5. MUSE Rapid Reflect Home Visitor 7.25.18 CLEAN

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

Expiration Date: xx/xx/20xx

Length of time for instrument: 12 minutes

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

RAPID REFLECT SELF-COMPLETED QUESTIONNAIRE – HOME VISITOR

Public reporting burden for this collection of information is estimated to average 12 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 – HOME VISITOR

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. One objective of MUSE is to learn about what happens during home visits and how home visitors and families interact during visits. The questions on this survey are about the home visit you conducted today and home visits that were scheduled but weren’t completed this week. It will take about 12 minutes to take this survey.

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

1. Enter the date of the home visit that you are reporting on: _____________

2. Did the caregiver complete a Rapid Reflect for this visit?

• Yes  SKIP TO Question 3

• No  GO TO Question 2a

2a. [If Question 2 = No] Why didn’t the caregiver complete a Rapid Reflect for this visit?

 Situation in the home wasn’t conducive to completing the Rapid Reflect (e.g., children needed attention, caregiver needed to attend to something immediately)

 Caregiver chose not to complete the Rapid Reflect

 I needed to leave

 Other __________________________________________

3. Amount of time spent travelling to today’s home visit (in minutes) _____________

4. Length of today’s home visit (in minutes) _____________

5. Location of today’s home visit: (CHECK ALL THAT APPLY)

• Primary caregiver’s home

• Friend/family member’s home

• Home visiting program office

• Car

• Clinic or other agency office

• Other location ___________________________________

6. Who actively participated in today’s home visit? (CHECK ALL THAT APPLY)

   Primary caregiver	Other relative(s)
   Primary caregiver’s spouse, partner, or another parent Index child’s grandparent(s)	Other/not sure Supervisor Other home visiting program staff
   Index child	Other external service provider
   Other child(ren) under age 5

7. Home visitors do many things during a home visit and often do multiple things at once. About how much time did you spend doing each activity during today’s home visit? The time does not need to add up to the “entire time.”

	No time	A little time		Some time	Most of the time	Entire time
Building relationship with caregiver						
Discussing caregiver’s goals						
Providing information/delivering curriculum content						
Modeling and coaching parenting skills						
Connecting caregiver with services and follow-up						
Gathering information/collecting data						

8. What topics did you cover during today’s home visit? (CHECK ALL THAT APPLY)

Caregiver (and other adult family members)

 Prenatal health /prenatal care

 Postpartum health /postpartum care

 Breastfeeding

 Physical health (outside of pregnancy and postpartum)

 Family planning

 Nutrition and physical activity

 Alcohol, commercial tobacco, and other drug use

 Mental health or stress

 Healthy relationships

 Domestic violence

 Social support

 Employment

 Education and job training

 Budgeting/making ends meet

 Meeting basic needs like food, utilities, health care and housing

 Child care

 Trauma (things that happened in the past that affect caregiver or family today)

 Cultural activities

Parenting behavior/Child outcomes

 Child health

 Child development

 Parent-child interaction

 Discipline/behavior management

 Feeding children (including formula and solids)

 Developmentally appropriate care/routines

 Co-parenting

 Child/home safety

9. How much of what you had planned did you get to cover in today’s home visit? (all, most, some, a little, none)

• All  SKIP TO Question 10

• Most  GO TO Question 9a

• Some  GO TO Question 9a

• A little  GO TO Question 9a

• None  GO TO Question 9a

9a. [If Question 9 = most, some, a little, or none] What were the main reasons you adjusted your plan for today’s home visit? (CHECK ALL THAT APPLY)

• Caregiver wanted to do something else

• Caregiver’s mood or behavior

• Child was not present for the home visit or child was asleep

• Something more urgent came up that we needed to address

• Environment was not conducive to covering that topic

• I didn’t feel like what I was doing was working

• Ran out of time

10. What challenges did you experience during today’s home visit? (CHECK ALL THAT APPLY)

• No Challenges

• Engaging an uninterested or fussy child

• Engaging an uninterested or distracted caregiver

• Building trust with a family

• Feeling uncomfortable talking about a certain topic

• Addressing a family crisis

• Discussing trauma or challenges experienced by someone in the family

• Conducting the home visit in the given environment

• Balancing family needs with program/curriculum goals

• Helping families access needed services

• Feeling concerned about my safety

• Having enough time

• Completing paperwork/data collection

• Other Specify _____________

11. The participant was interested in what we did during 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.

Multi-Site Implementation Evaluation of Tribal Home Visiting OMB Supporting Documents: Rapid Reflect Self-Completed Questionnaire – Home Visitor

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