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pdfJanuary 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
MULTI-SITE IMPLEMENTATION EVALUATION OF TRIBAL HOME VISITING (MUSE)
HOME VISITOR SURVEY
This collection of information is voluntary. Public reporting burden for this collection of information is estimated
to average 1 hour and 10 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: Home Visitor Survey
1
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
MUSE Home Visitor 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.
We are requesting that you complete this survey because you are a home visitor in one of the home visiting programs
participating in MUSE. Your answers will help us understand your role in the home visiting program and your perspective
on the program. Because home visitors’ jobs are complex and involve many different tasks, this survey is also complex
and a bit lengthy.
Your participation in this survey is voluntary. If you choose to participate, it will take about 1 hour and 10 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: Home Visitor Survey
2
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 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.)
Child development
Early childhood education
Education
Psychology
Social work/Social welfare
Public health
Nursing
Other (specify) ___________________
3. In what language(s) are you fluent enough to provide home visiting services? CHECK ALL THAT
APPLY
English
Local Native language (specify) _______________________
Spanish
Other (specify) _______________________
4. Prior to your current position, did you have experience providing home visiting services to families?
No
→ SKIP TO Question 5
Yes → GO TO Question 4a
4a. How many total years of experience do you have providing home visiting services, including your
current home visiting program and any other home visiting programs?
Less than 1 year
1-2 years
3-5 years
6-10 years
More than 10 years
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
3
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
5. Do you have experience working with families in any of the following settings? CHECK ALL THAT APPLY
In-home day care
Center-based Daycare
Preschool
School, grades K-12 (non-nurse)
School nurse
After school program
Special education program
Nursing
Home health care
Other health care
Social services
Mentoring programs
Mental health agencies
No prior experience
Other (specify): ________________
6. How many total years of professional experience do you have working with families and young children, including
home visiting jobs and other jobs doing related work (e.g., years of nursing experience plus years as a parent
educator in different settings)?
Less than 1 year
1-2 years
3-5 years
6-10 years
More than 10 years
7. Aside from your professional experience, how many years of experience do you have raising
children? Please include experience you have as a primary caregiver for any child(ren) including
your own and other's children. Please count experience providing regular, consistent care for a
child as a primary caregiver. Do not include babysitting or infrequent assistance with children.
Years of experience: ___________
B. CURRENT POSITION
1. How many years have you worked for your home visiting program? Include years worked for your home visiting
program in positions other than your current one.
Less than 1 year
1-2 years
3-5 years
6-10 years
More than 10 years
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
2. In what month and year did you begin your present job as a home visitor?
Month (Enter two digits for the month. For example, if you started in January enter “01”. If you cannot recall which
month you began, please leave this blank) _______ Year (Enter four digits for the year. For example, if you started
in 2012, enter “2012”) ________
3. How many hours do you work in a typical week?
Hours (For example, enter “1.5” if you spend an hour and a half): __________
4. How many families are in your current caseload?
No. of Families: ____________
5. The size of your current caseload is…
Lighter than you are able to handle effectively
About right
Heavier than you are able to handle effectively
6. In the past 6 months, how long have you had a caseload that was more than what you could handle effectively?
Never
Less than 1 month
1 month
2 months
3 months
4 months or longer
7. How likely is it that you will be in your current position 6 months from now?
Very likely → GO TO Section C
Somewhat likely → GO TO Question 7a
Somewhat unlikely → GO TO Question 7a
Very unlikely → GO TO Question 7a
7a. [If Question 7 = somewhat likely, somewhat unlikely, very unlikely] What factors affect whether you
will stay in your position? CHECK ALL THAT APPLY
Salary
Opportunities for advancement within the organization
Funding for my position is uncertain
Caring for children or other family members
Pursue additional education or training
Retire or stop working
Moving out of the area
The amount of data collection/paperwork I have to do with families
Challenging work environment
Other (specify) ___________________________
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
C. THE SERVICE ENVIRONMENT
This next section asks about the availability of services in the community you provide home visiting services to. If you
serve multiple communities, please answer the questions to the best of your ability, thinking about the service
environments of the communities you serve in general. You will be asked a series of questions about different service
types, such as, prenatal care and mental health treatment.
