Form 7 Family Post-Visit Form – Refinement Phase

OMB No: 0906-XXXX

Expiration Date: XX/XX/20XX

Family Post-Visit Questionnaire

Health Resources & Services Administration

Maternal and Child Health Bureau

ADAPT-HV

The Assessing and Describing Practice Transitions Among Evidence-Based Home Visiting Programs in Response to the COVID-19 Public Health Emergency (ADAPT-HV) project is funded by the Health Resources and Services Administration (HRSA) through a contract with The Policy & Research Group (PRG) and Mathematica.

What is the purpose of this questionnaire? This questionnaire aims to understand your impressions of the home visits you participated in and your perceptions of your child’s level of engagement during the visit.

There are no risks or benefits to your participation. Your participation in this questionnaire is voluntary. You have the right to skip any question or end your participation at any time at no penalty. Your decision about whether to complete this questionnaire or to answer any specific questions will not affect any services that you receive.

The questionnaire should take roughly 5 minutes to complete. Your name is NOT on this questionnaire, and the information you provide will be kept completely private. Though we will review responses to this questionnaire as a whole with program staff, your individual response will not be viewed on its own by study staff or program staff.

If you have any questions about the study, please contact Teresa Smith at The Policy & Research Group (teresa@policyandresearch.com or (225) 281-3783).

If you have questions about your rights as a research volunteer, you can call Health Media Lab Institutional Review Board at (202) 549-1982.

Public Burden Statement: This collection of information will be used to learn about families’ perceptions of their experience with their home visit after a visit is conducted. 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 control number for this information collection is 0915/0906-XXXX and it is valid until XX/XX/202X. This information collection is voluntary. Data will be kept private to the extent allowable by the law. Public reporting burden for this collection of information is estimated to average 0.08 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or paperwork@hrsa.gov. Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.

Given what you just read about the purpose of this project, please select a response below.

• I agree to provide my feedback on the home visiting services I’ve received to help the ADAPT-HV project to learn how to better deliver home visiting services. I understand that no personal information will be collected about me. [move to Q1]

• I do not agree to provide my feedback on the home visiting services I’ve received. I understand that there is no penalty for not answering these questions. [exit form]

[PAGE BREAK]

1. Please write in the first and last name of your home visitor: [Open-ended response]

2. How was your home visit today conducted?

• In-person

• Virtual

• Other (specify:)____________

3. During today’s visit, did your home visitor do any of the following?

	Yes	No	Not sure
a. [strategy 1]
b. [if applicable, strategy 2]

*Contents of this question and some subsequent questions will be customized for each site based on the strategies they identified to test in collaboration with the ADAPT-HV study team during staff focus groups conducted during Phases 1, 2, and/or 3.* 

4. On a scale from 1 to 5, in your opinion, how successful was your home visitor in keeping your child interested and involved during your home visit?

1. Not at all successful

2. Slightly successful

3. Somewhat successful

4. Moderately successful

5. Extremely successful

• Not applicable – the home visitor did not interact with my child during today’s visit

5. [if Q3a. is yes] On a scale from 1 to 5, in your opinion, how interested or involved did your child appear to be when the home visitor [strategy 1] during your home visit?

1. Not at all interested

2. Slightly interested

3. Somewhat interested

4. Moderately interested

5. Extremely interested

6. [if Q3b. is yes] On a scale from 1 to 5, in your opinion, how interested or involved did your child appear to be when the home visitor [strategy 2] during your home visit?

1. Not at all interested

2. Slightly interested

3. Somewhat interested

4. Moderately interested

5. Extremely interested

7. Is there anything else you would like to share about your visit today? [Open-ended response]

Thank you for completing this questionnaire!

If you have any questions about the study, please contact Teresa Smith at The Policy & Research Group (teresa@policyandresearch.com or (225) 281-3783).

If you have questions about your rights as a research volunteer, you can call Health Media Lab Institutional Review Board at (202) 549-1982.

The Policy & Research Group 2