EBHV agency fidelity/cost web-based data entry

AGENCY FIDELITY/COST WEB-BASED DATA ENTRY

DATA COLLECTION INSTRUMENT FOR LOCAL SITES

REPORTING ENTITY: LOCATIONS [DATA CAN BE ENTERED INTO THE SYSTEM BY THE GRANTEE OR IMPLEMENTING AGENCY, BUT REPORTING SHOULD BE AT THE LOCATION LEVEL]

FREQUENCY OF REPORTING: NOTED THROUGHOUT

This document is intended to provide information about reporting expectations for the fidelity and cost domains. This is not intended to be a data collection instrument. All data will be collection via a web-based data collection instrument. The instrument consists of the following sections:

I. LOCATION-LEVEL INFORMATION

Purpose: Gather general information about the location implementing the EBHV program including certification date, funding sources and cost information, staffing, and program capacity and referrals. For locations implementing more than one EBHV model, data will be collected by model.

II. HOME VISITOR AND HOME VISITOR SUPERVISOR INFORMATION

Purpose: Gather information about each EBHV home visitor and home visitor supervisor including demographic characteristics, experiences, and workload. For locations implementing more than one EBHV model, data will be collected by model.

III. FAMILY/CHILD INFORMATION

Purpose: Gather information about each family that is referred to and eligible for the EBHV program including demographic characteristics.

IV. HOME VISIT INFORMATION

Purpose: Gather information about the services each family enrolled in the EBHV program receives.

I. LOCATION LEVEL INFORMATION

PROGRAMS AND CERTIFICATION

Q#	Question	Response Type	Response Categories	Frequency of Reporting
L.1	Location name	Pre-populated	[Pre-populated with information provided by grantees]	Baseline only
L.2a	According to our records, the following EBHV models are being/will be implemented in this location.	Pre-populated	[Pre-populated with information provided by grantees] Will be one or more of the following: Nurse Family Partnership Healthy Families America Parents as Teachers Safe Care Positive Parenting Program Family Connections	Baseline only
L.2b	For each model, is this EBHV model currently being implemented or planned to be implemented?	Check Box	Currently implemented Implementation planned	Baseline; updated as information changes
L.2c	For each model, please describe any enhancements you are making to this EBHV model.	Open field		Baseline; updated as information changes
L.3a	For each model, has implementation of this EBHV model at this location been certified by the national model developer?	Check Box	Yes/No	Baseline; updated as information changes
L.3b	If yes, please provide the date the model was certified.	Open date field	[mm/dd/yy]	Baseline; updated as information changes

PROGRAM CAPACITY

	Question	Response Type	Response Categories	Frequency of Reporting
L.4	For this model, how many slots are currently funded?	Open number field	__, __ __ __ (# of families)	Baseline
L.5a	Has the number of families that can be enrolled when this EBHV model is at full capacity changed?	Check box	Yes No	Monthly
L.5b	If yes, how many families can now be enrolled?	Open number field	__, __ __ __ (# of families)	Monthly
L.6a	Between mm/dd/yyyy and mm/dd/yyyy, what is the total number of families that were newly referred for services through this EBHV model?	Open number field	__, __ __ __ (# of families)	Monthly
L.6b	Of all families referred between mm/dd/yyyy and mm/dd/yyyy, how many met the criteria for participation in the EBHV program?	Open number field	__, __ __ __ (# of families)	Monthly

	Question	Response Type	Response Categories	Frequency of Reporting
L.7	Please list each funding source for implementation of the EBHV program. Provide amount and funding, start date, and end date.	Open field	Source:__________ Amount: $_________ Funding start date: [mm/dd/yy] Funding end date: [mm/dd/yy]	Annual (January)
L.8	Describe any in-kind/non monetary donations that you have received in support of the EBHV program. Please include both materials and volunteer labor. Please provide an estimate of the monetary value of the donation.	Open field	Brief description of in-kind donation: ___________________________ Estimated monetary value: $_________ Date of receipt: [mm/dd/yy]	Annual (January)

FUNDING SOURCES

II. HOME VISITOR AND HOME VISITOR SUPERVISOR INFORMATION

DEMOGRAPHIC CHARACTERISTICS:

	Question	Response Type			Response Categories	Frequency of Reporting
L.9a	Name	Open field			[First] [Middle Initial] [Last] ____________ ___ _____________________	Baseline only
L.9b	Unique ID	[Generated by web-based system]				Baseline only
L.10	Gender	Check Box			Male Female	Baseline only
L.11	Age	Check Box			Under 20 years 20-29 years 30-39 years 40-49 years 50-59 years 60 or older	Baseline only
L.12	Race/ethnicity	Check Box			Check all that apply: Black/African-American Asian/Pacific Islander White, non-Hispanic American Indian/Native American Hispanic/Latina Other (specify):_____________	Baseline only
L.13a	Has this home visitor/supervisor completed high school or a GED?		Check box	Yes, completed high school Yes, completed GED No		Baseline only
L.13b	Has the home visitor/supervisor completed education or vocational training other than high school/GED?		Check box	Yes No		Baseline only
L.13c	If yes, highest degree obtained	Check Box			Vocational/technical training program Some college, no degree Associate degree Bachelors degree Masters degree (MA, MS, MSW, MFT, etc.) Professional degree (for example: LLB, LD, MD, DDS) Doctorate degree (for example: PhD, EdD	Baseline only
L.13d	If associate’s degree or higher, field of study	Check Box			Child development Early childhood education/education Nursing Social work/Social welfare Psychology Other (specify):	Baseline only
L.14	Is the home visitor/supervisor currently enrolled in any kind of school, vocational or educational program?	Check Box			Yes No	Baseline only
L14a	If the home visitor/supervisor is currently enrolled in any kind of school, vocational or educational program, please indicate the degree/credential sought and the field of study.				Degree/Credential Sought: Vocational/technical training program Some college, no degree Associate degree Bachelors degree Masters degree (MA, MS, MSW, MFT, etc.) Professional degree (for example: LLB, LD, MD, DDS) Doctorate degree (for example: PhD, EdD Field of Study: Child development Early childhood education/education Nursing Social work/Social welfare Psychology Other (specify):
L.15	Has this home visitor/supervisor ever been the primary caregiver for a child?	Check Box			Yes No	Baseline only

EMPLOYMENT CHARACTERISTICS

	Question	Response Type	Response Categories	Frequency of Reporting
L.16	Date on which home visitor/supervisor began working in this EBHV model	Open date field	[mm/dd/yy]	Baseline only
L.17	Role in the EBHV model	Check Box	Home visitor Supervisor Both Other	Baseline only
L.18a	Does this home visitor/supervisor usually work more than 35 hours per week? If no, please include number of hours worked in a typical week.	Check Box	Yes No If no, # of hours worked:	Baseline only
L.18b	If checked yes above, of the hours that this home visitor/supervisor usually works, what percentage are allocated to home visiting and what percentage are allocated to supervision in a typical week. If this home visitor/supervisor does only one activity (home visiting or supervising), enter 100% for that activity.	Open field	Percent allocated to home visiting: __ _ __ % Percent allocated to supervising: __ __ __%	Baseline only
L.19a	Has this home visitor/supervisor completed model-specific training?	Check Box	Yes No	Baseline; update as information changes
L.19b	If yes, date of certification or completion of model-specific training	Open date field	[mm/dd/yy]	Enrollment only
L.19c	If no, is this home visitor currently participating in a model-specific training or certification process?	Check Box	Yes No
L.20	Does this home visitor/supervisor have prior experience delivering home-based interventions to families?	Check Box	Yes No	Enrollment only
L.21	Is this home visitor/supervisor fluent in any of the following languages, to the extent that they can conduct home visits in that language?	Check Box	Check all that apply: English Spanish Other (specify):	Enrollment only
L.22a	If no longer working at this location in this EBHV model, date home visitor/supervisor stopped working.	Open date field	[mm/dd/yy]	As information changes
L.22b	Why is home visitor/supervisor no longer working in this EBHV model? Please select the primary reason.	Check box	Left the field Relocated/moved out of area Took a position with greater salary and/or responsibility Position eliminated Involuntarily separated (for example fired or let go) Other:_______________	As information changes

