Program Manager Survey 12 Month

OMB Control No: _____

Expiration Date: ______

Length of time for instrument: 0.50 hours

ATTACHMENT 12: MIHOPE PROGRAM MANAGER SURVEY_

12 MONTH

5/29/2012

PROGRAM MANAGER SURVEY: 12-Month

Update on

Inventory of Program’s Policy, Procedures, and Forms

Program Characteristics and Opinions

Community Resources

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. 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.

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].

Update on Inventory of the Program's Policy, Procedures, and Forms

The information you provide in this inventory will update the information you provided a year ago about the policies, procedures, and forms used to guide your program's work. View this as a type of inventory of the formal guidelines and forms used by your program in day to day operations. Please feel free to consult with other staff members (e.g. a supervisor of home visitors) if you need assistance in completing the inventory.

As part of updating this inventory we will also ask you to provide copies of some of the key documents to your site liaison XXX XXXXX. You can either do this yourself or have other program administrative or supervisory staff complete the inventory and/or gather the copies of the documents for your site liaison. 

1. POLICIES OF YOUR PROGRAM SITE

	We have a policy for this which has been in place more than 12 months	We have a policy for this which was put in place in the last 12 months	We do not have a policy on this
Broad goals (i.e. a list of goals for families receiving services from this program site)			
Intended outcomes for families			
Family eligibility criteria			
Home visit frequency and duration			
Staff - Roles and Responsibilities as in Job Descriptions Home Visitors Supervisors	 	 	 
Staff – Measurable Core Competencies that Staff Should Possess after Completing Training Home Visitors Supervisors	 	 	 
Limits on number of home visitors per supervisor			
Home visitor recruitment - minimum qualifications for hire			
Home visitor training Required trainings before being assigned families Required continuing training	 	 	 
Supervisor recruitment - minimum qualifications for hire			
Supervisor training Required trainings before being assigned home visitors Required continuing training	 	 	 
12. Supervision of home visitors Policy for office-based, one-on-one supervision Policy for observation of visits for supervision	 	 	 

B. POLICIES AND TOOLS FOR SCREENING/ASSESSMENT

Child Development Screening

1. Does your program site use standard questions or tools to screen children for developmental delay in the first year of life? 

 Yes  [IF CHECKED, PROCEED TO Q2]

 No  [GO TO Q9]

2. What questions or tools does your program site use for screening in the child’s first year of life? CHECK ALL THAT APPLY

	Required	Recommended	Program does not recommend or require, but some staff use	Not used
Ages and Stages Questionnaire (ASQ, ASQ-3)
Ages and Stages Questionnaire- Social Emotional (ASQ- SE)
Bayley Infant Neurodevelopmental Screener (BINS)
Denver or Denver II
Knowledge of Infant Development Inventory (KIDI)
Ounce Scale
PEDS or PEDS:DM
State, agency or program-designed questions or tools
Other tool (please provide name, if known) __________________

For each tool selected, respondent is asked to complete questions 3-8:

3. When during the child’s first year of life does your program site use TOOL to screen for developmental delay? CHECK ALL THAT APPLY

When the child is: 

 1    2    3    4    5    6    7    8    9    10    11    12 months old

After the family has been enrolled:   

 1    2    3    4    5    6    7    8    9    10    11    12 months  

 When the home visitor suspects developmental delay

 When the parent suspects developmental delay

4. What is your program site’s formal policy for the home visitor’s communication of screening results to the supervisor?

• Home visitors are required to share screening results with their supervisor for all families.

• Home visitors are required to share screening results with their supervisor for defined subsets of families.

• Home visitors are not required to share screening results with their supervisor.

• There is no formal policy for home visitor communication of screening results to the supervisor.

4. What is your program site’s policy for the home visitor’s education and support to the family in response to positive screening results?

• Home visitors follow a written protocol that specifies what to do in response to positive screening results.

• Home visitors are expected to consult with their supervisor or other expert within our program in deciding what to do in response to positive screening results.

• Home visitors can decide on their own how to act in response to positive screening results.

• There is no formal policy for the home visitor’s education and support to the family in response to positive screening results.

4. What referral options are available to home visitors in response to positive screening results? CHECK ALL THAT APPLY.

• Family referral to an expert on our home visiting program team

• Family referral to an expert outside our home visiting program team but within our agency

• Family referral to an outside agency

4. Which statement most accurately describes your program site’s policy for the home visitor’s initial role in making the referral?

• The home visitor’s initial role is to provide the family with information for accessing the resource, but it is the family’s responsibility to follow through on that information.

• The home visitor’s initial role includes helping the family access the resource, for example, by calling to arrange an appointment on behalf of the family.

• Our program site does not have a policy on this.

4. Which statement most accurately describes your program site’s policy for the home visitor’s monitoring of the family’s success in completing a referral?

• The home visitor is expected to monitor and report the family’s experience in completing a referral.

• The home visitor is expected to monitor the family’s experience in completing a referral, but is not required to report this.

• The home visitor is not expected to monitor the family’s experience in completing a referral.

• Our program site does not have a policy on this.

[RETURN TO NEXT TOOL OR GO TO NEXT SECTION]

4. What is your program site’s formal policy for the home visitor’s communication of her or the family’s concerns about potential developmental delay to the supervisor?

• Home visitors are required to share these concerns with their supervisor.

• Home visitors are not required to share these concerns with their supervisor.

• There is no formal policy for sharing these concerns with the supervisor.

4. What is your program site’s policy for the home visitor’s education and support to the family when the home visitor or the family has concerns about potential developmental delay?

• Home visitors follow a written protocol that specifies what to do in response to concerns.

• Home visitors are expected to consult with their supervisor or other expert within our program in deciding what to do in response to concerns.

• Home visitors can decide on their own how to act in response to concerns.

• There is no formal policy for the home visitor’s education and support to the family in response to concerns.

4. What referral options are available to home visitors in response to concerns about developmental delay? CHECK ALL THAT APPLY.

• Family referral to an expert on our home visiting program team

• Family referral to an expert outside our home visiting program team but within our agency

• Family referral to an outside agency

4. Which statement most accurately describes your program site’s policy for the home visitor’s initial role in making the referral?

• The home visitor’s initial role is to provide the family with information for accessing the resource, but it is the family’s responsibility to follow through on that information.

• The home visitor’s initial role includes helping the family access the resource, for example, by calling to arrange an appointment on behalf of the family.

• Our program site does not have a policy on this.

4. Which statement most accurately describes your program site’s policy for the home visitor’s monitoring of the family’s success in completing a referral?

• The home visitor is expected to monitor and report the family’s experience in completing a referral.

• The home visitor is expected to monitor the family’s experience in completing a referral, but is not required to report this.

• The home visitor is not expected to monitor the family’s experience in completing a referral.

• Our program site does not have a policy on this.

Parenting

1. Does your program site use standard questions or tools to assess parenting behavior, parent-child interactions, bonding, or attachment in the first year of life? 

 Yes  [IF CHECKED, PROCEED TO Q2]

 No  [GO TO Q9]

2. What questions or tools does your program use to assess parenting in the child’s first year of life? CHECK ALL THAT APPLY

	Required	Recommended	Program does not recommend or require, but some staff use	Not Used
Home Observation for Measurement of the Environment (HOME)				
Keys to Interactive Parenting Scale (KIPS)				
Knowledge of Infant Development Inventory (KIDI)				
Nurturing Parenting Competency Scale-C (NCAST)				
State, agency or program-designed questions or tools				
Other tool (please provide name, if known) __________________				

For each tool selected, respondent is asked to complete questions 3-8:

3. When during the child’s first year of life does your program site use TOOL to assess parenting? CHECK ALL THAT APPLY

When the child is: 

 1    2    3    4    5    6    7    8    9    10    11    12 months old

After the family has been enrolled:   

 1    2    3    4    5    6    7    8    9    10    11    12 months  

 When the home visitor suspects parenting problems

 When the parent suspects parenting problems

4. What is your program site’s formal policy for the home visitor’s communication of assessment results to the supervisor?

 Home visitors are required to share assessment results with their supervisor for all families.

 Home visitors are required to share assessment results with their supervisor for defined subsets of families.

 Home visitors are not required to share assessment results with their supervisor.

 There is no formal policy for home visitor communication of assessment results to the supervisor.

5. What is your program site’s policy for the home visitor’s education and support to the family in response to assessment results?

 Home visitors follow a written protocol that specifies what to do in response to assessment results.

 Home visitors are expected to consult with their supervisor or other expert within our program in deciding what to do in response to assessment results.

 Home visitors can decide on their own how to act in response to assessment results.

 There is no formal policy for the home visitor’s education and support to the family in response to assessment results.

6. What referral options are available to home visitors in response to concerning assessment results? CHECK ALL THAT APPLY.

 Family referral to an expert on our home visiting program team

 Family referral to an expert outside our home visiting program team but within our agency

 Family referral to an outside agency

7. Which statement most accurately describes your program site’s policy for the home visitor’s initial role in making the referral?

 The home visitor’s initial role is to provide the family with information for accessing the resource, but it is the family’s responsibility to follow through on that information.

 The home visitor’s initial role includes helping the family access the resource, for example, by calling to arrange an appointment on behalf of the family.

 Our program site does not have a policy on this.

