Formative Data Collections for Culture of Continuous Learning Project: A Breakthrough Series Collaborative for Improving Child Care and Head Start Quality

OMB #: 0970-0356

03/31/2018

Appendix D - Strengths and Needs Assessment

The BSC Team would like to learn more about your organization or agency’s characteristics and your level of interest in a Breakthrough Series Collaborative on social and emotional learning. The information will be used internally by the BSC Team and our CCL Project research team to inform the development of this project and research and implementation materials. No public report will be developed, and the findings will not be discussed publicly. Your responses will be kept private to the extent permitted by law. This Assessment should take you no more than 20 minutes to complete and your participation in completely voluntary. Thank you!

1. Based on what you heard during the information session, does the BSC sound like a model that could be a good fit for your ECE program agency?

   1. Yes

   2. No

   3. Maybe

2. What is the name of the program or organization where you work? __________________________________

3. What type of organization or program do you represent? (select all that apply)

   1. non-profit organization

   2. for profit organization

   3. program that is part of a larger/multi-site agency/organization

   4. Head Start or Early Head Start

4. Can you describe the population that your program/center serves? (select all that apply)

   1. Infants (6 weeks – 18 months)

   2. Toddlers (18 months – 2.9 yrs)

   3. Preschoolers (2.9 years – 5years)

   4. School-age (K – 12)

5. How many teaching staff members do you have working with children birth to five? __________________________________________

6. Approximately how many children do you serve (excluding school-age children)? _________

7. Who is your program or organization or agency administrator? ______________________________________________

8. If you were to participate in a Breakthrough Series Collaborative, who would be your proposed Team Senior Leader? _________________________________________________

   1. Contact information of proposed Team Senior Leader: ________________________

9. If you were to participate in a Breakthrough Series Collaborative, who would be your proposed Team Leader? _______________________________________________________

   1. Contact information of proposed Team Leader: ______________________________

10. Are you and/or staff at your program familiar with the CSEFEL Pyramid Model for social emotional learning? (select one)

    1. Yes

    2. No

    3. Somewhat

11. How many of your current staff have received training in CSEFEL? _____________________

12. What interests you about a BSC focused on social and emotional learning? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

13. Do you have any comments/questions about this project?

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

14. How interested are you in participating in a BSC to support children’s social and emotional learning and development? (select one)

    1. Very interested

    2. Somewhat interested

    3. Not at all interested

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.