OMB Control No: _____
Expiration Date: ______
Length of time for instrument: 1.00 hour
ATTACHMENT 11: MIHOPE PROGRAM MANAGER SURVEY PART 3_
BASELINE
5/29/2012
PROGRAM MANAGER SURVEY PART 3: COMMUNITY SERVICES INVENTORY
The U.S. Department of Health and Human Services has contracted with MDRC to evaluate the federal Maternal, Infant and Early Childhood Home Visiting (MIECHV) Program.
The Mother and Infant Home Visiting Program Evaluation (MIHOPE) is designed to build knowledge for policymakers and practitioners about the effectiveness of MIECHV.
Your answers will be kept confidential, except for the names of other community agencies you list in the survey and the contact information you provide for them. Only the research team will have access to this information. Your answers will not be shared with anyone at your program or any other agencies. In our research reports, the information you provide will not be attributed by name to you or your individual program.
One objective of MIHOPE is to learn how implementing agencies and other organizations work together to design and implement home visiting program services.
We are requesting that you complete this survey because you are the manager of one of the home visiting programs participating in MIHOPE. Your answers will help us understand your agency’s home visiting program service model and implementation system.
It will take about 1 hour to complete this survey.
The survey asks questions about the service availability and coordination with other service providers in your community.
If you are unsure how to answer a question, please give the best answer you can rather than leaving it blank.
We would appreciate your response by 5 p.m. on DD/MM/YYYY. If you have questions at any time during the study, please call Alexander Vazquez at MDRC toll-free at 1-877-311-6372 or email [email protected].
SERVICE AVAILABILITY AND COORDINATION WITH SPECIFIC COMMUNITY SERVICE PROVIDERS
Instructions: We need to learn about the availability of services for expectant women and families with young children in your community. For this section, it may be helpful to consult your program’s community resource guide and staff who regularly make referrals to the nine types community service providers listed below before starting the survey. The survey asks questions about the names of specific service providers that your program refers to and about the availability and accessibility of those services. Service providers may include other service providers in your community and other programs within your own agency.
At the end of the survey, you will be asked to enter contact information for selected community service providers, including agency name, point of contact name, point of contact email address, telephone number, and street address. You can do this yourself or have another staff person enter the information if you prefer. We will send each of these community service providers a brief web-based survey about the services they provide.
SERVICE TYPES:
Prenatal Care
Family Planning and Reproductive Health Care
Substance Use (Alcohol and Other Drugs) and Mental Health Treatment Services
Domestic Violence Shelter
Domestic Violence Counseling/Anger Management
Adult Education or Employment Services ( including GED, ESL, job placement, or job training)
Pediatric Primary Care
Child Care (including Child Care Resource & Referral Agencies)
Early Intervention Services for Children with Suspected or Diagnosed Disabilities or Delays (Part C)
PRENATAL CARE
Please rate the availability of [SERVICE] in your community.
[SERVICE] is almost always available to families who need it.
[SERVICE] is usually available to families who need it.
[SERVICE] is sometimes available to families who need it.
[SERVICE] is difficult to obtain for families who need it.
[SERVICE] is not available in our community.Is there a service provider in the community to which you refer families for prenatal care? (The term referrals includes referrals that your program makes directly, as well as information you provide to families so that they can contact the community providers to request services.)
Yes
No [SKIP TO QUESTION 16]
Don’t know [SKIP TO NEXT SERVICE TYPE]
IF YES: Please provide the name of the service provider to which you refer families for prenatal care most often: ____________________________ [NOTE: You will be asked for contact information for this service provider at the end of the survey.]
About how often does your program refer families to [SERVICE PROVIDER] for prenatal care?
No referrals
Every day or almost every day
Every week or almost every week
Once or twice a month
Less than monthly
Don’t know
About how many families have you referred to [SERVICE PROVIDER] in the past 3 months?
No referrals
1 to 3 referrals
4 to 10 referrals
11 to 20 referrals
More than 20 referrals
Don’t know
Does [SERVICE PROVIDER] keep a waiting list?
Yes
Sometimes
No [SKIP TO QUESTION 7]
Don’t Know [SKIP TO QUESTION 7]
[IF YES OR SOMETIMES] How long do families usually have to wait for services?
Less than a week
Less than a month
1 to 3 months
More than 3 months
Don’t know
Do families experience difficulties accessing services from [SERVICE PROVIDER]?