8. Which statement most accurately describes your program site’s policy for the home visitor’s monitoring of the family’s success in completing a referral?

 The home visitor is expected to monitor and report the family’s experience in completing a referral.

 The home visitor is expected to monitor the family’s experience in completing a referral, but is not required to report this.

 The home visitor is not expected to monitor the family’s experience in completing a referral.

 Our program site does not have a policy on this.

[RETURN TO NEXT TOOL OR GO TO NEXT SECTION]

9. What is your program site’s formal policy for the home visitor’s communication of her or the family’s concerns about parenting to the supervisor?

 Home visitors are required to share these concerns with their supervisor.

 Home visitors are not required to share these concerns with their supervisor.

 There is no formal policy for sharing these concerns with the supervisor.

10. What is your program site’s policy for the home visitor’s education and support to the family when the home visitor or the family has concerns about parenting?

 Home visitors follow a written protocol that specifies what to do in response to concerns.

 Home visitors are expected to consult with their supervisor or other expert within our program in deciding what to do in response to concerns.

 Home visitors can decide on their own how to act in response to concerns.

 There is no formal policy for the home visitor’s education and support to the family in response to concerns.

11. What referral options are available to home visitors in response to concerns about parenting? CHECK ALL THAT APPLY.

 Family referral to an expert on our home visiting program team

 Family referral to an expert outside our home visiting program team but within our agency

 Family referral to an outside agency

12. Which statement most accurately describes your program site’s policy for the home visitor’s initial role in making the referral?

 The home visitor’s initial role is to provide the family with information for accessing the resource, but it is the family’s responsibility to follow through on that information.

 The home visitor’s initial role includes helping the family access the resource, for example, by calling to arrange an appointment on behalf of the family.

 Our program site does not have a policy on this.

13. Which statement most accurately describes your program site’s policy for the home visitor’s monitoring of the family’s success in completing a referral?

 The home visitor is expected to monitor and report the family’s experience in completing a referral.

 The home visitor is expected to monitor the family’s experience in completing a referral, but is not required to report this.

 The home visitor is not expected to monitor the family’s experience in completing a referral.

 Our program site does not have a policy on this.

Emotional Well-Being, Depression, and Stress

1. Does your program site use standard questions or tools to assess parental emotional well-being, depression, or stress either prenatally or in the first year of life? 

 Yes  [IF CHECKED, PROCEED TO Q2]

 No  [GO TO Q9]

2. What questions or tools does your program use for assessment? CHECK ALL THAT APPLY

	Required	Recommended	Program does not recommend or require, but some staff use	Not Used
Brief Symptom Inventory (BSI)				
Center for Epidemiological Studies - Depression Scale (CES-D)				
Edinburgh Postnatal Depression Screening (EPDS)				
Kempe Family Stress Inventory (KFI)				
Parent Health Questionnaire (PHQ, PHQ-9)				
Parenting Stress Index (PSI)				
Protective Factors Survey (PFS)				
State, agency or program-designed questions or tools				
Other tool (please provide name, if known) __________________				

For each tool selected, respondent is asked to complete questions 3-8:

3. When during the child’s first year of life does your program site use TOOL to assess for parental emotional well-being? CHECK ALL THAT APPLY

When the child is: 

 Prenatal  1    2    3    4    5    6    7    8    9    10    11    12 months old

After the family has been enrolled:   

 1    2    3    4    5    6    7    8    9    10    11    12 months  

 When the home visitor suspects concerns

 When the parent suspects concerns

4. What is your program site’s formal policy for the home visitor’s communication of assessment results to the supervisor?

 Home visitors are required to share results with their supervisor for all families.

 Home visitors are required to share results with their supervisor for defined subsets of families.

 Home visitors are not required to share results with their supervisor.

 There is no formal policy for home visitor communication of results to the supervisor.

5. What is your program site’s policy for the home visitor’s education and support to the family in response to concerning assessment results?

 Home visitors follow a written protocol that specifies what to do in response to concerning assessment results.

 Home visitors are expected to consult with their supervisor or other expert within our program in deciding what to do in response to concerning assessment results.

 Home visitors can decide on their own how to act in response to concerning assessment results.

 There is no formal policy for the home visitor’s education and support to the family in response to concerning assessment results.

6. What referral options are available to home visitors in response to concerning assessment results? CHECK ALL THAT APPLY.

 Family referral to an expert on our home visiting program team

 Family referral to an expert outside our home visiting program team but within our agency

 Family referral to an outside agency

7. Which statement most accurately describes your program site’s policy for the home visitor’s initial role in making the referral?

 The home visitor’s initial role is to provide the family with information for accessing the resource, but it is the family’s responsibility to follow through on that information.

 The home visitor’s initial role includes helping the family access the resource, for example, by calling to arrange an appointment on behalf of the family.

 Our program site does not have a policy on this.

8. Which statement most accurately describes your program site’s policy for the home visitor’s monitoring of the family’s success in completing a referral?

 The home visitor is expected to monitor and report the family’s experience in completing a referral.

 The home visitor is expected to monitor the family’s experience in completing a referral, but is not required to report this.

 The home visitor is not expected to monitor the family’s experience in completing a referral.

 Our program site does not have a policy on this.

[RETURN TO NEXT TOOL OR GO TO NEXT SECTION]

9. What is your program site’s formal policy for the home visitor’s communication of her or the family’s concerns about parental emotional well-being, depression, or stress to the supervisor?

 Home visitors are required to share these concerns with their supervisor.

 Home visitors are not required to share these concerns with their supervisor.

 There is no formal policy for sharing these concerns with the supervisor.

10. What is your program site’s policy for the home visitor’s education and support to the family when the home visitor or the family has concerns about parental emotional well-being, depression, or stress?

 Home visitors follow a written protocol that specifies what to do in response to concerns.

 Home visitors are expected to consult with their supervisor or other expert within our program in deciding what to do in response to concerns.

 Home visitors can decide on their own how to act in response to concerns.

 There is no formal policy for the home visitor’s education and support to the family in response to concerns.

11. What referral options are available to home visitors in response to concerns about parental emotional well-being, depression, or stress? CHECK ALL THAT APPLY.

 Family referral to an expert on our home visiting program team

 Family referral to an expert outside our home visiting program team but within our agency

 Family referral to an outside agency

12. Which statement most accurately describes your program site’s policy for the home visitor’s initial role in making the referral?

 The home visitor’s initial role is to provide the family with information for accessing the resource, but it is the family’s responsibility to follow through on that information.

 The home visitor’s initial role includes helping the family access the resource, for example, by calling to arrange an appointment on behalf of the family.

 Our program site does not have a policy on this.

13. Which statement most accurately describes your program site’s policy for the home visitor’s monitoring of the family’s success in completing a referral?

 The home visitor is expected to monitor and report the family’s experience in completing a referral.

 The home visitor is expected to monitor the family’s experience in completing a referral, but is not required to report this.

 The home visitor is not expected to monitor the family’s experience in completing a referral.

 Our program site does not have a policy on this.

Maternal Substance Use (Tobacco, Alcohol and Other Drugs)

1. Does your program site use standard questions or tools to screen for maternal substance use, including tobacco, alcohol, or other drug use? 

 Yes  [IF CHECKED, PROCEED TO Q2]

 No  [GO TO Q9]

2. What questions or tools does your program site use for screening? CHECK ALL THAT APPLY

	Required	Recommended	Program does not recommend or require, but some staff use	Not Used
Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)				
Alcohol Use Disorders Identification Test (AUDIT)				
CAGE Questionnaire				
Parent Health Questionnaire (PHQ)				
4P’s Plus				
State, agency or program-designed questions or tools				
Other tool (please provide name, if known) __________________				

For each tool selected, respondent is asked to complete questions 3-8:

3. When during the child’s first year of life does your program site use TOOL to screen for substance use? CHECK ALL THAT APPLY

When the child is: 

 Prenatal  1    2    3    4    5    6    7    8    9    10    11    12 months old

After the family has been enrolled:   

 1    2    3    4    5    6    7    8    9    10    11    12 months  

 When the home visitor suspects substance use

 When the parent suspects substance use

4. What is your program site’s formal policy for the home visitor’s communication of screening results to the supervisor?

 Home visitors are required to share screening results with their supervisor for all families.

 Home visitors are required to share screening results with their supervisor for defined subsets of families.

 Home visitors are not required to share screening results with their supervisor.

 There is no formal policy for home visitor communication of screening results to the supervisor.

5. What is your program site’s policy for the home visitor’s education and support to the family in response to positive screening results?

 Home visitors follow a written protocol that specifies what to do in response to positive screening results.

 Home visitors are expected to consult with their supervisor or other expert within our program in deciding what to do in response to positive screening results.

 Home visitors can decide on their own how to act in response to positive screening results.

 There is no formal policy for the home visitor’s education and support to the family in response to positive screening results.

6. What referral options are available to home visitors in response to positive screening results? CHECK ALL THAT APPLY.

 Family referral to an expert on our home visiting program team

 Family referral to an expert outside our home visiting program team but within our agency

 Family referral to an outside agency

7. Which statement most accurately describes your program site’s policy for the home visitor’s initial role in making the referral?

 The home visitor’s initial role is to provide the family with information for accessing the resource, but it is the family’s responsibility to follow through on that information.

 The home visitor’s initial role includes helping the family access the resource, for example, by calling to arrange an appointment on behalf of the family.

