Form 3 Community Action Network (CAN) Survey

Healthy Start Evaluation and Quality Assurance

E. CAN Survey

Community Action Network (CAN) Survey

OMB: 0915-0338

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Attachment E

Community action network survey






The Healthy Start Community Action

Network (CAN) Survey


February 5, 2014






Shape1

Public Burden Statement: 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 project is 0915–0338. Public reporting burden for this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, searching existing data sources, and 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 Reports Clearance Officer, 5600 Fishers Lane, Room 10-49, Rockville, MD 20857.



ADMINISTRATIVE NOTES

  • The instrument is designed in a self-administered web format, estimated at 30 to 45 minutes in length.

  • The survey will be deployed only in English.

  • Text fills, noted in this instrument with use of brackets and text in all caps [FILL] are assumed as follows:

[ORG NAME] = Name of organization or agency completing the survey filled from sample file

[HEALTHY START GRANTEE] = Name of Healthy Start grantee

[CAN MEMBER] = Names of up to 10 CAN members filled from sample file. These will be identified by the respondent as the 10 active members of the CAN with which the respondent’s organization partners the most. If fewer than 10 organizations are identified, that is the number of organizations that will be filled.

  • The question source is listed in parentheses at the end of each survey item. If an item is new, the word new is used to describe the source. This will not be displayed to respondents. Sources include the following:

2011 National Healthy Start Project Survey

Community Voices for Coverage Leadership Team Follow-Up Survey

Living Cities Grantee-Partner Network Survey

Social Capital Assessment Tool Household Survey

Social Capital Assessment Tool Community Questionnaire

Survey of the Health of Adults, the Population and the Environment 2002

Wilder Collaboration Factors Inventory

  • Items that allow multiple responses have the instruction to “select all that apply” and items allowing only a single response have the instruction to “select only one.”

  • The instrument will be completed by CAN board members and committee chairs representing an organization that is formally or informally partnered with Healthy Start. Individuals in the community who are part of the CAN but do not represent a partner organization will not be asked to complete the Healthy Start CAN survey as the purpose of the survey is to assess the organizational networks in the community. Healthy Start participant perspectives will be captured through focus groups.

INTRODUCTION AND INSTRUCTIONS FOR RESPONDENTS

The Healthy Start Community Action

Network (CAN) Survey


Thank you for taking the time to complete this survey! As part of the national evaluation of the Healthy Start program, we want to learn about your organization’s experience working with Healthy Start and serving as a board member or committee chair of the Community Action Network (CAN) under Healthy Start’s current funding cycle, which started approximately September 2014. The CAN is an existing, formally organized partnership, advisory board, or coalition of organizations and individuals representing consumers and appropriate agencies that unite in an effort to collectively apply their resources to the implementation of one or more common strategies to improve the lives of women, children, and their families within a community. The questions in this survey will ask about your organization, your experience collaborating with [HEALTHY START GRANTEE] and your experiences as a member of the CAN. This survey should take approximately 30 to 45 minutes to complete.


The evaluation is being funded by the Health Resources and Services Administration’s (HRSA) Maternal and Child Health Bureau (MCHB). The information we obtain will be used for research purposes only. All of the information you provide will be kept confidential. The evaluation will not identify individuals or organizations in its reports to the MCHB.


The table below shows the sections of the survey and the questions in each section.



SECTION

QUESTIONS

A

ORGANIZATIONAL INFORMATION

A1-A5

B

COMMUNITY ACTION NETWORK PARTICIPATION

B1-B5

C

INFRASTRUCTURE FOR COLLABORATION

C1-C4

D

QUALITY OF COLLABORATION

D1-D4

E

PROGRESS TOWARD ACHIEVING GOALS

E1-E4

F

THE COMMUNITY

F1-F3

G

OTHER COMMENTS

G1


Instructions


  • Answer the questions by clicking your mouse on the appropriate box.

  • After you have answered the questions on one page, click the next button at the bottom of the page to continue. To go back to a previous page, click the back button.

  • If you have to stop, you can log out of the survey by closing your browser. You can return to the survey later by clicking on the link in your email.

  • When you reenter the survey, your previous answers will be saved. You also will be able to change your previous answers, if necessary.

Please complete the survey by [DATE]. If you have any questions about the survey, please contact [NAME] via email [EMAIL] or by telephone at [TELEPHONE NUMBER].

A. ORGANIZATIONAL INFORMATION

The first set of questions collects general information about [ORG NAME].


A1. How would you classify [ORG NAME]? (New)


Select all that apply.


HEALTH AGENCY/PROVIDER

  • State Title V agency 1

  • Medicaid agency 2

  • Local health department 3

  • Federally qualified health center 4

  • Private physician practice 5

  • Hospital 6

  • Mental health agency 7

  • Substance abuse treatment center 8

  • Other health agency/provider [SPECIFY] 9

Shape2

Specify (STRING 200)


PUBLIC SOCIAL SERVICE AGENCY/PROVIDER

  • WIC agency 10

  • Welfare agency 11

  • Child protective service agency 12

  • Head Start/Early Head Start organization 13

  • Child care agency 14

  • Public School 15

  • Court 16

  • Substance abuse treatment center 17

  • Other public social service agency [SPECIFY] 18

Shape3

Specify (STRING 200)


COMMUNITY-BASED AGENCY/PROVIDER

  • Faith-based organization 19

  • Advocacy organization 20

  • Professional association (for example, Association of Maternal and Child
    Health Programs, American Congress of Obstetricians and Gynecologists) 21

  • Ethnic organization (for example, tribal organizations) 22

  • Civic group (for example, National Organization for Women) 23

  • Other community-based agency/provider [SPECIFY] 24

Shape4

Specify (STRING 200)


A2. Which of the following types of direct services does [ORG NAME] provide to women, children, and families in the community? Do not include services for which your organization makes referrals. (New)


Select all that apply.


  • Adult education services (GED, ESL) 1

  • Adult primary care 2

  • Child care (including resources, referrals, and services) 3

  • Domestic violence counseling/anger management counseling 4

  • Early intervention services for children with
    suspected/diagnosed disabilities 5

  • Family planning and reproductive health services 6

  • Financial counseling services 7

  • Health insurance enrollment services 8

  • Housing/shelter services 9

  • Job training/employment services 10

  • Mental health services 11

  • Pediatric primary care 12

  • Substance (alcohol and other drug) use treatment 13

  • Teen support services 14

  • Transportation services 15

  • Youth education services 16

  • Women, infant, children (WIC) nutrition services 17

  • Other [SPECIFY] 18

Shape5

Specify (STRING 200)

  • [ORG NAME] does not provide direct services 00


A3a. How many clients did [ORG NAME] serve in the past year? (New)

Your best estimate is fine.

Total: ______________________

Don’t know d


A3b. How many of the total served in the past year are women of reproductive age (15–44 years old)? (New)

Your best estimate is fine. If your organization does not serve women, enter 0.


Women (reproductive age): ______________________

Don’t know d


A3c. How many of the total served in the past year are children under the age of 2? (New)

Your best estimate is fine. If your organization does not serve children under the age of 2, enter 0.


Children:____________________

  • Don’t know d


A4. How many staff members are employed by [ORG NAME]? Include staff members who interact directly with clients and administrative staff. (New)

Your best estimate is fine.



Select one per row


Number of Staff Employed

Don’t Know

a. Total staff members

______________________

d

b. Full-time staff members (35 or more hours a week)

______________________

d

c. Part-time staff members (less than 35 hours a week)

______________________

d


A5. How is [ORG NAME] funded? (New)


Select all that apply.


  • Federal grants 1

  • State grants 2

  • County funds 3

  • Foundation funding 4

  • Private funding 5

  • Organizational revenue 6

  • Other 7

Shape6

Specify (STRING 200)



B. COMMUNITY ACTION NETWORK PARTICIPATION

This next section asks about [ORG NAME]’s involvement with [Healthy Start Grantee] and the Community Action Network (CAN).


The CAN is an existing, formally organized partnership, advisory board or coalition of organizations and individuals representing consumers and appropriate agencies who unite in an effort to collectively apply their resources to the implementation of one or more common strategies to improve the lives of women, children, and their families within a community.


B1. When did you first learn about [Healthy Start Grantee]? Your best estimate is fine. (Living Cities Network-Partner Survey, A2 modified)

____/____

(MM/YYYY)

Don’t know d




B2. Collaborating can be defined as any joint planning, service coordination, cost-sharing initiatives, or other activities in which [ORG NAME] and [Healthy Start Grantee] worked toward a common goal.


When did [ORG NAME] begin collaborating with [Healthy Start Grantee]? Your best estimate is fine. (New)



____/____

(MM/YYYY)

Don’t know d


B3. When did [ORG NAME] become part of the CAN with [Healthy Start Grantee] and other organizations in the community? Your best estimate is fine. Please include a date on or after June 2014 to reflect the your participation in the CAN under the newest cycle of the Healthy Start project. (New)

____/____

(MM/YYYY)

Don’t know d



B4. Over the past 12 months, to what extent has [ORG NAME] been involved in the CAN? When thinking about involvement, consider [ORG NAME]’s participation in CAN initiatives in the community, attendance at CAN meetings, and communication with other CAN members. (Community Coalition Leadership Program Survey, A3 modified)


Select one only


Not at all 1

Little extent 2

Moderate extent 3

Great extent 4

Very great extent 5


B5. Over the past 12 months, to what extent has [ORG NAME] been involved in other collaborative groups in your community? (Community Coalition Leadership Program Survey, A4 modified)


Select one only


Not at all 1

Little extent 2

Moderate extent 3

Great extent 4

Very great extent 5


C. INFRASTRUCTURE FOR COLLABORATION

The next section asks about activities that [ORG NAME] may have been involved in with [Healthy Start Grantee], CAN members, and other organizations in the community during the past 12 months.


The CAN is an existing, formally organized partnership, advisory board or coalition of organizations and individuals representing consumers and appropriate agencies who unite in an effort to collectively apply their resources to the implementation of one or more common strategies to improve the lives of women, children, and their families within a community.


C1. Collaboration can be defined as any joint planning, service coordination, cost-sharing initiatives, or other activities in which your organizations worked together toward a common goal.


Based on your knowledge of your organization, please select up to 10 organizations from the list of CAN members below with which [ORG NAME] collaborated during the past 12 months. If [ORG NAME] collaborated with more than 10 organizations, select the 10 with which [ORG NAME] collaborated most closely. (New)


Select 10 organizations.


  • [FILL CAN MEMBER #1] 1

  • [FILL CAN MEMBER #2] 2

  • [FILL CAN MEMBER #3] 3

  • [FILL CAN MEMBER #4] 4

  • [FILL CAN MEMBER #5] 5

  • [FILL CAN MEMBER #6] 6

  • [FILL CAN MEMBER #7] 7

  • [FILL CAN MEMBER #8] 8

  • [FILL CAN MEMBER #9] 9

  • [FILL CAN MEMBER #10] 10


C2. During the past 12 months, in which of the following ways did [ORG NAME] formally and/or informally partner with [Healthy Start Grantee] and the other CAN members? (Community Voices for Coverage Leadership Team Follow-Up Survey, B1 modified)



SELECT ALL THAT APPLY

Community Action Network Members

[ORG NAME] signed formal memorandum of understanding with organization

[ORG NAME] met with organization for joint planning outside of CAN meetings

[ORG NAME] participated in collaborative group or working group with organization in addition to the CAN

[ORG NAME] submitted joint grant proposal


[LIST OF CAN MEMBERS FROM C1]














[Healthy Start Grantee]

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C3. During the past 12 months, in which of the following ways did [ORG NAME] collaborate with [Healthy Start Grantee] and the other CAN members regarding services for women, children, and their families?

