7 0906-0095 7_Family Post Visit Form-Refinement (Redline)

OMB No: 0906-0095

Expiration Date: 07/31/2027

Family Post-Visit 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 your impressions of the home visits you participated in and your perceptions of interactions with your child during the visit.

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 at no penalty. Your decision about whether to complete this questionnaire or to answer any specific questions will not affect any services that you receive.

The questionnaire should take roughly 5 minutes to complete. Your name is NOT on this questionnaire, and the information you provide will be kept completely private. Though we will review responses to this questionnaire as a whole with program staff, your individual response will not be viewed on its own by study staff or program staff.

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: 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 OMB control number for this information collection is 0906-0095 and it is valid through 7/31/2027. This information collection will be used to assess nominated ECHV programs’ interest in and eligibility for participation in the Assessing and Describing Practice Transitions Among Evidence-Based Home Visiting Programs in Response to the COVID-19 Public Health Emergency (ADAPT-HV) study. The time required to complete this information collection is estimated to average less than 0.08 hours 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.

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 received to help the ADAPT-HV project to learn how to better deliver home visiting services. I understand that no personal information will be collected about me. [move to Q1]

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

[PAGE BREAK]

1. Please write in the first and last name of your home visitor: [Open-ended response]

2. How was your home visit today conducted?

• In-person

• Virtual

• Other (specify:)____________

3. During today’s visit, did your home visitor do any of the following?

	Yes	No	Not sure
[strategy 1]	o	o	o
[if applicable, strategy 2]	o	o	o

*Contents of this question 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.*

4. Please briefly describe the skills, behaviors, or topics your home visitor coached you on during today’s visit. By coaching, we mean explaining or talking you through a specific parenting skill/behavior without demonstrating or showing you directly how to do it. [Open-ended response]

5. On a scale from 1 to 5, in your opinion, how successful were your home visitor’s attempts to coach you during today’s visit?

1. Not at all successful

2. Slightly successful

3. Somewhat successful

4. Moderately successful

5. Extremely successful

6. On a scale from 1 to 5, in your opinion, how much did the coaching you received today positively influence your child’s interest or active participation in the home visit?

1. Not at all

2. Slightly

3. Somewhat

4. A moderate amount

5. A great deal

7. On a scale from 1 to 5, please indicate how comfortable you feel using the behaviors or skills you learned during today's session.

1. Not at all

2. Slightly

3. Somewhat

4. A moderate amount

5. A great deal

8. On a scale from 1 to 5, please indicate how likely you are to use the behaviors or skills you learned during today's session in the future.

1. Not at all

2. Slightly

3. Somewhat

4. A moderate amount

5. A great deal

9. On a scale from 1 to 5, please indicate how much the coaching you received today influenced how comfortable you feel with your home visitor.

I feel:

1. Much less comfortable

2. Somewhat less comfortable

3. Stayed the same (no difference)

4. Somewhat more comfortable

5. Much more comfortable

10. On a scale from 1 to 5, how satisfied are you overall with your home visitor's attempts to coach you during your visit today?

1. Not at all satisfied

2. Slightly satisfied

3. Somewhat satisfied

4. Moderately satisfied

5. Extremely satisfied

11. Is there anything else you would like to share about your visit today? [Open-ended response]

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) 246-8504.

The Policy & Research Group 4