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pdfJanuary 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
MULTI-SITE IMPLEMENTATION EVALUATION OF TRIBAL HOME VISITING (MUSE)
PROGRAM COORDINATOR/MANAGER SURVEY
This collection of information is voluntary. Public reporting burden for this collection of information is estimated
to average 60 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: Program Coordinator/Manager
Survey
1
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
MUSE Program Coordinator/Manager Survey
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 program implementation and the experiences of families receiving home
visiting services.
We are asking you to complete this survey because you are a program coordinator/manager in one of the home visiting
programs participating in MUSE. Your answers will help us understand your role in the home visiting program and your
perspective on the program. Because program coordinators’ jobs are complex and involve many different tasks, this
survey is also complex and a bit lengthy.
Your participation in this survey is voluntary. If you choose to participate, it will take about 1 hour to complete this
survey. If you are unsure how to answer a question, please give the best answer you can instead of leaving it blank.
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.
We would appreciate your response by MM/DD/YYYY. If you have questions about the survey or at any time during the
study, please call Tess Abrahamson at James Bell Associates at ### or email ____.
2
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
A. BACKGROUND AND WORK EXPERIENCE
1.
What was the highest level/degree you completed in school?
Some high school, no diploma
High school/GED
Some college/no degree
Technical training or certification
Associate’s degree (e.g. AA, AS, ADN)
Bachelor’s degree (e.g. BA, BS, BSN)
Master’s degree or higher (e.g. MA, MS, MSW, MSN, PhD)
2. What were your main field(s) of study? CHECK ALL THAT APPLY. (Responses not limited to
highest degree completed.)
Child development
Early childhood education
Education
Psychology
Social work/Social welfare
Public health
Nursing
Other (specify) ___________________
3. Prior to your current position, did you have experience providing home visiting services?
No
→ SKIP TO Question 4
Yes → GO TO Question 3a
3a. [If Question 3 = Yes] Prior to your current position, how many total years of experience do you have
providing home visiting services, including your current home visiting program and any other home visiting
programs (this may include a previous position held at your current home visiting program and any other
home visiting programs)?
Less than 1 year
1-2 years
3-5 years
6-10 years
More than 10 years
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
4. Do you have experience working with families in any of the following settings? CHECK ALL THAT APPLY.
In-home day care
Center-based daycare
Preschool
School, grades K-12 (non-nurse)
School nurse
After school program
Special education program
Nursing
Home health care
Other health care
Social services
Mentoring programs
Mental health agencies
No prior experience
Other (specify): ________________
5. How many total years of professional experience do you have working with families and young children, including
home visiting jobs and other jobs doing related work (e.g., years of nursing experience plus years as a parent
educator in different settings)?
Less than 1 year
1-2 years
3-5 years
6-10 years
More than 10 years
6. Aside from your professional work, how many years of experience do you have raising
children? Please include experience you have as a primary caregiver for any child(ren) including
your own and other's children. Please count experience providing regular, consistent care for a
child as a primary caregiver. Do not include babysitting or infrequent assistance with children.
Years of experience: ___________
B. CURRENT POSITION
1. How many years have you worked for your home visiting program? Include years worked for your home visiting
program in positions other than your current one.
Less than 1 year
1-2 years
3-5 years
6-10 years
More than 10 years
2. In what month and year did you begin your present job as a program coordinator/manager?
Month (Enter two digits for the month. For example, if you started in January enter “01”. If you cannot recall which
month you began, please leave this blank) _______
Year (Enter four digits for the year. For example, if you started in 2012, enter “2012”) ________
4
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
3. How many hours do you work in a typical week? (For example, enter “1.5” if you spend an hour and a half.)
Hours: __________
4. Do you carry a home visiting caseload?
Yes
→ GO TO Questions 4a & 4b
No
→ SKIP TO Question 5
4a. [If Question 4 = Yes] How many hours per week do you spend making home visits and accomplishing
the related tasks? (For example, enter “1.5” if you spend an hour and a half.)
Hours: __________
4b. [If Question 4 = Yes] How many families are on your caseload?
Number of families: _________
4c. [If Question 4 = Yes] Please rate the size of your current caseload, given your other responsibilities as
a program coordinator/manager:
Lighter than you are able to handle effectively
About right
Heavier than you are able to handle effectively
5. In your role as program coordinator/manager, how often do you interact directly with families?
Daily
Weekly
Monthly
Less than monthly
Never
6. How likely is it that you will be in your current position 6 months from now?
Very likely
→ SKIP TO Section C
Somewhat likely
→ GO TO Question 6a
Somewhat unlikely → GO TO Question 6a
Very unlikely
→ GO TO Question 6a
6a. [If Question 6 = somewhat likely, somewhat unlikely, very unlikely] What factors affect whether you
will stay in your position? [CHECK ALL THAT APPLY]
Salary
Opportunities for advancement within the organization
Funding for my position is uncertain
Caring for children or other family members
Pursue additional education or training
Retire or stop working
Moving out of the area
Challenging work environment
Other (specify) ___________________________
5
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
C. PERCEPTIONS OF PROGRAM
Instructions: In this section, we would like to learn how staff members perceive their program’s intended outcomes. In
general, a program outcome is a benefit to a child, parent, or family. For example, some programs might see the
improvement of prenatal health as an important outcome.
