Form 6 Home Visitor Learning Cycle Form – Installation & Refine

OMB No: 0906-XXXX

Expiration Date: XX/XX/20XX

Home Visitor Questionnaire

Health Resources & Services Administration

Maternal and Child Health Bureau

ADAPT-HV

The Assessing and Describing Practice Transitions Among Evidence-Based Home Visiting Programs in Response to the COVID-19 Public Health Emergency (ADAPT-HV) project is funded by the Health Resources and Services Administration (HRSA) through a contract with The Policy & Research Group (PRG) and Mathematica.

What is the purpose of this questionnaire? This questionnaire aims to understand home visitors’ use of engagement strategies over each learning cycle of the ADAPT-HV study.

There are no risks or benefits to your participation. Your participation in this questionnaire is voluntary. You have the right to skip any question or end your participation at any time. There is no penalty if you choose not to participate in this questionnaire.

In order to know who has completed this questionnaire, we ask for your name and the name of the agency for which you work. This information will be removed when data are saved. We will not attribute any responses you give in the questionnaire to you personally and will not use your name when results from the research are shared. Only the research team will have access to individual responses. Your responses will be combined with other responses before results are reviewed. All data will be stored safely and destroyed at the end of the study.

The questionnaire should take roughly 10–15 minutes to complete.

If you have any questions about the study, please contact Teresa Smith at The Policy & Research Group (teresa@policyandresearch.com or (225) 281-3783).

If you have questions about your rights as a research volunteer, you can call Health Media Lab Institutional Review Board at (202) 549-1982.

Public Burden Statement: This collection of information will be used to learn about home visitors’ use of strategies being implemented during the ADAPT-HV study. 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 control number for this information collection is 0915/0906-XXXX and it is valid until XX/XX/202X. This information collection is voluntary. Data will be kept private to the extent allowable by the law. Public reporting burden for this collection of information is estimated to average 0.25 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or paperwork@hrsa.gov. Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.

Given what you just read about the purpose of this project, please select a response below.

• I agree to provide my feedback on the home visiting services I’ve provided to help the ADAPT-HV project to learn how to better deliver home visiting services.

• I do not agree to provide my feedback on the home visiting services I’ve provided. I understand that there is no penalty for not answering these questions. [exit form]

Please enter your name and your agency’s name below so that we know who has completed this questionnaire.

First name: [write-in]

Last name: [write-in]

Agency/organization name: [write-in]

VIRTUAL ENGAGEMENT STRATEGIES IMPLEMENTED

This section asks about the number of families with whom you have implemented virtual engagement strategies during home visits over the past week (7 days).

The questions will reference the specific child engagement strategies your agency has identified to test during this learning cycle through the ADAPT-HV study. As a reminder, those strategies are listed below.

1. [summarize strategy 1]

2. [summarize strategy 2, if applicable]

*Contents of this box and some subsequent questions will be customized for each site based on the strategies they identified to test in collaboration with the ADAPT-HV study team during staff focus groups conducted during Phases 1, 2, and/or 3.*

1. In total, how many families are you serving at this time (i.e., what is your current caseload?)

   • Write-in

2. In the past week, how many in-person home visits have you conducted?

   • Numeric write-in

3. [if number of in-person visits reported in Q2 is >0]

1. Of the [numeric response from Q2] in-person home visits you conducted this week, during how many did you use [strategy 1]?

   • Numeric drop down – maximum limit response from Q2

[if applicable]

2. Of the [numeric response from Q2] in-person home visits you conducted this week, during how many did you use [strategy 2]?

   • Numeric drop down – maximum limit response from Q2

4. In the past week, how many virtual home visits have you conducted?

   • Numeric write-in

5. [if number of virtual visits reported in Q4 is >0]

1. Of the [numeric response from Q4] virtual home visits you conducted this week, during how many did you use [strategy 1]?

   • Numeric drop down – maximum limit response from Q4

[if applicable]

2. Of the [numeric response from Q4] virtual home visits you conducted this week, during how many did you use [strategy 2]?

   • Numeric drop down – maximum limit response from Q4

STRATEGY CHALLENGES AND SUCCESSES

This section asks about challenges and successes that you may have encountered when implementing the strategies of interest during home visits in the past week.

[if number of visits reported in Q3a is >0 or Q5a is >0]

6. Briefly describe any challenges you experienced using [strategy 1] in the past week. Please specify whether the challenge(s) occurred during in-person or virtual home visits.

   • Open-ended response

7. Briefly describe any successes you experienced using [strategy 1] in the past week. Please specify whether the success(es) occurred during in-person or virtual home visits.

