Center for States: Innovation Survey

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to gather feedback on capacity building products and services to better meet the needs of child welfare professionals. Public reporting burden for this collection of information is estimated to average 5 minutes per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. If you have any comments on this collection of information, please contact Brian Deakins at the Children’s Bureau, Administration for Children and Families by email at Brian.Deakins@acf.hhs.gov.

OMB Control No. 0970-0494

Expiration Date: XX/XX/XXXX

Innovation Pilot Survey

The Capacity Building Collaborative is committed to continuously improving the relevance and utility of services provided and we are asking for your participation in a survey focused on the [Specific Innovation] used during [Service name]. Your feedback will help us strengthen our services to better meet your needs. Your participation is voluntary, and your responses will be reported anonymously. It should take about 5 minutes to complete the survey. If you have any questions, please contact the Center’s evaluation lead, Christine Leicht (christine.leicht@icf.com).

1. Rate your level of agreement with each of the following statements.
   
   
   

	Strongly Disagree	Disagree	Somewhat Disagree	Neutral	Somewhat Agree	Agree	Strongly Agree	N/A	Don’t Know
[Specific Innovation] helped me stay engaged during this <service/event>.	1	2	3	4	5	6	7	N/A	DK
[Specific Innovation] helped the <service/event> achieve its goals	1	2	3	4	5	6	7	N/A	DK
[Specific Innovation] encouraged me to interact with others.	1	2	3	4	5	6	7	N/A	DK
[Specific Innovation] improved my ability to learn what was shared.	1	2	3	4	5	6	7	N/A	DK
I am more likely to participate in a future [service/event] if I knew [Specific Innovation] was going to be utilized.	1	2	3	4	5	6	7	N/A	DK
[Specific Innovation] enhanced the overall quality of the <serve/event>.	1	2	3	4	5	6	7	N/A	DK
I would participate in [service type] using [Specific Innovation] again.	1	2	3	4	5	6	7	N/A	DK

2. Please describe your experience with [Specific Innovation]:

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3. Please choose one of the following regarding your experience with [Specific Innovation]

( ) I encountered no challenges with my participation

( ) I had challenges with [Specific Innovation] but was still able to participate.

Describe challenge(s): _________________________________________

( ) I had challenges with [Specific Innovation] and was unable to participate.

Describe challenge(s): _________________________________________

4. How would you suggest the Center engage other people with [Specific Innovation]?

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5. The Center is piloting [Specific Innovation], what suggestions do you have for future improvements?

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6. What are the key aspects of [Specific Innovation] that contributed to its usefulness?

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7. Which of the following best describes your employer/organization? 

( ) State Child Welfare Agency

( ) County Child Welfare Agency

( ) Territorial Child Welfare Agency

( ) Tribal Child Welfare Agency

( ) State or County Court/Legal System

( ) Tribal Court/Legal System

( ) Private or Community-based Child Welfare Agency

( ) Local Government/Tribal Council

( ) Law Enforcement Organization

( ) Primary Care/Health Care Services Provider

( ) Behavioral/Mental Health Services Provider

( ) Substance Abuse Services Provider

( ) Domestic Violence Services Provider

( ) Juvenile Justice Organization

( ) Primary/Secondary Education

( ) College/University

( ) Technical Assistance Provider

( ) Federal Government

( ) Other

1. What is your primary role in the agency?

( ) Agency Director/Deputy Director

( ) Program/Middle Manager

( ) Supervisor

( ) Caseworker/Direct Practice Worker/Frontline staff

( ) Parent Partner

( ) Other

2. Which of the following best describes your primary work responsibilities in the agency? (Select up to three)

[ ] Administration

[ ] Workforce Development/Training

[ ] Continuous Quality Improvement/Evaluation

[ ] Information Technology/SACWIS/Data Systems

[ ] Indian Child Welfare Act

[ ] Primary or Secondary Prevention

[ ] Child Protective Services

[ ] In-home Services/Promoting Safe and Stable Families

[ ] Foster Care/Placement/Licensing/Reunification

[ ] Adoption/Guardianship

[ ] Youth in Transition/Chafee/Independent Living Programs

[ ] Other

C) Which of the following best describes your primary role?

( ) CIP or TCIP Director/Coordinator

( ) CIP or TCIP Staff

( ) Judge

( ) Attorney for Child Welfare Agency

( ) Attorney for Parent

( ) Attorney for Child

( ) Attorney Guardian Ad Litem

( ) Court Administrative Officer

( ) Court/Attorney Data Manager/IT Staff

( ) Court Appointed Special Advocate/Non-attorney GAL/Advocate

( ) Court Case Worker/Social Worker

( ) Other

4. Which of the following best describes your primary role?

( ) Dean/Director/Administrator

( ) Teaching Faculty

( ) Training Academy Leadership/Staff

( ) Research Faculty/Staff (non-teaching role)

( ) Student

( ) Other

4. You selected other, please provide your type of organization and the role you currently serve.

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