4. MUSE Rapid Reflect Caregiver 7.9.18 CLEAN

DRAFT 7/9/18 OMB Control No.: xxxx-xxxx

Expiration Date: xx/xx/20xx

Length of time for instrument: 5 minutes

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

RAPID REFLECT SELF-COMPLETED QUESTIONNAIRE - CAREGIVER

This collection of information is voluntary. Public reporting burden for this collection of information is estimated to average 5 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 Rapid Reflect Self-Completed Home Visit Questionnaire –CAREGIVER

The Rapid Reflect collects information on what happened during a home visit. The survey will be completed by both caregivers and home visitors using a tablet provided by the MUSE team at the end of the home visit. Home visitors will be assigned one week out of each month to use the Rapid Reflect after each home visit that week.

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. This survey asks five questions about today’s home visit.

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

Your answers will be kept private. They cannot be seen by your home visitor or other home visiting program staff after you exit the survey. Your answers will not be shared with 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 is voluntary. If you choose to take the survey, it will take 5 minutes or less. If you are unsure how to answer a question, please give the best answer you can instead of leaving it blank.

1. I felt comfortable talking with my home visitor today about myself and my family.

• Strongly agree

• Agree

• Disagree

• Strongly disagree

2. I felt understood by my home visitor today.

• Strongly agree

• Agree

• Disagree

• Strongly disagree

3. How much of what you did today is useful in your everyday life?

• All

• Most

• Some

• A little

• None

4. Which of the following did you like most about today’s home visit?

• Getting useful information

• Feeling supported in my parenting

• Setting aside time to focus on my child

• Getting connected to other services (including transportation to services)

• Addressing a pressing need

• Having someone to talk to who understands my needs

• Getting support to achieve my goals for myself and my family

5. I’m glad I made the time for today’s home visit.

• Strongly agree

• Agree

• Disagree

• Strongly disagree

[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: Rapid Reflect Self Completed Questionnaire – Caregiver

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