Next Generation of Enhanced Employment Strategies Project - MOMS Partnership

Potential Participant Survey OMB Control Number: 0970-0531

Expiration Date: 7/31/2022

potential participant Survey

Introduction

A research organization named Mathematica is working with Viability to improve the MOMS Partnership program. We are going to ask you some questions about what you just heard about the program. The answers to your questions will help improve how MOMS Partnership is described. It should take about 5 minutes to complete this survey.

You can decline to complete the survey or leave any questions blank. Your individual response will not be associated with your name. All responses will be combined; no one outside the research team will know how you responded.

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to gather information for the purpose of rapid-cycle learning activities to strengthen programs. 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 #: 0970-0531, Exp: 07/31/2022. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Sheena McConnell; smcconnell@Mathematica-mpr.com

1. Based on what you heard today, do you think you might be eligible for MOMS Partnership?

1. Yes

2. No

If yes, move to question 2. If no, end survey.

2. To what extent do you agree or disagree with the following statements?

   Statement	Strongly disagree	Disagree	Agree	Strongly agree	Not sure
   I want to participate in MOMS Partnership.	1 	2 	3 	4 	5 
   I believe MOMS Partnership will help me.	1 	2 	3 	4 	5 
   I can make the time to fully participate in MOMS Partnership.	1 	2 	3 	4 	5
   I feel clear about what I need to do to enroll in MOMS Partnership.	1 	2 	3 	4 	5 
   I understand the study and what happens if I am not selected to participate in MOMS Partnership.	1 	2 	3 	4 	5
   I like the idea of participating in a study	1 	2 	3 	4 	5 

3. What might make it difficult for you to attend an enrollment appointment? Choose all that apply:

1. Lack of child care

2. Other family responsibilities

3. Lack of transportation

4. Employment or education commitments

5. Other, specify.

4. How likely are you to follow through and enroll in MOMS Partnership?

1. Very likely

2. Likely

3. Somewhat likely

4. Not at all likely

3