Semi-Annual Service Provider Assessment

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

Draft Content of Liberty Data Collection Template

(Service Providers)

OWH IPV Cross-Site Evaluation

[Note to programmer: Specific programming instructions (e.g., skip and display logic, etc.) are provided within brackets]

Introduction

The Office on Women’s Health is conducting a cross-site evaluation of the IPV Provider Network program, through which you have an agreement with {NORC will specify Grantee: __}. Thank you for providing information about your services related to the IPV Provider Network program.

Additionally, OWH also understands that your organization may or may not have special plans for serving clients referred by {NORC will specify Grantee: __} (i.e., specialized training, or specific protocols for monitoring and follow-up). For organizational protocols related to the IPV Provider Network program that you are planning but have not yet implemented, you will be asked questions about future implementation plans. Please answer these questions as they reflect your current concrete plans for future implementation (please do not select options simply because they are under consideration, for example).

OWH understands that there may be nuances to your replies to this survey. An opportunity to explain any of your responses will be available in a follow-up telephone interview.

Context: Description of organization’s services

1. Which of the following services does your organization provide or assist with? Please select all that apply.

   1. Health/Medical care

   2. Domestic violence

   3. Mental health

   4. Employment

   5. Housing

   6. Legal/Court services

   7. Substance use

   8. Transportation

   9. Education

   10. Other (please specify): ________________

Module I: Description of organizational staff training

2. Does your organization provide any special training on how to handle cases referred by [INSERT GRANTEE NAME/SITE]?

1. Yes, we provide special training to our staff for managing these cases.

2. Not yet, but we are planning to provide special training.

3. No, we do not plan to provide any special training for managing these cases.

[IF Q2=B, DISPLAY THE FOLLOWING TEXT]:

OWH understands that you have not yet begun training. Thinking about your current plans for future training, please answer the following questions.

[IF Q2=C, SKIP TO MODULE II]

[IF Q2=A]

[IF Q2=B]

Please indicate who conducts the trainings. Please select all that apply. IPV expert from [GRANTEE NAME/SITE] IPV expert from intervention site organization IPV expert from 3rd party organization Staff member from [GRANTEE NAME/SITE] who has undergone the same training Staff member from intervention site organization who has undergone the same training Other (please specify): ________________

Please indicate who will be conducting the trainings. Please select all that apply. IPV expert from [GRANTEE NAME/SITE] IPV expert from intervention site organization IPV expert from 3rd party organization Staff member from [GRANTEE NAME/SITE] who has undergone the same training Staff member from intervention site organization who has undergone the same training Other (please specify): ________________

[IF Q2=A]	[IF Q2=B]
Please indicate which of the staff positions are required to attend the trainings. Please select all that apply. Management Administrative staff Case workers Other (please specify): ______________	Please indicate which of the staff positions will be required to attend the trainings. Please select all that apply. Management Administrative staff Case workers Other (please specify): ______________

[IF Q2=A]	[IF Q2=B]
Are trained staff required to attend repeat or refresher trainings? Yes No	Will trained staff be required to attend repeat or refresher trainings? Yes No

Module II: Characteristics of referral services and procedures

6. Does your organization currently serve clients referred by [INSERT GRANTEE NAME]?

   1. Yes, we serve clients referred to our organization by [INSERT GRANTEE NAME].

   2. Not yet, but we are planning to serve clients referred by [INSERT GRANTEE NAME].

[IF Q6=B, DISPLAY THE FOLLOWING TEXT]:

OWH understands that you have not yet begun serving clients referred by [INSERT GRANTEE NAME]. Thinking about your current plans for future services, please answer the following questions.

[IF Q6=A]

[IF Q6=B]

Which of the following groups of IPV referrals does your organization serve? Please select all that apply. Women, ages 18+ Transgender Women, ages 18+ Men, ages 18+ Transgender Men, ages 18+ Gender Non-Conforming/Other, ages 18+ Girls, ages 17 and younger (please specify age range served _________) Transgender Girls, ages 17 and younger (please specify age range served _________) Boys, ages 17 and younger (please specify age range served _________) Transgender Boys, ages 17 and younger (please specify age range served _________) Gender Non-Conforming/Other, ages 17 and younger (please specify age range served _________)

Which of the following groups of potential IPV referrals does your organization plan to serve? Please select all that apply. Women, ages 18+ Transgender Women, ages 18+ Men, ages 18+ Transgender Men, ages 18+ Gender Non-Conforming/Other, ages 18+ Girls, ages 17 and younger (please specify age range served _________) Transgender Girls, ages 17 and younger (please specify age range served _________) Boys, ages 17 and younger (please specify age range served _________) Transgender Boys, ages 17 and younger (please specify age range served _________) Gender Non-Conforming/Other, ages 17 and younger (please specify age range served _________)

[IF Q6=A]

[IF Q6=B]

How would you describe [INSERT GRANTEE NAME/SITE]’s procedures followed for referring individuals to your organization? Please select all that apply. [GRANTEE NAME/SITE] calls us with the individual referred client on the phone at the same time to confirm connection. [GRANTEE NAME/SITE] introduces the individual referred client (on-site at the clinic) in person to confirm connection. [GRANTEE NAME/SITE] calls or emails us information about individual referred clients, but client makes her own contact with our agency. [GRANTEE NAME/SITE] follows up to confirm our connection with the referred client. [GRANTEE NAME/SITE] does not follow up to confirm our connection with the referred client. Client makes her own contact with our agency. [GRANTEE NAME/SITE] calls or emails us with summary information about list of clients from time to time. Other (please specify): _______________

