3. MUSE Caregiver 6 12 Month Follow-Up Survey 7.25.18 CLEAN

DRAFT 7/25/18 OMB Control NO.: xxxx-xxxx

Expiration Date: xx/xx/20xx

Length of time for instrument: 30 minutes

MULTI-SITE IMPLEMENTATION EVALUATION OF TRIBAL HOME VISITING (MUSE)

CAREGIVER 6 & 12 MONTH FOLLOW-UP SURVEY

This collection of information is voluntary. Public reporting burden for this collection of information is estimated to average 30 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 number and expiration date for this collection are OMB #: 0970-XXXX, Exp: XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Kate Lyon, James Bell Associates; 3033 Wilson Blvd. Suite 650, Arlington, VA 22201; MUSE.info@jbassoc.com.

MUSE Caregiver Survey

Thank you for taking part in the Multi-Site Implementation Evaluation of Tribal Home Visiting (MUSE). The purpose of this study is to learn about tribal home visiting programs and the experiences of families receiving home visiting services. The questions on this survey are about you and your family and your experiences with the home visiting program.

We are asking you to take this survey because you are receiving home visiting services and your program is participating in the MUSE research study.

Your answers will be kept private. Only the research study team will have access to this information. Your answers will not be shared with your home visitor or anyone at the home visiting program or any other agencies. We will not report information collected in this study in a way that could identify you or your program.

Your participation in this survey is voluntary. If you choose to take the survey, it will take about 30 minutes. If you are unsure how to answer a question, please give the best answer you can instead of leaving it blank.

Do you want to take the survey?

• Yes  GO TO Next Page

• No  END Survey

A. BASIC QUESTIONS ABOUT YOURSELF

This section will ask questions about your personal background.

1. Are you or your partner currently pregnant or have you had a baby while participating in the home visiting program?

   • Yes

   • No

2. Who lives with you in your household now? Check all that apply.

• Your partner (husband/wife/boyfriend/girlfriend)

• Parents (yours or your partner’s)

• Grandparents (yours or your partner’s)

• Siblings (yours or your partner’s)

• Other relatives

• Other non-relatives

3. How many adults 18 years or older live in your household? If YOU are over 18, please include yourself. Enter 0 if none. _____

4. How many children between the ages of 6 to 17 live in your household? If YOU are under 18, please include yourself. Enter 0 if none. _____

5. How many children 5 years old or younger live in your household? Enter 0 if none. ______

6. If your income were to stop suddenly, how long do you think you would be able to cover your basic expenses (housing, food, car, etc.) on your current savings?

• Less than 1 month

• 1-2 months

• 2-6 months

• More than 6 months

B. EXPERIENCES IN HOME VISITING

1. How long have you been enrolled in the home visiting program?

• 5-7 months

• 7-11 months

• 11-13 months

• 13 months or longer

2. How often do you have home visits?

• Weekly

• About every 2 weeks

• About every 3 weeks

• About once a month

• Less often than once a month

• Don’t know

3. Is this more often, less often, or exactly as often as you would like visits to be?

• More often than I'd like

• Less often than I'd like

• Exactly as often as I would like

3. Who decides how often you have visits?

• It is totally my decision

• It is mostly my decision

• It is a decision my home visitor and I make equally

• It is mostly my home visitor’s decision

• It is totally my home visitor’s decision

3. Are your home visits longer than you’d like, shorter than you’d like, or just as long as you’d like?

• Longer than I’d like

• Shorter than I’d like

• Exactly as long as I’d like

3. Who decides how long your home visits will be?

• It is totally my decision

• It is mostly my decision

• It is a decision my home visitor and I make equally

• It is mostly my home visitor’s decision

• It is totally my home visitor’s decision

3. Think back to when important things were explained, before you agreed to enroll. How close are the services you receive to what you expected?

• Exactly what I expected

• Mostly what I expected

• A little what I expected

• Not at all what I expected

3. Please show whether you agree or disagree with the following:

		Strongly disagree	Disagree	Agree	Strongly agree
1	The home visiting program will help me reach my personal goals.				
2	The home visiting program will help my child reach his or her full potential.				
3	The home visiting program helps me feel good about myself and my job as a parent.				
4	The home visiting program is an excellent use of my time.				
5	The home visiting program helps me get the things I need for my family.				

