6 LIA and Family Nomination Form

OMB Control #: XXXX-XXXX

Expiration Date: XX/XX/XXXX

INSTRUMENT 2: LOCAL IMPLEMENTING AGENCY AND FAMILY NOMINATION FORM

[Online survey to be programmed in Qualtrics]

Public Burden Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0906-XXXX. This information collection aims to explore how families that experience disparities in outcomes targeted by the MIECHV program experience home visiting services. This study is an initial step in understanding those experiences and will provide a better understanding of how MIECHV-funded home visiting programs currently address disparities and promote equity. Data collection activities include interviews, focus groups, online surveys, program observations, and review of documents and management information systems data. The time required to complete this information collection is estimated to average less than 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is voluntary and confidentiality is followed according to law. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, MD or paperwork@hrsa.gov. 

Introduction and Consent

We invite you to participate in this voluntary data collection for the Home Visiting Assessments of Implementation Quality (HV-AIM) project. The goal of the HV-AIM project is to assess relationships between home visiting implementation quality, program service delivery, and child and family outcomes. For this specific study, we hope to learn more about Black families’ experiences of home visiting services. We recently hosted the [insert title of informational webinar] to introduce the study and how we hope to engage local home visiting programs in this study. If you were unable to participate in the webinar, a recording of the webinar can be found here [insert link]. Details about this project, along with an FAQ, and informational flyer to share with parents can be found here [insert link].

The survey asks questions about your program’s work with Black families and efforts to promote equity. We are also asking for name and contact information for families that are eligible for study participation. Families are eligible for study participation if (1) they identify as Black, (2) they are enrolled in your home visiting program, and (3) your staff obtained permission from families to share their contact information with the HV-AIM project team.

There are no foreseeable risks involved in participating in this research beyond those experienced in everyday life. There are no direct benefits to you from participation; however, the information you provide about your home visiting program could support efforts to promote equity in home visiting. At completion of this survey, we will provide a site payment of $75 in appreciation of your time and for nominating families for study participation.

Your responses will be kept strictly private to the extent permitted by law. Only the HV-AIM project team will have access to this information. Your answers will not be shared with any other agencies. Your responses will be combined with responses from other participants and conveyed in the final report. In our research report, the information you provide will not be assigned by name to you or your program.

If you are unsure how to answer a question, please give the best answer you can rather than leaving it blank. You have the right to refuse a question and stop participation at any time, but we appreciate complete responses when possible.

The survey will take about 30 minutes to complete. Prior to completing the survey, please identify up to seven families that are eligible for the study. We estimate it could take up to 90 minutes to identify families and obtain their consent to share their contact information with the HV-AIM project team.

This survey should be completed by program staff who are nominating families and are knowledgeable about your program’s efforts to promote racial equity. The survey link can be shared with other staff members as necessary. Please note that you may start/restart the survey as needed but once you click "submit", you will not be able to make changes to your survey. Please email hv-aim@jbassoc.com if you have any issues with the survey or your survey link.

By clicking “Next,” you consent to participate in this survey. Please click “Next” to begin.

Section A. Background on your Home Visiting Program

A1. What is the name of your home visiting program?

________________________________________[WRITE-IN RESPONSE]

A2. What is the address of your home visiting program?

Street number and street name ______________[WRITE-IN RESPONSE]

City ____________________________________ [WRITE-IN RESPONSE]

State __________________________________ [WRITE-IN RESPONSE]

Zip code ________________________________ [WRITE-IN RESPONSE]

A3. What zip codes does your program provide home visiting services in?

Zip codes __________________________ [WRITE-IN RESPONSE]

A4. What type of organization is your program operating in? [Select all that apply]

1. Government health department/agency

2. Government education department/agency

3. Health care organization

4. Community-based nonprofit

5. Other (PLEASE SPECIFY): _____________________

A5. Which home visiting model(s) does your program implement? [Select all that apply.]

1. Child FIRST

2. Early Head Start – Home-Based Option

3. Family Spirit

4. Family Check-Up for Children

5. Health Access Nurturing Development Services (HANDS) Program

6. Healthy Families America (HFA)

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

8. Maternal Early Childhood Sustained Home-Visiting Program (MECSH)

9. Nurse-Family Partnership (NFP)

10. Parents as Teachers (PAT)

11. SafeCare Augmented

12. (Other (PLEASE SPECIFY): _____________________

A6. How many home visitors are employed by your home visiting program? [Include full and part time staff.]

______ [ALLOW VALUES RANGING FROM 1-999]

A7. How many home visitors employed by your program identify as Black? [Include full and part time staff.]

______ [ALLOW VALUES RANGING FROM 1-999]

A8. How many supervisors and program managers, excluding home visitors reported in A6, are employed by your home visiting program? [Include full and part time staff.]

______ [ALLOW VALUES RANGING FROM 1-999]

A9. How many supervisors and program managers employed by your program identify as Black? [Include full and part time staff.]

______ [ALLOW VALUES RANGING FROM 1-999]

A10. Is your program interested in being considered for participating in case studies as part of the HV-AIM study? Case studies include an in-person site visit to your program by members of the study team.

1. Yes

2. No

Section B. Families Your Program Works With

B1. How many families are currently enrolled in your program?

______ [ALLOW VALUES RANGING FROM 1-999]

B2. Does your program provide home visiting services in any communities (using your own definition of “community”) where most people (greater than 60%) who live there are Black?

1. No

2. Yes

B3. If yes to B2, approximately what percentage of communities served by your home visiting program are predominantly Black?

1. Less than 25%

2. Between 26 and 49%

3. Between 50 and 75%

4. More than 75%

B4. What is the total number of Black families currently enrolled in your program?

______ [ALLOW VALUES RANGING FROM 1-999]

Section C. Program Strategies to Promote Racial Equity

C1. Has your program engaged in any of the following activities over the past two years?

	Yes (1)	No (2)	I am not sure what this is (3)	If yes, please describe your program efforts
Conducted a root cause analysis of a racial or ethnic inequity or disparity
Provided staff training in implicit bias
Provided staff training on strategies to be anti-racist
Provided staff training on approaches to talking with families about race and racial identity
Provided staff training about the history of home visiting
Engaged in efforts to hire racially and ethnically diverse staff
Set aside program funds to support work on race equity
Engaged in reflective practices (within supervision or program wide) focused on equity
Implemented efforts to recruit racially and ethnically diverse families
Implemented efforts to ensure program content and materials are relevant and meaningful for Black families
Engaged in honest and open dialogues about race with staff and families

C2. In your own words, briefly describe your program’s commitment to racial equity?

______ [OPEN TEXT RESPONSE]

C3. In your own words, briefly describe your program’s efforts to promote racial equity.

______ [OPEN TEXT RESPONSE]

Section D. Family Nominations for Study Participation

D1. Please enter the names and contact information of up to seven families who:

1. have consented to share their contact information with the HV-AIM project team, and

2. are eligible for study participation. Families are eligible if they identify as Black and are enrolled in your home visiting program.

We will not share family contact information with anyone outside of the study team. We will reach out to nominated families directly. Families nominated are not required to participate, their participation is voluntary. Families will receive a $35.00 gift card if they choose to complete a HV-AIM survey. Families will need a device with access to the internet to participate. Families will also need to be able to read English to complete a survey. You can obtain an informational flyer to share with families here [insert link].

	First Name	Last Name	Primary Language	Best Way to Reach Family (text, email, phone call, etc.)	Phone Number	Email Address
Family #1
Family #2
Family #3
Family #4
Family #5
Family #6
Family #7