 Our program site does not have a policy on this.

8. Which statement most accurately describes your program site’s policy for the home visitor’s monitoring of the family’s success in completing a referral?

 The home visitor is expected to monitor and report the family’s experience in completing a referral.

 The home visitor is expected to monitor the family’s experience in completing a referral, but is not required to report this.

 The home visitor is not expected to monitor the family’s experience in completing a referral.

 Our program site does not have a policy on this.

[RETURN TO NEXT TOOL OR GO TO NEXT SECTION]

9. What is your program site’s formal policy for the home visitor’s communication of her or the family’s concerns about potential substance use to the supervisor?

 Home visitors are required to share these concerns with their supervisor.

 Home visitors are not required to share these concerns with their supervisor.

 There is no formal policy for sharing these concerns with the supervisor.

10. What is your program site’s policy for the home visitor’s education and support to the family when the home visitor or the family has concerns about potential substance use?

 Home visitors follow a written protocol that specifies what to do in response to concerns.

 Home visitors are expected to consult with their supervisor or other expert within our program in deciding what to do in response to concerns.

 Home visitors can decide on their own how to act in response to concerns.

 There is no formal policy for the home visitor’s education and support to the family in response to concerns.

11. What referral options are available to home visitors in response to concerns about substance use? CHECK ALL THAT APPLY.

 Family referral to an expert on our home visiting program team

 Family referral to an expert outside our home visiting program team but within our agency

 Family referral to an outside agency

12. Which statement most accurately describes your program site’s policy for the home visitor’s initial role in making the referral?

 The home visitor’s initial role is to provide the family with information for accessing the resource, but it is the family’s responsibility to follow through on that information.

 The home visitor’s initial role includes helping the family access the resource, for example, by calling to arrange an appointment on behalf of the family.

 Our program site does not have a policy on this.

13. Which statement most accurately describes your program site’s policy for the home visitor’s monitoring of the family’s success in completing a referral?

 The home visitor is expected to monitor and report the family’s experience in completing a referral.

 The home visitor is expected to monitor the family’s experience in completing a referral, but is not required to report this.

 The home visitor is not expected to monitor the family’s experience in completing a referral.

 Our program site does not have a policy on this.

Domestic Violence

1. Does your program site use standard questions or tools to screen families for problems with domestic violence in the first year of life? 

 Yes  [IF CHECKED, PROCEED TO Q2]

 No  [GO TO Q9]

2. What questions or tools does your program site use for screening? CHECK ALL THAT APPLY

	Required	Recommended	Program does not recommend or require, but some staff use	Not Used
Abuse Assessment Screen (AAS)				
Abusive Behavior Inventory (ABI)				
Conflict Tactics Scale (CTS-2)				
Domestic Violence Evaluation (DOVE)				
Life Skills Progression (LSP)				
NFP’s Relationship Assessment Form				
Women’s Experience with Battering (WEB)				
State, agency or program-designed questions or tools				
Other tool (please provide name, if known) __________________				

For each tool selected, respondent is asked to complete questions 3-8:

3. When during the child’s first year of life does your program site use TOOL to screen for domestic violence? CHECK ALL THAT APPLY

When the child is: 

 Prenatal  1    2    3    4    5    6    7    8    9    10    11    12 months old

After the family has been enrolled:   

 1    2    3    4    5    6    7    8    9    10    11    12 months  

 When the home visitor suspects domestic violence

 When the parent suspects domestic violence

4. What is your program site’s formal policy for the home visitor’s communication of screening results to the supervisor?

 Home visitors are required to share screening results with their supervisor for all families.

 Home visitors are required to share screening results with their supervisor for defined subsets of families.

 Home visitors are not required to share screening results with their supervisor.

 There is no formal policy for home visitor communication of screening results to the supervisor.

5. What is your program site’s policy for the home visitor’s education and support to the family in response to positive screening results?

 Home visitors follow a written protocol that specifies what to do in response to positive screening results.

 Home visitors are expected to consult with their supervisor or other expert within our program in deciding what to do in response to positive screening results.

 Home visitors can decide on their own how to act in response to positive screening results.

 There is no formal policy for the home visitor’s education and support to the family in response to positive screening results.

6. What referral options are available to home visitors in response to positive screening results? CHECK ALL THAT APPLY.

 Family referral to an expert on our home visiting program team

 Family referral to an expert outside our home visiting program team but within our agency

 Family referral to an outside agency

7. Which statement most accurately describes your program site’s policy for the home visitor’s initial role in making the referral?

 The home visitor’s initial role is to provide the family with information for accessing the resource, but it is the family’s responsibility to follow through on that information.

 The home visitor’s initial role includes helping the family access the resource, for example, by calling to arrange an appointment on behalf of the family.

 Our program site does not have a policy on this.

8. Which statement most accurately describes your program site’s policy for the home visitor’s monitoring of the family’s success in completing a referral?

 The home visitor is expected to monitor and report the family’s experience in completing a referral.

 The home visitor is expected to monitor the family’s experience in completing a referral, but is not required to report this.

 The home visitor is not expected to monitor the family’s experience in completing a referral.

 Our program site does not have a policy on this.

[RETURN TO NEXT TOOL OR GO TO NEXT SECTION]

9. What is your program site’s formal policy for the home visitor’s communication of her or the family’s concerns about potential domestic violence to the supervisor?

 Home visitors are required to share these concerns with their supervisor.

 Home visitors are not required to share these concerns with their supervisor.

 There is no formal policy for sharing these concerns with the supervisor.

10. What is your program site’s policy for the home visitor’s education and support to the family when the home visitor or the family has concerns about potential domestic violence?

 Home visitors follow a written protocol that specifies what to do in response to concerns.

 Home visitors are expected to consult with their supervisor or other expert within our program in deciding what to do in response to concerns.

 Home visitors can decide on their own how to act in response to concerns.

 There is no formal policy for the home visitor’s education and support to the family in response to concerns.

11. What referral options are available to home visitors in response to concerns about domestic violence? CHECK ALL THAT APPLY.

 Family referral to an expert on our home visiting program team

 Family referral to an expert outside our home visiting program team but within our agency

 Family referral to an outside agency

12. Which statement most accurately describes your program site’s policy for the home visitor’s initial role in making the referral?

 The home visitor’s initial role is to provide the family with information for accessing the resource, but it is the family’s responsibility to follow through on that information.

 The home visitor’s initial role includes helping the family access the resource, for example, by calling to arrange an appointment on behalf of the family.

 Our program site does not have a policy on this.

13. Which statement most accurately describes your program site’s policy for the home visitor’s monitoring of the family’s success in completing a referral?

 The home visitor is expected to monitor and report the family’s experience in completing a referral.

 The home visitor is expected to monitor the family’s experience in completing a referral, but is not required to report this.

 The home visitor is not expected to monitor the family’s experience in completing a referral.

 Our program site does not have a policy on this.

Other Screening Tools

1. Does your program use any other type of screening tool for other family issues not previously listed?

• Yes [Go to 2]

• No [GO TO SECTION C]

2. What questions or tools does your program use for screening?

	Required	Recommended	Program does not recommend or require, but some staff use
Please name or describe			

For each tool selected, respondent is asked to complete questions 3-8: \

3. When during the child’s first year of life does your program site use TOOL? CHECK ALL THAT APPLY

When the child is: 

 Prenatal  1    2    3    4    5    6    7    8    9    10    11    12 months old

After the family has been enrolled:   

 1    2    3    4    5    6    7    8    9    10    11    12 months  

 When the home visitor suspects a problem

 When the parent suspects a problem

4. What is your program site’s formal policy for the home visitor’s communication of screening results to the supervisor?

 Home visitors are required to share screening results with their supervisor for all families.

 Home visitors are required to share screening results with their supervisor for defined subsets of families.

 Home visitors are not required to share screening results with their supervisor.

 There is no formal policy for home visitor communication of screening results to the supervisor.

5. What is your program site’s policy for the home visitor’s education and support to the family in response to positive screening results?

 Home visitors follow a written protocol that specifies what to do in response to positive screening results.

 Home visitors are expected to consult with their supervisor or other expert within our program in deciding what to do in response to positive screening results.

 Home visitors can decide on their own how to act in response to positive screening results.

 There is no formal policy for the home visitor’s education and support to the family in response to positive screening results.

6. What referral options are available to home visitors in response to positive screening results? CHECK ALL THAT APPLY.

 Family referral to an expert on our home visiting program team

 Family referral to an expert outside our home visiting program team but within our agency

 Family referral to an outside agency

7. Which statement most accurately describes your program site’s policy for the home visitor’s initial role in making the referral?

 The home visitor’s initial role is to provide the family with information for accessing the resource, but it is the family’s responsibility to follow through on that information.

 The home visitor’s initial role includes helping the family access the resource, for example, by calling to arrange an appointment on behalf of the family.

 Our program site does not have a policy on this.

8. Which statement most accurately describes your program site’s policy for the home visitor’s monitoring of the family’s success in completing a referral?

 The home visitor is expected to monitor and report the family’s experience in completing a referral.

 The home visitor is expected to monitor the family’s experience in completing a referral, but is not required to report this.

 The home visitor is not expected to monitor the family’s experience in completing a referral.

• Our program site does not have a policy on this.