(New)



SELECT ALL THAT APPLY

Community Action Network Members

[ORG NAME] made referrals to organization

[ORG NAME] received referrals from organization

[ORG NAME] shared/used the same data system


[LIST OF CAN MEMBERS FROM C1]











[Healthy Start Grantee]

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C4. During the past 12 months, which of the following activities did [ORG NAME] engage in with [Healthy Start Grantee] and the other CAN members? (Community Voices for Coverage Leadership Team Follow-Up Survey, B2 modified)



SELECT ALL THAT APPLY

Community Action Network Members

[ORG NAME] organized/ implemented grassroots activities (for example, health fair or other community events)

[ORG NAME] participated in joint training with organization

[ORG NAME] developed joint program materials

[ORG NAME] met with policymaker or attended public meeting or hearing with the organization

[ORG NAME] developed media messages/ organized media events

[ORG NAME] assessed or “mapped” community needs using data


[LIST OF CAN MEMBERS FROM C1]








































[Healthy Start Grantee]

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D. QUALITY OF COLLABORATION

The following questions are about [ORG NAME]’s experiences as a member of the CAN.


The CAN is an existing, formally organized partnership, advisory board or coalition of organizations and individuals representing consumers and appropriate agencies who unite in an effort to collectively apply their resources to the implementation of one or more common strategies to improve the lives of women, children, and their families within a community.


D1. Please indicate your agreement with the following statements on a scale from “Strongly Disagree” to “Strongly Agree.”


Select one per row


Strongly disagree

Disagree

Neutral/ no opinion

Agree

Strongly agree

Collaboration in the community






a. Agencies/organizations in our community have a history of working together. (Wilder Collaboration Factors Inventory, 1)

1

2

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5

b. Trying to solve problems through collaboration has been common in this community. It’s been done a lot before. (Wilder Collaboration Factors Inventory, 2)

1

2

3

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5

c. Others (in this community) who are not a part of the CAN would generally agree that the organizations involved in the CAN are the “right” organizations to make this work. (Wilder Collaboration Factors Inventory, 4 modified)

1

2

3

4

5

d. The political and social climate seems to be “right” for starting a collaborative project like the CAN. (Wilder Collaboration Factors Inventory, 5 modified)

1

2

3

4

5

Resources






e. The CAN encourages effective and equitable allocation of limited resources. (New)

1

2

3

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5

f. The CAN is able to adapt to changing conditions, such as fewer funds than expected, changing political climate, or change in leadership. (Wilder Collaboration Factors Inventory, 22 modified)

1

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5

Representation






g. The people involved in the CAN represent a cross section of those who have a stake in what we are trying to accomplish. (Wilder Collaboration Factors Inventory, 9 modified)

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5

h. All the organizations that we need to be members of the CAN have become members of the CAN. (Wilder Collaboration Factors Inventory, 10 modified)

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5

i. The provider membership on the CAN is culturally representative of the target community. (New)

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5

j. People in the CAN have a clear sense of their roles and responsibilities. (Wilder Collaboration Factors Inventory, 20 modified)

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5

k. There is a clear process for making decisions among the members in the CAN. (Wilder Collaboration Factors Inventory, 21 modified)

1

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5

Commitment






l. The organizations that belong to the CAN invest the right amount of time in our collaborative efforts. (Wilder Collaboration Factors Inventory, 13 modified)

1

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5

m. The level of commitment among the CAN members is high. (Wilder Collaboration Factors Inventory, 15 modified)

1

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5

n. The CAN has tried to take on the right amount of work at the right pace. (Wilder Collaboration Factors Inventory, 24 modified)

1

2

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5

Communication






o. People in the CAN communicate openly with one another. (Wilder Collaboration Factors Inventory, 26 modified)

1

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5

p. I am informed as often as I should be about what goes on in the CAN. (Wilder Collaboration Factors Inventory, 27 modified)

1

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5

q. The leaders of the CAN disseminate information using a variety of modalities and technologies. (New)

1

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5

r. The people who lead the CAN communicate well with the members. (Wilder Collaboration Factors Inventory, 28 modified)

1

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5

s. Communication among the people in the CAN happens both at formal meetings and in informal ways. (Wilder Collaboration Factors Inventory, 29 modified)

1

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5

Mutual respect, understanding, and trust






t. People involved in the CAN always trust one another. (Wilder Collaboration Factors Inventory, 7 modified)

1

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5

u. I have a lot of respect for the other people involved in the CAN. (Wilder Collaboration Factors Inventory, 8 modified)

1

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5

v. My organization benefits from being involved in the CAN (Wilder Collaboration Factors Inventory, 11 modified)

1

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5

Goals






w. People in the CAN know and understand our goals. (Wilder Collaboration Factors Inventory, 32 modified)

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x. People in the CAN have established reasonable goals. (Wilder Collaboration Factors Inventory, 3 modified)

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y. What we are trying to accomplish as the CAN would be difficult for any single organization to accomplish by itself. (Wilder Collaboration Factors Inventory, 36 modified)

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5


D2. Do you feel the time spent at meetings with the CAN is productive? (Living Cities TII Grantee-Partner Network Survey, 15 modified)


Select one only

Not very productive 1

Moderately productive 2

Very productive 3


D3. During the past 12 months, how closely did [ORG NAME] work with each of the other organizations listed?


We define “closely” as a range between not working together at all to working closely with another organization on joint activities (from “1” to “5”). Examples of such activities might include joint planning, service coordination, cost-sharing initiatives, or other activities that work toward a common goal. (Living Cities TII Grantee-Partner Network Survey, 11a modified)


Please check one response per row

Organization

We do not work together at all

Shape7



We

work closely

[LIST OF CAN MEMBERS FROM C1]

1

2

3

4

5

Shape8


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5


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5


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5


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5


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5


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5



D4. Overall, how productive is [ORG NAME]’s current working relationship with each of the organizations listed below? A productive working relationship is one in which you feel you are making progress toward a goal. (Community Voices for Coverage Leadership Team Follow-Up Survey, B3)



SELECT ONE ON EACH LINE

Community Action Network Members

Not productive

Somewhat productive

Very productive

Can’t assess
















[LIST OF CAN MEMBERS FROM C1]





























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E. PROGRESS TOWARD ACHIEVING GOALS

The next questions ask about the CAN’s goals.


E1. In your organization’s view, what are the main goals of the CAN (Column A)? Please try to list three goals. Then, indicate how effective the CAN currently is in working toward each of these goals (Column B). (Living Cities TII Grantee-Partner Network Survey, 13 modified).


If there are more than three goals, please list the top three.


COLUMN A

COLUMN B

Main Goals

Not effective

Somewhat effective

Very effective

Do not know

______________________________

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2

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4

______________________________

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E2. What do you feel are the five top barriers the CAN faces in achieving its goals? (2011 National Healthy Start Project Survey, 78 modified)

Select up to five.

  • Competing agendas of member organizations 1

  • Insufficient resources in the state or community to support our CAN goals 2

  • Insufficient staff time dedicated to assisting the CAN in its efforts 3

  • Irregular CAN attendance by key members 4

  • Lack of collaboration/cooperation from necessary partners
    and stakeholders 5

  • Lack of history of collaborative effort among health and
    service providers in our community 6

  • Lack of participant involvement 7

  • Lack of resources for CAN activities 8

  • Lack of strategic plan for the CAN 9

  • Lack of strong CAN leadership 10

  • Unstable relationships among CAN members 11

  • Unsupportive political climate 12

  • Other (specify) 99

Shape9

Specify (STRING 500)


E3. To what extent has the CAN focused on improving the following community outcomes (New):



Select one for each row below . . .

Outcomes

Does not focus on this

Focuses on this to some extent

Focuses on this to a great extent

Do not know

a. Processes to support access to comprehensive care

1

2

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4

b. Navigation across health and social service systems

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4

c. Coordination and integration of care across health and social service systems

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d. Community mobilization and involvement

1

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4

e. Capacity to address social determinants of health

1

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f. Stability of families in the community

1

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4

g. Data systems to coordinate and provide care across organizations

1

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4

h. Integration of consumers into the planning of services

1

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4



E4. To what extent has the CAN made an impact on each of the following community outcomes (New):



Select one for each row below . . .

Outcomes

Made no impact

Made some impact

Made major impact

Do not know

a. Processes to support access to comprehensive care

1

2

3

4

b. Navigation across health and social service systems

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4

c. Coordination and integration of care across health and social service systems

1

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4

d. Community mobilization and involvement

1

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e. Capacity to address social determinants of health

1

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f. Stability of families in the community

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g. Data systems to coordinate and provide care across organizations

1

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h. Integration of consumers into the planning of services

1

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4

F. THE COMMUNITY

The next questions ask about the community that [ORG NAME] is located in.


F1. For each of the following statements, please indicate whether you strongly agree, agree, disagree, or strongly disagree regarding the community that [ORG NAME] is located in.



Select one for each row below . . .


Strongly agree

Agree

Disagree

Strongly disagree

Trust





a. People can depend on each other in this community. (Survey of the Health of Adults, the Population and the Environment 2002, 13a)

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b. People know they can get help from the community if they are in trouble. (Survey of the Health of Adults, the Population and the Environment 2002, 13c)

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c. Generally speaking, most people in the community can be trusted. (Social Capital Assessment Tool Household Survey, 5B10 modified)

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d. Differences between people living in the community (such as differences in education, wealth, race, religious beliefs, or ethnic background) tend to divide the community. (Social Capital Assessment Tool Household Survey, 4C1 modified)

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4

Community Participation and Mobilization





e. People in the community are inclined to attend local events like school concerts, religious gatherings, or neighborhood fairs. (Survey of the Health of Adults, the Population and the Environment 2002, 12 modified)

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f. Individuals often join together with other people in the community to address a common issue. (Social Capital Assessment Tool Household Survey, 4D3 modified)

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g. Most people feel accepted as a member of the community. (Social Capital Assessment Tool Household Survey, 5B10i modified)

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Access





h. People in the community often have difficulty accessing services like health care or social services. (New)

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i. It is common for people in the community to be excluded from access to services due to income level, gender, race, ethnicity, religious beliefs, or education level. (New)

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j. People in the community have access to phone and Internet, either through personal devices or public sources (like libraries). (New)

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4

Well-Being in the Community





k. This community is a good place to raise children. (Survey of the Health of Adults, the Population and the Environment 2002, 13d)

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l. People here look out mainly for the welfare of their own families, and they are not much concerned with community welfare. (Social Capital Assessment Tool Community Questionnaire, 1.19)

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m. Residents generally feel secure living in this community. (Survey of the Health of Adults, the Population and the Environment 2002, 13b modified)

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F2. Thinking about community issues (such as job and housing availability, safety and security, and the environment), in your opinion, in the past three years the overall quality of life of the people living in this community has . . . (Social Capital Assessment Tool Community Questionnaire, 1.13)


Select one only

Improved 1

Worsened 2

Remained the same 3



F3. Overall, how much impact do you think [ORG NAME] has in making the community a better place to live? (Survey of the Health of Adults, the Population and the Environment 2002, 17 modified)


Select one only

No impact 1

Small impact 2

Moderate impact 3

Big impact 4


G. OTHER COMMENTS

G1. Please share with us anything else about your interactions and experiences working with [Healthy Start Grantee Name] and the CAN. (New)














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