3. How much has the support you have received in the home visiting program made a difference for you in these areas?

		A big difference		Some difference	A little difference	No difference		Not applicable
1	Connecting with others to talk to as supportive friends							
2	Being more connected to my community and culture							
3	Having my child be healthy							
4	Feeding my child (including formula and solids)							
5	My child’s development (learning new physical and social skills, language development, and coping with emotions)							
6	Managing my child's behavior							
7	Making child care arrangement							
8	Interacting with my child in a supportive and positive way							
9	Co-parenting with my child’s father/mother							
10	Taking care of my baby or child (bathing, diapering, sleep, routines, etc.)							
11	Keeping my child and home safe							
12	[SKIP If not currently pregnant/did not have a baby while participating in the program] Having a healthy pregnancy							
13	[SKIP If not currently pregnant/did not have a baby while participating in the program] Staying healthy after I have my baby							
14	[SKIP If not currently pregnant/did not have a baby while participating in the program] Breastfeeding							
15	Improving my overall health							
16	Eating more nutritious meals and exercising							
17	Using family planning							
18	Quitting smoking							
19	Quitting using alcohol or drugs							
20	Dealing with stress							
21	Dealing with sadness							
22	Getting more education or job training							
23	Getting a job, or getting a better job							
24	Having healthy relationships							
25	Dealing with partner or family violence							
26	Coping with my own past abuse or trauma							
27	Meeting basic needs such as food, utilities, healthcare, and housing							
28	Budgeting/making ends meet							

C. SETTING GOALS

1. Have you and your home visitor ever talked about your goals and developed a plan for reaching them? This might include making a list of goals that you would like to accomplish and steps you could take to reach those goals.

• Yes

• No  SKIP to Section D on page 5.

• Not sure  SKIP to Section D on page 5.

2. How were your goals identified?

• I identified the goals myself

• I identified the goals with help from my home visitor

• My home visitor identified the goals with help from me

• My home visitor identified the goals for me

3. Was YOUR role in setting the goals…

• Bigger than you would have liked

• Smaller than you would have liked

• Just right

4. How similar are the goals you identified to what you were originally hoping for when you started home visiting?

• Very similar

• Similar

• Different

• Very different

5. How satisfied are you with the goals you set?

• Very satisfied

• Satisfied

• Dissatisfied

• Very dissatisfied

6. About how often do you and your home visitor talk about your goals?

• Every visit

• Most visits

• Some visits

• Hardly ever

D. WHAT HAPPENS IN HOME VISITS

1. Who usually decides what you talk about and do in home visits?

• It is totally my decision

• It is mostly my decision

• It is a decision my home visitor and I make equally

• It is mostly my home visitor’s decision

• It is totally my home visitor’s decision

2. Have you ever talked about the following topics with your home visitor? [For each YES GO TO Question 3 on page 6; for each no GO TO Question 4 on page 7]

		Yes	No	Not applicable
1	Connecting with others to talk to as supportive friends			
2	Being more connected to my community and culture			
3	Having my child be healthy			
4	Feeding my child (including formula and solids)			
5	My child’s development (learning new physical and social skills, language development, and coping with emotions)			
6	Managing my child's behavior			
7	Making child care arrangement			
8	Interacting with my child in a supportive and positive way			
9	Co-parenting with my child’s father/mother			
10	Taking care of my baby or child (bathing, diapering, sleep, routines, etc.)			
11	Keeping my child and home safe			
12	[SKIP If not currently pregnant/did not have a baby while participating in the program] Having a healthy pregnancy			
13	[SKIP If not currently pregnant/did not have a baby while participating in the program] Staying healthy after I have my baby			
14	[SKIP If not currently pregnant/did not have a baby while participating in the program] Breastfeeding			
15	Improving my overall health			
16	Eating more nutritious meals and exercising			
17	Using family planning			
18	Quitting smoking			
19	Quitting using alcohol or drugs			
20	Dealing with stress			
21	Dealing with sadness			
22	Getting more education or job training			
23	Getting a job, or getting a better job			
24	Having healthy relationships			
25	Dealing with partner or family violence			
26	Coping with my own past abuse or trauma			
27	Meeting basic needs such as food, utilities, healthcare, and housing			
28	Budgeting/making ends meet			

3. [For each yes response in Question 2 above] Please show how much you wanted to discuss each of the topics below with your home visitor.

