0920-1010 Attachment D - Survey - New

2

Attachment D

Institutional Awareness and Commitment Survey

Form Approved

OMB No. 0920-XXXX

Exp. Date:

INTRODUCTION

The purpose of this survey is to get a better understanding of your agency’s (or institution, organization, business, department) level of awareness and current efforts aimed to ensure safe, stable, nurturing relationships and environments and prevent child maltreatment both within your agency and around the state. The information you provide will be used to begin tracking the collective impact of agencies’ efforts towards the goal of ensuring safe, stable, nurturing relationships and environments for all children.

Compliance: Completion of this survey is voluntary.   You can stop answering the survey at any time.  

Risks and Benefits: There are no foreseeable or expected risks for participation in this survey. The expected benefit may be that you/your agency develops a heightened awareness of actions and data sources that may contribute to promoting safe, stable, nurturing relationships and environments for children.

Confidentiality: The mechanism for collecting this information is Survey Monkey, a secure website that meets the Safe Harbor and EU Data Protection Requirements.  All information collected will be maintained in a secure manner. Your answers are confidential and will only be viewed by the evaluation team and shared with your Steering Committee in aggregate (not identifying any agency).

INSTRUCTIONS

We would like this survey to represent the perspective of your whole agency. Please, either bring in a group of representatives from your agency to reflect on the position of the agency or answer the survey alone reflecting the position of the agency to the best of your knowledge (not your personal opinions).

We are collecting this information from a variety of agencies. Some questions may not apply to yours. For these questions, please check the “does not apply” box.

Agency Characteristics

Lets’ start with some basic questions about the characteristics of your agency.

NAME OF AGENCY: _________________________________________ DATE: ____________

Agency’s website: __________________________________________

SCOPE OF YOUR AGENCY’s WORK:

State-wide 2+ counties or cities but not state-wide one-county one-city

neighborhood(s) not city- or county-wide Other; Please specify_________________________

What does your agency do?

Who are your “clients”? (e.g., to whom does your agency respond to or provide services?)

About how many people does your agency employ?

Respondent Characteristics

In your agency, are you: A senior manager A middle manager Not a manager

How many years have you been with this agency?

How much influence do you have in your agency over:	None	Little	Some	A lot	All
Its strategic direction	0	1	2	3	4
How the budget gets allocated	0	1	2	3	4
Starting new programs or activities	0	1	2	3	4
Changing agency policies	0	1	2	3	4
Who your agency partners with	0	1	2	3	4
The messages your agency releases	0	1	2	3	4
Meeting agendas	0	1	2	3	4
Presentations	0	1	2	3	4

Agency’s Collective Values and Beliefs

Please check the answer that best corresponds to your agency.	Not at all				Com pletely	DK
Agency leadership values the wellbeing of employees’ families	0	1	2	3	4	99
Agency leadership values the well-being of all children	0	1	2	3	4	99
Staff in the a agency value the well-being of all children	0	1	2	3	4	99
Agency leadership considers scientific evidence important to inform policies, programs, or services.	0	1	2	3	4	99
Agency leadership considers the impacts on child well-being when setting priorities	0	1	2	3	4	99
Ensuring safe, stable, nurturing relationships and environments for all children is in alignment with your agency’s mission	0	1	2	3	4	99

Agency Knowledge and Awareness

Thinking about your agency’s leadership, to what extent would they agree or disagree with the following statements?	Disagree completely			Agree completely	DK
Safe, stable, nurturing relationships and environments can buffer adverse childhood experiences like child maltreatment or exposure to partner violence	1	2	3	4	99
Safe, stable, nurturing relationships and environments set children on a positive path for optimal development and health	1	2	3	4	99
Whether a child grows up to be a healthy adult is heavily influenced by his/her genes	1	2	3	4	99
Whether a child grows up to be a healthy adult is heavily influence by his/her parents’ choices	1	2	3	4	99
The cumulative impact of childhood stressors such as poverty or partner violence shape children’s brains	1	2	3	4	99
The cumulative impact of childhood stressors such as poverty or partner violence lead to risky health behaviors in adolescence	1	2	3	4	99
The cumulative impact of childhood stressors such as poverty or partner violence lead to adult chronic health conditions	1	2	3	4	99

