Attachment C - Survey - Screenshots of new instrument

EfC Institutional Awareness & Commitment Test

Form Approved 
OMB No. 0920­XXXX 
Exp. Date:  
Public Reporting burden of this collection of information is estimated at 28 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and 
maintaining the data needed, and completing 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for 
reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D­74, Atlanta, GA 30333; Attn: PRA (0920­XXXX). 

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

Let's start with some basic questions about the characteristics of your agency. 

Page 1

EfC Institutional Awareness & Commitment Test
1. NAME OF AGENCY:
5
6  

2. Agency website:

3. Please enter the date
MM

DD

YYYY

/

Today's Date

Agency Characteristics

/

4. Scope of Your Agency's Work:
j State­wide
k
l
m
n

j 2+ counties or cities, but not state­wide
k
l
m
n
j 1 county
k
l
m
n
j 1 city
k
l
m
n

j Neighborhood(s) not city­ or county­wide
k
l
m
n

Other (please specify) 

5. What does your agency do?
5
6  

Page 2

EfC Institutional Awareness & Commitment Test
6. Who are your “clients”? (e.g., to whom does your agency respond to or provide services?)
5
6  

7. About how many people does your agency employ?
Number of employees

Respondent Characteristics

8. In your agency, are you:
j A senior manager
k
l
m
n

j A middle manager
k
l
m
n
j Not a manager
k
l
m
n

9. How many years have you been with this agency?

10. How much influence do you have in your agency over:
None

Little

Some

A Lot

All

Its strategic direction

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

How the budget gets allocated

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Starting new programs or activities

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Changing agency policies

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Who your agency partners with

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

The messages your agency releases

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Meeting agendas

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Presentations

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Page 3

EfC Institutional Awareness & Commitment Test
Agency’s Collective Values and Beliefs
11. Please check the answer that best corresponds to your agency.
1 (Not at All)

2

3

4 (Completely)

Don't Know

Agency leadership values the wellbeing of employees’ families

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Agency leadership values the well­being of all children

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Staff in the a agency value the well­being of all children

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Agency leadership considers scientific evidence important to inform policies, programs, or services.

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Agency leadership considers the impacts on child well­being when setting priorities

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Ensuring safe, stable, nurturing relationships and environments for all children is in alignment with your agency’s 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

mission

Agency Knowledge and Awareness

12. Thinking about your agency’s leadership, to what extent would they agree or disagree with the following statements?
1 (Strongly 

4 (Strongly 

2

3

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Whether a child grows up to be a healthy adult is heavily influenced by his/her genes

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Whether a child grows up to be a healthy adult is heavily influenced by his/her parents’ choices

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

The cumulative impact of childhood stressors such as poverty or partner violence shape children’s brains

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

The cumulative impact of childhood stressors such as poverty or partner violence lead to risky health behaviors in 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

agree)
Safe, stable and nurturing relationships and environments can buffer adverse childhood experiences like child 

disagree)

Don't Know

maltreatment or exposure to partner violence
Safe, stable, nurturing relationships and environments set children on a positive path for optimal development and 
health

adolescence
The cumulative impact of childhood stressors such as poverty or partner violence lead to adult chronic health 
conditions

Agency Activities

Page 4

EfC Institutional Awareness & Commitment Test
13. Please check the degree to which your agency engages in the following activities during staff meetings
0 (Not at all)

1

2

3

4 (A lot)

Don't Know

Agency leadership discusses promoting safe, stable, nurturing relationships for children and families

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Agency staff discusses promoting safe, stable, nurturing environments for children and families

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Agency leadership considers scientific evidence when making decisions about policies, programs, or 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

services
Agency staff reviews scientific evidence related to policies, programs, or services for children and 
families

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

Page 5

EfC Institutional Awareness & Commitment Test
14. Please indicate if your agency directly provides this service, refers clients to this service, or funds this service
Directly provides

Refers Clients

Provides Funds

Don't Know

Pre­ or inter­conception health care

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Contraception

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Prenatal care

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Home visits for new parents

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Parent training programs

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Screening and referral of parents experiencing partner violence, mental illness or substance abuse

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Legal, mental, financial or other counseling for women experiencing partner violence

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Anticipatory guidance to parents around common parenting issues

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Developmental screening of children

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Health insurance for children

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Health insurance for parents

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Preschool without parent support services

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Preschool with family support services

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Family resource centers (lending books or toys, linking to services)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