[Return to Question 1]

Update on Program Site Characteristics

C. IMPLEMENTING AGENCY

1. What type of organization is your implementing agency?

 Community-based non-profit

 Local health department

 School district

 Health care organization

 Other (specify): _________

D. MIECHV AND MAJOR SOURCES OF FUNDING FOR [HV PGM SITE]

1. How much of [HV PROGRAM SITE]’s funding comes from MIECHV?

 None

 Less than 20%

 20-49%

 50–74%

 75% or more

2. Aside from MIECHV, what are the top two sources of funding for [HV PGM SITE] and the percent of its funding that comes from each?

   1. ______________________ provides  less than 20% of the program’s funding

[INSERT NAME OF SOURCE]  20-49% of the program’s funding

 50-74% of the program’s funding

 75% or more of the program’s funding

2. ______________________ provides  less than 20% of the program’s funding

[INSERT NAME OF SOURCE]  20-49% of the program’s funding

 50-74% of the program’s funding

 75% or more of the program’s funding

3. Not including funding from MIECHV, how stable would you say [HV PROGRAM SITE]’s funding is?

 Very stable

 Moderately stable

 Not too stable

 Not at all stable

4. Does your program site receive reimbursement for home visiting services from any of the following sources? SELECT ALL THAT APPLY

 No

 Medicaid

 Early Intervention

 Other (Please name)

E. NATIONAL MODEL GOALS

1. [HV PROGRAM SITE] uses the [NATIONAL MODEL]. The goals of [NATIONAL MODEL] are listed below. Rate how good a fit each of these goals is with your implementing agency’s mission.

a. [NATIONAL MODEL GOAL 1]

 Not a good fit with my agency’s mission

 A good fit with my agency’s mission

 An excellent fit with my agency’s mission

b. [NATIONAL MODEL GOAL 2]

 Not a good fit with my agency’s mission

 A good fit with my agency’s mission

 An excellent fit with my agency’s mission

c. [NATIONAL MODEL GOAL 3]

 Not a good fit with my agency’s mission

 A good fit with my agency’s mission

 An excellent fit with my agency’s mission

d. [NATIONAL MODEL GOAL 4]

 Not a good fit with my agency’s mission

 A good fit with my agency’s mission

 An excellent fit with my agency’s mission

2. Rate how much [HV PROGRAM SITE] emphasizes each goal in staff training and supervision.

a. [NATIONAL MODEL GOAL 1]

 No emphasis

 Some emphasis

 Moderate emphasis

 Strong emphasis

 Very strong emphasis

b. [NATIONAL MODEL GOAL 2]

 No emphasis

 Some emphasis

 Moderate emphasis

 Strong emphasis

 Very strong emphasis

c. [NATIONAL MODEL GOAL 3]

 No emphasis

 Some emphasis

 Moderate emphasis

 Strong emphasis

 Very strong emphasis

d. [NATIONAL MODEL GOAL 4]

 No emphasis

 Some emphasis

 Moderate emphasis

 Strong emphasis

 Very strong emphasis

F. OUTCOMES FOR ENROLLED FAMILIES

1. Considering all of the outcomes your program aims to achieve, how much of a priority is promoting good prenatal health, such as diet, exercise, rest, and not smoking?

										
0	1	2	3	4	5	6	7	8	9	10
Not a Priority at All					Moderate Priority					Highest Priority

2. Considering all of the outcomes your program aims to achieve, how much of a priority is preventing poor birth outcomes such as pre-term birth and low birth weight?

										
0	1	2	3	4	5	6	7	8	9	10
Not a Priority at All					Moderate Priority					Highest Priority

3. Considering all of the outcomes your program aims to achieve, how much of a priority is promoting breastfeeding?

										
0	1	2	3	4	5	6	7	8	9	10
Not a Priority at All					Moderate Priority					Highest Priority

4. Considering all of the outcomes your program aims to achieve, how much of a priority is promoting maternal physical health outside of pregnancy such as good nutrition, exercise, and rest?

										
0	1	2	3	4	5	6	7	8	9	10
Not a Priority at All					Moderate Priority					Highest Priority

5. Considering all of the outcomes your program aims to achieve, how much of a priority is promoting family planning and birth spacing?

										
0	1	2	3	4	5	6	7	8	9	10
Not a Priority at All					Moderate Priority					Highest Priority

6. Considering all of the outcomes your program aims to achieve, how much of a priority is preventing and reducing tobacco use?

										
0	1	2	3	4	5	6	7	8	9	10
Not a Priority at All					Moderate Priority					Highest Priority

7. Considering all of the outcomes your program aims to achieve, how much of a priority is preventing and reducing mental health and substance use problems?

										
0	1	2	3	4	5	6	7	8	9	10
Not a Priority at All					Moderate Priority					Highest Priority

8. Considering all of the outcomes your program aims to achieve, how much of a priority is preventing and reducing domestic violence?

										
0	1	2	3	4	5	6	7	8	9	10
Not a Priority at All					Moderate Priority					Highest Priority

9. Considering all of the outcomes your program aims to achieve, how much of a priority is promoting family economic self-sufficiency such as reaching goals for employment and education?

										
0	1	2	3	4	5	6	7	8	9	10
Not a Priority at All					Moderate Priority					Highest Priority

10. Considering all of the outcomes your program aims to achieve, how much of a priority is promoting child preventive care such as having all recommended well-child visits, being up-to-date on immunizations, and having parents baby-proof their home to prevent injuries?

										
0	1	2	3	4	5	6	7	8	9	10
Not a Priority at All					Moderate Priority					Highest Priority

11. Considering all of the outcomes your program aims to achieve, how much of a priority is promoting positive parenting behaviors, such as nurturing, encouraging the child’s learning, and using positive behavior management techniques?

										
0	1	2	3	4	5	6	7	8	9	10
Not a Priority at All					Moderate Priority					Highest Priority

12. Considering all of the outcomes your program aims to achieve, how much of a priority is preventing and reducing child abuse and neglect?

										
0	1	2	3	4	5	6	7	8	9	10
Not a Priority at All					Moderate Priority					Highest Priority

13. Considering all of the outcomes your program aims to achieve, how much of a priority is promoting child cognitive and language development and social- emotional well-being?

										
0	1	2	3	4	5	6	7	8	9	10
Not a Priority at All					Moderate Priority					Highest Priority

14. Check the appropriate box to show how your site’s priority for each outcome compares with the priority given to the outcome by the national model.

	We give this outcome a much lower priority than the national model does.	We give this outcome the same priority as the national model.	We give this outcome a much higher priority than the national model does	Don’t Know
Prenatal Health	      			
Poor birth outcomes	      			
Breastfeeding	      			
Maternal physical health outside of pregnancy	      			
Family planning and birth spacing	      			
Tobacco use	      			
Mental health and substance use	      			
Domestic violence	      			
Family economic self-sufficiency	      			
Child preventive care	      			
Positive parenting behaviors	      			
Child abuse and neglect	      			
Child development outcomes	      			

14. Check the appropriate box to show whether and how MIECHV funding has influenced how high a priority [HV PROGRAM SITE] now gives to each outcome.

	Because of MIECHV, we now give this outcome a lower priority than we once did.	MIECHV has not changed the priority we give to this outcome.	Because of MIECHV, we now give this outcome a higher priority than we once did.
Prenatal Health			
Poor birth outcomes			
Breastfeeding			
Maternal physical health outside of pregnancy			
Family planning and birth spacing			
Tobacco use			
Mental health and substance use			
Domestic violence			
Family economic self-sufficiency			
Child preventive care			
Positive parenting behaviors			
Child abuse and neglect			
Child development outcomes			

14. Aside from your state MIECHV agency, are there any other funders or other organizations that influence your agency to make any other outcome a high priority for [HV PROGRAM SITE]?

 No other funder or organization influences my agency to make any other outcome a high priority FOR [HV PROGRAM SITE]. [SKIP TO SECTION E]

 Yes

14. List up to five funders or other organizations and the outcomes they want your agency to make a high priority for [HV PROGRAM SITE].

	Funder or Other Organization	Outcomes They Want to Be a High Priority
a.
b.
c.
d.
e.

G. TARGETED FAMILIES

1. How does your agency consider each of the following family characteristics in relation to eligibility for enrollment in [HV Program Site]?

	[HV PROGRAM SITE] eligibility:
a.		First time mothers	 Requirement for eligibility  A consideration for eligibility, but not required  Not a consideration for eligibility  Disqualification for eligibility
b.		Teenage mothers	 Requirement for eligibility  A consideration for eligibility, but not required  Not a consideration for eligibility  Disqualification for eligibility
c.		Unmarried mothers	 Requirement for eligibility  A consideration for eligibility, but not required  Not a consideration for eligibility  Disqualification for eligibility
d.		Children with special health care needs	 Requirement for eligibility  A consideration for eligibility, but not required  Not a consideration for eligibility  Disqualification for eligibility
e.		Substance-using mothers	 Requirement for eligibility  A consideration for eligibility, but not required  Not a consideration for eligibility  Disqualification for eligibility
f.		Low-income families	 Requirement for eligibility  A consideration for eligibility, but not required  Not a consideration for eligibility  Disqualification for eligibility
g.		Families with prior CPS involvement	 Requirement for eligibility  A consideration for eligibility, but not required  Not a consideration for eligibility  Disqualification for eligibility
h.		Expectant mother	 Requirement for eligibility  A consideration for eligibility, but not required  Not a consideration for eligibility  Disqualification for eligibility
i.		Other (please describe) ____________	 Requirement for eligibility  A consideration for eligibility, but not required  Not a consideration for eligibility  Disqualification for eligibility

2. If [HV PROGRAM SITE] has more families identified as eligible than open slots at a particular time, how does the [HV PROGRAM SITE] prioritize the eligible families for enrollment?

