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pdfJanuary 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
MULTI-SITE IMPLEMENTATION EVALUATION OF HOME VISITING (MUSE)
LOCAL PROGRAM EVALUATOR 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 #: 0970-0521, Exp: 12/31/2021. 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.
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Local Program
Evaluator Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
MUSE Local Program Evaluator 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 program implementation and the
experiences of families receiving home visiting services.
We are asking you to complete this survey because you are an evaluator working with one of the home
visiting programs participating in MUSE. Your answers will help us understand your role in your home
visiting program and your perspective on the program.
Your participation in this survey is voluntary. If you choose to participate, it will take about 30 minutes
to complete this survey. If you are unsure how to answer a question, please give the best answer you
can instead of leaving it blank.
Your answers will be kept private. Only the MUSE study team will have access to this information. Your
answers will not be shared with anyone at your program or any other agencies. We will not report
information collected in this study in a way that could identify you or your program.
We would appreciate your response by MM/DD/YYYY. If you have questions about the survey or at any
time during the study, please call Tess Abrahamson at James Bell Associates at ### or email ____.
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Local Program
Evaluator Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
A. BACKGROUND AND WORK EXPERIENCE
1.
What was the highest level/degree you completed in school?
Some high school, no diploma
High school/GED
Some college/no degree
Technical training or certification
Associate’s degree (e.g. AA, AS, ADN)
Bachelor’s degree (e.g. BA, BS, BSN)
Master’s degree or higher (e.g. MA, MS, MSW, MSN, PhD)
2. What were your main field(s) of study? CHECK ALL THAT APPLY. (Responses not limited to
highest degree completed.)
Education
Psychology
Social work/Social welfare
Public health
Sociology
Other, specify: ___________________
3. How many total years of experience do you have working as a program evaluator?
Less than 1 year
1-2 years
3-5 years
6-10 years
More than 10 years
4. Other than as an evaluator, do you have experience working with children and families? (e.g. in home visiting, social
work, etc.)?
No
Yes. Please describe ___________________________________________
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Local Program Evaluator Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
B. CURRENT POSITION
1. When did you begin your present role as an evaluator for the tribal home visiting program? Please enter the month
and year in numeric format. If you cannot recall which month you began, please leave it blank.
Month _______ Year ________
2. Have you worked with the organization that administers the tribal home visiting program on other projects?
No [→ SKIP TO Question 3]
Yes [→ GO TO Questions 2a & 2b]
2a. [If Question 2= yes] If so, in what capacity? ___________
2b. [If Question 2= yes] How many years did you work with the agency or tribe in that
capacity?
Less than 1 year
1-2 years
3-5 years
6-10 years
More than 10 years
3. Are you employed by the organization that administers the tribal home visiting program?
No [→ GO TO Questions 3a & 3b]
Yes [→ SKIP TO Question 4]
3a. [If Question 3 = No] Which of the following best describes your employer?
University
Private company
Self-employed
Other (specify) _________
3b. [If Question 3 = No] My employer is very supportive of my work with the tribal home
visiting program.
Strongly agree
Agree
Disagree
Strongly disagree
4. On average, how many hours per month do you work as an evaluator for the tribal home visiting program? (For
example, enter “1.5” if you spend an hour and a half.)
Hours: __________
5. Is the time you have allocated to work with the tribal home visiting program adequate to fulfill your assigned duties?
Yes
No
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Local Program Evaluator Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
6. On average, how often are you in contact with the tribal home visiting program staff?
Daily
Weekly
Monthly
Less than monthly
Never
7. Which option best describes your relationship with the tribal home visiting program?
Just getting to know the staff and program
Know the program and staff pretty well
Fully involved in the staff team and program
8. The amount of time you spend working as an evaluator on the tribal home visiting program is…
More time than similar projects
About the same time as similar projects
Less time than similar projects
Not applicable (I don’t have any similar projects)
9. How likely is it that you will continue in your current evaluator role 6 months from now?
Very likely [→ SKIP TO Section C]
Somewhat likely [→ GO TO Question #9a]
Somewhat unlikely [→ GO TO Question #9a]
Very unlikely [→GO TO Question #9a]
9a. [If somewhat likely, somewhat unlikely, very unlikely] What factors affect whether you will stay in this role?
