4. MUSE Rapid Reflect Caregiver 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)
RAPID REFLECT SELF-COMPLETED QUESTIONNAIRE - CAREGIVER

This collection of information is voluntary. 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: Rapid Reflect Self
Completed Questionnaire – Caregiver
1

January 2019

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

Home visitor completes this page
Caregiver’s Program ID: _____
Home visitor first name or Staff ID: _____
Home visitor last name or Staff ID (leave blank if using Staff ID): _____
Go to next page then hand tablet to caregiver

Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Rapid Reflect Self
Completed Questionnaire – Caregiver
2

January 2019

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

Caregiver Rapid Reflect
1. I felt comfortable talking with my home visitor today about myself and my family.





2.

Strongly agree
Agree
Disagree
Strongly disagree

I felt understood by my home visitor today.





Strongly agree
Agree
Disagree
Strongly disagree

3. How much of what you did today is useful in your everyday life?






None
A little
Some
Most
All

4. Which of the following did you like most about today’s home visit?








Getting useful information
Feeling supported in my parenting
Setting aside time to focus on my child
Getting connected to other services (including transportation to services)
Addressing a pressing need
Having someone to talk to who understands my needs
Getting support to achieve my goals for myself and my family

5. I’m glad I made the time for today’s home visit.





Strongly agree
Agree
Disagree
Strongly disagree

Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Rapid Reflect Self
Completed Questionnaire – Caregiver
3

January 2019

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

[NEXT SCREEN]

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS
SURVEY.
Please click ‘Submit’ to exit the survey.

[NEXT SCREEN]

Please stop here and return the tablet back to your
home visitor.

Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Rapid Reflect Self
Completed Questionnaire – Caregiver
4