10. Program Implementation Survey 7.9.18 CLEAN

January 2019

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 20 minutes

MULTI-SITE IMPLEMENTATION EVALUATION OF TRIBAL HOME VISITING (MUSE)
PROGRAM IMPLEMENTATION SURVEY FOR MANAGERS

This collection of information is voluntary. Public reporting burden for this collection of information is estimated
to average 20 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.

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January 2019

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 20 minutes

MUSE Program Implementation Survey for Managers
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 a program coordinator/manager in one of
the home visiting programs participating in MUSE. Your answers will help us understand your
perspective on your program’s operations. You can complete this survey by yourself or ask the Program
Director to complete it with you or provide information for any of the responses.
Your participation in this survey is voluntary. If you choose to participate, it will take about 20 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 (other than the Program
Director if you choose to complete this with them). 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 ____.

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January 2019

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 20 minutes

A. 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 which provides [SERVICE TYPE] 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] Does the home visiting program have a memorandum of understanding
(MOU) or other service agreement in place with at least one agency that provides services
in this area?
 Yes
 No
 Don’t Know
1b. [If Question 1 = Yes] Do you have a designated point of contact with at least one agency that
provides services in this area?
 Yes
 No
 Don’t Know
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January 2019

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 20 minutes

1c. [If Question 1 = Yes] Overall, how would you rate your current coordination with
agencies in this area for making referrals?
 Poor or no coordination
 Fair
 Good
 Excellent
 Don’t know
 We partner with multiple agencies in this area and the level of coordination is
different with each agency
1d. [If Question 1 = Yes] For each service type available in your area, how easy or difficult
is it for the families you work with to get these services?
 Very easy [→ GO TO next service type]
 Somewhat easy [→ GO TO next service type]
 Somewhat difficult [→ GO TO #1e]
 Very difficult [→ GO TO #1e]
 Not sure [→ GO TO next service type]

1e. [If Question 1d = somewhat difficult or very difficult] 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

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January 2019

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 20 minutes

B. MIECHV and Major Sources of Funding for the Home Visiting Program
1. Aside from Tribal MIECHV, what are the top two sources of funding for the home visiting program
(the sources that provide the most amount of money) and the percent of the program’s total
funding (including Tribal MIECHV) that comes from each?
A. ______________________ provides
[Enter Funding Source 1]

 less than 20% of the program’s funding
(including Tribal MIECHV)
 20-49% of the program’s funding
(including Tribal MIECHV)
 50-74% of the program’s funding
(including Tribal MIECHV)
 75% or more of the program’s funding
(including Tribal MIECHV)

B. ______________________ provides
[Enter Funding Source 2]

 less than 20% of the program’s funding
(including Tribal MIECHV)
 20-49% of the program’s funding
(including Tribal MIECHV)
 50-74% of the program’s funding
(including Tribal MIECHV)
 75% or more of the program’s funding
(including Tribal MIECHV)

2. How much of the home visiting program’s funding comes from Tribal MIECHV?
 Less than 20%
 20-49%
 50–74%
 75%-95%
 Over 95%
3. Not including funding from Tribal MIECHV, how stable would you say the home visiting program’s
funding is?
 Very stable
 Moderately stable
 Not very stable
 Unstable
4. Does your program receive reimbursement for home visiting services from any of the following
sources? CHECK ALL THAT APPLY
 Medicaid
 Early Intervention
 Other (specify) _________________
 None of the above
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January 2019

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 20 minutes

C. FAMILIES SERVED
1. If the home visiting program has more families identified as eligible than open slots at a particular
time, which types of families are prioritized for enrollment when open slots are limited? CHECK ALL
THAT APPLY
 Our program does not set priorities within identified eligible families.
 Expectant mothers.
 Expectant mothers who are early on in their pregnancy.
 Expectant mothers who are late in their pregnancy.
 Low income families.
 Families of children with special health care needs.
 Families with the largest number of risk factors.
 Families living in particular communities.
 Other (specify) ___________________________________
2. How closely aligned are the home visiting program’s family eligibility requirements with the family
eligibility requirements of [NATIONAL MODEL]?
 Very well aligned
 Moderately well aligned
 Not very well aligned
 Not aligned at all
 Not sure

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January 2019

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 20 minutes

D. INCENTIVES
1. Does the home visiting program provide incentives to families for participating in the program? If so,
what kind of incentives?
 Does not provide incentives [→ SKIP to next section]
 Provides cash incentives [→ GO TO Question 1a]
 Provides gift card incentives [→ GO TO Question 1a]
 Provides child incentives [→ GO TO Question 1a]
 Provides coupons redeemable for items [→ GO TO Question 1a]
 Provides other type of incentive (specify): ___________________________________ [→ GO TO
Question 1a]
 Unsure [→ SKIP to next section]
1a. [If Question 1 = provides cash incentives, provides gift card incentives, provides child
incentives, provides coupons redeemable for items, or other type of incentive] What are
the circumstances for providing incentives? CHECK ALL THAT APPLY
 Give to all families
 Completing visits
 Participating in group meetings
 Following through on recommended activities
 Birth of child or subsequent birthdays
 Reengaging in program
 Other circumstance (specify): ___________________________________
 Unsure

E. STAFFING LEVELS AND CASELOADS
1. How many of the past 12 months has your program been fully staffed, that is, with home visitor
positions fully filled?
 None
 Less than 1 month
 1-3 months
 4-6 months
 7-9 months
 10 months or more
2. When a home visitor position becomes vacant, what strategies does your program use to provide
services to the families that were in that home visitor’s caseload? CHECK ALL THAT APPLY
 Graduate those families early
 Suspend visits for those families
 Reduce the expected visit frequency for those families
 Shift responsibility for those families to other home visitors
 Shift responsibility for those families to supervisor
 Other (specify): _________

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January 2019

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 20 minutes

3. On average, how long does it take from the time a new home visitor is hired for him/her to be fully
trained and ready to be assigned families?
 Less than 1 month
 1 month
 2 months
 3 months
 4-6 months
 Longer than 6 months
4. Do any of your home visitors currently have caseloads greater than the maximum called for in the
home visiting program’s policies?
 Our site does not have a policy for caseload limit.
 No, all home visitors have caseloads within the maximum allowed by our policy.
 Yes, one or more home visitors currently have caseloads above the maximum allowed by our
policy.
5. How many of the past 12 months has one or more of your home visitors had a caseload greater than
the maximum called for in your home visiting program’s policy?
 None
 Less than 1 month
 1-3 months
 4-6 months
 7-9 months
 10 months or more

F. HOME VISITOR RECRUITMENT AND HIRING
1. Did the home visiting program hire any new home visitors in the past 12 months?
 Yes
 No [→ SKIP to next section]
2. [If Question 1 = Yes] How many home visitor positions did you need to fill in the past 12 months?
________ NUMBER OF POSITIONS
3. [If Question 1 = Yes] On average, how long has it taken the program to find and select a candidate
for a home visitor position? Please include the time it takes to obtain approval to publish a job
announcement, the amount of time a job announcement must remain open, and the time it takes to
interview and select candidates.
 Less than 1 month
 1 month
 2 months
 3 months
 4-6 months
 Longer than 6 months

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January 2019

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 20 minutes

4.

[If Question 1 = Yes] On average, how long does it take between selecting a candidate and being
able to officially offer the candidate a position?
 1 week or less
 2 weeks
 3 weeks
 1 month
 2 months
 3 months or longer

5.

[If Question 1 = Yes] How easy or hard is it to recruit qualified home visitor candidates?
 Very hard
 Somewhat easy
 Somewhat hard
 Very easy

6.

[If Question 1 = Yes] Did you have difficulty recruiting home visitors with any of the following
particular qualifications? CHECK ALL THAT APPLY.
 Experience in home visiting
 Required education/degree
 Experience working in the community served
 Own transportation
 Other (specify): _________
[NEXT SCREEN]

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS
SURVEY.
Please click NEXT to exit the survey.

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