B5: RISE CCT Facilitator Survey

Attachment b5: RISE FACILITATOR survey

Emotional Permanency Instrument

Date:_____________________

Evaluation ID: _____________________

Respondent note: select the completion time period (circle one)

Baseline Follow-Up

As the facilitator of [insert child/youth’s name here] Care Coordination Team, we are interested in your assessment of his/her level of achieved permanency. Please look at the following answer choices and indicate your level of agreement with the following statements. [Place a check in the appropriate box]

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree	N/A
While in foster care, [insert child/youth’s name here] has connected or re-connected with relatives or caring adults who will be lifelong supportive connections
An adult has made a commitment to provide a permanent, parent-like relationship to [insert child/youth’s name here].
[insert child/youth’s name here] is living with an adult who has or plans to adopt him/her or become his/her legal guardian

_____________________________________________________________________________________Burden Statement: Public reporting burden for this collection of information is estimated to average 12 minutes. This estimate includes the time for reviewing instructions and completing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is 0970-0408 and it expires XX/XX/XXXX.

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