Form 1 Tailored Services Practive Model 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 7 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.

Tailored Services Practice Model Survey

Survey items would be rated on 5-point agreement scale (1 = Strongly Disagree to 5 = Strongly Agree).

These survey items would be appended to the Cross-Center Capacity Building Survey (instead of the Satisfaction survey items) at the close of every intensive services project (and the more intense brief projects, to be determined on a case-by-case basis).

PHASE	BEHAVIORS	ITEMS
Engagement	Performing outreach	Center representatives conducted outreach to our agency in a variety of ways that capitalized on previous engagements and efforts.
	Being responsive	Center representatives provided appropriate, timely responses to our agency communications.
	Building credibility	Center representatives built credibility by being well-informed about our state and best practices in child welfare.
	Providing clarity	Center representatives brought clarity to conversations about capacities, processes, and services.
	Collaborating	The Center helped create a team of representatives from all partner agencies that actively participated and collaborated to promote successful engagement.
Working as a Team	Joining a team	Center representatives ensured the team understood the project scope and specific team member roles and responsibilities.
	Integrating effort	The team operated in a way that maximized effectiveness of individual and collective efforts.
	Building team support and cohesion	The team operated cohesively in setting and accomplishing tasks, providing constructive feedback, and decision-making.
	Communicating and sharing information	Team members engaged in communications and supported the team’s continuous learning by sharing their own knowledge and experiences.
Service Delivery	Integrating service delivery	The partnership fostered mutual exploration of expectations through open dialogue and creation of a realistic scope of work for achieving shared goals.
	Pacing the work	Center representatives provided an appropriate amount of contact and support during the tailored service process.
	Guiding agency self-reflection	Center representatives encouraged an atmosphere of individual and organizational self-reflection and pursued opportunities for continuous quality improvement.
	Selecting strategies, activities, and tools	Center representatives engaged our agency in exploring and selecting evidence-based strategies, activities, and tools that are relevant to our state’s contexts.
	Promoting use of capacity building framework	Center representatives integrated the capacity dimensions and change process vocabulary into our discussions in an appropriate manner.
	Communicating with CB and collaborative partners	Center representatives engaged in respectful, open, and honest communication with our agency and partners throughout service delivery.
Tracking and Adjustment	Assessing capacity for tracking progress	Center representatives helped our agency increase our ability to monitor progress and make data-driven decisions.
	Developing an approach to understanding progress	Center representatives helped our agency identify potential indicators and data collection methods for monitoring our progress and achievement of outcomes.
	Collecting data to understand progress	Center representatives worked with our agency to identify and secure existing data and collect additional data needed for documenting progress and outcomes.
	Conducting analysis and building connections	Center representatives worked with our agency to identify appropriate analytic strategies and conduct data analysis to inform our decision-making.
	Discussing progress and planning effectively	Center representatives worked with the team to ensure reflective conversations about the project occurred regularly, including discussion of data about progress.
	Managing perceptions of progress	Center representatives facilitated discussions in an open environment that encouraged all team members to share their perceptions of initiative progress.
Transition to Sustainability	Planning for transition	Center representatives worked with the team to ensure our agency was focused on planning the transition from the beginning of the process.
	Deciding to transition and close	Center representatives helped our agency to reach a consensus on transitioning and closing services, while being respectful of individual opinions.
	Transitioning to sustained capacity building	Center representatives supported our agency in identifying strategies for sustaining and applying what we have achieved through the project, and the commitments needed for that sustainment.
	Facilitating a final meeting	The transition process included a reflective discussion about lessons learned, strengths and challenges, and suggestions for improvement.
	Ending services prematurely	If services ended prematurely, or inconsistently with the proposed plan, Center representatives discussed the possibility of reengagement and supported an amicable closure.

02/03/17