[SERVICE TYPES – The following service types will prefill in question 1 below. Respondents will be asked about each
service type once.]
A. Prenatal Care
B. Labor and Delivery
C. Breastfeeding Support
D. Primary Adult Healthcare
E. Family Planning and Reproductive Health Care
F. Substance Use (Alcohol and other drugs) Treatment
G. Mental Health Services
H. Domestic Violence Shelter
I. Domestic Violence Counseling/Anger Management
J. Job Training and Adult Education Services (including GED and ESL)
K. Employment Services
L. Pediatric Primary Care
M. Affordable Licensed Childcare
N. Early Intervention Services
O. Food Assistance
P. Basic Necessities (clothing, diapers, etc.)
Q. Transportation Services
R. Assistance with Housing
S. Dental Care
T. Legal Aid/Legal Services
1. Is there at least one organization that provides the following types of services in your area?
Yes → GO TO Question 1a
No
→ SKIP TO next service type
Don’t know
→ SKIP TO next service type
1a. [If Question 1 = Yes] For each type of service available in your area (as you indicated previously), how
easy or difficult is it for the families you work with to get these services?
Very easy → SKIP TO next service type
Somewhat easy → SKIP TO next service type
Somewhat difficult
→ GO TO Question 1b
Very difficult
→ GO TO Question 1b
Not sure → SKIP TO next service type
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
1b. [If Question 1a = relatively difficult or very difficult] For each type of service that is difficult
for families to access (as you indicated previously, why is it hard for families to get services in this
area? (CHECK ALL THAT APPLY)
Caregivers lack transportation to service
Services or appointments are rarely available (e.g. few providers in the area, wait
lists, etc.)
Caregivers can’t afford services
Poor follow through by provider
Difficulty meeting eligibility criteria
Caregivers do not want to receive services from certain providers (e.g., lack of
cultural competency, etc.)
Home visitors are not confident in the service
D. 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. Please 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 you 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 your program, on a scale of 0 to 10?
0 = Not a Priority
5 = Moderate priority
10 = Highest priority
Supporting prenatal health and obtaining
1 prenatal care (including dental
health/dental care)
Supporting postpartum health and
2 obtaining postpartum care (including
dental health/dental care)
3 Supporting breastfeeding
0
1
2
3
4
5
6
7
8
9
10
Not
sure
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
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January 2019
Supporting physical health outside of
4 pregnancy and postpartum health
(including dental health/dental care)
5 Supporting family planning
Preventing and reducing alcohol,
6
commercial tobacco, and other drug use
Promoting caregiver emotional well-being
7 and preventing and reducing mental health
problems or stress
8 Preventing and reducing domestic violence
Supporting healthy adult relationships
9 (with boyfriends/girlfriends,
husbands/wives, partners, co-parents)
Increasing social support (support from
10
family, friends, and community)
Furthering a caregiver’s education and job
11
training
Supporting getting a job, or getting a better
12
job
Supporting child health (including dental
13
health/dental care)
Ensuring appropriate child care
14
arrangements
Supporting parenting to promote child
15
development
Basic needs like food, utilities, housing,
16
transportation, and identification
17 Legal system and services
Supporting good nutrition and physical
18
activity
Supporting caregivers in budgeting and
19
making ends meet
Addressing unresolved issues from past
20
caregiver trauma
Connecting to community and culture
(attending community and/or cultural
21 activities, learning cultural teachings,
making new relationships with others in
your community)
22 Supporting parent-child interaction
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
0
1
2
3
4
5
6
7
8
9
10
Not
sure
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
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January 2019
Supporting positive discipline and behavior
management
Supporting caregivers in feeding children
24 (including formula and solids, and not
including breastfeeding)
Helping caregivers to establish and maintain
developmentally appropriate care/routines
25
(daily routines like bedtime, mealtime, bath
time)
26 Supporting effective co-parenting
27 Supporting child and home safety
23
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
0
1
2
3
4
5
6
7
8
9
10
Not
sure
2. Does your program expect you to develop a family goal plan with enrolled families? Your program might use a
different name for this, such as an individualized family service plan or support plan. When we use the term
“family goal plan” below, we are referring to a plan to guide and tailor home visiting to help families reach goals.
No, my program doesn't expect me to develop family goal plans (skip to #3)
Yes, my program expects me to develop family goal plans
Not Sure (skip to #3)
2a. On the previous page, you indicated that your program expects home visitors to develop family goal plans.
How much does your program agree or disagree with the following statements?
1
2
3
4
5
6
My program expects that …
every family should have a goal plan.
the family should take the lead in developing
the goal plan.
goals should align with our program's
priorities.
goals should address family’s specific
parenting needs.
the goal plan should guide what happens in
visits.
the family and I should review goal progress
and update the goal plan regularly.
Strongly
agree
Agree
Disagree
Strongly
disagree
Not sure
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
3. How much do you agree or disagree with the following statements?
I think that…
It is valuable to work with families to
develop a goal plan.
Families find it useful to develop a goal plan.
Families feel like I’m being pushy when I
bring up goal plans.
1
2
3
Strongly
agree
Agree
Disagree
Strongly
disagree
Not sure
4. How much do you agree or disagree with the following statement: Your program provides all of the materials
you need to cover the topics you want to with your families in home visits. Materials include home visiting
model and any supplemental curricula, materials, and resources your program uses.
Strongly agree
Agree
Disagree
Strongly disagree
5. How much do you agree or disagree with the following statement: The materials your program provides meet
the unique needs, values and priorities of the families you work with. Materials include home visiting model
materials and any supplemental curricula, materials, and resources your program uses.
Strongly agree
Agree
Disagree
Strongly disagree
6. When planning home visits, how often do you independently find materials to use during home visits that are
not provided by your model?
Never
Hardly any visits
Some visits
Most visits
Every visit
7. On average, how many hours do you spend each week planning home visits? (For example, enter “1.5” if you
spend an hour and a half)
______________ hours
8.
How many minutes do you typically spend planning a single home visit? (For example, enter “90” if you spend
an hour and a half)
_____________ minutes
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
10
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
9. Where do you go to for support when planning for home visits? How often you consult the following for help
when planning your home visits:
Hardly
any visits
Never
1
2
3
4
Model curriculum, materials and resources
Supplemental curricula, materials and
resources used by the home visiting
program
Other home visitors
Supervisor
Most
visits
Some visits
Every visit
10. How effective is your program overall at making a difference for families in the following areas?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Prenatal health/prenatal care (including dental health/dental
care)
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, co-parents)
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)
Not at
all
effective
Somewhat
effective
Mostly
effective
Very
effective
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
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January 2019
21
22
23
24
25
26
27
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
Not at
all
effective
Somewhat
effective
Mostly
effective
Very
effective
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
E. PERCEPTIONS OF HOME VISITOR ROLE
1. How much do you focus on improving outcomes for…?
1
2
3
4
Index child
Other children in the family or household
Primary caregiver(s)
Other adults in the family or household
Not at all
Very little
Somewhat
A lot
2. Sometimes caregivers bring up topics during home visits that you haven't been trained to address. How often
does this happen?
Never
Hardly any visits
Some visits
Most visits
Every visit
3. What does your program expect you to do during the visit if something comes up that you haven't been
prepared/trained to address?
My program expects me just to explain that I can only work on things covered in the program
My program expects me to direct the mother to a resource that CAN address this issue
My program expects me to try to work on this issue even though I'm not trained to address it
My program has no stated expectation for what I do
Not sure
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
4. Sometimes caregivers want visit activities to deviate from curricula and protocols. How often does this happen?
Never
Hardly any visits
Some visits
Most visits
Every visit
5. What does your program expect you to do during the visit if a caregiver wants to do things differently than in
the program curricula or protocols?
My program expects me to explain that I must follow the program curricula and protocols
My program expects me to modify visit activities to align with the caregiver’s preferences while still being
true to the 'spirit' of the curriculum or protocol
My program expects me to do things the way the caregiver prefers, even if this is very different from
program curricula and protocols
My program has no stated expectation for what I do in this situation
Not sure
F. SELF-EFFICACY
The next set of questions asks you to consider your own knowledge, skills and abilities needed to accomplish tasks
related to providing home visits. Please do not consider external barriers like lack of funding or time, agency policies, or
geography.
1. How confident are you that you can do the following things in most situations?
Not at all Not very Somewhat
confident confident confident
1
2
3
4
5
6
7
8
9
Balance family preferences with program
priorities
Communicate warmth, respect, and appreciation
to the family
Develop and use family goal plans
Conduct required screenings
Tailor activities in response to family interests,
concerns, and preferences
Build relationships and trust with caregivers and
their families
Deliver home visiting curriculum the way my
program and model intends
Model and coach parenting skills
Identify and communicate strengths to caregivers
Mostly
confident
Completely
confident
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
13
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
Not at all Not very Somewhat
confident confident confident
10 Helping families access needed services
11 Collect data and information from caregivers
Enter data and document what happens during
12
home visits
13 Plan home visits for families
14 Retain families and keep my caseload slots filled
Deliver the expected number of home visits for
15
each family
16 Support families in managing crises
Manage my time so that I can get everything
17
done that I need to do
Engage an uninterested or distracted caregiver
18
during a home visit
Engage an uninterested or fussy child during a
19
home visit
20 Ensure my safety when making home visits
21 Engage fathers in home visits
Work with multigenerational families and non22
traditional caregivers
Mostly
confident
Completely
confident
2. The next set of questions asks about working with caregivers around different topics or issues. How confident are
you that you can address the following issues with families during home visits?
Not at all Not very Somewhat
confident confident confident
1
2
3
4
5
6
7
8
Prenatal health/prenatal care (including dental
health/dental care)
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
Mostly
confident
Completely
confident
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
Not at all Not very Somewhat
confident confident confident
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
Healthy adult relationships (with
boyfriends/girlfriends, husbands/wives,
partners, co-parents)
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
Mostly
confident
Completely
confident
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
G. JOB SATISFACTION
1. The following questions ask how you feel about your job overall. How often do you feel this way?
1
2
3
4
5
6
7
8
9
The work I do is satisfying.
My job is boring.
My job allows me to be creative.
I feel respected at work.
My job is frustrating.
My work gives me a sense of
accomplishment.
My job is interesting.
The work I do is important.
My job is overwhelming.
None of
the time
A little of
the time
Some of
the time
Most of
the time
All of the
time
2. Think about your pay from this job. How much do you agree or disagree with the following about your pay?
1
2
3
I can depend on my paycheck to be regular
and on time.
The pay I get from this job is less than I
deserve for the work that I do.
The pay I get from this job is fair for my
qualifications.
Strongly
agree
Agree
Disagree
Strongly
disagree
Not sure
3. As you think about the pay you get from this job, which statement best describes your thoughts? The pay I
get from this job is…
Barely enough to live on
Enough to cover my normal expenses
Enough to live comfortably
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
4. For each job characteristic listed below, how satisfied or dissatisfied you are with your current job at the home
visiting program in this regard.
1
2
3
4
5
6
7
8
9
10
11
12
My job security
The amount of vacation time I receive
The amount of on-the-job stress
My chances for promotion
The size of my caseload
The amount of time required of me to get
the job done
The amount time I spend traveling to home
visits
The flexibility of my schedule
The health insurance benefits my employer
offers
The retirement plan my employer offers
The amount of leave or schedule flexibility
available for family and community
obligations
The control I have over my daily work
schedule
Very
dissatisfied
Dissatisfied
Satisfied
Very satisfied
13
The physical workspace
14
Balancing the different tasks that are
required of me
15
Being able to get my work done with the
amount of interruptions I experience
16
The recognition I receive at work for my
accomplishments
17
The amount of money I earn
18
My relationship with my immediate
supervisor
19
My physical safety while doing my job
20
My relationships with my coworkers
21
The training and professional development
opportunities available to me
22
23
How interesting the work is
My work-life balance
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
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January 2019
24
25
26
The mentoring and support I receive
My ability to contribute to others in a
meaningful way
My job overall
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
Very
dissatisfied
Dissatisfied
Satisfied
Very satisfied
5. We are interested in learning about how your job relates to the community where you provide home visiting
services. How much do you agree or disagree with the following statements?
Strongly
Strongly
Agree
Disagree
Not sure
agree
disagree
The local community is very involved in
shaping the home visiting services your
1
home visiting program provides.
My job makes me feel more connected to
2
my community.
I worry that my job has negatively impacted
3
how I'm perceived in the local community.
4
My job is meaningful to the local community.
My job makes a positive difference in the
5
local community.
My job is contributing to a brighter future for
6
the local community.
H. PROFESSIONAL QUALITY OF LIFE
1. When you provide home visits to families you have direct contact with their lives. As you may have found, your
compassion for those you provide home visits to can affect you in positive and negative ways. Below are some questions
about your experiences, both positive and negative, as a home visitor. Consider each of the following questions about
you and your current work situation. How often did you experience these things in the last 30 days?
1
2
3
4
5
I am happy.
I am preoccupied with more than one person I
provide home visits to.
I get satisfaction from being able to provide
home visits to people.
I feel connected to others.
I jump or am startled by unexpected sounds.
Never
Rarely
Sometimes
Often
Always
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
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January 2019
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
I feel invigorated after working with those I
provide home visits to.
I find it difficult to separate my personal life
from my life as a home visitor.
I am not as productive at work because I am
losing sleep over the traumatic experiences of a
person I provide home visits to.
I think that I might have been affected by the
traumatic stress of those I provide home visits
to.
I feel trapped by my job as a home visitor.
Because of my job as a home visitor, I have felt
"on edge" about various things.
I like my work as a home visitor.
I feel depressed because of the traumatic
experiences of the people I provide home visits
to.
I feel as though I am experiencing the trauma of
someone I have provided home visits to.
I have beliefs that sustain me.
I am pleased with how I am able to keep up with
home visiting techniques and protocols.
I am the person I always wanted to be.
My work makes me feel satisfied.
I feel worn out because of my work as a home
visitor.
I have happy thoughts and feelings about those I
provide home visits to and how I could help
them.
I feel overwhelmed because my case load seems
endless.
I believe I can make a difference through my
work.
I avoid certain activities or situations because
they remind me of frightening experiences of
the people I provide home visits to.
I am proud of what I can do as a home visitor.
As a result of home visiting, I have intrusive,
frightening thoughts.
I feel "bogged down" by the system.
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
Never
Rarely
Sometimes
Often
Always
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
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January 2019
27
28
29
30
31
32
33
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
Never
Rarely
Sometimes
Often
Always
I have thoughts that I am a "success" as a home
visitor.
I can't recall important parts of my work with
trauma victims.
I am a very caring person.
I am happy that I chose to do this work.
The chronic stresses in the lives of people I
provide home visits to make me depressed.
I take the stress of people I provide home visits
to home with me.
I get overwhelmed by the ongoing challenges
faced by the people I provide home visits to.
I. TRAINING
Earlier you answered questions about your program’s overall system for supporting you in your work. Next are some
questions more specifically about just the trainings you receive through your work with your home visiting program.
Home visiting staff receive training on many different topics from different organizations. Please include training
received from your home visiting model, your agency, tribe, or other partnering organizations including state sponsored
trainings. Do not include supervision sessions with your direct supervisor or other provider.
1. The training I receive provides me with everything I need to support the families I work with in the following areas:
1
2
3
4
5
6
7
8
9
Prenatal health/prenatal care (including dental
health/dental care)
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)
Strongly
agree
Agree
Disagree
Strongly
disagree
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
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January 2019
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
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
Strongly
agree
Agree
Disagree
Strongly
disagree
[In Question 1 above, for topics that received disagree and strongly disagree ratings, GO TO
Question 1a below. For topics that received agree or strongly agree ratings, SKIP TO next topic
in Question 1.]
1a. [If Question 1 = disagree or strongly disagree] For each topic area in which you do not feel fully
prepared to support families (as you indicated on the previous page), why do you not feel fully
prepared to support families in this area? CHECK ALL THAT APPLY
I didn’t get enough training in this area.
I didn’t fully understand the training I received in this area.
The training I received wasn’t useful.
I need something other than training to be able to support families in this area.
My program doesn’t focus on this area.
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
21
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
2. If you ask, can you attend trainings in specific areas relevant to your needs or professional goals?
No
Yes, I can once in a while when I ask
Yes, I can about half the time I ask
Yes, I can most of the times I ask
Yes, I can every time I ask
Not sure
3. How often do the trainings you attend directly relate to your day-to-day work with families?
Never
Rarely
Sometimes
Often
Always
4. How often are the trainings you attend helpful and engaging?
Never
Rarely
Sometimes
Often
Always
5. How often are the trainings you attend individualized to meet your needs?
Never
Rarely
Sometimes
Often
Always
6. How often do the trainings you attend offer techniques or materials that are relevant for your
community and the families you serve?
Never
Rarely
Sometimes
Often
Always
7. How long were you on staff as a home visitor before you received training in [the model]?
Less than 1 month
1 month
2 months
3 months
4-6 months
Longer than 6 months
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
22
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
8. How long after you received your initial [model] training did you feel prepared to make home visits on
your own?
Right away
Within 2 weeks
Within 1 month
Longer than 1 month
I do not feel ready yet
I haven’t been trained yet
9. How important is each of the following in preparing and supporting you as a home visitor…
1
2
3
4
5
6
7
8
9
10
Shadowing another home visitor
One-on-one time with my direct
supervisor
[Model] training sessions
Receiving reflective supervision
Talking with other home visitors
Case conferencing
Watching videos of other home visitors
Debriefing with my co-workers
Coursework/education in early childhood
development or a related field
Continuing education opportunities
Not at all
important
Minimally
important
Somewhat
important
Very
important
I haven’t
received
this
10. What other strategies have been important in preparing and supporting you as a home visitor?
___________________________________________________________________________________
J. SUPERVISION
We want to know how you feel about the amount of reflective supervision you receive. Reflective supervision is the
time you are able to spend with a supervisor or other provider exploring your thoughts, feelings, actions, and reactions
when working with families.
1. How do you feel about the amount of one-on-one reflective supervision you receive?
I’m getting too much
I’m getting just the right amount
I’m getting some but not enough
I’m not getting any
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
23
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
2. How do you feel about the amount of group reflective supervision you receive (i.e., reflective supervision you
receive with other home visitors)?
I’m getting too much
I’m getting just the right amount
I’m getting some but not enough
I’m not getting any
3. [SKIP if Question 1 AND Question 2 = I’m not getting any] Please answer the following questions about the person
who provides you with reflective supervision. This may be your direct supervisor, someone else within your agency,
or other provider. How often do you feel the following ways about the person who provides you with reflective
supervision?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
My reflective supervisor(s)…
…and I have a trusting relationship.
…and I have a regular supervision schedule.
…questions encourage details about my practice to
be shared and explored within the supervision
session.
…is engaged throughout the entire session.
…is both a teacher and a guide.
…makes me feel nurtured, safe, and supported
during supervision.
…shows me how to integrate emotion and reason
into case analyses.
…guidance improves my ability to be reflective.
…allows me time to come to my own solutions
during supervision.
…explores my thoughts and feelings about the
supervisory process itself.
…and I together set the agenda for supervision.
…thinks with me about how to improve my
observation and listening skills.
…listens carefully for the emotional experiences
that I am expressing.
…encourages me to talk about emotions I have felt
while consulting and working with families.
…keeps families’ and children’s unique experiences
in mind during supervision.
…wants to know how I feel about my consultation
or practice experiences.
…helps me explore cultural considerations in my
work.
Never
Rarely
Sometimes
Often
Always
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
24
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
4. In the past 12 months, has there been a time when you did not have a supervisor or someone in a leadership
position that you could go to for support in your job?
No
Yes, for less than 1 month
Yes, for 1-3 months
Yes, for 4-6 months
Yes, for 7-9 months
Yes, for 10 months or more
Unsure
5. In the past 12 months, has there been a time when you were unable to go to your supervisor or other provider for
reflective supervision -- to explore your thoughts, feelings, actions, and reactions when working with families?