[CHECK ALL THAT APPLY]
The pay I receive for this project
The funding for my role on this project is uncertain
Another project requires more of my time
Opportunities for advancement within my organization
Personal reasons (e.g., health, family obligations, change in career)
Retire or stop working
Moving out of the area
Challenging work environment with the home visiting program
Other (specify( ________________________
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Local Program Evaluator Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
C. PERCEPTIONS OF PROGRAM
Instructions: In this section, we would like to learn how staff members perceive their program’s intended outcomes. In
general, a program outcome is a benefit to a child, parent, or family. For example, some programs might see the
improvement of prenatal health as an important outcome.
Below is a list of possible outcomes for home visiting programs. We know your program may care about all of these
benefits, but we would like to know which is MOST important. We would like to get a sense of which outcomes you
think your program believes are more important than others. Select the response that best represents what you think
your program believes about the outcome.
To help you decide on an outcome's rank, think about whether it is discussed routinely in training
and supervision. Think about what staff are told about its importance. Select the response that
best describes your program's ranking of this outcome.
1. How much of a priority is each of the following outcomes for the tribal home visiting program, on a scale of 0 to 10?
0 = Not a Priority
5 = Moderate priority
10 = Highest priority
1
2
3
4
5
6
7
8
9
10
11
Supporting prenatal health and
obtaining prenatal care (including dental
health/dental care)
Supporting postpartum health and
obtaining postpartum care (including
dental health/dental care)
Supporting breastfeeding
Supporting physical health outside of
pregnancy and postpartum health
(including dental health/dental care)
Supporting family planning
Preventing and reducing alcohol,
commercial tobacco, and other drug use
Promoting caregiver emotional wellbeing and preventing and reducing
mental health problems or stress
Preventing and reducing domestic
violence
Supporting healthy adult relationships
(with boyfriends/girlfriends,
husbands/wives, partners, co-parents)
Increasing social support (support from
family, friends, and community)
Furthering a caregiver’s education and
job training
0
1
2
3
4
5
6
7
8
9
10
Not
sure
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Length of time for instrument: 30 minutes
Supporting getting a job, or getting a
better job
Supporting child health (including dental
health/dental care)
Ensuring appropriate child care
arrangements
Supporting parenting to promote child
development
Basic needs like food, utilities, housing,
transportation, and identification
Legal system and services
Supporting good nutrition and physical
activity
Supporting caregivers in budgeting and
making ends meet
Addressing unresolved issues from past
caregiver trauma
Connecting to community and culture
(attending community and/or cultural
activities, learning cultural teachings,
making new relationships with others in
your community)
Supporting parent-child interaction
Supporting positive discipline and
behavior management
Supporting caregivers in feeding
children (including formula and solids,
and not including breastfeeding)
Helping caregivers to establish and
maintain developmentally appropriate
care/routines (daily routines like
bedtime, mealtime, bath time)
Supporting effective co-parenting
Supporting child and home safety
0
1
2
3
4
5
6
7
8
9
10
Not
sure
2. Overall, how effective do you believe the tribal home visiting program is in MAKING A DIFFERENCE for families in the
following areas?
