenting Programs) Implementation of a family strengthening framework Implementation of an evidence-based parent education or support program Implementation of a therapeutic intervention Providing mental health consultant to family strengthening program staff		Select one response Professional training Screening/ assessment Classroom intervention Parent/family education activity Consultation	Select all that apply. Administrators Health Providers Mental health providers Social service providers Educators Parents Children Other, Please specify:	Select a response by checking the box to the left and then fill in the number in the blank. Health Providers______ Educators_____ Parents_____ Children ages 0-2____ ages 3-4____ ages 5-6____ ages 7-8____ ages 8 and over____ Other_____	Select all that apply. Health Providers Educators Parents Children Other, Please specify:	Select all that apply. 0-2 3-4 5-6 7-8	Select all that apply. Children’s homes Schools Early childcare education centers Community-based locations (e.g., community centers, service agencies, faith-based locations) Community mental health centers Medical provider’s offices Other, please describe: _________________

9) (Does not fit in table – please answer for each activity listed) If children participated in the activity, please list the percentage of children who were:

Male: ______

Female: ____

Other (please specify): ____

Hispanic, Latino/a, or Spanish origin: _____

American Indian or Alaskan Native: _____

Asian: _____

Black or African-American: _____

Native Hawaiian or Other Pacific Islander: _____

White: _____

Other (please specify): ____

10. How much (in dollars) was spent on this activity in the current reporting period? $______

11. What percentage of the current grant year’s local LAUNCH funding was spent on this activity in the current reporting period? ______%

12. What percentage of the current grant year’s state LAUNCH funding was spent on this activity in the current reporting period? ______%

13. Did you receive other sources of funding for this activity in the current reporting period?

    1. Yes

    2. No

14. If yes, what percentage of the activity’s funding came from LAUNCH in the current reporting period? _____%

15. Did any volunteer workers support this activity during the current funding period?

    1. Yes

    2. No

16. (Only if yes to #15). Please indicate the number of volunteer workers and overall total number of volunteer hours that supported this activity during the current reporting period.

    1. Number of volunteers: ___

    2. Total number of volunteer hours: ___

Pop-up window for screening activities

Which of the following child screening or assessment tools did you use?

Screening tools for children
[Insert drop down / check box list of possible screening and assessment tools]
Name of Screening Tool	Number of Times Administered in Past 6 Months
Ages and Stages Questionnaire (ASQ-3)
Ages and Stages Questionnaire: Social-Emotional (ASQ:SE)
Bailey Scales for Infant Toddler Development – III
Child Behavior Checklist
Devereux Early Childhood Assessment (DECA)
Modified Checklist for Autism in Toddlers (M-CHAT)
Peabody Picture Vocabulary – 4
Pediatric Emotional Distress Scale (PEDS)
Pediatric Symptom Checklist (PSC)
Social Skills Improvement System
Survey for Well-Being of Young Children
Other screening or assessment tool. Please describe: _____________________

Which of the following adult screening or assessment tools did you use?

Screening tools for adults
[Insert drop down / check box list of possible screening tools]
Name of Screening Tool	Number of Times Administered in Past 6 Months
Beck Depression Inventory
CAGE-AID
CES-D
Conflict Tactics Scale
Edinburgh Postnatal Depression Scale (EPDS)
Kempe Family Stress Checklist
Patient Health Questionnaire (PHQ)
Survey for Well-Being of Young Children – Family Form
Other screening or assessment tool. Please describe: ______________________

Pop-up window for family strengthening frameworks

Which family strengthening frameworks did you use?

• Positive Behavioral Interventions & Supports (PBIS)

• Touchpoints Approach

• Strengthening Families Framework

• Other. Please describe: _________________________

Pop-up window for evidence-based parent education or support programs

Which of the following evidence-based or promising practice family strengthening programs did you implement with parents?

• ACT – Parents Raising Safe Kids Program

• Centering Parenting

• Centering Pregnancy

• Chicago Parenting Program

• Circle of Security

• Effective Black Parenting Program

• Incredible Years Parent Training

• Legacy for Children

• Newborn Behavioral Observation

• Nurturing Parenting Program

• Parent Cafes

• Parent Child Interaction Therapy (PCIT)

• Parenting Wisely

• Positive Behavior Support

• Positive Indian Parenting

• Positive Parenting Program (Triple P)

• Systematic Training for Effective Parenting (STEP)

• Locally-developed or other family strengthening program model. Please describe: _________________________

Pop-up window for therapeutic interventions

Which of the following therapeutic interventions did you use?

• Trauma Recovery and Empowerment Model (TREM)

• Parent Child Interaction Therapy (PCIT)

• Other therapeutic intervention. Please describe: _____________________

OTHER DIRECT SERVICE ACTIVITIES

Did you implement any other direct services activities during the current reporting period?

• Yes

• No

If NO, why did you not implement any home visiting activities during the current reporting period?

• There is another source of funding for this strand. Please specify source of funding: _________________

• Plan to implement activities in the future, but still in the planning stages.

• Policy barriers exist (e.g., delays in agreements/contracts among agencies).

• Wrapping up grant activities.

• Other reason. Please specify: _________________

(Next page)

Add Activity

Please list all of the other direct services activities you have implemented during the current reporting period and answer the questions in the columns to the right. Please click on “Add activity” to add new activities to the table.

Activity	Please provide a brief description of this activity (100 words or less)	What type of activity is this?	Who directly participates in this activity?	How many of these individuals participated in the activity over the last 6 months?	Who is intended to benefit from this activity?	If this activity was intended to help children, what specific age range of child?	Where is the activity implemented?
Activity 1		Select one response Professional training Screening/ assessment Classroom intervention Parent/family education activity Consultation	Select all that apply. Administrators Health Providers Educators Parents Children Other, Please specify:	Select a response by checking the box to the left and then fill in the number in the blank. Health Providers______ Educators_____ Parents_____ Children ages 0-2____ ages 3-4____ ages 5-6____ ages 7-8____ ages 8 and over____ Other_____	Select all that apply. Health Providers Educators Parents Children Other, Please specify:	Select all that apply. 0-2 3-4 5-6 7-8	Select all that apply. Children’s homes Schools Early childcare education centers Medical provider’s offices Other, please describe: _________________

9) (Does not fit in table – please answer for each activity listed) If children participated in the activity, please list the percentage of children who were:

Male: ______

Female: ____

Other (please specify): ____

Hispanic, Latino/a, or Spanish origin: _____

American Indian or Alaskan Native: _____

Asian: _____

Black or African-American: _____

Native Hawaiian or Other Pacific Islander: _____

White: _____

Other (please specify): ____

10. How much (in dollars) was spent on this activity in the current reporting period? $_____

11. What percentage of the current grant year’s local LAUNCH funding was spent on this activity in the current reporting period? ______%

12. What percentage of the current grant year’s state LAUNCH funding was spent on this activity in the current reporting period? ______%

13. Did you receive other sources of funding for this activity in the current reporting period?

    1. Yes

    2. No

14. If yes, what percentage of the activity’s funding came from LAUNCH in the current reporting period? _____%

15. Did any volunteer workers support this activity during the current funding period?

    1. Yes

    2. No

16. (Only if yes to #15). Please indicate the number of volunteer workers and overall total number of volunteer hours that supported this activity during the current reporting period.

    1. Number of volunteers: ___

    2. Total number of volunteer hours: ___

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