 Our program does not set priorities within identified eligible families

 Expectant mothers are enrolled first

 Expectant mothers who are early on in their pregnancy are enrolled first

 Expectant mothers who are late in their pregnancy are enrolled first CHECK

 Low income families are enrolled first ALL

 Families of children with special health care needs are enrolled first THAT

 Families with the largest number of risk factors are enrolled first APPLY

 Families living in particular communities are enrolled first

 Other [SPECIFY] ___________________________________

3. How well has the [NATIONAL MODEL] communicated its family eligibility requirements to [HV PROGRAM SITE]?

 Very well

 Moderately well

 Not well

4. How closely aligned are [HV PROGRAM SITE] family eligibility requirements with the family eligibility requirements of the [NATIONAL MODEL]?

 Perfectly aligned

 Very well aligned

 Moderately well aligned

 Not well aligned

 Unsure

5. How well has your MIECHV state agency communicated its family eligibility requirements to [HV PROGRAM SITE]?

 Very well

 Moderately well

 Not well

6. How closely aligned are [HV PROGRAM SITE] family eligibility requirements with the family eligibility requirements of your MIECHV state agency?

 Perfectly aligned

 Very well aligned

 Moderately well aligned

 Not well aligned

 Unsure

7. Are there any other agencies, funders, or models that influence what families are prioritized?

 No

 Yes

(Please list)____________________

8. For which individuals does your program assume responsibility for improving outcomes?

		Individuals within Enrolled Families	Major Responsibility	Some Responsibility	No Responsibility
a.		Child			
b.		Mother			
c.		Biological father			
d.		Other father figure			
e.		Child’s other familial caregivers			
f.		Mother’s children older than the focal child			
g.		Pregnancies and children subsequent to focal child			

H. SERVICE DELIVERY

1. From your agency’s perspective, when, how often, and for how long should [HV PROGRAM SITE] provide home visits?

		What is the preference for:
a.		When families should begin services	 It is required that services start prenatally  It is preferred that services start prenatally  No preference  It is preferred that services start postnatally  It is required that services start postnatally
b		If any of first four above are selected, the following questions are asked: When during pregnancy families begin services?	 It is required that services start by [4-40] weeks  It is preferred that services start by [4-40] weeks  No preference
c.		How long families should be offered services	 Until child is born  Until child is 1 year old  Until child is 2 years old  Until child is 3 years old  Until child is 4 years or older  No preference
d.		How long each home visit should be	 At least 1 hour  1 hour on average  90 minutes  No preference

2. The [NATIONAL MODEL] calls for prenatal visits to take place [NATIONAL MODEL POLICY]. Does your local program have the same policy about frequency of visits?  (YES/NO) If not, please outline your policy about how often visits should occur.

3. The [NATIONAL MODEL] calls for visits with children ages birth to one year to take place [NATIONAL MODEL POLICY]. Does your local program have the same policy about frequency of visits?  (YES/NO) If not, please outline your policy about how often visits should occur.

4. The [NATIONAL MODEL] calls for visits with children older than one year to take place [NATIONAL MODEL POLICY]. Does your local program have the same policy about frequency of visits?  (YES/NO) If not, please outline your policy about how often visits should occur.

5. Overall, how well has [NATIONAL MODEL] communicated its policies on the timing and duration of home visits to [HV PROGRAM SITE]?

 Very well

 Moderately well

 Not well

6. Overall, how closely aligned are [HV PROGRAM SITE] policies on the timing and duration of home visits with the policies of [NATIONAL MODEL]?

 Perfectly aligned

 Very well aligned

 Moderately well aligned

 Not well aligned

 Unsure

7. Overall, how well has your MIECHV state agency communicated its policies on the timing and duration of home visits to [HV PROGRAM SITE]?

 Very well

 Moderately well

 Not well

8. Overall, how closely aligned are [HV PROGRAM SITE] policies on the timing and duration of home visits with the policies of your MIECHV state agency?

 Perfectly aligned

 Very well aligned

 Moderately well aligned

 Not well aligned

 Unsure

9. Which parent training techniques does your agency encourage home visitors to use in their work with families?

	Agency encourages in work with families:
a.	Role modeling of positive parenting practices	 Encourages use  Does neither  Discourages use
b.	Directing parent-child activities	 Encourages use  Does neither  Discourages use
c.	Observing and giving positive feedback on parent-child interaction	 Encourages use  Does neither  Discourages use
d.	Observing and giving constructive feedback on parent-child interaction (noting ways parent could improve his/her behavior)	 Encourages use  Does neither  Discourages use
e.	Playing with child/direct interaction with child	 Encourages use  Does neither  Discourages use

10. How well has the [NATIONAL MODEL] communicated its policies about the use of specific parent training techniques to [HV PROGRAM SITE]?

 Very well

 Moderately well

 Not well

11. How closely aligned are [HV PROGRAM SITE] policies about the use of specific parent training techniques with the policies of the [NATIONAL MODEL]?

 Perfectly aligned

 Very well aligned

 Moderately well aligned

 Not well aligned

 Unsure

12. How well has your MIECHV state agency communicated its policies about the use of specific parent training techniques to [HV PROGRAM SITE]?

 Very well

 Moderately well

 Not well

13. How closely aligned are [HV PROGRAM SITE] policies about the use of specific parent training techniques with the policies of your MIECHV state agency?

 Perfectly aligned

 Very well aligned

 Moderately well aligned

 Not well aligned

 Unsure

14. Which of the following supportive strategies for working with families does your agency encourage home visitors to use?

	Agency encourages in work with families:
a.		Caregiver goal setting		 Encourages use  Discourages use  Does neither
b.		Caregiver problem solving		 Encourages use  Discourages use  Does neither
c.		Crisis intervention		 Encourages use  Discourages use  Does neither
d.	Emotional support		 Encourages use  Discourages use  Does neither

15. How well has the [NATIONAL MODEL] communicated its policies about the use of specific supportive strategies for working with families to [HV PROGRAM SITE]?

 Very well

 Moderately well

 Not well

16. How closely aligned are [HV PROGRAM SITE] policies about the use of specific supportive strategies for working with families with the policies of the [NATIONAL MODEL]?

 Perfectly aligned

 Very well aligned

 Moderately well aligned

 Not well aligned

 Unsure

17. How well has your MIECHV state agency communicated its policies about the use of specific supportive strategies for working with families to [HV PROGRAM SITE]?

 Very well

 Moderately well

 Not well

18. How closely aligned are [HV PROGRAM SITE] policies about the use of specific supportive strategies for working with families with the policies of your MIECHV state agency?

 Perfectly aligned

 Very well aligned

 Moderately well aligned

 Not well aligned

 Unsure

19. Does the [HV PROGRAM SITE] provide incentives or gifts to families for participating in the program? If so, what kind of incentives?

 Does not provide incentives/gifts [GO TO Q21]

 Provides cash incentives/gifts

 Provides gift card incentives

 Provides child gifts or incentives

 Provides coupons redeemable for items

 Other type of incentive (specify): ___________________________________

 Unsure [GO TO Q21]

20. If yes, what are the circumstances for providing gifts or incentives? [CHECK ALL THAT APPLY]

 Give to all families

 Completing visits

 Participating in group meetings

 Following through on recommended activities

 Birth of child or subsequent birthdays

 Reengaging in program

 Other circumstance (specify): ___________________________________

 Unsure

21. Does your program site offer group or center-based services for families enrolled in home visiting?

 Yes

 No [ GO TO SECTION G]

22. If Yes, about how often a year are activities offered? _______ times a year

I. STAFFING LEVELS AND CASELOADS

1. Are all of your home visitor positions currently filled? If no, how many are currently vacant?

 No, Number of vacant positions: _________

 Yes

2. In the past 12 months, how often has your program been fully staffed, that is, with home visitor positions fully filled?

 100% of the time

 75-99% of the time

 50-74% of the time

 25-49% of the time

 less than 25% of the time

3. When a home visitor position becomes vacant, what strategies does your program use to provide services to the families that were in that home visitor’s caseload? CHECK ALL THAT APPLY.

 Close intake

 Graduate those families early

 Suspend visits for those families

 Reduce the expected visit frequency for those families

 Shift responsibility for those families to other home visitors

 Shift responsibility for those families to supervisor

 Other (specify): _________

4. On average, how long does it take from the time a new home visitor is hired for him/her to be fully trained and ready to be assigned families?

 1 week

 1 month

 2 months

 3 months

 4-6 months

 More than six months

 Other (specify): _________

5. Do any of your home visitors currently have caseloads greater than the maximum called for in [HV PROGRAM SITE]’s policies?

 Our site does not have a policy for caseload limit.

 No, all home visitors have caseloads within the maximum allowed by our policy.

 Yes, one or more home visitors currently have caseloads above the maximum allowed by our policy.

