1. MUSE Caregiver Enrollment Form 7.9.18_CLEAN

January 2019

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
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 #: 0970-0521, Exp:
12/31/2021. 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.
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: MUSE
Caregiver Enrollment Form

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January 2019

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 5 minutes

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.

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

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January 2019

DATA ELEMENT

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 5 minutes
DATA ENTRY

Caregiver’s Program ID
Assigned home visitor’s first
name or Staff ID
Assigned home visitor's last name
or Staff ID (leave blank if using
Staff ID):

Dates
Select caregiver's date of
enrollment into home visiting
program:
Select caregiver's date of consent
to participate in MUSE:

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

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