Form 7 Family Post-Visit Form – Refinement Phase

OMB No: 0906-XXXX

Expiration Date: XX/XX/20XX

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 communications you received from your home visitor in between home visits.

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.

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 information collection is part of the Assessing and Describing Practice Transitions Among Evidence-Based Home Visiting Programs in Response to the COVID-19 Public Health Emergency Study, which aims to identify and study practices implemented in response to the COVID-19 public health emergency that support evidence-based practice and have the potential to enhance home visiting programming. One of the practices the study identified is the use of informal contacts. Informal contacts are any contacts between a home visitor and family that occur between formal home visits (e.g., text messages, emails). The purpose of this information collection is to better understand, through rapid cycle learning, how MIECHV-funded home visiting programs can use informal contacts to improve service delivery and promote caregiver’s engagement and satisfaction. 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 private to the extent permitted by the law. The time required to complete this information collection is estimated to average less than 1 hour per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. 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, Maryland, 20857 or paperwork@hrsa.gov, Attention: Information Collections Clearance Officer.

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. Since your last home 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.*

3. Since your last home visit, which methods has your home visitor used to contact you? Select all that apply.

   1. Email

   2. Text

   3. Phone call

   4. Other? Please specify: ___________

• Not applicable – my home visitor has not contacted me since my last home visit [skip to Q12]

4. Since your last home visit, about how many times did your home visitor contact you using the following methods. Please count only the initial contact(s) your home visitor made, not any conversation that followed. [display only methods selected in Q3]

   1. Email? [numeric drop-down]

   2. Text? [numeric drop-down]

   3. Phone call? [numeric drop-down]

   4. Other? Please specify: ___________ [numeric drop-down]

5. Since your last home visit, what types of services, messages, or information did you receive from your home visitor (such as giving you information, checking in on your family, connecting you to a service, or answering your questions) through the following methods. [display only methods selected in Q3]

   1. Email? [Open-ended response]

   2. Text? [Open-ended response]

   3. Phone call? [Open-ended response]

   4. Other? [Open-ended response]

6. Since your last home visit, do you feel that your home visitor contacted you:

1. Too much

2. The right amount

3. Not enough

7. On a scale from 1 to 5, how satisfied are you overall with the conversations you had with your home visitor since your last home visit? By conversations, we mean any back-and-forth you had with your home visitor after they initially contacted you.

1. Not at all satisfied

2. Slightly satisfied

3. Somewhat satisfied

4. Moderately satisfied

5. Extremely satisfied

• Not applicable – I did not respond to the contact(s) I received from my home visitor

8. On a scale from 1 to 5, how satisfied are you overall with the content of the communication(s) you received from your home visitor since your last home visit? By content, we mean the reason they contacted you and what they shared, asked, or discussed.

1. Not at all satisfied

2. Slightly satisfied

3. Somewhat satisfied

4. Moderately satisfied

5. Extremely satisfied

9. On a scale from 1 to 5, in your opinion, how much did the communication(s) you received from your home visitor since your last home visit improve the quality of your visit today?

1. Not at all

2. Slightly

3. Somewhat

4. A moderate amount

5. A great deal

10. On a scale from 1 to 5, how much have the communication(s) you received from your home visitor since your last visit improve how comfortable you feel in your home visit today?

1. Not at all

2. Slightly

3. Somewhat

4. A moderate amount

5. A great deal

11. On a scale from 1 to 5, how much have the communication(s) you received from your home visitor since your last visit enhance how comfortable you feel in your home visits overall?

1. Not at all

2. Slightly

3. Somewhat

4. A moderate amount

5. A great deal

12. 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) 549-1982.

The Policy & Research Group 5