Supporting and Strengthening the Home Visiting Workforce (SAS-HV) : Online Pretest of Draft Reflective Supervision Measure

OMB #: 0970-0355

Expiration Date: 8/31/2024

Instrument 1: Screening Questionnaire

Thank you for your interest in the Supporting and Strengthening the Home Visiting Workforce (SAS-HV) project. Please complete this brief 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. We estimate that it will take about five minutes to complete the questionnaire.

Please keep in mind that we are looking for individuals with at least six months of experience providing reflective supervision in the home visiting context. Reflective supervision is the regular collaborative reflection between a home visitor and their supervisor that builds on the home visitor’s use of their thoughts, feelings, and values in their work with families. Reflective supervision is characterized by reflection, regularity, and collaboration.

Your participation in this questionnaire is voluntary. We encourage you to answer all questions so we can better assess your eligibility. Completing and submitting this questionnaire means that you consent for 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 us at sashv@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. 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

7. What is your primary language?

   1. English

   2. Spanish

   3. Chinese

   4. Filipino

   5. Vietnamese

   6. French

   7. Arabic

   8. Korean

   9. Other

8. How much experience do you have providing reflective supervision [if answered 6b 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 and the families you work with ...

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 by your home visiting program (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

4. Race and ethnicity of families you work with (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 you work with (select all that apply):

1. English

2. Spanish

3. Chinese

4. Filipino

5. Vietnamese

6. French

7. Arabic

8. Korean

9. Other

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

   1. Yes

   2. No

7. Which home visiting model(s) do home visitors you supervise 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. Nurse-Family Partnership (NFP)

13. Parents as Teachers (PAT)

14. Play and Learning Strategies (PALS)

15. SafeCare Augmented

16. Video-feedback Intervention to Promote Positive Parenting and Sensitive Discipline (VIPP/VIPP-SD)

17. Other, please list:

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

1. In-person, individual

2. In-person, group

3. Virtual, individual

4. Virtual, group

Your experience with reflective supervision in home visiting contexts

We would like to understand your experience with reflective supervision in the home visiting context. Please answer the questions below.

1. Have you received training or professional development on reflective supervision? If yes, please briefly describe.

2. Have you provided training, coaching, or support to others on reflective supervision? If yes, please briefly describe.

3. If you have any other information about your experience with reflective supervision, please briefly describe.

5

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to invite a sample of individuals to participate in online pretesting of a reflective supervision measure. 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 #: 0970-0351, Exp: 8/31/2024. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to James Bell Associates, 2000 15^th Street North, Suite 100, Arlington, VA 22201, (703)528-3230, sashv@jbassoc.com.