No
Yes, for less than 1 month
Yes, for 1-3 months
Yes, for 4-6 months
Yes, for 7-9 months
Yes, for 10 months or more
Unsure
6. In the past 12 months, has there been a time when you were unable to go to someone in your program with whom
you had a trusting relationship to explore your thoughts, feelings, actions, and reactions when working with
families?
No
Yes, for less than 1 month
Yes, for 1-3 months
Yes, for 4-6 months
Yes, for 7-9 months
Yes, for 10 months or more
Unsure
7. Since you began your position as a home visitor at your agency, how many direct supervisors have you had?
Enter Number: _______
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
25
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
8. The following topics may be discussed during one-on-one supervision. In order to meet your families’ needs would
you like to discuss the following topics with your one-on-one supervisor more, about the same, or less amount as
you do now?
1
2
3
4
5
6
7
8
9
10
Progress of particular families, including general updates and
celebrating successes.
Problem-solving for particular families. This includes getting families
connected to services, addressing challenging topics with families,
strategies for motivating families, and supporting families through
crises.
Managing my caseload. This includes the number of families on my
caseload, enrolling new families into home visiting, scheduling home
visits, and making the number of expected home visits.
Building my skills to provide information and support to families. This
includes planning home visits, delivering the curriculum, learning how
to model positive parenting and facilitate parent-child interaction, and
accessing training and professional development.
My thoughts, feelings, actions and reactions when working with
families, including any past trauma home visiting might bring up for
me.
My emotional wellbeing, including managing stress and exhaustion,
things happening in my personal life, and community events
influencing morale.
My professional development, including discussing my professional
development goals and actions that can be taken to achieve those
goals.
Working effectively with other team members, including collaborating
on activities, and roles and responsibilities of team members.
Data collection and entry, including tracking what data to collect and
when, questions about forms or assessments, data entry, explaining
data collection to families, completing forms in a timely manner.
Policies and procedures and other administrative topics. This includes
following agency or program policies and procedures, changes to
policies and procedures, completing administrative trainings and forms,
time and leave reporting, and performance reviews.
More
About the
same
Less
Unsure
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
26
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
9. How helpful is the support you get from your direct supervisor during one-on-one supervision in the following areas:
1
2
3
4
5
6
7
8
9
10
Tracking progress of particular families, including
general updates and celebrating successes.
Problem-solving for particular families. This includes
getting families connected to services, addressing
challenging topics with families, strategies for
motivating families, and supporting families through
crises.
Managing my caseload. This includes balancing work
with the number of families on my caseload, enrolling
new families into home visiting, scheduling home visits,
and making the number of expected home visits.
Building my skills to provide information and support
to families. This includes planning home visits,
delivering the curriculum, learning how to model
positive parenting and facilitate parent-child
interaction, and accessing training and professional
development.
Processing my thoughts, feelings, actions and reactions
when working with families, including any past trauma
home visiting might bring up for me.
My emotional wellbeing, including managing stress and
exhaustion, things happening in my personal life, and
community events influencing morale.
My professional development, including discussing my
professional development goals and actions that can be
taken to achieve those goals.
Working effectively with other team members,
including collaborating on activities, and roles and
responsibilities of team members.
Data collection and entry, including tracking what data
to collect and when, questions about forms or
assessments, data entry, explaining data collection to
families, completing forms in a timely manner.
Policies and procedures and other administrative
topics. This includes following agency or program
policies and procedures, changes to policies and
procedures, completing administrative trainings and
forms, time and leave reporting, and performance
reviews.
Not at all
helpful
A little
helpful
Somewhat
helpful
Very
helpful
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
27
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
10. How often do you rely on other home visitors in your program for support in the following areas:
1
2
3
4
5
6
7
8
9
10
Tracking progress of particular families, including general
updates and celebrating successes.
Problem-solving for particular families. This includes
getting families connected to services, addressing
challenging topics with families, strategies for motivating
families, and supporting families through crises.
Managing my caseload. This includes balancing work with
the number of families on my caseload, enrolling new
families into home visiting, scheduling home visits, and
making the number of expected home visits.
