Form 1 Center for States Information and Referral Survey

OMB Control No.: xxxx-xxxx

Expiration Date: xx/xx/20xx

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing 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.

Information and Referral survey

Instructions for On-line Survey Development

For each Information and Referral Requests received by the Center for States, a survey will be created in on-line survey software to gather feedback that can inform project planning. Given the changing nature and context of each request, it is important to be able to get feedback from recipients without creating undue burden by answering excessive questions that only marginally apply. To address this, the survey will be tailored to the unique information needs of each person to ensure low burden while informing high quality service provision. When creating each on-line survey, content specialists will use the required questions listed below and choose up to 3 context specific optional questions that can be added to the survey, as needed. This will allow for unique information needs to be met.

It is expected that each tailored survey will have no more than 10 questions, including 7 required questions and a maximum of 3 optional questions, with a burden of no more than 3 minutes.

Required Questions (7 required)

	Strongly Disagree	2	3	Neither	5	6	Strongly Agree
Center for States provides easy and quick access to information.	SD	2	3	N	5	6	SA
Information provided by the Center for States will be helpful in my work.	SD	2	3	N	5	6	SA
I would recommend the Center for States to others looking for information.	SD	2	3	N	5	6	SA
Overall, I was satisfied with my experience with the Center for States.	SD	2	3	N	5	6	SA

• What would have made your experience getting information from the Center for States more helpful? (Open Ended)

• Which of the following best describes your position or role? (Check all that apply)

• Administrative Leadership (director/deputies)

• Training Department/Division

• Supervisors

• Case Workers/Direct Practices Workers

• Data Managers & IT Staff

• Foster Care Managers

• Adoption Managers

• Courts

• CIP Coordinators

• Judges

• Attorneys

• Court Administrative Officers

• Attorney/Attorney-GALs

• Court/Attorney Data Managers & IT staff

• CASAs/Non-attorney GALs/other advocates

• Case Workers/Social Workers/Other

• Stakeholders

• Contracted Service Providers (provide examples)

• Law Enforcement

• Health

• Mental Health

• Substance Abuse

• Domestic Violence

• Education

• Community (provide examples)

• Families, Parents, Youth (provide examples)

• Foster Parent/Caregivers

• Tribal child welfare

• Tribal Council

• Tribal Court

• Tribal Elders

• Other tribal program (Please describe)

• In which State/Territory/Tribe do you work?___________

Optional Questions (choose up to 3)

Rating Questions (7pt likert scale)

• The information provided by the Information & Referral Services was timely & current.

• The information presented seems credible and accurate.

• I will share what I learned with others.

Open-ended questions:

• How and with what groups of colleagues will you share what you learned? Please provide the number of people that you are planning to share with/have shared with?

• What information were you seeking when you reached out to Information & Referral Services?

• Do you have any additional comments?

Response choice questions:

How did you learn about the Center for States? (Check all that apply)

• Capacity Building Collaborative webpage

• Center for States staff

• Center for Tribes staff person

• Listserv

• Colleague

• Hard-copy publication

• Advertisement (please specify)

• Search engine (e.g., Google, Yahoo)

• Social media (e.g., Facebook, Twitter, YouTube)

• Conference or presentation (please specify)

• Link from another webpage (please specify)

• Children’s Bureau

• Other (please specify):__________

How often do I anticipate (or am I) applying what was learned?

• Daily

• Weekly

• Monthly

• Quarterly

• Annually

• Never

How frequently do you use Information & Referral Services? (Check One)

• Never

• Once

• Every Few Months

• Monthly

• A Few Times a Month

• Weekly

• Two to Three Times a Week

Please select the various ways you [insert have already applied the information, plan to apply the information] from the [Information and Referral Services] in your work. (Check all that apply)

• Support program improvement

• Support policy development

• Provide information to clients/families

• Share with peers

• Support public awareness/advocacy

• Grant writing/Fundraising

• Train staff/colleagues

• Conduct research & evaluation

• My own professional development (e.g., increased knowledge)

• I have not yet applied this to my work

• Other (Please describe):__________

Please provide a specific example: ___________________________

I am involved in the following aspect of the Center for States capacity building services:

• Select all that apply:

• State team working with liaison

• Participating in constituency group

• Registered for one of the Center’s learning

• Learning Experiences (such as the CQI Training Academy, etc.)

How many years of service do you have in your current profession? (Check one)

• Less than 1 year

• 1–5 years of service

• 6–10 years of service

• 11–15 years of service

• 16+ years of service

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