6. In the past 12 months, how often has one or more of your home visitors had a caseload greater than the maximum called for in your program site’s policy?

 100% of the time

 75-99% of the time

 50-74% of the time

 25-49% of the time

 1-25% of the time

 Not at all

7. What is your program’s policy on the maximum number of home visitors per supervisor?

 No policy

 I don’t know

 Our policy is no more than ____full-time Home Visitors per full-time Supervisor

J. CURRENT STAFF

1. How many full-time home visitors are currently on staff?

_________ NUMBER OF HOME VISITORS

2. How many part-time home visitors are currently on staff?

_________ NUMBER OF HOME VISITORS

3. How many full-time supervisors are currently on staff?

_________ NUMBER OF SUPERVISORS

4. How many part-time supervisors are currently on staff?

_________ NUMBER OF SUPERVISORS

5. How many of your current home visitors are up-to-date on trainings?

¨ All

¨ Most

¨ Some

¨ None

¨ Don’t know

6. How many of your current supervisors are up-to-date on trainings?

¨ All

¨ Most

¨ Some

¨ None

¨ Don’t know

7. OTHER CLINICAL STAFF: Some home visiting programs have service providers who work as part of a team with home visitors (such as nurses, social workers, or mental health therapists). Please indicate whether there are clinical staff members who regularly (three or more times a year) work as part of a team with home visitors.

	Type of Service Provider:
a.		Health care worker		¨ No ¨ Yes part-time ¨ Yes full-time
b.		Social worker		¨ No ¨ Yes part-time ¨ Yes full-time
c.		Substance use (Alcohol and other drugs) treatment worker		¨ No ¨ Yes part-time ¨ Yes full-time
d.	Mental health therapist		¨ No ¨ Yes part-time ¨ Yes full-time
e.	Early Intervention/ Developmental services provider		¨ No ¨ Yes part-time ¨ Yes full-time
f.	Other staff [Specify] ________________		¨ No ¨ Yes part-time ¨ Yes full-time

8. DATA ENTRY: Does your program have any administrative staff who help home visitors enter information on service delivery into a management information system?

¨ No

¨ Yes

9. CONTINUOUS QUALITY IMPROVEMENT: Does your program have any staff with dedicated time to support continuous quality improvement activities? Continuous Quality Improvement is using data and information to inform performance and practice.

¨ No staff with dedicated time for continuous quality improvement (CQI) activities

¨ Yes, staff to design and direct CQI activities CHECK ALL

¨ Yes, staff to collect information for CQI activities THAT APPLY.

¨ Yes, staff to analyze information for CQI activities

K. YOUR OWN WORK EXPERIENCE

1. How many hours a week do you work as manager of [HV PROGRAM SITE]?

 Less than 10 hours

 10-19 hours

 20-34 hours

 35 hours or more

2. How long have you been in your current position as program manager/administrator?

 Less than 1 year

 1-2 years

 3-5 years

 6 years or more

3. Have you ever been a [NATIONAL MODEL] home visitor?

 No

 Yes

4. Have you ever been a [NATIONAL MODEL] supervisor?

 No

 Yes

5. Have you ever sat through the [NATIONAL MODEL] training for home visitors?

 No

 Yes

6. Have you ever sat through the [NATIONAL MODEL] training for supervisors?

 No

 Yes

7. Do you supervise any other home visiting program?

 No [SKIP TO SECTION D]

 Yes

 

8. What model do these other home visiting programs use? [SELECT ALL THAT APPLY]

 Nurse Family Partnership

 Parents as Teachers

 Healthy Families America

 Early Head Start

 Other (specify): _________

 

L. HOME VISITOR RECRUITMENT AND HIRING

1. Did [HV PROGRAM SITE] hire any new home visitors in the past 12 months?

 No [SKIP TO NEXT SECTION]

 Yes

2. How many home visitor positions did you need to fill in the past 12 months?

_________ NUMBER OF POSITIONS

3. How would you rate your experience recruiting qualified home visitor candidates?

 Very hard

 Somewhat hard

 Somewhat easy

 Very easy

4. Did you have difficulty recruiting home visitors with any of the following particular qualifications? CHECK ALL THAT APPLY.

 Interest in home visiting

 Required education/degree

 Bilingual in English and Spanish

 Own transportation

 Other (specify): _________

4. When the candidates are brought in to be interviewed, who interviews them? CHECK ALL THAT APPLY.

 Implementing agency program director

 Home visiting program manager

 Supervisor

 Home visitor

 Clinical Specialist

 Families

 Other (specify): _________

4. Are candidates always interviewed one-on-one, always by a group, or in both ways?

 One-on-one only

 By a group only

 Both one-on-one and by a group

4. Do candidates observe any home visits prior to hire?

 No

 Yes

8. Does a single person have the final say on hiring decisions or are hiring decisions made collectively?

 Single person

 Collectively [SKIP TO 10]

8. Who is this person, in terms of their position?

_________ POSITION

8. Once they begin work, do newly hired home visitors get a written copy of their specific roles and responsibilities?

 No

 Yes

8. Do home visitors get a written description of required competencies?

 No

 Yes

M. SUPERVISOR RECRUITMENT AND HIRING

1. Did [HV PROGRAM SITE] hire any new supervisors in the past 12 months?

 No [SKIP TO NEXT SECTION]

 Yes

2. About how many supervisor positions did you need to fill in the past 12 months?

_________NUMBER OF POSITIONS

3. How would you rate your experience recruiting qualified supervisor candidates?

 Very hard

 Somewhat hard

 Somewhat easy

 Very easy

4. Did you have difficulty recruiting supervisors with any of the following particular qualifications? CHECK ALL THAT APPLY.

 Interest in home visiting

 Required education/degree

 Bilingual in English and Spanish

 Own transportation

 Other (specify): _________

4. When the candidates are brought in to be interviewed, who interviews them? CHECK ALL THAT APPLY.

 Implementing agency program director

 Home visiting program manager

 Supervisor

 Home visitor

 Clinical Specialist

 Families

 Other (specify): _________

4. Are candidates always interviewed one-on-one, always by a group, or in both ways?

 One-on-one only

 By a group only

 Both one-on-one and by a group

4. Do candidates observe any home visits prior to hire?

 No

 Yes

8. Does a single person have the final say on hiring decisions or are hiring decisions made collectively?

 Single person

 Collectively [SKIP TO 10]

9. Who is this person, in terms of their position?

_________ POSITION

10. Once they begin work, do newly hired supervisors get a written copy of their specific roles and responsibilities?

 No

 Yes

11. Do supervisors get a written description of required competencies?

 No

 Yes

N. SUPERVISION OF SUPERVISORS

1. In [HV PROGRAM SITE], who provides supervision to the supervisor(s)?

 No one

 Home visiting program manager

 Implementing agency program director

 Other (specify): _________

2. How often is one-on-one supervision of supervisor(s) conducted?

 Weekly

 Every 2 weeks

 Every month

 Every 3 months

 Less than quarterly

3. How is one-on-one supervision of supervisor(s) documented?

 No documentation

 Notes are taken but not on a specific form

 Specific form is used

4. Does [HV PROGRAM SITE] have any group supervision of supervisors? If so, how often?

 No group supervision

 Annually

 Quarterly

 Twice a month

 Monthly

 Weekly

O. HOME VISITOR GROUP SUPERVISION, CASE CONFERENCE, AND PEER SUPPORT

1. Does [HV PROGRAM SITE] have any group supervision of home visitors? If so, how often?

 No group supervision [SKIP TO 3]

 Annually

 Quarterly

 Twice a month

 Monthly

 Weekly

2. Do supervisors use a form to guide group supervision? If so, how often do supervisors use this form?

 All of the time (100%)

 Nearly all (85%-99%)

 Most of the time (61%-84%)

 About half of the time (40%-60%)

 Some of the time (15%-39%)

 Nearly none (1-14%)

 None (0%)?

3. Does [HV PROGRAM SITE] conduct group case conferences for discussion of cases? If so, how often?

 No case conferences [SKIP TO 7]

 Annually

 Quarterly

 Twice a month

 Monthly

 Weekly

4. What is the position of the person who selects the case to be discussed?

 Implementing agency program director

 Home visiting program manager

 Supervisor

 Clinical specialist

 Home visitor

 Other (specify): _________

5. Who usually attends the case conferences? CHECK ALL THAT APPLY.

 Implementing agency program director

 Home visiting program manager

 Supervisor

 Clinical specialist

 Home visitor

 Other (specify): _________

6. Do the case conferences ever include outside experts? If so, how often?

 No outside experts, or very rarely

 We have outside experts about a quarter of the time

 We have outside experts about half the time

 We have outside experts about three-quarters of the time

 We always have an outside expert

7. Does your [HV PROGRAM SITE] provide formal opportunities for peer support such as time for staff to share their experiences and learn from one another?

 No

 Yes

8. Describe the peer support opportunities for your staff to share their experiences and learn from one another.

P. STAFF MEETINGS

1. Does [HV PROGRAM SITE] conduct staff meetings with supervisors, home visitors, and other program staff? If so, how often?