Building my skills to provide information and support to
families. This includes planning home visits, delivering the
curriculum, learning how to model positive parenting and
facilitate parent-child interaction, and accessing training
and professional development.
Processing my thoughts, feelings, actions and reactions
when working with families, including any past trauma
home visiting might bring up for me.
My emotional wellbeing, including managing stress and
exhaustion, things happening in my personal life, and
community events influencing morale.
My professional development, including discussing my
professional development goals and actions that can be
taken to achieve those goals.
Working effectively with other team members, including
collaborating on activities, and roles and responsibilities
of team members.
Data collection and entry, including tracking what data to
collect and when, questions about forms or assessments,
data entry, explaining data collection to families,
completing forms in a timely manner.
Policies and procedures and other administrative topics.
This includes following agency or program policies and
procedures, changes to policies and procedures,
completing administrative trainings and forms, time and
leave reporting, and performance reviews.
Never
Rarely
Sometimes
Often
Always
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
28
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
11. How helpful is the support you get from other home visitors in the following areas:
1
2
3
4
5
6
7
8
9
10
Tracking progress of particular caregivers, including
general updates and celebrating successes.
Problem-solving for particular caregivers. This includes
getting families connected to services, addressing
challenging topic with families, strategies for motivating
families, and supporting families through crises.
Managing my caseload. This includes balancing work
with the number of families on my caseload, enrolling
new families into home visiting, scheduling home visits,
and making the number of expected home visits.
Building my skills to provide information and support
to families. This includes planning home visits, delivering
the curriculum, learning how to model positive
parenting and facilitate parent-child interaction, and
accessing training and professional development.
Processing my thoughts, feelings, actions and reactions
when working with families, including any past trauma
home visiting might bring up for me.
My emotional wellbeing, including managing stress and
exhaustion, things happening in my personal life, and
community events influencing morale.
My professional development, including discussing my
professional development goals and actions that can be
taken to achieve those goals.
Working effectively with other team members,
including collaborating on activities, and roles and
responsibilities of team members.
Data collection and entry, including tracking what data
to collect and when, questions about forms or
assessments, data entry, explaining data collection to
families, completing forms in a timely manner.
Policies and procedures and other administrative
topics. This includes following agency or program
policies and procedures, changes to policies and
procedures, completing administrative trainings and
forms, time and leave reporting, and performance
reviews.
Not at all
helpful
A little
helpful
Somewhat
helpful
Very
helpful
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
29
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
K. ORGANIZATIONAL CULTURE AND CLIMATE
1. 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 your
home visiting program. This would include other home visitors, program coordinators/managers, supervisors,
evaluators, data managers and anyone else that might work closely with your program. 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
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 this 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.
Strongly
agree
Agree
Disagree
Strongly
disagree
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
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January 2019
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
With focus and effort, our team can do anything we set
out to accomplish.
Most people in our team can 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.
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.
Our 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.
Strongly
agree
Agree
Disagree
Strongly
disagree
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
2. Tribal home visiting programs have a lot of different leadership structures. For the next few questions, think
about the person in your home visiting program who serves as your team leader. How much do you agree or
disagree with the following statements?
1
2
3
4
5
6
7
8
9
10
Our team leader initiates meetings to discuss the
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.
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.
Strongly
agree
Agree
Disagree
Strongly
disagree
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Home Visitor Survey
32
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
L. CONNECTION TO COMMUNITY SERVED
1. Do you live in the same community or neighborhoods as the families you serve?
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 as the families you serve?
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 as the families you serve, 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 as the families you
serve?
Yes
No
Somewhat
3. In general, do you feel as though you and the families you serve 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: Home Visitor Survey
33
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 1 hour and 10 minutes
M. DEMOGRAPHICS
1. What is your Ethnicity?
Hispanic or Latino
Not Hispanic or Latino
2. What is your Race? CHECK ALL THAT APPLY
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: Home Visitor Survey
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| File Type | application/pdf |
| Author | Lyon@jbassoc.com |
| File Modified | 2019-02-06 |
| File Created | 2019-02-06 |