		Strongly disagree	Disagree	Agree	Strongly agree
	I wanted to discuss this with my home visitor:
1	Connecting with others to talk to as supportive friends				
2	Being more connected to my community and culture				
3	Having my child be healthy				
4	Feeding my child (including formula and solids)				
5	My child’s development (learning new physical and social skills, language development, and coping with emotions)				
6	Managing my child's behavior				
7	Making child care arrangement				
8	Interacting with my child in a supportive and positive way				
9	Co-parenting with my child’s father/mother				
10	Taking care of my baby or child (bathing, diapering, sleep, routines, etc.)				
11	Keeping my child and home safe				
12	[SKIP If not currently pregnant/did not have a baby while participating in the program] Having a healthy pregnancy				
13	[SKIP If not currently pregnant/did not have a baby while participating in the program] Staying healthy after I have my baby				
14	[SKIP If not currently pregnant/did not have a baby while participating in the program] Breastfeeding				
15	Improving my overall health				
16	Eating more nutritious meals and exercising				
17	Using family planning				
18	Quitting smoking				
19	Quitting using alcohol or drugs				
20	Dealing with stress				
21	Dealing with sadness				
22	Getting more education or job training				
23	Getting a job, or getting a better job				
24	Having healthy relationships				
25	Dealing with partner or family violence				
26	Coping with my own past abuse or trauma				
27	Meeting basic needs such as food, utilities, healthcare, and housing				
28	Budgeting/making ends meet				

4. [For each no response in Question 2 above] Please show how much how much you would like to discuss each of the topics below with your home visitor, if given the opportunity.

		Strongly disagree	Disagree	Agree	Strongly agree
	I WOULD LIKE to discuss this with my home visitor:
1	Connecting with others to talk to as supportive friends				
2	Being more connected to my community and culture				
3	Having my child be healthy				
4	Feeding my child (including formula and solids)				
5	My child’s development (learning new physical and social skills, language development, and coping with emotions)				
6	Managing my child's behavior				
7	Making child care arrangement				
8	Interacting with my child in a supportive and positive way				
9	Co-parenting with my child’s father/mother				
10	Taking care of my baby or child (bathing, diapering, sleep, routines, etc.)				
11	Keeping my child and home safe				
12	[SKIP If not currently pregnant/did not have a baby while participating in the program] Having a healthy pregnancy				
13	[SKIP If not currently pregnant/did not have a baby while participating in the program] Staying healthy after I have my baby				
14	[SKIP If not currently pregnant/did not have a baby while participating in the program] Breastfeeding				
15	Improving my overall health				
16	Eating more nutritious meals and exercising				
17	Using family planning				
18	Quitting smoking				
19	Quitting using alcohol or drugs				
20	Dealing with stress				
21	Dealing with sadness				
22	Getting more education or job training				
23	Getting a job, or getting a better job				
24	Having healthy relationships				
25	Dealing with partner or family violence				
26	Coping with my own past abuse or trauma				
27	Meeting basic needs such as food, utilities, healthcare, and housing				
28	Budgeting/making ends meet				

5. My home visitor spends most of his/her time

• Talking with me

• Talking with my child

• Talking with both my child and me

6. What happens if other family members are with you during a visit?

• My home visitor focuses on me and my child

• My home visitor talks with all family members but mainly focuses on me and my child

• My visitor includes all family members in visit activities

• This has never happened; it’s always just me and my child

7. The amount of time my home visitor spends filling out paperwork DURING visits is

• More than I’d like

• Less than I’d like

• About the right amount

8. Please show how much you agree or disagree with each of the following statements.

		Strongly disagree	Disagree	Agree	Strongly agree
1	I prefer to choose visit topics and activities myself rather than have the visitor choose them.				
2	I like it when my home visitor suggests ways to do things better as a parent.				
3	I appreciate when my visitor gives me an opportunity to talk about my mental health, substance abuse, or partner violence.				
4	If my visitor raises a concern about my parenting, it shows that she or he cares for and respects my family.				
5	I prefer my visitor to focus on the things I do well as a parent.				
6	I prefer for the home visitor to lead the visit. She or he can decide what we talk about and do.				
7	If my visitor asks about my mental health, substance use, or relationship with my partner, it is because she or he cares about me and my family.				
8	I would feel offended if my home visitor raised a concern about how I am parenting my child.				

