Instrument 1 - HomeEc Program Eligibility Screener_revised Dec2022_clean

Instrument 1

HomeEc Special Topic Study - Program Eligibility Screener

OMB#: 0970-0356

Expiration Date: 02/29/2024

Supporting Family Economic Well-Being through Home Visiting (HomeEc) Special Topic Study

PROGRAM ELIGIBILITY SCREENER

Introduction

Thank you for your interest in the HomeEc special topic study. We are studying how the COVID-19 pandemic has affected early childhood home visiting’s family economic well-being services. This brief questionnaire will help us understand a little more about your program. If selected, we will reach out to schedule a time with a representative from the program to discuss more about your program.

• This survey should take about 10 minutes to complete.

• If you are unsure how to answer a question, please give the best answer you can rather than leaving it blank.

• This survey is voluntary. There are no direct risks or benefits to participating. You may skip any questions you do not wish to answer; however, we hope that you answer as many questions as you can. You may withdraw from this study at any time without penalty.

• This study has received approval from the Health Media Lab Institutional Review Board (IRB). If you have any questions about this study or your rights as a research volunteer, please contact Sarah Avellar at savellar@mathematica-mpr.com.

• Please click on the START button below to complete your survey.

Screener questions

Q1. What is the name of the program you are nominating to participate in the HomeEc special topic study?

______________________________

Q2. Does the program provide home visiting services to parents with a young child and/or pregnant people?

• Yes

• No

Q3. In what community(ies), city(ies), or state(s) does the program provide services?

_____________________________

Q4. What main activities or services does the program provide to families to support their economic well-being or stability? Please complete one row for each activity (up to three activities).

	Type of activity Please very briefly describe the activity, such as coaching, case management, financial education, financial assistance or other activities	Did the program provide this activity during the COVID-19 pandemic (that is, in 2020 and 2021)?	If activity was provided during the COVID-19 pandemic: What was the intended number of hours per family for this activity? Please note if the intended number of hours is per week/per month or per year.
First activity to support family economic well-being
Second activity to support family economic well-being
Third activity to support family economic well-being

Q5. Please provide the following information for the person we should contact to learn more about the program.

First name:­­­­ _______________

Last name: ­­­­_______________

Phone: ­­­­_______________

Email address: ­­­­_______________

Role with the program: ­­­­_______________

Q6a. What is your relationship to the contact person?

• Self  END SURVEY AND SHOW THANK YOU

• Colleague or professional acquaintance  GO TO Q6b

• Other  GO TO Q6b

Q6b. Please provide your name and contact information if you will not be the main point of contact.

First name:­­­­ _______________

Last name: ­­­­_______________

Phone: ­­­­_______________

Email address: ­­­­_______________

Thank you for completing the HomeEc Special Topic Study Eligibility Screener!