No [SKIP TO QUESTION 9]
Yes
Don’t know [SKIP TO QUESTION 9]
[IF YES] CHECK ALL THAT APPLY:
Cost of the service is too high
Service location is too far away
Too dangerous to get there (located in high-crime neighborhood)
Service location is not near public transportation
Lack of transportation
Services only offered during working hours
Services not offered in families’ home language
Other eligibility rules
Other (specify):
Don’t know
Overall, how effective do you think [SERVICE PROVIDER] has been in delivering services to meet families’ needs for prenatal care?
Very effective
Quite effective
Somewhat effective
Not effective at all
Don’t know
Over the past three months, what types of activities were you involved in with [SERVICE PROVIDER]? Please check all that apply.
Met for joint planning
Submitted a joint grant proposal
Participated in joint training
Provided training to staff from [SERVICE PROVIDER]
Shared costs
Developed joint program materials
Contracted for specific services
Shared information about specific families
None of the above
Don’t know
In the past 3 months, how often has your program had contact with [SERVICE PROVIDER] about referred families or other issues listed above in question 10?
No contact
Every day or almost every day
Every week or almost every week
Once or twice a month
Less than monthly
Don’t know
[SERVICE PROVIDER] a program within your own agency?
Yes, [SERVICE PROVIDER] is part of my agency
No, [SERVICE PROVIDER]is part of another agency in the community
Don’t know
Do you have a memorandum of understanding (MOU) or other service agreement in place with [SERVICE PROVIDER]?
Yes
No
Don’t know
Do you have a designated point of contact at [SERVICE PROVIDER]?
Yes
No
Don’t know
Overall, how would you rate your current coordination with this agency in making referrals?
Poor or No Coordination
Fair
Good
Excellent
Don’t know
AFTER QUESTION 15, SKIP TO QUESTION 17.
Why does your program not make referrals for prenatal care?
There are no providers of this service available in the community.
There are providers of this service in the community, but we do not make referrals because:
Long waiting lists
Services are too expensive
Inconvenient location
Inconvenient hours of operation
Services not offered in families’ home language
Lower quality services than others available
Not a good match with the needs of our families
No relationship with service provider
Eligibility rules
Other (specify): _________
Don’t know
AFTER QUESTION 16, SKIP TO NEXT SERVICE TYPE.
Is there a second service provider in the community to which you refer families for prenatal care? (The term referrals includes referrals that your program makes directly, as well as information you provide to families so that they can contact the community providers to request services.)
Yes
No [SKIP TO QUESTION 31]
Don’t know [SKIP TO NEXT SERVICE TYPE]
IF YES: Please provide the name of the service provider to which you refer families for prenatal care most often: ____________________________ [NOTE: You will be asked for contact information for this service provider at the end of the survey.]
About how often does your program refer families to [SERVICE PROVIDER] for prenatal care?
No referrals
Every day or almost every day
Every week or almost every week
Once or twice a month
Less than monthly
Don’t know
About how many families have you referred to [SERVICE PROVIDER] in the past 3 months?
No referrals
1 to 3 referrals
4 to 10 referrals
11 to 20 referrals
More than 20 referrals
Don’t know
Does [SERVICE PROVIDER] keep a waiting list?
Yes
Sometimes
No [SKIP TO QUESTION 22]
Don’t know [SKIP TO QUESTION 22]
[IF YES OR SOMETIMES] How long do families usually have to wait for services?
Less than a week
Less than a month
1 to 3 months
More than 3 months
Don’t know
Do families experience difficulties accessing services from [SERVICE PROVIDER]?
No [SKIP TO QUESTION 24]
Yes
Don’t know [SKIP TO QUESTION 24]
[IF YES] CHECK ALL THAT APPLY:
Cost of the service is too high
Service location is too far away
Too dangerous to get there (located in high-crime neighborhood)
Service location is not near public transportation
Lack of transportation
Services only offered during working hours
Services not offered in families’ home language
Other eligibility rules
Other (specify):
Don’t know
Overall, how effective do you think [SERVICE PROVIDER] has been in delivering services to meet families’ needs for prenatal care?
Very effective
Quite effective
Somewhat effective
Not effective at all
Don’t know
Over the past three months, what types of activities were you involved in with [SERVICE PROVIDER]? Please check all that apply.
Met for joint planning
Submitted a joint grant proposal
Participated in joint training
Provided training to staff from [SERVICE PROVIDER]
Shared costs
Developed joint program materials
Contracted for specific services
Shared information about specific families
None of the above
Don’t know
In the past 3 months, how often has your program had contact with [SERVICE PROVIDER] about referred families or other issues listed above in question 25?