How would you describe [INSERT GRANTEE NAME/SITE]’s planned procedures for referring individuals to your organization? Please select all that apply. [GRANTEE NAME/SITE] will call us with the individual referred client on the phone at the same time to confirm connection. [GRANTEE NAME/SITE] will introduce the individual referred client (on-site at the clinic) in person to confirm connection. [GRANTEE NAME/SITE] will call or email us information about individual referred clients, but client makes her own contact with our agency. [GRANTEE NAME/SITE] will follow up to confirm our connection with the referred client. [GRANTEE NAME/SITE] will not follow up to confirm our connection with the referred client. Client will make her own contact with our agency. [GRANTEE NAME/SITE] will call or email us with summary information about list of clients from time to time. Other (please specify): _______________

[IF Q6=A]	[IF Q6=B]
Who in your organization handles intake of the clients referred by [INSERT GRANTEE NAME/SITE]? Dedicated administrative position Dedicated caseworker Anyone available from group of caseworkers Other (please specify): _________________	Who in your organization will handle intake of clients referred by [INSERT GRANTEE NAME/SITE]? Dedicated administrative position Dedicated caseworker Anyone available from group of caseworkers Other (please specify): _________________

10. Are clients referred by [INSERT GRANTEE NAME/SITE] documented or tracked differently from your usual clientele in your record system?

1. Yes

1. Please briefly describe the ways in which documentation and/or tracking differ for referrals from [INSERT GRANTEE NAME/SITE] and your usual clientele: ___________________

2. No

11. Do the services you provide to clients referred by [INSERT GRANTEE NAME/SITE] differ than those you provide to your usual clientele?

1. Yes

1. Please briefly describe the ways in which these services differ for referrals from [INSERT GRANTEE NAME/SITE] and your usual clientele : ________________

2. No

Module III: Procedures for monitoring and follow-up of referred clients

12. Do you have a policy in place that specifies procedures for your staff to follow-up and monitor clients referred by [INSERT GRANTEE NAME/SITE]?

1. Yes, our organization has procedures guiding staff follow-up of clients referred by [INSERT GRANTEE NAME/SITE].

2. Yes our organization has procedures guiding staff follow-up of clients referred by [INSERT GRANTEE NAME/SITE], but we have not yet had clients referred by [INSERT GRANTEE NAME/SITE] to follow.

3. No, our organization does not have specific procedures guiding staff follow-up of clients referred by [INSERT GRANTEE NAME/SITE].

[IF Q12=B, DISPLAY THE FOLLOWING TEXT]:

OWH understands that you have not yet have yet had clients referred by [INSERT GRANTEE NAME/SITE]. Thinking about your current plans for future implementation of monitoring and follow-up, please answer the following related questions.

[IF Q12=C, SKIP TO MODULE IV]

[IF Q12=A]

[IF Q12=B]

At what time intervals does follow-up occur? (If your program design has variability in the schedule of follow-up, please report the different time intervals that are relevant to your program) _____________ Set schedule (e.g., every month, every 3 months, semi-annually) What is the time schedule? ______________ According to the client’s own schedule (e.g., when she calls or returns to our office) Other (please specify): _____________

At what time intervals will follow-up occur? (If your program design has variability in the schedule of follow-up, please report the different time intervals that are relevant to your program) _____________ Set schedule (e.g., every month, every 3 months, semi-annually) What is the time schedule? ______________ According to the client’s own schedule (e.g., when she calls or returns to our office) Other (please specify): _____________

[IF Q12=A]	[IF Q12=B]
For how long does your organization specifically follow the clients referred by [INSERT GRANTEE NAME/SITE]? (If your organizational protocols allow for variability in the duration of follow-up, please report the different time intervals that are relevant to your program. If follow-up is indefinite, please respond to that effect.) _____________	For how long will your organization specifically follow the clients referred by [INSERT GRANTEE NAME/SITE]? (If your organizational protocols allow for variability in the duration of follow-up, please report the different time intervals that are relevant to your program. If follow-up will be indefinite, please respond to that effect.) _____________

Module IV: Challenges and contextual barriers to serving referred clients

15. What types of system/institutional challenges has your organization experienced with regard to serving clients referred by [INSERT GRANTEE NAME/SITE]? Please select all that apply. If a particular issue is not relevant to your program or relationship with [INSERT GRANTEE NAME/SITE], please mark “Not applicable.”

	Experiencing this issue	Not experiencing this issue	Not applicable
Insufficient staff to support referred clients
Insufficiently trained staff
Staff implement protocol for serving referred clients inconsistently
Staff implement protocol for follow up of referred clients inconsistently
Staff document information about referred clients inconsistently
Staff document follow-up information of referred clients inconsistently
Insufficient access to interpretation/translation services
Communication challenges among organizational staff
Communication challenges between [GRANTEE NAME] staff and organizational staff
Insufficient ability to discern whether clients were referred by [GRANTEE NAME]
Other (please specify):___________________

16. What types of client-related challenges has your organization experienced with regard to serving clients referred by [INSERT GRANTEE NAME/SITE]? Please select all that apply. If a particular issue is not relevant to your program, please mark “Not applicable.”

	Experiencing this issue	Not experiencing this issue	Not applicable
Referred clients difficult to reach for follow-up due to client non-responsiveness
Loss of contact due to change in client contact information (phone, email, address)
Client lacks transportation
Client lacks childcare
Other (please specify): _______________

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-xxxx. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer