Inst 4 - Survey of transfer potential and perceived competency

OMB #: 0970-0XXXX

Expiration Date: XX/XX/XXXX

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: This collection of information will be used to understand the extent to which toolkit users might go on to apply newly acquired knowledge and skills to their work. 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 subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB number and expiration date for this collection are OMB #: 0970-XXXX, Exp: XX/XX/XXXX. If you have any comments on this collection of information, please contact Sharon Newburg-Rinn, Ph.D., Sharon.Newburg-Rinn@acf.hhs.gov.

Prenatal Alcohol and Other Drug Exposures: A Child Welfare Practice Toolkit

Survey of Transfer Potential

Thank you for considering participation in this survey, a component of the U.S. Department of Health and Human Services’ evaluation of the Prenatal Alcohol and Other Drug Exposures: A Child Welfare Practice Toolkit. The purpose of the following questions is to understand the extent to which toolkit users might go on to apply their newly acquired knowledge and skills to their work. This information helps us to understand whether any changes need to be made to the toolkit content in the future to improve its usefulness to child welfare professionals such as yourself.

We realize how limited your time is; the survey should take approximately 5 minutes to complete. Your participation in the survey is voluntary. You may decline to answer any question you do not wish to answer, and you may exit the survey at any time. There are no risks involved in participating in the survey. While you will not receive any direct benefits from participating in this survey, your responses will help us learn more about the usefulness of the toolkit.

Your survey responses will be stored in a password-protected electronic database. Only evaluation team members will be able to access survey data. Your name or any other personally identifying information will not appear in any report. Be assured that your individual responses will not be shared with your colleagues, supervisors, leadership, or any other staff of your agency. Your survey responses will remain private to the full extent permitted by law.

If you have questions or concerns about the survey or the evaluation, you may contact Project Director Erin Ingoldsby at Ingoldsby@jbassoc.com.

Please select your choice below. You may print a copy of this consent form for your records. Clicking on the “Agree” button indicates that:

• You have read the above information

• You voluntarily agree to participate

• You are 18 years of age or older

• Agree

• Disagree

Section A. Measures of Transfer Potential

For this set of items, please indicate the extent to which you agree or disagree with the following statements.

		Strongly disagree	Disagree	Neutral or Unsure	Agree	Strongly agree
A-1	I feel motivated to use the toolkit to improve my skills at work.
A-2	I feel motivated to use the toolkit as an ongoing resource at work.
A-3	I will meet with my supervisor to discuss application of the toolkit in my work.
A-4	My supervisor expects me to use the toolkit in my work.
A-5	Even if no one notices, I will use knowledge learned from the toolkit in my work.
A-6	The information I received from the toolkit can be used with my clients.
A-7	I have already made a plan with a co-worker(s) to use the toolkit.
A-8	There is at least one co-worker who will be supportive of my attempts to apply the information from the toolkit.
A-9	I will have sufficient opportunities to practice these new ideas/skills/processes in my work.
A-10	My agency expects me to use the toolkit in my work.
A-11	I am confident that I will use the toolkit in my work.
A-12	I will have time to review the toolkit materials and to plan how I will implement them in my work.
A-13	I can identify specific cases/clients with whom the toolkit content can be used.
A-14	The toolkit content is consistent with my agency's mission, philosophy, and goals.
A-15	The toolkit content is consistent with my agency's policies.
A-16	The toolkit content is consistent with my individual responsibilities.
A-17	This toolkit will help me to continue learning in this topic area.
A-18	As a result of the toolkit, I will be a more effective social worker.
A-19	The information I learned from the toolkit can help make a difference with my clients.

Section B: Staff Training

For this set of items, please indicate the extent to which you agree or disagree with the following statements.

		Strongly disagree	Disagree	Neutral or Unsure	Agree	Strongly agree
B-1	Prior to the toolkit training, I was motivated to attend.
B-2	My supervisor helped to prepare me for the training by discussing my learning needs and potential applications of the new information/skills.
B-3	During the training, I was thinking of ways I could apply the toolkit content to my work.
B-4	The training provided sufficient opportunities to practice new skills/strategies.
B-5	The trainer provided some practical ideas that can be used in my work.
B-6	The trainer gave examples of when to use ideas/skills/strategies in my work with clients.
B-7	The trainer helped motivate me to want to try out the new ideas/skills/strategies on the job.
B-8	The training objectives were adequately addressed.
B-9	The trainer helped me to see how the training can be applied on the job.
B-10	After toolkit training, I will obtain prenatal alcohol exposure history for all my cases.
B-11	After toolkit training, I will obtain prenatal drug exposure history for all my cases.

Section C. Perceived Competence

For this set of items, please indicate the extent to which you agree or disagree with the following statements.

		Strongly disagree	Disagree	Neutral or Unsure	Agree	Strongly agree
C-1	Exposure to the toolkit increased my knowledge about prenatal alcohol.
C-2	Exposure to the toolkit increased my knowledge about other drug exposures.
C-3	Exposure to the toolkit increased my skills in addressing prenatal alcohol exposures.
C-4	Exposure to the toolkit increased my skills in addressing prenatal drug exposures.
C-5	Exposure to the toolkit increased my confidence to practice the skills highlighted in the toolkit (e.g., non-stigmatizing screening and assessment of prenatal substance exposure history, referral to services, offering families resources to address issues for children with prenatal alcohol exposures and their families, documenting information in case files)
C-6	As a result of exposure to the toolkit, I have developed new skills in identifying and screening for prenatal alcohol and other drug exposures.
C-7	As a result of exposure to the toolkit, I increased my knowledge of the effects of prenatal alcohol and other drug exposures on child development
C-8	As a result of exposure to the toolkit, I have developed new skills in knowing what to do (e.g., more assessment, referral to services, offering families resources to help address impacts when a child has prenatal alcohol exposures.)
C-9	As a result of exposure to the toolkit, I have developed new skills in knowing what to do (e.g., more assessment, referral to services, offering families resources to help address impacts when a child has prenatal drug exposures.)
C-10	As a result of exposure to the toolkit, I will now integrate addressing prenatal alcohol and other drug exposures in case plans.
C-11	As a result of exposure to the toolkit, I feel more comfortable talking to families about prenatal alcohol and other drug exposures and sharing resources with them.
C-12	As a result of exposure to the toolkit, I will now document prenatal alcohol and other drug exposures in case files and our agency’s data system (e.g., Comprehensive Child Welfare Information System/the state’s child welfare data system).

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