Instrument 6_Supervisor Questionnaire for Repeated Measures, 3-19-24_CLEAN

Instrument 6: Survey for Repeated Administration of the Reflective Supervision Measure

NOTE to OMB: This instrument will be completed by participants in the repeated measures subsample each time they complete the reflective supervision measure. The introduction and informed consent are included with the reflective supervision measure (Instrument 3).

Now we’d like to ask you a few questions about your reflective supervision session.

1. About how long (in minutes) did it take you to complete the reflective supervision measure?

2. Please provide the home visitor’s name. (Note that the study team will contact this home visitor to complete the home visitor survey; your responses will not be shared with them.) _____________

3. Please provide the home visitor’s email address:

_____________

4. Which session are you reporting on for this home visitor?

   1. First

   2. Second

   3. Third

Questions about the session

5. How was the session conducted?

   1. In person

   2. Virtual

6. In what language was the session completed?

   1. English

   2. Spanish

   3. Other language, please specify:

7. About how long was the session?

1. Less than 30 minutes

2. Between 30 minutes and 1 hour

3. Longer than 1 hour

4. Not sure

8. How typical, if at all, was this session compared to other sessions you have had with this home visitor?

5. Very typical

6. Somewhat typical

7. Not typical at all

Comments or explanation for your response:

9. About how long have you been providing reflective supervision to this home visitor?

1. Less than 3 months

2. Between 3 months and 6 months

3. More than 6 months but less than one year

4. One year or more

10. Did you serve as a home visitor alongside this home visitor prior to becoming their supervisor?

1. Yes

2. No

Questions about the home visitor participating in the supervision session [to be asked at first administration]

11. About how long has this individual been a home visitor?

1. 6 months or less

2. More than 6 months but less than one year

3. 1-2 years

4. 3-5 years

5. More than 5 years

6. Not sure

12. Does the home visitor identify as Hispanic, Latino, or Spanish origin?

1. Yes

2. No

3. Not sure, the home visitor has not shared this information

4. Prefer not to answer

13. Which race does the home visitor identify as?

1. American Indian Alaska Native

2. Asian

3. Black or African American

4. Native Hawaiian Other Pacific Islander

5. White

6. Other, please describe

7. Not sure, the home visitor has not shared this information

8. Prefer not to answer

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