Inst 1 - Survey of reactions to the toolkit

OMB #: 0970-0XXXX

Expiration Date: XX/XX/XXXX

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: This collection of information will be used to understand user reactions to the toolkit. Public reporting burden for this collection of information is estimated to average 3 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 subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB number and expiration date for this collection are OMB #: 0970-XXXX, Exp: XX/XX/XXXX. If you have any comments on this collection of information, please contact Sharon Newburg-Rinn, Ph.D., Sharon.Newburg-Rinn@acf.hhs.gov.

Prenatal Alcohol and Other Drug Exposures: A Child Welfare Practice Toolkit

Reactions to the Toolkit

Thank you for considering participation in this survey, a component of U.S. Department of Health and Human Services’ evaluation of the Prenatal Alcohol and Other Drug Exposures: A Child Welfare Practice Toolkit. This survey is an opportunity for the evaluation team to understand how agency staff feel about the potential usefulness of the toolkit. This information helps us to understand whether any changes need to be made to the toolkit content in the future to improve its usefulness to child welfare professionals such as yourself.

We realize how limited your time is; the survey should take approximately 3 minutes to complete. Your participation in the survey is voluntary. You may decline to answer any question you do not wish to answer, and you may exit the survey at any time. There are no risks involved in participating in the survey. While you will not receive any direct benefits from participating in this survey, your responses will help us learn more about the usefulness of the toolkit for professionals such as yourself.

Your survey responses will be stored in a password-protected electronic database. Only evaluation team members from the contract staff of JBA and ICF will be able to access survey data. Your name or any other personally identifying information will not appear in any report. Be assured that your individual responses will not be shared with your colleagues, supervisors, leadership, or any other staff of your agency. Your survey responses will remain private to the full extent permitted by law. 

If you have questions or concerns about the survey or the evaluation, you may contact Project Director Erin Ingoldsby at Ingoldsby@jbassoc.com.

Please select your choice below. You may print a copy of this consent form for your records. Clicking on the “Agree” button indicates that:

• You have read the above information;

• You voluntarily agree to participate;

• You are 18 years of age or older.

• Agree

• Disagree

We are interested in understanding how child welfare professionals feel about the toolkit. Based on your personal experience, for this set of items, please consider the content of the toolkit and indicate the extent to which you agree or disagree with each statement.

		Strongly disagree	Disagree	Neutral or Unsure	Agree	Strongly agree
1	Exposure to the modules and resources in the toolkit was an effective way for me to learn about prenatal exposures to alcohol and other drugs.
2	The introduction of new skills to assess and identify children with prenatal exposures to alcohol and other drugs was helpful.
3	The introduction of new skills to integrate information about children with prenatal exposures to alcohol and other drugs into case planning and service referrals was helpful.
4	The introduction of new skills to document information about prenatal exposures to alcohol and other drugs in case files was helpful.
5	The introduction of new skills to better support families to care for children with prenatal exposures to alcohol and other drugs was helpful.
6	Access to resources to build child welfare professionals’ knowledge about children with prenatal exposures to alcohol and other drugs was helpful.
7	Access to resources to share with families and caregivers to support children with prenatal exposures to alcohol and other drugs was helpful.
8	Overall, the toolkit seems useful.
9	I can use the information I learned from the toolkit with my clients.
10	I would rate the toolkit as important.
11	The toolkit is relevant to my job duties.
12	My work with clients will go more smoothly when I implement techniques I learned from the toolkit.
13	(Supervisors only) Staff that I supervise will be able to apply the toolkit in their work with children and families
14	(Supervisors only) The toolkit contained information that I can apply during supervision with my staff.

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