1
Prenatal health/prenatal care (including dental
health/dental care)
Not at all
effective
Somewhat
effective
Mostly
effective
Very
effective
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Local Program Evaluator Survey
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3
4
5
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10
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17
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21
22
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OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
Postpartum health/postpartum care (including
dental health/dental care)
Breastfeeding
Physical health outside of pregnancy and
postpartum health (including dental health/dental
care)
Family planning
Alcohol, commercial tobacco, and other drug use
Caregiver emotional well-being, mental health or
stress
Domestic violence
Healthy adult relationships (with
boyfriends/girlfriends, husbands/wives, partners, coparents)
Social support (support from family, friends, and
community)
Furthering a caregiver’s education and job training
Getting a job, or getting a better job
Child health (including dental health/dental care)
Making child care arrangements
Child development
Basic needs like food, utilities, housing,
transportation, and identification
Legal system and services
Nutrition and physical activity
Budgeting/making ends meet
Trauma (things that happened in the past that affect
caregiver today)
Connecting to community and culture (attending
community and/or cultural activities, learning
cultural teachings, making new relationships with
others in your community)
Parent-child interaction
Discipline/behavior management
Feeding children (including formula and solids, and
not including breastfeeding)
Developmentally appropriate care/routines (daily
routines like bedtime, mealtime, bath time)
Co-parenting
Child/home safety
Not at all
effective
Somewhat
effective
Mostly
effective
Very
effective
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Local Program Evaluator Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
D. EVALUATOR ROLE
1. Below is a list of skills and knowledge that evaluators working on Tribal MIECHV-funded grants may need.
Based on your experience working with the tribal home visiting program, how important are each of these
areas from not at all important to very important?
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2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Study design
Developing a data collection protocol
Conducting data analysis
Developing data collection forms
Training staff
Managing program data
Database engineering
Conducting data quality checks
Building relationships with program staff
Project management skills
Meeting facilitation/presentation skills
Translating evaluation terminology into lay terms
Negotiating multiple perspectives in planning
Advocating on behalf of the program
Influencing program decisions
Federal requirements
Home visiting services
Evaluation methodology
Data quality and cleaning procedures
Community protocols
Developing an IRB application
Not at all
important
Minimally
important
Somewhat
Very
important important
2. How often are you involved in overall program decision making for the tribal home visiting program?
Never
Rarely
Sometimes
Often
Always
3. Have you previously worked with the organization that administers tribal home visiting on any other programs or
projects?
Yes
No
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Local Program Evaluator Survey
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January 2019
4.
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
How often do you participate in the tribal home visiting program’s team meetings? Please include in-person and
telephone meetings.
Once a week or more
Every other week
Once a month
Less than once a month
Never
5. How often do you come on site to meet with the program?
I am located in the same building as the program staff
Once a week or more
Every other week
Once a month
Once every few months
Twice a year
Once a year
Never
6. How often do you interact with the following home visiting program team members? Please include in-person
meetings, telephone and email communication?
1
2
3
4
Program Director
Program Coordinator/Manager
Home Visitors
Other Program Staff
Daily
Weekly
Monthly
Less than monthly
Never
7. Have you ever observed a home visit?
Yes [→ GO TO Question 7a]
No [→ SKIP to Question 8]
7a. [If Question 7 = Yes] How many home visits have you observed? ___
8. Have you ever attended a family group event? A family group event is an event provided by the program that is
intended for more than one family.
Yes
No
9. Please tell us about your involvement with your tribal home visiting program. How involved are you involved in the
following activities:
1
2
3
Data quality checks
Developing data collection protocols
Data analysis
I am not
involved
I consult as
needed
I am
substantially
involved
I lead this
effort
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Local Program Evaluator Survey
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January 2019
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OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
Developing data collection forms
Training home visitors to collect data
Data management and cleaning
Database changes
Running reports
Interpreting data
Sharing data with staff
Sharing findings/presenting data to
stakeholders
I am not
involved
I consult as
needed
I lead this
effort
I am
substantially
involved
E. DATA SYSTEMS
1. How much experience did you have with data systems prior to working with your tribal home visiting program?
None [→ GO TO Question 1a]
Very little [→ GO TO Question 1a]
Some [→ GO TO Question 1a]
A lot [→ SKIP to Question 2]
1a. [If Question 1 = A lot, some, or a little] How adequate was your prior experience with data systems in
preparing you for the demands of this project?
More than adequate
Adequate
Not quite adequate
Not at all adequate
2. Which of the following reflect your involvement with the tribal home visiting program’s data system? CHECK ALL
THAT APPLY
I oversee all aspects of the data system
I provide training on the data system to incoming staff
I develop policies or procedures relevant to the data system
I supervise staff who do data entry
I do data entry
I work with IT or vendor to make changes to the data system
I access the data system for running reports
Other (specify)_______________________
3. Based on all sources of support, the level of support the tribal home visiting program receives related to their data
system…
Fully meets our needs
Meets most of our needs
Meets some of our needs
Meets very few of our needs
Does not meet our needs
Unsure
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Local Program Evaluator Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
4. How helpful have these kinds of data systems support been to the home visiting program team?
Not at
A little Somewhat Very
all
helpful
helpful
helpful
helpful
1
2
3
Support from the data system developers
(including trainings)
Support from your TEI capacity building
specialist
Support from the home visiting organization’s
internal IT department
Did not
receive data
system
support
from this
entity
5. Overall, does the primary data system meet the tribal home visiting program’s needs?
Yes
No
Not sure
6. How useful is the tribal home visiting program’s data system?
The system is extremely useful for meeting all of our reporting requirements
The system is useful but does not meet all of our data reporting needs
The system has some useful features but requires us to do a lot of extra work to
accomplish our data reporting requirements
The system makes it harder to meet our data reporting requirements than counting cases
by hand
Not sure
7. How easy or difficult to use is the tribal home visiting program’s data system?
Very easy
Somewhat easy
Somewhat difficult
Very difficult
Not sure
8. If possible, would you prefer an alternative data system to the one currently being used?
Yes
No
Not sure
9. Has your role in managing the data system changed over time?
Yes, I have more responsibility
Yes, I have less responsibility
Yes, I have the same amount of responsibility, but my tasks have changed
No
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Local Program Evaluator Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
F. PERFORMANCE MEASUREMENT
1. We are interested in learning how performance measurement has impacted your program. How much do you agree
or disagree with the following statements?
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2
3
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5
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7
8
9
10
11
12
Planning for performance measurement has
helped program leadership ensure high
quality implementation.
Discussions about performance
measurement have helped program staff
develop common priorities.
Program staff see performance
measurement as more of a chore than a
help.
Performance measurement requirements
have taken away from important program
work.
Performance measurement data have
helped home visitors see how they are
making a difference.
Looking at performance measurement data
has shown us where we can make
improvements.
Collecting so much performance
measurement data makes it hard to spend
enough time providing services to families.
This grant’s data reporting requirements are
too burdensome.
Other programs in this agency have
improved their data collection systems or
the way they use data as a result of the
home visiting program’s work on
performance measurement.
Technical assistance providers play a key role
in helping the home visiting program carry
out high quality performance measurement.
Performance measures are not aligned with
our program priorities.
Technical assistance adds additional burden
to our planning efforts.
Strongly
Agree
Agree
Disagree
Strongly
Disagree
Not Sure
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Local Program Evaluator Survey
13
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
G. CONTINUOUS QUALITY IMPROVEMENT
1. To what degree are you involved in the tribal home visiting program’s continuous quality improvement (CQI)
activities? CQI is using data and information to improve performance and practice.
The tribal home visiting program does not do CQI activities [→ SKIP to next Section]
I am not involved
I consult on these activities as needed
I am substantially involved
I lead the tribal home visiting program's CQI activities
2. The number of hours I have allocated to work with the tribal home visiting program allows time for me to support CQI
initiatives.
Yes
No
3. How have you supported the tribal home visiting program’s CQI activities? CHECK ALL THAT APPLY.
Leading CQI efforts
Consulting with program staff
Training staff on CQI
Providing or analyzing data for CQI
Creating/running trend charts
Monitoring data collection
Analyzing CQI data
Presenting CQI info to stakeholders
4. Does the tribal home visiting program hold meetings dedicated to reviewing data and CQI?
Program holds regular meetings focused solely on data and CQI
Program holds regular meetings where data and CQI are on the agenda for part of the meeting
Program holds regular meetings but data and CQI are only occasionally discussed
Data and CQI are not discussed at meetings
5. How many CQI projects has the tribal home visiting program worked on since receiving a Tribal
MIECHV grant?
0
1-3
4 or more
6. How have CQI efforts changed the tribal home visiting program’s service delivery?
CQI has made service delivery a lot better
CQI has made service delivery a little better
CQI has not made any difference
CQI has made service delivery a little worse
CQI has made service delivery a lot worse
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Local Program Evaluator Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
H. ROLE SATISFACTION
1. The following questions ask how you feel about your role with the tribal home visiting program. How often do you
feel this way?
Some of
None of
A little of
Most of the
All of the
the
time
the time
the time
time
time
The work I do with the home visiting
1
program is satisfying.
My work with the home visiting program
2
is boring.
My work with the home visiting program
3
allows me to be creative.
I feel respected in my work with the
4
home visiting program.
My work with the home visiting program
5
is frustrating.
My work with the home visiting program
6
gives me a sense of accomplishment.
My work with the home visiting program
7
is interesting.
The work I do with the home visiting
8
program is important.
My work with the home visiting program
9
is overwhelming.
2. We are interested in learning about how your job relates to the community served by the tribal home visiting
program. How much do you agree or disagree with the following statements?
1
2
3
4
5
6
7
The local community is very involved in shaping the home
visiting services the home visiting program provides.
Being connected to the local community is critical to my
success as an evaluator.
I worry that what I have to do to help with data
requirements negatively impacts how I am perceived in
the local community.
General distrust and/or unfamiliarity with data makes my
job harder on this project.
What I do as an evaluator is meaningful to people in the
local community.
What I do as an evaluator makes a positive difference in
the local community.
What I do as an evaluator is contributing to a brighter
future for the local community.
Strongly
Agree
Agree
Disagree
Strongly
Disagree
Not
Sure
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Local Program Evaluator Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
I. ORGANIZATIONAL CULTURE AND CLIMATE
The following questions ask you to think about how your home visiting team does its work. We want to know how
your team works together, takes in information, and makes decisions about the team’s approach to home visiting.
When answering questions about your team, please think about the staff that make up the tribal home visiting
program. This would include home visitors, program coordinators/managers, supervisors, evaluators, data managers
and anyone else that might work closely with the tribal home visiting program.
1. How much do you agree or disagree with the following statements?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Our team gets all the information it needs to do our work
and plan our schedules.
It is easy for our team to obtain expert assistance when
something comes up that we don't know how to handle.
Our team is kept in the dark about decisions that impact
day-to-day work and what may happen with the program
and its staff in the future.
Our team lacks access to useful training on the job.
Excellent work pays off in this organization.
It is clear what our team is supposed to accomplish.
Our team spends time making sure every team member
understands their role and responsibilities.
Our team has invested plenty of time to clarify our goals.
If you make a mistake on our team, it is often held against
you.
Members of our team are able to bring up problems and
tough issues.
People on our team are expected to conform to the group.
It is safe to try something new on our team.
It is difficult to ask other members of our team for help.
No one on our team would deliberately act in a way that
undermines my efforts.
Working with members of our team, my unique skills and
talents are valued and utilized.
Achieving our team's goals is well within our reach.
Our team can complete work as assigned without being
required to put in unreasonable time or effort.
With focus and effort, our team can do anything we set
out to accomplish.
Most people in our team have the ability to solve the
problems that come up in our work.
All members of our team have more than enough training
and experience for the kind of work they have to do.