Below is a list of possible outcomes for home visiting programs. We know your program may care about all of these
benefits, but we would like to know which is most important. We would like to get a sense of which outcomes you think
your program believes may be more important than others. Select the response that best represents what you think
your program believes about the outcome.
To help you decide on an outcome’s rank, think about whether it is discussed routinely in training and supervision.
Think about what staff in your agency is told about its importance. Select the response that best describes your
program’s ranking of this outcome.
1. How much of a priority is each of the following outcomes for your program, on a scale of 0 to 10?
0 = Not a Priority
5 = Moderate priority
10 = Highest priority
1
2
3
4
5
6
7
8
9
10
Supporting prenatal health and obtaining
prenatal care (including dental
health/dental care)
Supporting postpartum health and
obtaining postpartum care (including
dental health/dental care)
Supporting breastfeeding
Supporting physical health outside of
pregnancy and postpartum health
(including dental health/dental care)
Supporting family planning
Preventing and reducing alcohol,
tobacco, and other drug use
Promoting caregiver emotional wellbeing and preventing and reducing
mental health problems or stress
Preventing and reducing domestic
violence
Supporting healthy adult relationships
(with boyfriends/girlfriends,
husbands/wives, partners, co-parents)
Increasing social support (support from
family, friends, and community)
0
1
2
3
4
5
6
7
8
9
10
Not
sure
6
January 2019
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
Furthering a caregiver’s education and
job training
Supporting getting a job, or getting a
better job
Supporting child health (including dental
health/dental care)
Ensuring appropriate child care
arrangements
Supporting parenting to promote child
development
Basic needs like food, utilities, housing,
transportation, and identification
Legal system and services
Supporting good nutrition and physical
activity
Supporting caregivers in budgeting and
making ends meet
Addressing unresolved issues from past
caregiver trauma
Connecting to community and culture
(attending community and/or cultural
activities, learning cultural teachings,
making new relationships with others in
your community)
Supporting parent-child interaction
Supporting positive discipline and
behavior management
Supporting caregivers in feeding children
(including formula and solids, and not
including breastfeeding)
Helping caregivers to establish and
maintain developmentally appropriate
care/routines (daily routines like
bedtime, mealtime, bath time)
Supporting effective co-parenting
Supporting child and home safety
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
0
1
2
3
4
5
6
7
8
9
10
Not
sure
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
2. Because of local needs, programs sometimes prioritize different outcomes than the outcomes most emphasized by
national home visiting models. The next set of questions are about how your program’s priorities align with
[NATIONAL MODEL]. For each priority, how does your program prioritize this outcome compared to how [NATIONAL
MODEL] prioritizes this outcome?
We give
We give
this outcome
this outcome
a much
We give
a much
lower
this outcome
higher
priority than
the same
priority than
the national priority as the the national
model does national model model does
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Supporting prenatal health and obtaining prenatal
care (including dental health/dental care)
Supporting postpartum health and obtaining
postpartum care (including dental health/dental
care)
Supporting breastfeeding
Supporting physical health outside of pregnancy
and postpartum health (including dental
health/dental care)
Supporting family planning
Preventing and reducing alcohol, tobacco, and
other drug use
Promoting caregiver emotional well-being and
preventing and reducing mental health problems
or stress
Preventing and reducing domestic violence
Supporting healthy adult relationships (with
boyfriends/girlfriends, husbands/wives, partners,
co-parents)
Increasing social support (support from family,
friends, and community)
Furthering a caregiver’s education and job training
Supporting getting a job, or getting a better job
Supporting child health (including dental
health/dental care)
Ensuring appropriate child care arrangements
Supporting parenting to promote child
development
Basic needs like food, utilities, housing,
transportation, and identification
Legal system and services
Supporting good nutrition and physical activity
Supporting caregivers in budgeting and making
ends meet
8
Don’t
know
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
We give
We give
this outcome
this outcome
a much
We give
a much
lower
this outcome
higher
priority than
the same
priority than
the national priority as the the national
model does national model model does
20
21
22
23
24
25
26
27
Addressing unresolved issues from past caregiver
trauma
Connecting to community and culture (attending
community and/or cultural activities, learning
cultural teachings, making new relationships with
others in your community)
Supporting parent-child interaction
Supporting positive discipline and behavior
management
Supporting caregivers in feeding children
(including formula and solids, and not including
breastfeeding)
Helping caregivers to establish and maintain
developmentally appropriate care/routines (daily
routines like bedtime, mealtime, bath time)
Supporting effective co-parenting
Supporting child and home safety
Don’t
know
3. Does your program expect home visitors to develop a family goal plan with enrolled families? Your program might
use a different name for this, such as an individualized family service plan or support plan. When we use the term
“family goal plan” below, we are referring to a plan to guide and tailor home visiting to help families reach goals.
No, my program doesn't expect home visitors to develop family goal plans→ SKIP TO
question 4
Yes, my program expects home visitors to develop family goal plans → GO TO question
3a
Not Sure → SKIP TO question 4
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January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
3a. How much does your program agree or disagree with the following statements?
