5. MUSE Rapid Reflect Home Visitor 7.25.18 CLEAN

January 2019

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

MULTI-SITE IMPLEMENTATION EVALUATION OF TRIBAL HOME VISITING (MUSE)
RAPID REFLECT SELF-COMPLETED QUESTIONNAIRE – HOME VISITOR

Public reporting burden for this collection of information is estimated to average 12 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: Rapid Reflect SelfCompleted Questionnaire – Home Visitor
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January 2019

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

MUSE Rapid Reflect Self-Completed Home Visit Questionnaire – HOME VISITOR
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. One objective of MUSE is to learn about what happens during home
visits and how home visitors and families interact during visits. The questions in this Home Visitor Rapid
Reflect are about the home visit you just completed. It will take about 12 minutes to complete this
Rapid Reflect.
Your answers will be kept private. Only the MUSE study team will have access to this information. Your
answers 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 you or your program.

Caregiver’s Program ID: ______________________________________

Home visitor first name or Staff ID: ______________________________________

Home visitor last name or Staff ID (leave blank if using Staff ID): ________________________________

Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Rapid Reflect SelfCompleted Questionnaire – Home Visitor
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January 2019

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

1. Select the date of the home visit that you are reporting on: _____________
2. Did the caregiver complete a Rapid Reflect for this visit?
 Yes → SKIP TO Question 3
 No → GO TO Question 2a
2a. [If Question 2 = No] Why didn’t the caregiver complete a Rapid Reflect for this visit?
 Situation in the home wasn’t conducive to completing the Rapid Reflect (e.g.,
children needed attention, caregiver needed to attend to something
immediately)
 Caregiver chose not to complete the Rapid Reflect
 Caregiver wasn’t present for the home visit
 I needed to leave
 Other, please specify __________________________________________
3. Amount of time spent travelling to today’s home visit (in minutes). For example, enter “90” if you
spent an hour and a half. _____________
4. Length of today’s home visit (in minutes). For example, enter “90” if you spent an hour and a half.
_____________
5. Location of today’s home visit: (CHECK ALL THAT APPLY)
 Primary caregiver’s home
 Friend/family member’s home
 Home visiting program office
 Car
 Clinic or other agency office
 Other location, please specify ___________________________________
6. Who actively participated in today’s home visit? (CHECK ALL THAT APPLY)
 Primary caregiver
 Other relative(s)
 Primary caregiver’s spouse, partner, or  Home visiting program supervisor
another parent
 Other home visiting program staff
 Index child’s grandparent(s)
 Other external service provider
 Other/not sure
 Index child
 Other child(ren) under age 5
7. What topics did you cover during today’s home visit? (CHECK ALL THAT APPLY)






Basic needs like food, utilities, housing, transportation, and identification
Breastfeeding
Budgeting/making ends meet
Caregiver education and job training
Caregiver emotional well-being, mental health or stress

Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Rapid Reflect SelfCompleted Questionnaire – Home Visitor
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January 2019

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

 Caregiver physical health, outside of pregnancy and postpartum (including dental
health/dental care)
 Child development
 Child health (including dental health/dental care)
 Child/home safety
 Commercial tobacco, alcohol, and other drug use
 Co-parenting
 Cultural activities (attending community and/or cultural activities, learning
cultural teachings, making new relationships with others in your community)
 Developmentally appropriate care/routines for the child (daily routines like
bedtime, mealtime, bath time)
 Discipline/behavior management for the child
 Domestic violence
 Employment
 Family planning
 Feeding children (including formula and solids, and not including breastfeeding)
 Healthy adult relationships (with boyfriends/girlfriends, husbands/wives,
partners, co-parents)
 Legal services and system
 Making child care arrangements
 Nutrition and physical activity
 Parent-child interaction
 Postpartum health/postpartum care (including dental health/dental care)
 Prenatal health/prenatal care (including dental health/dental care)
 Social support (support from family, friends, and community)
 Trauma (things that happened in the past that affect caregiver today)
8. Home visitors do many things during a home visit and often do multiple things at once. About how
much time did you spend doing each activity during today’s home visit? The amount of time you
enter here may not add up to the entire time you spent doing this visit.
No
time

A little
time

Some
time

Most of
the time

Entire
time

a. Listening and providing emotional support











b. Discussing caregiver’s goals































e. Connecting caregiver with services and follow-up











f.











c. Providing educational information/delivering
curriculum content
d. Modeling and coaching parenting skills
Gathering information/collecting data

Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Rapid Reflect SelfCompleted Questionnaire – Home Visitor
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January 2019

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

9. How much of what you had planned did you get to cover in today’s home visit?
 None
→ SKIP TO Question 9a
 A little
→ GO TO Question 9a
 Some
→ GO TO Question 9a
 Most
→ GO TO Question 9a
 All
→ GO TO Question 10
 No plan was prepared; this was an unexpected visit due to an immediate crisis or other
reason
→ GO TO Question 10
9a. [If Question 9 = most, some, a little, or none] What were the main reasons you adjusted your
plan for today’s home visit? (CHECK ALL THAT APPLY)
 Caregiver wanted to do something else
 Caregiver’s mood or behavior
 Child was not present for the home visit or child was asleep
 Something more urgent came up that we needed to address
 Environment was not conducive to covering that topic
 I didn’t feel like what I was doing was working
 Ran out of time
10. What challenges did you experience during today’s home visit? (CHECK ALL THAT APPLY)
 No challenges
 Engaging an uninterested or fussy child
 Engaging an uninterested or distracted caregiver
 Building trust with the family
 Feeling uncomfortable talking about a certain topic
 Addressing a family crisis
 Discussing trauma or challenges experienced by someone in the family
 Conducting the home visit in the given environment
 Balancing family needs with program/curriculum goals
 Helping families access needed services
 Feeling concerned about my safety
 Having enough time
 Completing paperwork/data collection
 Other, please specify _____________
11. The participant was interested in what we did during today’s home visit.





Strongly agree
Agree
Disagree
Strongly disagree

Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Rapid Reflect SelfCompleted Questionnaire – Home Visitor
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January 2019

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

[NEXT SCREEN]

THANK YOU FOR TAKING THE TIME TO COMPLETE THE HOME
VISITOR RAPID REFLECT.

Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Rapid Reflect SelfCompleted Questionnaire – Home Visitor
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