EMPLOYMENT CHARACTERISTICS—MONTHLY UPDATES

	Question	Response Type	Response Categories	Frequency of Reporting
L.23	If a home visitor, what is his/her current caseload of families served through this EBHV model, as of xx/xx/xxxx?	Open field	__ __ __ (# of families)	Monthly
L.24	If a supervisor: L.24a. Number of home visitors in this EBHV model supervised by this staff person, as of xx/xx/xxxx. L.24b. Average hours of one-to-one supervision provided to each home visitor in this EBHV model between xx/xx/xxxx and xx/xx/xxxx.	Open field	a. __ __ __ (#) b. __ __ (hours)	Monthly

III. FAMILY/CHILD INFORMATION

REFERRAL INFORMATION:

	Question	Response Type	Response Categories	Frequency of Reporting
L.25a	Name of client (primary caregiver)	Open field	[First] [Middle Initial] [Last] ____________ ___ _____________________	Enrollment only
L.25b	Unique ID	[Generated by web-based system]		Enrollment only
L.26	Relationship to the target child	Check Box	Birth parent, adoptive parent or step parent Foster parent Grandparent Other relative Other nonrelative	Enrollment only
L.27	Initial referral date to EBHV model:	Open date field	[mm/dd/yy]	Enrollment only
L.28	Primary referral source	Check Box	WIC Friend or family Child welfare agency Other home visiting program Health care provider/clinic Medicaid School/child care provider Other (specify):	Enrollment only

DEMOGRAPHIC CHARACTERISTICS:

	Question	Response Type	Response Categories	Frequency of Reporting
L.29	Gender	Check Box	Male Female	Enrollment only
L.30	Age	Open field	[mm/dd/yy]	Enrollment only
L.31	Race/ethnicity	Check Box	Check all that apply: Black/African-American Asian/Pacific Islander White, non-Hispanic American Indian/Native American Hispanic/Latina Other (specify):_____________	Enrollment only
L.32	Primary language spoken in the home	Check Box	English Spanish Other (specify):_____________	Enrollment only
L.33a	Was the client born in the United States?	Check Box	Yes No	Enrollment only
L.33b	If no, what country was the client born in?	Open field		Enrollment only
L.33c	If no, how many years has the client lived in the United States?	Check Box/open field	One year or less More than one year: __ __ (number of years)	Enrollment only
L.34	Marital status	Check Box	Married Single, never married Widowed Divorced Separated	Enrollment only
L.35	Is the client currently working in a job for pay?	Check box	Yes, full-time (usually 35+ hours per week) Yes, part-time (usually less than 35 hours per week) No	Enrollment only
L.36a	Has the client completed high school or a GED?	Check box	Yes, completed high school Yes, completed GED No	Enrollment only
L.36b	If no, what was the last grade the client completed?	Open field	__ __	Enrollment only
L.37a	Has the client completed education or vocational training other than high school/GED?	Check box	Yes No	Enrollment only
L.37b	If yes, highest level of education obtained	Check box	Vocational/technical training program Some college, no degree Associate degree Bachelors degree Masters degree (MS, MA, MSW, MFT, etc) Professional degree (for example: LLB, LD, MD, DDS) Doctorate degree (for example: PhD, EdD	Enrollment only
L.38	Is the client currently enrolled in any kind of school, vocational or educational program?	Check Box	Yes No	Enrollment only
L.39	Is the client currently receiving any of the following public assistance services?	Check Box	No If yes, check all that apply: TANF/Welfare Medicaid – mother Medicaid – child Food stamps Social security administration (SSA) Unemployment insurance benefits State Children’s Health Insurance Program (SCHIP) WIC Government subsidized child care Other (specify)_________	Enrollment only
L.40	Which of the following categories best describes the client’s total yearly household income before taxes? Please include all sources of income from which she benefits.	Check box	Less than or equal to $3,000 $3,001 - $6,000 $6,001 - $9,000 $9,001 - $12,000 $12,001 - $15,000 $15,001 - $20,000 $20,001 - $30,000 $30,001 - $40,000 Over $40,000 Don’t know	Enrollment only

PREGNANCY HISTORY AND INFORMATION ON CHILDREN:

