Appendix F_Disparities Instrument 3_ Family Online Survey (RL)

OMB Control #: XXXX-XXXX

Expiration Date: XX/XX/XXXX

INSTRUMENT 1: REQUEST FOR INFORMATION ABOUT LOCAL IMPLEMENTING AGENCIES

Public Burden Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0906-XXXX. This information collection aims to explore how families that experience disparities in outcomes targeted by the MIECHV program experience home visiting services. This study is an initial step in understanding those experiences and will provide a better understanding of how MIECHV-funded home visiting programs currently address disparities and promote equity. Data collection activities include interviews, focus groups, online surveys, program observations, and review of documents and management information systems data. The time required to complete this information collection is estimated to average less than 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is voluntary and confidentiality is followed according to law. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, MD or paperwork@hrsa.gov. 

Initial Email to MIECHV Awardees

Dear [MIECHV Awardee],

I’m writing to introduce the Home Visiting Assessments of Implementation Quality (HV-AIM) project. The HV-AIM project is conducted by Child Trends and James Bell Associates for the Health Resources and Services Administration (HRSA) in collaboration with the Administration for Children and Families (ACF). The HV-AIM project assesses relationships between home visiting implementation quality, program service delivery, and child and family outcomes. For this specific study, we hope to learn about Black families’ experiences of home visiting services and home visiting programs’ efforts to promote equity. We recently hosted the [insert title of informational webinar] to introduce the study. We also shared how we hope to engage MIECHV-funded home visiting programs in this study. If you were unable to participate in the webinar, a recording of the webinar can be found here [insert link].

Specifically, we hope to learn about Black families’ experiences of inclusion and racial marginalization in home visiting services and their perceptions of home visiting in relation to their racial identity. We also hope to understand how home visiting programs have successfully worked with Black families and centered race equity in their work with families.

We plan to reach out to MIECHV-funded local implementing agencies (LIAs) to get more information about efforts to promote equity and to ask for their assistance in recruiting families for study participation. Project findings may be used to support future technical assistance to programs, home visiting’s continuous quality improvement (CQI) work, and future evaluation efforts. A brief description of the project along with some FAQs about the project is attached to this email.

We are asking for your help to gather information about MIECHV-funded LIAs in your state or jurisdiction. Specifically, for each LIA, we would like to know:

• LIA name

• Name of LIA primary point of contact

• Contact information (email and phone number) for LIA primary point of contact

• Model(s) implemented

• Zip codes for service areas

You can share this information with the HV-AIM project team by:

• Emailing us with this information in the body of an email or uploading documents to a secure OneDrive folder here [insert link]. Feel free to send existing documents or forms.

• Completing the attached Word document and sending it to us via email

• Scheduling a brief phone call with us to provide this information over the phone

Your assistance and participation in this project are completely voluntary and declining to share this information will not impact your MIECHV award or standing with HRSA. We really appreciate your consideration. If you could please provide the requested information by xx/xx/xx (within 1 week), we would be very grateful.

Thank you in advance for your time and assistance with this project,

[Team member name and contact information]

For each MIECHV-funded LIA in your state or jurisdiction, please provide:

Program name	Point of contact at program	Point of contact email address	Models implemented	Zip code

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