1
2
3
4
5
6
Strongly
agree
Agree
Disagree
Strongly
disagree
Not
sure
Strongly
agree
Agree
Disagree
Strongly
disagree
Not
sure
My program expects that …
Every family should have a goal plan.
The family should take the lead in developing the goal
plan.
Goals should align with our program's priorities.
Goals should address family’s specific parenting needs.
The goal plan should guide what happens in visits.
The family and the home visitor should review goal
progress and update the goal plan regularly.
4. How much do you agree or disagree with the following statements?
1
2
3
I think that…
It is valuable to work with families to develop a goal plan.
Families find it useful to develop a goal plan.
Families feel like home visitors are being pushy when they
bring up goal plans.
5. How much do you agree or disagree with the following statement: Your program provides all of the materials home
visitors need to cover the topics they want to with families in home visits. Materials include home visiting model
materials and any supplemental curricula, materials, and resources your program uses.
Strongly agree
Agree
Disagree
Strongly disagree
6. Please rate your agreement with the following statement: The materials your program provides meet the unique
needs, values and priorities of the families you work with. Materials include home visiting model materials and any
supplemental curricula, materials, and resources your program uses.
Strongly agree
Agree
Disagree
Strongly disagree
10
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
7. How much should home visitors focus on improving outcomes for…
1
2
3
4
Index child
Primary caregiver
Other children in the family or household
Other adults in the family or household
Not at all
Very little
Somewhat
A lot
8. What does your program expect home visitors to do during the visit if something comes up that they haven't been
prepared/trained to address?
My program expects home visitors just to explain that they can only work on things
covered in the program
My program expects home visitors to direct the mother to a resource that can address this
issue
My program expects home visitors to try to work on this issue even though they are not
trained to address it
My program has no stated expectation for what home visitors do
Not sure
9. What does your program expect home visitors to do during the visit if a caregiver wants to do things differently than
in the program curricula or protocols?
My program expects home visitors to explain that I must follow the program curricula and
protocols
My program expects home visitors to modify visit activities to align with the caregiver’s
preferences while still being true to the 'spirit' of the curriculum or protocol
My program expects home visitors to do things the way the caregiver prefers, even if this
is very different from program curricula and protocols
My program has no stated expectation for what home visitors do in this situation
Not sure
10. How effective is your program overall at making a difference for families in the following areas?
1
2
3
4
5
6
7
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
health (including dental health/dental care)
Family planning
Alcohol, commercial tobacco, and other drug use
Caregiver emotional well-being, mental health or
stress
11
Not at all
effective
Somewhat
effective
Mostly
effective
Very
effective
January 2019
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
Domestic violence
Healthy adult relationships (with
boyfriends/girlfriends, husbands/wives, partners, coparents)
Social support (support from family, friends, and
community)
Furthering a caregiver’s education and job training
Getting a job, or getting a better job
Child health (including dental health/dental care)
Making child care arrangements
Child development
Basic needs like food, utilities, housing,
transportation, and identification
Legal system and services
Nutrition and physical activity
Budgeting/making ends meet
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)
Parent-child interaction
Discipline/behavior management
Feeding children (including formula and solids, and
not including breastfeeding)
Developmentally appropriate care/routines (daily
routines like bedtime, mealtime, bath time)
Co-parenting
Child/home safety
12
Not at all
effective
Somewhat
effective
Mostly
effective
Very
effective
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
D. SELF-EFFICACY
The next set of questions asks you to consider your own knowledge, skills and abilities needed to accomplish tasks
related to supporting home visitors. Please do not consider external barriers like lack of funding or staff time, agency
policies, or geography.
1. How much do you agree or disagree with the following statement: Overall, I am able to support home visitors to do
their jobs well.
Strongly agree
Agree
Disagree
Strongly disagree
2. How confident are you that you can support home visitors to do the following things in most situations?
Not at all Not very Somewhat
confident confident confident
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Balance family preferences with program
priorities
Communicate warmth, respect and appreciation
to the family
Develop and use family goal plans
Conduct required screenings
Tailor activities in response to family interests,
concerns, and preferences
Build relationships and trust with caregivers and
their families
Deliver home visiting curriculum the way the
program and model intends
Model and coach parenting skills
Identify and communicate strengths to caregivers
Help families access needed services
Collect data and information from caregivers
Enter data and document what happens during
home visits
Plan home visits for families
Retain families and keep caseload slots filled
Deliver the expected number of home visits for
each family
Support families in managing crises
Manage their time so that they can get
everything done that they need to do
Engage an uninterested or distracted caregiver
during a home visit
Mostly
confident
Completely
confident
13
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
Not at all Not very Somewhat
confident confident confident
Engage an uninterested or fussy child during a
home visit
20 Ensure their safety when making home visits
21 Engage fathers in home visits
Work with multigenerational families and non22
traditional caregivers
19
Mostly
confident
Completely
confident
The next set of questions asks about supporting home visitors in their work with caregivers around different topics or
issues.
3. How confident are you that you can support home visitors to address the following topics with caregivers?
Not at all Not very Somewhat
confident confident confident
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
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 health (including dental
health/dental care)
Family planning
Alcohol, commercial tobacco, and other drug use
Caregiver emotional well-being, mental health or
stress
Domestic violence
Healthy adult relationships (with
boyfriends/girlfriends, husbands/wives,
partners, co-parents)
Social support (support from family, friends, and
community)
Furthering a caregiver’s education and job
training
Getting a job, or getting a better job
Child health (including dental health/dental care)
Making child care arrangements
Child development
Basic needs like food, utilities, housing,
transportation, and identification
Legal system and services
Mostly
confident
Completely
confident
14
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
Not at all Not very Somewhat
confident confident confident
18 Nutrition and physical activity
19 Budgeting/making ends meet
Trauma (things that happened in the past that
20
affect caregiver today)
Connecting to community and culture (attending
community and/or cultural activities, learning
21
cultural teachings, making new relationships
with others in your community)
22 Parent-child interaction
23 Discipline/behavior management
Feeding children (including formula and solids,
24
and not including breastfeeding)
Developmentally appropriate care/routines
25 (daily routines like bedtime, mealtime, bath
time)
26 Co-parenting
27 Child/home safety
Mostly
confident
Completely
confident
4. Program coordinators/managers take on many tasks in order to manage home visiting staff and successfully meet
the Tribal MIECHV grant requirements. The next set of questions asks you to consider your own knowledge, skills
and abilities needed to accomplish tasks related to managing a tribal home visiting program. If you are not
responsible for some of the tasks below, please mark “Not part of my job.” Please do not consider external barriers
like lack of funding or staff time, agency policies, or geography. How confident are you that you can do the following
tasks related to managing your home visiting program?
1
2
3
4
5
Develop and maintain
program policies and
procedures
Monitor program
performance
Support staff to enroll
enough families to keep
caseload slots filled
Recruit job candidates that
have the right skills and
experience to be effective
home visiting program staff
Successfully hire home
visitors and other program
staff
Not at all
confident
Not very
confident
Somewhat
confident
Mostly
confident
Completely
confident
Not part of
my job
15
January 2019
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
Not at all
confident
Not very
confident
Somewhat
confident
Mostly
confident
Completely
confident
Not part of
my job
Provide adequate training for
program staff
Retain home visiting staff
Adequately compensate staff
Support staff through the
challenging aspects of their
work
Build and maintain
relationships with other
service providers in the
community
Implement our program the
way we intend to, as
described in our
implementation plan
Balance model requirements
with local priorities
Ensure high quality data
collection
Use data to make decisions
guiding program
implementation
Sustain program funding
Provide a supportive work
environment for program
staff
Convene a local advisory
board for your program
Help program staff work
together as a team
Appropriately monitor
fidelity of program
implementation
Tailor our program to be
relevant to our local
community and culture
Cultivate community support
for the program
Monitor fiscal planning and
oversight
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January 2019
23
24
25
26
27
28
29
30
31
32
33
Cultivate tribal/agency
leadership support for the
program
Manage subcontractors (e.g.,
contracted evaluators,
clinical supervisors, data
consultants, etc.)
Effectively disseminate
information about our
program to professional
audiences
Effectively disseminate
information about our
program to
tribal/organizational
leadership
Effectively disseminate
information about our
program to community
audiences
Monitor employee
performance and
communicate with them
about improvement plans, if
needed
Balance multiple
requirements across different
funders
Utilize technical assistance to
achieve program goals
Submit required reports in a
timely manner (to funders,
tribe, agency, model, etc.)
Communicate effectively
with funders
Meet Tribal MIECHV grant
requirements without
putting in unreasonable time
and effort
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
Not at all
confident
Not very
confident
Somewhat
confident
Mostly
confident
Completely
confident
Not part of
my job
17
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
5. The following questions ask about your approach to being your home visiting program’s team leader. How much do
you agree or disagree with the following statements?
1
2
3
4
5
6
7
8
9
10
I initiate meetings to discuss the team's progress.
I am available for consultation on problems.
I am engaged in our team’s day-to-day work.
I manage crises in a calm and dependable way.
I help the team get through challenges they face in their
work.
I handle personnel issues thoughtfully.
I would go to bat for the team.
I have enough training and experience to be an effective
leader.
I treat all team members fairly.
I don’t really know what the team needs to do its job well.
Strongly
agree
Agree
Disagree
Strongly
disagree
E. JOB SATISFACTION
1. The following questions ask how you feel about your job overall. How often you feel this way?
1
2
3
4
5
6
7
8
9
The work I do is satisfying.
My job is boring.
My job allows me to be creative.
I feel respected at work.
My job is frustrating.
My work gives me a sense of
accomplishment.
My job is interesting.
The work I do is important.
My job is overwhelming.
None of
the time
A little of
the time
Some of
the time
Most of the
time
All of the
time
18
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
2. Think about your pay from this job. How much do you agree or disagree with the following about your pay?
1
2
3
Strongly
agree
Agree
Disagree
Strongly
disagree
Not sure
I can depend on my paycheck to be regular and on
time.
The pay I get from this job is less than I deserve for
the work that I do.
The pay I get from this job is fair for my
qualifications.
3. As you think about the pay you get from this job, which statement best describes your thoughts? The pay I get from
this job is...