K­12 education

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Tutoring children

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

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

Page 6

EfC Institutional Awareness & Commitment Test
15. Please indicate if your agency directly provides this service, refers clients to this service, or funds this service
Directly provides

Refers Clients

Provides Funds

Don't Know

Mentoring children

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Recreational activities for children

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Child care during work hours

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

After­school child care

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Summer child care

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Child care on week­ends or evenings

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Child care subsidies

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Interventions for maltreated children or their parents

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Services for children with or at risk of developmental delays or manifesting behavioral problems (IEPs or IFSPs)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Job training

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Financial literacy training

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Low cost financial services for families without savings or checking bank accounts

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Temporary shelters

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Affordable housing

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

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

Page 7

EfC Institutional Awareness & Commitment Test
16. Please indicate if your agency directly provides this service, refers clients to this service, or funds this service
Directly Provides

Refers Clients

Provides Funds

Don't Know

Urban planning, development, or transportation

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Zoning decisions

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Crime prevention

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Juvenile justice

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Rehabilitation of juvenile offenders

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Rehabilitation of adult offenders

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Income support for unemployed or low­income families

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

SNAP or WIC

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Food pantries

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Dissemination of information around parenting or child development

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Campaigns to change social norms around parenting or children

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Campaigns to promote family friendly work policies

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Policy development, evaluation, or analysis

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Research or Think Tank

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Other (please indicate service in text box below)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Other (please specify) 

5
6

Agency’s Policies on Work­Life Balance

Page 8

EfC Institutional Awareness & Commitment Test
17. 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% or more

Don't Know

Flex start and quit times?

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Alternative work days (e.g. compressed work weeks)?

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Telework from home at least once a week?

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Living wages ($22.70/hr for CA; $20.56 for CO; $24.84 for MA; $18.92 for NC; $19.49 for WA)?

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Job sharing or part­time opportunities?

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Paid leave to care for a new or sick child?

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Paid leave to attend school or other child­related events

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Paid sick leave or vacation for employees

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Child care (sliding­fee on site or subsidies for lower income)?

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Transportation subsidies provided to low­income employees?

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Housing subsidies provided to low­income employees?

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Breast feeding mothers given break time?

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Breast feeding mothers given private lactation room?

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Mental health counseling services provided?

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Substance abuse treatment services provided?

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Parenting training provided?

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Flexible spending accounts for health care or medications?

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Flexible spending accounts for child care?

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Support for professional development (e.g. tuition assistance, on­the­job­training)?

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Data Used by Agency in Past Year to Inform Decision­making

Page 9

EfC Institutional Awareness & Commitment Test
18. Please indicate which data your agency/organization have used in the last year to make decisions about policies or
programs that affect children or families in your state. Add another √ if these data are examined by race/ethnicity or
income.
Examined by 

Used past year

race/ethnicity

Examined by income

Don't Know

Number (#) of child homicides

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Child fatality review records

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

# of hospital discharges due to children’s intentional injuries

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

# of emergency room visits due to children’s intentional injuries

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Rate of reports to Child Protective Services (CPS)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

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

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

% of pregnant women receiving prenatal care in the first trimester

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

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

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

% births to teen parents

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

# of 911 calls attributed to partner violence

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

% of ambulatory care visits for mental illness, including substance abuse among women 15­45 yrs. 

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Length of wait list for treatment of substance abuse among adults

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

% of children under 5 years old evaluated for social emotional development

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

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

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

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

old

guidelines

Data Used by Agency in Past Year to Inform Decision­making, Part 2

Page 10

EfC Institutional Awareness & Commitment Test
19. Please indicate which data your agency/organization have used in the last year to make decisions about policies or
programs that affect children or families in your state. Add another √ if these data are examined by race/ethnicity or
income.
Examined by 

Used past year

race/ethnicity

Examined by income

Don't Know

% of unplanned pregnancies

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

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

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

% of services provided to parents and children reported to CPS that are evidence­based

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

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

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

% of parents reporting parental stress (i.e., child is harder to care for than most; child does things 

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

% children with a mentor

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

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

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

% children under 2 years old who watch TV

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

% children over 2 years old in front of a screen for more than 2 hours a day

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Affordability of child care

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Child care slots available / # of children less than 6 years old potentially needing child care

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

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

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Length of wait list for childcare subsidies

