2. MUSE Caregiver Baseline Survey

December 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)

CAREGIVER BASELINE SURVEY FOR TELEPHONE ADMINISTRATION

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.

Staff member completes this page

Caregiver’s Program ID: _____

First name of staff member administering the survey or Staff ID: _____

Last name of staff member administering the survey or Staff ID (leave blank if using Staff ID): _____

Go to next page then hand tablet to caregiver

MUSE Caregiver Survey

Hello! Thank you for taking the MUSE Caregiver Survey over the phone with me today. My name is [NAME] and I will be helping you complete the survey. I’m going to read you the questions from the survey and record your answers into the computer. If you are unsure how to answer a question, please give the best answer you can.

The questions on this survey are about you and your family and what you expect to get out of the home visiting program. Your answers will be kept private. Only the research study team will be able to see your answers. Your answers will not be shared with your home visitor or anyone at the home visiting program or any other agencies. We will not report information collected in this study in a way that could identify you or your program. The survey will take about 20 minutes to complete over the phone. Finally, I want to remind you that your participation is voluntary.

We want to ensure you have privacy while completing the survey. To do this make sure you are in a private space and that you don’t put the phone on speaker phone mode. Let me know when you are in a private space and we can begin.

Do you want to take the survey?

• Yes  GO TO Next Page

• No  END Survey

A. BASIC QUESTIONS ABOUT YOU

First, we’re going to begin with some basic questions about you and your personal background.

1. What is your sex? [Do not read response options aloud. If respondent doesn’t know how to answer, say “the response options include female and male.”]

• Female

• Male

2. Are you or your partner currently pregnant? [Do not read response options aloud.]

• Yes

• No

3. Do you already have children? [Do not read response options aloud.]

• Yes SKIP TO Question 3a

• No SKIP TO Question 4

3a. [SKIP if Question 3 = NO] How many children do you have? Please count any children that you are a primary caregiver for. _____

3b. [SKIP if Question 3 = NO or Question 3a = 0] How many children do you have under age 5? Please count any children that you are a primary caregiver for. _____

• Yes

• No

4. Have you ever helped raise any children other than your own? [Do not read response options aloud.]

• Yes

• No

4. What adults live with you in your household now?

• Your partner, such as your husband, wife, boyfriend, or girlfriend

• Your parents or your partner’s parents

• Your grandparents or your partner’s grandparents

• Your siblings or your partner’s siblings

• Other relatives

• Other non-relatives

• No other adults live with me

4. How many adults 18 years or older live in your household? If YOU are over 18, please include yourself. _____

4. How many children between the ages of 6 and 17 live in your household? If YOU are under 18, please include yourself. _____

4. How many children 5 years old or younger live in your household? _____

4. If your income were to stop suddenly, how long do you think you would be able to cover your basic expenses-- like housing, food, or a car-- on your current savings?

• Less than 1 month

• 1-2 months

• 3-6 months

• More than 6 months

4. What language do you prefer for visits?

• English

• Your tribal language

• Spanish

B. REASONS FOR ENROLLING & EXPECTATIONS IN HOME VISITING

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

• Less than 1 month

• 1-2 months

• More than 2 months

2. I’m going to read you a list of common reasons why families enroll in home visiting. I will ask you how important these reasons were in your decision to enroll in your home visiting program. Please tell me whether each reason was not important, somewhat important, important, or very important.

		Not important	Somewhat Important	Important	Very important
1	Connecting with others to talk to as supportive friends				
2	Being more connected to my community and culture. This could include attending community and/or cultural activities, learning cultural teachings, and making new relationships with others in your community.				
3	Having my child be healthy				
4	Feeding my child. This includes formula and solids, but not breastfeeding.				
5	My child’s development. This includes learning new physical and social skills, language development, and coping with emotions.				
6	Managing my child's behavior				
7	Making child care arrangements				
8	Interacting with my child in a supportive and positive way				
9	Co-parenting with my child’s father/mother				
10	Taking care of my baby or child, including bathing, diapering, sleep, and routines				
11	Keeping my child and home safe				
12	[SKIP if not currently pregnant] Having a healthy pregnancy				
13	[SKIP if not currently pregnant] Staying healthy after I have my baby				
14	Breastfeeding				
15	Improving my overall health				
16	Eating more nutritious meals and exercising				
17	Using family planning				
18	Quitting smoking				
19	Quitting alcohol or drugs				
20	Dealing with stress				
21	Dealing with sadness				
22	Getting more education or job training				
23	Getting a job, or getting a better job				
24	Having healthy adult relationships with boyfriends or girlfriends, husbands or wives, partners, and co-parents				
25	Dealing with partner or family violence				
26	Coping with my own past abuse or trauma				
27	Meeting basic needs such as food, utilities, housing, transportation, and obtaining identification				
28	Budgeting and making ends meet				
29	Legal system and services				

C. YOUR RELATIONSHIPS AND WELLBEING

1. Next, I’m going to ask you about your relationships with other people and the support you receive as a parent. If you are expecting your first child now, think about the support you think you will have as a parent once your child is born. Please tell me whether you strongly disagree, disagree, agree or strongly agree with each statement.

		Strongly disagree	Disagree	Agree	Strongly agree
1	There are people I know will help me if I really need it.				
2	There are people who call on me to help them.				
3	There are people who like the same social activities I do.				
4	I feel responsible for taking care of someone else.				
5	I am with a group of people who think the same way I do about things.				
6	There are people I can count on when I need help as a parent.				
7	I have close relationships that make me feel good.				
8	I have someone I can go to with questions about parenting.				
9	I have someone to talk to about decisions in my life.				
10	There are people who value my skills and abilities.				
11	I have a trustworthy person to turn to if I have problems.				
12	I feel a strong emotional tie with at least one other person.				
13	There are people who admire my talents and abilities.				
14	There are people I can count on in an emergency.				

2. [SKIP if you do not have children yet, Question A3 = No]

Now I am going to ask you whether you agree or disagree with the following statements. Please tell me whether you strongly disagree, disagree, agree, or strongly agree with the following statements:

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

3. [SKIP if you do not have children yet, Question A3 = No]

Now I am going to read some statements that describe different ways that parents interact with their children on a daily basis. How often is each statement true for you? Please tell me whether each statement is never true, rarely true, sometimes true, often true, or always true.

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

4. [SKIP if you do not have children yet, Question A3 = No]

Finally, I’m going to ask a few more questions about the support you receive as a parent. For each statement, please tell me whether you strongly disagree, disagree, agree, or strongly agree.

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

[NEXT SCREEN]

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS SURVEY.

Please click ‘Submit’ to exit the survey.

Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Caregiver Baseline Survey

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