15. MUSE Implementation Logs 7.9.18 CLEAN

January 2019

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 40 minutes

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

Public reporting burden for this collection of information is estimated to average 40 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.

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January 2019

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 40 minutes

Instructions for Completing the MUSE Implementation Logs
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.
The Implementation Logs collect information on your home visiting program's activities each month.
There are a total of 6 logs: New Staff Updates, Staff Departures Updates, Training, Family Group Events,
Group Supervision, and One-on-One Supervision.
Your information will be kept private. Only the MUSE study team and your program will have access to
this information. We will not report information collected in this study in a way that could identify you
or your program.
The amount of time it takes to complete the Implementation Logs varies depending on the number of
staff at each program and the number of activities to report. On average, it will take programs 40
minutes to complete.

NEW STAFF UPDATES
1. What is the name or staff ID of the new staff member?

New staff member first name or Staff ID:
New staff member last name (leave blank if using Staff ID):__________________
2. What is the work email address of [prefilled with staff member’s name or ID as reported in

Question 1]?
3. What was the position that [prefilled with staff member’s name or ID as reported in

Question 1] was hired into?
 Home Visitor
 Program Coordinator/Manager
 Program Director
 Data Manager
 Local Evaluator
 Other
If other position, please specify: __________

Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: MUSE
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January 2019

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 40 minutes

4. Please select [prefilled with staff member’s name or ID as reported in Question 1] 's start

date. If reporting for an external evaluator, please select the date the evaluator’s contract
began.

5. What was the approximate length of time it took to fill this position (in weeks):

___________________

STAFF DEPARTURES UPDATES
1. Please select the name or staff ID of the staff member who left their position.
2. Please select the position that [prefilled with staff member’s name or ID selected] left:








Home Visitor
Program Coordinator/Manager
Program Director
Data Manager
Local Evaluator
Other

If other position, please specify. __________
3. Please select [prefilled with staff member’s name or ID selected] ‘s departure date:

Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: MUSE
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January 2019

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 40 minutes

4. Please select the reason for [prefilled with staff member’s name or ID selected] ‘s

departure:
 Moved
 Took a new job
 Left for personal reasons
 Termination
 Other
If other reason, please specify.____________
5. Do you plan to rehire for this position?

 Yes
 No

TRAINING LOG
1. Did any program coordinators/managers or home visitors participate in training sessions

within the reporting month?
 Yes
 No
Please complete the following questions for a single training session only. After reporting
on this training session, you can report on additional training sessions attended in the
reporting month.

2. Please select the date for a single training session attended in the reporting month. If the

training session spanned multiple days, please only report the day the training began.

The following questions pertain to the training session held on [prefilled with date as
reported in question 2].

Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: MUSE
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January 2019

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 40 minutes

3. Please select the names or IDs of all staff members who attended this training. CHECK ALL

THAT APPLY.
[Names or IDs of staff members from local program will prefill in Question 3]
 staff member 1
 staff member 2
 staff member 3
 staff member 4
 staff member 5
 staff member 6
 Other
If other, please specify the staff member name or ID. _____________
4. How many total hours was this training session? If the training session was 30 minutes,

please report this as “0.5”. If the training session lasted multiple days, please report the
total number of hours it lasted. __________
5. What topics were covered in this training session? CHECK ALL THAT APPLY.

Topics Focusing on Supporting Caregivers:
 Prenatal health/prenatal care
(including dental health/dental care)
 Postpartum health/postpartum care
(including dental health/dental care)
 Breastfeeding
 Physical health outside of pregnancy
and postpartum (including dental
health/dental care)
 Nutrition and physical activity
 Family planning
 Commercial tobacco, alcohol, and
other drug use
 Caregiver emotional well-being,
mental health or stress
 Healthy adult relationships (with
boyfriends/girlfriends,
husbands/wives, partners, co-parents)
 Domestic violence

 Social support (support from family,
friends, and community)
 Employment
 Furthering caregivers’ education or job
training
 Budgeting/making ends meet
 Basic needs like food, utilities, housing,
transportation and identification
 Legal system and services
 Making child care arrangements
 Trauma (things that happened in the
past that affect caregiver today)
 Connecting to community and culture
(attending community and/or cultural
activities, learning cultural teachings,
making new relationships with others in
your community)

Topics Focusing on Parenting Behavior and Child Outcomes:

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January 2019

 Child health (including dental
health/dental care)
 Child development
 Parent-child interaction
 Discipline/behavior management

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 40 minutes

 Feeding children (including formula and
solids, and not including breastfeeding)
 Co-parenting
 Child/home safety
 Developmentally appropriate
care/routines (daily routines like
bedtime, mealtime, bath time)

Topics Focusing on Staff Roles and Responsibilities:
 Ensuring safety on the job
 General clinical and communication
skills
 Staff stress management and
emotional wellbeing
 Engaging fathers in home visiting
 Serving multi-generational families
and non-traditional caregivers
 Working with referral partners
 Data collection and entry

 Interactions with the child welfare
system
 Cultural sensitivity/diversity (learning
about other cultures and diversity;
interacting respectfully in culturally
diverse spaces)
 Supervisory methods (deliberate and
recognized approaches to supervision)
 Administrative tasks (agency policies and
procedures, paperwork, time and leave
reporting)

Other Topics:
 Other
If other, please specify. _____________

6. The training session was delivered:

 In-person
 Virtually
7. The training session was delivered by:







Program’s tribe or organization
Home Visiting Model
State
Federal Technical Assistance Provider (e.g. PATH, TEI)
Other _______________

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January 2019

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 40 minutes

FAMILY GROUP EVENTS LOG
1. Did your home visiting program offer any group events for families in the reporting month?
 Yes
 No
Please complete the following questions for a single family group event only. After
reporting on this family group event, you can report on additional family group events held
in the reporting month.

2. Please select the date of a single family group event offered for families in the reporting
month. If the group event spanned multiple days, please only report the day the event
began.

The following questions pertain to the family group event held on [prefilled with date
selected in Question 2].

3. How many total hours was this Family Group Event? If the event was 30 minutes, please
report this as “0.5”. If the group event lasted multiple days, please report the total number
of hours it lasted. __________
4. Number of people who attended: __________
5. What topic(s) and activities were addressed during the family group event? CHECK ALL
THAT APPLY.
Topics Focusing on the Caregiver and Other Adult Family Members:
 Prenatal health/prenatal care
(including dental health/dental care)
 Postpartum health/postpartum care
(including dental health/dental care)

 Employment
 Furthering caregiver’s education or job
training
 Budgeting/making ends meet

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January 2019

 Breastfeeding
 Physical health outside of pregnancy
and postpartum (including dental
health/dental care)
 Nutrition and physical activity
 Family planning
 Commercial tobacco, alcohol, and
other drug use
 Caregiver emotional well-being,
mental health or stress
 Healthy adult relationships (with
boyfriends/girlfriends,
husbands/wives, partners, co-parents)

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 40 minutes

 Domestic violence
 Social support (support from family,
friends, and community)
 Basic needs like food, utilities, housing,
transportation, and identification
 Legal system and services
 Making child care arrangements
 Trauma (things that happened in the
past that affect caregiver today)
 Connecting to community and culture
(attending community and/or cultural
activities, learning cultural teachings,
making new relationships with others in
your community)

Topics Focusing on Parenting Behavior and Child Outcomes:
 Child health (including dental
health/dental care)
 Child development
 Parent-child interaction
 Discipline/behavior management
 Feeding children (including formula
and solids, and not including
breastfeeding)

 Co-parenting
 Child/home safety
 Developmentally appropriate
care/routines (daily routines like
bedtime, mealtime, bath time)

Topics Focusing on Other Topics/Activities
 Celebrating holidays
 Family graduations from the program
 Other celebration
 Other
If other, please specify
_________________
6. The primary focus of the family group event was:
 Parents
 Children
 Both parents and children

Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: MUSE
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January 2019

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 40 minutes

GROUP SUPERVISION LOG
1. Did your home visiting program offer any group supervision sessions in the reporting
month?
 Yes
 No
1a. Why weren’t any group supervision sessions held in the reporting month?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Please complete the following questions for a single group supervision session only. After
reporting on this group supervision session, you can report on additional group supervision
sessions attended in the reporting month.