E. EXPERIENCES WITH YOUR HOME VISITOR

1. How would you describe your home visitor?

		Strongly disagree	Disagree	Agree	Strongly agree
1	Flexible				
2	Inflexible				
3	Supportive				
4	Caring				
5	Judgmental				
6	Knowledgeable				
7	Accepting				
8	Unprofessional				
9	Good listener				
10	Dependable				
11	Pushy				
12	Trustworthy				
13	Available when I need her				
14	Understanding				
15	Disrespectful				
16	Humble				
17	Interested in knowing more about me				

2. Show how much you agree or disagree with the following statements.

		Strongly disagree	Disagree	Agree	Strongly agree
1	My visitor wants me to tell her/him how I would like to spend the time during home visits.				
2	My visitor wants me to let her/him know if I don’t understand something.				
3	My visitor wants me to decide what we do in visits.				
4	My visitor wants me to let her/him know if I disagree with something she or he says.				

3. How often are the conversations and activities during visits interesting to you?

• Always

• Most of the time

• Sometimes

• Rarely

• Never

3. When I am bored or not interested in a topic or activity my home visitor

• Frequently does not notice

• Encourages me to continue anyway

• Suggests another topic or activity

• Asks what I would prefer to do

3. How often does your home visitor do the following:

		Never	Seldom	Some of the time	Most of the time
1	Gives me positive feedback.				
2	Shows warmth, respect and appreciation to my family.				
3	Shows that she or he wants to understand my perspective, concerns, and feelings.				
4	Makes sure that visit activities match my interests, concerns and preferences.				
5	Balances my interests with those of the home visiting program.				

3. Below are statements about some things home visitors may do. Please show how much you agree or disagree with each of the following statements about your home visitor.

		Strongly agree	Agree	Disagree	Strongly disagree	Not sure
	My home visitor . . .
1	Plans visits according to what I prefer.					
2	Asks me about and addresses family concerns, even if this means changing planned activities.					
3	Makes sure I understand what we are talking about before moving on.					
4	Focuses conversation and activities to fit my interests.					

3. Below are statements that describe how a parent might feel about her home visitor. Please show how often you feel that way. For example, if the statement describes the way you always think or feel, select the “Always” box.

		Never	Rarely	Sometimes	Often	Always
	How often do you think or feel this way?
1	My home visitor and I agree about the things I will need to do to benefit me and my family.					
2	What I am doing with home visiting gives me new ways of looking at my family's situation.					
3	There are certain things I wouldn’t say in front of my home visitor, even though we’re close.					
4	I believe my home visitor likes me.					
5	My home visitor does not understand what I am trying to accomplish with home visiting.					
6	I can talk to my home visitor about personal matters.					
7	I am confident in my home visitor's ability to help me.					
8	My home visitor and I are working toward mutually agreed upon goals.					
9	I feel that my home visitor appreciates me.					
10	My home visitor and I don’t really see eye to eye. She or he has given me advice that I disagree with.					
11	We agree on what is important for me to work on.					
12	My home visitor and I trust one another.					
13	My home visitor and I have different ideas on what I want and need.					
14	There are certain things about my home visitor that make it hard for me to relate to her.					
15	We have established a good understanding of the kind of changes that would be good for me.					
16	My home visitor respects my community and culture.					

3. The following statements describe different ways that home visitors might interact with families. Please choose the response that best describes how your home visitor interacts with you and your family?

		Never	Few visits	Some visits	Most visits	Every visit
1	My home visitor really listens to my concerns or requests					
2	My home visitor sees my family in a positive way					
3	My home visitor gives me information to make good choices					
4	My home visitor responds to my requests for information or guidance					
5	My home visitor tries hard to understand my family					
6	My home visitor recognizes my family’s strengths					
7	My home visitor empowers me to get the resources and support I need.					
8	My home visitor is flexible when my family’s situation changes					

3. How likely would you be to tell to your home visitor that you:

		Very unlikely	Somewhat unlikely	Somewhat likely	Very likely
1	Had not followed her/his suggestion?				
2	Disagreed with her/him?				
3	Are getting different advice from family or friends?				

F. YOUR RELATIONSHIPS AND WELLBEING

1. The next questions are about your relationships with other people. Please show how much you agree or disagree with each of the following statements.

		Strongly disagree	Disagree	Agree	Strongly agree
1	There are people I know will help me if I really need it.				
2	I do not have close relationships with other people.				
3	There is no one I can turn to in times of stress.				
4	There are people who call on me to help them.				
5	There are people who like the same social activities I do.				
6	Other people do not think I am good at what I do.				
7	I feel responsible for taking care of someone else.				
8	I am with a group of people who think the same way I do about things.				
9	There are people I can count on when I need help as a parent.				
10	I do not think that other people respect what I do.				
11	If something went wrong, no one would help me.				
12	I have close relationships that make me feel good.				
13	There is no one I can go to with questions about parenting.				
14	I have someone to talk to about decisions in my life.				
15	There are people who value my skills and abilities.				
16	There is no one who has the same interests and concerns as me.				
17	There is no one who needs me to take care of them.				
18	I have someone to help me when I have problems with my child(ren).				
19	I have a trustworthy person to turn to if I have problems.				
20	I feel a strong emotional tie with at least one other person.				
21	People are there to help me be a good parent.				
22	There is no one I can count on for help if I really need it.				
23	There is no one I feel comfortable talking about problems with.				
24	There are people who admire my talents and abilities.				
25	I do not have a feeling of closeness with anyone.				
26	There is no one who likes to do the things I do.				
27	There are people I can count on in an emergency.				
28	No one needs me to take care of them.				
29	Other people think that I am a good parent.				

2. Please show how much you agree or disagree with the following statements.

		Strongly disagree	Disagree	Agree		Strongly agree
1	The problems of taking care of a child are easy to solve once you know how your actions affect your child, like I do.					
2	I would make a good model for a new parent to follow.					
3	Being a parent is manageable, and any problems are easily solved.					
4	I am an expert in caring for my child.					
5	If anyone can find the answer to what is troubling my child, I am the one.					
6	I am comfortable in my role as a parent.					
7	I have all the skills necessary to be a good parent to my child.					

3. The following statements describe different ways that parents interact with their children on a daily basis. Please show how true each statement is for you.

		Never true	Rarely true	Sometimes true	Often true
1	When I am with my child I have difficulty staying focused on what is happening in the present.				
2	I rush through activities with my child without being really attentive to him or her.				
3	I am often so busy thinking about other things that I am not really listening to my child.				
4	I am aware of how my moods affect the way I treat my child.				
5	When I'm upset with my child I notice how I am feeling before I take action.				
6	When I am upset with my child, I calmly tell him or her how I am feeling.				
7	I notice how changes in my child’s mood affect my mood.				
8	I often react too quickly to what my child says or does.				
9	When I am feeling stressed, it is hard to pay enough attention to my child.				
10	I can usually manage stressful things that happen and still take care of my child.				

4. Please show how much you agree or disagree with the statements below.

		Strongly disagree	Disagree	Agree	Strongly agree
1	I am comfortable being a parent because my family and community are there to help me.				
2	Working together with family and friends I can solve many of the problems of caring for my child.				
3	Being a parent is manageable with the support of my family and friends.				
4	I am good at caring for my child because of what I have learned from my family and community about parenting.				

G. FINAL THOUGHTS

1. Now we would like you to think about your overall experience with The home visiting program. Please show how much agree or disagree with each of the following statements below.

		Strongly disagree	Disagree	Agree	Strongly agree
1	What I get out of the home visiting program is worth the time it takes to participate.				
2	There are some things I do differently now because of my experience in the home visiting program.				
3	I would recommend the home visiting program to my family and friends.				

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Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver 6 & 12 Month Follow-Up Survey

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