Barely enough to live on
Enough to cover my normal expenses
Enough to live comfortably
4. For each job characteristic listed below, how satisfied or dissatisfied you are with your current job at the home
visiting program in this regard?
Very
Very
Dissatisfied Satisfied
dissatisfied
satisfied
1
My job security
2
The amount of vacation time I receive
3
The amount of on-the-job stress
4
My chances for promotion
5
The number of home visitors I supervise
6
The amount of time required of me to get the job done
7
The amount of time I spend travelling for my day-to-day job
8
The flexibility of my schedule
9
The health insurance benefits my employer offers
10
12
The retirement plan my employer offers
The amount of leave or schedule flexibility available for
family and community obligations
The control I have over my daily work schedule
13
The physical workspace
14
Balancing the different tasks that are required of me
16
Being able to get my work done with the amount of
interruptions I experience
The recognition I receive at work for my accomplishments
17
The amount of money I earn
18
19
20
My relationship with my immediate supervisor
My physical safety while doing my job
My relationships with coworkers
11
15
19
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
Very
dissatisfied
Dissatisfied
Satisfied
Very
satisfied
21
The training and professional development opportunities
available to me
22
How interesting the work is
23
My work-life balance
24
The mentoring and support I receive
25
My ability to contribute to others in a meaningful way
26
My job overall
5. We are interested in learning about how your job relates to the community where you provide home visiting
services. How much do you agree or disagree with the following statements?
1
2
3
4
5
6
Strongly
agree
Agree
Disagree
Strongly
disagree
Not sure
The local community is very involved in shaping
the home visiting services your home visiting
program provides.
My job makes me feel more connected to my
community.
I worry that my job has negatively impacted how
I'm perceived in the local community.
My job is meaningful to the local community.
My job makes a positive difference in the local
community.
My job is contributing to a brighter future for the
local community.
20
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
F. Professional Quality of Life
1. When you work in home visiting services, you have direct contact with people’s lives. As you may have found, your
compassion for those you serve can affect you in positive and negative ways. Below are some questions about your
experiences, both positive and negative, as a home visiting program coordinator/manager. Consider each of the
following questions about you and your current work situation. How often did you experience these things in the
last 30 days?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
I am happy.
I am preoccupied with more than one person our
program serves.
I get satisfaction from being able to make home
visiting services available to people.
I feel connected to others.
I jump or am startled by unexpected sounds.
I feel invigorated after working with those our
program serves.
I find it difficult to separate my personal life from my
life as a home visiting program coordinator/manager.
I am not as productive at work because I am losing
sleep over the traumatic experiences of a person our
program serves.
I think that I might have been affected by the
traumatic stress of those our program serves.
I feel trapped by my job as a home visiting program
coordinator/manager.
Because of my role with the home visiting program, I
have felt "on edge" about various things.
I like my work as a program coordinator/manager.
I feel depressed because of the traumatic experiences
of the people our program serves.
I feel as though I am experiencing the trauma of
someone our program has served.
I have beliefs that sustain me.
I am pleased with how I am able to keep up with
home visiting techniques and protocols.
I am the person I always wanted to be.
My work makes me feel satisfied.
I feel worn out because of my work as a program
coordinator/manager.
I have happy thoughts and feelings about those our
program serves and how I could help them.
21
Never
Rarely
Sometimes
Often
Always
January 2019
21
22
23
24
25
26
27
28
29
30
31
32
33
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
I feel overwhelmed because my case load seems
endless.
I believe I can make a difference through my work.
I avoid certain activities or situations because they
remind me of frightening experiences of the people
our program serves.
I am proud of what I can do as a home visiting
program coordinator/manager.
As a result of home visiting, I have intrusive,
frightening thoughts.
I feel "bogged down" by the system.
I have thoughts that I am a "success" as a program
coordinator/manager.
I can't recall important parts of my work with trauma
victims.
I am a very caring person.
I am happy that I chose to do this work.
The chronic stresses in the lives of people our
program serves make me depressed.
I take the stress of people our program serves home
with me.
I get overwhelmed by the ongoing challenges faced by
the people our program serves.
Never
Rarely
Sometimes
Often
Always
G. TRAINING
We would like to know whether program coordinators/managers receive the training and supervisory support they need
to do their jobs well. Please tell us whether you would like additional training and support in order to successfully
accomplish the tasks related to being the home visiting program coordinator/manager.
1. How much additional training and supervisory support do you need to do the following parts of your job well:
A little
bit
A good
amount
None
1
2
3
4
5
6
7
Develop and maintain program policies and procedures
Monitor program performance
Support staff to enroll enough families to keep caseload
slots filled
Recruit job candidates that have the right skills and
experience to be effective home visiting program staff
Successfully hire home visitors and other program staff
Provide adequate training for program staff
Retain home visiting staff
22
Not part
of my job
A lot
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
A little
bit
A good
amount
Not part
of my job
None
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
Adequately compensate staff
Support staff through the challenging aspects of their work
Build and maintain relationships with other service
providers in the community
Implement our program the way we intend to, as described
in our implementation plan
Balance model requirements with local priorities
Ensure high quality data collection
Use data to make decisions guiding program
implementation
Sustain program funding
Provide a supportive work environment for program staff
Convene a local advisory board for your program
Help program staff work together as a team
Appropriately monitor fidelity of program implementation
Tailor our program to be relevant to our local community
and culture
Cultivate community support for the program
Monitor fiscal planning and oversight
Cultivate tribal/agency leadership support for the program
Manage subcontractors (e.g., contracted evaluators, clinical
supervisors, data consultants, etc.)