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

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

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

that bother them; felt angry with child; has someone they can turn to for help with parenting)

receive TANF

Data Used by Agency in Past Year to Inform Decision­making, Part 3

Page 11

EfC Institutional Awareness & Commitment Test
20. Please indicate which data your agency/organization have used in the last year to make decisions about policies or
programs that affect children or families in your state. Add another √ if these data are examined by race/ethnicity or
income.
Used past year

Examined by 
race/ethnicity

Examined by income

Don't Know

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

% of children who are food insecure

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

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

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

High school dropout rates

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Length of wait list for state­funded pre­K program or Head Start

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

% of schools with evidence­based education programs to prevent teen pregnancy

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Distribution of funding for schools in high poverty vs. low poverty districts

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

% children treated unfairly because of race/ethnicity

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

% of children living in poverty

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

% of children living in high poverty neighborhoods

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

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

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

% of children living in crowded households

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

% of homeless school­age children

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

% of homeless pre­school age children

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Cost of living for a family with 2 children

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

% of children with no parent fully employed year round

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

% of children with an incarcerated parent

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

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

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

% of businesses with family­friendly work policies (e.g., flex­time, telework, paid leave for children) or 

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

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

actually receive SCHIP/Medicaid

state policies that are family friendly
Other (please specify data in box below)
Please specify other data source used in last year: 

Page 12

EfC Institutional Awareness & Commitment Test
5
6

Collaboration

Please indicate YES, NO or DON'T KNOW for the following questions about collaboration. If YES, indicate how your agency collaborates; select DON’T KNOW if 
you don't know if agency collaborates or how your agency collaborates with this agency.  

For this survey collaboration includes: 
Referrals to an agency 
Coordinating services or programs 
Serving on advisory or planning groups 
Sharing data 
Developing legislation or policy 
Cross­training 
Sharing materials 

If it is your own agency, please choose YES and indicate the kinds of collaborations your agency engages in.  

21. Does you agency/organization collaborate with the Governor's Office?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Page 13

EfC Institutional Awareness & Commitment Test
22. If yes, how does your agency/organization collaborate with the Governor's Office?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

23. Does your agency/organization collaborate with the Dept. of Education?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Page 14

EfC Institutional Awareness & Commitment Test
24. If yes, how does your agency/organization collaborate with the Dept. of Education?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

25. Does your agency/organization collaborate with Family and Children Services?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Page 15

EfC Institutional Awareness & Commitment Test
26. If yes, how does your agency/organization collaborate with Family and Children Services?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

27. Does your agency/organization collaborate with Dept. of Human Services?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Page 16

EfC Institutional Awareness & Commitment Test
28. If yes, how does your agency/organization collaborate with a Dept. of Human Services?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

29. Does your agency/organization collaborate with the Dept. of Public Health?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Page 17

EfC Institutional Awareness & Commitment Test
30. If yes, how does your agency/organization collaborate with Dept. of Public Health?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

31. Does your agency/organization collaborate with a developmental disabilities agency?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Page 18

EfC Institutional Awareness & Commitment Test
32. If yes, how does your agency/organization collaborate with a developmental disabilities agency?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

33. Does your agency/organization collaborate with a child support agency?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Page 19

EfC Institutional Awareness & Commitment Test
34. If yes, how does your agency/organization collaborate with a child support agency (helping families get, change, or
enforce child support orders)?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

35. Does your agency/organization collaborate with a consumer protection agency?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Page 20

EfC Institutional Awareness & Commitment Test
36. If yes, how does your agency/organization collaborate with a consumer protection agency?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

37. Does your agency/organization collaborate with a Dept. of Transportation?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Page 21

EfC Institutional Awareness & Commitment Test
38. If yes, how does your agency/organization collaborate with the Dept. of Transportation?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

39. Does your agency/organization collaborate with a child care, early care, or early learning agency?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Page 22

EfC Institutional Awareness & Commitment Test
40. If yes, how does your agency/organization collaborate with a child care, early care or early learning agency?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

41. Does your agency/organization collaborate with the Police Department?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Page 23

EfC Institutional Awareness & Commitment Test
42. If yes, how does your agency/organization collaborate with the Police Department?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

43. Does your agency/organization collaborate with the Dept. of Justice?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Page 24

EfC Institutional Awareness & Commitment Test
44. If yes, how does your agency/organization collaborate with Dept. of Justice?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

45. Does your agency/organization collaborate with Dept. of Labor?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Page 25

