Family Level Assessment and State of Home Visiting (FLASH-V) - Formative Data Collection

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Overview

Instructions
(1) Local Implementing Agencies
(2) Centralized Intake Agencies
(3) General CI Information

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Sheet 1: Instructions

FLASH-V Eligibility Assessment Form Instructions
Thank you for taking the time to complete the FLASH-V Eligibility Assessment Form.
This form will take approximately 30 minutes to complete.
Your participation in this study is voluntary and information will be kept private to the degree permitted by the technology used.
The goal of this form is to identify MIECHV funded local implementing agencies (LIAs) and centralized intake agencies in your state that may be eligible to participate in FLASH-V.
The FLASH-V project aims to understand how LIAs are making decisions regarding which families will be offered services.
Instructions for completing both tabs of the FLASH-V Eligibility Assessment Form:
* Select "Enable Content" in the yellow bar at the top of the spreadsheet in order to complete this form.
(1) Local Implementing Agencies
	Columns A and B are prepopulated with information about your state's MIECHV funded LIAs
	For each LIA, please enter the applicable information into columns C-H.
		If you select "No" in column C, automated "Not applicable" text will appear in columns D-G because we will not be reaching out to these LIAs for participation in FLASH-V.
		For all LIAs, column H can be used to provide any notes about the LIA that are pertinent to the FLASH-V project.
	If an LIA is listed incorrectly on this form, or is no longer being funded by MIEVHV, please feel free to make corrections and/or strikethrough the row. If an LIA is missing, please feel free to add them to the bottom of the spreadsheet.
(2) Centralized Intake Agencies
	Columns A and B are prepopulated with information about your state's MIECHV funded LIAs
	For each LIA, please enter the applicable information into columns C-F.
		If you select "No" in column C, automated "Not applicable" text will appear in columns D and E because we will not be reaching out to these centralized intake agencies for participation in FLASH-V.
		For all LIAs, column F can be used to provide any notes about the LIA's centralized intake agency that are pertinent to the FLASH-V project.
FLASH-V Eligibility Assessment Form Definitions
LIAs that are eligible to participate in FLASH-V =
	LIAs that typically have a higher number of families interested in services than they have the capacity to serve
	Examples of LIAs that would be eligible for the study:
		(1) An LIA that typically has only 3-5 open slots, but receives about 10 new eligible referrals every month.
		(2) An LIA that has no open slots, but maintains a waitlist of eligible families.
		(3) An LIA that has no open slots, but receives eligible referrals to fill an open slot in the near future.
		(4) An LIA that has very little turnover in families, but continues to receive eligible referrals.
	Examples of LIAs that would NOT be eligible for the study:
		(1) An LIA that typically can serve all eligible families that are referred to its home visiting program. (Note: This may include an LIA that experiences a one-time staff
			shortage, leaving the program with no open slots at that point-in-time.)
		(2) An LIA that stops accepting incoming referrals from referral partners when it has no open slots
Centralized Intake Definition =
	Centralized intake, also referred to as “coordinated intake,” “common intake,” or “central intake,” provides a single entry point through which families are referred
		to or can request home visiting services and potentially other services in the community
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 number for this information collection is 0970-0356 and the expiration date is 03/31/2018.

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Sheet 2: (1) Local Implementing Agencies

FLASH-V Eligibility Assessment Form - Local Implementing Agency Information
Name of local implementing agency (LIA)	Model(s) implemented by LIA	Does the LIA typically have a higher number of families interested in services than it has the capacity to serve? (See Instructions tab for definitions.)	Name of primary contact person at LIA	Email address of primary contact at LIA	Phone number of primary contact at LIA, if readily available	Role of primary contact at LIA, if readily available	Please include any notes about this LIA that may be pertinent to this project, including any concerns about the study team reaching out to this LIA for participation in FLASH-V at this time
LIA 1	HFA, NFP	Yes	Jane Smith	smith@lia1.org	555-555-5555	Program Manager
LIA 2	HIPPY	Yes	Mary Johnson	johnson@lia2.edu	444-444-4444	Intake Coordinator	LIA is working on a grant application that is due at the end of July. They are currently very busy with this.
LIA 3	PAT	No	Not applicable	Not applicable	Not applicable	Not applicable
LIA 4	EHS, HFA	Unknown	Paul Jones	jones@lia4.gov	333-333-3333	Program Manager	LIA has expressed interest in research projects in the past.
LIA 5	NFP	Yes	Linda Williams	williams@lia5.org	222-222-2222	Nurse Supervisor

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Sheet 3: (2) Centralized Intake Agencies

FLASH-V Eligibility Assessment Form - Centralized Intake Agency Information
Name of local implementing agency (LIA)	Model(s) implemented by LIA	Is this LIA part of a centralized intake agency? (See instructions tab for definitions.)	Name of primary contact person at centralized intake agency	Email address of primary contact person at centralized intake agency	Please include any notes about this centralized intake agency that may be pertinent to this project, including any concerns about the study team reaching out to this agency for participation in FLASH-V at this time
LIA 1	HFA, NFP	Yes	Susan Brown	brown@ci1.org	Centralized intake agency is going through a change in leadership. They just recently hired a new Executive Director.
LIA 2	HIPPY	No	Not applicable	Not applicable
LIA 3	PAT	Yes	John Jackson	jackson@ci2.edu
LIA 4	EHS, HFA	Yes	Maria Thomas	thomas@ci3.gov	Centralized intake agency is swamped with referrals during the summer, so they may not have time to participate.
LIA 5	NFP, PAT	No	Not applicable	Not applicable

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Sheet 4: (3) General CI Information

FLASH-V Eligibility Assessment Form - Centralized Intake Agency Information
Are any of your state's MIECHV funded LIAs participating in a centralized intake agency (also referred to as “coordinated intake,”
“common intake,” or “central intake.” A centralized intake agency provides a single entry point through which families are referred
to or can request home visiting services and potentially other services in the community)?
If yes, please provide the following information on each centralized intake agency in your state that refers families to MIECHV funded LIAs.
Name of primary contact person at centralized intake agency	Email address of primary contact person at centralized intake agency	Please include any notes about this centralized intake agency that may be pertinent to this project, including any concerns about the study team reaching out to this agency for participation in FLASH-V at this time	If available, please provide the following information:
			Name of LIA(s) participating in centralized intake agency	Model(s) implemented by LIA(s) participating in centralized intake agency
Susan Brown	brown@ci1.org	Centralized intake agency is going through a change in leadership. They just recently hired a new Executive Director.	LIA 1, LIA 2, LIA 3	HFA, NFP, EHS
John Jackson	jackson@ci2.edu	Centralized intake agency is swamped with referrals during the summer, so they may not have time to participate.	LIA 4, LIA 5	PAT, HFA