2. Please select the date for a single group supervision session held in the reporting month. If
the group supervision session spanned multiple days, please only report the day group
supervision session began.

The following questions pertain to the group supervision session held on [prefilled with
date selected in Question 2].

3. Who led the group supervision session? CHECK ALL THAT APPLY.
 Tribal Home Visiting staff member
 External consultant
 Other (specify) _______________

Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: MUSE
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January 2019

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 40 minutes

4. Select the home visitors that participated in the group supervision session. CHECK ALL THAT
APPLY.
 Home visitor 1
 Home visitor 2
 Home visitor 3
 Home visitor 4
 Home visitor 5
 Home visitor 6
 Other staff
If other, please specify the staff member name or ID.
5. How many total hours was this Group Supervision? If the supervision was 30 minutes,
please report this as “0.5”. If the supervision lasted multiple days, please report the total
number of hours it lasted. _______
6. Which of the following topics were addressed during this group supervision session? CHECK
ALL THAT APPLY.
 Managing caseload
 Case presentations and discussion
 Home visitors’ thoughts, feelings, actions and reactions when working with families
 Home visitors’ emotional wellbeing
 Professional development goals
 Team building and team dynamics
 Data collection and entry
 Policies and procedures and other administrative topics
 Other (specify) _______________

ONE-ON-ONE SUPERVISION LOG
Answer the following questions about each one-on-one supervision session conducted with
[FILL HOME VISITOR NAME OR ID] during the past month.
1. During the past month, did your home visiting program provide any one-on-one supervision
sessions with [FILL HOME VISITOR NAME OR ID]? Please exclude supervision provided by an
external consultant.
 Yes
 No
1a. Why weren’t there any one-on-one supervision sessions with [FILL HOME VISITOR NAME
OR ID] this past month?
__________________________________________________________________________________
Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: MUSE
Implementation Logs
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January 2019

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 40 minutes

__________________________________________________________________________________
_________________________________________________________________________________

2. How many one-on-one supervision sessions did [FILL HOME VISITOR NAME OR ID] receive
this past month? Please exclude sessions provided by an external consultant. __________

The following questions will ask you to enter information about each one-on-one
supervision session provided to [FILL HOME VISITOR NAME OR ID] by your program during
the past month. Please enter information about each one-on-one supervision session
provided during the past month one at a time.

[NOTE: Questions 3 and 4 are reported for each supervision session reported.]
3. When did the first/next] one-on-one supervision session for [FILL HOME VISITOR NAME OR
ID] take place? Please make sure you are selecting a date from the past month, not the
current month.

4. Which of the following topics were addressed during this supervision session? CHECK ALL
THAT APPLY.











Family topic 1: Discussing progress of a particular family
Family topic 2: Problem-solving for a particular family
Home visitor topic 1: Managing caseload
Home visitor topic 2: Building skills to provide information and support to families
Home visitor topic 3: Home visitor’s thoughts, feelings, actions and reactions when
working with families
Home visitor topic 4: Home visitor’s general emotional wellbeing
Home visitor topic 5: Home visitor’s professional development
Program topic 1: Home visiting team dynamics
Program topic 2: Data collection and entry
Program topic 3: Policies and procedures and other administrative topics

Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: MUSE
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January 2019

OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 40 minutes

Additional Supervision provided to [FILL HOME VISITOR NAME OR ID]

5. Did [FILL HOME VISITOR NAME OR ID] receive one-on-one supervision from an external
consultant during the past month?
 Yes → GO TO Question 5a.
 No → SKIP TO Question 6.
5a. How many supervision sessions did [FILL HOME VISITOR NAME OR ID] receive from an
external consultant? ____________________

Observation of Home Visits

6. Did you or someone else from your home visiting program observe [FILL HOME VISITOR
NAME OR ID] during a home visit this past month?
 Yes → GO TO Question 6a
 No → SKIP to Supervision Log for next home visitor
6a. Was [FILL HOME VISITOR NAME OR ID] provided feedback after the home visit
observation?
 Yes
 No

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