Supporting and Strengthening the Home Visiting Workforce (SAS-HV)

Instrument 1: Screening Questionnaire

Thank you for your interest in the Supporting and Strengthening the Home Visiting Workforce (SAS-HV) project. Please complete this screening questionnaire to help us confirm your eligibility to participate in the project. The questionnaire includes questions about you, your home visiting program, and your experience with reflective supervision in the home visiting context.

Your participation in this questionnaire is voluntary. We encourage you to answer all the questions so we can better assess your eligibility. Completing and submitting this questionnaire means that you consent us to use your answers to determine your eligibility to participate in the project.

If you need any assistance or experience any technical problems with the questionnaire, please contact Mariel Sparr at sparr@jbassoc.com

Information about yourself

1. First name:

2. Last name:

3. Email:

4. Are you of Hispanic, Latino, or Spanish origin?

1. Yes

2. No

3. Prefer not to answer

5. What do you consider your race? Select all that apply.

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Native Hawaiian or Other Pacific Islander

5. White

6. Other, please describe

6. Do you speak English well enough to participate in a virtual group discussion in English?

   1. Yes

   2. No

7. What is your primary role with regard to reflective supervision? Select one.

   1. Receive reflective supervision

   2. Provide reflective supervision

   3. Receive and provide reflective supervision

8. How much experience do you have receiving reflective supervision [if answered 5a or c]?

   1. Less than one year

   2. 1-2 years

   3. 3-5 years

   4. More than 5 years

9. How much experience do you have providing reflective supervision [if answered 5b or c]?

   1. Less than one year

   2. 1-2 years

   3. 3-5 years

   4. More than 5 years

Information about home visiting programs with which you are associated ...

1. State(s), tribe, or territory in which the program(s) you work with provides home visiting services:

2. Geographic areas served, select all that apply:

   1. Urban

   2. Suburban

   3. Rural

   4. Frontier

3. Number of families served (select largest program you work with):

   1. Fewer than 25 families

   2. Between 25 and 50 families

   3. Between 51 and 74 families

   4. More than 75 families

   5. More than 100 families

4. Race and ethnicity of families served (select ethnicity and race for majority of families served, select all that apply):

   1. Hispanic or Latino or Spanish Origin of any race

   2. American Indian or Alaska Native

   3. Asian

   4. Black or African American

   5. Native Hawaiian or Other Pacific Islander

   6. White

   7. Other, please describe

5. Primary language of families served (select primary language for majority of families served, select all that apply):

1. English

2. Spanish

3. Chinese

4. Filipino

5. Vietnamese

6. French

7. Arabic

8. Korean

9. More than one language

10. Other

6. Do you provide home visiting services in a tribal community?

   1. Yes

   2. No

7. Which home visiting model(s) does your program implement? (select all that apply):

1. Attachment and Biobehavioral Catch-Up (ABC)

2. Child First

3. Early Head Start Home-Based Option (EHS)

4. Family Check-Up

5. Family Connects

6. Family Spirit

7. Health Access Nurturing Development Services (HANDS)

8. Healthy Families America (HFA)

9. Home Instruction for Parents of Preschool Youngsters (HIPPY)

10. Maternal Early Childhood Sustained Home-Visiting (MECSH)

11. Maternal Infant Health Program (MIHP)

12. Minding the Baby

13. Nurse-Family Partnership (NFP)

14. Parents as Teachers (PAT)

15. Play and Learning Strategies (PALS)

16. SafeCare Augmented

17. Other, please list:

8. Current approach to providing or receiving reflective supervision (select all that apply):

1. In-person, individual

2. In-person, group

3. Virtual, individual

4. Virtual, group

5. In-person, peer

6. Virtual, peer

Your experience with reflective supervision in home visiting contexts

Please briefly (3-4 sentences) describe your experience with reflective supervision in the home visiting context. For example, have you received training or professional development on reflective supervision? Have you provided training, coaching, or support to others on reflective supervision?

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