   • Open-ended response

[if number of visits reported in Q3b is >0 or Q5b is >0]

8. Briefly describe any challenges you experienced using [strategy 2] in the past week. Please specify whether the challenge(s) occurred during in-person or virtual home visits.

   • Open-ended response

9. Briefly describe any successes you experienced using [strategy 2] in the past week. Please specify whether the success(es) occurred during in-person or virtual home visits.

   • Open-ended response

[if applicable]

EXPERIENCES WITH STRATEGY IMPLEMENTATION

This section asks about your thoughts and feelings on your experiences implementing the strategies of interest during home visits in the past week.

Experiences with [strategy 1]

10. On a scale from 1 to 5, how often would you say a child’s engagement or participation improved/benefitted because of your use of [strategy 1] over the past week?

By engagement or participation we mean how interested or involved the child appeared.

1. Never

2. Rarely

3. Occasionally

4. Almost every time

5. Every time

11. On a scale from 1 to 5, how often would you say your rapport with your families improved/ benefitted because of your use of [strategy 1] over the past week?

By rapport, we mean a relationship characterized by agreement, mutual understanding, or empathy that makes communication possible or easy, demonstrated by friendly interaction, ease of communication, and/or feeling of emotional connection.

1. Never

2. Rarely

3. Occasionally

4. Almost every time

5. Every time

12. [if number of visits reported in Q3a is >0]

On a scale from 1 to 5, how confident did you feel in your ability to implement [strategy 1] effectively during in-person visits you conducted in the past week?

1. Not at all confident

2. Slightly confident

3. Somewhat confident

4. Moderately confident

5. Extremely confident

13. [if number of visits reported in Q5a is >0]

On a scale from 1 to 5, how confident did you feel in your ability to implement [strategy 1] effectively during virtual visits you conducted in the past week?

1. Not at all confident

2. Slightly confident

3. Somewhat confident

4. Moderately confident

5. Extremely confident

14. [if number of visits reported in Q3a is >0]

On a scale from 1 to 5, how comfortable did you feel implementing [strategy 1] during in-person visits you conducted in the past week?

1. Not at all comfortable

2. Slightly comfortable

3. Somewhat comfortable

4. Moderately comfortable

5. Extremely comfortable

15. [if number of visits reported in Q5a is >0]

On a scale from 1 to 5, how comfortable did you feel implementing [strategy 1] during virtual visits you conducted in the past week?

1. Not at all comfortable

2. Slightly comfortable

3. Somewhat comfortable

4. Moderately comfortable

5. Extremely comfortable

[if applicable]

Experiences with [strategy 2]

16. On a scale from 1 to 5, how often would you say a child’s engagement or participation improved/benefitted because of your use of [strategy 2] over the past week?

By engagement or participation we mean how interested or involved the child appeared.

1. Never

2. Rarely

3. Occasionally

4. Almost every time

5. Every time

17. On a scale from 1 to 5, how often would you say your rapport with your families improved/ benefitted because of your use of [strategy 2] over the past week?

By rapport, we mean a relationship characterized by agreement, mutual understanding, or empathy that makes communication possible or easy, demonstrated by friendly interaction, ease of communication, and/or feeling of emotional connection.

1. Never

2. Rarely

3. Occasionally

4. Almost every time

5. Every time

18. [if number of visits reported in Q3b is >0]

On a scale from 1 to 5, how confident are you in your ability to implement [strategy 2] effectively during in-person visits?

1. Not at all confident

2. Slightly confident

3. Somewhat confident

4. Moderately confident

5. Extremely confident

19. [if number of visits reported in Q5b is >0]

On a scale from 1 to 5, how confident are you in your ability to implement [strategy 2] effectively during virtual visits?

1. Not at all confident

2. Slightly confident

3. Somewhat confident

4. Moderately confident

5. Extremely confident

20. [if number of visits reported in Q3b is >0]

On a scale from 1 to 5, how comfortable do you feel implementing [strategy 2] during in-person visits?

1. Not at all comfortable

2. Slightly comfortable

3. Somewhat comfortable

4. Moderately comfortable

5. Extremely comfortable

21. [if number of visits reported in Q5b is >0]

On a scale from 1 to 5, how comfortable do you feel implementing [strategy 2] during virtual visits?

1. Not at all comfortable

2. Slightly comfortable

3. Somewhat comfortable

4. Moderately comfortable

5. Extremely comfortable

Thank you for completing this questionnaire!

If you have any questions about the study, please contact Teresa Smith at The Policy & Research Group (teresa@policyandresearch.com or (225) 281-3783).

If you have questions about your rights as a research volunteer, you can call Health Media Lab Institutional Review Board at (202) 549-1982.

The Policy & Research Group 6