Effectively disseminate information about our program to
professional audiences
Effectively disseminate information about our program to
tribal/ organizational leadership
Effectively disseminate information about our program to
community audiences
Monitor employee performance and communicate with
them about improvement plans, if needed
Balance multiple requirements across different funders
Utilize technical assistance to achieve program goals
Submit required reports in a timely manner (to funders,
tribe, agency, model, etc.)
Communicate effectively with funders
Meet Tribal MIECHV grant requirements without putting in
unreasonable time and effort
A lot
2. How much do you agree or disagree with the following statement: Overall, the training I receive provides me with
everything I need to manage the home visiting program.
Strongly agree
Agree
Disagree
Strongly disagree
23
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
3. Have you ever attended the [NATIONAL MODEL] training for home visitors?
Yes
No
4. Have you ever attended the [NATIONAL MODEL] training for supervisors?
Yes
No
5. Have you ever received training in how to manage staff?
Yes
No
6. How much do you agree or disagree with the following statement: Overall, the training I receive provides me with
everything I need to support the home visitors I supervise.
Strongly agree
Agree
Disagree
Strongly disagree
7. The following questions ask about the training you receive to help you supervise and support home visitors. How
much do you agree or disagree with the following statements?
The training I receive provides me with everything I need to support the home visitors I supervise in the following
areas:
1
2
3
4
5
Monitoring progress of particular caregivers, including general
updates and celebrating successes.
Problem-solving for particular caregivers. This includes getting
families connected to services, addressing challenging topics
with families, strategies for motivating families, and supporting
families through crises.
Managing caseloads. This includes the number of families on
their caseloads, enrolling new families into home visiting,
scheduling home visits, and making the number of expected
home visits.
Building home visitor skills to provide information and support
to families. This includes planning home visits, delivering the
curriculum, learning how to model positive parenting and
facilitate parent-child interaction, and accessing training and
professional development.
Home visitors’ thoughts, feelings, actions and reactions when
working with families, including any past trauma home visiting
might bring up for them.
24
Strongly
agree
Agree
Disagree
Strongly
disagree
January 2019
6
7
8
9
10
11
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
Home visitor emotional wellbeing, including managing stress
and exhaustion, things happening in their personal life, and
community events influencing morale.
Home visitor’s professional development, including discussing
their professional development goals and actions that can be
taken to achieve those goals.
Working effectively with other team members, including
collaborating on activities, and roles and responsibilities of team
members.
Data collection and entry, including tracking what data to
collect and when, questions about forms or assessments, data
entry, explaining data collection to families, completing forms in
a timely manner.
Policies and procedures and other administrative topics. This
includes following agency or program policies and procedures,
changes to policies and procedures, completing administrative
trainings and forms, time and leave reporting.
Monitoring home visitor performance and providing feedback.
This includes conducting both formal and informal performance
reviews and supporting improvement when needed.
Strongly
agree
Agree
Disagree
Strongly
disagree
[In Question 7 above, for areas that received disagree and strongly disagree ratings, GO TO Question 7a below.
For areas that received agree or strongly agree ratings, SKIP TO Question 8.]
7a. [If Question 7 = disagree or strongly disagree] In the previous question you reported that the training you
receive does not provide you with everything you need to support the home visitors you supervise in the
following area(s). Why do you think the training you received in the following area(s) has not fully prepared
you to support home visitors in this/these area(s)? CHECK ALL THAT APPLY
I didn’t get enough training in this area
I didn’t fully understand the training I received in this area
The training I received wasn’t useful
I need something other than to training to be able to support home visitors in this area
8. If you ask, can you attend trainings in specific areas relevant to your needs or professional goals?
No
Yes, I can once in a while when I ask
Yes, I can about half the time I ask
Yes, I can most of the times I ask
Yes, I can every time I ask
Not sure
9. How often do the trainings you attend directly relate to your day-to-day work with families?
Never
Rarely
25
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
Sometimes
Often
Always
10. How often are the trainings you attend helpful and engaging?
Never
Rarely
Sometimes
Often
Always
11. How often are the trainings you attend individualized to meet your needs?
Never
Rarely
Sometimes
Often
Always
12. How often do the trainings you attend offer techniques or materials that are relevant for your
community and the families you serve?
Never
Rarely
Sometimes
Often
Always
13. How important is each of the following in preparing and supporting home visitors?
Not at all
Minimally
Somewhat
important
important
important
1
Shadowing another home visitor
One-on-one time with his/her direct
2
supervisor
3
[Model] training sessions
4
Receiving reflective supervision
5
Talking with other home visitors
6
Case conferencing
Watching videos of other home
7
visitors
8
Debriefing with co-workers
Coursework/education in early
9
childhood development or a related
field
10
Continuing education opportunities
26
Very
important
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
H. SUPERVISION
1. The size of your current supervisor to home visitor ratio is…
Lighter than you are able to handle effectively
About right
Heavier than you are able to handle effectively
2. In the past 6 months, how long have you had a supervisor to home visitor ratio that was more than what you could
handle effectively?