Strongly
Agree
Agree
Disagree
Strongly
Disagree
Not
Sure
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Local Program Evaluator Survey
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Certain individuals in our team lack the special skills
needed for good team work.
We regularly take time to figure out ways to improve our
team's work processes.
Our team tends to handle differences of opinion privately,
rather than addressing them directly as a group.
Team members go out and get all the information they
possibly can from others-such as families, community
members, and other program partners.
Our team frequently uses information and data that leads
us to make important changes.
In our team, someone always makes sure that we stop to
reflect on the team's work process.
People on our team often speak up to test assumptions we
might have.
People on our team are encouraged to think outside the
box.
We invite people from outside our team to present
information or have discussions with us.
Our team uses data to see if our processes are leading to
the results we want.
Members of our team are encouraged to try new
strategies to see if they will work.
Members of our team support each other as we work to
master new skills.
The quality of work provided by our team is improving
over time.
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
Strongly
Agree
Agree
Disagree
Strongly
Disagree
Not
Sure
2. Tribal home visiting programs have a lot of different leadership structures. For the next few questions, think about
the person in the tribal home visiting program who serves as the team leader. How much do you agree or disagree
with the following statements?
1
2
3
4
5
Our team leader initiates meetings to discuss our team's
progress.
Our team leader is available for consultation on
problems.
Our team leader is engaged in our team’s day-to-day
work.
Our team leader manages crises in a calm and
dependable way.
Our team leader helps us get through challenges we face
in our work.
Strongly
agree
Agree
Disagree
Strongly
disagree
Not
sure
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Local Program Evaluator Survey
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January 2019
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7
8
9
10
Our team leader handles personnel issues thoughtfully.
Our team leader would go to bat for us.
Our team leader has enough training and experience to
be an effective leader.
Our team leader treats all team members fairly.
Our team leader doesn’t really understand what our
team needs to do its job well.
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
Not
sure
Strongly
disagree
Strongly
agree
Agree
Disagree
J. CONNECTION TO COMMUNITY SERVED
1. Do you live in the same community or neighborhoods the tribal home visiting program provides services to?
Yes [→ GO TO Question 1a]
No [→ SKIP TO Question 1b]
1a. [If Question 1 = Yes] In total, how many years have you lived in the same community or neighborhoods
the tribal home visiting program provides services to?
Less than 1 year
1-2 years
3-5 years
6-10 years
More than 10 years
1b. [If Question 1 = No] If you ever previously lived in the same community or neighborhoods the tribal
home visiting program provides services to, how long did you live there?
I never lived there
Less than 1 year
1-2 years
3-5 years
6-10 years
More than 10 years
2. Do you consider yourself a member of the same tribal or urban Indian community the tribal home visiting program
provides services to?
Yes
No
Somewhat
3. In general, do you feel as though you and the families the tribal home visiting program serves share a similar
cultural background?
Yes, with most families
Yes, with some families
Yes, with a few families
No
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Local Program Evaluator Survey
18
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 30 minutes
K. DEMOGRAPHICS
1. What is your Ethnicity?
Hispanic or Latino
Not Hispanic or Latino
2. What is your Race? (Select one or more)
American Indian or Alaska Native [→ GO TO Question 2a]
Asian [→ SKIP TO Question 3]
Black or African American [→ SKIP TO Question 3]
Native Hawaiian or Other Pacific Islander [→ SKIP TO Question 3]
White [→ SKIP TO Question 3]
2a. [If Question 2 = American Indian or Alaska Native] What is your tribal affiliation and/or identity?
_____________________________________________________________________
3. What is your age?
25 and under
26-29
30-39
40-49
50-59
60 or older
[NEXT SCREEN]
THANK YOU FOR TAKING THE TIME TO COMPLETE THIS SURVEY.
Please click NEXT to exit the survey.
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Local Program Evaluator Survey
19
| File Type | application/pdf |
| Author | West, Allison |
| File Modified | 2019-02-06 |
| File Created | 2019-02-06 |