	Question	Response Type	Response Categories	Frequency of Reporting
L.41a	Is the client currently pregnant?	Check box	Yes No/don’t know	Enrollment only
L.41b	If yes, estimated due date	Open date field	[mm/dd/yy]	Enrollment only
L.42	How many times has she been pregnant? If client is currently pregnant, do not count the current pregnancy.	Open field	__ __	Enrollment only
L.43	How many live births has the client had?	Open field	__ __	Enrollment only
L.44	How old was the client at the time of her first child’s birth?	Open field	__ __ years	Enrollment only
L.45	Target child’s date of birth	Open date field	[mm/dd/yy]	Enrollment; update after child is born if client is pregnant with child at enrollment
L.46a	Do any other children under age 18 live in the home? Please only include children whose primary caregiver is the client.	Check Box	Yes No	Enrollment only
L.46b	If yes, please provide date of birth of each additional child living in the home.	Open date field	[mm/dd/yy] [mm/dd/yy] [mm/dd/yy] [mm/dd/yy] [mm/dd/yy]	Enrollment only

PROGRAM EXIT

	Question	Response Type	Response Categories	Frequency of Reporting
L.47a	If client is no longer receiving services through the EBHV program, what date did services end?	Open date field	[mm/dd/yy]	Program exit only
L.47b	Date of last home visit	Open date field	[mm/dd/yy]	Program exit only
L.47c	Primary reason services ended	Check Box	Declined further participation (check primary reason below): Returned to work Returned to school Receiving services from another program Pressure from family members Refused new home visitor Dissatisfied with the program Client feels she has received what she needs from the program Incarcerated or other out of home placement for the mother Other (specify): Miscarried/ fetal death/infant death: __ __ / __ __ / __ __ __ __ (date) Moved out of service area Unable to locate Excessive missed appointments/attempted visits Child no longer in family’s custody (parental rights terminated) Maternal death Infant(s) delivered	Program exit only

IV. HOME VISIT INFORMATION

HOME VISITS

	Question	Response Type	Response Categories	Frequency of Reporting
L.48	Primary home visitor ID	Drop Down List	[Generated from home visitors identified in section II]	Enrollment/first home visit; update if any changes occur
L.49a	Date home visit scheduled	Open date field	[mm/dd/yy]	Visit by visit basis
L.49b	Was this visit completed	Check Box	Yes No	Visit by visit basis
L.50	Duration of visit	Open field	__ __ __ minutes	Visit by visit basis
L.51	Location of visit	Check Box	Participant’s home Other location	Visit by visit basis
L.52	Module being provided	Check Box	Health Home safety Parent-child interactions or parent-infant interactions Problem solving and counseling	Visit by visit basis
L.53	Please indicate the percent of time during the visit covering each of the following topics/activities:	Open field	Triple P Assessment activities_____% Listening and processing parent’s concerns and input ____% Explaining or demonstrating a parenting strategy, principle, or procedure ____% Parental practice and implementation of strategies ____% Providing feedback or prompting self-evaluation by parent ___% Unplanned or emergency event not part of the actual intervention ___% Safe Care Assessing parent (baseline or end of module)___% Describing target behaviors___% Explaining rationale/reason for behaviors___% Modeling alternative behaviors___% Observing parent practice skills and providing feedback_____% Rapport building conversation(s)_____% Unplanned or emergency event not part of the actual intervention ___% Family Connections Conducting structured assessment____% Developing service plan ___% Providing participant specific advocacy and referral ____% Providing therapeutic intervention ___% Unplanned or emergency event not part of the actual intervention ___% PAT Formal assessment and screening tasks ___% Presenting and conducting parent-child activity ___% Book reading time ___% Ongoing assessment of parent status and needs ____% Unplanned activities (addressing immediate needs/referrals) ___% HFA Child development related activities ___% Parent-child interaction related activities ___% Health care related activities ___% Activities related to family functioning ___% Addressing family’s environmental needs ___% Administrative activities ___% Unplanned or emergency event not part of the actual intervention ___%	Visit by visit basis
L.54	Total percentage of all planned content covered during the visit	Open field	__ __ %	Visit by visit basis

FINAL 8 9/17/09