Program Manager Survey_Part 1 Baseline

OMB Control No: _____

Expiration Date: ______

Length of time for instrument: 0.50 hours

ATTACHMENT 9: MIHOPE PROGRAM MANAGER SURVEY PART 1_ BASELINE

5/29/2012

PROGRAM MANAGER SURVEY PART 1: Inventory of Program’s Policy, Procedures, and Forms

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 inventory 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.

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

In this inventory we ask that you tell us 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. We anticipate it should take about a half hour to complete this inventory. Please feel free to consult with other staff members (e.g. a supervisor of home visitors) if you need assistance in completing the inventory.

Once you complete this inventory we will also be asking 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. 

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].

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	 	 	 

2. 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 [END SURVEY]

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]