EfC Institutional Awareness & Commitment Test
46. If yes, how does your agency/organization collaborate with the Dept. of Labor?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

47. Does your agency/organization collaborate with Dept. of Housing?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Page 26

EfC Institutional Awareness & Commitment Test
48. If yes, how does your agency/organization collaborate with the Dept. of Housing?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

49. Does your agency/organization collaborate with a state financial agency?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Page 27

EfC Institutional Awareness & Commitment Test
50. If yes, how does your agency/organization collaborate with a state financial agency?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

51. Does your agency/organization collaborate with a state environmental department/agency?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Page 28

EfC Institutional Awareness & Commitment Test
52. If yes, how does your agency/organization collaborate with state environmental department/agency?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

53. Does your agency/organization collaborate with the Community­Based Child Abuse Prevention (CBCAP) Program?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Page 29

EfC Institutional Awareness & Commitment Test
54. If yes, how does your agency/organization collaborate with the Community­Based Child Abuse Prevention (CBCAP)
Program?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

55. Does you agency/organization collaborate with Prevent Child Abuse state affiliate?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Page 30

EfC Institutional Awareness & Commitment Test
56. If yes, how does your agency/organization collaborate with Prevent Chlid Abuse state affiliate?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

57. Does your agency/organization collaborate with the Children's Trust Fund?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Page 31

EfC Institutional Awareness & Commitment Test
58. If yes, how does your agency/organization collaborate with the Children's Trust Fund?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

59. Does your agency/organization collaborate with the Chamber of Commerce?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Page 32

EfC Institutional Awareness & Commitment Test
60. If yes, how does your agency/organization collaborate with the Chamber of Commerce?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

61. Does your agency/organization collaborate with state­wide businesses?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Please specify the name of the business(es) 

Page 33

EfC Institutional Awareness & Commitment Test
62. If yes, how does your agency/organization collaborate with state­wide businesses?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

63. Does your agency/organization collaborate with technical colleges?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Please specify the name of the technical college(s) 

5
6

Page 34

EfC Institutional Awareness & Commitment Test
64. If yes, how does your agency/organization collaborate with the technical college(s)?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

65. Does your agency/organization collaborate with non­profits?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Please specify the name of the non­profit(s) 

5
6

Page 35

EfC Institutional Awareness & Commitment Test
66. If yes, how does your agency/organization collaborate with non­profits?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

67. Does your agency/organization collaborate with universities?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Please specify the universities 

5
6

Page 36

EfC Institutional Awareness & Commitment Test
68. If yes, how does your agency/organization collaborate with the universities?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

69. Does your agency/organization collaborate with coalitions/grass­roots organizations?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Please specify the coalition(s) or grass­roote organization(s) 

5
6

Page 37

EfC Institutional Awareness & Commitment Test
70. If yes, how does your agency/organization collaborate with coalition/grass­roots organizations?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

71. Does your agency/organization collaborate with public broadcasting?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Page 38

EfC Institutional Awareness & Commitment Test
72. If yes, how does your agency/organization collaborate with public broadcasting?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

73. Does your agency/organization collaborate with a regional TV station(s)?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

Page 39

EfC Institutional Awareness & Commitment Test
74. If yes, how does your agency/organization collaborate with regional TV station(s)?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

75. Does your agency/organization collaborate with a regional newspaper?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't Know
k
l
m
n

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EfC Institutional Awareness & Commitment Test
76. If yes, how does your agency/organization collaborate with a regional newspaper?
c Refers to this organization
d
e
f
g

c Coordinates or blends services or programs with this organization
d
e
f
g
c Serves on an advisory or planning group for this organization
d
e
f
g
c Shares data with this organization
d
e
f
g

c Develops legislation or policy with this organization
d
e
f
g
c Cross­trains with this organization
d
e
f
g

c Shares materials, information, or other resources with this organization
d
e
f
g
c Don’t know how my agency collaborates with this organization
d
e
f
g

77. What other organizations/agencies do you collaborate with that you haven't already listed?
Please indicate name of organization and how you collaborate by using the following:
­­Make referrals
­­Coordinates or blends services or programs
­­Serves on advisory or planning group(s)
­­Shares data
­­Develops legislations or policy
­­Cross­trains
­­Shares materials, information or other resources
­­Don't Know
1
2
3

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EfC Institutional Awareness & Commitment Test

Thank you for completing this survey. 

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