 No team meetings

 Annually

 Quarterly

 Twice a month

 Monthly

 Weekly

2. What are the main purposes of these meetings? CHECK THE TOP TWO.

 To build team cohesion

 To share administrative information

 To review program performance

 To provide continuing education

 Other (specify): _________

3. What is the position of the person who sets the meeting agenda?

 Implementing agency program director

 Home visiting program manager

 Supervisor

 Clinical specialist

 Other (specify): _________

4. Do the meetings ever include presentations by outside speakers? If so, how often?

 No outside speakers, or very rarely

 We have outside speakers about a quarter of the time

 We have outside speakers about half the time

 We have outside speakers about three-quarters of the time

 We always have an outside speaker

Q. PARENTING CURRICULA AND OTHER CURRICULA

Instructions: Listed by below are some of the major parenting curricula used by home visiting program staff. Please indicate if each parenting curricula is used by your program staff and if so, how often each parenting curriculum is used with families.

	NAME OF CURRICULUM	1. USED	2. HOW OFTEN USED
a.	Parents as Teachers/Born to Learn	 Used by program staff  Require staff to use  Recommend staff to use  Staff choice  Not used by program staff	 Every family  About three quarters of families  About half of families  About a quarter of families  No families, or very few
b.	Parents as Teachers/Foundational Training	 Used by program staff  Require staff to use  Recommend staff to use  Staff choice  Not used by program staff	 Every family  About three quarters of families  About half of families  About a quarter of families  No families, or very few
c.	PIPE	 Used by program staff  Require staff to use  Recommend staff to use  Staff choice  Not used by program staff	 Every family  About three quarters of families  About half of families  About a quarter of families  No families, or very few
d.	Great Beginnings Start Before Birth	 Used by program staff  Require staff to use  Recommend staff to use  Staff choice  Not used by program staff	 Every family  About three quarters of families  About half of families  About a quarter of families  No families, or very few
e.	Partners for a Healthy Baby	 Used by program staff  Require staff to use  Recommend staff to use  Staff choice  Not used by program staff	 Every family  About three quarters of families  About half of families  About a quarter of families  No families, or very few
f.	Learning Games	 Used by program staff  Require staff to use  Recommend staff to use  Staff choice  Not used by program staff	 Every family  About three quarters of families  About half of families  About a quarter of families  No families, or very few
g.	San Angelo	 Used by program staff  Require staff to use  Recommend staff to use  Staff choice  Not used by program staff	 Every family  About three quarters of families  About half of families  About a quarter of families  No families, or very few
h.	Growing Great Kids	 Used by program staff  Require staff to use  Recommend staff to use  Staff choice  Not used by program staff	 Every family  About three quarters of families  About half of families  About a quarter of families  No families, or very few
i.	Nurturing Program	 Used by program staff  Require staff to use  Recommend staff to use  Staff choice  Not used by program staff	 Every family  About three quarters of families  About half of families  About a quarter of families  No families, or very few
i.	Promoting First Relationships	 Used by program staff  Require staff to use  Recommend staff to use  Staff choice  Not used by program staff	 Every family  About three quarters of families  About half of families  About a quarter of families  No families, or very few
k.	Emotional Availability	 Used by program staff  Require staff to use  Recommend staff to use  Staff choice  Not used by program staff	 Every family  About three quarters of families  About half of families  About a quarter of families  No families, or very few
l.	Creative Curriculum	 Used by program staff  Require staff to use  Recommend staff to use  Staff choice  Not used by program staff	 Every family  About three quarters of families  About half of families  About a quarter of families  No families, or very few
m.	Agency-created curriculum [Please describe____________]	 Used by program staff  Require staff to use  Recommend staff to use  Staff choice  Not used by program staff	 Every family  About three quarters of families  About half of families  About a quarter of families  No families, or very few
n.	Other [Please describe____________]	 Used by program staff  Require staff to use  Recommend staff to use  Staff choice  Not used by program staff	 Every family  About three quarters of families  About half of families  About a quarter of families  No families, or very few

3. Are staff encouraged or discouraged to supplement model curriculum?

 Strongly encouraged

 Encouraged

 Neither encouraged nor discouraged

 Discouraged

 Strongly discouraged

4. How often are the topics or lessons discussed in a particular home visit driven by the family’s choice or interest in a topic?

 Always

 Often

 Sometimes

 Rarely

 Never

 Unsure

5. How often are the topics or lessons discussed in a particular home visit the home visitor’s choice?

 Always

 Often

 Sometimes

 Rarely

 Never

 Unsure

6. How often are the topics or lessons discussed in a particular home visit chosen due to program requirements?

 Always

 Often

 Sometimes

 Rarely

 Never

 Unsure

7. Are there any other curricula used by program staff that address other important topics such as adult development, domestic violence, mental health, and substance use? If so, please specify the topic(s) and name(s) of the curricula that are used most often by home visitors.

 No

 Yes

 [SPECIFY]: _________

R. ACCESS TO PROFESSIONAL CONSULTATION AND EXPERTS

1. Besides the supervisor, are there any professionals within [AGENCY] or outside [AGENCY] who help home visitors in dealing with unique or challenging situations? Typically, consultants would be people that the home visitor talks with in-person or by phone if s/he has a client with needs in a specific area. Consultants may also go with the home visitor to meet with a client in the client’s home.

 No [SKIP TO SECTION Q.]

 Yes – [FILL IN THE TABLE.]

2. What are the titles of the people with whom your staff consults?

2. What are the agencies/organizations of the people with which your staff consults?

	CONTENT AREA	AGENCY AFFILIATION	TYPES OF SUPPORT
		Check the box to indicate whether the consultants are internal (from the same agency as [HV PROGRAM SITE], external, or whether there are both internal and external consultants.	Check the box to indicate what types of support the consultant provides.
a.	Prenatal health	 Internal only  External only  Both of above	 Advice to home visitor  Direct service to client  Both of above
b.	Maternal post-natal health	 Internal only  External only  Both of above	 Advice to home visitor  Direct service to client  Both of above
c.	Substance use	 Internal only  External only  Both of above	 Advice to home visitor  Direct service to client  Both of above
d.	Mental health	 Internal only  External only  Both of above	 Advice to home visitor  Direct service to client  Both of above
e.	Healthy adult relationships/ domestic violence	 Internal only  External only  Both of above	 Advice to home visitor  Direct service to client  Both of above
f.	Family economic self-sufficiency	 Internal only  External only  Both of above	 Advice to home visitor  Direct service to client  Both of above
g.	Parenting to support child development	 Internal only  External only  Both of above	 Advice to home visitor  Direct service to client  Both of above
h.	Parenting to support child health	 Internal only  External only  Both of above	 Advice to home visitor  Direct service to client  Both of above

S. MANAGEMENT INFORMATION SYSTEM

1. Does [HV PROGRAM SITE] use a management information system to document service delivery? If so, who developed the management information system that your site uses? CHECK ALL THAT APPLY.

 No management information system to document service delivery [SKIP TO NEXT SECTION]

 We use a system that our own agency developed

 We use a system developed by the national home visiting model

 We use a system developed by a state agency

 We use a system developed by another organization [SPECIFY]______________________

2. What is the name of your management information system? (e.g., PIMS, FAMSYS, ETO, Visit Tracker)?

3. Who enters visit data into your management information system? CHECK ALL THAT APPLY.

 Home visitor

 Data entry clerk

 Other [SPECIFY] ___________________________

4. How does [HV PROGRAM SITE] use the management information system? CHECK ALL THAT APPLY.

 Reports for our own program-level performance monitoring and quality improvement

 Program performance reports for MIECHV

 Program performance reports for other funders

 Program performance reports for national model developer

 Monitoring performance of specific staff members

 To remind staff of activities to be carried out

 Other [SPECIFY] __________________________________________________

T. HOME VISITING PROGRAM MONITORING

1. ANNUAL OR BI-ANNUAL HOME VISITING PROGRAM REPORT

a. Do you prepare formal annual or bi-annual reports of [HV PGM SITE]’S performance?

 No [SKIP TO 2]

 Yes

b. With whom do you share results? CHECK ALL THAT APPLY.

 Home visitors

 Supervisors

 Agency executive(s)

 Advisory Board/Board of Trustees

 Funders

 National Model Developer

 State MIECHV Agency

 Broader community (e.g. posted on website)

 Accrediting organization [SPECIFY] ________________________________

 Other accrediting organization [SPECIFY] ___________________________

2. PROGRAM MONITORING OF MIECHV BENCHMARK INDICATORS

a. In your opinion, how high is the quality of the data collected by your [HV PGM SITE] to monitor performance for your state’s MIECHV indicators?

 Very high quality

 Moderate quality

 Poor quality

b. How does [HV PGM SITE] document activities and outcomes to monitor its achievement of MIECHV benchmark indicators?

 Through the management information system

 Through manual review of program records

 Through both the MIS and manual review of program records

3. MONITORING OF SPECIFIC ASPECTS OF PROGRAM OPERATIONS

a. Which of the following does [HV PGM SITE] routinely monitor?

REFERRALS INTO PROGRAM

 Number of referrals into program

 Appropriateness of referrals into program

FAMILY ENROLLMENT AND DISENROLLMENT

 Family acceptance rates

 Family retention rates at specific points (for example, at 12 months post-enrollment or when the focus child turns one year old)

 Reasons for family dropout

VISITS

 Visit frequency rates

 Visit length

 No show rates

SCREENING OF ENROLLED FAMILIES (NOT TO DETERMINE ELIGIBILITY FOR PROGRAM}

 Screening rates for maternal depression

 Screening rates for maternal substance use

 Screening rates for domestic violence

 Child developmental screening rates

 Others (please describe)____________________

4. CONTINUOUS QUALITY IMPROVEMENT

a. Has [HV PGM SITE] carried out any continuous quality improvement activities in the past 12 months from today’s date? Continuous Quality Improvement is using data and information to inform performance and practice.