Agency Activities

Please check the degree to which your agency engages in the following activities during staff meetings	Not at all				A lot	DK
Agency leadership discusses promoting safe, stable, and nurturing relationships for children and families	0	1	2	3	4	99
Agency staff discusses promoting safe, stable, and nurturing environments for children and families	0	1	2	3	4	99
Agency leadership considers scientific evidence when making decisions about policies, programs, or services	0	1	2	3	4	99
Agency staff reviews scientific evidence related to policies, programs, or services for children and families	0	1	2	3	4	99

Services for Families or Children’s Health or Development in your State

Please indicate if your agency directly provides this service, refers clients to this service, or funds this service	Directly provides			Refers clients			Provides funds			DK
	Yes		No	Yes		No	Yes		No	99
Pre- or inter-conception health care	1		2	1		2	1		2	99
Contraception	1		2	1		2	1		2	99
Prenatal care	1		2	1		2	1		2	99
Home visits for new parents	1		2	1		2	1		2	99
Parent training programs	1		2	1		2	1		2	99
Screening and referral of parents experiencing partner violence, mental illness or substance abuse	1		2	1		2	1		2	99
Legal, mental, financial or other counseling for women experiencing partner violence	1		2	1		2	1		2	99
Anticipatory guidance to parents around common parenting issues	1		2	1		2	1		2	99
Developmental screening of children	1		2	1		2	1		2	99
Health insurance for children	1		2	1		2	1		2	99
Health insurance for parents	1		2	1		2	1		2	99
Preschool without parent support services	1		2	1		2	1		2	99
Preschool with family support services	1		2	1		2	1		2	99
Family resource centers (lending books or toys, linking to services)	1		2	1		2	1		2	99
K-12 education	1		2	1		2	1		2	99
Tutoring children	1		2	1		2	1		2	99
Mentoring children	1		2	1		2	1		2	99
Recreational activities for children	1		2	1		2	1		2	99
Please indicate if your agency directly provides this service, refers clients to this service, or funds this service	Directly provides			Refers clients to			Provides funds for			DK
	Yes	No		Yes	No		Yes	No		99
Child care during work hours	1	2		1	2		1	2		99
After-school child care	1	2		1	2		1	2		99
Summer child care	1	2		1	2		1	2		99
Child care on week-ends or evenings	1	2		1	2		1	2		99
Child care subsidies	1	2		1	2		1	2		99
Interventions for maltreated children or their parents	1	2		1	2		1	2		99
Services for children with or at risk of developmental delays or manifesting behavioral problems (IEPs or IFSPs)	1	2		1	2		1	2		99
Job training	1	2		1	2		1	2		99
Financial literacy training	1	2		1	2		1	2		99
Low cost financial services for families without savings or checking bank accounts	1	2		1	2		1	2		99
Temporary shelters	1	2		1	2		1	2		99
Affordable housing	1	2		1	2		1	2		99
Urban planning, development, or transportation	1	2		1	2		1	2		99
Zoning decisions	1	2		1	2		1	2		99
Crime prevention	1	2		1	2		1	2		99
Juvenile justice	1	2		1	2		1	2		99
Rehabilitation of juvenile offenders	1	2		1	2		1	2		99
Rehabilitation of adult offenders	1	2		1	2		1	2		99
Income support for unemployed or low-income families	1	2		1	2		1	2		99
SNAP or WIC	1	2		1	2		1	2		99
Food pantries	1	2		1	2		1	2		99
Dissemination of information around parenting or child development	1	2		1	2		1	2		99
Campaigns to change social norms around parenting or children	1	2		1	2		1	2		99
Campaigns to promote family friendly work policies	1	2		1	2		1	2		99
Policy development, evaluation, or analysis	1	2		1	2		1	2		99
Research or Think Tank	1	2		1	2		1	2		99
Other (please describe):
Other (please describe)

Agency’s Policies on Work-Life Balance

% of employees supported

Please indicate the percent of employees at your agency (to the best of your knowledge) who are supported by the following policies:	0%	1%-33%	34%-66%	67%+	DK
Flex start and quit times?	0	1	2	3	99
Alternative work days (e.g. compressed work weeks)?	0	1	2	3	99
Telework from home at least once a week?	0	1	2	3	99
Living wages ($22.70/hr for CA; $20.56 for CO; $24.84 for MA; $18.92 for NC; $19.49 for WA)?	0	1	2	3	99
Job sharing or part-time opportunities?	0	1	2	3	99
Paid leave to care for a new or sick child?	0	1	2	3	99
Paid leave to attend school or other child-related events	0	1	2	3	99
Paid sick leave or vacation for employees	0	1	2	3	99
Child care (sliding-fee on site or subsidies for lower income)?	0	1	2	3	99
Transportation subsidies provided to low-income employees?	0	1	2	3	99
Housing subsidies provided to low-income employees?	0	1	2	3	99
Breast feeding mothers given break time?	0	1	2	3	99
Breast feeding mothers given private lactation room?	0	1	2	3	99
Mental health counseling services provided?	0	1	2	3	99
Substance abuse treatment services provided?	0	1	2	3	99
Parenting training provided?	0	1	2	3	99
Flexible spending accounts for health care or medications?	0	1	2	3	99
Flexible spending accounts for child care?	0	1	2	3	99
Support for professional development (e.g. tuition assistance, on-the-job-training)?	0	1	2	3	99

Data Used by Agency in Past Year to Inform Decision-making

In this next section, we would like to document the use of data to inform decisions. Collecting, analyzing, and/or reporting data are not considered “using data to inform decisions” even if the data were used by another agency. Answer yes only if your agency used the data to inform a decision. If “yes” (i.e., the specific data were used to inform a decision in your agency), please indicate whether the data were examined by race/ethnicity or income.

Please indicate (Yes or No) which data your agency/organization used in the past year to make decisions about policies or programs that affect children or families in your state. Then, indicate if these data were examined by race/ethnicity and/or income.

Used Past Year

Examined by race/ ethnicity

Examined by income

Yes

No

Don’t Know

Yes

No

Yes

No

Number (#) of child homicides

Y

N

DK

Y

N

Y

N

Child fatality review reports

Y

N

DK

Y

N

Y

N

# of hospital discharges due to children’s intentional injuries

Y

N

DK

Y

N

Y

N

# of Emergency Room visits due to children’s intentional injuries

Y

N

DK

Y

N

Y

N

Rate of reports to Child Protective Services (CPS)

Y

N

DK

Y

N

Y

N

% of children reporting 2+ Adverse Childhood Experiences in the National Children’s Health Survey

Y

N

DK

Y

N

Y

N

% of pregnant women receiving prenatal care in the first trimester

Y

N

DK

Y

N

Y

N

% of pregnant women or parents of young children with depression, exposure to partner violence, or substance abuse

Y

N

DK

Y

N

Y

N

% of pregnant women receiving information about or referral for depression, exposure to partner violence, or substance abuse from their health care provider

Y

N

DK

Y

N

Y

N

% births to teen parents

Y

N

DK

Y

N

Y

N

# of 911 calls attributed to partner violence

Y

N

DK

Y

N

Y

N

length of wait list for treatment of substance abuse or mental illness among adults

Y

N

DK

Y

N

Y

N

% children with no medical insurance

Y

N

DK

Y

N

Y

N

% of children <5 evaluated for social emotional develop.

Y

N

DK

Y

N

Y

N

% of parents of children under five who received anticipatory guidance using Bright Futures guidelines

Y

N

DK

Y

N

Y

N

Please indicate (Yes or No) which data your agency/organization used in the past year to make decisions about policies or programs that affect children or families in your state. Then, indicate if these data were examined by race/ethnicity and/or income.

Used Past Year

Examined by race/ ethnicity

Examined by income

Y

Yes

No

Don’t Know

Yes

No

Yes

No

% of unplanned pregnancies

Y

N

DK

1

N

1

N

% of women between 15-45 with access to family planning services

Y

N

DK

1

N

1

N

% of services provided to parents and children reported to CPS that are evidence-based

Y

N

DK

1

N

1

N

% of parents who physically punished their child in the past year

Y

N

DK

1

N

1

N

% of parents reporting parental stress (i.e., child is harder to care for than most; child does things that bother them; felt angry with child; has someone they can turn to for help with parenting)

Y

N

DK

1

N

1

N

% children with a mentor

Y

N

DK

1

N

1

N

% children who are read, sung, or told stories to

Y

N

DK

1

N

1

N

% children < 2 who watch TV

Y

N

DK

1

N

1

N

% children > 2 in front of a screen > 2 hours a day

Y

N

DK

1

N

1

N

Affordability of child care

Y

N

DK

1

N

1

N

Child care slots available / # of children < 6 potentially needing child care

Y

N

DK

1

N

1

N

Length of wait list for infant or toddler childcare and education programs such as Early Head Start

Y

N

DK

1

N

1

N

Length of wait list for childcare subsidies

Y

N

DK

Y

N

Y

N

% of families who are eligible for Temporary Assistance to Needy Families (TANF) who actually receive TANF

