2. MUSE Caregiver Baseline Survey 7.25.18 CLEAN

DRAFT 7/25/18 OMB Control No.: xxxx-xxxx

Expiration Date: xx/xx/20xx

Length of time for instrument: 15 minutes

MULTI-SITE IMPLEMENTATION EVALUATION OF TRIBAL HOME VISITING (MUSE)

CAREGIVER BASELINE SURVEY

This collection of information is voluntary. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number and expiration date for this collection are OMB #: 0970-XXXX, Exp: XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Kate Lyon, James Bell Associates; 3033 Wilson Blvd. Suite 650, Arlington, VA 22201; [email protected].

MUSE Caregiver Survey

Thank you for taking part in the Multi-Site Implementation Evaluation of Tribal Home Visiting (MUSE). The purpose of this study is to learn about tribal home visiting programs and the experiences of families receiving home visiting services. The questions on this survey are about you and your family and what you expect to get out of the home visiting program.

We are asking you to take this survey because you are receiving home visiting services and your program is participating in the MUSE research study.

Your answers will be kept private. Only the research study team will have access to this information. Your answers will not be shared with your home visitor or anyone at the home visiting program or any other agencies. We will not report information collected in this study in a way that could identify you or your program.

Your participation in this survey is voluntary. If you choose to take the survey, it will take about 15 minutes. If you are unsure how to answer a question, please give the best answer you can instead of leaving it blank.

A. BASIC QUESTIONS ABOUT YOU

This section will ask questions about your personal background.

1. What is your sex?

• Female

• Male

2. Are you or your partner currently pregnant?

• Yes  GO TO Question 2a

• No  SKIP TO Question 3

2a. [Paper version: SKIP if you or your partner are NOT currently pregnant]

[Electronic version: SKIP if Question 2 = NO]

Do you already have children?

• Yes  SKIP TO Question 3

• No  GO TO Question 2b

2b. [Paper version: SKIP if you or your partner are NOT currently pregnant]

[Electronic version: SKIP if Q 2 = NO]

Have you ever helped raise any children?

• Yes  SKIP TO Question 4

• No  SKIP TO Question 4

3. [Paper version: SKIP if you or your partner are currently pregnant and do not already have

children]

[Electronic version: SKIP if Question 2 = NO and Question 2a = NO]

How many children do you have? _____

3a. How many children do you have under age 5? Enter 0 if none. _____

3b. Not including these children, have you ever helped raise children other than your own?

• Yes

• No

4. Who lives with you in your household now? Check all that apply.

• Your partner (husband/wife/boyfriend/girlfriend)

• Parents (yours or your partner’s)

• Grandparents (yours or your partner’s)

• Siblings (yours or your partner’s)

• Other relatives

• Other non-relatives

4. How many adults 18 years or older live in your household? If YOU are over 18, please include yourself. _____

4. How many children between the ages of 6 to 17 live in your household? If YOU are under 18, please include yourself. Enter 0 if none. _____

4. How many children 5 years old or younger live in your household? _____

4. If your income were to stop suddenly, how long do you think you would be able to cover your basic expenses (housing, food, car, etc.) on your current savings?

• Less than 1 month

• 1-2 months

• 2-6 months

• More than 6 months

4. What language do you prefer for visits?

• English

• My tribal language

• Spanish

B. REASONS FOR ENROLLING & EXPECTATIONS IN HOME VISITING

1. How long have you been enrolled in the home visiting program?

• Less than 1 month

• 1-2 months

• More than 2 months

2. Below is a list of common reasons why families enroll in [home visiting]. Show the reasons that you enrolled in the home visiting program.

		Not a reason I enrolled	Somewhat important reason	Important reason	Very important reason
	I enrolled because I wanted support for
1	Connecting with others to talk to as supportive friends				
2	Being more connected to my community and culture				
3	Having my child be healthy				
4	Feeding my child (including formula and solids)				
5	My child’s development (learning new physical and social skills, language development, and coping with emotions)				
6	Managing my child's behavior				
7	Making child care arrangement				
8	Interacting with my child in a supportive and positive way				
9	Co-parenting with my child’s father/mother				
10	Taking care of my baby or child (bathing, diapering, sleep, routines, etc.)				
11	Keeping my child and home safe				
12	[SKIP If not currently pregnant] Having a healthy pregnancy				
13	[SKIP If not currently pregnant] Staying healthy after I have my baby				
14	[SKIP If not currently pregnant] Breastfeeding				
15	Improving my overall health				
16	Eating more nutritious meals and exercising				
17	Using family planning				
18	Quitting smoking				
19	Quitting using alcohol or drugs				
20	Dealing with stress				
21	Dealing with sadness				
22	Getting more education or job training				
23	Getting a job, or getting a better job				
24	Having healthy relationships				
25	Dealing with partner or family violence				
26	Coping with my own past abuse or trauma				
27	Meeting basic needs such as food, utilities, healthcare, and housing				
28	Budgeting/making ends meet				

C. YOUR RELATIONSHIPS AND WELLBEING

1. The next questions are about your relationships with other people. Please indicate how much you agree or disagree with each of the following statements. If you are expecting your first child now, think about the support you think you will have as a parent once your child is born.

		Strongly disagree	Disagree	Agree	Strongly agree
1	There are people I know will help me if I really need it.				
2	I do not have close relationships with other people.				
3	There is no one I can turn to in times of stress.				
4	There are people who call on me to help them.				
5	There are people who like the same social activities I do.				
6	Other people do not think I am good at what I do.				
7	I feel responsible for taking care of someone else.				
8	I am with a group of people who think the same way I do about things.				
9	There are people I can count on when I need help as a parent.				
10	I do not think that other people respect what I do.				
11	If something went wrong, no one would help me.				
12	I have close relationships that make me feel good.				
13	There is no one I can go to with questions about parenting.				
14	I have someone to talk to about decisions in my life.				
15	There are people who value my skills and abilities.				
16	There is no one who has the same interests and concerns as me.				
17	There is no one who needs me to take care of them.				
18	I have someone to help me when I have problems with my child(ren).				
19	I have a trustworthy person to turn to if I have problems.				
20	I feel a strong emotional tie with at least one other person.				
21	People are there to help me be a good parent.				
22	There is no one I can count on for help if I really need it.				
23	There is no one I feel comfortable talking about problems with.				
24	There are people who admire my talents and abilities.				
25	I do not have a feeling of closeness with anyone.				
26	There is no one who likes to do the things I do.				
27	There are people I can count on in an emergency.				
28	No one needs me to take care of them.				
29	Other people think that I am a good parent.				

2. Paper version: [SKIP if you do not have children yet]

Electronic version: [SKIP if Question A2a = No]

Please rate the extent to which you agree or disagree with each of the following statements.

		Strongly disagree		Disagree		Agree	Strongly agree
1	The problems of taking care of a child are easy to solve once you know how your actions affect your child, like I do.						
2	I would make a good model for a new parent to follow.						
3	Being a parent is manageable, and any problems are easily solved.						
4	I am an expert in caring for my child.						
5	If anyone can find the answer to what is troubling my child, I am the one.						
6	I am comfortable in my role as a parent.						
7	I have all the skills necessary to be a good parent to my child.						

3. Paper version: [SKIP if you do not have children yet]

Electronic version: [SKIP if Question A2a = No]

The following statements describe different ways that parents interact with their children on a daily basis. Please indicate how true each statement is for you.

		Never true	Rarely true	Sometimes true	Often true
1	When I am with my child I have difficulty staying focused on what is happening in the present.				
2	I rush through activities with my child without being really attentive to him or her.				
3	I am often so busy thinking about other things that I am not really listening to my child.				
4	I am aware of how my moods affect the way I treat my child.				
5	When I'm upset with my child I notice how I am feeling before I take action.				
6	When I am upset with my child, I calmly tell him or her how I am feeling.				
7	I notice how changes in my child’s mood affect my mood.				
8	I often react too quickly to what my child says or does.				
9	When I am feeling stressed, it is hard to pay enough attention to my child.				
10	I can usually manage stressful things that happen and still take care of my child.				

4. Paper version: [SKIP if you do not have children yet]

Electronic version: [SKIP if Question A2a = No]

Please rate how much you agree or disagree with each of the following statements.

		Strongly disagree	Disagree	Agree	Strongly agree
1	I am comfortable being a parent because my family and community are there to help me.					
2	Working together with family and friends I can solve many of the problems of caring for my child.					
3	Being a parent is manageable with the support of my family and friends.					
4	I am good at caring for my child because of what I have learned from my family and community about parenting.					

[NEXT SCREEN]

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS SURVEY.

Please click NEXT to exit the survey.

[NEXT SCREEN]

Please return the tablet back to your home visitor.

Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Participant Caregiver Survey

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