No contact
Every day or almost every day
Every week or almost every week
Once or twice a month
Less than monthly
Don’t know
Is [SERVICE PROVIDER] a program within your own agency?
Yes, [SERVICE PROVIDER] is part of my agency
No, [SERVICE PROVIDER] is part of another agency in the community
Don’t know
Do you have a memorandum of understanding (MOU) or other service agreement in place with [SERVICE PROVIDER]?
Yes
No
Don’t know
Do you have a designated point of contact at [SERVICE PROVIDER]?
Yes
No
Don’t know
Overall, how would you rate your current coordination with this agency in making referrals?
Poor or No Coordination
Fair
Good
Excellent
Don’t know
Don’t know
AFTER QUESTION 30, SKIP TO QUESTION 32.
Why does your program not make referrals to a second community service provider for prenatal care?
There are no other providers of this service available in the community.
There are providers of this service in the community, but we do not make referrals because:
One provider meets the needs of all of our families
Long waiting lists
Services are too expensive
Inconvenient location
Inconvenient hours of operation
Services not offered in families’ home language
Lower quality services than others available
Not a good match with the needs of our families
No relationship with service provider
Eligibility rules
Other (specify): _________
Don’t know
AFTER QUESTION 31, SKIP TO NEXT SERVICE TYPE.
Are there other service providers in the community to which you refer families for prenatal care? [NOTE: YOU WILL NOT BE ASKED TO PROVIDE CONTACT INFORMATION OR ANSWER ADDITIONAL QUESTIONS ABOUT THESE PROVIDERS.]
Yes
No [SKIP TO QUESTION 34]
Don’t know [SKIP TO NEXT SERVICE TYPE]
IF YES: Please list up to 3 additional community service providers.
1. ______________________________________________
2. ______________________________________________
3. ______________________________________________
SKIP TO NEXT SERVICE TYPE.
IF NO: Why does your program not make referrals to additional community service providers for prenatal care?
There are no other providers of this service available in the community.
There are providers of this service in the community, but we do not make referrals because:
Two providers meet the needs of all of our families
Long waiting lists
Services are too expensive
Inconvenient location
Inconvenient hours of operation
Services not offered in families’ home language
Lower quality services than others available
Not a good match with the needs of our families
No relationship with service provider
Eligibility rules
Other (specify): _________
Don’t know
SKIP TO NEXT SERVICE TYPE.
COMPLETE Questions 1 THRU 34 for ALL SERVICE TYPES B-I.
J. CONTACT INFORMATION FOR COMMUNITY SERVICE PROVIDERS [THE WEB-BASED VERSION WILL ONLY SHOW THE 2 PROVIDERS OF EACH SERVICE FOR WHICH THEY NEED TO PROVIDE CONTACT INFORMATION, NOT THE THREE FOR WHICH NO CONTACT INFORMATION IS REQUESTED].
We need contact information for these service providers.
LIST OF SERVICE PROVIDERS
We need contact information (point of contact name, point of contact email address, point of contact phone number, street address) for each of the above providers. We also need the names and contact information for up 5 other early childhood home visiting and parenting programs for infants in your community. If there are more than 5, please provide names and contact information for the 5 largest programs. Please include other home visiting or parenting programs for infants offered by your own agency or a public health agency if appropriate. We will send each community service provider and home visiting/parenting program for infants a very brief web-based survey to complete about the services they provide. Surveys will be sent to them via email immediately after you finish this survey.
It is important that you enter all of the contact information at one time. Please do not proceed to the next stage of the survey until you have all contact information ready to enter. Are you ready to provide this information now?
Provide contact information for all providers now
Provider contact information for all providers later
Contact Information for [AGENCY NAME]
Point of contact name*
Point of contact email address*
Point of contact phone number*
Street Address
City and State
Zip Code
*Required fields
COMPLETE FOR ALL SERVICE TYPES B-I.
K. OTHER HOME VISITING AND PARENTING PROGRAMS FOR INFANTS IN THE COMMUNITY
Instructions: We also need to learn about other early childhood home visiting and parenting programs for infants in the community you serve. List up to five other home visiting or parenting programs for infants in your community that enroll expectant women and/or families with children from birth to age 5. Please include other home visiting programs or parenting programs for infants offered by your own agency or a public health agency if appropriate. If there are more than five such programs in your community, list the five largest programs.
For each program, please enter the program director’s name and contact information.
Home visiting program name:*
Point of contact name:*
Point of contact email address:*
Point of contact phone number:*
Street address:
City and state:
Zip name:
*Required field
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | kdecell1 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |