2014 Staff Interviews - Administrators or Directors

ATTACHMENT C
SOCIAL NETWORK SURVEYS

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OMB No. XXX

Expiration Date xx/xx/XXXX

PROMISE Evaluation

Social Network Survey—Program Directors/Managers

Paperwork Reduction Act Statement – This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this project is 0960-XXXX.  We estimate that it will take about 10 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

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Name:

Job Title:

Agency:

State:

QUESTION 1 QUESTION 2 QUESTION 3

One year ago, how frequently did administrative staff from your organization communicate with administrative staff in the following organizations about issues pertaining to youth with disabilities and their families?

Now, how frequently does administrative staff in your organization communicate with administrative staff in the following organizations about issues pertaining to youth with disabilities and their families? (Do not count the bi-annual state [PROMISE/ASPIRE] meetings.)

One year ago, to what extent did your organization have an effective working relationship with each of the following organizations on issues related to youth with disabilities and their families?

a

b

c

d

e

a

b

c

d

e

a

b

c

Never

Once or twice a year

Every month or two

Every week or two

More than once a week

Never

Once or twice a year

Every month or two

Every week or two

More than once a week

Not at all

To some extent

To a considerable extent

Agency 1

Agency 2

Agency 3

Agency 4

Agency 5

Agency 6

Agency 7

Agency 8

Other [please specify]: _________________________

Other [please specify]: ________________________

For each row, please place an “X” in the column that best answers the question. For each question, please leave blank the rating for your own organization. If there are other organizations that you believe play a role in PROMISE that are not included, please add them in the boxes marked, “Other [please specify].” Continue on additional sheets if necessary.

For each row, please place an “X” in the column that best answers the question. For each question, please leave blank the rating for your own organization. If there are other organizations that you believe play a role in PROMISE that are not included, please add them in the boxes marked, “Other [please specify].” Continue on additional sheets if necessary.

QUESTION 4 QUESTION 5 QUESTION 6

Now, to what extent does your organization have an effective working relationship with each of the following organizations on issues related to youth with disabilities and their families?

In the past year, and related to your work on [PROMISE/ASPIRE], with which of the following organizations has your organization…

In the past year, and outside of your work on [PROMISE/ASPIRE], with which of the following organizations has your organization…

a

b

c

a

b

c

d

a

b

c

d

Not at all

To some extent

To a considerable extent

Shared resources (such as staff, facilities, or funding)?

Developed or improved data sharing capacities?

Developed or improved client referral processes?

Worked to improve service delivery to clients?

Shared resources (such as staff, facilities, or funding)?

Developed or improved data sharing capacities?

Developed or improved client referral processes?

Worked to improve service delivery to clients?

Agency 1

Agency 2

Agency 3

Agency 4

Agency 5

Agency 6

Agency 7

Agency 8

Other [please specify]: _________________________

Other [please specify]: ________________________

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OMB No. 0960-XXXX

Expiration Date xx/xx/XXXX

PROMISE Evaluation

Social Network Survey – Service Provider Staff

Paperwork Reduction Act Statement – This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this project is 0960-XXXX.  We estimate that it will take about 10 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

Page is intentionally left blank to allow for double-sided copying

Name:

Job Title:

Agency:

State:

One year ago, how frequently did you communicate with front-line staff (who work directly with clients) in the following organizations about client issues? If you were not in this position one year ago, please leave all of Question 1 blank.

Now, how frequently do you communicate with front-line staff (who work directly with clients) in the following organizations about client issues?

a

b

c

d

e

A

B

c

d

e

Never

Once or twice a year

Every month or two

Every week or two

More than once a week

Never

Once or twice a year

Every month or two

Every week or two

More than once a week

Agency 1

Agency 2

Agency 3

Agency 4

Agency 5

Agency 6

Agency 7

Agency 8

Agency 9

Agency 10

Other [please specify]: _________________________

Other [please specify]: ________________________

For each row, please place an “X” in the column that best answers the question. For each question, please leave blank the rating for your own organization. If there are other organizations that you work with in your efforts to serve youth with disabilities that are not on the list, please add them in the boxes marked, “Other [please specify].” Continue on additional sheets if necessary.

QUESTION 1 QUESTION 2

One year ago, and related to your work with youth or adults with disabilities, how often did you do the following with each organization? If you were not in this position one year ago, please leave all of Question 3 blank. N = Never S = Sometimes F = Frequently

a

b

c

d

e

f

Engage in joint training?

Share intake or assessment data on clients?

Refer clients to?

Receive referrals from?

Discuss a specific client’s needs, goals, and/or services (over the phone, in person, or via email)?

Meet with specifically on transition planning for a client?

Agency 1

N

S

F

N

S

F

N

S

F

N

S

F

N

S

F

N

S

F

Agency 2

Agency 3

Agency 4

Agency 5

Agency 6

Agency 7

Agency 8

Agency 9

Agency 10

Other [please specify]: _________________________

Other [please specify]: ________________________

For each row, please place an “X” in the column that best answers the question. For each question, please leave blank the rating for your own organization. If there are other organizations that you work with in your efforts to serve youth with disabilities that are not on the list, please add them in the boxes marked, “Other [please specify].” Continue on additional sheets if necessary.

QUESTION 3

Now, and related to your work with youth or adults with disabilities, how often do you do the following with each organization? N = Never S = Sometimes F = Frequently

a

b

c

d

e

f

Engage in joint training?

Share intake or assessment data on clients?

Refer clients to?

Receive referrals from?

Discuss a specific client’s needs, goals, and/or services (over the phone, in person, or via email)?

Meet with specifically on transition planning for a client?

Agency 1

N

S

F

N

S

F

N

S

F

N

S

F

N

S

F

N

S

F

Agency 2

Agency 3

Agency 4

Agency 5

Agency 6

Agency 7

Agency 8

Agency 9

Agency 10

Other [please specify]: _________________________

Other [please specify]: ________________________

For each row, please place an “X” in the column that best answers the question. For each question, please leave blank the rating for your own organization. If there are other organizations that you work with in your efforts to serve youth with disabilities that are not on the list, please add them in the boxes marked, “Other [please specify].” Continue on additional sheets if necessary.

QUESTION 4