Form 6 Home Visitor Learning Cycle Form – Installation & Refine

OMB No: 0906-XXXX

Expiration Date: XX/XX/20XX

Home Visitor 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 home visitors’ use of informal contacts over each learning cycle of the ADAPT-HV study.

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. There is no penalty if you choose not to participate in this questionnaire.

The questionnaire should take roughly 10–15 minutes to complete.

In order to know who has completed this questionnaire, we ask for your name and the name of the agency for which you work. This information will be removed when data are saved. We will not attribute any responses you give in the questionnaire to you personally and will not use your name when results from the research are shared. Only the research team will have access to individual responses. Your responses will be combined with other responses before results are reviewed. All data will be stored safely and destroyed at the end of the study.

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 information collection is part of the Assessing and Describing Practice Transitions Among Evidence-Based Home Visiting Programs in Response to the COVID-19 Public Health Emergency Study, which aims to identify and study practices implemented in response to the COVID-19 public health emergency that support evidence-based practice and have the potential to enhance home visiting programming. One of the practices the study identified is the use of informal contacts. Informal contacts are any contacts between a home visitor and family that occur between formal home visits (e.g., text messages, emails). The purpose of this information collection is to better understand, through rapid cycle learning, how MIECHV-funded home visiting programs can use informal contacts to improve service delivery and promote caregiver’s engagement and satisfaction. 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 private to the extent permitted by the law. The time required to complete this information collection is estimated to average less than 1 hour per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. 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, Maryland, 20857 or paperwork@hrsa.gov, Attention: Information Collections Clearance Officer.

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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 provided to help the ADAPT-HV project to learn how to better deliver home visiting services.

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

Please enter your name and your agency’s name below so that we know who has completed this questionnaire.

First name: [write-in]

Last name: [write-in]

Agency/organization name: [write-in]

INFORMAL CONTACTS IMPLEMENTED

This section asks about the number of families you’ve contacted between home visits and the number of informal contacts you’ve implemented over the past week (7 days).

The questions will reference the specific informal contact strategies your site has identified to test during this learning cycle through the ADAPT-HV study. As a reminder, those strategies are listed below.

1. [summarize strategy 1]

2. [summarize strategy 2, if applicable]

*Contents of this box and some 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.*

1. In total, how many families are you serving at this time (i.e., what is your current caseload?)

   • Write-in

2. In the past week, with how many families have you conducted home visits?

• Numeric write-in

3. In the past week, approximately what percentage of your caseload have you contacted informally in between visits using each of the following strategies?

	Percentage of caseload
[strategy 1]	Numeric write-in
[if applicable, strategy 2]	Numeric write-in

4. In the past week, approximately how many times in total have you contacted families informally in between visits using each of the following strategies?

	Total number of times
[strategy 1]	Numeric write-in
[if applicable, strategy 2]	Numeric write-in

5. What mode(s) did you typically use to make informal contacts in the past week using [strategy 1]? For example, phone call, text message, email. [Write-in]

6. Briefly describe the types of services or content you delivered through the informal contacts you made to families between visits in the past week using [strategy 1]. [Write-in]

7. What mode(s) did you typically use to make informal contacts in the past week using [strategy 2]? For example, phone call, text message, email. [Write-in]

8. Briefly describe the types of services or content you delivered through the informal contacts you made to families between visits in the past week using [strategy 2]. [Write-in]

STRATEGY CHALLENGES AND SUCCESSES

This section asks about challenges and successes that you may have encountered when implementing the strategies of interest during home visits in the past week.

9. Briefly describe any challenges you experienced using [strategy 1] in the past week.

   • Open-ended response

10. Briefly describe any successes you experienced using [strategy 1] in the past week.

    • Open-ended response

11. Briefly describe any challenges you experienced using [strategy 2] in the past week.

• Open-ended response

12. Briefly describe any successes you experienced using [strategy 2] in the past week.

    • Open-ended response

[if applicable]

EXPERIENCES WITH STRATEGY IMPLEMENTATION

This section asks about your thoughts and feelings on your experiences implementing the strategies of interest during home visits in the past week.

Experiences with [strategy 1]

13. On a scale from 1 to 5, how confident were you in your ability to implement [strategy 1] effectively in the past week?

1. Not at all confident

2. Slightly confident

3. Somewhat confident

4. Moderately confident

5. Extremely confident

14. On a scale from 1 to 5, how confident were you in your ability to use [strategy 1] to [achieve immediate goal of strategy 1] in the past week?

1. Not at all confident

2. Slightly confident

3. Somewhat confident

4. Moderately confident

5. Extremely confident

15. On a scale from 1 to 5, approximately how often did the recipients of informal contacts made using [strategy 1] reciprocate communication after the contact had been made?

1. Never

2. Rarely

3. Occasionally

4. Almost every time

5. Every time

[if applicable]

Experiences with [strategy 2]

16. On a scale from 1 to 5, how confident were you in your ability to implement [strategy 2] effectively in the past week?

1. Not at all confident

2. Slightly confident

3. Somewhat confident

4. Moderately confident

5. Extremely confident

17. On a scale from 1 to 5, how confident were you in your ability to use [strategy 2] to [achieve immediate goal of strategy 2] in the past week?

1. Not at all confident

2. Slightly confident

3. Somewhat confident

4. Moderately confident

5. Extremely confident

18. On a scale from 1 to 5, approximately how often did the recipients of informal contacts made using [strategy 2] reciprocate communication after the contact had been made?

1. Never

2. Rarely

3. Occasionally

4. Almost every time

5. Every time

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 4