 No [SKIP TO SECTION S]

 Yes

b. Check up to three topics addressed in quality improvement activities in the past 12 months.

 Referrals to program

 Family enrollment into program

 Family retention in program

 Frequency or length of visits

 Topics or activities during visits

 Screening, services or referral for maternal depression

 Screening, services or referral for maternal substance use

 Screening, services or referral for domestic violence

 Screening, services or referral for poor parent-child interaction

 Screening, services or referral for child developmental delay

 Others (please describe)___________________

U. REFERRAL SOURCES FOR [HV PROGRAM SITE]

1. From what sources are your families referred? Please estimate the percentage of families that you get from each source.

 Self-referral ____%

 Centralized intake ____%

 Hospitals ____%

 Health departments____%

 Prenatal clinics ____%

 Pediatric clinics ____%

 Child welfare services ____%

 WIC ____%

 Schools ____%

 Other [SPECIFY]: _________ ____%

2. Do you have formal referral agreements with these organizations?

 No

 Yes [SELECT ALL THAT APPLY]

 Centralized intake

 Hospitals

 Health departments

 Prenatal clinics

 Pediatric clinics

 Child welfare services

 WIC

 Schools

 Other [SPECIFY]

3. How frequently does staff contact women directly at these organizations?

 Very frequently

 Somewhat frequently

 Rarely

 Never

Update on Community Resources

V. SERVICE AVAILABILITY

PRENATAL CARE

1. Please rate the availability of prenatal care in your community.

 Prenatal care is almost always available to families who need it.

 Prenatal care is usually available to families who need it.

 Prenatal care is sometimes available to families who need it.

 Prenatal care is difficult to obtain for families who need it.

 Prenatal care is not available in our community.

2. Is there at least one service provider, either within your own agency or in another agency in the community, to which you refer families for prenatal care?

 Yes

 No [SKIP TO NEXT SERVICE TYPE]

 Don’t know [SKIP TO NEXT SERVICE TYPE]

3. Is/are the prenatal care provider/s to which you make referrals located within your own agency, outside your agency, or both?

 Within my agency

 Outside my agency

 Both inside and outside my agency.

 Don’t know

FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE

4. Please rate the availability of family planning and reproductive health care in your community.

 Family planning and reproductive health care is almost always available to families who need it.

 Family planning and reproductive health care is usually available to families who need it.

 Family planning and reproductive health care is sometimes available to families who need it.

 Family planning and reproductive health care is difficult to obtain for families who need it.

 Family planning and reproductive health care is not available in our community.

5. Is there at least one service provider, either within your own agency or in another agency in the community, to which you refer families for family planning and reproductive health care?

 Yes

 No [SKIP TO NEXT SERVICE TYPE]

 Don’t know [SKIP TO NEXT SERVICE TYPE]

6. Is/are the family planning and reproductive health care provider/s to which you make referrals located within your own agency, outside your agency, or both?

 Within my agency

 Outside my agency

 Both inside and outside my agency.

 Don’t know

SUBSTANCE USE (ALCOHOL AND OTHER DRUGS) AND MENTAL HEALTH TREATMENT SERVICES

7. Please rate the availability of substance use and mental health treatment services in your community.

 Substance use and mental health treatment services are almost always available to families who need it.

 Substance use and mental health treatment services are usually available to families who need it.

 Substance use and mental health treatment services are sometimes available to families who need it.

 Substance use and mental health treatment services are difficult to obtain for families who need it.

 Substance use and mental health treatment services are not available in our community.

8. Is there at least one service provider, either within your own agency or in another agency in the community, to which you refer families for substance use and mental health treatment services?

 Yes

 No [SKIP TO NEXT SERVICE TYPE]

 Don’t know [SKIP TO NEXT SERVICE TYPE]

9. Is/are the substance use and mental health treatment service provider/s to which you make referrals located within your own agency, outside your agency, or both?

 Within my agency

 Outside my agency

 Both inside and outside my agency.

 Don’t know

DOMESTIC VIOLENCE SHELTER

10. Please rate the availability of domestic violence shelters in your community.

 Domestic violence shelters are almost always available to families who need it.

 Domestic violence shelters are usually available to families who need it.

 Domestic violence shelters are sometimes available to families who need it.

 Domestic violence shelters are difficult to obtain for families who need it.

 Domestic violence shelters are not available in our community.

11. Is there at least one domestic violence shelter, either within your own agency or in another agency in the community, to which you refer families?

 Yes

 No [SKIP TO NEXT SERVICE TYPE]

 Don’t know [SKIP TO NEXT SERVICE TYPE]

12. Is/are the domestic violence shelter/s to which you make referrals located within your own agency, outside your agency, or both?

 Within my agency

 Outside my agency

 Both inside and outside my agency.

 Don’t know

DOMESTIC VIOLENCE COUNSELING/ANGER MANAGEMENT

13. Please rate the availability of domestic violence counseling/anger management in your community.

 Domestic violence counseling/anger management is almost always available to families who need it.

 Domestic violence counseling/anger management is usually available to families who need it.

 Domestic violence counseling/anger management is sometimes available to families who need it.

 Domestic violence counseling/anger management is difficult to obtain for families who need it.

 Domestic violence counseling/anger management is not available in our community.

14. Is there at least one service provider, either within your own agency or in another agency in the community, to which you refer families for domestic violence counseling/anger management?

 Yes

 No [SKIP TO NEXT SERVICE TYPE]

 Don’t know [SKIP TO NEXT SERVICE TYPE]

15. Is/are the domestic violence counseling/anger management provider/s to which you make referrals located within your own agency, outside your agency, or both?

 Within my agency

 Outside my agency

 Both inside and outside my agency.

 Don’t know

ADULT EDUCATION OR EMPLOYMENT SERVICES (INCLUDING GED, ESL, JOB PLACEMENT, OR JOB TRAINING)

16. Please rate the availability of adult education or employment services in your community.

 Adult education or employment services are almost always available to families who need it.

 Adult education or employment services are usually available to families who need it.

 Adult education or employment services are sometimes available to families who need it.

 Adult education or employment services are difficult to obtain for families who need it.

 Adult education or employment services are not available in our community.

17. Is there at least one service provider, either within your own agency or in another agency in the community, to which you refer families for adult education or employment services?

 Yes

 No [SKIP TO NEXT SERVICE TYPE]

 Don’t know [SKIP TO NEXT SERVICE TYPE]

18. Is/are the adult education or employment service provider/s to which you make referrals located within your own agency, outside your agency, or both?

 Within my agency

 Outside my agency

 Both inside and outside my agency.

 Don’t know

PEDIATRIC PRIMARY CARE

19. Please rate the availability of pediatric primary care in your community.

 Pediatric primary care is almost always available to families who need it.

 Pediatric primary care is usually available to families who need it.

 Pediatric primary care is sometimes available to families who need it.

 Pediatric primary care is difficult to obtain for families who need it.

 Pediatric primary care is not available in our community.

20. Is there at least one service provider, either within your own agency or in another agency in the community, to which you refer families for pediatric primary care?

 Yes

 No [SKIP TO NEXT SERVICE TYPE]

 Don’t know [SKIP TO NEXT SERVICE TYPE]

21. Is/are the pediatric primary care provider/s to which you make referrals located within your own agency, outside your agency, or both?

 Within my agency

 Outside my agency

 Both inside and outside my agency.

 Don’t know

CHILD CARE (INCLUDING CHILD CARE RESOURCES & REFERRAL AGENCIES)

22. Please rate the availability of child care in your community.

 Child care is almost always available to families who need it.

 Child care is usually available to families who need it.

 Child care is sometimes available to families who need it.

 Child care is difficult to obtain for families who need it.

 Child care is not available in our community.

23. Is there at least one service provider, either within your own agency or in another agency in the community, to which you refer families for child care?

 Yes

 No [SKIP TO NEXT SERVICE TYPE]

 Don’t know [SKIP TO NEXT SERVICE TYPE]

24. Is/are the child care provider/s to which you make referrals located within your own agency, outside your agency, or both?

 Within my agency

 Outside my agency

 Both inside and outside my agency.

 Don’t know

EARLY INTERVENTION SERVICES FOR CHILDREN WITH SUSPECTED OR DIAGNOSED DISABILITY OR DELAYS

25. Please rate the availability of early intervention services in your community.

 Early intervention services are almost always available to families who need it.

 Early intervention services are usually available to families who need it.

 Early intervention services are sometimes available to families who need it.

 Early intervention services are difficult to obtain for families who need it.

 Early intervention services are not available in our community.

26. Is there at least one service provider, either within your own agency or in another agency in the community, to which you refer families for early intervention services?

 Yes

 No [SKIP TO NEXT SERVICE TYPE]

 Don’t know [SKIP TO NEXT SERVICE TYPE]

27. Is/are the early intervention services provider/s to which you make referrals located within your own agency, outside your agency, or both?

 Within my agency

 Outside my agency

 Both inside and outside my agency.

 Don’t know