Y

N

DK

Y

N

Y

N

% of families who are eligible for Supplemental Nutrition Assistance Program (SNAP) or WIC vouchers who actually receive SNAP/WIC

Y

N

DK

Y

N

Y

N

% of children who are food insecure

Y

N

DK

Y

N

Y

N

% of families who are eligible for State Children’s Health Insurance Program (SCHIP)/Medicaid who actually receive SCHIP/Medicaid

Y

N

DK

Y

N

Y

N

High school dropout rates

Y

N

DK

Y

N

Y

N

Length of wait list for state-funded pre-K program or Head Start

Y

N

DK

Y

N

Y

N

% of schools with evidence-based education programs to prevent teen pregnancy

Y

N

DK

Y

N

Y

N

Distribution of funding for schools in high vs low poverty districts

Please indicate (Yes or No) which data your agency/organization used in the past year to make decisions about policies or programs that affect children or families in your state. Then, indicate if these data were examined by race/ethnicity and/or income.

Used Past Year

Examined by race/ ethnicity

Examined by income

Yes

No

Don’t Know

Yes

No

Yes

No

% children treated unfairly because of race/ethnicity

Y

N

DK

Y

N

Y

N

% of children living in poverty

Y

N

DK

Y

N

Y

N

% of children living in high poverty neighborhoods

Y

N

DK

Y

N

Y

N

% children living in neighborhoods with low social capital

Y

N

DK

Y

N

Y

N

% of families with children who pay > 30% of income for housing

Y

N

DK

Y

N

Y

N

% of children living in crowded households

Y

N

DK

Y

N

Y

N

% of homeless school-age children

Y

N

DK

Y

N

Y

N

% of homeless pre-school age children

Y

N

DK

Y

N

Y

N

Cost of living for a family with 2 children

Y

N

DK

Y

N

Y

N

% of children with no parent fully employed year round

Y

N

DK

Y

N

Y

N

% of children with an incarcerated parent

Y

N

DK

Y

N

Y

N

Average interest rates for payday, auto title, or pawnshop loans

Y

N

DK

Y

N

Y

N

% of businesses with family-friendly work policies (e.g., flex-time, telework, paid leave for children) or state policies that are family friendly

Y

N

DK

Y

N

Y

N

Other, please describe

Other, please describe

Please indicate YES, NO, or Don’t know for the following questions about collaboration. If “YES”, please indicate how your agency collaborates with them. For this survey, collaboration includes referral to an agency; coordinating services or programs; serving on an advisory or planning group; sharing data; developing legislation or policy; cross-training; or sharing materials, information, or other resources. If it is your own agency, please choose “YES” and indicate the kinds of collaborations your agency engages in. Where the name of an agency is blank, please specify the name of the agency/organization where space is provided.

Agency or organization.

Our agency collaborates with this organization

Refers to this organiza-tion

Coordinates or blends services or programs with this organization

Serves on an advisory or planning group for this organiza-tion

Shares data with this organiza-tion.

Develops legislation or policy with this organization

Cross-trains with this organiza-tion

Shares materials, information, or other resources with this organization

Don’t know how my agency collabo-rates with this org

Yes

No

Don’t know

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

DK

Governor’s Office

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Dept of Educ

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Family & children services

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Human services

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Public Health

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Developmental disabilities

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Child support

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Consumer protection

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Transportation

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Early Care or learning

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Police

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Justice

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Labor

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Housing

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Finance

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Environment

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

CBCAP

Agency or organization.

Our agency collaborates with this org

Refers to this org.

Coordinates services or programs with this org

Serves on n advisory or planning group with this org

Shares data with this org.

Develops legislation or policy with this org.

Cross-trains with this org,

Shares materials With this org.

Don’t know how my agency collabo-rates with this org

Yes

No

Don’t know

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

DK

State Prevent Child Abuse

Y

N

DK

N

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Children’s Alliance

Y

N

DK

N

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Children’s Trust Fund

Y

N

DK

N

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Chamber of Commerce

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Businesses with state-wide coverage ___________

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

_____________

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Non-profits ___________

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

____________

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Technical college(s) ___________

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

____________

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Universities ___________

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

____________

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Coalitions/grass root organizations ___________

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Public broadcasting

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Regional TV station

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

DK

Regional newspaper

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

Y

N

N

DK

Other: ___________

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

Y

N

N

DK

___________

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

Y

Y

N

N

DK

___________

Y

N

DK

Y

N

Y

N

Y

N

Y

N

Y

N

N

Y

N

N

DK