Never
Less than 1 month
1 month
2 months
3 months
4 months or longer
3. Given your program’s resources and the training and support you’ve received, how confident are you that you can
support home visitors in the following areas during one-on-one or group supervision?
1
2
3
Monitoring progress of
particular caregivers, including
general updates and celebrating
successes.
Problem-solving for particular
caregivers. This includes getting
families connected to services,
addressing challenging topics
with families, strategies for
motivating families, and
supporting families through
crises.
Managing caseloads. This
includes the number of families
on their caseloads, enrolling new
families into home visiting,
scheduling home visits, and
making the number of expected
home visits.
Not at all
confident
Not very
confident
Somewhat
confident
Mostly
confident
Completely
confident
Not part
of my job
27
January 2019
4
5
6
7
8
9
Building home visitor skills to
provide information and
support to families. This includes
planning home visits, delivering
the curriculum, learning how to
model positive parenting and
facilitate parent-child
interaction, and accessing
training and professional
development.
Home visitors’ thoughts,
feelings, actions and reactions
when working with families,
including any past trauma home
visiting might bring up for them.
Home visitor emotional
wellbeing, including managing
stress and exhaustion, things
happening in their personal life,
and community events
influencing morale.
Home visitor’s professional
development, including
discussing their professional
development goals and actions
that can be taken to achieve
those goals.
Working effectively with other
team members, including
collaborating on activities, and
roles and responsibilities of team
members.
Data collection and entry,
including tracking what data to
collect and when, questions
about forms or assessments,
data entry, explaining data
collection to families, completing
forms in a timely manner.
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
Not at all
confident
Not very
confident
Somewhat
confident
Mostly
confident
Completely
confident
Not part
of my job
28
January 2019
10
11
Policies and procedures and
other administrative topics. This
includes following agency or
program policies and
procedures, changes to policies
and procedures, completing
administrative trainings and
forms, time and leave reporting,
and performance reviews.
Monitoring home visitor
performance and providing
feedback. This includes
conducting both formal and
informal performance reviews
and supporting home visitors
where they need to improve.
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
Not at all
confident
Not very
confident
Somewhat
confident
Mostly
confident
Completely
confident
Not part
of my job
4. In the past year, has there been a time when you did not have a supervisor or someone in a leadership position that
you could go to for support in your job?
Yes
No
Unsure
5. In the past year, has there been a time when you were unable to go to your supervisor or other provider to explore
your thoughts, feelings, actions and reactions when working with home visitors and families?
Yes
No
Unsure
6. In the past year, has there been a time when you were unable to go to anyone in your program that you had a
trusting relationship with to explore your thoughts, feelings, actions and reactions when working with home visitors
and families?
Yes
No
Unsure
7. Since you began your position as a supervisor at your agency, how many direct supervisors have you had?
Enter Number: _______
29
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
I. OBSERVATION OF HOME VISITS
1. Do you ever observe home visitors during actual visits or by reviewing video-recordings of their visits as part of
supervision?
No → SKIP TO Section K
View video recordings only → GO TO question 2
Observe in person only → GO TO question 2
View video recordings and observe in person → GO TO question 2
2. Do you observe all home visitors or only under certain conditions? CHECK ALL THAT APPLY.
Observe all home visitors
Observe home visitors who are newly hired
Observe home visitors who request to be observed
Observe home visitors who need extra help
Observe home visitors under other conditions (specify): _________
3. About how many times per year do you observe each home visitor?
Less than 1 time per year
1 time per year
2 times per year
3-10 times per year
11 or more times per year
4. Do you use any specific tool(s) or form(s) for observing home visits?
Yes, what is the name of the tool(s) or form(s)? _________
No → SKIP TO question 5
→ GO TO Question 4a
4a. [If Question 4 = Yes] Did you receive training on using this tool(s) from the tool developers?
Yes, in-person training → GO TO Question 4b
Yes, virtual training
→ GO TO Question 4b
No
→ SKIP TO Question 4c
4b. [If Question 4a = Yes] How long ago did you receive this training?
Within the last year
1 or 2 years ago
3 or more years ago
4c. [If Question 4 = Yes] How much do you agree or disagree with the following statement: I feel I could
use additional training in using this tool(s).
Strongly agree
Agree
Disagree
Strongly disagree
30
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
4d. [If Question 4 = Yes] How satisfied or dissatisfied are you with the rating areas this tool(s) includes?
Very dissatisfied
Dissatisfied
Satisfied
Very satisfied
4e. [If Question 4 = Yes] How useful do you find this tool(s) for guiding your home visit observations?
Extremely useful
Somewhat useful
Not at all useful
5. How important is observation in your overall supervision and evaluation of home visitors?
Observation is the most important tool for evaluating home visitors
Observation is one of several essential tools for evaluating home visitors
Observation can be useful for evaluating home visitors, but it is not essential
Observation is not a very useful way to evaluate home visitors
Observation is not at all useful for evaluating home visitors
6. When you observe a home visit, what types of feedback do you give to the home visitor? CHECK ALL THAT APPPLY
Written feedback on a standard form
Written feedback not on a standard form
Verbal feedback with explicit areas for improvement
Verbal feedback with little specific instruction
I do not give feedback
7. How much do you agree or disagree with the following statements:
1
2
3
4
5
6
Home visitors behave differently when they are
being observed than when they are doing a
visit on their own.
