Form 1 Pre-Test

Registrant ID ________

Infant Adoption Awareness Training Program (IAATP)

Trainee Survey

Instrument A: Pre-test

INFANT ADOPTION AWARENESS TRAINING PROGRAM

Participant Information

We are pleased that you have chosen to participate in the Understanding Infant Adoption training. As part of the Infant Adoption Awareness Training project, we are required to submit information documenting our efforts and their effect.

We would appreciate your response to a brief survey that will help us understand what knowledge you may already have about infant adoption, your reasons for taking the course, and your current role, if any, in adoption activities.

Completion of the form will take approximately 10 minutes and is voluntary. During the workshop you will also have an opportunity to evaluate the training and its effectiveness. As the final stage in our evaluation, we will follow up with you by email, asking you to complete a brief follow-up survey. All information you provide will help us to evaluate and improve the training, support services, and materials.

We will protect your data by ensuring that your name does not appear in any written reports, and your name is not associated with any comments you choose to make about the program. Data will be presented only in aggregate form.  

You may decline to participate without penalty. If you decide to participate, you may withdraw from the evaluation at any time without penalty and without loss of benefits to which you are otherwise entitled.

Completion of the survey indicates you have read the above information and agree to participate in data collection for evaluation of the Understanding Infant Adoption Training program.

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 15 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.

To be completed by evaluation staff: Registrant ID _____________ Eligibility Code ______

Last Name ____________________________ First Name ­_______________ MI ____

Address 1 ___________________________________________________________________

Address 2 ___________________________________________________________________

City _________________________________________ State _________ Zip ____________

Email ______________________________________ Phone: ( ) - extension .

Organization Name _____________________________________________________________

City ___________________________________________ State _________ Zip ____________

1. Which of the following best describes your workplace? (Check one)

• Non-Profit Hospital

• For-Profit Hospital

• Community Health Center

• Private Doctor Office

• Health Department

• Family Planning Clinic

• Crisis Pregnancy Center

• Court/Probation/Corrections

• Child Welfare Agency (public or private)

• School

• Faith-Based Organization/Church

• Mental Health/Behavioral Health

• Public Economic Services

• Teen and/or Family Support/Resource Center

• University/College

• Adoption Agency

• Other (specify) _______________________________

2. What is your primary role at work? (Check one)

• Administrator (non-clinical)

• Physician Assistant/Nurse Practitioner

• Social Worker/Case Manager/Counselor/Therapist

• Certified Nurse Midwife/Midwife/Doula

• Health Educator/Instructor

• Office Manager/Administrative Support

• Physician/MD/DO/Psychiatrist

• Nurse (RN/PHN/LPN/NA)

• Other (specify) ___________________________________

3. Which best describes the services you normally provide to women with unintended pregnancies? (Mark all that apply)

• I give clients brochures, pamphlets or handouts

• I discuss community resources with clients

• I make referrals to community resources

• I provide options counseling

• I make assessments of individuals’ needs

• I have not provided any of these services

4. How long have you provided these services to pregnant women?

______ Years _____ Months  N/A

5. Which of the following options does your agency usually present to women with unintended pregnancies? (Mark all that apply)

• Continuing the pregnancy to term and parenting the child

• Making an adoption plan

• Terminating the pregnancy

• Other (specify) _______________________________

• Don’t know

5. Approximately how many clients with unintended pregnancies have you personally encountered in the last three months? __________ clients

For the next few questions (questions 7 through 9), please refer to your usual activity over the past three months.

5. On average, how much time did you spend per client providing options information or referral services? (If you do not provide these services, enter “N/A”) __________ minutes

5. When talking to clients with an unintended pregnancy about their options:

1. How often did you engage in the following activities?

(If you do not provide options counseling, mark “N/A.”)

i. I used open-ended questions	Often Sometimes Rarely Never N/A
ii. I helped clients find their own answers	Often Sometimes Rarely Never N/A
iii. I tried to make the discussion interactive	Often Sometimes Rarely Never N/A
iv. I let my values guide the discussion	Often Sometimes Rarely Never N/A

2. How likely were you to talk about adoption as an option with clients who were experiencing an unintended pregnancy?

• Very likely

• Likely

• Somewhat likely

• Not likely

• Not likely at all

• N/A

3. How often did you engage/involve birth fathers in the discussions?

• Often

• Sometimes

• Rarely

• Never

• N/A

4. Did you provide the following types of referrals, if requested? (Mark all that apply)

• Prenatal care and delivery

• Pregnancy termination

• Infant care

• Foster care

• Adoption

• I don’t make referrals

5. Did you communicate or collaborate with licensed adoption agencies for clients who were interested in adoption? (If your responsibilities do not include working with adoption agencies on behalf of clients, mark “N/A”)

   • Yes

   • No

   • N/A

6. On average, how often did you refer interested clients to adoption agencies/resources for additional information? (If your responsibilities do not include referring clients to adoption agencies/resources, mark “N/A”)

• Never

• Once a month or less

• Two to three times a month

• Once a week

• Two to four times a week

• Daily

• N/A

7. Have you coached or trained other professionals on presentation of the adoption option?

   • Yes

   • No

5. How often did you engage in the following activities?

a. Discussed the client’s reaction to the pregnancy	 Often  Sometimes  Rarely  Never  N/A
b. Discussed the advantages and disadvantages of the various pregnancy options with clients	 Often  Sometimes  Rarely  Never  N/A
c. Assessed the client’s need for other supportive services	 Often  Sometimes  Rarely  Never  N/A
d. Discussed the possibility of including other family members in future discussions	 Often  Sometimes  Rarely  Never  N/A
e. Explained the rights of birth mothers, birth fathers, and families according to applicable federal and state laws	 Often  Sometimes  Rarely  Never  N/A

10. Mark each item “True” or “False”

Adoptive families receive non-identifying medical and social history on the birth parents, regardless of the type of adoption.	 True  False
Providing non-directive, non-coercive options counseling includes allowing the client to refuse receiving information.	 True  False
Pregnant teens often overestimate the challenges of parenting.	 True  False
In a fully disclosed (“open”) adoption the names and addresses of birth parents and adoptive parents are known to both parties.	 True  False
A client should only be referred for adoption services when the counselor knows that the client has reached a final decision to pursue adoption.	 True  False
Culturally responsive helping professionals are prepared to include extended family members in an options discussion if the client wants them included.	 True  False
Regardless of the client’s interest, all pregnancy options should be discussed.	 True  False
Adoptive parents are legally bound to allow birth parents’ continued contact with the child when an adoption is “open.”	 True  False
It is important for staff who provide options counseling to agree with the client’s decision.	 True  False
Birth parents usually experience some degree of grief and loss, regardless of the type of adoption they choose.	 True  False
Pregnant teens may need less time than adults to be ready to discuss their options.	 True  False
A counselor should consider whether or not the client is exposed to domestic violence when discussing pregnancy options.	 True  False
Birth fathers have the right to be notified of the birth and the adoption plan before their parental rights are terminated and the adoption is finalized.	 True  False
To increase rapport, counseling staff should share their own opinion about adoption with the client during options counseling.	 True  False
Under Federal adoption laws, tribes can intervene in court cases regarding the adoption of Native American children.	 True  False
A birth mother who chooses adoption can change her mind at any time before the judge has made the final decree.	 True  False
Staff who discuss the adoption option with clients should know enough about adoption law to dispel some of the client’s misunderstandings about adoption.	 True  False
Counselors should consider allowing pregnant teens to rehearse with them what they will say to a birth father or parent.	 True  False
Being a culturally responsive counselor includes taking a lead role in the decision making for clients from cultures that view helping professionals as authority figures.	 True  False
Staff should know the types of services a resource can provide when making a referral for a client.	 True  False
Whether a client can afford to pay adoption fees should be part of the pregnancy options decision.	 True  False
When working with pregnant teens who are minors, it is important to know whether your state allows minors to make an adoption plan without the consent of their parents or legal guardians.	 True  False
“Semi-open” adoptions allow contact between birth parents and adoptive parents through an agency or attorney without the identity of the birth parents being revealed.	 True  False
Federal adoption laws ensure the rights of birth parents to specify the race, color, or national origin of the adoptive parents.	 True  False
A birth mother cannot make her legal decision about adoption until after the baby is born.	 True  False
Non-directive, non-coercive options counseling requires staff to be aware of their own values and beliefs.	 True  False

11. How would you describe your overall opinion about adoption?

• Very favorable

• Somewhat favorable

• Neither favorable or unfavorable

• Somewhat unfavorable

• Very unfavorable

11. How familiar are you with the adoption process?

 Very familiar  Somewhat familiar  Not at all familiar

11. Select the response that best reflects your opinion.

I believe that adoption:	Strongly Agree	Agree	Neither agree or disagree	Disagree	Strongly Disagree
Is an option that should be presented when a woman is unsure of her decision regarding her pregnancy.
Is an option that I should help the birth parents select if they are unable (e.g., because of age, financial, emotional, or intellectual status) to effectively parent their child.
Is an equally viable option to the other options for an unintended pregnancy.
Is more likely to be successful if the birth parent(s) and adoptive parents share all identifying information and have an open adoption.
Is something that should be presented to diverse cultures (e.g., African-American, Hispanic, Asian, Native American)?

11. Do you agree or disagree with the following statements?

	Strongly Agree	Agree	Neither agree or disagree	Disagree	Strongly Disagree
It is a good idea for pregnant teenagers to consider placing the child for adoption.
Adoption is a risky option because it has undesirable emotional and social effects on the pregnant client.
Placing a child for adoption is a kind of abandonment.
Adoption is a solution to an unplanned pregnancy that works well for children who are adopted.
Adoption is always an appropriate solution for an unplanned pregnancy.
If a close female relative or friend of mine were considering adoption for an unplanned pregnancy, I would support her in this decision.

11. Do you think children adopted as infants are more likely, equally likely, or less likely than other children to:

Have problems at school	 More likely  Equally likely  Less likely
Have behavior problems	 More likely  Equally likely  Less likely
Be well adjusted	 More likely  Equally likely  Less likely
Have problems with drugs and alcohol	 More likely  Equally likely  Less likely
Be happy	 More likely  Equally likely  Less likely
Have medical problems	 More likely  Equally likely  Less likely
Be self-confident	 More likely  Equally likely  Less likely

11. How did you learn about the Infant Adoption Awareness training?

• Brochure

• Conference

• Contacted by training providers

• Supervisor

• Co-worker

• Mailing

• Poster

• Professional organization

• Website

• Fax

• Other (please specify): ____________________________________

11. Is this your first time attending the Infant Adoption Awareness training?

 First time attending training  Refresher session  Other (specify) ________________

11. Please tell us about yourself:

a) Gender:  Male  Female

b) Hispanic or Latino Origin:  Yes  No

c) Race: (Mark one or more)  American Indian or Alaska Native

• Asian

• Native Hawaiian or Other Pacific Islander

• Black or African American

• White

d) Age Range:  18 – 21  46 – 55

 22 – 25  56 – 65

 26 – 35  66 or older

• 36 – 45

e) Education (highest completed):  High school or GED

• Some college or Associate degree

• Bachelors degree

• Masters degree

• Doctoral degree

• Medical certification/licensure (e.g., PA/CPM/CNA/LPN/RN)

• Professional degree (e.g., MD/DO/NP/APN)

• Other (specify) ___________________________________

Thank you for your participation in this survey.

IAATP Cross-Site Evaluation Trainee Pre-Test (JBA-OMB rev.) 8