1. MUSE Caregiver Enrollment Form 7.9.18_CLEAN

DRAFT 7/9/18 OMB Control No.: xxxx-xxxx

Expiration Date: xx/xx/20xx

Length of time for instrument: 5 minutes

MULTI-SITE IMPLEMENTATION EVALUATION OF TRIBAL HOME VISITING (MUSE)

CAREGIVER ENROLLMENT FORM

Public reporting burden for this collection of information is estimated to average 5 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. The OMB number and expiration date for this collection are OMB #: 0970-XXXX, Exp: XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Kate Lyon, James Bell Associates; 3033 Wilson Blvd. Suite 650, Arlington, VA 22201; MUSE.info@jbassoc.com.

MUSE Caregiver Enrollment Form

Thank you for taking part in the Multi-Site Implementation Evaluation of Tribal Home Visiting (MUSE). The purpose of this study is to learn about tribal home visiting programs and the experiences of families receiving home visiting services. In order to gather information about caregivers’ experiences with home visiting, we need some basic information about each caregiver who has consented to participate in MUSE. After a caregiver consents to participate in MUSE, the home visitors will complete the Caregiver Enrollment Form about that caregiver. Information from the Caregiver Enrollment Form will be used to track data collection with families, provide data collection reminders to home visitors, and ensure data quality. Completing the Caregiver Enrollment Form will take approximately 5 minutes per caregiver.

Information about caregivers will be kept private. Once this information has been provided to MUSE, only the MUSE study team will have access to this information and it will not be shared with anyone at your program or any other agencies. We will not report information collected in this study in a way that could identify caregivers, you or your program.

Data element	DATA ENTRY
Local Program ID
Date of enrollment into the home visiting program
Assigned home visitor
Date of consent to participate in MUSE
Optional Tag/Label (e.g., caregiver initials or other local identifier)

Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: MUSE Caregiver Enrollment Form

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