The way families act in a home visit is pretty
much the same whether the visit is being
observed or they are just with their home
visitor.
Most families don’t seem to mind when I go
along on home visits to observe.
Being videotaped is more uncomfortable for
families than having someone there in person
observing a home visit.
I do not have the time I need to conduct home
visit observations and provide feedback.
Home visitors find it helpful to receive feedback
from observations of their visits.
Strongly
agree
Agree
Disagree
Strongly
disagree
Unsure
31
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
J. ORGANIZATIONAL CULTURE AND CLIMATE
The following set of questions asks you to think about how your home visiting team does its work. We want to know
how your team works together, takes in information, and makes decisions about the team’s approach to home visiting.
When answering questions about your team, please think about the staff that make up your home visiting program. This
would include home visitors, program coordinators/managers, supervisors, evaluators, data managers and anyone else
that might work closely with your program.
1. How much do you agree or disagree with the following statements?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Our team gets all the information it needs to do our work
and plan our schedules.
It is easy for our team to obtain expert assistance when
something comes up that we don't know how to handle.
Our team is kept in the dark about decisions that impact
day-to-day work and what may happen with the program
and its staff in the future.
Our team lacks access to useful training on the job.
Excellent work pays off in this organization.
It is clear what our team is supposed to accomplish.
Our team spends time making sure every team member
understands their role and responsibilities.
Our team has invested plenty of time to clarify our goals.
If you make a mistake on our team, it is often held against
you.
Members of our team are able to bring up problems and
tough issues.
People on our team are expected to conform to the group.
It is safe to try something new on our team.
It is difficult to ask other members of our team for help.
No one on our team would deliberately act in a way that
undermines my efforts.
Working with members of our team, my unique skills and
talents are valued and utilized.
Achieving this team's goals is well within our reach.
Our team can complete work as assigned without being
required to put in unreasonable time or effort.
With focus and effort, our team can do anything we set out
to accomplish.
Most people in our team have the ability to solve the
problems that come up in our work.
All members of our team have more than enough training
and experience for the kind of work they have to do.
32
Strongly
agree
Agree
Disagree
Strongly
disagree
January 2019
21
22
23
24
25
26
27
28
29
30
31
32
33
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
Certain individuals in our team lack the special skills needed
for good team work.
We regularly take time to figure out ways to improve our
team's work processes.
Our team tends to handle differences of opinion privately,
rather than addressing them directly as a group.
Team members go out and get all the information they
possibly can from others-such as families, community
members, and other program partners.
Our team frequently uses information and data that leads us
to make important changes.
In our team, someone always makes sure that we stop to
reflect on the team's work process.
People on our team often speak up to test assumptions we
might have.
People on our team are encouraged to think outside the
box.
We invite people from outside our team to present
information or have discussions with us.
Our team uses data to see if our processes are leading to the
results we want.
Members of our team are encouraged to try new strategies
to see if they will work.
Members of our team support each other as we work to
master new skills.
The quality of work provided by our team is improving over
time.
33
Strongly
agree
Agree
Disagree
Strongly
disagree
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
K. CONNECTION TO COMMUNITY SERVED
1. Do you live in the same community or neighborhoods your program provides services to?
Yes → GO TO Question 1a
No → SKIP TO Question 1b
1a. [If Question 1 = Yes] In total, how many years have you lived in the same community or
neighborhoods your program provides services to?
Less than 1 year
1-2 years
3-5 years
6-10 years
More than 10 years
1b. [If Question 1 = No] If you ever previously lived in the same community or
neighborhoods your program provides services to, how long did you live there?
I never lived there
Less than 1 year
1-2 years
3-5 years
6-10 years
More than 10 years
2. Do you consider yourself a member of the same tribal or urban Indian community your
program provides services to?
Yes
No
Somewhat
3. In general, do you feel as though you and the families your program serves share a similar
cultural background?
Yes, with most families
Yes, with some families
Yes, with a few families
No
34
January 2019
OMB Control No.: 0970-0521
Expiration Date: 12/31/2021
Length of time for instrument: 60 minutes
L. DEMOGRAPHICS
1. What is your Ethnicity?
Hispanic or Latino
Not Hispanic or Latino
2. What is your Race? (Select one or more)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
→ GO TO Question 2a
→ SKIP TO Question 3
→ SKIP TO Question 3
→ SKIP TO Question 3
→ SKIP TO Question 3
2a. [If Question 2 = American Indian or Alaska Native] What is your tribal affiliation
and/or identity?
_____________________________________________________________________
3. What is your age?
25 and under
26-29
30-39
40-49
50-59
60 or older
[NEXT SCREEN]
THANK YOU FOR TAKING THE TIME TO COMPLETE THIS SURVEY.
Please click NEXT to exit the survey.
35
| File Type | application/pdf |
| Author | Lyon@jbassoc.com |
| File Modified | 2019-02-06 |
| File Created | 2019-02-06 |